Establishing a comprehensive networkwide pressure ulcer identification process.

BACKGROUND: Pressure ulcers (PUs) are a critical concern, endangering patients and requiring significant resources for treatment in Stage II/IV. The Centers for Medicare & Medicaid Services (CMS) denies reimbursement in cases where a more complex diagnosis-related group (DRG) is assigned as a result of hospital-acquired conditions such as a PU that could have been reasonably prevented. IMPLEMENTATION: An interdisciplinary PU present-on-admission (POA) team developed an algorithm to support the early identification of PUs for units participating in the process. This approach standardized work, resulting in consistent (1) skin assessment, (2) physician notification, (3) reporting of findings in the patient safety reporting system, and (4) communication to receiving units. Computer-entry tools were developed and completed for six months by the patient care services unit-based process improvement councils; these councils made possible immediate "loop closure" for either positive feedback or needed reeducation with the nursing staff. RESULTS: The total number of PUs recognized and reported after implementation of the process improvement initiative--from April 1, 2008, to March 31, 2009--increased to 1,103--an increase of 36.3% in PU reporting when compared with the same period the year before. This initiative has yielded 100% effectiveness in identifying Stage III/IV PUs POA and in preventing hospital-acquired Stage III/IV PUs. The success of the project has helped to ensure high-quality patient care and protection of precious fiscal resources. CONCLUSIONS: The data suggest that the identification of all PUs that are present at time of admission is clinically feasible.

Collaboration in wound photography competency development: a unique approach.

OBJECTIVE: The objective of this study was to enhance conventional wound assessment and documentation of clinicians by incorporating the use of digital imaging into the medical record using standardized photography requirements. DESIGN: A review of current literature, existing clinician practice, and identification of barriers preceded the development and implementation of a clinical practice guideline, with a performance checklist, aimed at improving the wound photography (WP) process. In addition, establishing standards of practice and behavior modification were used to improve clinician proficiency in digital photography. SETTING AND PARTICIPANTS: Wound clinicians providing specialty care within the acute care setting. MAIN OUTCOME MEASUREMENTS: Following educational sessions, evaluation of clinician competence in using equipment and adherence to standard digital imaging protocols with the use of a performance checklist permitted educators to validate clinician skill. MAIN RESULTS: Establishing consistency in digital imaging results is an overall enhancement of the WP process by increasing clinician satisfaction and efficiency, improving assessment skills, and enriching documentation. Competency strengthens one's skill set and serves to create a common language, leading to improved communication among clinicians and resulting in enhanced wound assessment. CONCLUSIONS: WP plays a valuable role in delivering effective patient care by strengthening wound assessments and documentation. Recognizing the need for consistent standards, clinical educators from Lehigh Valley Health Network designed an educational program using a multifaceted approach, including clinical practice guideline development, education, and competency assessment. Enmeshing current practices, expert opinion, and clinician knowledge resulted in an innovative process using interdependent, yet independent, components to achieve enhanced wound assessment.

Progressive wound necrosis associated with postoperative thrombocytosis in mastectomy and immediate breast reconstruction surgery: report of a case.

A 37-year-old who underwent splenectomy for motor vehicle accident-related injuries was diagnosed with stage IIA carcinoma of left breast 12 years later. She underwent bilateral mastectomy and bilateral immediate unipedicle TRAM flap reconstruction. Her preoperative platelet counts ranged from 332 to 424 K/cmm. Intraoperative fluorescein confirmed mastectomy flap viability. On postoperative day 1, platelet count was 374 K/cmm and all suture lines appeared benign. The patient was discharged 3 days later with healthy appearing tram flaps and slight epidermolysis in the abdominal region. Over the next 2 weeks, both the mastectomy flaps and the abdominal region underwent progressive necrosis as the platelet count increased to 1390 K/cmm. Aspirin therapy was instituted at this time. The TRAM flaps remained completely viable. Eighteen days later, the patient required wound debridement with secondary closure of the breast wounds. Platelet count peaked at 1689 K/cmm 2 days later (postoperative day 38). The wounds deteriorated again and were managed conservatively. Two months after mastectomy, the first area of spontaneous healing was documented (platelet count 758 K/cmm). Ultimately, wounds healed as platelet count reached its preoperative baseline. We hypothesize that an abnormal secondary thrombocytosis at subdermal plexus level caused problematic healing in this patient's mastectomy and abdominal flaps.