Regardless of wound type, I always had the Braden Risk Assessment Scale on my mind as I generated the wound treatment plan, so the “prevention” thought process was there, somehow innate as a nurse. Years four through nine in wound care were spent running an inpatient wound care program for a 400-bed acute care hospital. I just knew that nutritional status had an enormous impact on patient wound healing, but I didn’t have evidence to back it up, because I hadn’t looked into it. I just knew it was more important than it got credit for… and then I began to learn about it first-hand.
I had several patient care scenarios where poor nutritional status was highlighted for me, but I couldn’t get anyone else to buy-in to the fact that it played such a huge part in the outcome. It took a few, eh-hem, serious and adverse learning opportunities, before anyone in leadership started to listen. I had the pleasure of meeting our facility’s RD early on, during the review of one such adverse event.
She was very knowledgeable, and had felt her own frustrations reach the tipping point, so it was truly a match made in heaven when we met and began to discuss an acute-care-world where nutrition was given the respect it deserves. She was so willing to learn about pressure ulcers and prevention, and she was equally open to sharing what she knew about nutrition with me. What we didn’t know, between the two of us, we sought to find out, and what each learned was shared immediately with the other. Finally! Someone who got what was in my brain! Why? Because NUTRITION was in my brain, and she was an RD!
We made a great team, each of us excited about what the other had to share. We had figured out how to improve our patient outcomes, and worked tirelessly to show that to anyone who had a role in patient care. We began to collaborate...not just talk here and there, but to actively communicate about the patients we were seeing. I began referring patients to the RD team, and she began informing the wound care team about patients with poor nutritional status. This open communication helped me to really understand what it meant to have an interdisciplinary team involved in the care of a patient.
We thought, “How can we make this better?” because by the time RD was brought in, there were already wounds present, or the patient was already malnourished. And by the time the wound care team was brought in on a patient, they already had a pressure ulcer or a wound. How could we empower the nurses to take action?? We both realized that for every Braden subscale category, there were actions the nurse could take to intervene, but for nutrition, the only action was passive: to initiate a referral to RD. We decided to change that.
What else could the nurse do for nutrition? We needed to empower the nurses with interventions that took action for the patient. So we did. We created an oral nutrition supplement protocol. The RD established criteria and I helped determine criteria for prevention of pressure ulcers or wound healing. Together we came up with 5 simple categories of triggers that the RN could easily identify, which would then be used in the decision tree for oral supplementation. The categories and triggers were:
If any of the 12 triggers were selected, the nurse was to use the decision tree to determine what oral nutritional supplement to begin for the patient. Factors considered in the decision tree included whether the patient was diabetic, if the patient had impaired renal function, and whether the patient needed tissue building. To initiate a protocol in the State of California, an MD order is required, so all it took was a TO from the MD to get nutrition initiated for the patient!
What we learned through this active, engaged collaboration between RD and Wound Care, was that we could make a big difference in the outcomes for our patients, if we opened up to each other and started utilizing the talents we each have, to focus our care for the patient.
