At Hancock Regional Hospital, we offer a state-of-the-art outpatient wound care clinic specializing in all types of skin and wound care including, burns, lacerations, pressure injuries, ulcers, and surgical wounds. We also treat many people with chronic, non-healing wounds, often associated with complications from diabetes and related vascular disorders.
The clinic serves outpatients, as well as patients admitted to the hospital. Patients who first visit the wound clinic may also be admitted to the hospital. Likewise, patients already in the hospital may need to have follow-up care at the clinic. Because the wound clinic is typically open Monday through Friday, patients who need to be seen outside of clinic hours are often treated in the ER until they can be seen during clinic hours.
Regardless of where the patient is being seen, continuity of wound treatment between care settings is vitally important to the patient’s recovery. At Hancock, we’ve helped bridge the gaps in care by implementing multidisciplinary wound care protocols for patients, as well as related physician notifications.
Assessing the need
Wound care is essentially a specialty area. The staff in our wound clinic work with wound and skin problems on an everyday basis compared to the hospital staff. We knew we had to make processes more consistent and create standards within workflows — essentially helping to ease burdens for our hospital nurses and doctors around such things as identifying and classifying wounds at the onset.
Acute care physicians and nurses would often classify wounds differently and would order something different from what our doctors and nurses would order at the wound clinic. The lack of consistency was inefficient, and could lead to longer treatment and healing time for patients. With the help of our clinical nurse liaison, we determined the following care gaps:
- Lack of continuity of wound treatments for patients being seen in the wound clinic as outpatient when admitted as inpatient
- No standardization of wound treatments for patients in inpatient units with wounds
- Difficulty with communicating the development of new wounds
- Need for additional communication to the physician of new or existing wounds
Leveraging the right tools within the EHR
We looked to our EHR to help us define workflow procedures. All of the information and tools were there, we just needed to put the right steps in place for each discipline. Staff leveraged tools such as:
- Query links and tools to communicate to nurses
- Status boards throughout the process
- Surveillance boards to set notifications, order sets, if necessary. Prior to patients being seen at the wound clinic, staff could set up short-term order sets first.
For example, now, when a patient with a skin problem presents at the hospital, the acute nurse documents the skin problem on admission assessment or on physical assessment. That documentation sends the patient to the Surveillance board and also triggers a printout to the wound clinic. The skin problem query links to an order for short-term treatment and inpatient wound assessment interventions. Nurses document the skin risk assessment on admission, and during every shift, so that query links trigger the appropriate interventions.
To ensure the continuity of care, the wound clinic nurse then receives the printout, pulls the patient up on the Surveillance board, and reviews charting from inpatient nurse. From there, the nurse determines whether the patient needs to be seen, and documents if they’re not seen and the reason why.
If the clinic does see the patient, that nurse completes the wound assessment, including pictures of the wound, and discontinues short-term treatment. Orders are placed via the wound order set — placing per protocol and queuing for physician signature. The nurse also includes orders for support surface, off-loading, dressing change, and compression, and places any referrals needed for the outpatient wound clinic. The patient is given discharge instructions/forms and, if warranted, orders a consultation with a wound care physician. Once the patient leaves, they are removed from the Surveillance board.
In terms of the steps involved for the physician or hospitalist, once the clinic nurse places the orders, that queues the signature from the physician. The physician is able to view a condensed assessment of the wound(s) from clinical panel. If they want to see the full assessment, they are directed to patient care tab within medical record. The physician is also able to review wound clinic nurse notes on the clinical panel with the associated pictures.
For long term patients who are already being treated in the hospital for other reasons but develop a skin or wound problem during their stay (such as ulcers or bed sores, for example), our protocols also outline that a wound care clinic nurse comes to the hospital to address and help treat those specific wounds. The wound clinic nurse has autonomy through protocols to assess and treat wounds, helping to alleviate the burden from physicians and primary care nurse to assess and decide appropriate treatment
Achieving desired outcomes
Surveillance is a wonderful tool, and it plays a major role in the continuity of care protocols we have in place. Upon intake, for any patient with some type of skin condition or wound, the nurse updates the chart which sends an alert through the Surveillance board, so that all the appropriate staff are aware of the patient and what they need to have treated. Not only is everyone alerted to the problem upfront, but we can also head things off from getting worse because we have the right assessment and triggers in place. By implementing interdisciplinary wound protocols, we can more effectively:
- Continue care started with wound treatments in the wound clinic if the patient becomes admitted
- Prevent at-risk patients from developing wounds
- Communicate existing wounds on admission (nurse, physician, wound clinic) Communicate new wounds that develop (nurse, physician, wound clinic)
- Provide standardized treatment of wounds
- Continue treatment of wounds on discharge (referral to wound clinic, if needed)
Thanks to taking a step back and looking at what wasn’t working, we now better serve our patients and have helped ease extra burdens from our hospital clinicians.
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