VOL: 97, ISSUE: 48, PAGE NO: 64
Julie Taylor, RGN, DPSN, is wound care sister (nursing homes), South Staffordshire Healthcare NHS TrustJulie Taylor, RGN, DPSN, is wound care sister (nursing homes), South Staffordshire Healthcare NHS Trust
It has been acknowledged that working in a nursing home is quite different from working in NHS hospitals or community trusts (Nazarko, 1995). It is not uncommon for nurses in nursing homes to work in isolation and therefore miss out on the support that comes from working in a team. Furthermore, wound care products are obtained via individual patient prescription which can sometimes lead to a delay in the start of appropriate treatment.
South Staffordshire Health Authority covers an area of approximately 750 square miles. Within this area there are 96 nursing homes providing around 3,500 beds. In 1997 a nurse was appointed who would be responsible for wound care practice in nursing homes registered by the authority. Before then practitioners in nursing homes who required advice regarding wound care contacted the clinical nurse specialists from the acute and community services. However, as these specialists could not cover all areas, some homes had no access to this service and the nursing homes inspection and registration department had observed inconsistencies in the provision of wound care in the homes. Furthermore, the wound care specialists that were available found they were spending increasing amounts of time visiting nursing home patients.
In 1998 a full-time wound care sister with responsibility for wound management in nursing homes was appointed. Her remit was to provide wound care advice and support to patients and their carers in nursing homes, educational support to the nursing home sector, and to monitor the assessment of care needs and the development, implementation and evaluation of programmes of care.
In order to develop the role it was necessary to gather some baseline information to ascertain what was happening in nursing homes regarding wound management issues.
Because of the number of homes involved in the survey and their wide geographical spread it was decided that a questionnaire would be the easiest and quickest way of contacting all parties.
The health authority's nursing homes inspection and registration department holds a forum every three months to meet with the matrons/clinical managers from the nursing homes. The wound care sister was invited to use this meeting to launch the survey. Its aims were highlighted and everyone's cooperation was sought. Distribution of questionnaires was carried out by the inspection and registration department.
The questionnaire was divided into two parts. Each home received one copy of part one which was a general questionnaire designed to collect specific information about the home. Part two aimed to get the views of as many trained staff as possible, and several copies of this were sent to each home.
Results - part one
Thirty questionnaires were returned - a response rate of 31.2%. Although the response rate was low, the geographical spread of respondents was similar to the spread of nursing homes in the health authority and could therefore be considered to give a representative view of the area. At the time of the survey 139 wounds were identified. This included 71 pressure ulcers, 35 leg ulcers and 33 other wounds. Pressure ulcers accounted for just over half of the wounds in nursing homes.
Cullum et al (1995) reported a prevalence of 14.2% in hospital studies, Preston (1991) reported 6.7% in the community and a prevalence of 7.9% was reported by Shiels and Roe (1998) in nursing homes. Because the questionnaire had asked for the total number of beds in the nursing home and not how many beds had been occupied at the time it was not possible to calculate the prevalence of pressure ulcers at the time of the study. However, if all the beds had been occupied at the time of the study, a pressure ulcer prevalence of 5.3% would have been reported, which compares favourably with the above examples.
Assessment and classification
Seventy per cent (n=21) of the respondents were using wound assessment charts, although these varied depending on the type of documentation used in each home. Ninety per cent (n=27) were using a pressure ulcer risk calculator, with Waterlow (1985) being the most popular (73%). Seventy-three per cent of respondents (n= 22) were using a pressure ulcer grading system, with nine different classifications in use. There appeared to be some confusion about pressure ulcer grading systems, however, with a number of homes mixing these up with wound classification systems and one home reporting Waterlow as their grading system. The most popular pressure ulcer grading system in use was Stirling (Reid and Morrison, 1994), which was being used by 36% (n=11) of the homes.
Pressure relieving/redistributing equipment
The numbers provided for this section of the questionnaire were not wholly accurate, as some respondents mentioned cushions or mattresses but did not supply figures. Although every home had at least one piece of pressure-relieving/redistributing equipment, none had a mixture of types to provide for all levels of risk. Eight homes had a mixture of cushions and mattresses for people assessed at medium or low risk of developing pressure ulcers but there were none for high-risk patients. Ten homes had no pressure-relieving cushions at all. Forty per cent of cushions in use were fibre-filled, which would be recommended for comfort only.
There tended to be a wider range of mattresses in the homes, with overlays accounting for 31% of these, other static mattresses 12% and alternating equipment accounting for 29%. There was some confusion as to which risk categories various mattresses catered for. Sheepskins were identified by some homes as pressure-relieving aids, but these were not included in any calculations.
Results - part two
One hundred and seven questionnaires were returned (a response rate of 13.3%) and at least 70% (n=75) of these were from registered general nurses. A wide variety of answers were obtained in this section of the questionnaire. For example, the question 'list ways in which wound assessment could be more accurate' had 47 different answers. Suggestions included using a wound assessment chart, measuring and tracing, improved knowledge, taking photographs and using specialists.
To make analysis easier, responses that involved the same theme were combined and the most popular ones recorded.
When asked which solutions they used for wound-cleansing the majority of respondents said normal saline, but only some of these said they would warm it before use. A small number of respondents suggested that chlorhexidine was a suitable cleansing solution. The five most commonly stated reasons for cleaning a wound were to remove debris, to remove slough/necrotic tissue, to clean dirty wounds, to reduce infection and to limit trauma to granulating tissue.
An antiseptic is rarely required in wound cleansing and can damage granulating tissue, cause toxicity and damage surrounding tissue (Morrison, 1990). Most antiseptics are deactivated in the presence of pus and body fluids and will therefore have little effect on infected wounds (Leaper et al, 1987).
A total of 573 responses were generated in this section. Dressings that were being used on a regular basis are shown in Fig 1. It was encouraging to see that the new generation wound care products have replaced traditional products, such as gauze dressings. Although dry dressings were fairly high on the list, they are often used as a secondary rather than primary dressing. Tulles were still being used by 4.5% (n=26), even though their role in wound care is limited (Hollinworth, 1997).
Appropriateness of care
To determine whether the right treatments were being used in wound care respondents were asked to suggest wound contact materials and secondary dressings for the different stages of wound-healing (Fig 2).
Hydrogels (Flanagan, 1995) and hydrocolloids (Thomas, 1992) can be effective in the management of necrotic wounds, and this is reflected in the results of this survey. However, varidase was also high on the list for use on necrotic wounds, yet it is expensive and there can be contraindications to its use.
Combining products was popular, for example a hydrogel with a hydrocolloid. If this practice is to continue it is advisable to use products manufactured by the same company that have been tested for compatibility. Necrotic wounds are often very dry, which does not make alginates an ideal choice.
One-and-a-half per cent (n=2) of responses suggested the use of tulle dressings on granulating wounds. This is not ideal, as new granulation tissue grows into the matrix of the tulle and is damaged at each dressing change (Hollinworth, 1997).
Six per cent (n=8) of responses suggested a dry dressing as the wound contact material for an epithelialising wound. Even at this stage such products are not recommended as a primary dressing, as the wound still needs a moist warm environment to encourage migration of epithelial cells (Winter, 1962). Also, at this stage the wound is not usually wet enough to require an alginate, as suggested in 5% of responses.
Managing infected wounds
The total number of treatments identified in this section was 154. A lot of nurses appeared to encounter problems managing infected wounds and a number of wound care products were identified for use on such wounds (Fig 3).
If an infection is causing clinical symptoms the first line of treatment should be systemic antibiotics. Topical antibiotics and medicated tulles are not recommended for infected wounds (Gilchrist, 1994).
Only 87 of the respondents answered this section of the questionnaire. Sixty six per cent (n=57) of respondents said they had done some study relating to wound care. Two respondents were trained in Doppler assessment and 26 in compression bandaging.
Respondents were asked to state areas of wound care they would like to know more about. These included compression bandaging, Doppler assessment, information on dressings, wound assessment, methicillin-resistant Staphylococcus aureus and infected wounds, leg ulcers and the use of mattresses and cushions.
- The majority of nursing homes were using wound assessment charts, pressure ulcer risk calculators and pressure ulcer grading systems, but it was not possible to assess whether they were being used properly;
- From the information collected, staff appeared to be using wound care products in appropriate situations;
- All respondents were eager to learn and suggested a variety of areas for future education;
- Pressure-relieving equipment available in the homes was inadequate and where available staff were not always certain of its correct use;
- There appeared to be confusion regarding cleansing and managing infected wounds.
Subsequent developments to the service include formulation of a wound care course, the development of a link nurse system to promote dissemination of information, pressure ulcer prevalence monitoring and the use of a wound management product formulary.
Nursing homes now care for more people than the NHS, but we know little about the nursing needs of people living in homes. Julie Taylor's research into the prevalence and type of wounds nursing home residents have is welcome. Her aim of educating nursing home staff in research-based care is an important beginning but we must go further than that. Nursing home staff need access to funding and time off so that they can develop expertise in house. Residents have never been frailer and needed nursing expertise more. The other issue that needs to be addressed is the FP10 system. Some excellent wound care products, such as larvae, have to be bought because they are not available on FP10.
Linda Nazarko, MSc, RN, director of nursing, Nightingale House