By Heidi Cross, MSN, RN, FNP-BC, CWON

“At all times material hereto, Defendant facility failed to formulate, adopt, monitor and enforce policies, procedures, and protocols relevant to skin and wound care prevention and treatment, resulting in plaintiff sustaining a devastating, disfiguring and painful pressure injury.”

Introduction

I have been there, done that. Sitting in the fact witness chair in front of a plaintiff attorney who is wildly waving a copy of my facility’s wound care policy and procedure, demanding to know why certain things weren’t included in the policy, and why what was in the policy was not followed to the letter. Plaintiff attorneys have the right to demand copies of a facility’s policy and procedures as part of discovery and will go through them with a fine-tooth comb, compare what is in the policy with the care that was provided, and fault the facility for any deviations. It goes without saying that I promptly returned to my facility with a new understanding for how our policy was written and possible gaps and weaknesses.

First, a Little Background:

We always seem to use the term “Policy and Procedures,” but ultimately, we are probably talking more about “Policy,” which is defined as “a guide to any decision-making in relation to processes or activities that regularly take place or might be expected to occur.”¹ The term “Procedures” usually encompasses exact protocols to be followed in a step-by-step fashion, distinct from a well-written policy. Simply put, like using your GPS, a policy serves as a road map for care within the facility; procedures provide the turn-by-turn directions. The purpose of a policy is to allow staff members to understand their overall duties and responsibilities, and the policy standardizes care across the facility.

A Few Tips for Creating Better Policies

• NEVER use absolutes. That means never use the words never, always, must, shall, everyone/everybody/nobody, or words such as immediately. For example, a written policy that a patient MUST be turned every 2 hours is, to begin with, unrealistic. And failure to do so even once breaches the policy. For a better way related to positioning, refer to the National Pressure Injury Advisory Panel (NPIAP) guidelines, which state that repositioning should be conducted on “an individualized basis” with “consideration to the individual’s level of activity and ability to independently reposition.”²
• Base your policy on current evidence-based guidelines and literature. There are many guidelines out there such as from the NPIAP, the Wound, Ostomy and Continence Nurses Society, the World Union Wound Healing Society, the Infectious Diseases Society of America, the Society for Vascular Surgery, and others. In your policy, list in reference format what literature you are using.
• Update your policy at least every few years, by checking out what new guidelines are out there and what may have changed. Guidelines are updated on average about every 5 years, and you want to base your policy on the most current practices.
• Standardize your policy format for all policies across your facility.
• Involve any wound specialists in compiling policies, but don’t forget bedside staff input. They are the ones actually providing the day-to-day patient care and know what truly may or may not be realistic.
• Train and educate all relevant staff about your policy, and make sure staff knows how to access the policy. It does not speak well of a facility to have patient care staff in a deposition look blankly at the attorney when confronted with the policy and say, “I didn’t know about that.”
• Have all policies easily available and accessible.

Some Specifics From the Agency for Health Care Research and Quality

The following items are recommended by the Agency for Healthcare Research and Policy for preventing pressure injuries in hospitals³:

• Your skin care policy should contain a statement regarding the facility’s commitment to pressure injury prevention and management.
• It should include a standard protocol for assessing a patient’s risk for developing a pressure injury.
• Perform a risk assessment well as a skin assessment at least on admission, on transfer, and with a change of condition. (Note: at least weekly wound assessment is the usual base standard of care, with perhaps more frequent skin assessments.)
• List what steps are to be taken if a pressure injury is not healing.

Other Things to Consider in Your Policy:

• Minimum wound documentation expectations
• When to refer to the wound team or wound specialist
• When to place the patient on a specialty surface
• When to refer to the dietitian
• Physician and family notification
• Change of treatment plan
• Wound photography

Additionally, keep your policies succinct and to the point so that busy staff does not have to wade through a wordy document to find the answer to a simple question. I suggest that training and education related to skin and wound care assessment (staging?) and management (dressings and skin products?) be kept separate from the policy or as an addendum.

Conclusion

Writing an effective policy involves a fine balance between being too specific and not including enough. Try to see it through a legal lens when designing your policy and envision what faults and questions a plaintiff lawyer may raise in a lawsuit.

References

1. Hollnagel E. Safety-I and Safety-II: the Past and Future of Safety Management. Ashgate Publishing, Ltd; 2014.
2. National Pressure Injury Advisory Panel. Prevention and Treatment of Pressure Ulcers/injuries: Clinical Practice Guidelines. The International Guideline 2019. Accessed June 23, 2022. www.npiap.com
3. Agency for Healthcare Research and Policy. Preventing Pressure Ulcers in Hospitals. 2014. Accessed June 23, 2022. www.ahrq.gov/patient-safety/settings/hospital/resource/pressureulcer/tool/index.html

About the Author
Heidi H. Cross, MSN, RN, FNP-BC, CWON, is a certified Wound and Ostomy Nurse in Syracuse, NY. She has extensive experience caring for wound and ostomy patients in acute care as well as in long term care facilities. Currently, she is employed by CNY Surgical Physicians consulting for nursing homes in the Syracuse area, and has served as an expert witness for plaintiff and defense attorneys.

The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, HMP Global, its affiliates, or subsidiary companies