When a resident in a skilled nursing facility develops a wound, an abscess or a dislodged feeding tube, the first instinct is often to send them to the hospital. In many cases, that trip isn’t necessary.
A wound care provider visiting the facility can handle a wide range of procedures right at the bedside, saving the patient an uncomfortable transfer and saving staff a great deal of time.
That said, not everything can or should be done at the bedside. This post walks through the procedures Crescent Wound Care providers can perform in a facility, the factors that determine whether a procedure is safe to do on-site, and when a hospital is the better choice.
Common Bedside Procedures
The list below isn’t exhaustive, but it covers most of what comes up in a skilled nursing setting:
- Debridement
- Biopsies
- Cauterization
- Incision and drainage
- Excisions
- Suturing
- Feeding tube (G-tube) replacement
- Injections
- Skin substitutes
Debridement is by far the most common. Feeding tubes are a close second in terms of how often facility staff ask about them. G-tubes fall out, clog, twist and get damaged all the time, and Crescent physicians are comfortable replacing them. Many carry spare feeding tubes with them so the problem can be fixed during the same visit rather than a week later.
The First Question: Should It Be Done at the Bedside?
Before any procedure, the real question is whether it belongs in the facility at all.
Consider a large lesion on a patient’s face, sitting right over the eyelid. If the same lesion were on the calf or buttock, it would be straightforward to manage on-site. On the face, next to the eye, it is a different situation entirely, and that patient belongs in a hospital.
There can sometimes be an expectation that any procedure can be done in the facility. There’s a well-known story of a facility getting frustrated with a surgeon who wouldn’t perform an amputation on-site: “You’re a surgeon, aren’t you? Why don’t you just do it?” A below-the-knee amputation simply can’t be done at the bedside. That may seem obvious, but it isn’t always obvious to everyone.
There is a line between what can be safely handled in the facility and what can’t, but it isn’t a hard rule like “anything under seven centimeters is fine.”
It depends on the setting, what the patient can tolerate, and what both the physician and the facility are comfortable with. Sometimes a provider is willing to proceed and the facility prefers to send the patient to the hospital, and that is a perfectly reasonable decision. These are the main factors that shape that decision.
Consent
Consent is always required. Many residents in skilled nursing facilities have dementia and can’t consent for themselves. Even when a procedure is clearly needed, it can’t legally be performed without consent, so a power of attorney or family member needs to be involved.
In a hospital, when something is truly emergent and the patient can’t consent, two physicians can sign off that the intervention is necessary. In a facility, a second physician usually isn’t available, so in those cases the patient has to be sent to the hospital.
Equipment, Lighting and Supplies
This one is easy to overlook. An operating room has several powerful overhead lights and staff to position them. A patient’s bedside doesn’t. A good headlamp makes a huge difference, but if the provider can’t clearly see what they’re working on, that alone is a reason not to proceed.
Size and Location
The face, scalp and other sensitive areas are very different from the upper back or buttocks. A scalp cyst that has grown to around 12 centimeters, for example, may be completely benign, but the scalp bleeds heavily and a lesion that size can’t be safely removed outside an operating room. At one or two centimeters, it would have been a simple procedure. This is a good reminder to address lesions early, while they’re still small.
Pain Control
Most Crescent physicians carry benzocaine spray and lidocaine. The spray works well for small debridements, while lidocaine injections provide better anesthesia for excisions or drainage.
Even so, some patients can’t tolerate a procedure. Pain is very personal. Some patients have issues with pain medication, some can’t tolerate even the injection, and some simply refuse because they’re afraid it will hurt.
It helps to remember that necrotic tissue is non-viable, and non-viable tissue has no sensation. That is the whole point of debridement. Most of the time it is very well tolerated, although patients may feel it if the provider reaches healthy tissue. Providers will often check with staff on whether a patient is likely to tolerate a procedure. If a patient is asking for pain medication every 15 minutes, a non-urgent debridement can wait while another approach is found.
Bleeding
Not long ago, patients on blood thinners were relatively uncommon, and many of today’s medications, such as Eliquis and Plavix, didn’t exist. Now, in a skilled nursing setting, it is more unusual to see a resident who isn’t on one.
This means minor bleeding that would be trivial for most people can be hard to stop. For small procedures like incision and drainage or debridement, it is very unlikely to be life-threatening, but it is messy, it worries patients, and most importantly, it makes it hard to see. Tissue can’t be safely removed if blood keeps filling the field.
Anatomy matters too. The scalp and face bleed heavily. The groin may look easy to work in, but the femoral vessels sit just below the surface, even in patients with obesity.
At the bedside, the options for controlling bleeding are limited:
- Packing with gauze, which works well and is usually enough, even for patients on blood thinners
- Suturing, since most Crescent physicians carry suture material and instruments
- Cautery, using either silver nitrate or loop electrocautery (a heated probe, not the type of electrocautery used in an operating room). It is effective, but it can be very painful.
Debridement: The Foundation of Wound Care
Wounds often develop necrotic tissue and slough, as seen in pressure ulcers on the sacrum. Debridement removes this dead tissue and is the most common bedside procedure in wound care.
There are several types. Mechanical debridement can be as simple as using gauze to peel off dead tissue. Enzymatic or chemical debridement is another option. Santyl is the product most people think of, but Silvadene does the same job at half the cost or less and is a good alternative unless the patient is allergic.
Chemical debridement takes longer, though. It is applied and then checked the following week, and results can take weeks. The advantage of sharp debridement, using a scalpel or curette, is that the dead tissue is removed immediately.
At the bedside, a conservative approach is best. More tissue can always be removed later, but nothing can be put back.
The wound doesn’t need to be perfectly clean after one visit. The provider removes what can be safely removed, applies something like Silvadene, and returns the following week to do more. Within a couple of weeks, most wounds are very clean. Going too deep risks removing viable tissue, reaching nerve or muscle, or causing bleeding.
Debridement helps in two key ways:
- It restarts healing. A small amount of bleeding is actually a good thing. Blood brings collagen, fibroblasts, white blood cells and the inflammatory factors that drive healing. Wounds that have been stalled for months often begin responding once they’re debrided.
- It reduces bacterial burden. Dead tissue has no blood flow, so antibiotics can’t reach it and white blood cells can’t fight infection there. It becomes a reservoir for bacteria, and removing it lowers the risk of infection.
When patients notice their wound bleeding after debridement, it is often a reassuring sign. It means blood is reaching the wound, which is the first step toward healing.
Biopsies
Biopsies come up frequently, and one of the most common reasons is a persistent rash. A rash may be treated with one medication after another without improving. A wound care provider can take a small sample at the bedside and send it to the lab for a definitive answer.
Skin cancers are also common in this population, as many residents grew up before sunscreen was widely used. Getting an appointment with a dermatologist can take a long time, while most of these biopsies can be done at the bedside with local anesthetic.
There are two main types:
- Incisional biopsy: a piece of a large lesion or rash is taken to identify what it is
- Excisional biopsy: a small lesion, such as a half-centimeter spot that looks like a basal cell cancer, is removed entirely and still sent to the lab
Before any procedure, it is worth asking whether the result will change the patient’s care. If a 90-year-old patient has had a benign-looking spot for most of their life and wants it biopsied out of curiosity, it can still be done if they insist, but it’s worth discussing whether a procedure that won’t change their treatment is really worthwhile. A procedure should never be done just for the sake of doing it.
Cauterization
Cauterization is used far more often than many people expect, and it can be remarkably effective. Hypertrophic granulation tissue, an overgrowth of tissue in the wound bed, can keep a wound from closing for years. After treatment with silver nitrate, the excess tissue recedes and the skin can finally grow over it.
The two most common methods are:
- Chemical cautery with silver nitrate, commonly used for hypertrophic granulation tissue
- Thermal cautery with a loop cautery device, which can also remove skin tags and other very small benign lesions
Freezing is another option for small lesions, although most providers don’t carry that equipment to facilities.
A chronic diabetic foot ulcer stalled by hypertrophic granulation tissue is a classic example. When there are signs of healing around the edges, the wound is trying to heal and the excess tissue is getting in the way. A couple of silver nitrate treatments can get it moving again.
Incision and Drainage
Incision and drainage is needed more often than many people realize, and it is usually simple to perform at the bedside.
Abscesses are the most common reason. They can result from trauma, but bacteria can also enter the bloodstream through something as routine as brushing teeth or stubbing a toe. In immunocompromised patients, those bacteria can settle in the fat beneath the skin and form an abscess, sometimes with no obvious source.
Inclusion cysts are another frequent reason and come up regularly in skilled nursing residents. They are common on the back and in the groin. These cysts produce a waxy material, and when their opening (the small dark spot called the punctum) becomes blocked with skin, dirt or bacteria, the cyst becomes irritated, inflamed and sometimes infected.
Treatment is simple: the area is numbed, opened and drained. These cysts and abscesses are very tender, and patients almost always feel relief right away. The procedure may be uncomfortable, but patients are nearly always glad to have it done.
Hematomas are very common in patients on blood thinners. A resident bumps their shin, and it keeps bleeding under the skin. The skin stays intact, but the hematoma grows until the pressure causes the skin above it to die. These can look alarming and often lead to antibiotics and emergency room visits. In many cases, the necrotic skin can simply be removed (the patient can’t feel it because it is dead), the hematoma evacuated and the bleeding controlled. The patient is left with a wound that then needs to heal, but the immediate problem is resolved.
Thrombosed perianal veins, often called external hemorrhoids, are less common in this setting but can also be treated at the bedside. They are very painful and often appear after a hard bowel movement. The treatment is to open the area and remove the clot, and when it is done early, the pain resolves almost immediately.
Excisions
In a skilled nursing setting, excisions mostly involve skin lesions such as small basal cell cancers and inclusion cysts.
After an inclusion cyst is drained, its capsule remains and can fill up and become infected again. The standard approach is to let the area heal for a month or two, then remove the small nodule that remains, send it to the lab and close the site with a stitch. Many patients choose not to have this done, but it is a simple option.
Suturing
Accidents happen in any facility. A resident in a powered wheelchair might fall asleep, slump onto the joystick and drive into a wall, cutting their leg. Facilities often send these patients out, but when a Crescent provider is available, lacerations like this can be sutured on-site.
Facilities are encouraged to call their Crescent provider, even at an unusual time. If the provider is nearby, they can often stop by and take care of it, keeping the patient out of the emergency room for something that can be handled in the facility.
G-Tubes and Suprapubic Catheters
“Do you replace G-tubes?” is one of the most common questions facility staff ask. The answer is yes.
The key with G-tubes and suprapubic catheters is speed. They should be replaced within 24 hours, and sooner is better. The opening begins to close quickly, and once it does, the patient will need a procedure in interventional radiology or a GI lab.
If the tract is well formed, a new tube can simply be placed through the opening. A G-tube isn’t even strictly required. A Foley catheter works well to keep the tract open: it is inserted, the balloon is inflated to hold it in place, and the patient can be fed and flushed through it as before. That said, most Crescent physicians carry G-tubes.
Injections
Injections are less common in skilled nursing facilities, but they can help certain patients with chronic pain. For example, a well-known inguinal nerve injection is often very effective for groin pain when no hernia is found, or when pain persists after a hernia repair.
Injections may also be considered for trigger points or joint pain. Some Crescent physicians are comfortable performing them, depending on the problem, what the patient wants and how accessible the area is.
Skin Substitutes
Skin substitutes are a topic of their own and generate a lot of questions. Here are the basics.
New products come out constantly. Skin substitutes are appropriate for chronic wounds, which under Medicare and Medicaid criteria means a wound that hasn’t shown signs of healing for 30 days. The wound also needs to be clean and in an appropriate location, otherwise there is no benefit. The criteria are strict both medically and for billing purposes.
Crescent Wound Care has a dedicated team that regularly reviews patient lists to identify who meets the criteria, and providers then decide whether a skin substitute would help. Like wound VACs, Santyl or Hydrofera Blue, skin substitutes are very effective in the right situation but aren’t right for every wound. For patients who qualify, they are a valuable treatment that can be applied at the bedside.
Bringing Care to the Bedside
The goal is to bring as much care as safely possible to the bedside, so residents receive timely treatment without unnecessary trips to the hospital. If you have a question about a resident, a wound or whether a procedure can be handled in your facility, reach out to Crescent Wound Care.
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