On 1/14/2010 Betsy Lenhart BSN, RN said:

Our program is set up much like Carolyn Crumleys. We have a preprinted physician order form for specialty beds (this includes Braden score with selection), nurses have autonomy in choosing skin care products based on skin algorithm, dieticians have a protocol for orders and consults can be ordered by nurses and are triggered by a low Braden score or documentation of a pressure ulcer in computer system. Our WOCN have provided additional education to physicians and residence on staging and documentation. At one of our system hospitals that has a wound care clinic a physician actively participates with the in house skin care teams.

On 1/4/2010 irene jankowski said:

Teresa, thanks for your input. As we are moving forward with the pressure ulcer projects at 4 different hospital systems, it is clear that lack of teamwork is having an impact on efficient implementation of pressure ulcer prevention programs. The doctors are vital members of our "teams". Standing orders do provide nurses with the opportunity to implement activities, but we need to be careful to avoid acting without communicating. Nurses can be more vocal with other health care team members about what we are doing to prevent injuries and how other members can help and participate in this effort.

On 12/21/2009 Teresa T. Goodell,RN,CNS,PhD said:

My experience has echoes Ms. Crumley's: physicians are not willing to put time into planning meetings or implementation efforts, but do want to be heard. In this situation, protocols and standing orders seem like a good solution, although they do leave out the possibility that one clinician will address a prevention issue that another has overlooked. "Routine" communication with physicians about diet, activity orders, etc. also has a way of getting missed or at least relegated to the position of least importance when other priorities compete. It is up to primary nurses to ensure that routine, but important, concerns are not neglected.

On 10/19/2009 irene jankowski said:

Arlene, thank you for this information. Sounds like you have some great physician input. The doctors I have spoken with are very concerned about this issue. One said he wished he had more information since he was completely unfamiliar with the nursing-focused program and the nursing protocols in use. He was also interested in the ability of nurses to score a patient for pressure ulcer risk.

On 10/18/2009 Arlene Morin said:

Last year we were cited regarding issues on patients with pressure ulcers. As part of our action plan we had to hire an out of hospital consultant. The consult advised us to include MD's in our pressure ulcer education. When MD's did document, many did not document with accuracy. At that point, we had no physician membership on our PUP (Pressure Ulcer Prevention Committee). Our facility has embraced this MD need. The PUP committee has provided MD's with education on PU's. There is also a MD champion at our facility who is not only an ID MD but she manages our wound care center. She is currently undergoing an education session for presenting at a weekly MD grand rounds. When the PUP committee provided education to our hospitalists - much to our surprise, it was embrassed with more questions and further education needs. Facilities must have MD buy in for prevention of pu's. MD's must also be aware of the pu's to be able to document them. This was another area that we found we were lacking in from a nursing perspective. We developed several tools in conjunction with our current documentation system which we are hopeful will help in this issue.

On 10/17/2009 Deanna Vargo said:

Six years ago a team gathered to develop Pressure Ulcer Prevention and treamtment plans/policy for an acute care facility. We had WOCN, Risk counsel, infection control, nurse managers,... but no physician on the committee. After our plans were drafted, the medical team did review in a meeting and approve the policy to be implemented - this included the prevention piece. My experience is that the physicians do not want to linger and schedule meeting after meeting; however, do like to give input after many of the issues have been worked out. We did have one physician who wanted to retract at the end due to concerns if prevention/treatment would be inplace and he would not know of the need. His statement "what if a familily calls and asks me and I do not know anything about it". He was reminded of his need to review the chart for new orders implemented....and pt's condition. Policy's did pass, and the results showed success in audit scores as well as physician survey results.

On 10/16/2009 Marijane Hauer said:

MDs are not a part of our Pressure Ulcer Prevention Task Force, but as a part of our Pressure ulcer prevention policy, nurses are required to notify MDs if patients refuse to reposition and reason (usually pain). Pain control and nutrition are key areas for MDs to address for preventing pressure ulcers. MJ Hauer U of MN Medical Center, Fairview Minnesota

On 10/16/2009 Carolyn Crumley CWOCN said:

Skin care and pressure ulcer prevention is primarily a nursing function. We are very lucky if we can even get the physicians involved with treatment of pressure ulcers, much less prevention. They are very happy to delegate prevention to nurses. Our pressure ulcer prevention plan includes approved standing orders for consults, skin care products, specialty beds, etc. If the patient needs something that requires a physician order, the nurses and/or the WOC nurse requests an order.