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Breaking Up: Ending Comfortable Relationships with Standard Treatments

Gauze and Chicken Divan have some commonalities: both are easy, quick, inexpensive, and have French connections-- which somehow makes both seem perhaps better than they really are. But both Chicken Divan and gauze may be too easy and as such, create an unwillingness to try something new.

It was the Ancient Egyptians and Greeks who first used woven fabric as bandages for wounds thousands of years ago. However, the continued use of gauze is far more based on tradition than on its functionality. Ancient Egyptians were familiar with the classic signs of infection; however, it was not until the nineteenth century work of Louis Pasteur and Robert Koch that the link was made between infection and specific pathogenic microbes. Then, it wasn’t until the 1978 work of JW Costerton that the biofilm paradigm was discovered, named, and defined by this pioneer.  Ongoing research is now showing that effective treatment of a chronic wound requires aggressive treatment of biofilm.

The French connection comes from the French word “gaze” which means gauze and is linked to the concept of gazing through a gauze veil. It is this lattice work which allows bacteria to penetrate up to 60 layers of gauze. Further the gauze itself is a breeding ground for bacteria, allowing maturation of biofilm within access of host nutrition but above and separated from action of host immunity. Bacteria can be up to 1000 times more tolerant to antimicrobial treatment than planktonic/free floating microorganisms. The recalcitrance of biofilm cannot be effectively addressed by a simple gauze sponge therefore more advanced modalities must be added to routine treatment options. 

When it comes to topical wound and post op incisional management, gauze is used far too often. It is no longer considered the standard of care as a primary wound dressing. So why does it remain the go-to, top drawer tool for wound care providers? A simple answer is that wound care is not taught routinely in medical and nursing schools. Therefore, many providers are not aware that the science and practice has advanced to more sophisticated wound dressings which treat patients more effectively. There are times when gauze is exactly the right option. However, It can also be labor intensive, require ongoing monitoring and frequent change, can be painful to remove, can leave pieces behind in the wound, and increases the bacteria and bioburden in the wound area.

There are thousands of other options available and there are multiple options for each stage of wound healing. Some kill bacteria-causing infection and include antimicrobial agents. Others have electronic sensors that can indicate changes in the wound as it heals. Some are skin substitutes, others are regenerative material. These can decrease healing time, be cost effective, and improve a patient’s quality of life.

The current challenge is in selecting from among these myriad options. The acronyms NERDS & STONEES help with that determination. NERDS for Non-Healing, Exudate, Red Friable Tissue, Debris/Discoloration, and Smell; STONEES for Size Increasing, Temperature Elevation, OS (probe to bone), New Breakdown, Erythema/Edema, Exudate, and Smell. Is it topical? Or is systemic treatment necessary? Each wound requires careful assessment to determine proper care.

Like medicine and wound care, treatment options evolve and improve. Gauze, like Chicken Divan, is likely to remain an option in the arsenal of wound care. But like other recipes, it is no longer the only choice and wound care must continue to provide the highest level of evidence-based care to patients.

How to Achieve Complete, Accurate Documentation

How to Achieve Complete, Accurate Documentation

Elizabeth E. Hogue, Esq.
Office: 877-871-4062
Fax: 877-871-9739
E-mail: [email protected]
Twitter: @HogueHomecare


Complete, accurate documentation is paramount in health care!  Practitioners can’t achieve quality of care for their patients without it. Licensure and certification depend upon it.  It’s necessary for payment.  Avoiding possibly devastating results from audit activities by outsiders; including target probe and educate (TPE), RACs, ZPICs, etc.; relies upon complete, accurate documentation.  It’s just plain crucial!  And yet…providers continue to struggle mightily with inadequate documentation that regularly produces adverse results.  How can the problem be addressed effectively?  

Anecdotally, it seems that most providers know how to produce complete, accurate documentation, but they don’t.  Now there is a study that seems to verify that this is indeed the case.  Researchers from the University of Manchester, Columbia University and Appalachian State University worked with the Visiting Nurse Services of New York (VNSNY) to address questions about compliance.  The results of the study appeared in the American Journal of Infection Control on June 14, 2018.

The study revealed that knowledge is not the most important factor with regard to compliance with effective infection control measures.  The nurses in the study certainly knew about and understood standards of care regarding effective infection control.  Rather, the study showed that attitude, as opposed to knowledge and experience, was the key factor to achieving compliance.  The results of this study also seem applicable to compliance with applicable standards for complete, accurate documentation.

When providers identify deficiencies in documentation, it is often tempting to provide additional education to staff about how to document completely and accurately.  The assumption seems to be that practitioners aren’t documenting completely and accurately because they don’t know how to do it.  Instead, it now appears that the issue isn’t knowledge or experience at all.  According to this study, it’s all in the attitude!

Consequently, targeted strategies to alter the attitudes and perceptions of staff members are needed.  When staff members see documentation as the linchpin that it is, they will do a better of completing documentation that is complete and accurate.  How can managers change the attitudes and perceptions of staff members?  

It seems likely that documentation must become personal.  That is, practitioners must have some “skin in the game.”  In other words, the importance of complete, accurate documentation is not avoidance of some distant payment denials or adverse audit results that may impact staff members little, if at all.  The consequences of inadequate documentation must come home to practitioners in order to change attitudes and perceptions.

Managers can likely determine how best to accomplish necessary changes in attitudes and perceptions of their staff members. It may be helpful to individualize strategies for doing so.  Perhaps it’s time to tie compensation extremely closely to the timely preparation of complete, accurate documentation.

In short, less emphasis on reeducation and more emphasis on attitudes and perceptions is needed now!



©2018 Elizabeth E. Hogue, Esq.
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