John, a bariatric patient of 102 kilos, was admitted to a hospital in Calgary with extensive septic wounds on May 11, 2017. He spent four weeks there, immobile due to stage three pressure ulcers on his coccyx, bilateral heels and left upper thigh. He also had a stage two pressure ulcer on his right thigh. When he was transferred to a rural hospital near his home on June 15, he had little hope for his future.
“John was very down,” says Norma Schock, RN and care manager. “Though he hadn’t seen a plastic surgeon yet, he was told his lower leg should be amputated.”
“He really thought his life was over,” says Joanne Yurko, RN and educator.
But the interprofessional team at Black Diamond Oilfield General Hospital had a plan.
Complex wound care with limited resources
Teamwork and resourcefulness are vital in a small hospital with 17 medical beds, a small staff and limited equipment.
“We don’t have a wound team,” says Joanne. “Nurses are generalists here. We troubleshoot our own problems.”
The team drew on experience, theory and other resources. The entire multidisciplinary staff supported John to give him the best possible outcomes.
Joanne noticed John’s wounds were extremely dry; his scabs and dead tissue needed debriding. She spoke with the wound team at the South Health Campus and created a personalized treatment plan for John. She recommended that the complexity and depth of his wounds would benefit from negative pressure wound therapy (V.A.C. Therapy®) and the Oilfield Hospital physician wrote an order for it.
Joanne worked one-on-one with nursing staff to ensure consistent aseptic technique between treating each of his wounds. A schedule was set up to ensure knowledgeable staff were available to take care of him.
“It was a very complex process,” says Joanne.
All of his wounds were dressed at the same time, which took two hours and two to three RNs, licensed practical nurses (LPNs) and health-care aides (HCAs) each time. Dressing changes required significant teamwork and coordination of unit activity due to the small unit staff. Three of John’s wounds were attached to V.A.C. Therapy® pumps, which require frequent assessments and troubleshooting. It was not unusual for seals to break and for the entire process to be repeated on shifts with few staff available.
Taking John to the washroom or getting him ready for physio posed significant challenges. The unit functioned around what John needed.
In addition to managing John’s wounds, the team worked to meet his needs holistically:
- An air bed supported wound healing and prevented further wounds.
- A larger room with a bigger TV accommodated equipment but also improved his mood.
- A nutritional protein supplement increased his protein intake, which was essential for wound healing.
- A mobilizing plan helped strengthen John’s core and leg muscles and avoided pressure on his heel injuries using stand-to-lift equipment.
- He worked closely with physiotherapists and occupational therapists to regain mobility. They also encouraged John to participate in his care and notice the rewards of his efforts.
- An open door visiting policy allowed John to stay connected to his friends and family.
“We had many discussions about lifestyle changes he needs to make,” says Joanne. “That’s where it all comes back to. If he didn’t have tools or hope, he wouldn’t participate in his own care.”
The team saw his wounds improve each week.
“At first, John wasn’t able to sit up in bed. We had to use an air bed to help him. Then we moved to using sit-stand equipment to get into a wheelchair. He couldn’t stand on his wounded legs for long,” says Norma. “Then he moved on to a walker and a cast boot on just one foot.
A team accomplishment
“It really is a feat for our LPNs, RNs and HCAs to plan this together,” says Norma. “It was less about tolerating the new workload and more about unity.”
The wound care procedure stands out in Norma and Joanne’s mind.
“We had good hand hygiene. We prevented wound cross-contamination. He never got sick while he was here and his sepsis never returned. Our team’s attention to detail ensured his body could heal without further infection delays,” says Joanne.
On October 20, John was discharged with home care visits and just one remaining wound V.A.C. Therapy® appliance.
The team essentially gave John a new lease on life: “We gave him hope, dignity and a chance to live outside the hospital,” says Joanne.
“All of our teams and departments used our skills and the resources available to us. Our patient was able to walk out of the doors upon discharge. That is something to celebrate!” says Norma.
Source: College & Association of Registered Nurses of Alberta