Effective Use of Your Wound Care Nurse: Setting Up & Implementing a Wound Care Program

1. Effective Use of Your Wound Care Nurse: Setting Up & Implementing a Wound Care Program Jeri Lundgren, RN, BSN, PHN, CWS, CWCN Director of Clinical Services Gulf South Medical Supply Director of Wound & Continence Pathway Health Services March 2012

2. Wound Care Nurse • Utilized when a wound happens • Typically is responsible for the weekly documentation of a wound • Ensures appropriate treatment strategies

3. Think Outside the Box

4. Utilization of a Wound Nurse • Prevention • Education • F314 Compliance • Monitoring

5. Educate the Wound Care Nurse • Consider WOCN or WCC certification • Prevention • Etiology of wounds • Assessment & Documentation • Treatment modalities • F314 Training • MDS 3.0 Section M Training • OASIS-C Integumentary Items

6. Getting Started • Development of a Skin Care Team • Key Nursing Assistants from ALL shifts • Nurse Managers • Key Floor Nurses from ALL shifts • Therapy • Dietary • Physician/NP/Medical Director • Housekeeping/Maintenance

7. Skin Care Team Meetings • Develop a SET schedule for the Skin Care Team meetings • Initially may need to be weekly to bi-weekly • Monthly

8. Skin Care Team Meetings • Agenda • Review current residents with wounds • Progress • Topical Treatment • Support surfaces/equipment • Heel lift • Turning Schedule • Incontinence management • Nutritional Support • Therapy Involvement • Compliance/Barriers to plan of care

9. Skin Care Team Meetings • Agenda • Review ALL Residents (bring in treatment book) • Review Treatment sheets • Decrease/change in mobility • Change in appetite, eating habits or weight loss • Change in continence • Change in cognition • Overall changes/decline

10. Skin Care Team Meetings • Agenda • Review Supplies/Equipment • Support Surfaces (bed & wheelchair) • Heel lift devices • Positioning devices • Perinea cleansers and barrier ointments/creams • Lifting devices • Topical dressings

11. Weekly Wound Rounds • Involvement of: • Minimum of: • Nurse Manager • Floor Nurse • Nursing Assistant • If possible the wound team members • Therapy • Dietary • Physicians/NP GREAT TIME FOR BED SIDE EDUCATION

12. Assess Communication On-going communication and involvement with the direct caregivers? How do the caregivers communicate skin concerns (verbally or written)?

13. Assess Communication Between shifts and between caregivers (last time turned & toileted at a minimum)? Are interventions being communicated to the caregivers (turning schedules, heel lift, toileting, etc.)? Between Units? Between health care settings?

14. Assessing Programs Break your pressure ulcer prevention program down into two areas: Admission process On-going Prevention Program Utilize the Quality Improvement process when assessing each program

15. Admission Process Developing a task force to evaluate the admission process: Assess when and where your admissions are happening Who is Doing the Admission Assessments Reality -- not what the policy and procedure states

16. Admission Process All care settings admission process (within the first 24 hours) should include: A head to toe skin inspection by the licensed staff (ideal within 8 hours) A risk assessment for the potential for skin breakdown Development of a temporary plan of care Communication to the caregivers

17. Admission Process Admission Process Tips At a MINIMUM Temporary Care Plan within 24 Hours to Include: Support surfaces (bed and W/C) Turning & repositioning schedules Incontinence care & keeping skin clean and dry Heels elevated off bed Dietary and therapy referrals Access to topical dressings if admitted with pressure ulcers

18. Prevention • What is your on-going prevention program?

19. Prevention Program Assessment Does your current prevention program include: On-going Risk Assessments per care setting guidelines? On-going skin inspections? Daily with cares Weekly Upon discharge On-going updates to the plan of care?

20. Interventions • A list of interventions to correlate with potential risk factors, to help develop the plan of care

21. Supplies/Products Pressure redistribution bed surface, including access to low-air-loss and air-fluidized beds if needed Wheelchair cushions Heel lift devices and/or pillows

22. Supplies/Products Barrier ointments/creams to protect from incontinence (are they accessible to the caregivers) Lifting and positioning devices Dietary supplements as appropriate

23. Monitoring Programs • All staff should be involved • Continuous

24. Monitoring the Programs • Monitoring turning and repositioning (sticky notes) • Monitoring toileting schedules • Assessment and confirmation that equipment is in place and functioning properly

25. Monitoring Programs • Ensure IDT is being proactive and discussing high risk individuals (immobile, losing weight and incontinent) • Monitor daily cares to ensure they are inspecting the skin, doing proper peri-care, ROM, feeding/supplements, weights, I & O, etc.

26. Monitoring Programs • Monitoring that the risk assessment and skin observations are done at appropriate intervals • Monitoring that the plan of care reflects interventions being implemented and identified risk factors • Do the risk assessments, physician orders, caregiver assignment sheets and MDS/RAPS match the care plan?

27. Treatment • Overall Treatment Program

28. Discovery of a Pressure Ulcer • Notification of the Physician and family/designee of the development of a wound, regardless of stage • Documentation of the wound(s) • New risk assessment • Evaluate Support Surfaces • Evaluate turning and repositioning • Evaluate all interventions • Up-date the care plan • Up-date the nursing assistants assignment sheets

29. Communication • Physician/NP, Family, Interdisciplinary Team, Skin Care Team & Direct Care givers • Upon Discovery • No Progress in 2 weeks • Decline • Healed

30. Supplies/Products • Moisture dressings (i.e., hydrogels, hydrocolloids and transparent films) • Absorptive dressings (i.e., foams and calcium alginates) • Debriding Agents (Santyl, Medical grade honey) • Access to adjunctive therapies (i.e., V.A.C., Infrared, E-Stim, Ultrasound, etc.)

31. Supplies/Products • Powered Support surfaces • Air, gel or foam wheelchair cushions • Dietary supplementation

32. Monitoring Programs • Monitor ALL nurses doing dressing changes and wound assessments • Monitor treatment records and documentation records • Monitor the Physician and NP orders, diagnosis and progress notes appropriate • Ensure IDT is actively discussing/identifying wounds not showing progress

33. Refusal of Care • Risk/Benefit Discussion • Discuss resident’s condition • Treatment options • Expected outcomes • Consequences of refusing treatment (pressure ulcer development, sepsis and even death) • Offer relevant alternatives • Recommend showing residents/families pictures of pressure ulcers

34. Refusal of Care • Risk/Benefit Conversation • Document the date of discussion in care plan and put resident’s request in care plan • Review quarterly, with re-admission and with change of condition

35. On-going Education • Recommend doing educational programs in this order • Prevention • Assessment and Documentation • Treatment Modalities • Lower Extremity Ulcers • Do bedside follow up after educational programs • Do education on orientation and periodically throughout the year

36. Skin Care Programs Overall, if you keep the Resident’s/Patient’s best interest in mind, your program will succeed!!!

37. Resources www.wocn.org (Wound, Ostomy & Continence Nurse Society) Available Guidelines: • Prevention and Management of Pressure Ulcers • Management of Wounds in Patients with Lower-Extremity Arterial Disease • Management of Wounds in Patients with Lower-Extremity Neuropathic Disease • Management of Wounds in Patients with Lower-Extremity Venous Disease

38. Resources www.ahrq.gov (Agency for Health Care Research and Quality, formally AHCPR) Call: 1-800-358-9295 for FREE guidelines: • Clinical Practice Guideline Number 3: Pressure Ulcers in Adults: Prediction and Prevention • Clinical Practice Guideline Number 15: Treatment of Pressure Ulcers • Patient Guide for Pressure Ulcer Prevention

39. Resources • www.aawm.org (American Academy of Wound Management) Has a list of Certified Wound Care Specialists • www.npuap.org (National Pressure Ulcer Advisory Panel) • www.woundsource.com Great source to find wound care products and companies/vendors

40. Thanks for your participation!!! Jeri Lundgren, RN, BSN, PHN, CWS, CWCN jeri.lundgren@pathwayhealth.com Cell: 612-805-9703

41. Questions? Kristi Wergin, RN, BSN, Program Manager 952-853-8561 Kwergin@stratishealth.org www.stratishealth.org

42. Stratis Health is a nonprofit organization that leads collaboration and innovation in health care quality and safety, and serves as a trusted expert in facilitating improvement for people and communities.  This material was prepared by Stratis Health, the Minnesota Medicare Quality Improvement Organization, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The materials do not necessarily reflect CMS policy. 10SOW-MN-C7-12-81 043012