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Purpose and Objectives • To educate wound care clinicians on the benefits that a multidisciplinary approach provides in caring for patients with and at risk for wounds. • List the multidisciplinary team involved in patient wound assessment in an inpatient rehabilitation setting. • Identify the contribution of multiple disciplines in prevention of wounds in an inpatient rehabilitation setting. • Describe the benefits of multiple disciplines in the treatment of wounds to expedite healing. Benefits of a Multidisciplinary Wound Care Team in an Inpatient Rehabilitation Setting HealthSouth Rehabilitation Hospital of Mechanicsburg Sarah Lohman, MSN, RN, NEA-BC, CNO • Barbara Elmore, BSN, RN, WOCN • Karen Burket, DPT, NCS, CWS References Making Health Care Safer II: An Updated Critical Analysis of the Evidence for Patient Safety Practices. Section E. General Clinical Topics Chapter 21. Preventing In- Facility Pressure Ulcers Nancy Sullivan, B.A. Evidence Reports/Technology Assessments, No. 211 Whittington K, Briones R. National Prevelance and Incidence Study: 6-Year Sequential Acute Care Data. Advances in Skin & Wound Care. 2004;17:490-4. Whittington, K., Patrick M. & Roberts, J. L. (July 2000). A national study of pressure ulcer prevalence and incidence in acute care hospitals. J Wound Ostomy Continence Nurs. 27(4):209-15. Gadd, M. (2012). Preventing Hospital-Acquired Pressure Ulcers. J WOCN. 292-294. Wound, Ostomy and Continence (1 June 2010). Guideline for prevention and management of pressure ulcers. WOCN clinical practice guideline. 2:96. Patient Assessment • Physicians, nurses, occupational therapists, physical therapists, dietitians, and at times, speech therapists complete admission assessments for all patients. • The full team approach evaluates the patient’s strengths and weaknesses from the viewpoint of a variety of expert mindsets. Wound Prevention The Braden Risk Assessment Tool is well established in the wound care community as a valid and reliable tool for assessment of pressure ulcer risk. An inpatient rehabilitation center with a multidisciplinary approach to patient recovery inherently focuses on most, if not all, of the Braden subset categories. Sensory perception - Identify and communicate the need to manage pressure-related discomfort Moisture - Skin’s exposure to moisture Activity - Overall daily activity level of the patient Mobility - Ability to complete transitions and stabilize body once new position is achieved Nutrition - Normal adult nutritional intake, including protein and fluid intake Friction and shear - Able to negotiate bed and seating surfaces with clearance between body and indicated surface - Full control of body to stabilize positions throughout day Activity • Nursing staff receives advanced training in mobility of patients, allowing for increased use of toilets and bedside commodes.. • Interdepartmental patient communication boards are in place at the patient’s bedside, allowing for staff consistency with patient assistance needs for bedside tasks. • For best carryover, therapy staff demonstrates specific techniques with difficult transfers to nursing staff. • Minimum of 15 hours of therapy a week for the duration of the average 12.4 day length of stay Mobility • Four 45-minute sessions of therapy are spaced throughout the day to provide for mobility throughout the course of the day and needed rest periods between therapy. • Nursing and therapy staffs communicate during the entire length of stay to determine when a patient is safe to independently negotiate within and outside of their room. Family members are trained to assist with patient needs in the event that the patient continues to require assistance with some aspects of care. Nutrition • The dietary plan is established based on a patient’s medical conditions and specific nutritional needs. • Additional protein and fluid intake provided for patients with wounds • Supplements offered when consumption of meals is below 50% and monitored by nursing staff. • Therapeutic dining is provided with nursing, speech therapy and occupational therapy to increase the patient’s ability to safely ingest adequate nutrition. Friction and Shear • Nursing staff receives advanced education in mobility techniques that allow for greatest patient participation. • Significant amount of time in therapy sessions focuses on mobility techniques • Therapy sessions also include patient education and practice sessions to enhance carryover. • Seating and positioning tools increase successful positioning and minimize shearing effects at rest. Wound Prevention Sensory Perception Comprehension Expression Social Interaction Problem Solving Memory Rehabilitation Approach to Treating Patients with Wounds • Continued focus on Braden subset categories to minimize risk of additional skin damage • 24-hour focus on increasing patient’s level of independence • Educating patients and families on wound and impact of managing health conditions is a hospital-wide focus • Physiatrists and internists manage the patients’ health conditions, pain and direct the overall care • Nursing staff assists with pain control, completes wound treatments, supports patients’ advancing independence, manages positioning, prevention measures and bed surfaces • Registered dietitians assist with meal selection to address nutritional demands and provide supplements as needed • Therapy staff develops customized education programs, selects seating surfaces, assists with positioning and may provide adjunct modalities • Case management oversees scheduling formal education with family members and manages the transition of care for the patient after discharge Multidisciplinary Skin and Wound Care Team • Primary Members are Nurse: WOCN and Physical Therapist: CWS • Complimentary clinical view-points of these two disciplines results in a comprehensive, whole patient approach to healing • Members are resources to the hospital staff • Team completes weekly rounds on patients with or at risk for developing pressure ulcers • Consults may be triggered by a concern of any clinical staff member • Wound nurse coordinates with physicians post-assessment to manage best wound treatments, bed surfaces and pain control • Physical therapist provides adjunct treatments and manages seating surfaces Incidence and Prevalence • It is the combined efforts of the team that allows for a 0.47 wound incidence rate (WIR), despite an average admission Braden score below 19. • For comparison, this is a 0.002% wound incidence for stage II or greater, during an average length of stay of 12.4 days. • Pressure ulcer prevention studies from 1999-2011 indicate wound incidence post implementation of multi-component initiatives from 0.448% to 12% in both acute care and long-term care settings. Moisture • Focus on the patient’s ability to independently manage bowel and bladder tasks, toileting, and transfers • Utilization of bowel and bladder retraining • Nursing staff monitors thoroughness of urine void with non-invasive bladder scanners. Patient inconti- nent of bladder during first 48 hours of admission No: no training neccessary Yes: Start bladder traing program Obtain timer, determine time frame (two hours), inform charge nurse Nursing shift- toshift reports, communicate with therapies Educate: patient to use time if able Documentation: plan of care, IDD, therapy billing sheet, education record Patient Level of Independence FIM® scores from January 1 to August 14, 2014

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Page 1: Benefits of a Multidisciplinary Wound Care Team in an ...a1a2b942b201254527e0-1746b8788090c8c59faefcb7081d38b4.r72.cf1.rackcdn.…members and manages the transition of care for the

Purpose and Objectives• Toeducatewoundcarecliniciansonthebenefitsthatamultidisciplinary

approachprovidesincaringforpatientswithandatriskforwounds.• Listthemultidisciplinaryteaminvolvedinpatientwoundassessmentinan

inpatientrehabilitationsetting.• Identifythecontributionofmultipledisciplinesinpreventionofwoundsinan

inpatientrehabilitationsetting.• Describethebenefitsofmultipledisciplinesinthetreatmentofwoundsto

expeditehealing.

Benefits of a Multidisciplinary Wound Care Team in an Inpatient Rehabilitation SettingHealthSouthRehabilitationHospitalofMechanicsburg

SarahLohman,MSN,RN,NEA-BC,CNO•BarbaraElmore,BSN,RN,WOCN•KarenBurket,DPT,NCS,CWS

ReferencesMakingHealthCareSaferII:AnUpdatedCriticalAnalysisoftheEvidenceforPatient

SafetyPractices.SectionE.GeneralClinicalTopicsChapter21.PreventingIn-FacilityPressureUlcersNancySullivan,B.A.EvidenceReports/TechnologyAssessments,No.211

WhittingtonK,BrionesR.NationalPrevelanceandIncidenceStudy:6-YearSequentialAcuteCareData.AdvancesinSkin&WoundCare.2004;17:490-4.

Whittington,K.,PatrickM.&Roberts,J.L.(July2000).Anationalstudyofpressureulcerprevalenceandincidenceinacutecarehospitals.JWoundOstomyContinenceNurs.27(4):209-15.

Gadd,M.(2012).PreventingHospital-AcquiredPressureUlcers.JWOCN.292-294.

Wound,OstomyandContinence(1June2010).Guidelineforpreventionandmanagementofpressureulcers.WOCNclinicalpracticeguideline.2:96.

Patient Assessment• Physicians,nurses,occupationaltherapists,physicaltherapists,dietitians,and

attimes,speechtherapistscompleteadmissionassessmentsforallpatients.• Thefullteamapproachevaluatesthepatient’sstrengthsandweaknesses

fromtheviewpointofavarietyofexpertmindsets.

Wound PreventionTheBradenRiskAssessmentTooliswellestablishedinthewoundcarecommunityasavalidandreliabletoolforassessmentofpressureulcerrisk.Aninpatientrehabilitationcenterwithamultidisciplinaryapproachtopatientrecoveryinherentlyfocusesonmost,ifnotall,oftheBradensubsetcategories.

Sensory perception -Identifyandcommunicatetheneedto managepressure-relateddiscomfortMoisture -Skin’sexposuretomoistureActivity -OveralldailyactivitylevelofthepatientMobility -Abilitytocompletetransitionsandstabilize bodyoncenewpositionisachievedNutrition -Normaladultnutritionalintake,includingproteinand fluidintakeFriction and shear -Abletonegotiatebedandseatingsurfaceswithclearance betweenbodyandindicatedsurface -Fullcontrolofbodytostabilizepositionsthroughoutday

Activity• Nursingstaffreceivesadvancedtrainingin

mobilityofpatients,allowingforincreaseduseoftoiletsandbedsidecommodes..

• Interdepartmentalpatientcommunicationboardsareinplaceatthepatient’sbedside,allowingforstaffconsistencywithpatientassistanceneedsforbedsidetasks.

• Forbestcarryover,therapystaffdemonstratesspecifictechniqueswithdifficulttransferstonursingstaff.

• Minimumof15hoursoftherapyaweekforthedurationoftheaverage12.4daylengthofstay

Mobility• Four45-minutesessionsoftherapyare

spacedthroughoutthedaytoprovideformobilitythroughoutthecourseofthedayandneededrestperiodsbetweentherapy.

• Nursingandtherapystaffscommunicateduringtheentirelengthofstaytodeterminewhenapatientissafetoindependentlynegotiatewithinandoutsideoftheirroom.Familymembersaretrainedtoassistwithpatientneedsintheeventthatthepatientcontinuestorequireassistancewithsomeaspectsofcare.

Nutrition• Thedietaryplanisestablishedbasedona

patient’smedicalconditionsandspecificnutritionalneeds.

• Additionalproteinandfluidintakeprovidedforpatientswithwounds

• Supplementsofferedwhenconsumptionofmealsisbelow50%andmonitoredbynursingstaff.

• Therapeuticdiningisprovidedwithnursing,speechtherapyandoccupationaltherapytoincreasethepatient’sabilitytosafelyingestadequatenutrition.

Friction and Shear• Nursingstaffreceivesadvancededucation

inmobilitytechniquesthatallowforgreatestpatientparticipation.

• Significantamountoftimeintherapysessionsfocusesonmobilitytechniques

• Therapysessionsalsoincludepatienteducationandpracticesessionstoenhancecarryover.

• Seatingandpositioningtoolsincreasesuccessfulpositioningandminimizeshearingeffectsatrest.

WoundPreventionSensoryPerception

Comprehension

Expression

SocialInteraction

ProblemSolving

Memory

Rehabilitation Approach to Treating Patients with Wounds• ContinuedfocusonBradensubsetcategoriestominimizeriskof

additionalskindamage• 24-hourfocusonincreasingpatient’slevelofindependence• Educatingpatientsandfamiliesonwoundandimpactofmanaging

healthconditionsisahospital-widefocus• Physiatristsandinternistsmanagethepatients’healthconditions,pain

anddirecttheoverallcare• Nursingstaffassistswithpaincontrol,completeswoundtreatments,

supportspatients’advancingindependence,managespositioning,preventionmeasuresandbedsurfaces

• Registereddietitiansassistwithmealselectiontoaddressnutritionaldemandsandprovidesupplementsasneeded

• Therapystaffdevelopscustomizededucationprograms,selectsseatingsurfaces,assistswithpositioningandmayprovideadjunctmodalities

• Casemanagementoverseesschedulingformaleducationwithfamilymembersandmanagesthetransitionofcareforthepatientafterdischarge

Multidisciplinary Skin and Wound Care Team• PrimaryMembersareNurse:WOCNandPhysicalTherapist:CWS• Complimentaryclinicalview-pointsofthesetwodisciplinesresultsina

comprehensive,wholepatientapproachtohealing• Membersareresourcestothehospitalstaff• Teamcompletesweeklyroundsonpatientswithoratriskfor

developingpressureulcers• Consultsmaybetriggeredbyaconcernofanyclinicalstaffmember• Woundnursecoordinateswithphysicianspost-assessmenttomanage

bestwoundtreatments,bedsurfacesandpaincontrol• Physicaltherapistprovidesadjuncttreatmentsandmanages

seatingsurfaces

Incidence and Prevalence• Itisthecombinedeffortsoftheteamthatallowsfora0.47wound

incidencerate(WIR),despiteanaverageadmissionBradenscorebelow19.

• Forcomparison,thisisa0.002%woundincidenceforstageIIorgreater,duringanaveragelengthofstayof12.4days.

• Pressureulcerpreventionstudiesfrom1999-2011indicatewoundincidencepostimplementationofmulti-componentinitiativesfrom0.448%to12%inbothacutecareandlong-termcaresettings.Moisture

• Focusonthepatient’sabilitytoindependentlymanagebowelandbladdertasks,toileting,andtransfers

• Utilizationofbowelandbladderretraining

• Nursingstaffmonitorsthoroughnessofurinevoidwithnon-invasivebladderscanners.

Patientinconti-nentofbladderduringfirst48

hoursofadmission

No:notrainingneccessary

Yes:Startbladdertraingprogram

Obtaintimer,determinetime

frame(twohours),informcharge

nurse

Nursingshift-toshiftreports,

communicatewiththerapies

Educate:patienttousetimeifable

Documentation:planofcare,IDD,

therapybillingsheet,education

record

PatientLevelofIndependence

FIM®scoresfromJanuary1toAugust14,2014

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