I would like to recognize the wound ostomy nurse team. This hard-working team of professional nurses deserves recognition for:
Excellent clinical care demonstrating outcomes better than national benchmarks
Quality improvement work demonstrating improved patient outcomes
Outstanding interprofessional teamwork
Innovative development of a tablet application for conducting skin surveys
Standardization of evidence-based care through policies and procedures
Ongoing education of patients and professionals
The wound ostomy nurses coordinate and run the monthly STAR (Skin Team and Advocate Resource) shared governance committee meetings to provide education and collaborate with unit skin champions on strategies to improve skin and wound care and reduce hospital-acquired pressure injuries. This shared governance committee has been a model of staff nurse engagement in shared governance for many years. Twice a year or more, the STAR leadership will have meetings that provide committee members with education and Continuing Education (CE) credit. In addition, they have brought in national experts on pressure injury prevention and treatment and coordinated all day visits where the expert meets with staff on high-risk areas such as intensive surgical services (ISS) areas and the perioperative (POD) areas to discuss unique challenges in their settings. On these occasions, they have also coordinated Nursing Grand Rounds on various aspects of pressure injury prevention open to all staff in the organization. This was done in 2016 with Dr. Joyce Black and in 2014 with Dr. Todd Brindle. In May 2017, an expert on medical adhesive-related skin injuries presented to the STAR committee. The wound ostomy nurses and the STAR committee have demonstrated exceptional interprofessional collaboration with active membership and project work including respiratory therapists, physical therapists, occupational therapists, and dietitians. The STAR Committee has also extended membership on the committee to nursing assistants who provide much of the care essential to the prevention and minimization of hospital-acquired pressure injuries.
Along with the help of the STAR committee, Nursing Quality, and unit leadership, they conduct quarterly skin surveys where all adult and pediatric inpatients are surveyed for evidence of pressure injuries. The wound ostomy nurses see every patient that is identified as having a pressure injury to stage the wound, make recommendations, and document. The surveys usually include the assessment of over 500 patients with wound nurses describing, staging and making recommendations for about 20-25 patients on each survey day along with their usual daily workload of ostomy and other wound patients. Over years of conducting quarterly skin surveys, the wound ostomy nurses have been instrumental in the innovative development of a tablet application to improve the efficiency of gathering and reporting skin survey data.
The wound ostomy nurses follow up on any skin integrity patient safety net (PSN) that is related to hospital-acquired pressure injuries. After a report of a potential pressure injury is filed, the wound nurse will complete an assessment of the site of injury for evidence of pressure injury. This helps to identify the severity of the injury and provides the opportunity for the wound ostomy nurse to make care recommendations to the nursing staff on the unit and to the providers.
The wound ostomy nurses in response to and in collaboration with burn surgeon, Dr. Lucy Wibbenmeyer, recently developed pressure injury prevention order sets and protocols. There is an order set that nurses can implement to populate worksheets so that care is standardized and consistent. There is also an order set that providers can implement that includes what nurses are able to order as well as adding a support surface and consultation for wound ostomy nurse, physical therapy, and/or dietitian intervention.
Regular policy/procedure/protocol review is an important part of every healthcare organization. Not only do the wound ostomy nurses provide vital input to policies, procedures, and protocols related to wound, skin and ostomy care, they take the lead on many reviews and also develop needed evidence-based policies, procedures, and protocols. Recent new protocols developed by the team include AC-AMBP-AMB-22.103 Protocol for Ordering Wound Nurse Consult and NP-02.030 Protocol for Ordering Pressure Injury Prevention/Treatment Orders by the Wound Ostomy Nurses. Recent policies that the team has provided review/revision for include ostomy care policies and related home care instructions, skin care policies such as care of a skin tear and topical lotions, creams and ointments. In addition to reviewing UIHC policies and procedures, they review related Elsevier Clinical Skills content when revisions have been made by Elsevier.
In efforts to improve nursing documentation of pressure injuries and prevention strategies implemented, the wound ostomy nurses have worked closely with the Nursing Informatics and Hospital Clinical Information Systems (HCIS) staff to improve skin assessment and care documentation. Safety intervention flowsheet rows cascade based on Braden/Braden Q/Neonatal Skin Condition Scale (NSCS) subscale scores to facilitate nursing documentation of prevention strategies implemented. Ongoing documentation updates include modifying the flowsheet rows for skin condition description and skin condition location. After meeting with the Nursing Informatics team and the Clinical Documentation group to propose the recommended changes, the Clinical Documentation group felt this would be a very helpful upgrade to the documentation system. This change is planned to be rolled out after the presentation to the Nurse Management Council and Staff Education Committee in April.
In collaboration with hospital coders, the wound ostomy nurses have developed smart phrases where they document wound and skin assessments and recommendations. This helps the coders document the necessary data for establishing the severity of illness and for mandatory reporting to external agencies. Many providers throughout the organization utilize the wound ostomy nurse documentation within their notes. This has increased the frequency and accuracy of skin and wound assessment documentation especially related to pressure injuries.
When the wound ostomy nurses identified pressure injuries resulting from intraoperative positioning (occipital and prone injuries), they established an interprofessional committee to address pressure injuries and prevention in the ORs. An OR HAPI committee was established in 2010 and includes nursing representatives from MOR, ASC, Children’s OR, anesthesia, surgery. This committee, led by the wound ostomy nurses, has successfully implemented several strategies to reduce pressure injuries in the POD including upgrade of the intraoperative surfaces (OR pads), use of preventive dressings, revision of the intraoperative positioning policy, coordination of a positioning device fair and campaign to increase availability of gel positioning devices in all ORs. Members of this committee were awarded a grant from the University of Iowa College of Nursing to investigate predictive factors for pressure injury in the operating room. Results from this work were presented at the March 2018 National Pressure Ulcer Advisory Panel Annual Conference: Where Research Meets Practice in Las Vegas. The successful collaboration of this committee has also been presented in a poster at the Iowa Organization of Nurse Leaders (IONL) in 2017, the Association of periOperative Registered Nurses (AORN) in March 2018, will be presented at the American Society of PeriAnesthesia Nurses (ASPAN) conference in April 2018 and the Wound Ostomy Continence Nurses Society annual meeting in June 2018. Because of the work of this committee, it is common to have residents in a quality rotation attend the meeting.
The wound ostomy nurses are active members in the Wound Ostomy and Continence Nurses Society (WOCN) and the Iowa Affiliate WOCN. It is common for them to bring ideas back from the conference they have attended and implement things they have learned. As a result of some of this work, the organization was able to showcase the work in the Magnet redesignation documents. It was the result of information brought back from a national conference that the organization brought in Z-Flo positioning cushions for use in the OR to reduce occipital pressure injuries. It is now used to help prevent pressure injuries in many settings (e.g. intensive care units, general care areas, pediatric units) to provide comfort and positioning that reduces hospital-acquired pressure injuries. Another example of the “volunteer” work that the team is engaged in is the coordination and facilitation of regular Ostomy Support Group meetings held in the community.
Not only do the wound ostomy nurses follow inpatients, they see patients in the ambulatory setting, either in collaboration with the provider or as nurse only visits. The wound ostomy nurses worked with coders, NIS, HCIS, and nursing finance to identify and establish a process to capture preoperative ostomy teaching, follow-up of ostomy patients, and follow-up of wound patient’s charges and help the organization to capture missed revenue.
To help track and document volume of patients served by the wound ostomy services, the team developed a wound ostomy navigator in the electronic medical record that is used to pull monthly reports of wound ostomy nurse visits. The report includes the reason for the visit, location of the visit and the time the visit took to complete. This helps the organization identify and track trends in volumes which is helpful when considering staffing needs.
The wound ostomy nurses coordinate all of the hospital’s initiatives to reduce and maintain low rates of hospital-acquired pressure injuries, conduct pre and post-operative ostomy care and instruction, and provide consultation on skin and wound issues as requested. These expert clinicians are able to help patients and families through difficult times as they face situations they never expected to experience. Not only are these nurses skillful but they are compassionate, patient and gentle in the care they provide. They have a natural knack of putting people at ease and of helping patients and families find hope and relief in, often times, crisis situations.
The wound ostomy nurses are continually looking for ways to improve and maintain quality skin, ostomy and wound care for the patients and families they serve. I am always excited to hear their ideas and visions for exceptional quality and safe patient care.