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The on-site wound care unit: a blueprint for success.

Setting aside an area of your facility for specialized wound care is do-able and worthwhile

Your skin care protocol is dated. Treatment is sometimes redundant, often inconsistent, and always costly, and the pharmacy is filled with products that are seldom, if ever, used. Your most experienced wound care nurse works on an ambulatory unit and hospitalizations for pressure sores are increasingly frequent.

If even one of these scenarios sounds remotely familiar, there is room for improvement in your facility's provision of skin and wound care. In November 1992, St. Augustine Manor, a long-term and rehabilitative nursing facility in Cleveland, Ohio, addressed these issues by opening a 20-bed on-site unit devoted exclusively to the comprehensive treatment of pressure sores. All nurses on the unit are trained in aggressive prevention of skin lesions and consistent, cost-effective wound care, performed under interdisciplinary management. By all accounts, since the unit's opening, the number of acquired pressure ulcers has gone down significantly.

The following outline is intended as a general model for those facilities interested in designing a new unit, refurbishing an existing unit, or simply setting aside a small number of beds for wound prevention or treatment. The basic steps taken by St. Augustine can and should be customized, scaled up or scaled down, to meet the needs of your facility. Please note that the order suggested here is somewhat arbitrary, since many steps overlap.

Make a Commitment

The staff's level of commitment to a large, long-term interdisciplinary project is directly proportional to that of the administration. That commitment must be strong enough to weather the many ups and downs inherent in such a project.

Conduct Research

Once a commitment has been made, it's important to gather as much information as possible about the needs of the population you will be serving and the most effective ways to do so. St. Augustine conducted extensive research that included a literature review, a telephone survey of social workers and nurses, and focus groups of physicians. The research revealed a need to serve not only the facility's own residents, but transitional patients from the community as well.

A visit to, or telephone contact with, a facility with a unit similar to the one you've planned is an excellent way to obtain a "sneak preview" and helpful ideas. The unit's coordinator and staff are uniquely qualified to prepare you for what lies ahead and will likely be more than willing to do so.

Hire or Appoint a Program Coordinator

Whether you're able to hire a nurse enterostomal therapist (ET) consultant, as did St. Augustine, or you appoint an RN already on staff with an interest and experience in skin and wound care, one person should be responsible for coordinating the project from inception to implementation. That person should, at the very least, be an RN with excellent leadership and communication skills and a thorough knowledge of geriatric skin and wound care.

The coordinator advises on staffing; conducts staff education; coordinates protocol and policy development revisions consistent with Agency for Health Care Policy and Research (AHCPR) guidelines(*); monitors treatments and their documentation; evaluates inventory and products for purchase; and serves as an interdepartmental liaison and contact with community resources. A certain amount of autonomy is suggested for the coordinator to perform the job effectively.

Formulate a Plan

Your plan is developed, refined, and finalized during interdisciplinary meetings with the administrator, coordinator, all department heads, and other key staff. At St. Augustine, the first of four meetings over the 1-year planning period was devoted to setting goals: surveying the present situation (protocol, census, staff, physical layout, equipment, funding) and deciding where the facility wanted to be within a specific timeframe.

It is during this initial meeting that decisions are made with respect to the population that will be served and whether the unit will be geared toward either preventive care in high-risk residents or treatment of existing ulcers. Begin by thinking big, i.e., brainstorming about the ideal unit for your facility. Then prioritize your goals to formulate a realistic plan. This is the time for any and all questions and input from staff. Be sure to take fastidious notes and make a tentative schedule for discussion of the above-mentioned topics.

Select Candidates

Your criteria for admission to the unit will be based upon your goals and capabilities, and the population you intend to serve. A validated risk assessment tool will help identify the best candidates for admission to the unit. St. Augustine found that concentrating the most difficult cases (stage 3 and 4 ulcers) in one unit was conducive to providing the most effective, efficient care.

Be realistic about your capabilities and don't be afraid to say no to new admissions. Filling every bed with residents requiring total lifts and complicated treatments will rapidly lead to staff burn-out. When in doubt, the admissions director should always consult the head nurse or coordinator.

Begin Centralizing Residents

The sooner residents are moved to a single location, the sooner that location can begin functioning as a unit. As long as staffing is stable (no nurses on leave, etc.), this can and should be done even before a site has been finalized. New residents can be admitted directly to the designated site.

Begin Staff Education

Staff education should begin as soon as possible and continue indefinitely. At St. Augustine, the formal sessions conducted monthly by the coordinator later evolved into small, informal sessions on the unit or at the bedside. The initial session conducted by the coordinator and administrator was held to inform the staff of the plans and to clarify their purpose. The meeting was mandatory for all department heads and optional for any other interested staff directly involved in patient care.

From the very basic to the more sophisticated, these sessions should include basic orientation to skin care terminology, products, and their intended purposes, current modalities in prevention and wound healing, treatment mechanisms, and the "how to's" of wound care. The staff's needs and expectations should be surveyed frequently, and issues such as communication and interdisciplinary management of pressure ulcers can be addressed in a nonconfrontive manner that encourages questions and instills confidence and consistent care. Cooperation and communication with OT, PT, and RN are vital from the outset.

Review and Revise Policies and Procedures

This is an ongoing, time-consuming, and admittedly tedious nuts-and-bolts process. It should, however, be initiated as soon as possible by the coordinator, director of nursing, quality assurance staff, infection control and treatment nurses. Whether starting from scratch or revising existing policies, the facility-wide policies and procedures must be consistent with AHCPR guidelines and the goals of your program.

The following issues are among those that must be addressed, finalized, and documented as part of your official policies and procedures for skin and wound care:

* Criteria for admission to the unit, new resident admissions, and special circumstances, such as alternate plans for a day with an unusually large number of admissions.

* Specific preventive and therapeutic protocols. All care must be individualized.

* Infection control

* Treatment approach. Decide how skin care will be provided. An interdisciplinary skin and wound care team facilitates prevention and individualized care. Make sure treatment expectations are realistic.

* Quality assurance measures addressing skin status and treatment efficacy; what will be documented; who will document and how often; and who will monitor documentation. Treatments should be updated and employed consistently by all shifts. Documentation inservices may be required.

* Criteria for skin and wound care products. Guidelines are being developed with the assistance of the National Pressure Ulcer Advisory Panel (NPUAP)(*). Avoid purchasing an entire product line which may lock you into products you don't need. Develop a means to educate all staff in the use of all products.

Staff the Unit

Below-minimum staffing of NAs and licensed nurses hampers effective prevention and risks treatment omission errors that are costly both in dollars and in delayed wound healing.

Ultimately, your wound care nurses should work almost exclusively on the wound care unit. You may, however, have to substitute "primarily" for "exclusively" to allow for turnover and frequent "floating." At some point, the entire nursing staff should be rotated through the unit so that staff from other units can step in and maintain consistent care, as well as receive some good basic education in the techniques.

Perform Cost Analysis

The project coordinator, administrator, department heads, purchasing clerks and other staff involved with finances will require several meetings to finalize issues related to funding for the unit itself, staffing, equipment, and related expenses.

Funding for the project will vary according to type of facility, the population served, and community resources. If a budget for the unit is not available, a number of funding options are available, such as private contributions, grants from local philanthropic organizations (be sure to hire a grants coordinator, if at all possible), and matching funds or donations from churches or businesses.

In addition to pharmaceuticals, funds must be available for items such as specialty beds, high-tech mattresses and overlays, wheelchairs, staff education materials, a camera for documentation, a slide projector for inservices, and occupational and physical therapy equipment (eg, positioning devices). The program coordinator should be responsible for meeting with product representatives, testing products, and making recommendations to the product committee.

Open the Unit

Your protocols are in place, your trained nurses are centralized, treatment is designed to be effective and efficient: You're finally ready to officially "launch" the program. Be patient. This is a time of adjustment, when unanticipated problems (and, yes, benefits) are sure to surface. Now that you're able to recognize additional needs first-hand, don't be afraid to make changes. This is the time to rethink and reevaluate. Communication, constant evaluation, documentation, and accessibility are never as important as during the initial months when you are establishing your baseline of operations.

Staff education continues, making certain all new staff are oriented to the unit. The coordinator monitors treatment efficacy and staff efficiency by checking skin grid sheets for the weekly ulcer length, width, and depth documentation required by OBRA.

You may find that an open house for residents' family, health care professionals, and the community at large is an excellent way to market the facility.

Ongoing Evaluation

Prevention, treatments, documentation, medications, equipment, finances, staff, and quality of life all must be evaluated during the life of the program. Your quality assurance team will set the standards and chain of command for that evaluation. Quality assessment tools may be coordinated by a single treatment nurse if yours is a smaller facility. A larger home may instruct a nurse on each unit to collect the necessary information, eg, weekly wound measurements and documentation of all breakdown, including stage 1 ulcers.

Product efficacy should be evaluated regularly to identify the need for change and to avoid waste.

Secrets to Success

Communication is central to the success of any specialty unit or program. It extends from the administrator, to the OT, PT, or RD therapist, to the purchasing clerk, all of whom are now familiar with the goals of the program, their roles and the roles of their colleagues.

Accessibility is equally important. The coordinator, dietician, and infection control nurse, for example, should be able to meet at a moment's notice to discuss a particular resident. At St. Augustine, the staff had access to the coordinator's home phone number to maintain communication during off hours. As for documentation, while every nursing home staff member knows its importance when the surveyors come to inspect, careful documentation is also the key to evaluating the results of your labor. It is also a vehicle for individual caregivers to take credit for the quality of care they provide.

* For more information on the Agency for Health Care Policy and Research (an arm of the U.S. Department of Health and Human Services - Public Health Service), write the Agency at the Executive Office Center, Suite 501, 2101 East Jefferson Street, Rockville, MD 20852. For more information on the National Pressure Ulcer Advisory Panel, please write Anne McCooey, NPUAC, SUNY at Buffalo (Beck Hall), 3435 Main Street, Buffalo, NY 14214, or call 716-831-2143.

Judy Schaffer, RN, is a certified enterostomal therapist with a degree in gerentology. She served as the project coordinator for the St. Augustine Manor Wound Care Unit and has several years of experience as a nursing home wound and skin care nurse. She is now based in St. Louis, where she works as an independent consultant in geriatric wound and skin care.
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Article Details
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Title Annotation:Special Section
Author:Schaffer, Judy
Publication:Nursing Homes
Date:May 1, 1993
Previous Article:Non-pressure sore wounds: the Wound Care Center approach.
Next Article:Pressure ulcers: keys to prevention.

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