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When Mark S. Granick, MD, arrived at Allegheny University Hospital in Philadelphia, the hospital had no program for managing pressure ulcers, nor did it have a standardized protocol for preventing them. Nurses received differing opinions on how to treat wounds depending on which physician they asked, and notions sometimes varied widely. A hospital survey revealed that a disconcertingly high number of patients succumbed to pressure during their hospitalization.
With nosocomial wounds often costing thousands of dollars per patient, and some extraordinary cases draining hospital coffers to the tune of hundreds of thousands, not to mention the human costs of the morbidity suffered by patients, Granick, chief of plastic surgery, initiated an aggressive wound prevention and treatment program. The result was the formation of a multidisciplinary wound care team. Members followed standardized protocols to identify at-risk patients and provide aggressive intervention. The plan has resulted in decreased morbidity and significantly lower costs.
"The wound care team was the coalescence of different medical and paramedical practitioners in the hospital who dealt with wounds," says Granick. Nurses are central to the team. Granick calls the team nurse driven. Other members include representatives from nutrition, enterostomal therapy, pharmacy, rehabilitation, and materials management. The team is headed by a plastic surgeon.
At the outset of the program, the hospital’s administration and medical staff empowered Granick and his colleagues to establish a committee to assess the status of wound care and prevention at the hospital, as well as available wound care products. An evaluation of various specialty support mattresses also was authorized.
Under the protocol developed by the wound care committee, patients admitted to the hospital are evaluated by a nurse, who conducts a thorough skin integrity assessment. A Braden or Norton scale assessment is used to determine each patient’s risk level for skin breakdown. High-risk patients are automatically scheduled for a complete wound care assessment. At this point, the wound care team becomes involved in the process.
"Our team would stop by to see the patient and determine whether a special support surface was indicated, to make sure a nutrition consult was ordered if indicated, and to explain to nurses the correct care of any early wounds that were present and the care of skin surfaces if there was a problem with maceration or incontinence," says Granick. "We wanted to make sure there was some consistency in the management of patients."
When a patient presents with existing noteworthy large wounds, the team confers with members of the staff to obtain permission for a plastic surgeon to consult with the patient, thus ensuring that patients with established wounds receive aggressive care from the outset of their hospitalization.
Results of the program have been encouraging. Granick says he deals less frequently with wounds now than before the team was established, chiefly because fewer patients acquire pressure ulcers during hospitalization.
Annual studies to track the effect of the team show big drops in prevalence. In 1993, 22.6% of 164 patients had at least one pressure ulcer. The 164 patients surveyed had 57 pressure ulcers, and 82.4% of them were nosocomial.
By 1996, only 16 of 184 patients surveyed had 30 pressure ulcers, a prevalence of only 8.7%. Only 43.3% of those were nosocomial. Over the same period, the overall percentage of patients getting nosocomial ulcers decreased from 21.0% to just 4.3%.
"These decreases are highly statistically significant," says Granick. "All of the other parameters we looked at, including nutrition, serum albumin levels, and other factors improved significantly over the four-year period."
The decreased wound prevalence in the hospital clearly has led to an associated drop in costs related to wound care, and measurement of the economic impact is currently under way. Granick says one hospital-acquired pressure ulcer he looked at cost the hospital about $220,000 in nonreimbursed funds. Most patients who acquire stage I or II ulcers cost the hospital an additional $1,500 to $2,000, and the average cost per patient who develops stage III to IV ulcers is $20,000 to $60,000, Granick estimates. Those costs often are not reimbursed.
The National Health Services and Practice Pattern Survey of 1990, a federally commissioned report, puts the costs even higher: $14,000 to $20,000 for stage I to II pressure ulcers and $30,000 to $65,000 for stage III to IV ulcers.
For a multidisciplinary team approach to be successful, it needs the approval of the medical staff and the hospital administration, says Granick. "The medical staff is really key. The biggest concern we had was that the medical staff physicians would perceive that we were usurping the management of their patients. They were afraid that if we developed this type of system we would write orders and notes on patient charts that they may not be interested in having."
To circumvent any potential turf clashes, it was agreed that the initial screening would be conducted by a nurse who would not write any comments on the patient’s chart. However, if a patient had significant wound problems, a member of the wound care team would ask the appropriate staff physician to order a consultation. "They’ve never refused to do that," says Granick. "It turns out that we provide them with a tremendous service, and at this point they more or less expect us to see patients who have serious wounds."
He adds that once the team was in place and functioning, the staff quickly realized that the wound care personnel were not attempting to take over patient management but to assist in the care of particular problems in which they had expertise.