Cath Lab Digest

T he decision to use a specialty support surface for the prevention or treatment of skin breakdown is becoming increasingly complex. As technology advances, a growing array of surface choices has become available. In addition, an aging patient population and the higher acuity level now seen in hospitals can present healthcare professionals with increasingly difficult care management issues. The focus on financial stewardship in healthcare also necessitates careful attention to appropriate resource use without the loss of care quality. These factors, along with growing concerns about patient safety and professional liability, highlight the importance of making appropriate decisions about skin and ulcer care using support surfaces.

With these issues in mind, a project was undertaken in a large, urban facility to evaluate and revise an existing specialty support surface decision tool based on current published literature and expert opinion. The revised tool was pilot tested and updated where necessary.

Methods

Setting. The project was initiated in a 600-bed tertiary care hospital in a large urban center in western Canada — a regional referral center caring for high acuity patients and recognized for its leading-edge programs in emergency care, women’s health, ophthalmology, internal medicine (including innovative acute geriatric care services), interventional cardiology, critical care, and surgery. Interdisciplinary collaboration and innovation are commonplace in many program areas, making this a viable setting to undertake a project of this nature.

Original instrument. A decision support tool for the use of specialty surfaces had been developed in 2000 and was in use throughout the relevant care areas. Elements included in the tool were the patient’s Braden Score,^1,2 mobility/activity indicators, and identification of existing skin breakdown. The tool allowed considerable latitude in decision-making based on other clinical factors and established professional practices and had not been formally evaluated. Although hospital staff were familiar with the tool, review of appropriate use was necessary in light of escalating support surface rental costs and confusion caused by the multifactorial nature of skin maintenance and the pace of technological advancement.

Personnel. The project was initiated and led by the senior operating officer of patient care and managed by a project coordinator who ensured that all critical project tasks were completed. The nurse practitioner for geriatric services, who also chairs the hospital’s Skin and Wound Care Committee, provided clinical expertise.

Purpose. The project aimed to review and evaluate the existing decision tool, ensure that current evidence was incorporated into an updated decision tool, allow for broad professional input into the development of the new tool, and achieve cost savings while recognizing the importance of specialty support surfaces in preventing and treating skin breakdown in institutionalized patients.

Project approach. To accomplish the goals, the following strategies were incorporated into the project plan:

  • The literature review completed to create the first instrument would be updated to focus on developments in the topic area during the last 3 years.

  • A sample of completed existing decision tool forms would be audited to determine compliance with the guidelines and identify areas where the tool no longer conformed to the evidence or was unclear in its direction.

  • Current decision makers and users of the existing algorithm (Skin and Wound Committee members, nurse educators, unit managers, physicians) would be interviewed regarding current practice and issues in the decision-making process.