ostomy care enterostomal therapy nursing in the ... - nswoc.ca · mountain house, alberta, canada...

Copyright © 2010 by the Wound, Ostomy and Continence Nurses Society J WOCN ■ January/February 2010 53

OSTOMY CARE

Enterostomal Therapy Nursing in the Canadian Home Care SectorWhat Is Its Value?

Linda Baich � Donna Wilson � Greta G. Cummings

Approximately one-third of all home care patients have woundcare needs. Home care patients tend to be older and have multiple chronic diseases rendering them at risk for developingwounds and impairing their ability to heal wounds.Enterostomal therapy (ET) nurses have expertise in wound, ostomy, and continence care, and were recently recognized bythe Canadian Nurses Association as a specialty practice. Wecompleted a systematic review in order to identify and synthe-size evidence about the value of ET nurses in the Canadianhome care sector, focusing on wound care. A literature searchwas conducted, using 9 computerized library databases. Eightarticles were identified for review; each was analyzed usingqualitative content analysis. Two themes emerged from ouranalysis: (1) assessing the outcomes of ET nurse involvement inclient care and (2) methods for using ET nurses’ expertise.Within these themes, the benefits of ET nurses working inhome care were identified: (1) a decreased number of visits, (2) reduced wound-healing times, (3) successful healing, (4) reduced cost of wound care, (5) greater support for nursesand families, (6) fewer emergency department visits, (7) fewerhospital readmissions, (8) increased interest in education inwound care among other nurses, and (9) standardized protocols for wound care. Although only 8 studies were locatedfor this review, their findings provide evidence that ET nurses’contributions to wound care are not only positive but also necessary in the home care sector.

■ Introduction

Home care nurses are generalists who care for patientswith a wide range of disorders.1,2 Patient assignments aretypically distributed over a geographical area,1,2 requiringthem to travel to homes within their assigned region. Inthe Canadian healthcare system, a home care nurse pro-vides care for as many as 70 or more patients at a giventime, depending on the need and complexity of each case.Registered nurses often provide case management, whichincludes organizing services for patients via referrals to avariety of professionals and nonprofessionals such ashealthcare aides or homemakers.

The demand for home care nursing has increased in re-cent years, partly because of fiscal restraints on the health-care system imposed in the 1990s.3 In the province ofAlberta, the number of home care patients doubled be-tween 1991 and 2001.4 Technological advances and thewish to be at home have also influenced care, resulting inshorter hospital stays and shifting diagnostic tests andtreatments to an outpatient basis.5 Early hospital dis-charge, and an increase in the number of frail-elders livingat home, has contributed to the increased growing popu-lation of high-acuity home care patients.3

The prevalence of chronic disease is increasing as a re-sult of multiple factors such as advanced age, obesity, long-term exposure to environmental toxins, and the availabilityof treatments that save lives but do not cure the underlyingillness.6 Chronic disease and aging increase the risk of de-veloping wounds and impair the wound-healing process.7

The majority of patients with established wounds are nowtreated in their home rather than in hospital.8 This standardof management differs from earlier care delivery patternswhen only one-third of all wound care patients were re-ceiving wound care through a home care program.2,9-11

Advances in wound care knowledge and technologieshave resulted in an escalation in the number of availablewound care products, including many that have very spe-cific indications for use. In the Canadian healthcare sys-tem, generalist home care nurses do not have the advancedtraining needed to manage complicated wounds. Instead,we advocate that ET nurses should be required to provide

J Wound Ostomy Continence Nurs. 2010;37(1):53-64.Published by Lippincott Williams & Wilkins

� Linda Baich, MN, RN, Instructor, Red Deer College, Red Deer,Alberta, Canada.� Donna Wilson, PhD, RN, Professor & Caritas Nurse Scientist, Facultyof Nursing, University of Alberta, Edmonton, Alberta, Canada.� Greta G. Cummings, PhD, RN, Associate Professor, Faculty ofNursing, University of Alberta, Edmonton, Alberta, Canada.Corresponding author: Linda Baich, MN, RN, 5312-38 St, RockyMountain House, Alberta, Canada AB T4T 1V5 ([email protected]).Editor’s Note: As noted by the authors, the Canadian NursesAssociation has recently recognized wound, ostomy and continencenursing as a specialty nursing practice. In Canada, the official designa-tion is ET Nurse. That designation has been preserved in this article.

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54 Baich et al J WOCN ■ January/February 2010

this level of care. Nevertheless, we also recognize that thecare offered by ET nurses is costly when compared to thatby nursing aides or licensed practical nurses, especially inthe home care sector. In addition, ET home care nurses arerare in the Canadian healthcare system, so determiningtheir value in the home care sector is important. In orderto evaluate the accumulated evidence on the value of ETnursing in the Canadian home care sector, we conducted asystematic review of published, peer-reviewed research lit-erature focusing on ET nursing care of wounds.

■ Operational Definitions

ET NurseIn the Canadian healthcare system, ET nurse is the termused for baccalaureate-prepared registered nurses whohave also completed a postgraduate program from arecognized ET nurse education provider. This preparationresults in a specialized body of knowledge in wound,ostomy, and continence management. Certification for ETnurses has recently been approved by the Canadian NursesAssociation, using the designation of CETN(C). In theUnited States, this specialty practice is called WOCnursing.12

Canadian Home Care SectorThe home care sector is the setting in which nursing ser-vices are delivered to patients who are neither in hospitalnor living in a continuing care facility. Homes include pri-vate dwellings where the patient lives alone or with otherssuch as family members or caregivers. In 2007, theCanadian Home Care Association defined home care as“array of services, provided in the home and communitysetting, that encompass health promotion and teaching,curative intervention, end-of-life care, rehabilitation, sup-port and maintenance, social adaptation and integration,and support for the informal (family) caregiver.”13(p1)

Home care programs integrate the delivery of healthcareservices in the home setting with community services suchas meals on wheels, day programs, respite care facilities,volunteer services, and transportation services.

Value of ET NursingWe defined the value of ET nursing as the positive or nega-tive outcomes of ET nursing in the home care sector ascompared to services provided by a generalist home carenurse. This value may include direct cost increases or sav-ings, quality of life for the patients, provision of educationfor healthcare providers and patients, changes in healthpolicy, improved self-care, or improved case managementfor the patients.

Methods

The following question guided the review and search strat-egy for this systematic review: “What is the value of ET

nursing in the home care sector?” The search strategybegan with a search of 9 computerized library databases(CINAHL, MEDLINE, Health Source, Global Health,PubMed, AgeLine, Cochrane, Web of Science, and Scopus).All indexed years in each electronic database weresearched. Librarians at the University of Alberta assisted inselecting and searching these databases. Gray and col-leagues explained that “databases search the available ar-ticles or entries based on specific words or phrases, calledkey words.”14(p54) The key words/terms included enteros-tomy, nursing, home care services, wounds, and pressure ulcers.The search identified 313,650 articles that contained oneor more of these terms. Combining these individual termswithin a search resulted in 49 articles, only 4 of which metthe inclusion criteria for review after a reading of the ab-stracts and, in some cases, the full articles. The referencelists from these 4 articles, as well as other peer-reviewedstudies and gray literature, were hand searched to discoverarticles that the library database searches did not display.Key author searches added more articles for consideration.An additional 67 potential full-text articles were thus iden-tified, retrieved, and screened, yielding 2 more researchstudies. A search through Google produced 1 more re-search article for review, and a review of the CanadianAssociation for Enterostomal Therapy Web site located a2007 Ontario study now published in the Journal ofWound, Ostomy and Continence Nursing.15 The completesearch resulted in a total of 8 reviewable studies. A sum-mary of this search is presented in Table 1.

Inclusion criteria were as follows: (1) the article is a re-port of a research study, (2) the study had an entire or par-tial focus on the value of ET nursing, (3) it focused onwound care, and (4) the care took place within the homecare sector. The Quality Assessment and Validity Tool forcorrelational studies was chosen to rate the validity of thedesign of each study (Figure 1). This tool was adaptedfrom an instrument that Estabrooks and associates16 ini-tially developed and Cummings and Estabrooks17 subse-quently adapted. The answers to 13 questions on researchdesign, sampling, measurement, and statistical analysiswere scored, and each study received a score of high,medium, or low. Table 2 summarizes the ratings of the 8 studies.

Data elements were extracted from each study and or-ganized in Table 3, in part to facilitate ease of analysis, andthe articles were then analyzed using a standard contentanalysis method in order to identify central themes in thearticles.18 Findings were categorized into 9 mutually ex-clusive categories. Categories are groups of content fromthe text that represent similar meanings,19,20 and themesare the thread of underlying meaning throughout the con-tent of the text or categories; they are not mutually exclu-sive.19 Table 4 shows the frequencies of categories oroutcomes. Webb21 recommended this method, which isused for qualitative research content analysis, to examinefindings to identify key information, group information

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into categories, and link them into themes. Contentanalysis is a way to structure a large amount of data into amanageable form.18 Because only 8 articles were identifiedas potentially relevant for review, all 8 were reviewed, al-though not all fulfilled every research quality criterion forinclusion.

Findings

Five of the 8 studies were conducted in the United Statesand 3 in Canada. Two of the 8 studies22,23 combined quan-titative and qualitative research methods to compare out-comes of the implementation of technological devices

TABLE 1.

Literature Search: Electronic Databases

Database (All Years) Search Terms Combined With And Number of Abstracts

CINAHL Enterostomy 1,428NursingHome care servicesWounds and pressure ulcers

MEDLINE Enterostomy 310,415NursingHome care servicesWounds and pressure ulcers

Health Source: Nursing Academic Edition Enterostomy 1091NursingHome care servicesWounds and pressure ulcers

Global Health Enterostomy 0NursingHome care servicesWounds and pressure ulcers

PubMed Enterostomy 534NursingHome care servicesWounds and pressure ulcers

AgeLine Enterostomy 0NursingHome care servicesWounds and pressure ulcers

Cochrane Enterostomy 1NursingHome care servicesWounds and pressure ulcers

Web of Science Enterostomy 20NursingHome care servicesWounds and pressure ulcers

Scopus Enterostomy 160NursingHome care servicesWounds and pressure ulcers

Google Home care services 1Wounds care

Manual search References from key articles and author searches, Web sites 67Total: Titles and abstracts 313,717First selection of articles for screening 1944Second selection 116Final selection of included articles 8

WON200104.qxp 1/5/10 8:42 AM Page 55


among home care nurses, health support aides, and ETnurses. The other 6 studies were quantitative research viaretrospective chart studies that included a cost analysis, acomparative method using charts before and after the in-tervention of ET nurses, and a prospective managementstudy. Three of the studies incorporated small samples (N � 35, N � 30, and N � 21).10,21,24 The other 5 studies hadlarger sample sizes, ranging from 100 to 767.15,23,25-27

At least 2 people should select articles for inclusion toensure that a systematic review can be replicated14,28 andappropriate articles are not missed.29 Because this recom-mendation was not implemented (only the primaryauthor chose literature for inclusion), our study is open tobias. However, the second author reviewed the articles andthe analysis and synthesis of the findings to reducepotential bias.

From the findings of these 8 studies, 2 themes wereidentified that reflected the progression of this body ofresearch literature. The 3 earlier studies10,24,26 assessed theoutcomes of involving an ET nurse in patient care. Theyincluded the following categories: (1) decreased number ofvisits, (2) decreased healing times, (3) successful healing,and (4) decreased cost of wound care that comprisedtheme 1. The 5 later studies,15,21,23,25,27 which comprisedtheme 2, examined the influence of ET nurse expertisewithin a team, workgroup, or unit. The second themeincluded the same 4 categories as theme 1, along withadditional 5 categories: (1) support for nurses and families,

ET Nursing in the Canadian Home Care Sector: What Is its value?Quality Assessment and Validity Tool for Correlational Studies

Study:__________________________________ First Author:____________________________Publication Information: Date:_______________ Journal: _____________________________

Design: NO YES1. Was the study prospective? 0 12. Was probability sampling used? 0 1

Sample:1. Was sample size justified? 0 12. Was sample drawn from more than one site? 0 13. Was anonymity protected? 0 14. Response rate more than 60% 0 1

Measurement:1. Are the outcomes of ET nursing measured accurately? 0 12. Was a valid instrument used for measurement? 0 13. Are the effects of ET nursing observed rather than self-reported? 0 24. If a scale was used for measuring effects, is internal consistency �0.70? 0 15. Was a theoretical model/framework used for guidance? 0 1

Statistical Analysis:1. If multiple effects studied, are correlations analyzed? 0 12. Are outliers managed? 0 1

Overall Study Validity Rating (circle one) TOTAL:____(key: 0–4 � LO; 5–9 � MED; 10–14 � HI) LO MED HI

FIGURE 1. Quality Assessment and Validity Tool for correlational studies. Adapted fromCummings and Estabrooks.17

TABLE 2.

Summary of Quality Assessments: 8 Studies

Number of Studies

Criteria No Yes

DesignProspective studies 3 5Used probability sampling 7 1

SampleAppropriate/justified sample size 3 5Sample drawn from more than 1 site 5 3Anonymity protected 0 8Response rate �60% 1 7

MeasurementReliable measures of ET nursing 0 8

outcomesValid measures of ET outcomes 1 7Effects/outcomes observed rather 0 16

than self-reporteda

Internal consistency �0.70 7 1Theoretical model/framework used 6 2

Statistical analysesCorrelations analyzed when 5 3

multiple effects studiedManagement of outliers addressed 7 1

aThis item scored 2 points. All others scored 1 point.

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J WOCN ■ Volume 37/Number 1 Baich et al 57TA

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J WOCN ■ Volume 37/Number 1 Baich et al 59TA

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WON200104.qxp 1/5/10 8:42 AM Page 60


(2) fewer emergency room visits, (3) fewer hospital read-missions, (4) increased interest in education in wound careby nurses, and (5) standardized protocols for wound care(Table 4). A discussion of each of the 2 themes and these 9categories follows.

■ Assessing Outcomes of ET NurseInvolvement in Patient Care

Three quantitative research articles focused on the positiveoutcomes associated with ET nurses’ practice in the homecare sector.10,24,26 Arnold and Weir26 were the first to com-pare the time of healing plus the number of nursing visitsbetween WOC and non-WOC nurses working in 5 homecare agencies in southern Florida. A retrospective review of519 patient charts was conducted; WOC nurses cared for275 of the patients, and non-WOC nurses cared for 244 pa-tients. The WOC nurses achieved a 78.5% healing rate,with an average of 31.6 visits per patient, whereas the non-WOC nurses’ healing rate was 36.6%, with an average of 17visits per patient.

O’Brien and coworkers24 compared the cost of healing21 home care patients’ pressure ulcers with the projectedcost of hospital stays to heal the wounds. Their mean agewas 74.6 years. Twenty-one patients with stage III pressureulcers were discharged from 2 hospitals in Philadelphia totheir homes, where they received care from their familiesand a WOC nurse. The risk factors for this group includedcardiac disease, hypertension, end-stage renal disease,smoking, diabetes, chronic brain syndrome, cerebrovascu-lar accident, and above-the-knee amputations. Nineteenout of 21 ulcers healed over a period of 6 to 32 weeks. Thecost of home care averaged $200 per day, whereas the costof 1 day in hospital was projected to be $900 (US). The re-searchers further noted that 2 patients whose ulcers didnot heal had no family support.

Bedell and coinvestigators10 used a retrospective chartreview to study outcomes of 15 patients cared for by WOCnurses. These outcomes were compared with those of 15 pa-tients who had not had WOC nursing. They found an av-erage cost saving of $1,697 (US) per case when a WOC nursewas involved in wound care. The study occurred in a largenonprofit home care agency in New York. When hydrocol-loid rather than gauze dressings were used, the number ofvisits was reduced from daily to twice weekly, and the rateof healing increased. The reduced number of visits andfaster rates of healing were responsible for the decreasedcost of wound care. Bedell’s group10 credited these savingsto the knowledge and care-management skills of the WOCnurses. This study is included in both themes as the secondphase examined the utilization of WOC nurses’ expertise.

■ Utilization of ET Nurse Expertise

Six studies used quantitative data and data analysis meth-ods to explore the enhancement of services via ET nurses.

In the second phase of their study, Bedell and coinvestiga-tors10 examined cost savings achieved by a wound careteam led by a WOC nurse. Team members were nurses whowere interested in and had completed a 14-hour course onwound care, participated in monthly wound care teammeetings, and then conducted joint visits with other mem-bers of the team, in consultation with the WOC nurse. Thecompetence of team members was evaluated using a skilllaboratory several months after the team was formed, andthe charts of 30 cases in which the wound care team hadprovided care were reviewed 1 year after the team forma-tion. Patients managed by the wound care team of WOCnurse had an average savings of $353 (US) per case. Earlyintervention by the WOC nurse or the wound care teamalso yielded better clinical outcomes, including a reducednumber of visits, faster healing rates, fewer hospital read-missions, fewer emergency room visits, and improved pa-tient care. Due to the wound team’s success in improvingpatient outcomes, 10 nurses achieved their WOC nurse cer-tification and others aspired to further education.

In a quantitative study that involved a WOC nursewho consulted with remote caregivers via telemedicineand online software, Bolton and associates25 chose pa-tients with a total of 767 wounds from 3 long-term care fa-cilities, 1 long-term acute care hospital, and 12 home careagencies. The WOC nurse guided wound care treatmentthat was delivered by home care professionals. They alsoentered patient data on software containing standardizedprotocols for wound care. Their results validated the stan-dardized protocols of the software program and revealedthat WOC nursing decreased wound-healing times.Multiple factors were attributed to faster healing and re-duced number of visits. Early intervention prevented thedevelopment of full-thickness wounds, and the WOCnurse enabled remote caregivers to provide more consis-tent wound assessments and care. The use of a WOC nurseincreased the likelihood that moist wound-healing tech-niques (rather than gauze dressings) were used, resultingin faster healing and fewer visits. The use of hydrocolloiddressings and standardized protocols resulted in an esti-mated savings of $969 (US) for every pressure ulcer and$766 (US) for every venous ulcer compared to the cost ofusing gauze dressings.

Harrison and colleagues,27 Canadian-based studyshowed that nurses with increased education in woundcare improved the outcomes for people in home care withleg ulcers. They conducted their quantitative study in anurban-rural setting of Ontario with a population of ap-proximately 1 million. After completing a needs assess-ment, they estimated the prevalence of leg ulcers in thisregion at 1.8 cases per 1,000 population. A new servicemodel was developed that centralized service for leg ulcersin one office. After investing in a 1-year in-depth educa-tion program from Thames Valley University in theUnited Kingdom, these nurses partnered with nurses whohad received an extensive orientation to leg assessment.

WON200104.qxp 1/5/10 8:42 AM Page 61


The additional education and partnering increased theexpertise of staff at this site. In addition, the need forindividual wound care orders from family doctors waseliminated when a care protocol was adopted. Harrison’sgroup27 compared 108 patients who received care that fol-lowed the new protocol to a group of 78 patients who re-ceived care according to the previous organizationalstructure based on individual orders from family doctors.They found that the median cost of treating patients withleg ulcers decreased from of $1,923 (Cdn) to $406 (Cdn)with the new protocol. The average number of visits topatient homes each week decreased from 3 to 2.1, and theaverage total number of visits needed for healing droppedfrom 37 to 25. Although these nurses were not certified ETnurses, this study was included because it showed thatnurse education on wound care, similar to that providedto ET nurses, improves outcomes.

Semotiuk23 piloted a Web-based software program toextend the services of 2 ET nurses working in home care inthe Capital Health Region of Alberta. Before the use of thisprogram, the ET nurses were able to see only 4 or 5 patientsdaily because of the complexity of the cases and travel timebetween patients. Home care nurses were taught to use dig-ital cameras and the Pixalere software program (WebMedTechnology Inc, British Columbia, Canada) before thepilot study began. During the pilot study, 100 patients re-ceived wound care services from the home care nurses thatincluded standardized assessments using the software.Home care nurses sent a digital picture of the wound to theET nurse or specialist physician for consultation. Patients,staff nurses, ET nurses, and the physician specialist weresurveyed to assess their satisfaction with the quality of thedigital images and communication with the use of the soft-ware. The results show a high level of satisfaction amongpatients with the care received and among generalist homecare nurses with regard to easy access to the ET nurse spe-cialists. The ET nurses favored the system because theywere able to increase the number of consultations to an av-erage of 10 patients per day and reduce the number of con-sultations with the physician. ET nursing services weresubsequently increased more than twice as much as beforethe pilot, and travel time was decreased by 25%. A cost-sav-ings analysis was not completed.

Litzinger and coworkers22 explored using WOC nursesmore efficiently through video teleconferencing forwound care evaluation and consultation in the treatmentof wounds. The study was set in rural Pennsylvania. Nursesand home health aides completed 270 visits to 35 patientsover a 2-year period using portable video teleconferencingequipment, which enabled transmission from the home tothe WOC nurse at a remote location. Use of this technol-ogy reduced the number of visits and travel expenses ofthe WOC nurses. The WOC nurses were able to see morepatients, ensure continuity of care through consultations,and support the staff in their patients’ homes. Litzinger’sgroup reported that the WOC nurses’ care reduced healing

times and saved $25,208 (US) in time and travel expensescompared to the average cost of $45,500 (US).

Harris and Shannon15 conducted a retrospective auditof 496 patient charts in a wound clinic in Toronto in orderto compare the cost of care between ET nurses who pro-vided care and a team of nurses with partial ET nursing in-volvement. Healing times and costs were comparedaccording to wound type, which included diabetic foot ul-cers, venous stasis ulcers, stages II and III pressure ulcers,surgical wounds, and other diabetic wounds. Each categoryof wound consistently illustrated a considerable decrease incost with ET nurse care compared to the team of RNs andLPNs who provided occasional ET nursing care. Harris andShannon15 used the prevalence of each type of wound inOntario to extrapolate a projected savings of $2.4 billion(Cdn) with ET nurse settings, which means that the resultscan be considered persuasive.30 Two studies used bothquantitative and qualitative research methods. Tobin andBegley31 recommended that mixed methods be used in fu-ture research to maximize the advantages of both methods.

It is unknown why researchers in countries other thanthe United States and Canada have not conducted re-search on this topic. The prominence of studies from theUnited States may be related to the fact that WOC nursingoriginated there and that country has a longer history ofthese specialists’ contributions to the care of wounds. It isalso possible that the emphasis on costs and cost contain-ment in the US health system will continue to ensure thatstudies to reduce healthcare costs are undertaken there.Finally, although other studies may have been conducted,the key words used may not have identified them becauseof variations in international terminology.

Technical AnalysisTheme 1 assessed patient outcomes when receiving ETnursing care. We identified 3 studies that provided evi-dence that the use of ET nurses reduced overall costs be-cause of their expert wound care in the home caresetting.10,24,26 These findings are congruent with the resultsof other studies that assessed the value of ET nurseswithin the hospital setting.32,33 Six studies10,15,22,23,25,27

showed cost savings as a result of a decreased,10,22,24 num-ber of nursing visits to patients. This reduction was linkedto the use of occlusive rather than gauze dressings.Capasso34 compared the cost and efficacy of hydrocolloiddressings to those of wet-to-dry saline dressings and alsoconcluded hydrocolloid dressings are more cost-efficient.Nevertheless, additional studies are needed to verifywhether the expertise of ET nurses in home care can re-sult in improved healing.

Both Bedell and colleagues10 and Bolton’s group25 re-ported that early intervention with high-quality dressingsupplies resulted in faster healing and higher healing rates.The study by Bolton and coworkers25 serves as a benchmarkfor healing outcomes for pressure and venous ulcers, whichtended to heal within a 12-week time frame. This important

WON200104.qxp 1/5/10 8:42 AM Page 62


finding needs to be explored to determine the influence ofET nursing on healing time in the home care setting.

Our second theme10,22,24 was the use of specialized ETnurse expertise. Three studies10,23,27 involved ET nurses whoestablished teams to provide care to patients with wounds.With the guidance of the ET nurses, home care nurses in-creased their knowledge of and interest in wound care, re-sulting in fewer emergency room visits and readmissions.Further research is required to examine how ET nurses canbest educate and support other home care nurses and stim-ulate the commitment of generalist home care nurses toproviding quality wound care. The role of ET nurses inmentoring and role modeling also needs to be explored.

Bolton and coworkers,25 Litzinger and colleagues,22 andSemotiuk23 investigated the use of technology (telemedi-cine, videoconferencing, and Web-based software) whenproviding direct ET nursing services. Each of the tech-nologies was shown to increase the ability of ET nurses toprovide care to more patients within a given period oftime. Technology is opening new options for health de-livery, and the need for research on how to best use thisavenue for ET nursing in the home care sector is apparent.Bolton and coworkers25 demonstrated that application ofresearch-based evidence in providing wound care reduceswound-healing time and the number of visits required forhealing. More research is needed to determine effectivemethods for applying current best evidence to woundmanagement in the home care setting.

O’Brien’s group24 reported that 2 of 21 participantswith pressure ulcers who did not heal lacked family orfriends to support their care. Additional research is neededto discover the role of family and friends in wound careand to determine how an ET nurse can best support indi-viduals who live alone.

■ Conclusion

The available literature on the value of ET nursing in thehome care sector reveals that the presence of an ET nurseimproves healing times, wound closure rates, and associ-ated costs. Other benefits of ET nursing include feweremergency room visits by home care patients with woundsand fewer readmissions to hospital. When ET nurses sup-port generalist home care nurses, they increase the homecare nurses’ knowledge, confidence, and interest in fur-thering their education in wound care. Although existingevidence is limited, our reviews strongly suggest that useof ET nurses is beneficial to wound management in thehome care sector in Canada.

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3. Hollander M, Chappell N. Synthesis Report: Final Report of theNational Evaluation of the Cost-effectiveness of Home Care.Victoria, British Columbia, Canada: National Evaluation of theCost-Effectiveness of Home Care; 2002.

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34. Capasso V. The cost and efficacy of two wound treatments: ef-fectiveness of saline and hydrogel dressings. AORN J.2003;77:984, 986, 988-992.

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