I spent yesterday morning with a very lively and passionate group of nurses who help heal ulcers and wounds. They work all over the Puget Sound region in medical clinics and urgent care facilities helping people with diabetes and other conditions that lead them to have ulcers and wounds on their feet and legs. When a foot ulcer is not well managed it can be disastrous. Infection can spread through the skin and muscles into the bones of the feet, into the bloodstream and that can lead to a deadly blood borne infection called septicemia. If a foot ulcer is not well managed the person may have to have their foot or leg amputated. It is one of the most feared of all the complications of diabetes. It is easy to see why these nurses are so passionate about what they do. When their treatment works well they are saving feet, legs, and lives.
They were meeting to share ideas with each other but more important than that, to agree that they would all start treating wounds and foot ulcers the same way. Many of them did not like that idea. Over the years they had learned some tricks that they were sure worked for them. Some of them were reluctant to change and do things the way someone else was doing it. So why did they agree to change? Because when we all looked at how well their patients were doing it wasn't nearly as good as they thought, or as good as it could be. They used different dressings for the wounds. Sometimes they got doctors to put the patients on antibiotics, sometimes they didn't. They didn't all evaluate the wounds in the same way. They didn't always write down how long, wide and deep the wound was. So if that nurse was off for a few days and the patient came in to see someone else that person didn't know whether the wound was smaller or larger than when they were seen before. So the new person couldn't tell if the wound was getting better or worse. The nurses varied in how often they saw patients with wounds, and on how much of the surrounding dead skin they should cut off to allow the wound to heal better.
It turns out that many of the technical details of treating wounds have been studied in well-designed research trials. So we know how often to see someone back, when to use antibiotics and when they are not needed. We know the best way to cut off the dead skin, how to record treatment properly and when patients need to be referred on for more advanced treatments (like putting the patient in a hyperbaric oxygen chamber or having surgery to increase the circulation to the feet). But over the years some of the nurses had forgotten those research results or had been told to do things a different way by doctors. They had got sloppy with the way they wrote down their treatments. They liked to try new and different things just to see if it would help.
But although it may seem boring to all agree to treat wounds in a standard way it is the most powerful way to improve things. If everyone agrees to assess wounds in the same way, agrees to record the length, width and depth of the wound at every visit, and agree to how to cut of the dead skin and on how to check for infection and to see if their is enough blood going to the wound then it is much easier to compare how everyone is doing. Once everyone is treating wounds in a standard way then it becomes much easier to improve the treatment. If one of the nurses thinks of an improvement to the standard treatment (perhaps because she read about a new research study that proved that a new dressing speeded up the healing) then all of the nurses in all the different clinics can try the new dressing. If they all agree that this speeds up the healing then the new dressing can become part of the NEW standard work for healing wounds.
Luckily, by the end of the day yesterday these talented and passionate nurses agreed that they could learn best from each other if they agreed to do things in the same boring standard way, then compare their results, and try to look for better ways to improve their care. So the standard work doesn't stay standard and boring for long - it keeps improving over time so that more and more patients get their ulcers to heal faster and avoid losing their legs.
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