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fter reading this article, I am confident that you will understand how important it is to "just say no," especially with regard to some of the wound care decisions that you are responsible for making within your facility. This article will explain the direct correlation between your willingness to "just say no" and achieving positive patient outcomes.
       I would like to present the following assumption: The products that you select and utilize impact your clinical outcomes. Later on in the article, I will offer a specific example where this was proven to be true.
       Let's begin by talking about the word no. It is sometimes uncomfortable to tell someone no. Responding positively to a request usually results in maintaining a particular comfort level between you and the respondent. On the other hand, when you respond in the negative, you run the risk of creating a level of discomfort and perhaps conflict with the other person. Therefore, in most situations, it is probably easier to just say yes. In many instances, however, it may actually be a wiser choice to say no or at least to challenge the issue before saying yes.
       It is often easier for us to say no when we are very familiar with the situation or topic at hand and the associated benefits/consequences. When we are familiar with the topic, we are able to effectively support our position, and many times, we can actually convert the other person to our way of thinking. The key here is to have a crystal clear understanding of the facts and use these facts to support your position.
       Now let's talk about wound care. Regardless of your role, you are most likely familiar with the importance wound care plays within the long-term care environment. You may or may not be aware of the following. There appears to be a very concerning trend taking place within the long-term care market. The trend is related to the role that pharmacies play in the supplying and billing of wound dressings. Here's the trend: Pharmacies that supply wound care products are making the decision about which products you will use.
       This trend is very concerning due to several factors. Number one, you are the wound care expert. You attend conferences, read valuable publications, and meet with wound care sales people. Your pharmacy, on the other hand, is a pharmacy. Their primary business is pharmaceuticals--drugs. They are and should be utilized as valuable resources to help you understand and select the most appropriate drug, depending on the specific bacteria or infection that you are trying to treat.
       Number two, who is the individual within your facility that is responsible for managing wounds? That individual is probably you. Given that you get the credit and take the heat for wound care results, why are you letting your pharmacy dictate your product selection?
       In 1994, the Agency for Health Care Policy and Research or AHCPR (now the Agency for Healthcare Research and Quality or AHRQ), under the US Department of Health and Human Services, published Clinical Practice Guideline Number 15: Treatment of Pressure Ulcers.1 Guidelines developed by the AHCPR are intended to assist practitioner and patient decisions about appropriate healthcare for specific conditions. Clinical Practice Guideline Number 15: Treatment of Pressure Ulcers was written by experts well recognized for their work within the field of pressure ulcer management. With litigation in long-term care on the rise and awards for negligent wound care reaching into the millions of dollars, the AHCPR Guidelines have become a key reference tool used by attorneys. Actually, more copies of this valuable publication have been requested by attorneys than any other profession. The legal profession is acutely aware that pressure ulcer management is one avenue to focus on when suing a nursing home for negligence. Given the astronomical awards as of late, one wound care mistake has the ability to bankrupt a nursing home or an entire organization.
       Next question: Are all wound dressings equal? Undoubtedly, you answered no. Wound dressings are not alike. Contrary to some belief, the major manufacturers of wound dressings spend massive amounts of money on R&D. The objective? To provide you with the highest quality products to help you achieve positive patient outcomes.
       It is the products researched and manufactured by these quality companies that you need to utilize within your facility. Most likely, these manufacturers will be able to provide you with substantial data that document the impact their products will have on managing pressure ulcers or, better yet, preventing pressure ulcers from occurring. The other important component these companies are committed to is providing staff education. Some of the programs even offer CEUs. Even if your state doesn't require CEUs for license renewal, obtaining these credits should prove valuable during your annual review. Acquiring these education credits demonstrates to your employer that you are dedicated and committed to staying abreast of best practices. Implementing these best practices will positively impact your facility's wound care outcomes.
       With all the products that are currently available on the market, there is no way that you can be an expert on all of them. This is where you need to tap a very valuable resource. That resource is your local wound care sales representative. The well-trained wound care sales representative should be charged with the objective of detailing you on the features, benefits, and contraindications associated with their products. There are several companies out there that put their representatives through extensive wound care training, so they are able to effectively meet this objective.
       All products are not created equally, and all product representatives are not equally qualified. Some companies go to great lengths to attract the brightest and most dedicated individuals to call on important customers, such as you. The abilities and knowledge possessed by your representative should be a key component in your decision-making process.
       Recently, a wound care professional shared the following story. Her facility's pharmacy provider (the pharmacy is not owned by the facility but a third party responsible for supplying Medicare and Medicaid billable items, such as wound dressings) had begun dictating the "appropriate" wound dressings for her group of nursing homes. Evidently, the pharmacy had struck a deal with a particular manufacturer and began substituting her requested product with an inferior product. The wound care professional was beside herself. As a trained wound care clinician, she was the individual charged by her organization as being accountable for the results or lack of results produced by her wound care program. Therefore, she went to great lengths to research products, which included extensive product evaluations.
       Within days of the pharmacy's new deal, the clinician began receiving the inferior products.
       Why would this occur, you ask? The answer is simple: profit. The pharmacy receives an allowable from Medicare or Medicaid in many instances based on the product category not based on the particular brand. Therefore, it is in the pharmacy's best interest to find the cheapest product in a particular category and substitute it in place of the higher quality product. Higher quality usually means higher price--not always but usually. The higher priced products come with all the items discussed above--research, training, and highly trained representation.
       The pharmacy ended up making a higher profit margin, which is the difference between what they paid for the product and what they were reimbursed under Medicaid (in this case). This type of practice has helped make millions of dollars for these companies.
       Needless to say, the wound care professional was in a bind. She was accountable for the results but not getting the "tools" that she needed to do her job effectively.
       Here's what happened. The wound care professional decided to meet with the pharmacy in question. She agreed to conduct a side-by-side evaluation of the two products. Both manufacturers sent in their representatives to "in service" the staff. Within days, it was evident that the low-priced product was not effective. The dressing was falling off, which of course opens the wound to contaminants, increases the labor required for more frequent dressing changes, and reduces the rate of wound healing.
       It became clear that the pharmacy's preferred product was negatively impacting wound care outcomes, increasing the risk of infection, increasing patient pain and discomfort, and ultimately exposing the nursing home chain to potential litigation.
       In the end, the pharmacy begrudgingly agreed to supply this group of nursing homes with the products that the wound care professional had determined were most appropriate. This obviously cut into the pharmacy's profits. Unfortunately, the pharmacy continued to supply other nursing homes, those without a strong wound care advocate, with the inferior products.
       There are many excellent pharmacies and third-party billers that are as dedicated to patient outcomes as you are. However, there are also many that fall into the above-mentioned category.
       Moving forward, consider the following:
       It is important that you understand the reason a pharmacy or third-party payor is trying to persuade you to use a particular brand is, in many instances, as mentioned above, driven by profit margin, not evidence-based medicine. Your pharmacy has the ability to and must supply you with the product you desire regardless of their profit margin. The exceptions to this are the instances where the product costs the pharmacy more than the allowable or your product of choice is not covered by Medicare or Medicaid. In these cases, it is understandable that the pharmacy will not be able to provide your desired product. At this point, you will need to decide if the product you desire is one that you absolutely need within your arsenal and, if so, if your facility is willing to pick up the cost.
       As mentioned earlier, one of the most effective ways to learn about new products is to meet regularly with the representatives of each of the companies. Ask them to fully explain the features and benefits of their products, any possible side effects, and the value-added services that accompany the products. Challenge them to provide you with information that documents the performance of each product. You may need this information to support your case with the pharmacy. I also recommend that you ask for references. Who else in the area is using the product? Take the time to pick up the phone and call the references. Be sure to also ask about the level of service that they are receiving from the sales representative. The time you take to check references will be well worth the effort. Another important issue you will want to ask the product representative about is reimbursement. Specifically, are the products covered by the payor (which is most likely Medicare or Medicaid) and what is the allowable versus the price charged to your pharmacy?
       Now it is time to evaluate the products you feel may best support your objectives. If possible, you will want to evaluate similar products on the same patient. For instance, choose a patient with two similar wounds. On one wound place product A and on the other wound place product B. Be sure that you and your sales representative set measurable objectives for the evaluation (e.g., the wound packing material absorbs enough fluid to remain in the wound for at least one day).
       Medicare Policy states that the "dressing size should be based on and appropriate to the size of the wound. For wound covers, the pad size should usually be about 2 inches greater than the dimensions of the wound. For example, a 5cm x 5cm (2in x 2in) wound would require a 10cm x 10cm (4in x 4in) pad size."2 By sizing the wound correctly, you will assure maximum dressing wear time. It is extremely important to state you will not accept substitutions!
       At this point, you will be able to determine your supplier's motivation. If they balk and respond with, "We don't carry that brand," give them your sales representative's phone number and ask them to order the product. If they still tell you they will not supply the product you have diligently researched but instead will send you brand X, just say no.
       Once you have gained the commitment of your supplier, you will want to schedule some time to sit down again with the sales representatives who have been awarded your business. It is important you request your sales representatives schedule in-service education on a regular basis to assure the appropriate usage of their products. These in-services will result in getting the best possible outcomes from the products and assure you stay within the usage guidelines that have been established for each product category. If a product is not performing and requires more frequent dressing changes than what is called for in the guidelines, there is a good possibility the product will not be reimbursed, and your facility will be required to pay for the product. In addition to product usage in-services, you will also want to take advantage of the additional education programs offered by the manufacturer. As previously mentioned, many of the programs may offer education credits. Work with your wound care representative and schedule each of the programs you desire for the next 12-month period. This level of commitment to wound care education will impress even the most unpleasant inspector.
       By understanding this information and following these recommendations, you will guarantee the best possible outcomes for your residents. You will also be playing a major role assisting your facility with avoiding wound care negligence. Remember, you have the right and responsibility to "just say no."