Authors

  1. Newbern, Stacy BSN, RN-BC, CWCN, OMS, FNP

Article Content

A CERTIFIED Wound Care Nurse (CWCN) is a nurse who's successfully completed an advanced training program in wound assessment and management. CWCNs care for patients with wounds caused by injuries, diseases, or medical treatments. They also provide wound prevention recommendations and interventions for at-risk patients and pre- and postsurgical care and education for patients. This article, which discusses the need for more full-time CWCNs as inpatient staff, includes a literature review supporting the value CWCNs offer patients and employers in both improved quality of care and cost reduction.

 

Wide-ranging responsibilities

CWCNs work with multidisciplinary healthcare teams and provide services that include wound assessment, wound cleansing, nonexcisional and conservative sharp wound debridement, negative pressure wound therapy, compression wraps, treatment planning, and wound-related medication recommendations, as well as ongoing patient assessment and treatment. This national certification, which requires advanced nursing skills, can be obtained at different nursing education levels. Two nationally recognized certification boards, the National Alliance of Wound Care and Ostomy (for RNs, LPNs, and other clinicians) and the Wound, Ostomy Continence National Certification Board (for clinicians with a bachelor's degree or higher), offer specialized training and standardized tests for certification. Certification is also available for advanced practice nurses (APRNs). APRN certification requires a focus on core role competencies specific to the APRN.

 

Patient-care guidelines

The Wound, Ostomy and Continence Nurses Society was founded in 1968 and currently has more than 5,000 members, many of whom help write and secure national guidelines for wound care practice.1 Research shows that when compared with traditional practices ("how things have always been done"), evidence-based practice yields higher-quality healthcare, better patient outcomes, and lower costs.2 National clinical guidelines for wound care set forth by Health Service Executive, Inc., an Ireland-based health organization managed by the Ireland Department of Health, describe corporate responsibilities for current best practice that are widely recognized as national guidelines:3

 

* A collaborative and interdisciplinary approach to wound management is recognized as the optimal approach to preventing and managing wounds.

 

* Clinical practice in wound management should comply with and respect legislation, scope of practice, clinical practice guidelines, and organizational policies and procedures.

 

* Compliance with the above ensures patient safety and facilitates wound healing.

 

 

For a facility to provide evidence-based best practice, consistency in the quality of care must be provided to patients in all areas. Evidence-based best practices to prevent hospital-acquired pressure injuries include assessment, use of pressure-redistribution surfaces, repositioning, nutritional support, and moisture management. All of these specialized interventions are included in the CWCN's advanced training.4 The CWCN contributes to the quality of patient care by providing direct care, education, and consultation for patients, and consultation and direction for non-CWCN nurses. They also develop procedures, guidelines, and protocols for patient care.4

 

Literature review

Wound care requires a multidisciplinary approach to provide holistic, comprehensive care for patients who may have several comorbidities.5 One study of effective wound care centers identified that multidisciplinary teams including a CWCN had a greater than 50% improvement in reducing amputation rates and wound-related complications compared with teams without a CWCN.4,5 Data obtained from the National Database of Nursing Quality Indicators have linked nursing specialties, and the CWCN in particular, to lower hospital-acquired pressure injury rates and better pressure injury risk assessment and prevention practices.4 In an independent study performed and trialed within the Veterans Affairs Healthcare System, universal pressure injury prevention bundles with CWCN support lowered the incidence of unit-acquired pressure injuries from 15.5% (without CWCN support) to 2.1% (with CWCN support) on average.1

 

A study by Aydin and colleagues compared unit/patient characteristics, nurse workload, nurse expertise, and hospital-acquired pressure injury preventive clinical processes of care for prevalence of hospital-acquired pressure injuries in 789 medical-surgical units at 215 hospitals.3 The study found that RN workload, expertise, and clinical process of care (risk assessment) can be adjusted to reduce the incidence of hospital-acquired pressure injuries through support strategies for the unit nurse. These include full-time nurses experienced in wound care and stress the importance of early skin and pressure injury risk assessment.3 These studies support the concept that more CWCN involvement with inpatient assessment and care results in better patient and facility outcomes.

 

These studies are also significant because insurance companies are increasingly basing their reimbursement rates on patient outcomes and quality of service. The estimated cost of hospital-acquired pressure injury care is $9.1 billion to $11.6 billion each year and is linked to an increase in patient pain, lower quality of life, and increased mortality risk during a hospital stay.6

 

A study of all-payer statewide administrative data for California from 2007 to 2009 compared pressure injury rates and hospital charges for adults discharged from acute care hospitals after the Hospital-Acquired Conditions Initiative pressure injury payment changes. Initiated by Medicare and other payers, these changes included refusal to pay for Stage III and Stage IV hospital-acquired pressure injuries, which decreased payments in the state overall by $310,444 for all payors and $199,238 for Medicare. Other initiatives reduced payments related to skin injuries, decreasing the amount to $62,538,586 for all payors and $47,237,984 for Medicare.6

 

According to Bureau of Labor statistics, in 2014 the average hourly rate of pay for general hospital nurses in the United States was $35.71.7 Utilizing the average amount provided by this statistic, hiring one full-time CWCN to provide wound assessments and treatments for 5 days each week, or a 40-hour workweek, would cost the average hospital approximately $74,267 per year-potentially less than what a hospital-acquired injury or skin infection may cost the hospital.

 

Current practices in most hospital facilities allow clinical nurses and providers to place wound care consultations via the patient electronic health record when a wound care nurse is employed by the facility. This practice relieves the workload of the unit nurse, who spends an average of 1 hour on each inpatient consult, including assessment, development of treatment plan and relaying the plan to the healthcare provider; cleansing, debriding, and dressing the wound; and documenting. For patients with multiple wounds or affected body surfaces, the consult may take up to 2 hours.

 

If we know that having a CWCN in the hospital setting is supported by national advisories, and evidence-based best practice indicates positive outcomes when the CWCN works as part of the multidisciplinary team, why aren't hospitals adding them to the team?

 

Assessing skin integrity

Evidence-based best practice indicates each patient should have a skin integrity risk assessment on admission to the unit and every 24 hours using a tool to identify existing wounds or increased risks for wounds so interventions can be initiated immediately to prevent further injury.8 The National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel/Pan Pacific Pressure Ulcer Injury Alliance 2014 guideline identifies that adults with medical devices are at risk for pressure injuries (B strength of evidence) and recommend evaluating skin under and around medical devices at least twice daily for signs of pressure-related injury.9 A pressure injury risk assessment tool is considered necessary for a comprehensive pressure injury prevention program.8

 

The Braden scale risk assessment tool was introduced in the late 1980s and has since become the most used and validated pressure injury tool.10 The score is based on six variables: activity, mobility, nutritional status, sensory perception, moisture, and friction and shear, with a maximum score of 23. A score equal to or lower than 18 indicates an increased risk for pressure injury and the need for evidence-based interventions designed to maintain or restore skin integrity.10 In a study to determine the efficacy of multidisciplinary interventions on reducing the incidence of hospital-acquired pressure injuries, the Braden scale was found to have a sensitivity of 92.30% for predicting the development of pressure injury.10 No risk assessment tool, however, is meant to replace clinical assessments and professional judgment; it's designed for use in conjunction with clinical assessments.

 

The National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel/Pan Pacific Ulcer Injury Alliance 2014 clinical guideline recommends use of a systematic process for determining pressure injury risk including clinical judgment, skin assessment, and review of risk factors that are not part of the pressure injury risk assessment tool, because not all risks are quantified on the Braden Scale or other tools used for pressure injury risk assessment.9 Because CWCNs have advanced skills, they can recognize risk factors not included in the Braden scale by performing a comprehensive clinical assessment of the skin; evaluating comorbidities, health, and functional status; identifying risks related to medical devices; and immediately implementing preventive and intervention care plans. These measures improve patient outcomes and quality of service in the inpatient setting, and reduce workloads for the unit nurse and provider.

 

Quality improvement proposal

Evidence-based best practice guidelines recommend having nurses who are specially trained in wound care provide care for patients with wounds or who are at risk for pressure injuries in both inpatient and outpatient settings. Employing a full-time CWCN to care for these patients streamlines treatment and makes the most efficient use of hospital and clinic resources while reducing workload for unit nurses.

 

Using evidence-based guidelines for wound care treatments as outlined by the Wound Ostomy and Continence National Clinical Practice Guidelines for Prevention and Management of Pressure Ulcers (Injuries) can help standardize care and ensure that the CWCN provides the required assessments, care planning, and implementation of treatment for patients at high risk for healthcare-acquired infections secondary to loss of skin integrity and development of pressure injuries.3 Employing a full-time CWCN on the inpatient unit facilitates timely responses to wound care-related needs, improving patient outcomes and decreasing costs to the patients and facilities. For more information, see Wound care resources.

  
Table Wound care res... - Click to enlarge in new windowTable Wound care resources

REFERENCES

 

1. Wound Ostomy and Continence Nursing Board. History. http://www.woc_ncb.org/about-us/history. [Context Link]

 

2. Agency for Healthcare Research and Quality. Preventing pressure ulcers in hospitals. What are the best practices in pressure ulcer prevention that we want to use? 2014. http://www.ahrq.gov/professionals/systems/hospital/pressureulcertoolkit/putool3.html. [Context Link]

 

3. Wound Management Association of Ireland. National Guidelines for Best Practice and Evidence-Based Guidelines for Wound Management. 2016. http://www.wmai.ie/wpcontent/uploads/2011/09/wound_guidelines_2009.pdf. [Context Link]

 

4. Boyle DK, Bergquist-Beringer S, Cramer E. Relationship of wound, ostomy, and continence certified nurses and healthcare-acquired conditions in acute care hospitals. J Wound Ostomy Continence Nurs. 2017;44(3):283-292. [Context Link]

 

5. Kim PJ, Evans KK, Steinberg JS, Pollard ME, Attinger CE. Critical elements to building an effective wound care center. J Vasc Surg. 2013;57(6):1703-1709. [Context Link]

 

6. Meddings J, Reichert H, Rogers MA, Hofer TP, McMahon LF Jr, Grazier KL. Under pressure: financial effect of the hospital-acquired conditions initiative. A statewide analysis of pressure ulcer development and payment. J Am Geriatr Soc. 2015;63(7):1407-1412. [Context Link]

 

7. U.S. Bureau of Labor Statistics. Occupational Employment Statistics. 2017. http://www.bls.gov/oes/tables.htm. [Context Link]

 

8. Gadd MM, Morris SM. Use of the Braden Scale for pressure ulcer risk assessment in a community hospital setting: the role of total score and individual subscale scores in triggering preventive interventions. J Wound Ostomy Continence Nurs. 2014;41(6):535-538. [Context Link]

 

9. National Pressure Ulcer Advisory Panel/European Pressure Ulcer Advisory Panel/Pan Pacific Pressure Ulcer Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Perth, Australia: Cambridge Media; 2014. [Context Link]

 

10. Mallah Z, Nassar N, Kurdahi Badr L. The effectiveness of a pressure ulcer intervention program on the prevalence of hospital acquired pressure ulcers: controlled before and after study. Appl Nurs Res. 2015;28(2):106-113. [Context Link]