1. Hess, Cathy Thomas BSN, RN, CWCN

Article Content

Clinical decision making for wound management is dependent on the types of patients evaluated in your care settings, the skill sets of the clinicians making the decisions for those patients, the products available to manage the patient, and the documentation platform used to capture the work performed. Essentially, every step along the patient engagement continuum is strategically guided through process. In order to strategically manage your process, workflow analysis is imperative.


A workflow is a set of tasks that are completed to accomplish a goal. Your workflow should be defined with chronological processes, depicted typically through the sequential use of forms for documentation within an electronic medical record, and identified by the set of people or other resources available to perform those processes and the interactions among them. Providing this process-driven approach for yourself and to your employees can maximize the department's efficiencies and patient throughput and ensure you have completed the necessary quality and patient safety documentation during the patient's course of care.


It is important to analyze workflows at least annually to ensure you are capturing the proper documentation elements in the proper sequence to maximize clinical, operational, and regulatory efficiencies.



Including assessments, such as a nutrition assessment, is key to your workflow. Nutrition risk assessment tools assist the practitioner in understanding the strategies necessary to identify the levels of nutrition risk. Many nutritional components are critically important in the wound healing process. Improper nutrition can affect a patient's immune function, collagen synthesis, and wound tensile strength, which are needed during and after the wound healing process.


Further clinical factors for wound and skin assessment include understanding the physical findings of the wound and skin, the evaluation of the patient's laboratory values and diagnostic tests, nutrition needs, and management modalities, such as topical dressings, drugs, support surface products, and off-loading devices. Optimizing your workflow with the proper diagnostic and documentation processes is critical to these understandings.


Clinical Order Sets

Including clinical order sets in your workflow is another way to improve compliance and patient outcomes. Let's take a closer look at the construction of clinical order sets, building upon the aforementioned nutrition assessment and the respective laboratory values necessary for evaluating nutrition.


Clinical order sets (basically, predefined templates) are one way to ensure patient safety and reduce risk. Creating order sets for the wound types seen in your department provides a common platform and support for clinical decisions related to a specific condition or medical procedure. Further, creating wound-specific laboratory values assists with the consistency of ordering and care.


Laboratory values are helpful in assessing and monitoring any chronic underlying medical conditions as well as the patient's nutrition status. These values should be evaluated at the first patient encounter to establish a baseline for care. In addition, if healing is not occurring as expected, these values can be tracked regularly, as triggered within your follow-up workflows, to ensure that local and systemic factors are not contributing to poor healing. Important parameters to evaluate include protein levels, complete blood count, erythrocyte sedimentation rate, liver function tests, glucose and iron levels, total lymphocyte count, blood urea nitrogen and creatinine levels, lipoprotein levels, vitamin and mineral levels, and urinalysis. Even if only one deterrent is present, healing cannot occur (Table).

Table. NUTRIENTS NEC... - Click to enlarge in new windowTable. NUTRIENTS NECESSARY FOR WOUND HEALING

Organizing the various laboratory values and assessment data is helpful to maintain the knowledge base necessary to yield an accurate wound diagnosis. Using clinical order sets within your workflow can improve quality and patient safety processes and create time efficiencies. As an example, laboratory tests can be categorized in the following assessment data and placed in a clinical order set within your workflow:


1. Nutrition laboratory assessments


a. Albumin


b. Prealbumin


c. Transferrin


d. Total lymphocyte count


e. Vitamins


f. Minerals


2. Chemistry


a. Renal


b. Electrolytes


c. Glucose


d. Hepatic/hepatitis


e. Lipids


f. Hemoglobin A1c


g. Amylase/lipase


h. Iron/ferritin


i. Parathyroid hormone


3. Hematologic


a. Complete blood count with differential


b. Sedimentation rate


c. Glucose 6 phosphate dehydrogenase


d. Protein C/S


e. Fibrinogen/fibrin degradation products/D-dimers


f. Prothrombin time/partial thromboplastin time


g. Cryoglobulins/cryofibrinogens


h. Antiphospholipid antibodies


i. Sickle cell


j. Serum protein electrophoresis


k. Antithrombin 3



Creating and maintaining clinical order sets require ongoing evaluation and maintenance to ensure the proper data are captured in your workflows. Define the clinical order sets for your department. Integrate clinical order sets into your workflows to enhance your department's success in providing quality, safe, and efficient patient care.