A 15% decline in the prevalence of pressure ulcers. A 30% drop in the number of pressure ulcers acquired during an inpatient stay. Several quarters with no reports of hospital-acquired pressure ulcers.
Nazareth Hospital in Philadelphia certainly has something. More accurately, the 205-bed community hospital in Northeast Philadelphia has someone: Lori Dwyer, CRNP, DNP(c), NP-C, CWCN. Behind these clinical victories is a wound care nurse practitioner who took on a concern so large that in 2002, the federal government attached a monetary value to finding its solution. Since Medicares inclusion of pressure ulcers on its list of “never events” — hospital-acquired conditions excluded from reimbursement — all clinical care providers eyes have been trained on preventing these skin issues. At Nazareth Hospital, all the eyes looking for pressure ulcers have been trained by Dwyer.
“Lori Dwyer has made us all better,” said Michael Segal, DO, medical director at the hospitals Center for Wound Healing and Hyperbaric Medicine. “Shes brought us to a level of expertise that we wouldnt have accomplished otherwise.”
Segal, a family practitioner who is certified in wound care, said he relies on Dwyers expertise and is grateful to have her as part of the outpatient wound care units staff. “I feel like I went to school alongside Lori,” he said. “She teaches me things.
“Theres a whole different emphasis — paradigm — here. The teaching takes on a different level,” Segal said. “We can be a lot more aggressive in preventive procedures.”
As a result of the facilitywide pressure ulcer prevention initiative, spearheaded by Dwyer, the Mercy Health System hospital has a cadre of wound care champions, a wound care cart on every inpatient nursing unit and a culture of awareness that reaches from the bedside into the administrative suites. The improved outcomes arose from a strategic mix of targeted education for clinical care staff, more frequent prevalence-and-incidence studies, improved charting and earlier, evidence-based interventions.
This preserved the hospitals Medicare reimbursement rates, improved patient safety and landed Dwyer a national audience for her research on wound prevention.
“Prior to the implementation of this program, the hospital surveyed pressure ulcer incidence by using an annual industry-sponsored prevalence study,” according to the abstract Dwyer wrote to accompany the poster presentation she gave in June at the Wound, Ostomy and Continence Nurses Society annual conference in Charlotte, N.C. One of many changes in protocol under the initiative was to conduct prevalence and incidence studies four times a year and produce custom reports for each inpatient nursing unit.
Another innovation capitalized on technology to help with prevention and education. Pressure ulcer order sets are now incorporated into the electronic medical records, and nursing staff receive automatic alerts when mandatory tutorials are uploaded into the hospitals computer system.
While Dwyer is committed to collecting quality data, she does not want to lose perspective on whom her research is designed to help.
“When you talk about improving outcomes, you do want to get a better score,” she said. “But you want the patient to say, ‘I got great care.”
Dwyer, a DNP candidate at La Salle University in Philadelphia, created a more comprehensive tool for assessing a patients risk of developing skin issues. The tool, which provides key data for the prevalence and incidence studies, uses probing questions with an eye toward the care environment to capture more information from providers and medical staff. Dwyer noted the patient risk factors vary from unit to unit, meaning the training needs for clinical care staff also could be different.
“[For example, in the ICU and CCU,] we look at things like: Is the head of the bed elevated more than 30 degrees?” Dwyer said. While the literature on wound prevention recommends a lower elevation, critical-care protocols often require sharper angles. Therefore, Dwyer and her wound care champions — nurses who voluntarily obtained additional training in wound care to serve as points of knowledge on their units — ensure that caregivers know to turn the patients with higher beds more frequently to prevent skin breakdown.
Dwyer, who evaluates and treats wounds on all inpatient units and works with Segal at the outpatient Center for Wound Healing and Hyperbaric Medicine, praises her nursing colleagues for their roles in pressure ulcer prevention and treatment.
“We wouldnt have the quality of program we have without the nurses buy-in,” she said. “I think theyre dynamite.”
Susan Hansen is a freelance writer.