ADVANCE Best Nursing Team 2012
Skin Care Committee, Texas Health Presbyterian Hospital Dallas
Through extensive education, collaboration and innovation, the Skin Care Committee at Texas Health Presbyterian Hospital Dallas lowered the prevalence of hospital-acquired pressure ulcers (HAPU) facilitywide to 0 percent.
Texas Health Dallas has included nurses in process improvements, including HAPU, for more than a decade, but in recent years the nurses on the Skin Committee have taken interventions to the next level.
"We realized we were still trying to solve the problem of pressure ulcers with the same approaches we had been using for several years," said Cynthia Ekes, MA, BSN, RN, NEA-BC, director of nursing for acute care. "And so, we pulled our team together and asked them to come up with new and creative ways to prevent HAPU."
Together they came up with a variety of initiatives centered on increasing the knowledge and expertise of all caregivers involved in skin assessments and interventions. "This team took a fresh approach to the age-old problem of pressure ulcers, freeing themselves from the boundaries of traditional methods and utilizing a positive deviance approach to the problem" said Cole Edmonson, DNP, RN, NEA-BC, FACHE, chief nursing officer, "and the results speak for themselves."
The team, which meets monthly, partnered with the wound, ostomy and incontinence nurses, physical therapy and nutrition units to identify best practices. New processes were put in place that promoted early identification of HAPU, as well as staff awareness and understanding.
For instance, the "turning buddy" system was implemented, which establishes a schedule ensuring patients are turned every 2 hours. In addition, at shift change, the nurse leaving and the nurse coming on duty assess the patient together at the bedside.
All wounds, pressure ulcers or otherwise, are photographed and imported to the electronic medical record system when a patient is admitted. This is for the benefit of the direct care staff, as well as a means to communicate with other units.
"We have closed the loop of communication between the nurses at the bedside and the wound care clinic, where a lot of our patients go when they're outpatients," said Debbie Kelp, RN, chair of the Skin Care Committee.
Increased knowledge was a central focus. The RNs' assessment skills were enhanced through a web-based training module, which illustrated the stages of skin breakdown and the accompanying characteristics. Approximately 90 percent of all RNs completed this training.
The importance of such practices and the positive outcomes that would result were presented to other direct care RNs through the designation of unit-level Skin Care Champions.
In an effort to raise awareness, the Skin Care Champions from each unit meet quarterly to receive education from the WOCNs, physician wound specialists and the vendors who provided skin care products. This knowledge was then brought back to their individual units.
Also, these nurses conduct quarterly Skin Prevalence studies, which involves assessing the skin of every adult in-patient. Units that are not showing improvement are required to conduct the studies more frequently. Some occurred as often as once a week until the unit showed and maintained the necessary standards.
"These studies give us a snapshot of where we are in one given day with all patients in the hospital," Ekes said. "The heightened awareness and the new diligence of everyone from the bedside nurse to the manager involved in that unit has been the catalyst for change. The ownership at the microsystem level has truly helped transform the care process."
To confirm reliability of the assessments conducted by the Skin Resource nurses, the WOCNs conduct a second assessment later in the day of each HAPU identified in the quarterly prevalence study, according to Texas Health's BNT entry.
All disciplines support one another, ensuring continued success and positive outcomes.
The Skin Care Committee also identified another staff population that could benefit from additional expertise and experience: patient care technicians (PCTs).
"We recognized and embraced how important PCTs are in the patient's care team every day. They often see the patient more than the nurse does on certain days," Kelp said. "And so we included them on our committee, which strengthened their personal accountability."
PCTs participate in the quarterly studies and receive specialized HAPU training, which focuses on early detection and what to report to the patient's nurse.
"We include more people all the time; it's very interdisciplinary," Kelp said. "Physical therapy is involved, nutrition is involved, the wound care clinic is involved, and the physicians are involved. It's about everyone looking out for that patient's skin."
Awareness & Accountability
While initially, time and staffing posed a challenge, the benefits revealed themselves through the Skin Prevalence studies. Improvement could be seen firsthand and was recognized, which helped to eliminate any lingering staff concerns regarding workload.
"Change, even good change, can be stressful. We embraced that resistance was going to happen as part of the change process, especially as it was going to change the work flow and some of the daily routines for clinicians," Ekes said. "In the beginning of the process change we kept everyone focused on the end goal and recognized that workflow change was a challenge, but in the long run it was less work for everyone and would provide better outcomes."
"When they hardwired that practice of looking at the skin and looking at it more frequently we had less and less skin issues," Kelp added. "So they were able to see the value, plus hospital recognition of nurse-sensitive indicators is very high."
While education is key, it was quickly realized that there also had to be accountability. "That's how this whole plan was driven. We put the accountability right at the bedside and the managers and directors support that," she stressed.
Since the revamping of the Skin Care Committee, hospital stays have shortened and complications have lessened because of patients avoiding pressure ulcers while they are being treated.
The data has shown a steady decrease in the incidence of HAPU. In the fourth quarter of 2009, HAPU exceeded 10 percent, but by second quarter 2011, the Skin Prevalence study showed a hospitalwide HAPU rate of 0.8 percent.
The most recent fourth quarter study confirmed the benefits of increased expertise with a HAPU prevalence of 0 percent.
On top of this clear improvement, patients have shown increased satisfaction and understanding of their care. Nurses make a point to explain the Skin Prevalence studies and the corresponding benefits.
"In addition, reporting at the bedside includes the patients in their plan of care and helps to set goals for that day," Ekes said. "They feel the nurses are communicating better with them."
As the team moves forward with a 0 percent incidence of HAPUs, the Skin Care Committee remains dedicated to upholding the highest standards of patient care.
"The challenge for us now is to maintain the gain that we have made and that is absolutely as hard as getting to where we are now," Kelp emphasized. "We have to keep the awareness alive, we have to keep people accountable and education has to be a part of it."
The added attention to hospital wide expertise has led to increased accountability and dedication, which can translate beyond HAPU.
"I am sure future projects will grow as the staff continues to see and understand the impact they have had on changing processes and improving outcomes for patients," Ekes noted. "And they will be able to use those same types of tools to improve other aspects of the care that we deliver."
Catlin Nalley is editorial assistant at ADVANCE.