San Antonio, TX—The creation of a dedicated wound ostomy care (WOC) team resulted in an almost complete elimination of pressure ulcers in a 74-bed hospital, according to nurses who created it and described the program at the Oncology Nursing Society 41st Annual Congress.
"We have a new sense of awareness of the importance of pressure ulcer prevention," said Stephanie Terry, BSN, RN, CWOCN, PCCN, HN-BC, who co-created the program with Joe Rudolph, BSN, RN, CWOCN, DWC, of Cancer Treatment Centers of America at Eastern Regional Medical Center in Philadelphia, PA.
The 2 certified wound ostomy and continence nurses direct the skin integrity care for all the institution's inpatients and outpatients.
Oncology patients are at high risk for skin issues. Contributing factors include immobility, poor nutrition, lack of adherence with self-care regimens, change in mental status, and cancer treatment, "which, in addition to slowing or stopping the growth of cancer, can affect a person's skin, hair, and nails," she said.
"The year 2013 was eye-opening for us," said Ms Terry. "Our hospital-acquired pressure ulcer prevalence rate was a shocking 11%! The benchmark really should be zero. We knew we needed to make some changes."
Pressure ulcers (bedsores) are caused by constant pressure on one area of the body. For patients who are bedridden, an air or water pad that lies on top of the mattress helps prevent them. Special "low-air-loss beds" or "air-fluidized beds" may also help prevent ulcers or keep them from worsening.
"In response to the high-risk oncology patient and our high quarterly prevalence rates, the skin wound ostomy team, aka, SWOT, was born," she said.
Recruitment and Training
Nursing recruitment for the original SWOT was accomplished by flyers, emails, and rounding on the floors, with Ms Terry and Mr Rudolph seeking out nurses who had expressed a special interest in skin, wound, and ostomy care. Currently, 25 nurses are dedicated to "skin excellence" and have been labeled the "skin champions."
SWOT agreements were designed to outline expectations and provide team members with a sense of membership. These agreements are aligned with the institution's incentive program, known as the professional clinical ladder.
Training of the skin champions is conducted through a yearly in-depth educational module, along with monthly meetings to review prevalence rates. Root-cause analysis creates "mindfulness of how we can improve the care we provide to our patients, and a culture of awareness and safety," Ms Terry said.
Before implementation of the program, pressure ulcers were tracked through consults with the WOC nurse, but this system lacked transparency.
"At the time, we didn't have a grip on what was going on in the hospital, and we didn't have the tools we needed to implement that transparency," Ms Terry told The Oncology Nurse-APN/PA.
Today, an electronic variance system has significantly increased transparency; it allows staff to notify the WOC nurses, the quality department, and senior management of all skin integrity issues in both the inpatient and outpatient settings. The system also allows the wound experts to document incidence, which represents daily occurrences and is the best quality measure of the prevention program, she explained.
"With the electronic variance system, we are more proactive and there is lots more transparency," she noted.
A critical component of the program is Wound Care Wednesday, a proactive assessment of skin integrity for all hospitalized patients that is completed each Wednesday by a skin champion. This nurse also completes a rounding tool that focuses on specific details, including Braden score and the use of proper interventions for high-risk patients. The data can be used to identify and address areas of weakness.
Pressure ulcer prevalence is now determined monthly. It includes assessment by 2 nurses (with another nurse recording data), followed by chart review (nutritional status, etc) and debriefing.
The SWOT program has had a clear impact on the facility and stakeholders, Ms Terry reported.
The hospital-acquired pressure ulcer prevalence rate decreased from a high of 11% in 2013 to below 1% in 2015, with resulting declines in penalties to the hospital. Skin assessment documentation on admission and during hospitalization has improved. Nursing staff are now more aware of the available skin, wound, and ostomy products, and they report increased satisfaction. SWOT has also served as a model for improvement in other areas, for example, leading to the creation of the Fall and Safety Team.
SWOT has received significant support from senior management, as evidenced by proper staffing ratios that facilitate adequate training of floor nurses. The team structure continues to improve with the addition of team leaders, she said.
"We continue to set short-term goals," Ms Terry added, "that will eventually lead to the overall goal of maintaining a hospital-acquired pressure ulcer rate of zero!"
Terry S. Evolution of a skin wound ostomy team (SWOT) program to meet the challenges of oncology patients. Presented at: Oncology Nursing Society 41st Annual Congress; April 28-May 1, 2016; San Antonio, TX.