My Scope of Practice: A Healthy Skin Champion
Positive clinical outcomes for skin safety and health are of growing importance in health care, particularly in light of the fact that the Agency for Healthcare Research and Quality (Rockville, MD) estimates 2.5 million patients develop pressure injuries annually. The 3M Award for Excellence in Skin Safety (3M, St Paul, MN; WOCN Society, Mount Laurel, NJ) recognizes a health care facility for a successful skin integrity program. Now in its seventh year, the award highlights innovation and dedication by certified wound care nurses to deliver quality, evidence-based care to the body’s largest organ.
“Our pressure injury prevention need recognition was two-fold,” Amy explained. “First, we did not have a dermatology department or anyone overseeing skin care, so we felt skin integrity was not being prioritized as well as it should. We needed a more formal program to determine our pressure injury incidence and prevalence to help us know where to focus improvement efforts. Second, once we began tracking this data, we felt our rate wasn’t acceptable and it needed attention.”
In 2012, 2 clinical educators at Connecticut Children’s began the hospital’s Skin Care Program, which is centered on the Solutions for Patient Safety (SPS) International Consortium of Childrens’ Hospitals’ standard hospital-acquired conditions (HACs) bundle. This evidence-based foundation uses assessment, device rotation, patient positioning, and appropriate bed surface and moisture management as its key tenets for patient care and incorporates education, training, and mandatory reporting for facility staff.
“Once the program started, other team members quickly became interested to learn more and participate, including a few members who became wound care certified to help clinical team members when skin issues arose,” Amy says. “We eventually recruited our twentieth Healthy Skin Champion, which allowed us to have representation in every in-patient area in the hospital.”
Today, the Skin Care Team comprises 10 certified wound care (WCC) nurses and 60 Healthy Skin Champions, a title not taken lightly at the hospital. According to Amy, a Healthy Skin Champion “adheres to and models best practices for pressure injury prevention bundles and mentors both team members and clinical staff using ‘200% accountability’ when practice gaps are identified. Healthy Skin Champions attend quarterly extended skin care team meetings to participate in decision-making and quality improvement discussions and receive continuing education training relevant to skin integrity. Champions also wear a skin care team vest to ensure visibility to the team while on duty.”
In addition to the Healthy Skin Care Champions, the Team is supported by a number of dedicated clinical nurses, nurse leaders, clinical educators, registered respiratory therapists, patient care assistants, and a registered dietitian.
At the core of the program is high-reliability patient safety. For example, the Team maintains Daily Management System (DMS) boards through every unit and department. These boards display specific key process and resource quality metrics that are reviewed twice daily at scheduled unit/department huddles. A monthly calendar featuring several HAC bundles in either red (noncompliance) or green (compliance) keep a visual reminder of the progress of ongoing quality initiatives for staff, patients, and their families. Also on these DMS boards are the bed numbers of patients who are at risk for skin injury. This list is updated at the beginning of each shift to keep the entire health care team aware. These at-risk patients receive daily pressure injury prevention bundle audits from Healthy Skin Champions. In this process, the Champions assess bundle adherence, ensure delivery of appropriate skin care as per the bundle, and coach front-line nurses as needed.
Since its implementation 6 years ago, the Skin Care Program and its Champions and WCC nurses continue to maintain a pressure injury prevalence rate lower than the National Database for Nursing Quality Indicators and meet the SPS shared harm reduction goals. The team conducts quarterly pressure injury prevalence audits and tracks the Connecticut Children’s performance against children’s hospitals nationwide.
Amy described one recent instance where the Skin Care Team stepped in to mitigate a standout problem. “In 2017, our organization recognized and responded to an increased incidence of pressure injuries that developed underneath the hubs of peripheral intravenous catheters. Our skin team researched best practices, examined several products available to protect our patients’ skin, and changed our organization’s policy to now require a foam or hydrocolloid protective skin product beneath the hub of all peripheral intravenous catheters. We have since seen a reduction in the number of pressure injuries related to peripheral intravenous catheters.”
For anyone interested in beginning their own facility Skin Care Team or Program, Amy offers some valuable advice. “Start by educating everyone on the importance of skin integrity for hospitalized patients. We have to start doing a better job of thinking skin first. Then, enlist in a group like SPS – that gives you structure, interactive processes and organizational help – for guidance in kicking off and sustaining an evidence-based program. It’s also incredibly helpful to share your experiences with others. Attend conferences and events to share information and learn from other organizations. And, perhaps most importantly, never stop advocating for your patients’ well-being.”
Being a Healthy Skin Champion and reducing pediatric pressure injury prevalence are the sum and substance of Amy’s scope of practice.