Legal Implications for Wound Care Part 4: The Current State of Wound Nursing
Katherine Piette, Co-Founder, and CEO
Wounds are a significant healthcare issue affecting 8M people in the U.S. alone. They not only represent a significant economic burden ($96B annually), but they negatively impact the quality of life of persons with a wound, often leading to the loss of a limb or even death. (1) (See Corstrata Blog - “The Lack of Wound Care Expertise and Its Implications”)
Wounds are neither a medical specialty nor a disease; no one owns them. Board certification for nurses and physicians specializing in wound care is available through multiple accredited organizations - the American Board of Wound Management (ABWM), the Wound Ostomy and Continence Nursing Certification Board, the National Alliance of WoundCare, etc. The number of certified physicians and nurses by the accrediting organizations is as follows:
ABWM Board Certified Wound Physicians (CWSP) = 1090 (2)
ABWM Board Certified Wound Nurses (CWS) = 1682 (2)
WOCNCB Board Certified Wound Nurses (WOCN) = ~9,000 (3)
Compounding the problem of so few certified clinicians for the number of patients with wounds is that 90% of all board-certified wound specialty nurses practice in acute care hospitals and outpatient wound care centers, which translates to a critical lack of access beyond those settings, including the home, where the overwhelming majority of patients receive care.
Ideally, an interdisciplinary team provides wound care management. In reality, at least initially, most wound patients are seen by non-wound care specialists (4). The “Burden of Wounds” study” showed marked variations in clinical practices for wound management from assessment, diagnosis, and use of evidence-based practices. (1) This punctuates the lack of access to wound specialists and the lack of use of an interdisciplinary approach to wound care.
What do we know about the current practice of wound care?
In practice, the responsibility for the day-to-day care of wound patients primarily falls on nurses. Registered nurses are responsible for assessing patients with a wound, making clinical decisions based on the most appropriate evidence-based, nurse-led interventions, and measuring critical patient outcomes. The core competencies for specialist wound care nurses is well established; however, the separation of the wound competencies between non-specialist and specialist wound nurses is still undefined in contrast to other specialist nursing groups such as infection control nurses or certified palliative and hospice nurses. (4) Universally, the literature shows that non-wound specialty nurses have a significant knowledge deficit when it comes to providing care to wound patients. (5, 6) This knowledge gap is especially evident in the lack of wound assessment accuracy and the lack of use of evidence-based wound treatment plans.
A comprehensive, holistic wound assessment is foundational to effective wound management. It includes the proper identification of wound type/etiology, precise wound staging of pressure injuries, appropriate advanced wound dressing selection, and use of an evidence-based treatment plan (See Corstrata Blog - “Legal Implications for Wound Care Part 1: Wound Assessment”). Corstrata real world data confirms a deficit in wound assessment accuracy: in our patient population, we find wound etiologies are misidentified 30% of the time, pressure injuries are mis-staged 50% of the time, and evidence-based practice is not applied 70% of the time.
Equally important is the use of evidence-based practice to reduce wound healing times, improve clinical quality and financial outcomes, and improve patient quality of life. Wound management is a rapidly evolving science that requires knowledge of or access to evidence-based best practice wound management. Studies related to wound care practice by non-specialty nurses have indicated that evidence-based interventions in wound care are often underutilized. (5)
Why do we see a lack of wound knowledge in non-wound specialty nurses?
Inadequate wound education and training are the primary contributors to the deficit. (5). Undergraduate nursing school wound curricula are fragmented and inconsistent and provide limited instruction on wound prevention and care. A study done by Zulkowski et al. found that “70% of the nurses did not have sufficient education on chronic wounds in their basic nursing preparation” (7) In addition, the study showed that the curriculum failed to cover basic wound-related healing modalities, skills such as wound cultures, or dressing types. Wound care is a relatively new and developing area of expertise compared to other nursing specialties. It challenges nurses to extend their knowledge base and develop expertise in evidence-based wound care.
How do non-wound specialty nurses practice wound care?
Unfortunately, the literature observes that non-wound specialty nurses do not draw on evidence-based practice for their wounds but rather call on historical practices that they learned from their more experienced peers (5). At Corstrata, we witness the continued application of these outdated practices - i.e., the application of wet-to-dry dressings, daily dressing changes, etc. that are contrary to evidence-based practice and have a negative impact on wound healing.
How do we solve the problem?
There are multiple avenues to attacking poor wound management. One certainly is the need to provide more intensive training and education, not only in undergraduate nursing curricula but also in all care settings providing wound care. This includes arming non-wound specialists with access to evidence-based wound care practice resources and clinical decision support systems - i.e., wound care algorithms - for assistance in clinical decision-making.
Recently developed digital health and telemedicine tools allow for non-wound specialists to readily access wound specialists. By engaging with virtual wound specialists, providers are able to significantly expand the number of patients they can “see,” expanding the ability to care for complex patients.
Wounds are routinely cared for by non-wound specialist nurses that receive limited wound education and training in nursing school. As a result, these nurses often fail to employ evidence-based wound care principles.
There is limited access to board-certified wound nurses, with only 10+K wound nurse specialists to care for a wound population of 8M.
This translates to suboptimal wound care leading to extended healing times, reduced quality of life, and increased healthcare costs.
Corstrata was founded as a solution to provide access to scarce wound specialists. Our staff of board-certified wound nurses (CWS, WOC Nurses) provides virtual wound consultations employing evidence-based wound practice to all 50 states, DC, and Puerto Rico.
Sen CK. Human Wounds and Its Burden: An Updated Compendium of Estimates. Adv Wound Care (New Rochelle). 2019 Feb 1;8(2):39-48. doi: 10.1089/wound.2019.0946. Epub 2019 Feb 13. PMID: 30809421; PMCID: PMC6389759
Certification Statistics. American Board of Wound Management. (n.d.). Retrieved October 23, 2022, from https://abwmcertified.org/about-us/certification-statistics/
WOCNCB Certification. Wound, Ostomy, and Continence Nursing Certification Board. (n.d.). Retrieved October 23, 2022, from https://www.wocncb.org/certification
World Union of Wound Healing Societies (2020) Strategies to reduce practice variation in wound assessment and management: The T.I.M.E. Clinical Decision Support Tool. London: Wounds International. Available at: www.woundsinternational.com
Welsh, L. (2018), Wound care evidence, knowledge, and education amongst nurses: a semi-systematic literature review. Int Wound J, 15: 53-61. https://doi.org/10.1111/iwj.12822
Ruth Haram, Elisabeth Ribu, Tone Rustøen, The views of district nurses on their level of knowledge about the treatment of leg and foot ulcers, Journal of WOCN, Volume 30, Issue 1, 2003, Pages 25-32, ISSN 1071-5754, https://doi.org/10.1067/mjw.2003.4.
Zulkowski K, Capezuti E, Ayello E, Sibbald R (2015) Wound care content in undergraduate programs: We can do better. World Council of Enterostomal Therapists J 35: 10-13. https://www.primescholars.com/articles/wound-care-education-for-undergraduate-nursing-students-96323.html