By Jeffrey M. Levine MD, AGSF, CWS-P
Editor's Note: The views expressed in Dr. Levine’s posts are solely those of the author, and do not represent the views of any medical school or national organization.
By Kara S. Couch, MS, CRNP, CWCN-AP
Hospital-acquired pressure ulcers (HAPUs) pose a challenge for acute and post-acute care environments and are listed as hospital-acquired conditions (HACs) by the Centers for Medicare & Medicaid Services (CMS). Other HACs include central line–associated blood stream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs). Although CLABSIs and CAUTIs have seen a decrease in prevalence over the past decade, the HAPU is the only HAC that has not. In my recent WoundSource webinar, I discussed the topic of building a pressure ulcer prevention program within hospitals. The webinar is still available for viewing on WoundSource.com.
In the webinar, I addressed:
Below are my answers to some of the frequently asked questions that were submitted during the webinar.
Question: How often should a patient be turned?
Answer: There are no true objective data to give a definitive answer to this. Some patients need to be turned every two hours, some can go longer, some shorter. I would defer to your facility or organization directives on this for now.
Question: How many full-time WOC nurses do you have to assist with your prevention program?
Answer: We have one full-time FTE WOCN and another who is per diem and works two to three days per week.
Question: In what time frame from admission should the four-eye skin check be completed? What is considered delayed?
Answer: That depends on your organization. We decided to make it within four hours of admission (to meet with The Joint Commission requirements for initial nursing assessment), four hours of transfer to another floor, and if the patient has been off the floor for more than four hours.
Question: How many skin champions per unit do you recommend?
Answer: That entirely depends on your floor structures, but at least two are desirable to have resources for all shifts. We have a mix of RNs and patient care techs.
Question: How did you choose your skin champions?
Answer: We sent out a request for volunteers. If a floor did not have any interested parties, we asked the nurse managers to nominate someone.
Question: Do you see many re-hospitalizations related to pressure injuries or pressure injury infection?
Answer: Yes. I don't know the exact number, but pressure ulcers are by far our most frequent consult type, and we unfortunately see some patients repeatedly. Anecdotally, the patients with repeated hospitalizations are those who are more resource poor than others.
Question: How do you get your staff on board with the training programs?
Answer: It's dedicated education time. The huddles and take-five messages are built into the normal routine of the floors.
Question: How can you gain leadership's support when they are not on board with the need for the prevention program?
Answer: Calculate the cost of care for HAPUs versus prevention, and that usually gets their attention. Further, organizations are dedicated to patient safety, and an HAPU is a patient safety event.
Question: Can you describe the organizational structure for the wound program that integrates inpatient and outpatient?
Answer: Our wound clinic is on the ground floor of the hospital. The inpatient nurses have their office next door to the nurse practitioners (NPs) and the physicians' office. In the morning, the list of consults is triaged between the WOCNs and NPs. The NPs are available in real time for additional consults during the day or to assist with a procedure such as sharp debridement.
Question: How do you handle wounds (e.g., from a fall) that have not manifested at the time of admission but become apparent a few days later?
Answer: We ask the admitting or primary service to document extremely carefully the circumstances that led to the admission and that were likely to lead to evolving skin damage.
Question: Can you walk through any order sets or formal processes your team had with nutrition embedded in the workflow or where nutrition interventions were initiated manually by dietitians?
Answer: We have a meeting twice a week to compare our lists. The RDs get consults based on length of stay, and the providers can initiate one anytime. We also will place orders for nutrition consults during the week between our meetings (Tuesdays and Fridays) to avoid delay.
Question: Who educates the floor staff in your hospital? Is this run by the wound team or the "champions" on each unit?
Answer: The wound team does real-time training at the bedside. The champions have monthly modules. The hospital educators are a tremendous help as well.
Question: What were some of the challenges you faced from the frontline teammates, and how did you overcome them?
Answer: The main challenge is probably task fatigue. Our nurses have so many things to do daily; sometimes prevention is not always top of mind. We work very hard to work our prevention, assessment, and treatment efforts into the normal workflow and charting.
Question: How did you combat the kick back from RN staff on the four-eyes assessment that they "don't have time"?
Answer: We wove the four-eyes workflow into the regular assessment that they are already responsible for. Regular audits help to reinforce the expectation and accountability. Real-time feedback is essential.
Question: Do you think multilayered dressings at the sacrum are important to decrease HAPUs? Could this cause providers not to check underneath the dressing and miss evolving conditions?
Answer: Multilayered dressings have robust evidence that they are valuable tools for HAPU prevention. They can be peeled down for skin evaluation and then re-attached. They typically are changed every three days or as needed if contaminated.
About The Author
Ms. Couch graduated with her Master of Science in Nursing (FNP) from Georgetown University in 2002. She is a Certified Wound Care Nurse-Advanced Practice by the Wound Ostomy Continence Nurses Board. Her primary wound interests are in amputee care, wound infection, venous ulcers and pressure ulcers.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.