A team approach to effective wound care: continuity, consistency contribute to successful healing.

Most nursing facilities will tell families they do wound care, but not all wound care programs are as effective and successful as others. There are key elements that have made the wound care program at Island Nursing and Rehab Center, Holtsville, New York, a truly successful team effort.

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We feel the core of our success is due to an established wound care team, with expertise in various areas to complement each other. Our team consists of the three of us (one physician specialist and two nurse practitioners), a dietitian, and rehab staff including a physical and occupational therapist. We have a strong emphasis on consistency, doing wound rounds weekly, without exception. Since wounds are individual, we vary treatment as needed for each resident, knowing that each resident should be assessed separately.

The initial wound assessment occurs after admission when nurses make a referral to the nurse practitioner, requesting a wound evaluation. Within 24 hours of admission, we evaluate, stage, and order the appropriate treatment.

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Weekly assessment

Each week we do rounds with the full team, assessing each resident with wounds. The dietitian evaluates the nutritional status of each resident to be sure he or she is receiving the appropriate supplements. She follows blood work to monitor the nutritional status of the resident, following the protein status very closely. Rehab staff provide input on support surfaces including wheelchair cushions and mattresses for pressure reduction. Team members approach the resident and the wound from their own area of expertise and each recommendation is thoughtfully considered when making a plan.

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Residents are followed daily by the nurse practitioners and staff nurses, many of whom have been working together for years. The relationship between the nurses, aides, and the nurse practitioners is key. They each share in responsibility of monitoring wounds and following through with treatment. With a commitment to the wound care program, the nursing staff is focused on observation and reporting. A constant focus and awareness of wound care and excellent communication from the nursing staff enables us to be aware of even the smallest change in a timely manner.

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At Island Nursing and Rehab Center we have placed a priority on having the same members of the wound care team evaluate patients each week. Another benefit is that we do not have different people measuring the wounds. Not everyone would measure the same wound the same way or have the same experience and expertise. We know that with the same skilled team working each week, that there is consistency in the evaluation and measuring process.

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Treatment

Treatment options include tried and true methods as well as high-tech options such as wound vac. But we feel that with our focus, we are highly attentive and aggressive, which ultimately makes us successful in healing. Our motto, "Identify early and treat small."

Sharp debridement 

With a skilled wound care physician as part of our team, we are able to provide sharp debridement at bedside. Dr. Bhanumathy Vinaya uses local anesthesia for Stage 3 or 4 wounds that have necrosis or slough. Done with a scalpel, dead tissue is removed to allow healthy tissue to grow and fill in the ulcer. Sharp debridement is followed by the daily application of an enzymatic agent. Sharp debridement also provides faster results when done correctly and should only be done by someone with advanced medical training and skill. For our facility, we are pleased that our patients have the benefit of a skilled professional who is able to provide this, as it promotes better healing.

Prevention

At Island Nursing and Rehab Center, our wound care team is constantly educating the staff. Our goal is for those who have direct patient contact to always recognize a wound, particularly those in the early stages. We also focus on early identification of patients who are at high risk for developing pressure ulcers and put preventive measures in place immediately upon admission. We use low air loss mattresses that alternate airflow and specialized wheelchair cushions for patients with lower back/buttock wounds or areas of potential concern. Our feeling is that if the patient doesn't move, the pressure does.

Supportive care 

Other supportive care includes heel lift booties for all actual heel wounds and also for residents at risk. Blood work, other than monitoring protein status, includes monthly prealbumin levels until prealbumin is within range, followed by three-month checks on prealbumin once it is in range. We also follow up on hematocrit and hemoglobin levels as well. We use fecal incontinence bags and Foley catheters as necessary to prevent wound contamination. Frequent repositioning is key and is taught to all staff involved in patient care.

For other facilities looking to improve their wound care, our suggestion is commitment, consistency, and continuity. Empower your staff so there is a commitment to focus, observe, and to communicate. Try to establish a specific team, where each week the same members see the patients so that progress can be monitored most effectively and seamlessly. One last piece of advice--stay on top of the program. Continuity at the end of the day will enhance your healing rates, make your administration happier, and improve the quality of life for your patients.

Tips for Establishing a Successful Wound Care Program

* Staff education

* Continuity of team

* Strong communication between nursing staff and wound care team

* Support materials in place

BY BHANUMATHY VINAYAGASUNDARAM, MD, CWS; LOIS HALPIN, MS, ANP-BC, CWS; AND CATHERINE SULLIVAN, MS, ANP-BC, GNP-BC

Bhanumathy Vinayagasundaram, MD, CWS; Lois Halpin, MS, ANP-BC; and Catherine Sullivan, MS, ANP-BC, GNP-BC are part of the wound care team at Island Nursing and Rehab Center, Holtsville, New York. For more information, call [phone] or visit www.islandnursing.org. To send your comments to the authors and editors, e-mail [e-mail].