Easing the pressure of wound care: working as a nurse practitioner in wound care for a regional district health board is an award-winning and rewarding job.

It's hard to deny the evidence that nurse practitioner (NP) Pip Rutherford is making a big difference in her speciality of wound care. Endorsed as an NP in December 2004 and employed as an NP by Hawke's Bay District Health Board (DHB) in July 2005, Rutherford has an impressive range of statistics showing the impact of her work on reducing the prevalence of pressure areas in hospital patients and boosting diabetes ulcer healing rates. Since she instigated the Prevalence and Incidence Study in the DHB in 2001, the prevalence of pressure areas has reduced from one in three patients to one in five. Another innovation has been the diabetes ulcer clinic, established three years ago, which also has impressive figures: over the first two years of the clinic's existence, 63 percent of wounds heated and 25 percent improved. Gathering the skills, knowledge and education to make such an impact on wound care and healing has been a career-long journey. That career began in 1969 in remote Western Australia where she worked as relieving matron at a nine-bed community hospital. "It was a baptism of fire. I did ambulance work, suturing, dressings, x-rays. As well as the clinical work, I learnt the importance of community in health care. The community of Wickepin had a strong sense of ownership of the hospital and support for the hospital was fantastic."

She and her husband and fatuity returned to New Zealand in 1982 and after working as a relieving practice nurse, she started work on a medical ward at Hastings Hospital in 1986. Following some years on this ward, she became one of three clinical nurse advisers for the medical service in 1996. With a team of colleagues, she was part of a smart group that oversaw the huge logistical operation of moving patients out of Hastings Hospital to Napier Hospital as the new regional hospital was built, and then back into the new hospital

In 1998 the DHB adopted a new model of care involving case management and care co-ordination. She was appointed to a new rote of case co-ordinator for wound care and intravenous therapy. In her time in the medical service she dealt with many complex wounds: non-healing ulcers, pressure areas, cellulitis. When she took up the co-ordinator position, she began studying for a post-graduate diploma in case management through Melbourne University, financially supported by the DHB. Rutherford was also wanting to enhance her clinical skirts and Monash University in Melbourne offered a range of postgraduate papers in wound care. Rutherford believes this combination of study gave her the background to move into an NP rote. "I knew I wanted to stay in clinical practice and there were not many career chances to do that, so the evolution of the NP role was very timely for me."

The path to NP endorsement was not entirely smooth. The Nursing Council initially declined educational equivalence but reversed its decision after Rutherford appealed. She remains grateful to NZNO's professional nursing adviser Susanne Trim for encouraging her to appear and assisting her through that process. Once endorsed as an NP, employment as such was not guaranteed. "I was the first NP in Hawke's Bay and the director of nursing (DON), Elaine Papps, and I had to demonstrate that such a role was needed."

The pressure area study and the diabetes ulcer clinic were already established--they had formed part of her NP application portfolio--but she had to make a business case for the NP role within the DHB. This was made easier by the fact that in a postgraduate paper looking at organisational analysis, she had developed a theoretical framework for a wound care service centred on a specialist GP. For her case to the DHB she altered this to a service centred on an NP. The DON was very supportive of the NP role and could see its benefits for the DHB. But when the Otago DHB advertised for a wound care NP, Rutherford, not yet confirmed in an NP role in Hawke's Bay, applied and got the job. An NP position subsequently became available at HBDHB and Rutherford chose to stay.

Her theoretical wound care service is now becoming a reality, with her as the specialist clinician. She has developed outpatient wound clinics--"a new direction and a new way of working." They function in the same way as consultant clinics and are herd monthly for dermatology, plastic surgery and infectious diseases patients. There is also a monthly clinic for wounds that don't fit any of those categories. These are earning some revenue for the DHB.

Clinics at the local PHO

Another recent development has been bi-monthly clinics at a local primary hearth organisation (PHO), the Hastings Health Centre. "One of the PHO nurses joins me and the GPs refer patients to the clinic. We do a full wound and vascular assessment and educate the patient about their wound. We are art sharing knowledge together and the PHO is appreciating having access to a wound perspective and knowledge it has not had before," Rutherford said. She will see people in their own homes if they are too sick to attend a clinic but there is no funding for that service as yet. And funding, or tack of it, is one of the big challenges of her role. "The Accident Compensation Corporation (ACC) has not factored into its funding streams the fact that NPs practise autonomously. We cannot directly access ACC funding and that is frustrating." But she is on an ACC working party and hopes that direct funding will be available in the not too distant future.

The autonomy of the NP roles enables Rutherford to correct data and took at outcomes. "From the data bases I can look at heating outcomes, the products used and be predictive about which wounds might heat and which might not."

Correcting baseline data in 2001 on the prevalence and incidence of pressure areas among hospital patients enabled Rutherford to see the big picture nobody else had seen. "Nurses work on their wards and know what's happening there but there was no big picture of the prevalence of pressure areas."

It was not a pretty picture, with one in three patients having pressure areas. That data provided Rutherford with the evidence needed to introduce a mattress replacement strategy in acute and rehabilitation areas throughout the hospital. The pressure-relieving mattresses have been a significant factor in the reduction of risk. So has nurses' increasing awareness of risk factors and how to reduce them. All patients are now assessed on admission for pressure area risk, using the Waterlow Scale. This examines 22 parameters including age, build, clinical condition, mobility, continence and nutrition.

Lack of resources

Why was the incidence of pressure area wounds so high? Rutherford believes greater patient acuity was the biggest factor but a tack of resources, eg the mattresses and a lack of awareness of preventative nursing actions were also factors. "Two hourly turns are not really appropriate. For some people one hour may be too long. And massaging the area is not a good idea as this can damage skin integrity. Nurses have to be very proactive about preventing pressure area wounds."

Nurses' awareness has been increased through education session in all acute areas, by improved documentation, and by nurses' involvement in collecting the data for the study. "Each year over the five years the study has been going, different nurses from each ward have done the survey. They have studied and been certified as assessors for the survey."

This multi-pronged approach to pressure area prevention has paid great dividends. Although the study was officially launched in 2001, Rutherford has been collecting data on pressure areas since 1999. In that year, 39 people had nosocomial pressure areas and 15 arrived in hospital with them. In the last year, 26 patients had pressure areas on admission and 11 acquired them in hospital. "What these statistics show me is that there have been great strides in pressure area care in hospital but also how sick some people are at home."

Rutherford's work in significantly reducing the incidence of pressure areas within the hospital has been recognised. The study won the award for the applied research category in the DHB's inaugural health innovation awards, announced last month. Rutherford said she was felt "very surprised and a bit overwhelmed" at winning the category.

She stresses that good skin care, off-loading pressure either by mattresses or positioning, and managing continence and nutrition are the keys to prevention. Rutherford is keen to take the study results and her messages into rest-homes to ensure the incidence of pressure area wounds in those admitted to hospital also reduces. The diabetes ulcer clinic was established three years ago by Rutherford and the DHB's diabetes nurse educator and podiatrist. The clinic is in the orthotics department, an ideal setting, according to Rutherford. Three to four people are seen at the weekly clinic. The first visit involves an hour-long assessment of the patient, including the wound, vascular function, medication, nutrition and family and social circumstances. The full wound assessment includes a diagnosis, ie whether it is an arterial or venous ulcer or one casued by rheumatoid arthritis; the state of heating is identified and the depth of damage, and Rutherford decides on management of the wound, which could be light compression bandaging or a referral to a vascular surgeon. Rutherford, the diabetes nurse educator and the podiatrist all take part in the initial assessment. A clinical photograph is taken at each visit, providing a visual record of wound healing. The impressive wound healing outcomes mean the work is "really, really rewarding".

Data collection vital

Again, data collection has been a vital part of her work at the clinic. Rutherford has analysed the eight amputations that have occurred among clinic patients over the last three years. "The analysis showed that the original wound, which eventually led to the amputation, was, in 80 percent of cases, from a pressure area caused by footwear. So it is a joy to have the clinic in the orthotics department where any problems caused by footwear can be rectified." As well as the clinics, Rutherford assists nurses on the wards. "The staff nurses have direct access to me. A nurse will ring me and we will arrange to see the wound together. We will assess the wound and make a diagnosis and discuss treatment and/or referral."

Rutherford does between 60 and 80 such visits a month and also assists emergency department, acute assessment unit and outpatient staff. Her accumulated knowledge and expertise is readily shared in a variety of local, national and international forums. Later this month she is holding a day-long seminar for all registered clinicians in Hawke's Bay. It includes a range of guest speakers on subjects from dog bites and trauma to the anatomy and physiology of healing; from wound management and dressings to preventable wounds; from wound infection to documentation. Up to 130 people will attend--"there is a yearning for the information," she says. She is presenting the results from the diabetes ulcer clinic at next month's wound society conference in Wellington; she has presented to house surgeons at the DHB; would like to present results from the diabetes ulcer clinic to the Grand Round; has presented at international conferences and runs a journal club open to all health professionals in the DHB. She also lectures in wound care to nursing students at the Eastern Institute of Technology and to nurses orientating to the DHB. Rutherford has taken a break from study this year but intends to complete her prescribing practicum next year.

She clearly relishes the autonomy of her rote and its rewards but is frustrated that because of the immense clinical load, more research is difficult. She appreciates the support of her two NP wound care colleagues, Jenny Phillips in Palmerston North and Julie Betts in Hamilton and knows the DHB's DON fully understands the role and its challenges and is able to articulate that board-wide. Rutherford is very aware that hers is not a "solo role" but one that relies on all nurses and many other health disciplines to achieve the impressive results.

An area where she would like to see further improvement is in wound diagnosis. "So many wounds don't have a diagnosis and, if there is no diagnosis, we are not treating the cause." She urges nurses to consider the whole person, not just the wound in their care, and to combine clinical practice with further education. "I would have struggled in this role without the knowledge of health policy, organisational change and all I learnt in post-graduate study." It seems ironic now that originally she was not confident she would have a rote as an NP in the DHB. But that role, while still evolving, is well established "and it is much better than I had ever anticipated".