My Scope of Practice: At the Center of a Center of Excellence

  Inspired by the final words of her father and later validated by her dying brother’s support for what he called “her gift,” Cathleen (“Cathy”) Markley, RN, BS, CWOCN, pursued a career in nursing and nurtured an interest in patients with complex wounds. Now the Wound Care Nurse at Select Specialty Hospital’s Camp Hill and York (Pennsylvania) long-term acute care (LTAC) facilities, Cathy has overseen so much growth in her practice that her “hospitals within hospitals” are moving to a free-standing facility in 2008. Her devotion to wound care helped Select Specialty Hospital-Central Pennsylvania earn a “Center of Excellence” award for wound treatment – parent company recognition from a corporation that operates 93 LTAC hospitals and is not frivolous about its acknowledgment program.   Formerly a professional horsewoman who managed her own farm and taught riding, Cathy received her Associate’s degree in nursing from Harrisburg Area Community College in 1991. She began working as an ICU nurse for Carlisle Hospital, taking courses one night a week to earn a bachelor’s degree – a pursuit that took almost 10 years. She joined Select Medical in 2001 as one of the initial ICU nurses hired to open the Camp Hill site; her strong suits were ventilator weaning and chronic ventilator patient care. “I had a strong desire to see patients out of their unstable states through the rehabilitation process,” Cathy says. “Surgical patients with complex wounds were always interesting to me.” Working with the surgeons of Carlisle Hospital and the WOCN nurses of Holy Spirit Hospital (Select facilities) enhanced not only her appreciation for the challenges of wound care, but also her wound care techniques. “The corporate wound care guidelines include a pre-established system of measuring and photo documentation and a set of wound care protocols but we individualized the formulary,” she explains. “As my knowledge increased, the pieces (of wound care) began to fall into place.”

  Soon, Cathy was tapped to head the wound care program at Select Camp Hill and Select York. These 31-bed and 21-bed LTACs, respectively, are self-contained units within their hospitals (a few services are supplied by the host hospitals, Holy Spirit Hospital and York Hospital). Each LTAC features a dedicated staff that includes nursing, physical therapy, occupational therapy, and speech therapy; its own pharmacy; and an independent medical records department; laundry, dietary, and laboratory services are subcontracted through the host hospitals. Average length of stay is 25 days under Medicare guidelines. The LTACs specialize in ventilator weaning, wound care, multisystem failure patients, and bariatrics. Cathy says her unique perspective of increased length of stay allows her to monitor patient outcomes more consistently.

  Cathy expanded her knowledge and skills by participating in Select’s Cooperate Mobile Internship on wound care and she was afforded the opportunity to consult the WOCNs at the host hospital as necessary. In addition, a forward-thinking former CEO encouraged her to obtain WOCN certification – a quest that almost was derailed by the health of her older brother, Pat. He was in the terminal stage of colon cancer and Cathy helped with his care. But during her weekly trips from Pennsylvania to North Carolina to see him, he encouraged her to secure certification; in turn, she “taught the Duke University Hospital hospice nurses about Xenaderm (Healthpoint),” which was used to manage Pat’s fistula. She completed the wound program in November 2004; Pat died that December.

  In her current position, Cathy’s responsibilities include wound care team leadership at both hospitals. “The general guidelines are set by the corporate office but the daily management is based on patient population,” she says. “I evaluate and monitor each patient and consult on new or difficult wound patients. Training all the licensed staff in wound care and monitoring the yearly competencies also is a large part of my job. Plus, I work with our vendors, physicians, and staff to plan inservices. I have worked with some of our vendors to find satisfactory products such as rental beds and have helped change product lines to better suit my patients’ needs. My history of outcomes-oriented care allows me to recommend plans of care for my wound patients.”

  Cathy works with Dr. Anastasius Peter, a surgeon from Susquehanna Surgeons Ltd. As Director of Wound Care, Dr. Peter rounds on the wound patients who are not assigned to another surgeon at the time they are admitted to the hospital. With Cathy’s input, Dr. Peter evaluates the wounds weekly. “I review the wound care history and current treatment plan with Dr. Peter,” Cathy says. “He is very receptive to advanced wound care products and always interested in current trends and advancements.” Cathy also works with other consulting surgeons and infectious disease physicians to provide wound care treatments with nursing time and patient outcomes in mind.

  At the corporate level, the challenge is to create product continuity while at the individual hospitals the goals are always patient-specific. Cathy uses the knowledge she has gained as a WOCN to individualize the treatment plan for each patient. She works with her materials manager along corporate guidelines, as well as with surgical groups, to establish product use, – for example, to enable fistula patients to be discharged to home with a manageable appliance. “This is always a great source of satisfaction for me,” she says.

  For Cathy, some of the barriers to providing optimal care are cost and staffing. “I try to establish a program that is easy to understand and follow and provides an optimum environment for wound healing in a time-effective manner for staffing,” Cathy says. “I work with our nursing liaisons to review our patient population and wound care goals and with our case managers to ensure continuity of care after patients are discharged.”

   “I truly love what I do,” Cathy says. “I have a busy schedule with a lot of latitude. I plan my days to allow for interruptions and emergencies. I work with my director’s schedule to make his rounds run smoothly. One of the things I like about my position is that you can see wounds making progress and where your contributions make a difference. I also enjoy the fact that I can support my staff and share my knowledge and enthusiasm for wound care.”

  Cathy knows her role will evolve – not only because of the new facility but also because of some of the revolutionary new products coming available to enhance wound prevention and management. “I am a fan of technology,” Cathy says. “I think science will continue to make progress and I want to be right there, trying new ideas and products. My role as an educator will continue to evolve as I educate each new staff member. But I do not see myself leaving the bedside. Participating in and encouraging a team approach to wound care yields excellent outcomes in my scope of practice.”

My Scope of Practice is made possible through the support of ConvaTec, a Bristol-Myers Squibb Company, Princeton, NJ. This article was not subject to the Ostomy Wound Management peer-review process.