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Wound, Ostomy and Continence: Specialty Nurses Effecting Positive Outcomes

Current national changes in reimbursement for facility-acquired pressure ulcers, catheter-associated urinary tract infections, falls and other “never events” have focused the spotlight on the critical need to prevent these adverse events. This national movement may come to launch the work of wound, ostomy and continence (WOC) nurses to a more prominent position.

In the U.S., millions of individuals suffer from wound, ostomy and continence disorders today, and the numbers are expected to increase with the rising numbers of elderly and chronically ill in our society, according to research published by the Wound, Ostomy and Continence Nurses Society. Optimal management of individuals with these disorders can result in improved patient outcomes and cost-savings for health care institutions.

As specialized health care practitioners, WOC nurses can identify problems at early stages and proactively intervene to educate and empower patients and caregivers to recognize, prevent, and manage WOC-related complications using evidence-based practice. Educated and certified WOC specialty nurses serve as valuable resources to case managers in the effort to manage patients with complex needs. Whether supporting a patient’s return to a productive lifestyle or providing palliative care, WOC nurses are uniquely qualified to deliver cost-effective interventions in multiple health care settings, including inpatient, outpatient and long-term care and home health.

A Healing Presence

The role of WOC nurses is multifaceted. Primarily, WOC nurses coordinate care and employ a full range of skills to promote healing and independence. As clinical experts, WOC nurses provide direct care to individuals with abdominal stomas, wounds, fistulae, drains, pressure ulcers and continence disorders. They also participate in the assessment, planning, implementation and evaluation of care needs while educating patients, families and nursing staff about preventive measures and techniques to optimize healing.

As consultants, researchers and administrators, WOC nurses play a pivotal role in establishing and implementing programs to ensure that optimal care is delivered. Such programs include those targeted at preventing and reducing pressure ulcers and other wounds, as well as ostomy and continence problems.

Wound Care Needs

The prevalence of wounds of many types is increasing. Due to their high costs and high rates of morbidity and mortality, these wounds are attracting the attention of health care providers, third-party payers, legislators and litigators. Findings from U.S. and Canadian studies have shown that patients who were cared for by WOC nurses (also known as enterostomal therapy nurses, or ETs) had better healing-rate and cost outcomes compared to patients cared for by non-WOC nurses.

A bulk of the reason for improved outcomes may reside in training. WOC nurses are specially prepared to manage both acute and chronic wounds, such as fistulae, dehisced surgical wounds, pressure ulcers and other non-healing wounds like those resulting from lower extremity arterial disease (LEAD), venous disease and neuropathy. Many of these acute and chronic wounds are preventable. All are manageable.

Pressure ulcers represent a significant health care problem. The goal of health care professionals is to identify those at risk so that the implementation of individualized preventive interventions can occur as soon as possible. Once a pressure ulcer occurs, the responsibility often falls on clinical experts to guide efficacious and cost-effective therapy to treat the ulcer, prevent its deterioration, and prevent the occurrence of additional ulcers. Additional responsibilities include educating patients and families about pressure ulcers — a critical factor in developing a better understanding of their roles in assessing, preventing and managing pressure ulcers.

LEAD affects one-third of older persons, and a full 50 percent of individuals with LEAD are undiagnosed, according to published research.Clinicians often use unreliable assessment measures such as pulse palpation and claudication history to assess perfusion status, according to recent studies. Individuals with LEAD are vulnerable to tissue loss, infections and lower limb amputation due to ischemia.

Treatment of LEAD wounds depends on accurate, comprehensive assessment. Noninvasive vascular tests, such as ankle brachial index or toe brachial index tests, are an essential component of a comprehensive lower extremity examination to assess healing potential and guide treatment decisions that may include debridement, compression therapy, adjunctive therapy, and referrals for surgical interventions. Identifying blood flow is essential prior to debridement, as expert opinions in recent clinical guidelines recommend maintaining stable eschars on lower extremities in cases of ischemia where blood flow is inadequate for healing.

Wounds due to venous disease can affect a person’s life in significant ways. They can interfere with employment as well as social and recreational activities. Venous wounds have a major economic impact due to lost productivity, high costs for dressings and health care, and an extremely high rate of recurrence (57 to 97 percent, according to research), reflecting the failure to effectively manage the underlying problem.

Compression therapy is the cornerstone of effective treatment for venous ulcers. Compression must be applied properly with the knowledge of perfusion status based on a complete assessment by a clinical expert who can differentiate venous, arterial and neuropathic disease. In cases of mixed venous and arterial disease, compression therapy must be adapted or avoided altogether based on the perfusion status.

Lower-extremity neuropathic disease (LEND) is a common feature of many systemic diseases — like diabetes — that leads to autonomic dysfunction, loss of sensation and tissue loss. Far too often, infection, gangrene and amputations result from the combined effects of ischemia and LEND. Research shows that consistent prevention, assessment and management of wounds by a wound care expert, along with managing associated disorders and symptoms such as infection, osteomyelitis, and Charcot fracture, are essential for limb preservation in patients with LEND.

Specialists with an in-depth understanding of the etiology, pathology and healing process of wounds, along with knowledge of the principles of topical care, WOC nurses are well prepared by education, training and experience to develop and implement wound management programs, deliver expert clinical care, and provide oversight to maximize healing outcomes.

Advanced clinical skills of WOC nurses for wound care include the ability to: perform comprehensive assessments (i.e., areas concerning the patient, the wound, risk and nutrition); perform conservative sharp instrumental wound debridement and chemical cautery with silver nitrate with physician orders; manage complex wounds with fistulae, tubes or drains; select topical therapies; and recommend prevention strategies, support surfaces for pressure redistribution, complex treatment modalities, and adjunctive therapies.

Ostomy Care Needs

Patients undergoing ostomy surgery, whether temporary or permanent, require intensive physical and emotional care to return to their daily lives. Individuals who undergo an ostomy can experience problems with body image and sexuality and limitations with employment and social and recreational activities. Difficulties encountered by patients with ostomies include stomal retraction, stenosis, or prolapse; parastomal skin irritation, hernias, pouch leakage, and odor.

Without the guidance of an expert, patients with ostomies can find themselves in a “cycle of misery.” However, WOC nurses can facilitate positive outcomes for patients with colostomies, urostomies, ileostomies, and continent diversions. Advanced clinical skills of WOC nurses for ostomy care include preoperative stoma site marking and education, complex pouch fitting and product selection, treatment of parastomal skin complications, and sexual, dietary and vocational counseling.

Continence Care Needs

Living with fecal or urine incontinence due to muscle or nerve dysfunction, infection, surgery, sphincter deficiencies or psychological disorders can cause a great burden on patients and families, and can strain limited health care resources. Loss of continence can also lead to premature institutionalization of patients and cause skin and wound-care complications. Fortunately, most patients can be cured or, at least, experience improvement in their conditions with expert care and guidance.

Advanced clinical skills of WOC nurses for continence care include performing urodynamics, education for intermittent and/or self-catheterization, behavior training and pelvic muscle re-education; selecting collection devices and products to manage incontinence, and performing complex tasks. In response to “never events,” continence nurses can guide facilities in designing programs to prevent catheter-associated urinary tract infections and decrease the fall-risk associated with uncontrolled incontinence.

Benefits of WOC Nurses

WOC specialty nurses can serve as optimal resources to case managers and facilities across care settings. Additionally, specialty nurse services can provide a marketing advantage and serve as a new revenue source in some settings. The multiple benefits from utilizing WOC specialty nurses include the following:

+ Faster healing.
+ Reduced facility-acquired wound, ostomy and continence problems.
+ Decreased occurrence/recurrence of wound, ostomy and continence complications.
+ Increased patient comfort.
+ Decreased length of stay.
+ Decreased recidivism.
+ Decreased staff management time.
+ Reduced unnecessary or unscheduled visits.
+ Increased cost-effective use of supplies and equipment.
+ Improved reimbursement.
+ Improved protocols and documentation to enhance regulatory compliance.
+ Improved coordination of multidisciplinary care, continuity of care and post-discharge follow-up.
+ Reduced liability.

Society and Certification

The Wound, Ostomy and Continence Nurses Society (WOCN) and the Wound, Ostomy and Continence Nursing Certification Board (WOCNCB), respectively, are two organizations that exist for the education and certification of wound, ostomy and continence specialty nurses. These organizations believe that nurses who are responsible for managing the nursing care of patients with wound, ostomy and continence needs can best demonstrate competency by completing a WOCN Society-accredited, nursing education program (WOCNEP) in the specialty areas in which they practice. WOCNEPs provide intensive educational experiences including in-depth didactic instruction in specialty and professional practice content and precepted clinical practicums.

Specialty nurses can be educated and credentialed in all three areas of the WOC scope of practice or in one or two of the specialties. WOC specialty nurses educated by WOCNEPs and/or certified by WOCNCB have at least one year of current clinical nursing experience after RN licensure and a baccalaureate degree or higher.

To support the work of WOC specialists and other health care providers, WOCN provides multiple educational products and services. WOCN has developed four evidence-based guidelines for the assessment and management of wounds due to pressure, arterial disease, venous disease and neuropathy. Other resources includes an online image library with slides of various types of wounds, multiple practice guides, fact sheets, patient guides, instructional CDs, and position statements on topics such as:

+ Pressure ulcer assessment and staging.
+ Debridement.
+ Measurement of ankle brachial index.
+ Stoma site marking.
+ Basic ostomy skin care.
+ Convex pouching.
+ Discharge planning for patients with a new ostomy.
+ Peristomal skin complications.
+ Stomal complications.
+ Catheter-acquired urinary tract infections.
+ Bladder diary guides.
+ Reversible causes of urinary incontinence.

Multiple online and onsite continuing education offerings are available to address the spectrum of specialty WOC nurse practice via the WOCN website and at annual conferences. Information about the WOCN’s educational offerings, products and services, and accredited WOCNEPs can be found at www.wocn.org. Information about the credentialing process can be accessed at www.wocncb.org.