Expertise Beyond Borders: Virtual WOCN Patient Access Program Positively Impacts Healthcare Across the Global Care Continuum
Category: Practice Innovation
Abstract: Background: Decreasing hospital reimbursement has resulted in shorter lengths of stay, where patients with complex wound and ostomy care needs are discharged sooner and often to settings where their complexities are met with fragmented or sub-par care.1 A key contributor to this disparity is the limited number of certified wound care clinicians in post-acute settings. Purpose: The purpose of this project is to describe the reach/use of free virtual access to the specialized services of a Board-Certified Wound-Ostomy Nurse (CWON). Methods: A virtual WOC Nurse patient access environment was created with options for general education and/or an individualized wound or ostomy assessment. For individualized assessments, a form queries the client regarding the history of the wound or ostomy challenge. A photo upload is required. This information is dispatched to a CWON who reviews the information and provides an Individualized Plan of Care (IPOC). The IPOC provides a summation of the problem and recommended solutions, based on current evidence-based standards of care. The IPOC is intended to be used by the patient or clinician to guide discussions with a primary care provider. Result: This virtual WOC Nurse resource has provided wound and ostomy care education to 10,912 clients from 97 different countries since its inception in 2013. Pressure injury education accounted for close to 50% of client visits, followed by the wound care and ostomy care nurse assessments; through which a client can consult with a CWON. Highest use was in March 2021, during the height of the COVID pandemic, when access to many resources were limited. Conclusion: The ongoing success of this virtual WOC Nurse resource demonstrates how innovation in patient access avenues can extend advanced wound and ostomy care knowledge beyond the hospital walls across the Global care continuum.
Note from the Author: This program is innovative because it existed long before telehealth was common. This service was offered prior to COVID and has continued since 2012-3. It is not an industry initiative but a 501(c)3 non-profit organization through which free education and WOC Nurse services are available to both patients and healthcare providers alike. It is funded 100% by me and has been since its inception.
How low can we go: Zero medical device related pressure injuries in ECMO patients through interprofessional collaboration
Category: Case Study
Abstract: Background. Extracorporeal membrane oxygenation (ECMO) removes carbon dioxide and oxygenates the blood before sending the oxygenated blood to the body tissues. This allows the blood to “bypass” the heart and lungs which allows those organs to rest and heal. Due to the critical nature of these patients, they are at very high risk for developing pressure injuries (PI). PIs are associated with poor outcomes including pain and discomfort, increased length of stay (LOS), decreased patient satisfaction and increased costs. PI rates are one of 10 Patient Safety Indicators (PSI 03) that are scored and reported to the Centers for Medicare and Medicaid Services (CMS) and Agency for Healthcare Research and Quality (AHRQ). PSI 03 occurrence presents a financial implication with payment reductions to a facility. Introduction. The aim of this project was to reduce the occurrence of PIs in ECMO patients admitted to adult cardiopulmonary intensive care units (ICU) at an academic medical center through a multidisciplinary team approach for process improvement. Methods. A retrospective baseline analysis of PIs was conducted on 77 patients from January-June 2020. This revealed an overall PI occurrence rate of 32%, of which 25% were related to the use of a medical device. Therefore, the first phase of the project was focused on reducing the number of medical device related pressure injuries (MDRPI). The Plan Do Study Act (PDSA) methodology was used for this project. Multiple interventions were implemented including, but not limited to, use of 5-layer foam dressing around ECMO cannula to cushion ear, a standardized tracheostomy PI prevention protocol, a sedation weaning protocol to promote mobility, and a volume-based protocol for tube feedings. Pre-selected consults to the WOC Nurse, Dietician, and PT/OT were also added to the order set at ECMO initiation. Results. The percentage of MDRPI occurrence in 2021 was 0%. Subsequently, the total number PI was reduced by 69% and the number of PSI 03 PI was reduced by 71% among 227 patients from July 2020 - December 2021. Discussion. MDRPI was eliminated in one of the most vulnerable patient populations. Additional opportunities for future process improvement projects within the ECMO population were identified.
Nursing Student's Knowledge and Attitudes Towards Pressure Injury Prevention
Category: Clinical Research
Abstract: Introduction. Pressure injuries are a major healthcare problem that is associated with numerous negative impacts on patients as well as hospitals. Nurses play an important role in identifying and preventing pressure injuries. The purpose of the study is to explore the knowledge and attitudes of senior nursing students towards pressure injury prevention. Purpose/Aims. Using a descriptive exploratory design, a convenience sample of senior nursing students at a medium-sized university in the southeastern United States completed a web-based survey. The survey was developed using the Pieper-Zulkowski Pressure Ulcer Knowledge Test and the Moore Price Attitude Scale. Descriptive analysis of the responses was performed. Results. There were 36 respondents (participants) to the survey; majority being female (n=32, 88.9%) and white (n=25, 69.4%). Pressure injury prevention knowledge scores ranged from 44% to 78%; the average score was 62.81% (SD: 8.024), indicating an overall poor knowledge of pressure injury prevention. In contrast, the average attitude score was 37.44 (SD: 2.568), demonstrating a positive attitude towards pressure injury prevention. Conclusion. In this study, senior nursing students had limited knowledge of pressure injury prevention but positive attitudes. To address this knowledge deficit, nursing education programs should include more information related to pressure injuries as students transition to the nursing workforce and influence the development of pressure injury prevention practices. Additional research is needed to explore the relationship between knowledge and attitude as it pertains to pressure injury prevention and nursing students. There is also a need for further exploration of what influences a better understanding of pressure injury prevention.
Evaluation of Wound Care Education for Home Health Nurses Through an Application of the Transtheoretical Model of Change
Category: Practice Innovation
Abstract: Background:Current evidence indicates that while 50% of all home healthcare is focused on the treatment of wounds (Lindholm & Searle, 2016), a large majority of home health nurses express negative attitudes and a lack of knowledge regarding proper wound care (Ayello et al., 2017). This gap in knowledge can lead to further complications for the patient, diminished quality of life, and increased care costs (Olson et al., 2019). Objective: The objective of this study was to implement a comprehensive wound care education program for home health nurses to improve their ability to perform wound care in the home setting and to evaluate the potential for home health nurses to use their knowledge through the transtheoretical model (TTM) of change. Methods: A quantitative pre-/post-intervention study was used to compare nurse motivation for change via the stages of the TTM before and following the implementation of a wound care education program. Using a modified version of the University of Rhode Island Change Assessment Scale (University of Maryland, 2021), the stage of change for the nurse was assessed before and following the educational program. Final URICA scores were compared with baseline scores to determine if changes in motivation occurred. Findings: A total of 15 home health nurses were enrolled in the study. Average TTM scores at baseline were 3.4 indicating a low motivation to change: TTM stage precontemplation. Upon completion of the educational program, scores from the URICA scale increased to an average of 21.4 indicating nurses had entered the preparation stage of change as per the TTM.(P < 0.01). Conclusion: Comprehensive wound care education for home health nurses may increase the motivation of nurses to treat this condition leading to better health outcomes and lower care costs for patients.
A Scoping Review of COVID Skin Manifestations for Pressure Injury Differentiation at the Point of Care
Category: Clinical Research
Abstract: Background: SARS-CoV-2 infection has spread all over the world in the last year, causing millions of COVID-19 cases among humans with a large variability of symptoms and signs, including those on the skin. Although respiratory symptoms are the most common, other findings could affect patients with COVID-19, including quite nonspecific cutaneous signs, such as urticarial, macular papular rash, and varicella-like eruptions. While the latter have been observed in patients with proven infection [1,2], during the first phases of the COVID-19 pandemic, a contemporary cluster of chilblain-like lesions with no certain relationship with the infection has been reported. Purpose: The purpose of this study was to analyze published evidence, to elucidate characteristics of COVID-related skin changes to guide identification and differentiation from pressure injuries at the point of care. Methods: A three-phase scoping review was conducted using the Arksey and O’Malley framework. Only primary sources were included. Out of ** articles found, ** articles with a total of ** were include. Clinical presentations of COVID-related skin changes were abstracted, categorized, and analyzed. Trends were identified and compared to known pressure injury characteristics. Results: The data was analyzed across a total sample of ** adult patients with ** skin injuries.
Adjuvant Nutritional Support to Assist in the Treatment of Chronic Wounds
Abstract: Background: Chronic wounds pose unique challenges that need to be addressed by practitioners. Co-morbid conditions, the environment of the wounds, and the patient's nutritional status need to be identified and corrected as efficiently as possible. Nutrition is often delegated to last place in the problem-solving paradigm. Purpose: The purpose of this case presentation is to elucidate the effects on outcomes of adding specialized nutritional supplements with liquid collagen and citrulline to assist with wound closure. Cases: Patient #1 is a 66-year-old male with a history of renal disease, hypertension, Klippel-Feil Syndrome, Heterozygous Factor II hypercoagulable State. He was found to have a congenital vertebral anomaly with neural foraminal stenosis of the cervical spine and had fusion and hardware placement from C2-Tl on March 28, 2022. He developed a wound infection and was taken back to surgery for irrigation and debridement with wound vac placement on 6 occasions. Perioperative chemistries showed that he had normal glucose levels. His albumin was 4.0 and total protein was 6.2. He was taking at home daily multiple vitamins and folic acid. His original presentation on 05/23/2022 revealed a full thickness wound 11.7 x 8 x 1.8cm with exposed bone and hardware. At our facility, he underwent serial debridements, chemical cautery with silver nitrate, and hyperbaric oxygen treatments. He was started on nutritional supplements with hydrolyzed collagen peptides and L-citrulline 60 mls daily on 06/09/2022. He was last seen on 07/27/2022. His bone and hardware are completely covered and his wound measures 3.5 x 2 x 0.1cm. Patient #2 is a 69-year-old male with an extensive PMH including mixed arterial venous disease, DM2, exposure during 9/11 causing tracheal stenosis, lymphedema and wheelchair bound. The patient has been seen since mid-2017 with therapies including debridement’s, vascular interventions, IV antibiotics, multiple dressing treatments, compression wraps, and lymphedema pumps. The patient had experienced minimal healing during that time. The patient was started on nutritional supplements with hydrolyzed collagen peptides and L-citrulline 60 mls daily on 08/11/2022. The wound measured 10.5 x 8.5 x 0.2cm with multiple satellite wounds. He was last seen on 08/29/2022, the wound measured 9.6 x 8.2 x 0.2cm with satellite wounds closed. Patient #3 is a 69-year-old female who was diagnosed with right breast cancer mid-2020. She had a biopsy done of the right-sided lesion which came back positive for triple negative disease. She had a preoperative MRI which showed possible lymph node on the right side and a hot lesion on the left breast as well. She underwent bilateral mastectomies in November 2020. She underwent radiation to the right anterior chest wall February - April 2021. She underwent bilateral reconstruction 2/2022 which was originally uneventful. In 5/2022 she had a spontaneous rupture of the incision and wound dehiscence. The plastic surgeon eventually had to take her back to surgery to remove the implant on the right side. Patient presented with open wound to the right chest on 05/20/2022, dimensions 3.2 x 0.7 x 0.8cm with 5.1cm undermining 10-1 o’clock. At our facility she underwent serial debridement’s, chemical cautery with silver nitrate, attempted surgical closure, and hyperbaric oxygen treatments. She was started on nutritional supplements with hydrolyzed collagen peptides and L-citrulline 60 mls daily on 08/11/2022. She was last seen on 08/29/2022. The wound measures 1 x 0.
Can the Addition of Soft Silicone Adhesive Foam Dressings to the Prone Patient Pressure Injury Prevention Protocol Decrease Facial and Posterior Neck Pressure Injuries?
Category: Practice Innovation
Abstract: Topic: Studies have shown using foam adhesive dressings can redistribute pressure and help prevent pressure injuries. Covid-19 presented new challenges for a 25 bed Medical Intensive Care Unit in a large Academic Medical center in the Southeast, which in April 2020 was converted to an exclusively Covid-19 ICU. One of the treatment modalities for lung injury related to Covid-19 is prone positioning these patients. This can cause pressure injuries in locations that are not found with supine patients. Multiple soft silicone foam dressings are used to pad anterior bony prominences to decrease pressure injuries. Prone positioned patients also have an increased risk of disfiguring pressure injuries on the face and back of neck. Purpose/Method: Participants consisted of medical ICU Covid 19 positive patients undergoing proning therapy for lung injury. Prior to initiation of proning therapy, adhesive foam dressings for pressure redistribution were placed on anterior bony prominences by the unit nurse. As proning therapy continued and pressure ulcers appeared on the non-padded areas of cheeks and necks, the WOC Nurse, Nursing, and Respiratory therapists collaborated and implemented adhesive foam dressings to be placed on these areas as well. To facilitate application of these protective and prevention measures, respiratory therapy developed kits of premade endotracheal tube tape and foam dressings to be taken to intubations or for prone positioning patients. Results: Prior to implementation of multilayer foam dressings on the face and back of neck, the Medical ICU documented 4 pressure ulcers on 3 different patients on the face from the pressure caused on the cheek from the pillow; one patient required plastic surgery to repair damage from this pressure injury. All patients receiving proning therapy with face and neck foam dressings were monitored for face or neck injuries caused by pressure from the prone positioning. None of these patients developed pressure injuries. Conclusions: After implementation of tape kit, there were zero incidences of posterior neck pressure injuries and one incidence of facial pressure injury. The addition of the soft silicone dressings to the face to the proning protocol has shown to decrease pressure injuries.
Pressure Injury Prevention and Management: A Gap Analysis using Key Stakeholder Perspective
Category: Clinical Research
Abstract: PURPOSE: To examine pressure injury (PI) prevention/management using an innovative gap analysis methodology and key stakeholder engagement. Specific aims included: 1) development of a key stakeholder council; 2) literature review of PI prevention; 3) integration of key stakeholder perspective; 4) development/testing of a valid and reliable gap analysis instrument; and, 5) gap analysis of current PI practice. METHOD: A mixed-method convergent design and gap analysis approach were used at an academic university and Level I Trauma Center. An integrative lit review was performed. Qualitative interviews (recorded, transcribed, and analyzed) with 26 key stakeholders were completed. Gap analysis instrument was developed and psychometrically tested. A gap analysis of PI practices was performed.
Quantitative data were summarized using descriptive and comparative analysis; qualitative data were analyzed using thematic approach. RESULTS: The Council comprised of academic faculty with expertise in evidence-based practice (EBP), PI prevention, research methods, executive leadership, healthcare systems, and Lean Six Sigma methods. Clinical practice members included the Chief Nursing Officer, nursing manager, medical librarian, clinical nurse leaders (critical care, emergency, medical-surgical), advanced practice providers, and interprofessional healthcare. The literature review/appraisal resulted in 32 articles for a full-text review; concept map was developed, and 79 EBP items. CVI was conducted with a S-CVI 0.95. The hospital’s gap analysis resulted in a content present score of 56/79 (71%), a level of detail score of 82/237 (35%), ease of use score of 126/237 (53%), and total score of 265/553 (48%). Those EBP items that scored 4 or less (1-7) were identified as a gap. The Council rated the “gaps” according to priority (1-4) for action for development of an improvement strategy. CONCLUSION: This study provides a: 1) model for stakeholder engagement, 2) valid/reliable gap analysis instrument; and 3) method to identify gaps between current PI prevention practice and EBP quality indicators.
Pressure Injury Prevention in the Acute Care Setting:
Where do you Start?
Category: Clinical Research
Abstract: Purpose: To examine the current prevalence of pressure injuries (PI) and incontinence, examine the prevention practices, and to establish a benchmark for future improvement efforts. Method: A team of nurses was trained, using the International Pressure Ulcer Prevalence (IPUP) survey methodology, to conduct a first-ever prevalence survey in a 400 bed Level I Trauma hospital in the Alabama southern gulf coast region. Data were collected by trained nurses using the IPUP paper survey form, on March 9, 2022. Data were collected through observation and medical record review. Any PIs identified were confirmed by the Wound, Ostomy, Continence nurses. Data were entered into the IPUP website by two team members. Results: 14 trained nurses collected the data on 187 patients across 14 units. The majority of patients were male (n=99 (54%); age ranging 16 to 89 years of age. Total PI prevalence was 21/187 (11.23%) with 7/21 (3.7) being hospital-acquired pressure injuries (HAPI). The majority of HAPI were male (n=4/7, 57%) and the majority of those with a HAPI (n= 3, 43%) were 50-59 years old; 29% (n=2/7) were 80-89 years old. Almost 72% (n=5/7) of those with a HAPI occurred between day 7-18. The majority of HAPI were related to a medical device (6/7, 86%). Skin and risk assessment was performed 100% of the time but prevention interventions in those with a HAPI were lacking 14% of the time (moisture management, nutrition, repositioning, and redistribution surface). Incontinence prevalence was 69/187 (37%), with 4/7 (19%) of those with a HAPI being incontinent of both urine and feces; 3/7 (43%) had moisture associated skin damage. Incontinence interventions were lacking. Conclusion: This PI prevalence survey provided a benchmark for the future as improvement strategies are implemented. Improvement opportunities are focused on repositioning, incontinence/moisture management, support surfaces, and nutrition.
Effective Heel Pressure Injury Prevention: More Than Just Pillow Talk
Category: Clinical Research
Abstract: Background: Although most heel pressure injuries are preventable, they remain the most common site for deep tissue pressure injury and the second most common site overall.1 Pillow offloading for heel pressure injury prevention (PIP) is a common first line intervention, due to the perception that the practice is inexpensive and effective. But is it? Purpose: In the absence of published data, the singular purpose of this project was to assess the effectiveness of pillow offloading for heel PIP. Methods: A retrospective review of point prevalence data was conducted. Inclusions were patients with pillow offloading in use for pressure injury prevention or treatment. Heel offloading was deemed effective if the heels were free of the bed or chair surface at the time of assessment.1 Data was abstracted from a larger data set of preventive care observations and analyzed in aggregate form. Result: Twenty-one months of point prevalence data across 449 adult hospitalized patients in 32 U.S. hospitals was analyzed. The sample included both intensive care and non-intensive care units in 14 academic medical centers and 18 Magnet designated facilities. 100% of patients had a heel protection protocol in place, with pillow offloading as standard practice. 26.2% of the patients were offloaded appropriately. 72.8% of the patients had one or both of the heels in contact with the bed. Conclusion: Heel offloading with pillows is rarely employed consistently, correctly, or sustained over time. Based on this national study across a diverse sample of facilities and patients, approximately 3 in 4 patients may experience ineffective offloading and are therefore at risk for heel pressure injuries. Based on these findings, consideration should be given to employing more effective, sustainable, evidence-based heel protection early. These heel PIP measures may include, but are not limited to prophylactic dressings, offloading boots, and other heel positioning aids.
Smooth Sailing Through the Waves of a Pressure Injury Prevalence Survey
Category: Practice Innovation
Abstract: Background: The National Database of Nursing Quality Indicators (NDNQI) provides an electronic Pressure Injury Survey Guideline and Training class. However, WOC nurses at our center determined that additional tools were needed to enhance the mandated surveys. WOC nurses streamlined the process for an organized survey to include education for unit nurses and ‘real-time' guidance to meet patient care needs via a communication tool used by the survey team. This poster will describe the WOC-designed process for unit nurse education and user-friendly communication tools implemented to create an improved survey. Methods: WOC nurses organized quarterly survey dates. They reinforced education to nurses on patient care policies, survey dates, and expectations. They recruited clinical leaders, and champions from the Skin Wound Assessment Team. These members completed the NDNQI required training. One month prior to surveys, an announcement was sent to managers, Directors of Quality and Medical-Surgical. On survey day, team reviewed existing pressure injuries, bony prominences, and chart audits. They were alerted to important criteria such as medical device-related injuries; interventions such as foam dressings, specialty mattresses, incontinence barrier creams; securement of foley catheters; offloading equipment; nutrition, and restraints. They received a WOC nurse-developed communication tool entitled, “Interventions Needed” which was given and explained to unit nurses for follow-up needs of at-risk patients (e.g., overlay mattress). The team referred to a schedule, so as not to interrupt nurses during interdisciplinary patient rounds. Conclusion: Reinforcing education and enhancing communication ensures smooth and efficient surveys. Successful surveys not only provide mandatory information to NDNQI but enable opportunities to teach skin assessment skills, prevention, and pressure injury knowledge through additional innovative methods. Survey outcomes are reported to managers in a graph developed by WOC nurses for dissemination to staff.