Managing Pressure Injuries in Home Health Care

Chronic pressure injuries present a significant challenge in the home health care setting. Despite the use of standard wound care practices such as offloading and pressure distribution, these wounds may take a long time to heal and patients and their families often give up hope. Moreover, there is a dearth of evidence-based practice specific to this setting, so providers must rely on trial and error, underscoring the need for sharing best practices and disseminating knowledge in this area.

To make matters worse, many pressure injuries are located on the sacrum and can be complicated by undermining. Undermining is caused by erosion of the subcutaneous tissue under the edges of the wound and results in large and often deep wounds with a small opening. Pressure injuries are caused by unrelieved pressure that may decrease blood flow to the affected area; without proper treatment, these injuries can lead to tissue ischemia and necrosis.¹ Complicated undermining, lack of blood flow, and low quality of life demand solutions to get these wounds to close. 

One particularly useful product is Endoform (Hollister Incorporated, Libertyville, IL) dermal template. Endoform dermal template is a collagen dressing with an intact extracellular matrix (ECM).² When placed in a clean wound where the patient’s ECM is damaged or missing, Endoform dermal template provides a temporary ECM scaffold the patient’s body can use to help grow new tissue.^3,4 In addition, the product can help provide broad-spectrum matrix metalloproteinase reduction,⁵ useful for chronic wounds in which elevated protease levels may slow healing progress.⁶ Another major benefit of Endoform dermal template is that it incorporates into the wound, eliminating the need for removal and potential disturbance to the wound bed. Lastly, this advanced product is accessible and affordable in the home health care setting because it is reimbursable by Medicare as a collagen dressing.⁷

Overall, for the treatment of undermining, I am consistently finding that this collagen ECM dressing facilitates progress toward closure of wounds patients had given up on. This case is representative of a patient with pressure injuries admitted to my practice. 

A 73-year-old woman was referred by her primary care physician for the management of nonhealing sacral and bilateral ischial pressure injuries with significant undermining. The patient had experienced cardiopulmonary arrest 5 months previous and had since been in a vegetative state and was ventilator dependent. A sacral wound present for 5 months had significant undermining (see Figure 1) and multiple wound areas. 

Following initial assessment and cleansing, my first approach was to get the wounds clean. An antimicrobial ointment was applied to the devitalized tissue according to product instructions for use to promote autolytic debridement. Once the wounds were clean, Endoform dermal template was applied to act as a temporary scaffold. Cover dressings included Hydrofera Blue READY^™ antimicrobial foam dressing and Restore foam dressing (both from Hollister Incorporated). The wound was assessed twice weekly, and the home health nurse and the patient’s daughter were educated on the prevention of further skin breakdown, advanced wound care products, nutrition, monitoring for signs/symptoms of infection, and proper incontinence care. 

After 5 months of care using the advanced wound care products, wound size decreased and signs of healing were evident (see Figure 2). At 6 months, the wound continued to improve dramatically and was resolved 7 months from admission (see Figure 3). The family expressed its gratitude for the resolution of the wound.

In my experience, Endoform dermal template successfully supports the healing of pressure injuries and improves patient and caregiver satisfaction in the home health care setting. The product makes my job easier and makes patient care more efficient; I now use this product for all my pressure injury cases. 

Dr. Gonzalez is a wound care specialist, MedSource Consultants Miami, FL; and Clinical Assistant Professor, Undergraduate Nursing Department, Nicole Wertheim College of Nursing and Health Sciences, Florida International University, Miami, FL.

Wound Care in the First Person is made possible through the support of Hollister Inc, Libertyville, IL (www.hollister.com). The opinions and statements of the clinicians providing Wound Care in the First Person are specific to the respective authors and not necessarily those of Hollister Inc, OWM, or HMP. This article was not subject to the Ostomy Wound Management peer-review process.