What an honor it is to be the wound care “superhero”—the guru, the healer, the go-to person. Unfortunately, this honor may be accompanied by wound care overload—too much to do in too little time.
Once someone is crowned the superhero specialist, others may try to transfer every aspect of wound and skin care to that person—all treatment plans, assessments, documentation, prevention, education, and accountability. Superheroes don’t cry, so they don’t complain about the workload. Yet, the overload must be controlled. (more…)
By Nancy Chatham, RN, MSN, ANP-BC, CCNS, CWOCN, CWS, and Lori Thomas, MS, OTR/L, CLT-LANA
An estimated 7 million people in the United States have venous disease, which can cause leg edema and ulcers. Approximately 2 to 3 million Americans suffer from secondary lymphedema. Marked by abnormal accumulation of protein-rich fluid in the interstitium, secondary lymphedema eventually can cause fibrosis and other tissue and skin changes. (more…)
The ability to understand or “read” lower-extremity redness in your patient is essential to determining its cause and providing effective treatment. Redness can occur in multiple conditions—hemosiderin staining, lipodermatosclerosis, venous dermatitis, chronic inflammation, cellulitis, and dependent rubor. This article provides clues to help you differentiate these conditions and identify the specific cause of your patient’s lower-extremity redness. (more…)
The Affordable Care Act of 2010 requires nursing homes to have an acceptable Quality Assurance and Performance Improvement (QAPI) plan within a year after the start of the QAPI regulation. While the implementation of this regulation may be a year out, now is the time to start applying its principles. Reducing pressure ulcer rates is a great program to target for a QAPI plan.
A team approach
If you decide to use pressure ulcers as your QAPI project, don’t take on your entire program at once. Break the program down into system subsets (for example, admission process, prevention program, and weekly rounds). Determining the status of your program in each subset—completed, needs improvement, or not completed—can help you prioritize which areas to target. It’s important you have support from leadership for your efforts.
I’ll use the example of the admission phase (ensuring that within the first 24 hours, skin and risk concerns are identified and a temporary plan of care is implemented) to illustrate a QAPI project. To address this area, a team was created, including representation from staff members involved with the admission process. The team then used the problem-solving model Plan-Do-Study-Act (PDSA) to examine the process.
The first step in the PDSA cycle is to Plan. During this step, you:
• evaluate and analyze the current process to determine baseline data, which are used to measure progress
• identify system performance gaps
• determine the root cause of the performance gaps
• develop an action plan that identifies the goals, steps, responsible staff, and target dates.
In our example, the team determined that within the first 24 hours, skin inspections were being completed only 10% of the time. The root-cause analysis revealed that the admission nurses didn’t feel competent to document identified pressure ulcers or skin concerns, so they deferred it until the wound nurse was available. The team’s action plan included the following:
• Develop and educate all the facility nurses on how to complete and accurately document a skin inspection.
• Develop and implement a competency evaluation to assess the nurse’s ability to apply the knowledge at the bedside.
• Develop an ongoing plan to ensure all nurses receive this education during orientation and yearly thereafter.
The team also set the following goal:
By the end of the next quarter, 100% of admitted patients will have an accurate skin inspection completed within 24 hours of admission.
The second step of the PDSA cycle is Do. During this step, you implement and execute the plan, while documenting your observations and recording data.
In our example, the “Do” was to:
• develop and provide the skin inspection education and bedside competency evaluations
• develop an evaluation and tracking
system
• add the education to the orientation program
• add the education to the staff development calendar to be offered yearly.
The third step of the PDSA cycle is to Study: In this phase, you:
• reevaluate and analyze the system
• compare the results with the baseline data and predictions
• summarize what was learned and accomplished and what needs to be improved
• determine if another PDSA cycle is
necessary to continue to improve the system.
Once all staff had been properly educated and competency testing completed, an analysis of the rate and accuracy of the admission skin inspections done within 24 hours of admission was completed. It was found that 100% of the patients admitted had a complete skin inspection done within 24 hours. However, not all the nurses could accurately stage pressure ulcers, so it was determined that the system needed improvement to ensure accurate assessments.
The last step of the PDSA cycle is to Act. In this step, you:
• determine what changes need to be made
• modify the plan to continue to improve the system
• repeat the PDSA cycle as necessary.
In our example, the team determined the nurses needed more guidance and education on staging of pressure ulcers. Therefore, a new PDSA cycle was set to ensure the nurses are competent in this area.
Benefits for staff and patients
It may be difficult to start the QAPI project and at times the process may be stressful, but keep in mind that a successful pressure ulcer QAPI project can improve not only the quality of life and care of your patients but also morale and team building for your staff. n
Jeri Lundgren is director of clinical services at Pathway Health in Minnesota. She has beenspecializing in wound prevention and management since 1990.
Study finds less-invasive method for identifying osteomyelitis is effective
Researchers have found that using hybrid 67Ga single-photon emission computed tomography and X-ray computed tomography (SPECT/CT) imaging combined with a bedside percutaneous bone puncture in patients with a positive scan is “accurate and safe” for diagnosing osteomyelitis in patients with diabetes who have a foot ulcer without signs of soft-tissue infection.
The new method, which avoids an invasive bone biopsy, has a sensitivity of 88% and a specificity of 93.6%. In the study of 55 patients, antibiotic treatment was avoided in 55% of suspected cases.
MRSA strains will likely continue to coexist in hospitals and communities
The strains of methicillin-resistant Staphylococcus aureus (MRSA) differ in the hospital and community settings, and both are likely to coexist in the future, according to a study in PLOS Pathogens.
C. difficile prevention actions fail to stop spread
Despite increasing activities to prevent the spread of Clostridium difficile, infection from C. difficile remains a problem in healthcare facilities, according to a survey of infection preventionists by the Association for Professionals in Infection Control and Epidemiology (APIC).
The survey found that 70% of preventionists have adopted additional interventions in their healthcare facilities since March 2010, but only 42% have seen a decline in C. difficile infection rates; 43% saw no decline.
A total of 1,087 APIC members completed the survey in January 2013. The survey also found that more than 92% of respondents have increased emphasis on environmental cleaning and equipment decontamination practices, but 64% said they rely on observation, rather than more accurate and reliable monitoring technologies, to assess cleaning effectiveness.
In addition, 60% of respondents have antimicrobial stewardship programs at their facilities, compared with 52% in 2010. Such programs promote the appropriate use of antibiotics, which can help reduce the risk of C. difficile infection.
Mast cells may not play significant role in wound healing
“Evidence that mast cells are not required for healing of splinted cutaneous excisional wounds in mice,” published in PLOS One, analyzed wound healing in three types of genetically mast-deficient mice and found they reepithelialized their wounds at rates similar to control mice. At the time of closure, the researchers found that scars in all the mice groups were similar in both “quality of collagen deposition and maturity of collagen fibers.” The findings fail to support the previously held belief that mast cells are important in wound healing.
Study identifies effective casting for diabetes-related plantar foot ulcers
Nonremovable casts that relieve pressure are more effective than removable casts or dressings alone for the treatment of plantar foot ulcers caused by diabetes, according to an analysis of clinical trials.
The authors of “Pressure-relieving interventions for treating diabetic foot ulcers,” published by The Cochrane Library, reviewed 14 randomized clinical trials that included 709 participants. Nonremovable pressure-relieving casts were compared to dressings alone, temporary therapeutic shoes, removable pressure-relieving devices, and surgical lengthening of the Achilles tendon.
The study also notes that when combined with Achilles tendon lengthening, nonremovable devices were more successful in one forefoot ulcer study than the use of a nonremovable cast alone.
Most studies were from the United States (five) and Italy (five), with Germany, the Netherlands, Australia, and India each contributing one study.
Prescriber preference drives use of antibiotics in long-term care
The study of 66,901 patients from 630 long-term care facilities found that 77.8%
received a course of antibiotics. The most common length (41%) was 7 days, but the length exceeded 7 days in 44.9% of patients. Patient characteristics were similar among short-, average-, and long-duration prescribers.
The study authors conclude: “Future trials should evaluate antibiotic stewardship interventions targeting prescriber preferences to systematically shorten average treatment durations to reduce the complications, costs, and resistance associated with antibiotic overuse.”
Electrophysical therapy may be helpful for diabetic foot ulcers
The authors of the study in International Wound Journal reviewed eight trials with a combined total of 325 patients. Five studies were on electrical stimulation, two on phototherapy, and one on ultrasound. Because of the small number of trials, the possibility of harmful effects can’t be ruled out, and the authors recommend “high-quality trials with larger sample sizes.”
Significant geographic variations in spending, mortality exist for diabetic patients with foot ulcers and amputations
The study in Journal of Diabetes and Its Complications found that higher spending wasn’t associated with a significant reduction in 1-year patient mortality. In addition, rates of hospital admission were associated with higher per capita spending and higher mortality rates for patients.
Home-based exercise program improves life for lymphedema patients
An individualized, home-based progressive resistance exercise program improves upper-limb volume and circumference and quality of life in postmastectomy patients with lymphedema, according to a study published in the Journal of Rehabilitation Research and Development.
With so much focus on dressing choices, it’s easy to forget the importance of wound cleansing. Cleaning a wound removes loose debris and planktonic (free-floating) bacteria, provides protection to promote an optimal environment for healing, and facilitates wound assessment by optimizing visualization of the wound. You should clean a wound every time you change a dressing, unless it’s contraindicated.
Here’s a review of how to choose and use a wound cleanser so you can see if your practice is up to date. (more…)
Each month, Apple Bites brings you a tool you can apply in your daily practice.
Description
A hydrocolloid dressing is a wafer type of dressing that contains gel-forming agents in an adhesive compound laminated onto a flexible, water-resistant outer layer. Some formulations contain an alginate to increase absorption capabilities. The wafers are self-adhering and available with or without an adhesive border and in various thicknesses and precut shapes for such body areas as the sacrum, elbows, and heels. Click here to see examples of
hydrocolloid dressings.
To begin appropriate treatment for chronic venous insufficiency (CVI), clinicians must be able to make the correct diagnosis. Part 1 (published in the March-April edition) described CVI and its presentation. This article provides details of the CVI diagnosis (including the differential diagnosis from other diseases), disease classification to help assess the extent of CVI, diagnostic studies used to diagnose CVI, and various treatment options to “rescue” the patient from CVI. (more…)
The elevator door opens and you step in to find yourself face to face with the important person you’ve wanted to meet to discuss your promising idea. It’s the chance you wouldn’t want to miss. But that chance lasts only as long as the elevator ride. You have less than a minute to make an impression. Do you have an elevator speech ready?
What’s an elevator speech?
An elevator speech is any short speech that sells an idea, promotes a business, or markets an individual. It’s a short summary, or pitch, that quickly describes the value of a service, product, or organization. The term is a metaphor for unexpected access to someone to whom you’d like to sell an idea or proposal. It derives from the early days of the Internet boom when web development companies needed venture capital. Firms were swamped with applications for funding, and in many cases, the companies that won the cash were those whose reps had a simple pitch and could explain a business proposal in an elevator in the time it took to ride to their floor.
A great elevator speech describes and sells an idea in less than a minute. Of course, it’s not restricted to elevators. It comes in handy any time and anywhere you need to give a concise presentation to capture someone’s interest so you can move to the next step—a follow-up call, a referral, a meeting, or a partnership.
Why clinicians need an elevator speech
You need to be able to describe what you do, what you’re interested in doing, and how you can be a resource to someone. The ability to sum up a unique aspect of your service or expertise in a way that excites others is a fundamental skill. Doing this in a brief, persuasive manner is an asset for any professional. A good elevator speech should grab one’s attention in a few words and make that person want to know more about you. Here are examples where a good elevator speech would be helpful:
• Thomas goes to a recruitment fair hoping to get an interview at a certain hospital.
• Mary is finishing her master of science degree and is interested in a position in a new wound care clinic.
• Caroline has written a book on grant writing and would like to present her ideas at a conference.
• Brian is interested in research and would like to join the research team.
• Mindy is trying to expand her wound consultation business.
You can use an elevator speech when you want to grab someone’s attention at a meeting, convention, or other social situation. In such situations, people typically ask, “What do you do?” A well-planned elevator speech can make the listener’s ears perk up and want to know more.
How to prepare an elevator speech
Before you can write an elevator speech, you need to know yourself, what you can offer, what problems you can solve, and what benefits you can bring to the prospective contact. For example, you may be an expert in professional communication and know strategies you can teach other staff to promote a better workplace environment.
You also need to know your audience. Will you direct your pitch to an administrator, a unit manager, or staff? You’re more likely to succeed if your elevator speech is targeted to a specific audience and you adjust it to that audience. Try to prepare different pitches for different audiences; a generic pitch is almost certain to fail. (See Key elements of a good elevator speech by clicking the PDF icon above.)
In today’s busy world, clinicians must be able to communicate in a succinct, persuasive manner. Your elevator speech is your introduction to others. It has to be good. Keep practicing it and perfecting it so you can speak with poise and polish. The more often you give it, the better it will become. It’s a great way to put your best foot forward when you have only a small window of opportunity to make a good impression.
Sjodin T. Small Message, Big Impact: The Elevator Speech Effect. New York, NY: Portfolio; 2012. Sprung S, Giang V. 6 keys to delivering a powerful elevator pitch. Business Insider Web site. www .businessinsider.com/terri-sjodin-how-to-deliver- an-elevator-speech-2012-10. October 26, 2012. Accessed October 26, 2012.
Kathleen D. Pagana is a keynote speaker and professor emeritus at Lycoming College in Williamsport, Pennsylvania. She is the author of The Nurse’s Communication Advantage and The Nurse’s Etiquette Advantage. She is also the coauthor of Mosby’s Diagnostic and Laboratory Test Reference, 11th ed. To contact her, visit www.KathleenPagana.com.
The guidelines include recommendations for practice, education, policy, and future resource. Strategies for implementation are given, as well as several useful appendices, such as:
• Debridement Decision-Making Algorithm
• A Guide to Dressing Foot Wounds
• PEDIS: Diabetes Foot Ulcer Classification System
• Offloading Devices
• Optimal Treatment Modalities.
PREPARE is a useful and patient-friendly website designed to help prepare people to make complex medical decisions. The website was developed by clinical researchers from the San Francisco VA Medical Center; the University of California, San Francisco; and NCIRE—The Veterans Health Research Institute.
PREPARE uses videos to provide concrete examples of how to identify what is most important in life; how to communicate that with family, friends, and doctors; and how to make informed medical decisions when the time comes. Users can also download a PDF of a PREPARE pamphlet.
Free guides for infection prevention from APIC
Download two free implementation guides for infection prevention from the Association for Professionals in Infection Control and Epidemiology (APIC):
This revised guide contains strategies for prevention, considerations for specific patient populations, evolving practices, and how to incorporate current regulations.
Topics include:
• C. difficile in pediatrics and skilled nursing facilities
• pathogenesis and changing epidemiology of C. difficile infection diagnosis
• environmental control
• new and emerging technologies
• tools and examples to help apply preventative measures, such as hand hygiene monitoring, environmental cleaning, and isolation compliance.
This guide includes infection-prevention standards, regulations, and best practices, as well as instructions, examples, and tools to conduct surveillance and risk assessments.
One of the worst fears of a wound care clinician is inadvertently compressing a leg with critical limb ischemia—a condition marked by barely enough blood flow to sustain tissue life. Compression (as well as infection or injury) could lead to necrosis, the need for amputation, or even death. The gold standard of practice is to obtain an ankle-brachial index (ABI) before applying compression. However, recent research and expert opinion indicate an elevated or normal ABI is deceptive in patients with advanced diabetes. What’s worse, in the diabetic foot, skin may die from chronic capillary ischemia even when total blood perfusion is normal. For information on how to perform an ABI and interpret results, click on this link. (more…)
