Skin Care Protocols

[RedSox33RN]

Just recently, at a hospital I left due to a move back North, we had instituted new skin care protocols, namely that we had done a complete head-to-toe skin care assessment (after primary and secondary triage and surveys) and charted it, mostly of the bed and wheelchair-bound patients. It all stemmed from the new Medicare rulings that they would not pay for decubs that occured in the hospital.

Anyway, I wonder if anyone had any of their protocols they could share. I have a friend that will be forwarding me a copy of the new ones in the ED, but is on vacation and can't get them for two weeks. I didn't get a chance to fully go over them before I left, and wish I had a copy now. I was discussing them with a new colleague recently, and they were going to be instituting protocols also, so I want to review them, and see where they differ from other ED's, or what/if other ED's are doing regarding skin care.

Thank you!

[FERN-tastic]

We just started doing this as well, but I don't remember the protocol off the top of my head. I do know we do the head to toe assessment and photograph any areas of breakdown. We also have to tell the physicians to be sure and document the breakdown in their chart or else it's not covered by medicare.

So, I guess even if the RN documents over and over the amt of breakdown on admission to the ED, if the doc doesn't document it it doesn't count. :icon_roll

[CoffeeRTC, BSN, RN]

I would think that at the very least it would need to include an initial head to toe assessment with measurements and a risk assessment. After that it should go towards prevention and treatment of decubs. This should include agressive wound treatments proper positioning either thru support surfaces (special mattress/ beds) or simple turning. Then look at incontinance care...everyone should have a barrier cream applied. Longer term patients....look at the nutrition. If they don't eat, at least they should be offered a hi protein snack.

In our LTC we've gotten back to the basics...clean em, feed em, move em. Sounds simple...sometimes it isn't.

[Altra, BSN, RN]

... the amt of breakdown on admission to the ED ...

Sometimes semantics are important.

Patients are not "admitted" to the ED -- ED patients are outpatients, not inpatients.

Thorough skin assessments are an important part of admission assessments when the patient is admitted to an inpatient unit.

Personally, I'm a stickler for assessing my patients' skin, and I document breakdown thoroughly. It's backup documentation for the admission assessment for those patients who are admitted.

[FERN-tastic]

Sometimes semantics are important.

Patients are not "admitted" to the ED -- ED patients are outpatients, not inpatients.

Thorough skin assessments are an important part of admission assessments when the patient is admitted to an inpatient unit.

Personally, I'm a stickler for assessing my patients' skin, and I document breakdown thoroughly. It's backup documentation for the admission assessment for those patients who are admitted.

I know patients are outpatient while in the ED until admit orders are written. I was tired and chose the wrong word. Very sorry.

[FlyingScot, RN]

I would think that at the very least it would need to include an initial head to toe assessment with measurements and a risk assessment. After that it should go towards prevention and treatment of decubs. This should include agressive wound treatments proper positioning either thru support surfaces (special mattress/ beds) or simple turning. Then look at incontinance care...everyone should have a barrier cream applied. Longer term patients....look at the nutrition. If they don't eat, at least they should be offered a hi protein snack.

This is a nice thorough synopsis of a skin care protocol except for one thing...nobody and I mean nobody who works in the ER would have time to do it. At the most we might be able to document where and approximately what size wounds are visible. Complete head to toe assessments are a rare thing in the ER. In general we do what is called a focused assessment which is focusing on the problem at hand. Now if the problem is decubs then a more detailed assessment would be provided. We can't provide special mattresses and creams and the only snack most of us have available is a cold turkey sandwich and graham crackers. I'm certainly not saying that skin care isn't important but protocols need to be department specific. For example, one of our skin care protocols was that anybody on a backboard over age 50 was to be seen and hopefully cleared in 15 minutes or less to prevent sacral decubs. Also, we did a great deal of teaching with the local EMS to encourage them to use a vacuum board whenever possible. If we found a wound on a patient we simply dressed it with a DSD (per our wound care nursing team). Most of us were pretty good at slapping on a tegaderm to areas that were slightly reddened and of course we reported what we found. We didn't stage wounds, we left that for the experts. So while your plan is really good it would be nearly impossible to implement in its entirety in the ER.