According to the National Cancer Institute, an estimated 1.6 million new cases of cancer will be diagnosed in the United States in 2016. The number of people living beyond a cancer diagnosis reached nearly 14.5 million in 2014 and is expected to rise to almost 19 million by 2024.1
Throughout the course of their disease, oncology patients may need to be hospitalized for a surgical procedure, treatment regimen and/or management of other oncologic complications. An area of primary concern throughout the hospitalization is not only managing patients' acute complications, but making sure appropriate safety measures are in place to support the patient's integumentary system to prevent pressure injuries.[*] Oncology patients are at high risk for skin issues for a variety of reasons, including: pain, fatigue, compromised immune system, decreased mobility, malnutrition, and interruption of skin integrity secondary to radiation and chemotherapy treatment.2
Prior to 2013, at Cancer Treatment Centers of America Eastern Regional Medical Center all wound, ostomy, and continence needs were managed through physician consultations. Assessments and interventions carried out by the wound, ostomy and continence (WOC) nurses were reactive. The high rate of hospital-acquired pressure ulcers (HAPU) along with inadequate documentation of skin assessments throughout admission and in-patient stays were key findings to prompt an intervention. HAPU prevalence rates were as high as 11% throughout 2012-2013.
A significant change in culture and practice was needed throughout the institution to determine how we prioritize and manage skin health within the hospital. So in 2013, CTCA created its Skin Wound Ostomy Team (SWOT). The shift from a reactive plan of care to a proactive, preventive plan of care is the type of quality improvement program we sought to achieve and provide for our patients.
Building the Team
TheWOC nurses met with the Director of Quality and the Director of Nursing to outline their plan to increase education in the hospital through the use of advanced skin care educated nurses.3 Once guidelines for the development were approved, the recruitment phase began. WOC nurses sought to enlist other nurses during the hospital's annual skills fair and through SWOT advertisements in weekly newsletters. Incentives for nurses included recognition from fellow peers, contact hours for educational offerings, and points for their professional clinical ladder.3
All SWOT members signed an agreement to complete required education (three continuing education units yearly) and attend biannual education in-services provided by the WOC nurse. They would also be required to participate in three monthly prevalence studies and three weekly skin rounds that became known as "Wound Care Wednesdays" yearly. Attendance was mandatory at a four-hour education classroom session. The education consisted of pressure ulcer staging and interventions, pressure ulcer prevention, various wound etiologies, surfaces, and hands-on-training with ostomy and wound care products.3 Members were also given the opportunity to spend eight hours with a WOC nurse. Individual reviews of each nurse's knowledge base and skill set determined who would be required to obtain additional hands-on training with patients.
As the structure of the team was building, the need to evaluate current processes and products was warranted.4 Hospital skin protocols and products were assessed and updated with the latest evidence-based research and practices for our patient population.5 All new education materials and supplies were made available to nurses on units. With these new protocols and products in place, implementation of care could be carried out in an effective, efficient, and consistent manner. Having the appropriate materials available for floor nurses was essential for staff compliance and optimal patient outcomes.
Upon implementation of the SWOT and new protocols, audit tools were used to better capture pressure ulcers at our institution.6 Monthly results were obtained and reported to the Quality Department while the weekly skin round audit tool was collected and stored in a binder on each unit. The binder included extra data collection paper, protocols, and education resources. These papers were collected monthly and logged into an Excel spreadsheet.
As with any new program we recognize barriers and areas of improvement.6 For example, some nurses appear to be more vested than others, and some feel they are not provided with enough opportunities to participate in activities. Additionally, the skin audit tool is not consistently completed by the appropriate staff. As these threats have been identified as weaknesses, it also allows us to identify areas of improvement.
Change and Growth
We see an opportunity for teaching, change and growth. All feedback is welcome and changes are made to better serve patients and staff. Hospital policies and protocols are continuously assessed and those changes are presented to the nursing practice, SWOT and management teams prior to implementing.
Since its creation, we have seen improvement in nurse education, reduction in HAPU and overall improved quality of care as a result of the SWOT initiative. More consultations and variance reports are being generated for high-risk patients and implementations of correct protocol intervention are higher based on WOC nurse findings upon assessment. The implementation of daily incidence has improved transparency within our hospital and has been standardized throughout Cancer Treatment Centers of America. Incidence rates of pressure ulcers have remained low: 1.025% in 2014, and 1% in 2015. Prevalence rate for 2015 was 0.33% and recent prevalence studies have shown zero hospital acquired pressure injuries. This is paramount as pay for performance values improved outcomes. The utilization of skin teams may be something all oncology hospitals want to implement.
1. National Cancer Institute. Cancer Statistics. 2016. http://www.cancer.gov/about-cancer/understanding/statistics
2. Haas ML, & Moore-Higgs GJ. (Eds.). (2010). Principles of skin care and the oncology patient. Oncology Nursing Society.
3. Taggart E, McKenna L, Stoelting J, Kirkbride G, & Mottar R. (2012). More Than Skin Deep: Developing a Hospital-Wide Wound Ostomy Continence Unit Champion Program. Journal of Wound, Ostomy & Continence Nursing, 39(4), 385-390.
4. Delmore B, Lebovits S, Baldock P, Suggs B, & Ayello E. (2011). Pressure Ulcer Prevention Program: A Journey. Journal of Wound, Ostomy & Continence Nursing, 38(5), 505-513. doi:10.1097/WON.0b013e31822ad2ab
5. Carson D, Emmons K, Falone W, & Preston A. (2012). Development of pressure ulcer program across a university health system. Journal of Nursing Care Quality, 27(1), 20-27.
6. Ratliff C, & Tomaselli N. (2010). WOCN update on evidence-based guideline for pressure ulcers. Journal of Wound, Ostomy & Continence Nursing, 37(5), 459-460. doi:10.1097/WON.0b013e3181f17cae
Joe Rudolph and Stephanie Terry work at Cancer Treatment Centers of America at Eastern Regional Medical Center in Philadelphia, Penn.
[*] On April 13, 2016, the term "pressure injury" replaced "pressure ulcer" in the National Pressure Ulcer Advisory Panel Pressure (NPUAP) injury staging system, according to the NPUAP. The content and information gathered throughout this quality improvement program were initiated prior to this change in definition. Therefore, pressure ulcer and hospital acquired pressure ulcer (HAPU) were used to describe events throughout this program. Click here to read more about the new NPUAP staging system.