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Getting the SKINny
Current events and issues of relevance to WOC Nurse practice, updates on new website features and links to external sources of interest to WOC nurses.
Wednesday, March 04, 2015
Recently, the American Board of Internal Medicine (ABIM toughened the maintenance of certification requirements for physicians who are Board certified in Internal Medicine, causing a storm of controversy in the medical community, questioning whether a recertification exam is really a reliable gauge of physician knowledge, judgment, skills and familiarity with new standards.  The debate being aired out in that professional community should cause all of us to pause and ponder some of the same questions and processes in our specialty.
The idea of specialty certification for physicians, as well as nurses dates back many years as a way to protect the public and ensure that specialists do, in fact, have the appropriate knowledge, skills and training.  The idea of certification was originally conceived as a one time event, similar to licensure examination.  But as the pace of healthcare advancement and science changed so rapidly, specialty boards began to question whether a single test was the best way to ensure competency.  More frequent activities were deemed to be necessary to communicate to the public that professionals were keeping pace with advancements in their practice.  Our specialty nursing certification requires a 5 year recertification which is much more stringent that the 10 year recertification now required by the ABIM.  They are also 'grandfathering' older fellows completing training prior to 1990, an option not available in our nursing specialty certification. 
Yes, it is true that many healthcare professionals are dedicated to keeping up with advancements in their specialty practice.  There are many who would be meeting the equivalent of recertification requirements in their regular job duties.  There are a variety of ways to keep pace with advancements.  It is even easier to access information today in this digital world.  But we also must admit that there are those among us who would never seek out educational opportunities if they were not required to do so.  People who display specialty credentials, but whose practices clearly have not kept pace with scientific advances, give all of us a black eye.
Obtaining continuing education in one's specialty may be a vehicle to gain knowledge, but acquisition of knowlege alone is not a measure of one's competence.  The certification/recertification process is an attempt to measure judgment based on knowledge and prevailing standards.  The certification and recertification process may be a flawed method of ensuring competence in a specialty, but it is the best that we have right now.  It is much more than time-consuming busy work designed to support a certification structure.  It is one step in our ongoing efforts to improve patient care.

Tuesday, February 10, 2015
Several weeks ago, CMS announced its continued enforcement on reducing hospital errors by cutting reimbursement to 721 facilities having the highest rates of infections, blood clots, falls, pressure ulcers and other adverse events.  Some of the nations most renowned and prestigious institutions were included in the list of agencies penalized, including nearly half of academic medical facilities.  One out of every seven hospitals in the nation will have their Medicare payments cut by 1 percent over the next fiscal year.  The penalties are estimated to total $373 million.  In addition, some states are issuing their own penalties on hospitals that are repeat offenders.  These new penalities come on top of other financial incentives, such as fining hospitals for having too many readmissions.
This new round of penalties comes with some of the same, and legitamate complaints.  Hospitals who do a good job of identifying and tracking problems are often penalized for their efforts because their data may look worse.  Even though CMS adjusted infection rates by the type of hospital, thus trying to account for patient acuity, academic medical centers complain that the adjustments are inadequate considering the complex patients that they handle.  Health analysts express concern about penalizing publicly owned hospitals who serve as the safety net for the poor.
Every regulation and rule comes with both intended and unintended consequences.  I think we all applaud the focus on patient safety and quality care.  WOC nurses are at the center of things, helping to reduce hospital acquired pressure ulcers, catheter associated urinary tract infections and surgical site infections.  Financially penalizing hospitals certainly is a powerful motivator.  But it also might take valauable resources from institutions already struggling to care for the poorest and the sickest.

Friday, December 05, 2014
The Center for Clinical Investigation (CCI) of the Wound, Ostomy and Continence Nurses (WOCN) Society Foundation is pleased to announce the Call for Proposals for one 2015 Member's research grant in the amount of $10,000.  If you are a registered nurse and a current member of the WOCN Society, you are eligible to be a Principal Investigator of this grant, and are invited to apply. 
Through this grant, the CCI and WOCN Society aims to expand the existing research base for WOC nursing practice and to facilitate WOC nurses to be engaged in reearch as clinical investigators.
The 2015 WOCN Society Member's Research Grant funds studies that aim to improve health outcomes of patients with WOC problems, strengthen the evidence base of WOC nursing practice, and enhance the delivery of WOC nursing care.
Studies the CCI is interested in funding include but are not limited to those that increase knowledge about WOC nursing interventions promoting patient health and well-being, describe the epidemiology, issues and impact of WOC health problems and the need for WOC nursing care, and evaluate the benefits of WOC nursing on health care delivery.  WOC nursing interventions may relate to nursing assessment, prevention, and management.
Studies that include diverse or underrepresented populations, in various clinical settings, or strategies that are culturally sensitive. advovcate for patients, or increase health literacy and patient/family care capacity are welcome.
Studies that investigate comparative effectiveness of devices or products, medical procedures, or pharmacologic trials are of low priority.
Please follow this link for more information.  The submission deadline is Monday, February 9, 2015 by 4:30 pm (CST).

Saturday, November 01, 2014
In this edition of the JWOCN, authors Jodi McDaniel and Kristine Browning give us the state of the evidence on the effect smoking has on wound healing in their article Smoking, Chronic Wound Healing, and Implications for Evidence-Based Practice.  This article is approved by ANCC for 2.8 contact hours.
As the authors clearly report, a distiction should be made about the health risks associated with nicotine versus the health risks posed by the tobacco smoke.  Cigarette smoking provides the 'double whammy' of combining the hazards of both.  Thus smoking tobacco is much more deleterious than when nicotine is delivered by other means such as by spray, gum, inhalers, lozenges and patches.  As healthcare providers, our goal should always be to move the patient toward total smoking cessation.  But the addictive nature of smoking should also be recognized and these alternative nicotine delivery methods should be appreciated as a pathway to cessation.
Electronic cigarettes, commonly referred to as e-cigarettes, are a new method of nicotine delivery currently available on the market.  The authors do not specifically address this new modality.  There is current debate on whether these e-cigarettes are less harmful than conventional cigarettes.  There is no tobacco in these products.  The nicotine is vaproized.  And even though there is no tobacco, there are other known toxins in the e-cigarette cartridges.  These products may be useful in helping to suppress the urge to smoke and may be a useful tool as part of a smoking cessation plan.  However, the effect that vaporized nicotine and cartridge chemicals has on wound healing has yet to be determined.  The wound nurse should remain alert to updated research findings and regulations to guide clinical recommendations on the use of this product.

Sunday, October 05, 2014
A Group Purchasing Organization (GPO) is an entity that is created to leverage the purchasing power of a group of businesses in order to gain discounts from vendors based on the collective buying power of the GPO members.  Group purchasing is a strategy that has been used for years in many differnt industries from groceries to manufacturing. 
The first healthcare GPO was established in 1910 by the Hospital Bureau of New York. The Medicare Prospective Payment System, more commonly known to hospitals as the Diagnosis Related Group (DRG) payment structure instituted in 1983, caused all hospitals to focus their attentions on cost containment fostering rapid expansion in GPOs.  By 2007, it was estimated that 97 percent of all not-for-profit, non-governmental hospitals participated in some form of group purchasing.

Despite the growth of these entities, they are not without controversy.  The controversies lie in how the GPOs are funded, typically by a membership or administartive fee paid by the vendors. GPO members are typically rewarded with top tier pricing for goods and services in addition to rebates for compliance with buying contracts.  GPOs have historically been exempted from all anti-kickback legislation and regulations.

Most wound, ostomy and continence nurses have, at one point, run head-on into the reality of a GPO, particularly when a certain product is needed to serve a particular patient's needs. While most buying contracts allow a certain allowance for going off-contract to purchase certain unique products to meet individual patient needs, local purcahsing departments are generally charged with buying contract compliance.  Depending on your internal politics, it can be very challenging to convince a purchasing agent as to the medical necessity of going off-contract to achieve a certain patient outcome.

As hospitals, home care agencies, outpatient clinics and long term care facilities continue to face huge financial pressures, they will continue to seek new ways to manage their costs.  WOC nurse must not only accept the GPO as a way of life, but we must embrace them.  I think it is best to influence product formularies from the inside.  Product formularies must be based on clinical outcomes, and who better than clinicians can articulate this?  But the days of getting every product that we want to have on the shelf are long over.  We can no longer just look at clinical outcomes, but we must also look at institutional outcomes and the costs of doing business.  If we don't step up, others will do it for us.


About the Author

Lee Ann Krapfl
Wound, Ostomy and Continence Nurse (1991 – present) at Mercy Medical Center in Dubuque, IA. Practices the full scope of wound, ostomy and continence care for adult and pediatric patients. Provides WOC nursing services in acute care, long term care, home care and outpatient settings. Has been an active member of the WOCN Society, most recently serving on the Council as the Chair of the Public Policy Committee.