Wound Care Nursing Drives Efforts to Reduce Pressure Injuries, Support Patients With Limb Loss

At TIRR Memorial Hermann, the wound care team has undertaken an ambitious, multiyear program focused on preventing hospital-acquired pressure injuries (HAPIs), enhancing wound healing and management, conducting comprehensive risk assessments and supporting patients with limb loss. This holistic approach ensures improved care quality and better outcomes for patients facing these complex challenges.

“We are fortunate to have a team of experienced wound care nurses who care for inpatients while they are at TIRR Memorial Hermann,” notes Nicole Harrison, MBA, BSN, RN, NEA-BC, vice president and chief nursing officer at TIRR Memorial Hermann. “We want to showcase the great work the wound care team has done, highlighting the empowerment of nursing, the use of evidence-based practices and whole-team collaboration.”

According to Juliette Lowe, BSN, RN, CWON, and the clinical coordinator II for Wound Care Services at TIRR Memorial Hermann, the efforts began during fiscal year (FY) 2021, when the organization hired its first wound, ostomy and continence (WOC) nurse. These specialists hold a baccalaureate degree or higher and have completed accredited specialty education programs focused on caring for patients who have a wound, an ostomy or problems with incontinence.

“WOC nursing is considered the gold standard for wound care, and really focuses on treating the whole patient, not just the hole in the patient,” Lowe says. “TIRR is leading pressure injury prevention and truly improving the ability of wound care nurses to practice to their full scope, including writing guidelines and policies.”

Doing so involves a deep understanding of the evidence on pressure injury prevention as well as wound healing and management, a process that motivated the team at TIRR Memorial Hermann to reevaluate how to use evidence-based practice to improve outcomes and reduce harm.

Lowe and her colleagues on the hospital’s newly formed HAPI Taskforce conducted a survey evaluating HAPIs across the facility, and found that during FY 2021, more than 50% of HAPIs at TIRR Memorial Hermann involved medical devices.

“Our patient population is at high risk for medical device−related pressure injuries (MDRPIs),” Lowe explains. “We care for patients with spinal cord injuries and traumatic brain injuries, many of whom are unable to feel or respond to pressure related pain caused by medical devices.”

The team developed a strategic action plan targeting the four medical devices that were responsible for over 75% of the MDRPIs—casts, compression stockings, ankle/foot orthoses and bivalves, with the goal of decreasing the rate of MDRPIs during FY 2022.

“What we honed in on was making sure registered nurses (RNs), physical therapists, occupational therapists, speech therapists—our whole staff– understand the risk factors for getting a pressure injury related to a medical device, and then make sure we were focusing on best practices to improve them,” Lowe says.

The results were significant. During 12 months, the rate of decrease per 1,000 patient-days was 44% for HAPIs, and 54% for MDRPIs. A poster summarizing the strategy was presented at the American Nurses Credentialing Center National Magnet Conference, where it was honored with a third-place ranking for Pathway to Excellence.

The success of the project motivated the wound care team to go further, examining additional approaches to achieve even more significant gains: This involved looking to outside organizations for guidance.

Inspired by North American Spinal Cord Injury Consortium (NASCIC) “Pressure Ulcer Prevention and Treatment Following Spinal Cord Injury” clinical guidelines (2014) and National Pressure Injury Advisory Panel (NPIAP) “Prevention and Treatment of Pressure Ulcers/Injuries: Clinical Practice Guideline” (2019), the wound care team led Memorial Hermann in developing its own set of pressure injury prevention guidelines, focused on providing evidence-based practice dependent on patient-specific risk factors. The resulting guidelines were implemented in 2023.

In October 2023, an educational course taught to clinical RNs at TIRR Memorial Hermann focused on improving recognition of patients at risk for pressure injuries, using the Braden Scale risk assessment tool.

“By this point, we had the Memorial Hermann clinical guidelines, and we wanted to really make sure that our nurses understood how to score using the Braden Scale, which is used across the organization,” Lowe recalls.

The educational program proved to the team the importance of teaching the “why” of scoring and demonstrated improvement in interrater reliability of over 90%, a level that has been sustained for more than 10 months.

In total, the efforts put into place by the wound care team have resulted in large-scale improvements. “From the beginning of this journey to this year, the percentage of HAPIs has decreased by 85%,” Lowe notes. “Moving forward, I’m confident this will improve even further.”

Future research opportunities will shed light on addressing numerous questions posed by the NASCIC, such as determining which dressings may be best for deep tissue injury resolution, or other questions, including if medical companies can help resolve deep tissue injuries, or the effect that health care disparities may have on pressure injuries for non−English-speaking patients.

“Our Amputee and Limb Loss Rehabilitation Program at TIRR Memorial Hermann takes a comprehensive, multidisciplinary approach to care, which includes certified wound care nurses, physical therapists, occupational therapists, psychologists, prosthetists and specialized, affiliated limb loss physicians,” Lowe explains. “This level of collaboration is unique and not often seen elsewhere. We believe patients experience improved outcomes and a better quality of life when they receive this high level of comprehensive care prior to going home. Through our commitment to continuous learning, evidence-based practice and comprehensive, multidisciplinary care, TIRR Memorial Hermann is not only advancing the prevention and management of hospital-acquired pressure injuries but also empowering patients to achieve the highest quality of life possible. With the dedication of our expert wound care team and the collaboration of all our specialties, we are confident that these improvements will continue to have a lasting impact on patient outcomes and safety.”

Harrison agrees and emphasizes that continually learning and putting those findings into practice is key to the long-term refinement of the organization’s care. “We recognize that we continuously have to be in a learning environment. Just because we’ve made great progress, we have more improvements to make,” she says.