Wound care protocols keep all providers on same page

Hospital’s program earns results and recognition

If there’s a truism about the often ambiguous process of wound healing, it’s that a multidisciplinary approach works best. Hospital home health staff at Illinois Valley Community Hospital in Peru, IL, have been able to achieve this often-elusive goal using a quality improvement program for a comprehensive and standardized wound care protocol.

Not only do the improvements ensure that staff are literally on the same page in wound treatment, but the efforts also won honorable mention recognition from Press, Ganey Associates, a quality improvement company in South Bend, IN. The hospital and its home health agency, Illinois Valley Home Health Services, were noted for the program as well as for the cooperation between physicians and the nursing staff.

The program was developed because of the need to create a cohesive and consistent wound care regime, and to draw together the various players, says Deb Puetz, RN, a staff nurse with Illinois Valley Home Health. The first step was the formation of a wound care committee consisting of nurses from the medical and surgical floors and from home care; a nutritionist; and a physical therapist.

Committee members compiled data on an enormous variety of wound care products and studied volumes of educational material on staging and treating wounds. They also consulted with representatives from wound care product manufacturers to come up with a standardized and specific plan for various stages and types of chronic wounds.

Puetz and the committee presented the plan to the medical staff, which agreed that the contents could serve well as wound care standing orders. Physicians would always keep the option of modifying the recommendations to fit a specific case.

Puetz notes that the protocols give added weight to suggestions made to physicians, who also benefit because they can consult manuals placed in all of the patient care areas, or they can just ask the nurses.

"It was a way in which we could approach a physician and say, for instance, According to our wound care protocol, this is what’s recommended for a stage II pressure ulcer, and we would recommend this product.’ But it leaves the final decision to the physician. The medical staff has been very cooperative, and our outcomes have improved. We even went so far as to recommend certain products," says Puetz.

Inservices were held with the hospital and home health nursing staff, physical therapy, central supply, and nutritionists. According to hospital staff, the results have been "awesome."

"Everyone was cooperative," Puetz says. "It was a pleasure to see the team approach to such a common problem. All patients were evaluated with the Braden Risk Assessment Scale, and prevention was included in planning for care."

The plan contains fairly detailed descriptions for various wound scenarios and includes the following documents:

• individual wound and skin protocols for stage 1, stage 2, stage 3, and stage 4 wounds (see copy of stage 1 protocol, p. 42);

• skin/wound assessment form (see form, p. 43);

• Braden Risk Assessment Scale (see p. 44);

• wound care flow sheet;

• prevention guidelines for patients;

• bladder/bowel incontinence protocol.

In addition, a separate wound care manual addresses products, basic wound cleansing, wound irrigation, wound packing, skin barrier sprays, transparent films, non-adhering dressings, foam dressings, wet-to-dry dressings, hydrocolloids, hydrogels, calcium alginates, enzymatic debriders, and whirlpool treatment.

An example of how the new program works involves a case study of a patient named Lew. The 62-year-old man was struggling with an exacerbation of his colorectal cancer. A bowel obstruction, secondary to metastases, had occurred. The development of a painful fistulous tract from his small bowel to what had been his rectum also had occurred. The high digestive enzyme content of the small bowel caused the fistula drainage to eat away at the skin of his buttocks, causing massive erythema and maceration.

Drainage pads had to be changed every 30 minutes. Because of the combination of such intense care needs and pain, the patient could not leave home, and eventually even walking became difficult. Physicians in his original hospital could not help him and simply ordered topical ointments, which resulted in no real improvements.

The patient finally went to Illinois Valley Hospital to see a colorectal surgeon. The surgeon called a wound care committee consult, which Puetz calls an unusual example of cooperation between physicians and nurses. The following course of care ensued:

• A modified #28 French Foley catheter was inserted three inches into the fistula, and a 30 cc balloon was inflated.

• The end of the catheter was attached to a drainage bag.

• A calcium alginate rope was inserted around the foley to absorb any escaping fistula drainage.

The results were dramatic, and the fistula closed within two weeks. The patient also was able to resume walking, dress in sweat pants, and leave the house periodically. His pain decreased, and occasionally he went shopping. The fistula management system functioned well until his death of cancer in January.

Puetz attributes the success of the treatment to the hospital’s wound care program and the spirit of cooperation it fostered. "It showed a concerted effort resulting in a standardized wound protocol to improve patient care was only the beginning," Puetz says. "That an MD would order a nursing consult for a difficult problem was extremely validating and shows the team approach to problem solving."