Editor’s note: There are no financial disclosures related to this article. The era of pay-for-performance in healthcare is here, and payment formulas based on quality measures will soon become the standard. Because of related high-cost and high-volume adverse events, pressure ulcers have been identified by organizations such as the Centers for Medicare & Medicaid Services, the Joint Commission, the Agency for Healthcare Research Quality, and others as a quality measure across all healthcare settings. They are also sure to come under increased scrutiny as the Affordable Care Act goes into effect. Because of the interdisciplinary nature of wound care, communication is critical to maintaining the process of healing, and attention to the processes of information exchange will gain dividends in favorable outcomes and reimbursement.
Communicating to the Wound Care PatientBy nature of their various (and often multiple) comorbidities, wound care patients reside in a spectrum of healthcare settings. Communication is important for all types of chronic wounds due to a large spectrum of causation, particularly as it pertains to nonhealing traumatic or surgical wounds, diabetic wounds, arterial wounds, and those caused by venous disease. There are several avenues of communication that should be considered, all of which require attention to maintaining optimum transfer of information among providers and patients. This effort includes continuing education of caregivers and patients, and may require review of institutional policies, procedures, and technologies to optimize proper “flow” of information. Clinical wound data is complex, as are the details related to description and treatment. Asking for constructive feedback is also an important part of the communication chain to ensure that instructions are transmitted accurately and effectively across all parties. Along with information related to proper nutrition and self-care of dressings and devices, communication should always include an individualized strategy for patients to manage their wounds. Gaps in the transfer of information can result in misunderstandings, misuse of products, missed follow-up appointments, and liability risk. Additionally, dissatisfied patients and families are sometimes a byproduct of inadequate communication/education. Institutions that accept transfer patients should not be subjected to “surprises” when a patient is found to have an unexpected or poorly documented wound. Research suggests that improved communication leads to not just improved patient safety and outcomes, but patient and family satisfaction and reductions in length of stay.1
Forming A Communication ‘Network’An interdisciplinary team for wound care should be comprised of both formal (the team that functions within a wound care setting) and informal (ie, provider-to-family and physician-to-physician when located in different environments) networks. Patient networks can also include nurse practitioners, private practitioners, case managers, home attendants, visiting nurses, pharmacists, orthotists, physical therapists, and others. Proper communication for wound care involves transferring the right information at the right time to the right person who is capable of analyzing everything and is then able to utilize what he/she knows. Consider these six tips on how to “grease the wheels” of communication within the system of care for patients who live with pressure ulcers and other chronic wounds: 1) Caregiver to patient or family: For patients who live with pressure ulcers, they and their families require instruction regarding proper self-care management and further prevention modalities. This includes education on appropriate pressure redistribution surfaces and mobilization techniques. Patients being discharged or those who reside in the community require education on wound care, including pressure relief, dressing changes, and nutrition, as well as a ready supply of products. 2) Patient or family to caregiver: Patients should be encouraged to ask questions about their health and their wound care and should be provided with a contact number for a caregiver who is knowledgeable and readily available. If a new wound occurs or if an existing wound deteriorates, patients should be instructed to immediately notify their caregivers so that new, worsening, or underlying medical problems that require investigation and/or immediate treatment can be considered. 3) Nurse to physician and physician to nurse: Nurses and physicians are often locked within their respective “silos” and sometimes do not communicate in a timely manner, but physicians need to be aware of any deterioration in skin condition immediately. Skin problems such as moisture-associated dermatitis and stages I and II pressure ulcers are often not communicated to a physician because they only require nursing interventions according to a facility’s policies. This is potentially troublesome if the physician does not properly examine a wound. A physician’s wound care instructions must be timely, legible, and complete. Specific information must be present on wound care orders, such as location of the wound, type of dressing, and frequency of application. 4) Physician to physician: Pathologic conditions regarding skin should be documented and communicated along the continuum of care. Skin care has often been delegated to nurses, a philosophy that is no longer applicable in today’s risk-management and patient-centered environment. Different medical specialties may have alternative views on issues such as wound classification and treatment, and these should be openly discussed to facilitate the best collaborative approach to wound healing. Discharge summaries are critical documents that physicians rely upon for comprehensive information on a hospital stay, yet they often lack information on wounds and wound care. If a patient develops a wound during a hospital stay, this should be listed in the discharge summary along with current treatments, prescriptions, and follow-up appointments with wound specialists. 5) Facility to facility: Information concerning wound-specific documentation and treatment must accompany patients when they are referred across the healthcare continuum. When patients are transferred between facilities, it is critical that accurate wound care information accompany them. The risk-management environment has brought attention to documentation discrepancies between hospitals and nursing homes, which may reflect directly on quality-related issues. Patients should have a total skin assessment when being discharged and upon arrival at any facility. This also applies to the visiting nurse who begins a course of home services. This enables caregivers to be informed of critical issues such as obtaining proper prevention devices and promptly continuing the appropriate treatments. 6) Proper use of technology: Proper design and implementation of a wound care electronic health record (EHR) can bring the patient and caregiver network together and fill potential gaps. The EHR can provide comprehensive take-home information that the patient or caregiver can use when going from provider to provider. There is also the possibility of web-based, password-protected information that can enable different providers to access wound care information. Michael Cioroiu is co-director and Jeffrey Levine is a staff physician at the Center for Advanced Wound Care at Beth Israel Medical Center, NY.
Reference1. Preventing Pressure Ulcers in Hospitals: A Toolkit for Improving Quality of Care, Agency for Healthcare Research and Quality. Accessed online at www.ahrq.gov/research/ltc/pressureulcertoolkit/putoolkit.pdf.