On 9/28/2009 Isabel Bales said:

Hello Irene! Great job! Very impressive! I will be following this from time to time. I am very interested in this program. Thanks for sharing! Isabel

On 8/18/2009 Cathy Van Houten, BSN, RN, CWON said:

Congratulations Irene. I am very lucky that I work at a large university hospital that 4 years ago did not have any WOC Nurses on staff/inpatient, but now has 4 full-time WOC Nurses. We have gone from a high double digit pressure ulcer prevalence to a less than 3% prevalence. What happened? Vision and support from Nursing Administration, as well as the CEO, COO CFO and Chrief Quality Officer. We purchased top of the line critical care bed systems, educated staff, formed critical care and med/surg skin and wound teams, brought new products in with support from Value Analysis (breathable underpads, barrier creams, wedges, etc), received support from Nursing Education in implementing the educational programs for nursing on pressure ulcer prevention and skin care. We (WOC Team) have also been invited to speak about pressure ulcer prevention to Residents/interns, mid-lvele providers, student nurses and others. We have come a long way in a short period of time, and our CNO has made it clear to staff that our goal is zero pressure ulcers. Nurse Managers are being held accountable and any hospital acquired ulcer is entered into our events reporting system. Anything beyond a stage II makes it into the weekly Harm Report. PT, OT, Nutrition, aides, patients, families and the OR staff all play a role in prevention. I believe that a major key in our turn-around is a change in culture and support from nursing administration.

On 8/3/2009 Sandra Seaton CWCN said:

Thank you for your time, A huge barrier that I am battling at my hospital and with joint commission is that the skin care products now have a NDC code on them and are considered medications and cannot be left at the bedside, they are OTC's per FDA because they make the statement skin protectant on the lables. Because the definition of what cannot be left at the bedside is so broad and must be secured,this is leaving the skin care products difficut for the bedside nurses and NA's to get to when they are needed. A good Skin Care Program is not going to work if it is difficult and the products are not available when they are needed. Any help getting that changed would be much appreciated.

On 7/31/2009 wildan said:

want to know about patien safety as clinical risk managemet

On 6/15/2009 Maureen Porras said:

Irene, Congratulations on your new journey! I remember seeing the posting and thought, "WOW, what a great opportunity!” I am currently working as an ICU nurse and provide some per diem coverage for the FT WOCN at my hospital. Being a bedside nurse who completes the Braden scale everyday, I do see the changes and how that reflects in my bedside care, changes in the care plan and things that need to be addressed in our daily bedside multidisciplinary rounds. What I experience in actual patient repositioning both in my unit, and when I am acting as WOCN, there is a direct correlation between time and resource. There are times that my peers are just as busy as I am, with new orders, dealing with labile blood pressure, oxygen saturation issues; "repositioning" does get put lower on the list. Given my unique outlook, I try my best to keep it high. Unfortunately my peers are not always willing to stop what they are doing to help reposition. They have 2 heavy patients that are requiring many medications, new tube feeding, trach care, oral care and all those daily bedside things that happen in the hospital. Now add on top of that a slow computer system, multiple charting requirements, it truly comes down to "nurse-power". I wish that in stead of "lift-teams" we had "turn-teams”. I love the research, however true implementation of the recommendations always comes down to hands on bedside care. With nursing cuts, staffing cuts and patient ratio issues, without the additional pair of hands, I just am not sure how a good “plan” will be actually implemented with all the economic constraints that hospitals are experiencing. I wish you all the best and look forward to the new recommendations that will be presented from all your hard work!

On 6/15/2009 Myra Varnado, RN CWOCN said:

I think some folks see completion of the Braden as a "One TIME" requirement, which is completed on admission, and then it is DONE. To be of value, Braden scale must be viewed as a dynamic tool and process which mirrors changes in the patient's condition throughout the care delivery and identifies changes in the patient's care needs.

On 5/29/2009 Paolo Vega, RN, BSN said:

I have worked in Beth Israel Medical Center before and Irene Jankowski is the greatest wound care resource I've known ever since I began my career in nursing. I would like to laud her in being a Nurse Safety Scholar. She deserves it and I'm proud of you!

On 5/22/2009 Luanne Bowen, BS< RN CWON said:

Having both a home care and now a hospital background I have to say I see the similar problems with the Braden Scale in both areas. When the nurse identifies the risk on the Braden tool, there is often no specific intervention implemented. For example, if the patient's Braden score reflects incontinence, the plan of care should include prompted voiding, bladder training, skin protection, etc. Instead, the tool is being used as if the score simply means the patient is "at risk." In a way, this scenario is worse as it reflects we identified specific problems and did not institute corresponding interventions. A tool to assist nurses from this point of view may be ideal.

On 5/22/2009 Lee Ann Krapfl said:

One barrier that you haven't mentioned is confusion or unclear delineation about the role of the wound nurse/team. As a wound nurse, I see my my hospital's committment to this role as a positive one. But I will acknowledge that too often staff nurses are unwilling to accept their responsibility or accoutability for pressure ulcer prevention, identification, staging and treatment, thinking that it is the "wound nurse's' problem." Important pressure ulcer prevention interventions (ie: obtaining a specialty mattress or bed) is often delayed until the wound nurse is available. Even when there are protocols or decision tress in place for staff to utilize, they wait until the 'expert' is available.

On 5/22/2009 Lee Ann Krapfl said:

One barrier that has not been mentioned is confusion about the role of a Wound Specialist/Team. The existence of a wound nurse(s)should be viewed as a positive. But it can certainly be a barrier depending on how the role is defined and how this person functions. Sometimes staff refuse to accept any accountability or responsibility for decision making, thinking that pressure ulcer prevention, identification and staging are "the wound nurses' problem." Too often, important preventive interventions are delayed (ie: placement on a specialty bed or surface) until the wound nurse is available. Even when there are protocols and decsion trees in place for staff to use in the absence of the wound nurse, there is a natural inclination to wait for the 'expert' to arrive before intervening.

On 5/21/2009 Pam Schopp-Young said:

This task is a wonder to hear about, especially being able to provide thought on what some of the problems are with prevention. Besides the usual educated staff in appropriate numbers and effective products and screening tools, supportive administrative staff is essential to be willing to provide the basics that staff needs. This would include critically looking at their facility to ensure there is room available to have all pts OOB in chairs which fit them, providing the lift equipment to get them out safely, having enough electrical outlets of the correct voltage to power all the equipment a pt needs (including pressure redistribution devises which are sacrificed when other medical equipment is needed and there are not enough outlets)and having an organization with the philosophy that no one stays in bed, with rare exception. Thank you for asking for comments.

On 5/21/2009 Mary Brennan said:

I am so thrilled that you have accepted this position. As a bedside clinician, you are facing the same issues I am and we have this opportunity to have you speak for us with JC. I am in favor of regulations but the frustration is that we still do not understand this phenomonum of pressure. Skin failure is very real but we do not equate it with the same significance as we do heart or kidney failure. Let us know how we may help.

On 5/21/2009 Irene Jankowski said:

Thanks for the ongoing comments. I hope you can keep them coming: Focus is - what are the barriers to successfully implementing a pressure ulcer prevention program and reach the goal of preventing most pressure ulcers - What needs to change? We all agree that what we have is not perfect and that we need to use clinical judgement that individualizes our plans for each patient since there are so many variables - there isn't a "one size fits all risk assessment tool or prevention plan" Second, we are concerned about the financial resources that may not be readily available; Third, training of staff is inconsistent and not sustainable Fourth, doctors must get more education and participate more actively Fifth, a nurse expert who has the top level administrative and financial support in pressure ulcer prevention and treatment is critical to the success of preventing and treating pressure ulcers-More......

On 5/21/2009 Barbara Hahler said:

I agree that the Braden Scale is not specific for the acute care patient in 2009---esp the ICU pt. The vast majority of my ICU pts are all at high risk, so how does one differentiate which surface to use. The Braden Q has added a category that examines hemodynamic status of the pt. Needs to be some exclusions. What am I to do when I have the pt on a low air loss bed, nutrition is maximized, he is turned q2h, heels are elevated, but he still develops a pressure ulcer? Need updated educ in nursing schools. They are still teaching 4 stages of pressure ulcers. I find students can calculate a Braden Score, but then have difficulty relating it to care Limited time and money for education due to limited resources Agree that manager must buy into skin care. Some think my pts are special and can't be disturbed to have WOCN nurse look at them

On 5/21/2009 Renee Cordrey said:

I think that prevention will never be effective unless nursing management truly supports the efforts. This means more than lip service. This means that the expectation is that adequate prevention measures WILL be implemented, and if not, that failure will be addressed appropriately. Excuses, such as "our patients are very sick" "or "we're too busy" will not be accepted. A second component is that physicians need to be more engaged. Most of them only look at the skin outside the bedsheet, even when they know an ulcer is present. Many physicians do not, perhaps are unable to, distinguish between wound types and stages, and as a result, appropriate orders are not given. Even when a wound is known about, the feeling tends to be that someone else will take care of it, and the physician is disengaged from that problem, and its care. Prevention of pressure ulcers is even moro off the radar, as the physician is focused on the more "immediate" problems at hand.

On 5/21/2009 Laura Courtney RN, BSN, CWOCN said:

My area of expertise lies in home care. I see interpretation issues regarding PU with staff as well as MD's as a barrier. Braden scale interpretation is another area and with homecare, we need to protect our profession by doing those head to toe skin assessments. That is what is expected and sadly is not always done due to time constraints. Also, the lack of education for the general public is a true barrier in home care. Many of our patient's do not understand what they should and should not be doing to prevent ulcer formation. I also see this with MD's recommending the use of a donut-type cushion or prescribing a hydrocolloid to go on everything.

On 5/21/2009 Lori Fuhrer said:

Congratulations and what a challenge! I second what Nancy Broderick said and this goes deeper....I have run into opposition about "forward" thinking from administrators, peers, physicians (though not as much from physicians, I must admit...), and fellow CWOCN's. Joint Commission has a news release about this terrible problem and it is called "Joint Commission Alert: Stop Bad Behavior Among Health Care Professionals". It is really happening out there and is one of the barriers to great patient care.

On 5/21/2009 Jeannine Thompson said:

In trying to get a handle on the HA PUs and the costs of specialty bed rentals and over use of underpads, I have found that 75% of the nurses do not interpret the Braden correctly and cannot stage a pressure ulcer. Also many are using the definition DTI to avoid recording a Stage III and IV PU.

On 5/21/2009 Lee Ann Krapfl, BSN, RN, CWOCN said:

Congratulations, Irene! First, I appreciate the WOCN's leadership in developing a Position Statement on Unavoidable Pressure Ulcers. They have done a wonderful job of identifying factors that need to be considered and the holes in the evidence. I think most agree that there are pressure ulcers that are unavoidable, but how is this defined? And how common or rare are they? Let the debate begin. Second, hospitals can do a better job of creating a culture of patient safety which includes pressure ulcer prevention. I worry that the current economic downturn will limit everyone's ability to implement best practices. Staffing cuts and lack of resources is a reality. I do feel strongly that we should not be afraid. We now have the force of regulations supporting what we do and preach everyday. I personally think it will now be easier to quanify our value to our facility, agency or community. One thing I would like to see addressed is staffing and it's impact in pressure ulcer development. We should consider skill mix and experience as well. I think student nurses today are exposed to so many more things than I was in my education 30+ years ago. But as a result, many of the novice nurses simply do not have the importance of turning/repositioning drilled into them, like I had in my Fundamentals course. The experienced staff grasp pressure ulcer prevention. But the novice nurses need more. This is where we are focusing our educational resources.

On 5/21/2009 Shirley Alltop RN, BSN CWOCN said:

The role of prevention is one of identification as well as intervention. I would like to see some studies on the physiology of development especially as it relates to the gluteal areas such as perfusion of the tissue, tissue failure as it coorelates with other organs failing. The Braden has been validated as a useful tools in many studies. Interventions need to be implemented to address the risk factors, in addition there are other areas not addressed like pre-existing PU or history of PU and paralysis. It is wonderful having a CWOCN on board. Congratulations!

On 5/21/2009 sonya clark said:

I am a CWOCN and I have many concerns with pressure ulcer prevention. With the economy today, many hospitals are cutting budgets, decreasing the number of nurses at the bedside and limiting specialty mattress usage. I also feel that hospitals will start hiring other types of wound care nurses not as experienced in area such as specialty bed usage and selection and evaluating the "whole patient". Paperwork for the nurses and continued regulations requiring more paperwork restrict the nurses ability to care for the patients properly.

On 5/21/2009 Irene Jankowski said:

So many patients and families have suffered as a result of pressure ulcers, and, as Grace has said we are still learning about how these ulcers evolve and we are still searching for the best methods for preventing these injuries. Education is a key and information is out there. Just go to the internet and search for "pressure ulcers" and guideline after guideline will come up. How many facilities are giving out written brochures/forms that explain pressure ulcer prevention techniques to families? Are we sharing enough information with families and caregivers so that we can develop partnerships to prevent skin breakdown injuries?

On 5/20/2009 Linda Laursen said:

My son is a c-4 quad and our hospital refuses to take responsability for level 4 soars they inflicted on my son by placing him on a bed pan for over an hour. We told the nurse not to do it and use a chucks pad, he refused to listen me and my son as did the rest of the staff. This resaulted to blood infections when he laid in his own urine for hours and numerous visits to wound care specialists, larva treatments vac-traetments and later a colostomy and a supra-pubic, only because the staff would not listen to the people who take care of him on a daily basis, now for 22 years. thank you

On 5/20/2009 Grace Blaney said:

I may be condemned for saying this but when trying to identify high risk patients I think the Braden scale has significant limitations. The number and severity of medical conditions in a hospitalized pt. has significant implications for tissue tolerance. At what point should a pt. be on a specialty bed? And then what type of specialty bed? Lack of good evidence for some prevention practices? Much of draft NPUAP guidelines being expert opinion.... Also, despite education, staging of pressure ulcers is inconsistent even sometimes among certified experts. Stage I may involve more than partial thickness injury but still be intact? Deep tissue injury with intact skin not being accepted by CMS?

On 5/20/2009 Irene Jankowski said:

Thanks Nancy and Grace. Nancy you are bringing out some of the important issues those of us at the bedside are dealing with every day. As I continue to review the literature, looks like we all pretty much have the same protocols and very similar approaches - looks like the successful implementers are the groups with the adminstrative power to push change along with the finances to make sure the appropriate resources are available. Hospital-wide team approaches are also looking stronger than the traditional nursing department only approach. Thanks for the responses, keep them coming.

On 5/20/2009 Nancy Broderick,MSN, FNP-C, CWOCN said:

Wonderful to be represented. You asked about barriers and here are a few we have. 1) the whole idea of change for the nursing staff 2) not consistant support from administration 3) fear of more responsibility 4) peer pressure. We have champions who are having issues with teaching and trying to change their peers. They have too much push back Hope that is what you are looking for

On 5/20/2009 Grace Blaney said:

This is a great opportunity for all to share. In these challenging economic times and pending "updated" international PU guidelines, we all need to focus on pt. outcomes Grace Blaney, RN, CWOCN Winthrop University Hospital, Mineola, NY

On 5/19/2009 Lori said:

Congrats Irene for being selected! I know you will make a difference and thank you for asking all of us to assist you...

On 5/19/2009 Rochelle Salmore said:

WOW! What a great thing to have a WOCN on the JCR board. Congratulations! In your reading, learning and discussing, I'm looking forward to hearing when and what criteria will be used for unavoidable pressure ulcers. I kow WOCN has the white paper, but that seems like only the beginning as there aren't any criteria. I ran across a 3 year old paper from Hill-Rom (I think) listing some criteria, such as if the patient has two or more of the following, their PU would be classified as unavoidable. examples: diabetes, poor nutrition, quadriplegic etc I thought some of them were just "excuses". Good luck to you!!

On 5/19/2009 Irene Jankowski said:

Thank you, Linda, for your kind words. I am especially interested in everyone's views about what the barriers are to implementing a consistently effective pressure ulcer prevention program. Is to not enough staff, wrong equipment, not enough training, etc. Why is it that patients get pressure ulcers even though we have a pressure ulcer prevention program in place?

On 5/7/2009 Linda Everly RN BSN CPHQ said:

Irene: Congratulations on being selected for the position of Nurse Safety Scholar. I can't thank you enough for sharing this experience with "us" out here in the hospitals and long-term care facilities. I will love living vicariously through you. I am working on my Masters in Healthcare Administration and my Capstone Project is to develop and implement a Skin Care Program in our acute hospital and long-term care facility. It is going really well so far, but I look forward to hearing and seeing what you bring to the table. Linda Everly RN BSN CPHQ Director of Quality Improvement, Risk Management, Infection Control