Power of 3
As healthcare spending in Canada continues to climb, pressure on healthcare administrators to deliver cost-efficient care is intensifying—and policymakers are ever-more focused on ensuring quality and system sustainability. Wound, ostomy and continence challenges are common across all Canadian healthcare settings—and their management places a financial burden on the healthcare system. Registered Nurses Specialized in Wound, Ostomy and Continence (NSWOCs) can help alleviate the financial strain facing administrators and policymakers through the provision of higher quality care, reduced costs and improved outcomes for patients.
"My NSWOC was my support line. She gave me her knowledge, friendliness and respect. To this day I think about how lucky I was that she was available and that she offered her phone number to reach her at any time. Sixteen years later, I live without a large bowel, I have a stoma—and I have never looked back.
With the help of this nurse, today I am healthy both physically and mentally."
Ostomy Patient, Nova Scotia
FOR A MORE SUSTAINABLE SYSTEM
With a tri-specialization in wound, ostomy and continence, NSWOCs are helping address the challenges facing Canada’s healthcare system. Employing NSWOCs is an effective strategy for controlling costs through high-quality, evidence-based care that leads to better outcomes for patients. NSWOCs bring about these benefits as care providers but also as sources of specialized knowledge for interdisciplinary healthcare teams, care consultants to other health professionals, as well as through best practice and protocol development, research and other avenues.
A SYSTEM UNDER STRAIN
Every year, Canada’s provincial and territorial governments spend more than $250 billion in total on health care (Canadian Institute for Health Information [CIHI], 2018). CIHI data suggests healthcare spending encompasses more than 35% of annual provincial/territorial budgets (CIHI, 2018).
In the next decade as the country’s population ages, that spending is going to increase. Longer life expectancies and declining fertility rates are contributing to an overall older demographic (World Health Organization, 2015). With an aging population come higher rates of chronic disease (Harris & Shannon, 2008). Economic models predict that healthcare costs will rise by 1% each year between 2010 and 2036 due to population aging alone (Mackenzie & Rachlis, 2010).
THE PRESSURE ON HEALTHCARE LEADERS
To get maximum value out of every dollar, healthcare organizations across the country frequently operate under tight financial constraints while continuing to strive to deliver high-quality patient care. Administrators are continually seeking ways to optimize their human and economic resources with evidence-informed clinical decisions and cost-effective products and services. The pressure to be maximally efficient is even greater in jurisdictions like Ontario, Quebec and British Columbia, where healthcare funding is tied to the numbers of patients seen and procedures done.
One in four people in Canada will be elderly by 2036.
– Statistics Canada, 2018
Administrators are also tasked with meeting the growing demand for services. With too few open beds in hospitals and long-term care facilities, patients face lengthy wait times. Moving patients from hospitals to community care is one strategy to help rein in healthcare costs and free up beds in acute-care settings (Canadian Foundation for Healthcare Improvement, 2018). This also shifts the pressure onto home care services to meet demand and control spending.
At the policy level, governments face the unenviable challenge of ensuring both high-quality care and system sustainability. They want to see favourable public reporting numbers, optimal patient access and flows, low hospital readmission rates—and balanced budgets.
HOW NURSES SPECIALIZED IN WOUND, OSTOMY AND CONTINENCE HELP
Successful management of wounds, ostomy and continence challenges requires specialty care. Common across all Canadian healthcare settings, these issues can be expensive to treat. Wounds, which can be the result of trauma, surgery or a symptom of many common and chronic conditions, alone cost Canada about $3.9 billion a year, or 3% of the country’s total annual health spending (Wound Care Alliance, 2012).
The exact number of patients living with acute and chronic wounds in Canada is unknown, as there is no accurate national database. Based on prevalence, the number is high and growing with the aging population. It is known, however, that an estimated 70,000 people in Canada are living with an ostomy, and thousands more each year undergo some form of ostomy surgery (a colostomy, ileostomy or urostomy; Ostomy Canada Society, n.d.). People who have an ostomy often experience significant complications that require extensive management and treatment beyond the body-altering initial surgery, adding to patient stress and already substantial care costs.
Wound care alone costs Canada $3.9 billion a year, or 3% of total annual health spending.
– Wound Care Alliance, 2012
Incontinence is a highly prevalent condition that involves the accidental leakage of urine or feces—and is often mistakenly considered a natural part of aging. Over one million incontinence cases (urinary or fecal) have been reported in Canada, and estimates put the true number closer to 3.5 million—almost 10% of the Canadian population (Taylor & Cahill, 2018). Incontinence is also one of the main reasons cited for admission to long-term care facilities. Excess moisture and bacteria associated with continence challenges can contribute to dermatitis and other skin problems that add to care needs and reliance on the healthcare system. Proactive management strategies are not available to most people living with continence challenges. The costs of body-worn containment products and urinary catheters to the system are also significant and will continue to grow as Canada’s population ages and chronic disease rates climb.
Wound, ostomy and continence challenges will continue to be significant drivers of care needs and expenses as Canada’s population ages. The challenge for administrators is to meet these needs through effective and cost-efficient care. A nurse with a tri-specialty—opposed to a general practice, non-specialized nurse—offers a unique advantage for healthcare organizations to meet these challenges.
Nurses Specialized in Wound, Ostomy and Continence (NSWOCs) are registered nurses trained specifically to design and implement meticulous, evidence-informed care plans for patients with wound, ostomy and continence challenges. NSWOCs contribute to care effectiveness and cost-efficiency through:
Leadership on interdisciplinary healthcare teams, promoting current, evidence-informed methods and cost-efficient care decisions to resolve wound, ostomy and continence challenges
Use of advanced and specialized approaches to guide the assessment, treatment and/or management of wound, ostomy and continence challenges
Education of patients and their families to improve self-engagement and informed care
Contributions to research including guidelines and policies, products and priority areas for future research
The combination of these practices leads to higher-quality care, lower costs and better outcomes for patients.
THE PATH TO TRI-SPECIALIZATION IN CANADA
NSWOCs receive a competency-based education through the Wound, Ostomy and Continence Institute. The Institute’s Wound, Ostomy and Continence – Education Program (WOC-EP) is designed for registered nurses with at least two years of clinical experience (Wound, Ostomy & Continence Institute, n.d.). The WOC-EP teaches advanced knowledge in the tri-specialty areas with a focus on quality clinical and cost outcomes, and prepares nurses to write the Canadian Nurses Association (CNA) certification exam in wound, ostomy and continence. CNA certification grants the CNA WOCC(C) credential, which indicates that core competencies in the three specialty areas have been met with knowledge updated every five years.
INDIRECT CONTRIBUTIONS TO WOUND, OSTOMY AND CONTINENCE CARE
NSWOCs have developed and participated in numerous national and provincial best practice guidelines and recommendations for wound, ostomy and continence challenges that help healthcare professionals make better decisions and prioritize care plans. Examples include NSWOCC’s (2018) Nursing Best Practice Recommendations for Enterocutaneous Fistula and Enteroatmospheric Fistula, Wounds Canada’s (2017) Best Practices for Skin and Wound Management, the Registered Nurses’ Association of Ontario’s (2019) Ostomy Best Practice Guidelines, best practice recommendations for intermittent catheterization, and several guidelines for the prevention and treatment of skin tears (International Skin Tear Advisory Panel, n.d.). This work promotes evidence-based practice and higher-quality wound, ostomy and continence care delivery in practice settings across the country.
About 70,000 people in Canada are living with an ostomy, and thousands more each year undergo some form of ostomy surgery.
– Ostomy Canada Society, n.d.
BENEFIT 1: HIGHER QUALITY CARE
High-quality care improves outcomes for patients and care providers. This includes shorter stays and reduced care costs through lower rates of hospital-acquired conditions such as pressure injuries (Boyle, Bergquist-Beringer, & Cramer, 2017). Rates of hospital-acquired conditions are an important indicator of overall performance, which makes minimizing these a key priority for healthcare administrators.
CARE BASED ON EVIDENCE AND SUPPORTED BY TRUST
A literature review examining NSWOCs’ impact in home care for patients with wounds identified numerous benefits when an NSWOC was involved directly in administering care or as a consultant to other care providers (Baich, Wilson, & Cummings, 2010). Benefits included greater healing success, faster healing times, increased interest in wound care education among other nurses, and the introduction of standardized protocols for wound care (Baich et al., 2010). Benefits of NSWOC care have also been observedin the other tri-specialty areas (Westra, Bliss, Savik, Hou, & Borchert, 2013; Taneja et al., 2017).
NSWOCs tend to be dedicated patient advocates, ensuring patients receive the most appropriate care for their circumstances. This helps build trust between patient and provider, which is a critical role given the intimate nature of wound, ostomy and continence conditions. As Baker (2001) put it, an NSWOC “… acts as an advocate when she [or he] enhances the patient’s sense of personhood, self-worth, and dignity.”
Pressure injuries occur with a mean prevalence rate of 26% across Canadian healthcare settings.
– Woodbury & Houghton, 2004
NSWOCs also contribute to the quality of care as educators of patients and other practitioners (Boyle et. al, 2017). An NSWOC treating a patient who needs an ostomy, for example, can play a significant role in helping patients and their families adjust to life after the surgery (Baker, 2001). They often share their knowledge with interdisciplinary team members and other staff who can then apply it in their own roles. By developing quality-enhancing procedures, guidelines and protocols, NSWOCs inform the selection of suitable, cost-effective supplies and equipment (Boyle et al., 2017).
BENEFIT 2: LOWER COSTS
Controlling costs is critical across every facet of the healthcare system. The growing prevalence of wounds and high expenditure for wound management across all healthcare settings have made wound care a particular budgetary focus in Canada and around the world. NSWOCs are trained to assess and treat many types of complex wounds with evidence-based strategies that can help prevent complications.
Savings through effective wound management can be substantial: the average cost of treating a diabetic foot or leg ulcer in 2007 was $8,000 USD—versus $17,000 USD to treat an infected diabetic wound or ulcer (Kruse & Edelman, 2006). Applied consistently, advanced wound care practices can translate into big savings. One report estimated that Ontario could reduce costs by 66%—for savings of $338 million—by adopting best practices for the treatment of patients with diabetic leg and foot ulcers (Shannon, 2007). Lower rates of infection and amputation would account for $24 million in savings.
Similar savings are attainable through the application of NSWOCs’ tri-specialization to patients who have ostomy or continence challenges. Peristomal skin problems (when the skin around the stoma becomes irritated or infected) affect one-third of colostomy patients and two-thirds of urostomy and ileostomy patients (Williams, 2012). This complication can drive up care costs substantially. One study found a higher likelihood of readmission and healthcare costs that were approximately $80,000 USD higher in patients with peristomal skin problems. NSWOCs have the expertise to identify peristomal skin problems early or prevent them entirely, avoiding higher care costs than necessary.
By adopting best practices for the treatment of diabetic leg and foot ulcers, Ontario could save $338 million, cutting care costs by 66%.
– Shannon, 2007
BENEFIT 3: BETTER OUTCOMES
Getting patients out of acute care faster frees up beds for new cases. Through specialized treatment approaches and prevention strategies, NSWOCs measurably reduce durations of hospital stays and facilitate patient access and flow.
FASTER HEALING, LESS PAIN
Wound, ostomy and continence challenges contribute to pain and discomfort. One study compared the treatment of chronic wounds by NSWOCs and general staff nurses in home care (Arnold & Weir, 1994). Substantially more wounds were healed (78.5%) when an NSWOC provided the care versus a general staff nurse (36.3%). Another compared outcomes in home care patients with surgical wounds, pressure ulcers, urinary incontinence, bowel incontinence and urinary tract infections (Bliss et al., 2013). Those assigned to NSWOCs had more severe conditions than patients assigned to other nurses but showed significant improvement in the number of pressure ulcers and surgical wounds and frequency of incontinence.
Incidence of incontinence is twice as high at home healthcare agencies without a specialized wound, ostomy and continence nurse.
– Westra et al, 2013
Another study (Westra, Bliss, Savik, Hou, & Borchert, 2013) calculated that home care agencies employing NSWOCs are more likely to see improvements in conditions including pressure ulcers (nearly twice as likely) urinary incontinence (40% more likely), lower extremity ulcers and surgical wounds (20% to 40%), and bowel incontinence (14%). It found specifically that the incidence of incontinence in home healthcare agencies with no NSWOC is twice that of those with an NSWOC.
Agencies employing an NSWOC were also more likely to see conditions stabilized, including urinary incontinence (2.3 times more likely), surgical wounds (50%), pressure ulcers (30%), urinary tract infections (20%) and bowel incontinence (16%).
NSWOCs also contribute to better patient outcomes by reducing pain associated with certain conditions. For example, patients with superficial infections or infected chronic leg ulcers experienced significant reductions in pain by taking part in NSWOC-directed leg-functioning conditioning activities (Kelechi, Mueller, Spencer, Rinard, & Loftis, 2014).
NSWOCs Across the Continuum of Care
NSWOCS IN ACUTE CARE
THREE SPECIALTIES IN ONE NURSE
The advantage of NSWOCs’ tri-specialization is especially clear when patients frequently have needs that require more than one area of specialty. Some patients have needs in two areas—or all three, which was the case with one patient treated at a hospital in Toronto. The patient needed abdominoperineal resection (APR) surgery. Outcomes of that surgery included wound complications, continence challenges and a permanent colostomy.
The NSWOC on the care team was able to deliver high-quality, evidence-based care for the patient’s wound, ostomy and continence needs. The NSWOC was involved from the beginning, including in stoma marking and preoperative patient and family education. Care continued after the operation, with the NSWOC monitoring and attending to this patient’s complex needs even post-discharge. Thanks to a tri-specialty in wound, ostomy and continence, the nurse had the knowledge needed to provide optimal care to this patient.
Key Resources & Downloadable Files
Power of 3 Webinar
Identify key challenges patients face accessing specialized wound, ostomy and continence care, and identify the unique ways NSWOCs contribute to strong patient outcomes.
Provide information to support NSWOCs in communicating their essential role in specialized wound, ostomy and continence care from the bedside to administrators to government.
Discuss a clear expression of value that defines the NSWOC profession, its purpose and the unique contribution NSWOCs make to the Canadian Healthcare system.
Review the “Power of 3” communication tools that can support positioning NSWOCs for value.