1. System Change Presentation: Daily Skin Inspections Camilla Hansen 11/25/13

2. Wound/Skin Management Policy  Every 3 years the VA Maryland Health Care System must update their nursing policies including the wound/skin care management policy  Changes made at the last policy update included purchasing standard wheelchair cushions for all residents that were wheelchair bound, organizing a pressure ulcer committee, and ensuring that all residents have daily skin inspections  Wheelchair cushions were ordered and given to all wheelchair bound residents and a pressure ulcer committee was organized  Staff began checking resident’s skin every day for any problem areas however no one was documenting that the skin inspections had been completed

3. Long Term Care Institute Survey  Each year the long term care institute surveys the Perrypoint VA to make sure policies are being followed  The 2012 long term care institute found that although residents may have been receiving skin inspections it was not documented anywhere  If the skin inspection was not documented then in the court of law it has not been performed

4. Wound Liaison Meetings  At the Perrypoint VA there is one wound care nurse but each unit has a wound liaison  The wound liaison attends meetings, wound retreats, and is a resource for fellow staff members  The wound liaisons and wound care nurse met at a group meeting to discuss how we could properly document the daily skin inspections

5. Daily Skin Inspections Documentation  At the meeting we decided the best place to document the daily skin inspections was in the treatment books and because the inspections were part of a policy a doctor’s order was not needed to include them in the treatment books  On each resident’s treatment sheet the following was written:  Daily skin inspection was performed, write either yes or no  If there were any skin changes, was the charge nurse notified, write yes or no

6. Reddin’s Change Theory  Diagnosis: According the 2012 survey, the wound/skin care policy was not being followed because staff were not documenting that daily skin inspections were being completed  Top management, the wound care nurse, and staff nurses were made aware of the problem  The wound care nurse and wound liaisons were assigned to fix the problem

7. Reddin’s Change Theory  Mutual Setting of Objectives: Because daily skin inspections were part of the new policy, changes had to be made  Group emphasis: The wound liaisons and wound care nurse wanted to come up with an easy way to document that skin inspections were being completed so that they could be in compliance with the policy but not take up too much of the staff’s time with lengthy documentation

8. Reddin’s Change Theory  Maximum information: Ideas were expressed at the wound care meeting by the wound liaisons of the different units  Discussion of implementation: The wound care nurse wrote down several ideas that the group thought would work and then the ideas were voted upon

9. Reddin’s Change Theory  Discussion of implementation and use of ceremony and ritual: An staff in-service was conducted on each unit by the wound liaison to teach staff members how to document correctly in the treatment book as well as how to complete a thorough skin inspection  Because nursing assistants typically conduct the skin inspection during AM care the documentation was only to be done by the day shift staff members  If a staff member found a problem area on a resident, then they were to notify the charge nurse so that he or she could do a skin assessment and document in the electronic record accordingly

10. Reddin’s Change Theory  Resistance interpretation: Because some staff members forget to complete the treatment books a compliance monitor was instituted  Each week the wound liaison would have to randomly select 5 residents and then record their results on the monitor sheet  The compliance monitor was then to be emailed to the wound care nurse and unit nurse manager  If a inspection was not completed on one of the monitored days, then the staff name had to be included  If a staff member failed to document more than 3 times on any given monitor then they would receive another in-service

11. Compliance Monitor Example for Mr. Smith 11/11 to 11/15 DateDid caregiver initial that inspection was completed? If there were any skin changes, was the charge nurse notified? If “yes” was recorded, did the charge RN do a skin assessment and document in CPRS? 11/11Yes Yes, skin assessment was done and changes were documented in CPRS 11/12YesNo, no changes 11/13YesNo, no changes 11/14Not completed (John Doe was caregiver) 11/15YesNo, no changes

12. Compliance Results  At first many staff members came to me, the wound liaison for my unit with questions regarding how to document in the treatment book as well as what problem skin areas look like  Over time though I have found that the daily skin inspections have tremendously helped our unit  The daily skin inspection documentation was implemented roughly 3 months ago and so far we have only had 1 new pressure ulcer that developed  The pressure ulcer that was found was documented as a stage II and healed within 2 weeks  Documenting in the treatment book helps remind staff members to tell the charge nurse about a problem skin area that they might have seen  Nursing assistants feel a better sense of responsibility because they are helping to reduce the prevalence of pressure ulcers on our unit  Problem areas are treated quicker so that a pressure ulcer does not develop or if one does appear it can be treated quickly

13. References Roussel, L. (2013). Management and Leadership. 6 th ed. Mobile, AL: Jones & Bartlett.