In my 11 years here at Children's National Hospital, there has been one nurse who has amazed me with her creativity, grace, tenacity, and leadership. Laura Welch, BSN, RN, CWON, NPD-BC, CPN (yeah, look at all those letters) is the embodiment of the nurse I aspire to be. She is an absolute asset to the organization. Laura is currently the Senior Clinical Outcomes Coordinator within the Department of Nursing Science, Professional Practice and Quality. We initially met via the Skin Team. I joined the skin team back in 2017 when I worked in the CICU. Laura had been running the group for quite a few years at that point. Laura inspired me to ask questions and take pride in being an autonomous RN. She was the first motivational push that I had to present a poster for the hospital at conferences.

Since around mid-2021, Laura has been the sole leader of the Skin Team. She manages the monthly meetings known as "Prevalence Day" for the entire hospital. During Prevalence Day, every patient within the physical walls of CNMC is assessed for pressure injuries. This data is collected and reported to NDNQI through Laura. Each unit has representatives who attend these meetings. We start the day at 0700 sharp with education and inter-rater reliability, where we look at images of pressure injuries and stage them based on their severity. We discuss the treatment plan and prevention plan for each injury. Each unit will then break out and assess the patients on their unit. These audits are returned to Laura before the afternoon session. Afternoon sessions continue with guest speakers or engaging with hospital reps to learn about products. 

Prevalence Day is a huge undertaking. Laura seamlessly creates an invigorating 8-hour monthly agenda. Coordinating over 70 nurses from every area of the hospital is no simple feat. Skin Team would not exist without Laura. This hospital-based committee should have co-chairs, yet Laura fearlessly carries the entire group on her back. She has requested a co-chair for years, but no one has joined her. Month to month, she is the glue that holds the ensemble together.

Skin Rounds and ACAs

During COVID, Laura began Skin Rounds to decrease the hospital prevalence rate of Hospital Acquired Pressure Injuries (HAPIs). The patients were extremely sick. Laura collaborated with the Charge Nurses of the CICU, PICU, and NICU to identify these high-risk patients so there was increased awareness of the level of care required. Through variables such as Braden Q scores, Laura recognizes patients of higher acuity. Laura designs her Skin Rounds based on the data collected from Prevalence Day. She prioritizes units that have the most pressure injuries. She uses evidence and data to give precedence to her model. 

Ultimately, the Skin Rounds evolved into what they are today. Laura divides her time tactfully and efficiently to address the floors that have the most prevalent HAPIs. Shift to shift, Laura connects with the nurses caring for these patients to detect barriers to documenting/wound care. She follows patients as they progress to Acute Care. Laura is visible to staff nurses as a resource and an expert in skin. She promotes evidence-based wound healing and injury prevention. She has a wealth of knowledge regarding all the products the hospital carries. 

During Prevalence Day, if a stage 3, stage 4, deep tissue pressure injury (DTPI) or unable to stage (UTS) is identified, it must be reported to the Department of Health. The hospital classifies these injuries as a "high harm event." Laura has created the Pressure Injury Apparent Cause Analysis (ACA) system. During an ACA, Laura will confidentially set up a meeting with staff nurses and nurse leaders of floors that present with a high-harm skin injury event. She presents the patient's history, highlighting the timeline of the pressure injury. Then Laura engages in conversation, starting with contributing factors that led to the injury. She then opens the dialogue to the mitigation strategies. These approaches both address the present patient and future patients. Mitigation strategies look at ways to avoid these injuries as well as treat the current situation. Following mitigation strategies, action items are discussed. Action items are efforts that are followed up immediately. An example could be "Increase situational awareness to PICU RN staff: post picture of the injury in the break room and send out in weekly updates". These action items are assigned to an owner. 

The summary of the ACA is reviewed with the Skin Team during the next prevalence day. Without a formal review and dissemination of discussion, nurses at the bedside aren't able to learn about the pressure injuries present. Prevention strategies must start with admission. Awareness of skin health is key. Without Laura performing these ACAs, bedside nurses wouldn't learn about prevention of future events. Education is empowering. Coming together to learn from these events is how we can improve outcomes in the future. Without Laura, this wouldn't be possible. 

I appreciate that Laura has created a space for me to grow my nursing career beyond inpatient care. She has opened my eyes to the world of quality improvement. She promotes proactive medical care as opposed to reactionary. Even though I exclusively work the night shift, I know that my dayshift peers in the NICU, PICU, CICU, and the Acute Care Floors recognize Laura. Her advocacy of education for RNs and RTs is felt. She is a powerful leader of Children's National Hospital. We are lucky to have her.