Pressure injury prevention and management are sometimes overlooked in the hospital setting, where the focus is generally on acute illness. Given the immense implications in terms of cost, complications, reputation, and risk management, it is in the interest of all facilities to maximize quality of care with regard to wounds. This post will offer some suggestions on how this can be accomplished in hospitals by tweaking the system for maximum quality.

Improving Effectiveness of the EMR for Wound Care

EMRs have basically taken over record keeping in hospitals, but many EMRs do not appropriately capture pressure injury prevention and treatment. Companies that provide these electronic tools may not appreciate the need to accomplish this task. Information is often scattered about, and fields to input wound description - including measurements, treatment, and preventive interventions - may not even exist. Some EMRs allow repopulation of wound description from days earlier without revision, even if the wound is changing.

EMRs require redesign to assemble all wound care information into a "nest," where it is easily retrievable, as well as "hard stops" for evolving wound description and ongoing interventions. Digital interdisciplinary bridges are needed to alert physicians of alterations in skin condition, and doctors need them to list wounds and relevant treatment plans in problem lists and discharge summaries. Programmers of EMRs can accomplish this by placing doctors, nurses (including WOC nurses), and risk managers in focus groups for how best to maximize user-friendliness, while also bringing all the necessary information together.

Empowering the WOC Nurse

The WOC nurse is the team member with the most up-to-date knowledge of pressure injury prevention and treatment, and is generally well trained in wound assessment. In a world where physicians may not be attuned to the issues, WOC nurses can fill the gap. However, many hospitals do not have WOC nurses, and others do not have enough WOC nurses to fulfill all responsibilities. This includes ensuring that documentation is accurate and complete, applying preventive interventions in a timely manner, educating nursing staff on preventive and treatment modalities, monitoring the wound care formulary, and serving as a bridge for physicians whose patients are either at risk for wounds or have skin integrity issues that require attention.

Until all medical doctors recognize that pressure injuries, as well as any disruptions in skin integrity, are a medical problem, WOC nurses will have to fill the gap. This can be accomplished by proper staffing, as well as empowering the WOC nurse position. Empowerment means granting the authority and opportunity to get things done within the system, and making sure they are done properly.

Engaging and Educating Physicians

The system of medical education has not fully recognized the fact that skin is an organ that requires care and treatment. As a result, pressure injuries—particularly those that do not yet require surgical procedures—are not on the list of concerns for most doctors. Exceptions do exist, as the field of Geriatrics has embraced pressure injuries as a "Geriatric Syndrome," and knowledge of this topic is required for Board Certification by the AGS and ABIM.

Today, most internists (including hospitalists and subspecialists) are not adequately educated in preventive technologies, such as mattresses and overlays, and are unfamiliar with wound treatments and their proper application. Many hospitals do not require physician orders for wound dressings, considering them nursing interventions. It is a common observation that doctors do not list pressure injuries in their problem list—in either inpatient notes or discharge summaries.

Skin is a complex, multifunctional organ that requires equal recognition and monitoring as the heart, liver, lung, etc. All physicians need to be engaged and educated on pressure injury prevention, wound care formularies, and proper decision making algorithms with regard to diagnosis and treatment. The need is so great, I have advocated for wound care education as a requirement for licensure—analogous to the requirements for child abuse detection and infection control.

In Summary

The topic of pressure injuries has never been popular. Nonetheless, this medical problem incurs huge costs in terms of direct care and legal liability, and is a critical component of the multibillion-dollar wound care industry. Hospitals will continue to pay a premium to cope with this issue until maximum quality is achieved within their systems.

About the Author
Dr. Jeffrey Levine is a board-certified internist and geriatrician with over thirty years of experience in wound care in hospitals, nursing homes, and home care environments. He is a voluntary attending physician at the Mount Sinai Medical Center in Manhattan, and Associate Professor of Geriatrics and Palliative Care at the Icahn School of Medicine at Mount Sinai. He received his fellowship training in geriatrics at the Mount Sinai Medical Center where he began his interest in chronic wounds. He is an elected board member of the National Pressure Ulcer Advisory Panel (NPUAP).

Dr. Levine's interest in pressure ulcers began in the 1980s during his geriatric training when he noticed that many of his nursing home patients had pressure ulcers but there was little reliable information on treatment methods. This motivated him to study not just prevention and treatment of chronic wounds, but to delve into the rich history of wound care over the centuries. He has since published a number of articles on historical topics ranging from wound care in ancient Egypt through the 20th Century.