Transcript
Dot Weir:
Welcome to the SAWC Difference Makers Podcast, where breakthroughs meet the bedside.
I’m your host, Dot Weir. Let’s dive into today’s conversation.
For this episode of the Difference Maker series, I am so happy to be joined by Dr. Diane Krasner, who is well known to most people, but also a very old and very dear friend of mine. We’ve been friends for, we just realized, over 40 years. So we agree that Aveda was a beautiful thing if you see us in person.
Anyway, Diane has been, in my book, one of the leaders in all things ET nursing and WOC nursing. We’re going to get to all that, but she has been such a difference maker and a change agent over the years that I’m very, very proud to have her here today as a guest.
Welcome, Dr. Diane Krasner.
Diane Krasner:
Well, thank you, Dot. I’m so pleased that you’ve started this podcast series because I think it’s really important that we share our stories.
Dot Weir:
Let’s go back a little bit in history because you and I were sort of there from the beginning. I mean, we weren’t part of the original ET nurse or WOC nurse groups, but I think that started in the late 1970s.
I went for my training in 1980. You were in 1985. But if you recall, at least for me, we didn’t really do wound care when I first started. It was pretty much ostomy care, and we transitioned into wound care. But you have such a gift for telling some of the historical stories, so I’m going to ask you to share that with us.
Diane Krasner:
I was actually in 1985 at the Harrisburg ETNEP—we called it that in those days, Enterostomal Therapy Nursing Education Program. I was in the first class that had a week of wound care in the eight-week program. So we had seven weeks of ostomy and one week of wound care, and it really piqued my interest.
I loved the ostomy part, but I was just so curious about the wound part. As the years went by, of course, I became subspecialized in wound care, even though we did the full scope of practice in those days.
Dot Weir:
Diane, I just want to give the listeners a comparison. I went to Harrisburg also, in 1980, and we had two hours of wound care because that’s just not what ET nurses were doing. We were just appreciating a moist wound healing environment. So that’s how much changed within that five-year span.
Diane Krasner:
But we always were concerned about the peristomal skin. We had an interest in skin and wounds. We just didn’t quite realize it.
After my first six months in practice, I went to my first IAET meeting in Las Vegas. In those days, they used to have a big sit-down lunch for everyone who was attending. I was standing in line, waiting to get in, and someone pointed a few people out for me and said, “There’s Norma Gill.”
Norma Gill was the first ET and founded the ET program with Dr. Turnbull at the Cleveland Clinic. For me, it was like meeting Florence Nightingale. I went up to her and was so nervous. To this day, I remember my hands were shaking. I introduced myself and said, “I’m a brand-new ET.” She threw her arm around my shoulder and said, “Honey, come and sit next to me at lunch.”
That was the beginning of my great friendship with Norma. I didn’t know until after that she loved new ETs. That was her passion. She became a great role model for me, and it was her advocacy work that really rubbed off on me early.
She approached Paula Erwin-Toth and me about helping her write her autobiography. She had these boxes and boxes of materials in her garage that she wanted us to go through. We took a slightly different approach, and we did a festschrift in her honor. That has since been published and republished as a commemorative edition by the WCET, the World Council of Enterostomal Therapists. We gave her a copy on her 75th birthday, and I would say it was the nicest thing I ever did in my life.
Dot Weir:
That’s awesome. And for those listening, I don’t know that we defined it, but back then, ET nurse was enterostomal therapy nurse, which did not even encompass the full scope of practice that is encompassed by wound, ostomy, and continence nursing now.
Diane Krasner:
Yes. Norma always opposed us taking on a bigger scope because she felt that ostomy patients would get short shrift. In a certain way, she has been right about that. On the flip side, it’s wound care that sustained us and kept us in business because there are a lot of wound patients, and there aren’t as many ostomy patients.
Dot Weir:
With the newer surgical techniques, I was practicing when the end-to-end stapling device began to be used, so they were able to reattach the colon so much lower down into the rectum. Science has changed that, too.
As much as I love wound care, I always loved my ostomy patients and the relationship. Unfortunately, with short hospital stays, that has had the biggest negative impact on ostomy patients. It’s not the lack of trained specialists, I think. It’s the shortened hospital stays.
I remember pre-DRGs, patients would come in for their bowel prep and have orders written after surgery: “Keep in hospital to learn ostomy care.” Now they’re barely walking, and they leave maybe being able to empty their pouch. That’s a very sad thing because I think it leads to a lot of problems downstream. So, lots of history there.
Moving on from that, although that’s a critical part of both of our histories, both of us became involved with HMP and with SAWC by attending the first one in 1988. I’ve been to every single one since, and I’m currently the co-chair with Rob, which is great. You and I were also part of starting the Association for the Advancement of Wound Care, and I remember that meeting well in San Diego. Do you want to talk about that?
Diane Krasner:
Yes. I think it’s important to think about how SAWC was unique because it was an interprofessional approach. Up until then, all the interest in wound and ostomy was either groups of nurses, groups of physicians, or specialist physicians. SAWC brought everyone to the table.
HMP, with their wisdom—and I was thinking of several themes that have been in my life for the past 40 or 45 years, and HMP has certainly been one of them—has, in part through just empowering us, enabled us to do so many things. Then they had the idea that there should be an association to bring us all together. So the AAWC was born, and you and I were both involved from the early years.
I’ll never forget when Pat Scullin came to my house in Baltimore and said, “How about if we turn some of those talks from SAWC into a book?” So that birthed the Chronic Wound Care book that I ended up working on for over 35 years.
Dot Weir:
Amazing. Actually, Chronic Wound Care—I don’t remember which edition—was my very first book chapter that I was ever part of. You gave me that break into my first writing. I’ve got a few more now, but that was my very first book chapter.
Diane Krasner:
Providing those opportunities for other people is really important. My three mentors—George Rodeheaver, Louise Colburn, and Tom Stewart—I met all three of them at the very same moment when I went to my first Gaymar lecture.
In those days, Gaymar was a mattress overlay company, and they were providing education around the country. It was the first time, I think, that there were these big seminars. They would go with faculty and educate nurses on pressure ulcers in those days.
I was so excited because I got flown to my first conference. It was a big deal for me. The night before, they had a little reception, and that’s where I met those three, who to this day remain part of my life and mentors forever. They provided me the first opportunities to speak and to write.
Then I joined very early in my career with NPUAP, which Tom Stewart and Louise had co-founded. George has always been my research mentor. Having those mentors and having those mentors provide opportunities for you in life is critically important. Now I’m trying to do the same thing with the young people I’m involved with who are going to take over from us.
Dot Weir:
Right. When I think of my mentors, you’re one of them, but Yvonne is one of them, too. Yvonne Fowler, for those listening, is often not given enough credit. She had the vision when she was approached by Pat Scullin and Harry Hurley to think about a meeting. She had the vision for that interdisciplinary meeting. She was the founding chairperson with Bill Eaglstein, I think—or maybe he joined a little later—for SAWC.
Then she was the first president of the AAWC. I was the first treasurer, and you were our executive director, I think. Yvonne and I attended a Gaymar conference in Buffalo, New York, in the winter and went to see Niagara Falls just because we could. So much history there.
How many editions of Chronic Wound Care did you ultimately have? Five-ish?
Diane Krasner:
We had five. Then, at the suggestion of Peter Norris, because the book had gotten so big that we were dividing it into volumes, he said, “Why don’t you do an essentials book? No one wants to read 500 pages of wound care anyway.”
So we took some of the best chapters from the first five editions and put them into the essentials book. Then we did a second edition of the essentials in hardbound and softbound. Eventually, we did just an electronic version. Leah Van Rijswijk and I co-edited that. It is being provided now free to the members of the Post-Acute Wound and Skin Integrity Council—PAWSIC.
Dot Weir:
Yes, we will definitely get to that. So much history here.
Diane, when I think about you, you are such an advocate. You mentioned the younger incoming people you work with, and that you are a mentor and a leader for people entering the profession of wound, ostomy, and continence, or just wound care. There are so many ways that you impact people’s careers and their lives.
You’re also an advocate for doing the right thing and understanding what’s going on with skin. That leads me to have you talk about your early interest in recognizing some of the changes that take place with people’s skin when they’re ill or elderly, starting back in 2008 with the SCALE document. Why don’t you tell us about that?
Diane Krasner:
Maybe I’ll take a little step back beyond that. In 1991, when I was at a WCET meeting in Atlanta, I ended up with an obstruction, in the hospital, and having emergency surgery for endometriosis. After that, I ended up with a dehisced wound.
My favorite surgeon, who I did a lot of stomas with and took care of many of his patients, was debriding my wound. He was hurting me. No anesthesia. I grabbed his hand with the scalpel in it and said, “Michael, what are you doing to me? You’re hurting me.” He looked at me like, “Oh, there’s a patient there.” And he said, “Well, you’ve been doing those to patients for years.”
That was my moment of turning to the issue of wound pain, when I realized, being the patient, that yes, we were torturing a lot of patients. I was just getting ready to pick my dissertation topic. I was going to do fecal incontinence and skin breakdown, and I switched and did wound pain.
By that time, we had started the AAWC and the Canadian Association for Wound Care, and its chair, Gary Sibbald, hooked me up with Frank Ferris, a palliative care physician in Canada, to speak on wound pain. I meandered from there into palliative care and began to really focus on these skin changes at life’s end and realize how important they were, and how much we had all ignored them.
My old friend Tom Stewart from Gaymar days, who was then president of Gaymar, convened a SCALE panel and got you and about 15 other people who had been involved in these areas, which were sort of marginal. People didn’t talk a lot about wound pain in those days. They certainly didn’t talk a whole lot about end-of-life skin changes and wounds. Only a few had published or really given a lot of thought to that, including Diane Langemo, who had written one of the first failure models.
We published the SCALE panel after we did a modified Delphi. We actually went around the world collecting feedback at various wound conferences and published our initial consensus statements, got feedback, and then finally published our final document in 2009 as a modified Delphi on skin changes at life’s end.
That was important foundational work. Karen Kennedy was doing her work on the Kennedy terminal ulcer at the time. She also participated in our SCALE panel. Jeffrey Levine was doing work. Now we come to today, when we’re evolving into discussions on skin failure.
We all have been saying for years that the skin is an organ, the largest organ of the body, and it can fail also.
Dot Weir:
Starting with Karen Kennedy Evans’ work, we always associated it with a dying process versus an illness process, if I’m stating that correctly, which is important from all kinds of pathways: prevention, documentation, and, let’s face it, the legal issues that arise from patients who break down when they’re critically ill.
That leads me to the recent NSWOC—Nurses Specialized in Wound, Ostomy and Continence Canada—meeting that we were just at together in Vancouver a couple of weeks ago, where I was literally enthralled and amazed at your presentation related to skin failure. It’s such an important consideration.
We used to associate it, like with Karen Kennedy Evans’ work, with the dying patient. But now we know that the skin—we’ve always talked about it being the largest organ—is an organ that can fail, just like your heart, your kidneys, your lungs, or anything else. It’s on the outside, so it’s much more visible than those other things, and it has far-reaching implications.
I’d like you to expand on and give us a mini explanation of the lecture you did in Vancouver.
Diane Krasner:
Thank you. This is my latest passion, so I’m always happy to talk a little bit about skin failure.
This started, again, with one of those opportunities that just kind of flew in the door and sounded interesting. We had not a clue what we were getting into. At the very first board meeting of the Post-Acute Wound and Skin Integrity Council—PAWSIC—someone who follows guidance and regulations very closely told us, this was in 2023, about new guidance from CMS for long-term care that said SCALE, Kennedy terminal ulcer, and skin failure are not considered pressure ulcers and should not be coded on MDS Section M.
We were thrilled because we had been wanting recognition of that for a long, long time. But the problem was that there was no place then to code those things. If you can’t code in the United States, then you have issues with reimbursement and care across the continuum.
So we voted, without really knowing what we were getting into, and said, “We’re going to go for ICD-10 codes. We’re going to pursue this.”
We were pretty novice at that point, but we submitted our first application for the codes in November 2023. Then the ICD-10 committee came back to us and said, “Why don’t you work with the American Academy of Dermatology? They have a lot of experience in developing codes.” They hooked us up with Stan McNicholas, and we’ve been working on those codes ever since.
At the end of the day, the importance is not ICD-10 codes for diagnosis and reimbursement, but for identifying those patients who are at risk for skin failure or who have skin failure to assure they get on the right care pathway. That’s the bottom line of all this.
You can get really stuck in the weeds of all these codes and extender codes and so on. But the most important thing is to remember that there’s this phenomenon. We don’t understand it completely. We need to know more about the underlying etiology and pathology that causes skin failure or results in skin failure.
But we at PAWSIC and the American Academy of Dermatology believe that we will understand that by doing research on large data sets—not 50 patients, not 100 patients, but 100,000 patients—so that we can do the multivariate analysis to see what, in fact, are the comorbidities, conditions, and risk factors that put patients at risk for skin failure.
You talk to any clinician who has been in wound care for any length of time, and they have seen skin failure. They just didn’t have a label for it. They know it exists, but there’s still a whole lot we don’t know.
Dot Weir:
You talk about these big data sets. Where will these patients come from? Just Medicare coding groups? How do you find thousands of patients?
Diane Krasner:
If you have ICD-10 codes, then you can find them in the Medicare data set.
The reality is that when we designed our skin failure codes, we used Diane Langemo’s theoretical framework for several reasons. We felt it was the most practical and operationalizable of theories out there. We felt that it would be easy to implement across all care settings.
The thing about skin failure is that it’s not just in home care, long-term care, or ICUs. It’s everywhere. We need to be able to have a system that works in all those different settings, where the provider groups are very diverse.
You can have acute skin failure in long-term care. You can have end-stage skin failure in the ICU. You can have both in one patient. I have a legal case right now where the patient started with acute skin failure, but was in the ICU for six months and ended up at end of life and had end-stage skin failure.
So it is complicated, but it’s just taking off your old lenses, your old glasses, and looking at this phenomenon in a new way with an open mind. Then we need to be able to look for patients at risk for skin failure. In fact, there may be more of those than patients at risk for pressure injury, since we do such a good job with pressure injury prevention these days.
Dot Weir:
Absolutely. How does someone follow this, Diane? Can they join PAWSIC? Is this a group that they can follow?
Diane Krasner:
Yes. PAWSIC is putting out materials that are free, and PAWSIC basic membership is free. If you want to join the PAWSIC Skin Failure SIG—shared interest group—you have to become a PAWSIC member.
We’re trying to publish and put out as much as we can and share the tools we’ve developed so far, including a clinical assessment tool. We have several other documents, and we are aiming for a July release of our skin failure codes position paper that explains our thinking and rationale for the code proposal that we’ve put forth to the ICD-10 committee.
We’re hoping to present the latest iteration in September to the ICD-10 committee, and hopefully soon it will get passed. I understand from experienced people that these processes can go on for three, four, or five years. That’s not unusual. As I keep saying, this is a marathon, not a sprint, but we’re in it for the long haul.
Dot Weir:
For sure. Redefine PAWSIC for everyone and let them know how they can find it online.
Diane Krasner:
It’s the Post-Acute Wound and Skin Integrity Council, and the website is pawsic.org.
We’re three years old. We were founded by a group of interprofessional people who had a post-acute focus: home care, long-term care, outpatient care. We felt there was a gap in attention to post-acute care issues. So much of chronic wound care is getting shifted to the post-acute environment, which is a resource-poor environment. We felt there was a need to have a group specifically focused on post-acute care and all its rules, regulations, and issues.
Dot Weir:
I applaud the work you are doing, and I encourage everyone to go to the website, pawsic.org, and follow this. When things are out there for comment, comment on them, because the collective information that can be gathered can always help further this along.
Diane Krasner:
I would be remiss if I didn’t also mention another new organization that came up about the same time as PAWSIC, and that was the Coalition for At-Risk Skin. It is also interested in skin issues, but more on the prevention side.
We are also about three years old. We are just launching our website, coalitionforatriskskin.org. It’s a long one. We call ourselves CARS.
We’re developing resources to help people, patients, caregivers, and family members prevent skin problems before they happen. We started out as an advisory board of Medline. Medline had brought us together, and we did our first consensus document, which you can download from our website, on at-risk skin.
Then, encouraged by Medline, we went off and decided we would be best served by becoming our own independent nonprofit organization. That was quite a process. It took a couple of years to become a 501(c)(3). But we’re now standing on our own, have our own website, and are about to do our first webinar and another consensus document.
Dot Weir:
As you know, I’m keenly interested in that, and I’m advocating to join your group because I have a huge interest in skin from the standpoint of pH. So stay tuned for that.
I was at that first presentation that you all did. I think it was at a WOCN meeting. In the middle of the table were all these things like creamers and ketchup packets. The whole point was that we don’t moisturize our skin enough. I learned from that myself because my skin’s not getting any younger.
Diane, the things that you do—that’s what I mean. You’re such an advocate for good care, good skin care, and spreading the word and advocating not only for patients, but also for providers. I’m proud to call you my friend and certainly my colleague.
Thank you so much for joining. I hope we can maybe convene again for another one because you have such a well of information, and we want you to bring back information as it arises and as this effort moves forward so that we can keep everyone informed.
For those of you listening, thank you for joining us, and we will see you on other podcasts for the Difference Makers.
Outro:
The SAWC Difference Makers Podcast is brought to you by the Symposium on Advanced Wound Care, one of the leading forums for advancing wound care education, research, and collaboration, and Wounds, the official journal of SAWC.