Patient Care Vignette
A 67-year-old woman was admitted for an elective aortic valve replacement. Operation was uneventful and she was admitted to the ICU having been extubated in the Operating Room. She did well and was transferred to the acute care floor on day 2. A Rapid Response Team was activated due to shortness of breath and low oxygen saturation. She was readmitted to the ICU where she was found to have pneumonia. She required intubation and invasive mechanical ventilation, and then developed septic shock. She needed temporary dialysis for salt and water overload while her kidneys recovered. She survived the long ICU course (2 months) but developed pressure ulcers along her buttocks, heels, and the back of her head. Local wound care including a wound care specialist addressed her wounds and they were starting to heal when she was transferred to an acute rehabilitation facility. The wounds are painful and interfere with her ability to participate in rehabilitation as completely as she and her family would like.
ROLE OF THE WOUND CARE SPECIALIST IN THE ICU
Wound care specialists (WCSs) are unique clinicians who are brought to the bedside by a clinical team to aid in preventing, managing, and following both acute and chronic wounds. In the ICU, acute wounds are the more common problem to be addressed. WCSs may be specifically trained nurses, advanced practice providers (more commonly nurse practitioners than physician assistants), but quite commonly include surgeons trained in plastic and reconstructive surgery (aka. plastic surgeon). For certain wounds, surgeons will need to operate to clear infected or dead tissue, a process termed debridement.In some facilities, there is a wound care team that involves all of these kinds of WCSs. These team members help assess wounds, determine how they arose, prescribe and deliver therapies to address wounds, and regularly participate in quality initiatives to help decrease the likelihood of acute wounds from developing. Examples of such initiatives include deploying pressure relief mattresses and specialty beds for certain patient populations, evaluating the impact of long Operating Room (OR) times on pressure ulcers in those with clinically severe obesity, and recommending best practices for hospital teams to reduce wounds related to how devices are secured to patients (e.g., indwelling bladder catheter, aka “Foley” catheter). Therefore, the WCS is an integral member of the ICU team with roles that extend to the acute care floor and outpatient care since wounds may persist beyond the patient’s ICU and hospital stay (Fig. 10-1).
Wound Care Specialists and Types of Care Provided.
WHAT HAPPENS IN THE ICU FROM THE PERSPECTIVE OF THE WOUND CARE SPECIALIST?
The surgical ICU presents a particular set of challenges with respect to wounds. Wounds encountered in the ICU range from the acute wounds of injury, ...