Cath Lab Digest

You have been asked by your facility’s administrative team to train a staff for the new Wound Center that is to open in a few short months or even weeks. That should be fairly simple, right? After all, seasoned nurses, physical therapists, and other clinicians from multiple disciplines have been hired. Or maybe it’s not so easy. Often, staff members hired for hospital outpatient wound centers are pulled or transferred from the acute care setting — folks who enjoy caring for patients with wounds who have worked with the general hospital population, not exclusively with wound patients. This can present challenges in the educational process. Hiring an experienced wound care practitioner will require specificity in outpatient clinic training.

A systematic approach to staff training can result in a positive outcome for you, your staff, your clinic and most importantly, your patients. Staff should be knowledgeable regarding basic general care as well as assessment, treatment, and documentation specific to wound management.

BASIC PATIENT CARE IN AN OUTPATIENT SETTING
Patients receiving care in an outpatient clinic will require full nursing or physical therapy assessments.Vital signs (blood glucose, function, nutritional status, bowel and bladder control, cognitive status, sensation, and level of independence) must be evaluated at each visit.This may include interviewing the patient’s caregiver or family members.

Outpatient and inpatient assessments differ in that much of this information may come via report rather than direct observation (eg, diet and nutritional status). In the clinic, we can rely only on what we are told and by what we observe in the hour or so the patient is present, unlike the hospital where a constant monitoring system is in place. The clinician must learn to interpret subtle signs. For example, a patient or family member may report performing daily dressing changes but displays poor eyesight and/or lacks the hand dexterity necessary. Changes in that patient’s plan of care will be required to accommodate appropriate wound care in the home.

WOUND ASSESSMENT
In assessing wounds, standardization and accuracy among staff members are imperative — assessing wounds is what we are expected to do best. Clinicians need to be proficient in recognizing the signs and symptoms of basic and atypical types of wounds that may present in the clinic. If staff members are unable to identify specific atypical wounds, they should at least identify what is abnormal so the physician can be alerted and treatment plans altered if necessary. All clinical staff members should be knowledgeable regarding pressure ulcers (including staging), arterial ulcers, venous insufficiency ulcers, diabetic neuropathic ulcers, and burns as well as ulcers related to shear, friction, and moisture.

Wound measurement and description are key to documenting progress and altering the plan of care. Ulcers should be accurately staged and described in all documentation, including appearance of wound bed and periwound tissue, anatomic location, odor, and pain level, as well as color and consistency of exudate. Clinicians must not forget that wound assessment extends beyond the actual wound. Staff proficiency in assessing skin turgor, pulses, edema, circumferential measurements, ankle-brachial indices (ABIs), mobility of affected joints, and integrity of periwound skin is integral to appropriate evaluation and will dictate treatment options.

WOUND TREATMENT
Patients come to wound centers expecting state-of-the-art wound treatment. Many have exhausted all other options in treating chronic wounds and are anticipating rapid and complete healing rendered by persons who are familiar with all of the latest techniques.The ability to appropriately select and apply dressings are two of the most basic skills staff members should possess. Again, because we provide care in an outpatient environment, patients live at home or in some sort of skilled or assisted facility, a fact that differentiates from acute care the types of dressings and mode of application available. Dressings conducive to a patient’s lifestyle and that can be easily changed by the patient, caregiver, or home healthcare (HHC) provider need to be selected. Because the patient is not in clinic every day, the dressing application needs to be easily duplicated by the person who actually applies it. Wound center staff must be able to teach the caregiver or patient the appropriate application of the dressing selected.

Staff must be well trained in applying various types of compression therapies, wound cleansing, offloading techniques, and debridement (if within the parameters of their state practice act and part of their expected duties), as well as in the adjunctive physical modalities offered at your facility, including ultrasound treatments, pulsed lavage with suction, electric stimulation, negative pressure wound therapy, biotherapy, vasopneumatic compression, ultraviolet therapy, and monochromatic infrared radiation.
The clinicians providing treatment must be credentialed to do so. Physical therapists do not need to learn infusion therapy and nurses do not need to pass competencies on estim but both clinician groups should be aware of what the other has to offer and support their efforts.