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When two home health nurses in Polson, MT, formulated a comprehensive wound care protocol, they wanted to persuade caregivers in their sparsely populated area to abide by policies based on accumulated knowledge. Using information from wound care workshops and a federal agency’s guidelines on wound care, Lisa B. Winegart, RN, a supervisor with Lake County Home Health, and Lori A. Erb, RN, a nurse with St. Joseph Home Health, created the document.
They thought it would be a struggle to get area physicians to abide by the protocol. To their surprise, however, their audience was quite receptive, says Winegart. "What sold them more than anything was the cost savings we demonstrated could be realized from following the protocol," she says. Two wound care case studies in which the protocols were applied were very influential in winning physician support. In one case, approximately $600 was saved by following procedures outlined in the wound care protocol; savings in the second case reached $2,000. The savings, explains Winegart, resulted from the need for fewer skilled nursing visits and fewer wound care supplies. Patients also find the protocol convenient, she adds.
With the approval of physicians, Winegart and Erb introduced the protocol to nurses at their respective home health agencies and to the staff of a nursing home. They also have consulted with caregivers in adjoining Missoula County who follow a similar protocol.
The foundation of the protocol is the theory that as long as the patient is kept as healthy as possible and factors that stimulate wound growth are reduced, the body will take care of itself. "The intent of all of our education is to get the patient healthy," Winegart explains. Therefore, the protocol covers procedures for both wound patients and those who are "at risk" for developing wounds.
The protocol contains a tool for conducting a comprehensive integument assessment; sections on mechanical loading and support surfaces, nutrition, skin care guidelines, ulcer care guidelines; and a pressure sore status tool.
Winegart and Erb initiated development of the protocol because of the fragmented education among those who care for chronic wound patients, especially when it comes to expectations of care. "I think many people don’t anticipate that skin can break down until it is too late," says Winegart. "They’re sometimes unaware of the potential for breakdown and might have the attitude that it’s not going to happen to me.’ They assume that everything will turn out OK, even if they aren’t rigorous in their care. With this type of attitude, it may not seem crucial to turn the patient every two hours, for instance. I don’t think many patients or practitioners realize that wound breakdown will happen inevitably if proper care protocols aren’t abided by, such as proper nutrition, regular turning, and good skin care."
Winegart also emphasizes that a major component of chronic wound care is waiting, which runs contrary to the nature of many health care providers. "We attend to the factors that we can, but a large part of the healing process is to allow the wound to do it’s own thing. We don’t want caregivers to get upset if a wound doesn’t do what is expected," she says.
For example, nurses and physicians are often unaware that after using hydrocolloid dressings, wounds may appear worse before they begin to look better. "If you don’t know this, you’re likely to interfere with what had been appropriate care or even totally alter the course of care," she says.
Several years ago, Winegart recalls, a physician using a hydrocolloid dressing changed care orders because she didn’t know that it was normal for the wound’s appearance to worsen at first. "The physician put the patient on IV medication and twice-a-day whirlpools, which resulted in huge and unnecessary costs," she says.
In the absence of an accepted protocol, clinicians have followed seemingly random courses of care without much regard for procedures that are known to work. They routinely treat wounds with Silvadene or use peroxide or Betadine to clean them, Winegart says. She’s known physicians to order wet-to-dry dressings changed every 24 hours, which "makes no sense."
Winegart and Erb hope to persuade as many caregivers as possible to follow the protocol, thus getting health care providers in their region focused toward comprehensive and aggressive wound care. Being located in a town of 4,000 people in the heart of the Rocky Mountains hasn’t made their task any easier. Polson sits within the boundaries of the Flathead Indian Reservation only 40 miles from Glacier National Park. Billings, the state’s largest city (not exactly a metropolis with a population of 85,000) is an eight-hour drive.
"That’s part of the problem in many areas of Montana," Winegart says. "If your physicians aren’t actively reading about new developments in wound care, which is not an area that many are particularly interested in, they don’t know about the most current care regimens. We’ve taken on the responsibility of educating them. Our intent is certainly not to cross any professional boundaries with physicians. We have to honor their orders, but we ask them to be open to other approaches."
At the Womack Army Medical Center in Fort Bragg, NC, researchers have found that white petrolatum, when used as a post-procedural wound care ointment, is equally effective at preventing infection and presents a minimal risk of allergy when compared with bacitracin.
According to their report, which was published in the Journal of the American Medical Association (1996; 276:972-977), Maj. David Phillips Smack, MD, and colleagues compared the effects of the two ointments on rates of wound infection and contact dermatitis in a randomized study of 992 patients who underwent dermatologic surgical procedures.
Nine wounds among patients in the petrolatum group became infected, compared with four in the group receiving bacitracin a statistically insignificant difference. The incidence of contact dermatitis in the study and control groups was also similar.
Smack says, "A frequently cited reason for not using white petrolatum for wound care is that it has been shown to delay healing . . . but there was no clinically significant differences in healing between the treatment groups on day 1 . . . day 7 . . . or day 28 after the procedure."
The study authors conclude that frequent episodes of allergy, a potential for selection of resistant bacterial strains, and high costs associated with antibiotic ointments make white petrolatum an attractive choice for postoperative wound care.