Sebastian Probst, and Georgina Gethin at the European Wound Management Association outline the challenges of treating wounds in a home care environment.
The European Wound Management Association (EWMA) aims to promote best practice in wound management and to advocate for the rights of people with wounds, to receive the best possible care in a timely manner that meets the needs of the individual and the health service. The document Home Care-Wound Care (HCWC)1 was developed by a group of experts within EWMA and supported by representatives of organisations in the UK and Germany, to provide a set of recommendations on wound care in the home care sector at a European level. The document sought to generate critical discussion and debate of what prerequisites, conditions and knowledge/skills of healthcare practitioners are required to manage wounds in the patients’ home. The document provides examples of the organisation of wound care across Europe with 3 case exemplars.
The need for this document is underscored by rising costs of healthcare driven mainly by increased costs of medicines and devices, increased capital costs and an increase in the numbers of people with chronic conditions requiring primary and secondary healthcare support. In tandem with this has been the shift in the delivery of services from hospital to the home care setting and this shift is clearly seen in the field of wound management 2, 3. The increasing pressures for early discharge from acute hospitals means that more wounds which heretofore were managed in acute settings are now being cared for in the community, and in patients own homes. In Europe today, it is estimated that around 70-90 % of wound care is conducted in the community, the majority of such being delivered by nurses 4, 5. At least 50% of the work load of the primary care nurses is spent on provision of wound care, and a study from Ireland sets this figure at 68%6.
The challenges of providing wound care in the home within Europe is underscored by the patient chronicity as 76% of patients with chronic wounds have 3 or more comorbid conditions including hypertension, vascular disease and arthritis and up to 46% have diabetes 7. Home care clients today are becoming older and have more complex health needs than previously known. Thus, home care patients tend to require extensive help 8, 9.
The role of the patient and informal carers
There is a paucity of research which focuses on the subject of HCWC from a clinical perspective 10-14. This gap can be illustrated by the fact that there are no guidelines or recommendations of minimum requirements for providing best care to patients with wounds and their families in the home care setting. Furthermore, there is some evidence to suggest that many patients receiving health care services at home never have their wound aetiology diagnosed 10, 11.
Patients’ needs in chronic wound care often continue over weeks, months or even a lifetime. Therefore, planning wound care requires empowering patients and their informal carers by involving them and allowing them to contribute to decision making and ensuring that they are satisfied with the care they receive. Probst et al.15 reported how patients and their informal carers receive little support and practical information from healthcare professionals. Other literature shows that healthcare professionals need to include patients and their informal carers in their care by providing information and advising them on how to manage a wound in the home care sector, where to get dressings and how to choose the appropriate dressing, and how to cope with wound-related symptoms 16-18.
Chronic wounds are common in primary care settings and require a high level of resources, and can have a profound impact on a patient’s quality of life. Hence, collaboration between the patient and practitioner is important. However, living with a non-healing wound at home can have a pervasive and profound effect on the daily lives of patients 19. The impact of physical, psychological as well as social effects and quality of life are overwhelming. For most patients caring for a chronic wound in the home care setting is a challenge as all aspects of daily life are affected including limitations of mobility, personal hygiene and simple things such as choosing shoes and clothes18.
We must recognise the challenges inherent to being treated in the home environment. Often, practitioners work alone, so they must adapt what they have to provide a suitable home care setting for delivery of wound care. Building a team approach with the expertise, views, and opinions of the patients and their informal carers are also critical. Together, team-building and adapting to the environment are important factors for successful HCWC. The HCWC document places specific emphasis on the under recognised role of the informal carer in the provision of wound prevention strategies and wound management. These carers are often family members with no formal training in wound care. However, this 215 group requires special attention as they may feel overwhelmed and overburdened by their new role and responsibilities.
Home care is organised and funded differently within Europe. In taking care of patients with a wound and in helping to prevent the onset of a wound, a needs assessment is mandatory and is best performed by specialists in wound management. Health care professionals need to acquire skills and knowledge on how to manage wounds in the home care setting, and develop a team based approach to care delivery. Inclusion of patients and informal carers is vital to the success of this process. Already this document has seen EWMA initiate a follow-up project in the UK to develop a network of experts and implement a UKfocused guidance document together with key players in the fields of wound care, home and community care, and patient organisations. Another project in Germany is also being planned and more national projects are likely to follow.
1 Probst S., Seppänen S., Gerber V., Hopkins A., Rimdeika R., Gethin G., EWMA Document: Home Care-Wound Care: Overview, Challenges and Perspectives. J Wound Care 2014; 23 Suppl 5a: S1-S41.
2 OECD, Health at a glance: Europe 2012, in OECD Publishing2012: http://dx.doi.org/10.1787/9789264183896-en.
3 Bartkowski, R., [Length of hospital stay due to DRG reimbursement]. Ther Umsch 2012; 69: 1, 15-21.
4 Genet, N., Boerma, W.G., Kringos, D.S., et al., Home care in Europe: a systematic literature review. BMC Health Serv Res 2011; 11: 207.
5 Romagnoli, K.M., Handler, S.M., Ligons, F.M., et al., Home-care nurses’ perceptions of unmet information needs and communication difficulties of older patients in the immediate post-hospital discharge period. BMJ Qual Saf 2013; 22: 4, 324-32.
6 O’Keeffee, M., Evaluation of a community based wound care programme in an urban area. Poster presented at: Innovation Education Implementation. (EWMA Conference, Prague – Czech Republic) 2006; 127.
7 Friedberg, E., Harrison, M.B., Graham, I.D., Current home care expenditures for persons with leg ulcers. Journal wound ostomy continence nursing 2002; 29: 4, 186-192.
8 Aylward, S., Stolee, P., Keat, N., et al., Effectiveness of continuing education in long-term care: a literature review. Gerontologist 2003; 43: 2, 259-71.
9 Axelsson, J.,Elmstahl, S., Home care aides in the administration of medication. Int J Qual Health Care 2004; 16: 3, 237-43.
10 Westra, B.L., Bliss, D.Z., Savik, K., et al., Effectiveness of wound, ostomy, and continence nurses on agency-level wound and incontinence outcomes in home care. J Wound Ostomy Continence Nurs 2013; 40: 1, 25-53.
11 Bliss, D.Z., Westra, B.L., Savik, K., et al., Effectiveness of wound, ostomy and continence-certified nurses on individual patient outcomes in home health care. J Wound Ostomy Continence Nurs 2013; 40: 2, 135-42.
12 Pieper, B., Templin, T., Dobal, M., et al., Home care nurses’ ratings of appropriateness of wound treatments and wound healing. Journal wound ostomy continence nursing 2002; 29: 1, 20-28.
13 Pieper, B., Templin, T., Dobal, M., et al., Wound prevalence, types, and treatments in home care. Adv Wound Care 1999; 12: 3, 117-126.
14 Jorgensen, S.F., Nygaard, R.,Posnett, J., Meeting the challenges of wound care in Danish home care. J Wound Care 2013; 22: 10, 540-5.
15 Probst, S., Arber, A.,Faithfull, S., Malignant fungating wounds: the meaning of living in an unbounded body. Eur J Oncol Nurs 2013; 17: 1, 38-45.
16 Probst, S., Arber, A., Trojan, A., et al., Caring for a loved one with a malignant fungating wound. Support Care Cancer 2012; 20: 12, 3065-70.
17 Grocott, P., Gethin, G.,Probst, S., Malignant wound management in advanced illness: new insights. Curr Opin Support Palliat Care 2013; 7: 1, 101-5.
18 Probst, S., Arber, A.,Faithfull, S., Coping with an exulcerated breast carcinoma – an interpretative phenomenological study. Journal of Wound Care 2013; 22: 7, 352-360. 19 Green, J., Jester, R., McKinley, R., et al., Patient perspectives of their leg ulcer journey. J Wound Care 2013; 22: 2, 58, 60-2, 64-6.
Authors: Sebastian Probst, Zurich University of Applied Sciences (ZHAW), Switzerland – Georgina Gethin, School of Nursing & Midwifery, NUI Galway, Ireland
Sebastian Probst, and Georgina Gethin
European Wound Management Association