New wound care rules prompted by troubles

All staff signed off on new protocols

When Susan B. Allen Memorial Hospital Home Health of El Dorado, KS, was surveyed last year by the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations (JCAHO), there was one problem.

It was one of those fluke, accidents-happening-close-to-home problems, where your staff know the patient so well that it’s easy to forget standard procedures. "We all felt like kicking ourselves," recalls Martha McCabe, administrator for the hospital-based agency.

The problem occurred during the survey week. A home health aide provided daily cream ointment, soap, and water treatment to a diabetic, double-amputee patient, who had been receiving the agency’s services for about three years. During one visit, the aide noticed that the patient’s skin breakdown had exacerbated, and so the aide reported the problem to the patient’s home health nurse.

The nurse, who was very familiar with this particular patient’s skin breakdown problems, took an unfortunate shortcut and neglected to visit the patient herself before calling the physician for a change in treatment. It was a big mistake.

"A home health aide is not certified or licensed to assess wounds; it’s the responsibility of the RN to make that visit that day, assess it, and then make a call to the physician," McCabe explains.

The Joint Commission surveyor noted this omission and gave the agency a Type 1 violation in wound care. "We were all stressed out with the surveyor around, and busy with our regular patient visits, so it was one of those things that she forgot to do," McCabe says. "But she should have done it."

After the survey results came in, the agency re-educated staff on wound care treatment and procedures, and tightened the wound care protocols. As a result, the Joint Commission has accredited the agency, and wound care outcomes have improved, McCabe says.

The new protocols outline for staff exactly what they need to do regarding patient care, documentation, assessing problems, and follow-up care.

Here are the new wound care protocols:

Susan B. Allen Home Health Services Wound Care Management

Patients with diagnosed compromised skin integrity, including all classifications of wounds, will be managed by an RN. The RN will be the coordinator of all services for the patient, which includes the evaluation of care and treatment for wounds and skin conditions, as well as routine evaluation of healing/progress of wounds and compromised skin conditions. All disciplines must follow the care plan as written by the RN, and all orders as signed by the physician. Any changes in wound care/treatments must be initiated by the RN, upon approval with verbal and written orders by the patient’s physician.

At any time other disciplines in the home assess a change in the patient skin or wound condition, they must immediately notify the RN case manager, any staff RN, or the on-call RN. The discipline then must document the contact to the RN regarding change in patient condition. It is the responsibility of the RN to make a home visit before the end of that day of the report, assess the condition, recommend any continued or changed treatment, and receive verbal orders from the physician before the change occurs. It is the responsibility of the RN to document the approved physician order changes to the chart and the care plan immediately.

Because chart information is maintained electronically as well as in written format, it is the responsibility of every discipline to review the care plan for the patient prior to any treatment or care. Changes reflected in wound or skin care will be reflected in updated care plans as prepared by the RN. Should other disciplines have questions regarding treatment or care of patient wounds or skin, they are to contact the RN case manager as appearing on the chart and as appearing on the last update of the care plan. Disciplines may not change treatment or care without prior approval of the RN, who in turn must receive verbal or written orders prior to such change.

If the discipline providing simple, clean dressing changes is a home health aide, prior to the first home visit the aide must receive verbal instruction from the RN case manager on the specific dressing care to that specific patient. The care plan must be reviewed with the aide as well as prior to the first home visit. Home health aides who encounter problems with completing the dressing change, (i.e. dressings stuck to the skin; dressings not adhering over covering the size of the wound), as set forth in the care plan, must contact the RN case manager or another staff RN IMMEDIATELY from the home in order for the RN to come to the home to make an assessment of the problem. Failure of the RN to make a home visit on that day will result in absence of meeting the standard of care of the agency, and disciplinary action per the organization policy will be applied to the RN. The physician will also be notified. The failure of any other discipline to report a change in condition for patient will also result in disciplinary action.

As well at the time of home visits, if disciplines assess new wounds, i.e. skin tears due to falls, or exacerbation of existing wounds and skin conditions, or excessive drainage, then they must contact the RN case manager or another staff RN IMMEDIATELY in order for the RN to assess the condition and recommend change of treatment upon consultation with the physician.

The clinical supervising RN of the agency will review wound protocols at the time of admission, every 60 days, and when necessary as to evaluate the progress of wound/skin healing among the entire patient population. It is the responsibility of all disciplines to consult with the RN, as well as each patient RN case manager, at any time there is a question in care for the wounds, skin, or condition in general for each patient. All disciplines are to document to the chart consultations, verbal contacts, and telephone contacts with all staff RNs. n

For more than 100 years, the American Red Cross has been at the cutting edge of disaster relief activities, helping people prevent, prepare for, and cope with disasters and other emergencies. That’s why your Red Cross has published the following information about Y2K — its potential effects and what you can do to be prepared.


What is Y2K and why are people concerned? The year 2000 technology problem, or bug, as it is sometimes called, was created in the early days of computers, when memory in computers was scarce and expensive. Programmers took shortcuts whenever possible to save space. Instead of using a four-digit code for year dates, a two-digit entry was used. This practice persisted, long after the need for saving space was eliminated. The two-digit code was also used in embedded chips, which exist in many devices that control processes, functions, machines (like cars), building ventilation systems, elevators, and fire and security alarm systems, which are part of our everyday lives.

When the year 2000 comes, programs that have been coded with two-digit year codes will not distinguish between the years 2000 and 1900. If the program includes time-sensitive calculations or comparisons, results are unpredictable. No one knows what problems may occur, how widespread they may be, or how long they will last. The good news is that federal, state, and local governments, banks and other financial institutions, retail businesses, and every other group affected by this problem have been working to resolve it, and a great deal of progress has been made.

When could Y2K problems happen? Most people anticipate Y2K problems may happen Dec. 31, 1999, at midnight. Many experts predict that the problem is more likely to be a persistent one over a few years rather than a single "crash."

For example, there may be a computer-based problem with other dates, such as April 9, 1999, which is the 99th day of the year, or on Sept. 9, 1999. In the past, a series of nines was used to indicate termination of a computer program, and some experts believe that when all nines show up in a date sequence, some computer systems could read it as a program termination command. There also is some concern regarding fiscal year 2000 dates in those organizations with fiscal years that start earlier than Dec. 31, 1999. Also, the year 2000 is a leap year, and the leap year date 02/29/00 may be a problem for some computer programs as well.

What kinds of things could happen as a result of Y2K problems? The President’s Council on Y2K Conversion, established by the White House, as well as a special Senate committee, have focused their attention on defining the scope of the Y2K problem. Hearings have been conducted by the U.S. Senate Special Committee on the Year 2000 Technology Problem and have focused on the following eight areas:

1. Utilities and the national power grid;

2. International banking and finance;

3. Health care;

4. Transportation;

5. Telecommunications;

6. Pension and mutual funds;

7. Emergency planning;

8. General business.

The potential effect of the Y2K technology problem on any of those areas is unknown, and the situation continues to change as federal, state, and local governments, industries, businesses, and organizations, as well as the general public, take actions to reduce the problem. Experts who spoke at the Senate hearings believe that there may be localized disruptions. For example, in some areas, electrical power may be unavailable for some time. Manufacturing and production industries may be disrupted. Roads may be closed or gridlocked if traffic signals are disrupted. Electronic credit card transactions may not be processed. Telephone systems may not work.

Because no one can be certain about the effects of the Y2K problem, the American Red Cross has developed the following checklist for you. These are some easy steps you can take to prepare for possible disruptions. All of these recommendations make good sense, regardless of the potential problem:


Y2K Checklist

___ Check with manufacturers of any essential computer-controlled electronic equipment in your home to see if that equipment may be affected. This includes fire and security alarm systems, programmable thermostats, appliances, consumer electronics, garage door openers, electronic locks, and any other electronic equipment in which an embedded chip may control its operation.

___ Stock disaster supplies to last several days to a week for yourself and those who live with you. This includes having nonperishable foods, stored water, and an ample supply of prescription and nonprescription medications that you regularly use. See your family disaster supplies kit for suggestions.

___ As you would in preparation for a storm of any kind, have some extra cash or traveler’s checks on hand in case electronic transactions involving ATM cards, credit cards, and the like cannot be processed. Plan to keep cash or traveler’s checks in a safe place, and withdraw money from your bank in small amounts well in advance of Dec. 31, 1999.

___ As you would in preparation for a winter storm, keep your automobile gas tank above half full.

___ In case the power fails, plan to use alternative cooking devices in accordance with manufacturer’s instructions. Don’t use open flames or charcoal grills indoors.

___ Have extra blankets, coats, hats, and gloves to keep warm. Please do not plan to use gas-fueled appliances, like an oven, as an alternative heating source. The same goes for wood-burning or liquid-fueled heating devices that are not designed to be used in a residential structure. Camp stoves and heaters should only be used outdoors in a well-ventilated area. If you do purchase an alternative heating device, make sure it is approved for use indoors and is listed with the Underwriters Laboratories (UL).

___ Have plenty of flashlights and extra batteries on hand. Don’t use candles for emergency lighting.

___ Examine your smoke alarms now. If you have smoke alarms that are hard-wired into your home’s electrical system (most newer ones are), check to see if they have battery back-ups. Every fall, replace all batteries in all smoke alarms as a general fire safety precaution.

___ Be prepared to relocate to a shelter for warmth and protection during a prolonged power outage or if for any other reason local officials request or require that you leave your home. Listen to a battery-operated radio or television for information about where shelters will be available.

___ If you plan to use a portable generator, connect what you want to power directly to the generator; do not connect the generator to your home’s electrical system. Also, be sure to keep a generator in a well-ventilated area — either outside or in a garage, keeping the door open. Don’t put a generator in your basement or anywhere inside your home.

___ Check with the emergency services providers in your community to see if there is more information available about how your community is preparing for any potential problems. Be an advocate and support efforts by your local police, fire, and emergency management officials to ensure that their systems will be able to operate at all times.

The American Red Cross helps people prevent, prepare for, and respond to emergencies. We’re in your neighborhood every day, providing disaster preparedness information and teaching classes in first aid and other lifesaving skills, to help keep families like yours safer. For more information, please contact your local Red Cross chapter.

Courtesy of the American Red Cross. All rights reserved in all countries. Visit the American National Red Cross at