Author: Mounia sabasse Co Author: Shyarlin Ruba Rashid Hospital. Dubai.UAE

1. The Impact Of Implementing Evidence Standardized
Wound Assessment Tool
In Planning Quality Care For Patients With Wounds
Author: Mounia sabasse
Co Author: Shyarlin Ruba
Rashid Hospital. Dubai.UAE

2. The Rationale Behind The Project:
The routine wound care team rounds done in the 600
bedded tertiary care center identified,
A deficiency in wound assessment and documentation.
 The tunneled and cavity wound were not properly
packed with the dressings.
 There was no evidence documented that an wound
assessment was carried out prior dressing of the wound.
 Most of the staffs were not able to identify a tunnel or
undermining
 This resulted in mismanaged wounds and delayed
wound healing.

3. Aim and Project Design:
Aim:
To improve the quality of care for patients with wounds
through implementing standardized wound assessment
and documentation tool.
Project Method:
 FOCUS PDCA model.
 Study design-Retrospective chart audit.
 Root cause analysis identified –By clinical observation
 Intervention planned through balance score cards.

4. Analysis Of Audit Data
1.A chart audit done in
selected units revealed the
following findings,
 262-charts of patients with
open wounds were audited
 Only 22% charts had
complete wound
documentation
 78% of charts had no
wound documentation.
PRE-AUDIT
22%
78%
MET
NOT MET

5. Process of implementation
Compliance
audit on WA
form done
every 2
months
Implementation
of
wound
assessment
and
Documentation
form
Developed
instruction
guide for
wound
assessment
form

6. Post –Project Audit
22%
76%
90% 88%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
PRE-AUDIT 1ST POST
AUDIT
2ND POST
AUDIT
4TH POST
AUDIT
CHARTS WITH COMPLETE DOCUMENTATION
PRE-AUDIT
1ST POST AUDIT
2ND POST AUDIT
4TH POST AUDIT

7. Sustainability Plan
 Chart audits were conducted once in 2months to monitor
the compliance.
The results of chart audits communicated to all unit in
charges in the hospital on a regular basis.
A specified day was identified for measurement of
wounds per week (Measurement Monday).
Surprise clinical rounds were done to observe the
practice change.

8. Lessons Learnt
 There is a wide gap between the knowledge and
practice of nurses related to wound assessment and
documentation.
 Structured ,standardized education is vital in improving
the competence level of nurses related to wound
assessment.
 Simplified tools make nurses more compliant with
regard to wound documentation.

9. Acknowledgements
The successful implementation and continuous
surveillance of the project was made possible
only with the help of 40 Wound care link
nurses ( each per unit).

10. References
1.Keast DH, Bowering CK, Evans AW, Mac Kean GL, Burrows C, D’SouzaL. MEASURE: a proposed
assessment framework for developing best practice recommendations for wound assessment.
Wound Repair Regen. 2004;12(3):S1–S17.
2. Flanagan M. A practical framework for wound assessment 2: methods. Brit J Nur.
1997;6(1):6–11.
3. Russell L. The importance of wound documentation and classification. Brit J Nurs.
1999;8(20):1342–1354
4.Goldman RJ, Salcido R. More than one way to measure a wound: an overview of tools and
techniques. Advances Skin Wound Care.2002;15(5):236–243.
5. Hess CT. The art of skin and wound care documentation. Home Health Nurse.
2005;23(8):502–513.
6. Cuzzell J. Wound assessment and evaluation: wound assessment guidelines. Dermatol Nurs.
2002;14(4):265–266.
7. Langemo D, Anderson J, Hanson D, Hunter S, Thompson P. Measuring wound length, width,
and area: which technique. Advances Skin WoundCare. 2008;21(1):42–45.
8. Brown G. Wound documentation. Advances Skin Wound Care. 2006;19(3):155–165.