INTRODUCTION

Canadian long-term care (LTC) facilities are expected to be a safe haven for our vulnerable aging population. However, in a 2010 report, titled "Quality Improvement Road Map to Restoring and Promoting Continence," by health Quality Ontario, it was noted that as many as 50% to 75% of LTC residents will suffer from some degree of incontinence, predisposing them to falls and pressure injuries. These statistics support the notion that Canada's LTC sector is in crisis and the wound, ostomy, and continence (WOC) needs of its residents are going unmet. Currently, in the province of Ontario, as much as 50% of health care services are allocated to wound management1 and according to a 2010 Health Quality Ontario report, titled "Quality Improvement Road Map to Restoring and Promoting Continence," urinary incontinence is one of the main reasons for LTC admission. Even though 92% of Ontario's LTC facilities stating that their focus would be decreasing the number of facility-acquired pressure injuries, there has only been a decrease of 0.4% in incidence rates in the 5 years since the commitment was made.2,3

The province of Ontario is home to 78,762 LTC beds among 630 facilities. From an economic standpoint, when the number of LTC beds is coupled with a new or worsening pressure injury incidence rate of 2.6% and an estimated cost of $70,000 per pressure injury according to the Canadian Patient Safety Institute in a 2016 report, titled "Hospital Harm Improvement Resource: Pressure Ulcer," the resultant potential cost to Ontario taxpayers is as high as Canadian dollar (Can$) 140 million annually. Skin tears are another wound etiology affecting residents of LTC facilities. Data were reported from a recent study that 20.8% of Ontario LTC residents will suffer from a skin tear for an estimated cost of Can$1million annually.4 It is widely believed, and noted in the Canadian Institute for Health Information's 2013 report on compromised wounds in Canada, that given the potentially rudimentary and flawed public reporting system for wounds, the prevalence and incidence of pressure injuries, for example, are likely much higher than reported to the Ministry of Health and LTC.

Wound care-related concerns are not the only financial burden realized in the LTC sector. Given the high prevalence of LTC residents suffering from incontinence (75%) and continence products cost as much as Can$2100 per resident per year according to the Canadian Continence Foundation, it is estimated that 59,000 Ontario LTC residents will require containment products at a potential cost of as much as Can$123 million annually. A reduction of just 5% of product costs would save as much as $6 million.

Adverse events relate to WOC conditions have been reported in the media such as the sad case of an elderly patient who passed away due to complications related to a pressure injury, which was seen in 2 June 2019 CBC and CTV News articles. This patient developed an infected pressure injury, which had gone unnoticed for a lengthy period of time. Reports of this case led to the publication of pressure injury data in the media, such as the CTV News article published in 2020, titled "Man 'Rotting Alive' from Bedsore Dies of Infection," which included discussion of the high incidence of pressure injuries in LTC residents. Despite a public outcry in the media, we assert that little has changed since that time within Ontario in the way of WOC management in LTC.

The COVID-19 pandemic has shed a light on the Ontario LTC sector. Canadian military were deployed to the Ontario LTC facilities to provide staffing support and relief. An unexpected by-product of the military support was a resulting military report that bore witness to substandard care being provided to LTC residents in Ontario. As discussed by a 2020 CBC News article, included in the report were concerns pertaining to the level of knowledge and care provided related to wound and continence issues. Wound care was noted to be one of the 5 greatest concerns identified by the military in the review of the LTC facilities. The military reported a gross lack of appropriate wound management due to supply shortages and educational deficits. It was noted that when there was a lack of access to specialized wound nurses, wounds would significantly deteriorate. Poor catheter care was also reported with reuse of nonsterile supplies and abnormalities going unreported such as bleeding.

In response to this report, multiple organizations, including the Canadian Nurses Association (CNA), released their own reports regarding improving the care of LTC residents. In the CNA 2020 vision of LTC in Canada, the CNA highlighted that the lack of specialized nursing services, including those specialized in WOC, negatively effects residents. Nurses specialized in wound, ostomy, and continence (NSWOCs) are the only nurses certified by the CNA in WOC care.

It is unfortunate that given the high prevalence of complex wounds among LTC residents, only 69 NSWOCs according to an internal Nurses Specialized in Wound, Ostomy and Continence Canada report provide care and support to LTC clients in Canada, and only 20 of whom are dedicated to solely work in LTC. It is posited that with 630 LTC facilities in Ontario, the fact that the majority of which are not serviced by an NSWOC is contributing to the persistently high prevalence of patients with WOC-related conditions in Ontario LTC facilities.

Since the release of the military report and reports from both provincial and national health care organizations, there have been calls from all sides of the political spectrum for change. In a May 2020 Toronto Sun article, titled "'Heartbreaking, Horrific, Shocking': Allegations Against Ontario Long-term Care Homes Detailed," Ontario Premier Doug Ford noted that the military report was the "most heart-wrenching report" he had ever read, while the Canadian Prime Minister noted that the report was "deeply disturbing."

Given the nonpartisan view that changes must occur in the LTC sector, and the emphasis that has been placed on WOC issues, both in recent reports and in the media, we assert that now is the time to act on making changes to improve the care of those living in Ontario's LTC system. Health care in Ontario has provincial oversight, and we assert that the Ontario provincial government must act to improve WOC issues in LTC.

ANALYZING THE ISSUE TO DEVELOP A SOLUTION

There have been a number of government programs such as the Health Quality Ontario Restoring and Promoting Continence Program in addition to medical device company-driven WOC-related programs that have been made available to LTC staff over the past decade. Nevertheless, we assert that these programs have led to no marked improvement in care.

The Ontario Long Term Care High Intensity Needs Fund (HINF) provides funding to LTC facilities to prevent hospital admissions and allow for earlier hospital discharges. Sadly, despite the inclusion in the HINF manual of the potential benefit of including an NSWOC in a skin health program, there exists no funding allocated to allow for LTC facilities to include NSWOCs in the care of LTC residents. Rather, access to HINF funding requires assessment by a physician or nurse practitioner, with no requirements for them to have additional education or knowledge related to wound, ostomy, or continence issues, despite evidence to suggest that when NSWOCs are involved in care, wounds heal faster, costs are contained, and resident satisfaction improves.5 Given the lack of NSWOCs involved in care of residents residing in LTC, it is not surprising that recent reports have highlighted the lack of appropriate knowledge and supplies for WOC management in LTC facilities. Current Ontario legislation mandates LTC skin care programs, demonstrating recognition of skin health as an important issue, yet the legislation stops short of including guaranteed access to NSWOCs. Yet, specialists such as physiotherapists and dietitians are required by legislation.

Previous solutions have included education and various funding models, such as the previously described HINF; however, all have failed to meet the requirements of LTC residents and those who care for them. Those with the specialized knowledge and skill sets to manage WOC prevention and management have not been included in funding, education, and access to service decisions. This must be rectified in order to improve the current situation in LTC.

SHAPING THE SOLUTION

To address the needs of WOC residents in LTC, the following recommendations have been developed by the Nurses Specialized in Wound, Ostomy and Continence Canada:

1. All residents living in LTC must be provided with ongoing prevention and management of WOC issues by a CNA-certified NSWOC.

2. Wound, ostomy, and continence education programs must be made available to all registered and nonregistered staff, ideally provided by certified NSWOCs and must include a mentorship component to ensure sustainability.

3. Annual prevalence studies regarding WOC issues must be conducted, and results reported publicly, allowing for benchmarking and quality improvement.

MOVING FORWARD

Skin health issues in LTC have been a key issue brought to light due to recent media reports and the COVID-19 pandemic. Although there have been prior attempts to reduce the incidence of wound issues, these attempts have failed to significantly impact rates. Thus far, there have been no attempts to increase access to NSWOCs despite there being objective benefits to having these specialists available for skin health issues. The inclusion of NSWOCs in legislation has the potential to improve upon patient safety, reduce costs, and improve patient care. In addition to improving quality of life for those suffering from WOC issues, these specialized nurses act as educators and have an opportunity to improve education related to skin health in the LTC setting.

Given the political climate and the current bipartisan agreement on the need to improve care provided in the LTC sector, we assert there is an opportunity to make meaningful and impactful change to improve the skin health of Ontarian LTC residents. We believe that immediate action must be taken to improve upon the safety and well-being of Ontario's vulnerable LTC population.

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