My Scope of Practice: For the Little People

    Children aren’t just little people. They are little people with big imaginations. — Marie Oren-Sosebee

    When Marie Oren-Sosebee, RN, BSN, CWOCN, became a nurse, she imagined herself working in a clinic for the indigent or in a year-round camp for children with disabilities. She followed a somewhat different path, still grasping small hands along the way. In the mere 6 years since she earned her nursing degree, Marie has specialized in pediatric Wound, Ostomy and Continence Nursing (WOC Nurse). She became the first WOC Nurse for Children’s Healthcare of Atlanta, designed the WOC Nurse role for her institution, implemented educational programs including systemwide inservicing on products, helped develop the Wound Prevention Team, and increased her involvement in pediatric healthcare causes. She is most proud of her efforts in ostomy care: her facility boasts less than 5% re-admits for discharged patients with ostomies living at home.
Marie graduated with an ADN from North Georgia College and State University, Dahlonega, Ga, in 1999. She went to work as an acute care floor nurse in the inpatient Surgical/Urological department of Children’s Healthcare of Atlanta, Scottish Rite campus and concurrently received her BSN in 2000 while working as a night shift nurse. Children’s is a non-profit, three-hospital organization (Egleston, Scottish Rite, and as the result of a recent merger, Hughes Spalding), one of the largest pediatric healthcare systems in the country. Patient age ranges from birth to 21 years.

    “When I first began working in surgery and urology, I treated kids with dehisced wounds and ostomies with skin and pouching problems,” Marie says. “We did the best we could but there was no nurse specialist to consult. I was frustrated, particularly by one troublesome case. I presented these concerns to my manager. Appreciating the need, the facility advertised for a WOC nurse but it eventually came back to me to start the program.”

    In 2002, Children’s provided support and funding for Marie to enhance her ostomy and wound care education by sending her through the Emory University WOCNEC Program. Thereafter came the task of sculpting the responsibilities of the WOC Nurse, which include but are not limited to: serving as primary patient educator for patients undergoing new ostomy or continent diversion; consulting with assistance to staff regarding management of draining wounds and fistulas, ostomies and peristomal skin breakdown, percutaneous tubes, fecal and urinary incontinence, and acute and chronic wounds; establishing bowel/bladder programs (eg, clean intermittent catheterization and digital stimulation); assisting staff maintain knowledge and competence in pediatric wound, ostomy, and continence care; managing an independent practice; and serving as a leader for nursing staff. In addition, the WOC Nurse is actively involved in the inpatient charging pathway, statistical record-keeping, and annual competency documentation; provides set-up and management of wound and ostomy durable medical equipment; and serves as a community resource for wound and ostomy education for local hospitals and pediatrician offices.

    This is not an occasion of “Do as I say.” Marie’s to-do list includes numerous presentations and initiatives, including implementation of soft silicone dressing and negative pressure wound therapy and providing the necessary training for their appropriate, competent use. She believes speaking engagements are the best way to get the word out. The annual conferences she helps organize are attended by staff from her facility and southeastern Georgia — her presentations have included Skin, Wound, and Ostomy Care in Infants for neonatal nurses and talks on basic pediatric ostomy care and the WOC Nurse consultation process for new RNs. Additional related enterprises Marie has spearheaded include tracking PICU-acquired pressure ulcers, obtaining a Georgia Medicaid waiver for one-piece ostomy pouches in the infant/young pediatric population, systemwide streamlining of product formularies, and the creation of pediatric WOC Nurse outpatient services (in progress).

    Last year, Marie was one of three clinicians involved in the development of a Wound Prevention Team. The multidisciplinary team comprises clinicians from the PICU, NICU, TICU, rehab, physical therapy, quality management, nursing, and respiratory therapy; physicians; and the WOC Nurse. The Team became responsible for systemwide tracking of ICU-acquired pressure ulcers, nursing and physician education on pressure ulcers, trialing and implementing the Braden Q Skin Risk Assessment Tool in the ICUs, and implementing support surface guidelines and interventions for high-risk patients. “Children are as prone to pressure ulcers as adults but they occur in different parts of the body,” says Marie. “Support surfaces are not designed for pediatrics so they must be fashioned according to size, age, and weight. There’s not much research out there to guide you. But our interventions were successful. When we first tracked pressure ulcers (using WOC Nurse consultation statistics) in the PICU, we had 17 consults for Scottish Rite campus PICU-acquired pressure ulcers in 2004. But in 2005, once we put the Wound Care Team together and developed a better prevalence and incidence tracking method, we reduced our numbers to nine.” The Team continues to streamline tracking, prevention, and intervention practices as the hospitals evolve and incorporate computerized ordering and documentation.

    Obviously, all of the equipment must be in different sizes to accommodate preemies, infants, toddlers, school-age children, and adolescents. In her first formal speaking engagement for her NICU, Marie spoke about preemie stomas no bigger than a pencil eraser. Another challenge has been applying negative pressure wound therapy to such young patients — an infrequent occurrence until systemwide training was offered and clinicians gained expertise. The youngest patient thus far to be “vac-ed” was 2 years old. “Medical technology is keeping our infants alive but we need to address the resultant surgical and skin issues in their little bodies,” Marie says.

    Two cases exemplify the diverse challenges of providing wound care to young people. “We had a preemie with a double-barrel jejunostomy in the NICU who was deteriorating quickly,” Marie says. “She had capillary leak and we couldn’t keep the ostomy appliance on her skin. We developed an arrangement that allowed us to wick away moisture to better secure the appliance. In another case, a teenage, paralyzed gunshot victim with limited resources needed negative pressure wound therapy on an outpatient basis. He was unable to receive outpatient wound vac therapy due to Georgia Medicaid denial so he remained an inpatient in order to receive wound care.”

    Of her many-faceted responsibilities, Marie says she enjoys teaching — parent, child, grandparent, staff, and the students she precepts — the most. “I enjoy the challenges of addressing the different ways people learn,” she says. “I learn something new each time I teach. I absolutely love direct patient care.” Her biggest personal challenge? Prioritizing. “Initially, it was difficult to decide where to start in creating a pediatric WOC Nurse inpatient program. I relied on surrounding adult WOC nurses, the Emory WOCNEC resources, manufacturers, support groups, pediatric and neonatal professional journals, and the Internet to become pediatric WOC Nurse-educated — my own ‘Pediatric WOC Nursing 101’. I learned about our population, our current wound/ostomy/continence products, and how the system functioned from a business viewpoint from fellow nurses, educators, managers, case managers, physical therapists, pharmacists, physicians, and the reimbursement team. Support from staff nurses and physicians with whom I already was working helped make my position a reality.”

    Marie predicts her department will continue to grow over the next few years (currently, she works full time with two part-time employees) and that she may become a care coordinator. Focus will shift to policy creation and the development of standardized care methods for skin issues, including CPap/BiPap mask breakdown, IV extravastation injuries, and pressure ulcer management. “Our department is becoming more involved in providing pediatric wound and ostomy care education and initiatives through presentations and conferences. We are currently working to establish outpatient WOC Nurse services in one of our clinics — justification for this endeavor is tedious. I have been keeping a log of patients going home with wounds and ostomies to determine who is covered by private or public insurance to ensure reimbursement and my business department has been working with Georgia Medicaid to get pre-approval for certain cases.” Personally, Marie plans to continue volunteering for the Youth Rally and increasing support for kids’ causes in her region.

    Exciting, challenging, and always evolving, pediatric WOC Nursing sparks in Marie an appreciation for being imaginative and adaptive. “It is a riot to have to sing, blow bubbles, and stand on my head to change a 3-year-old’s dressing,” she says. “It is a joy to have a little one wrap his arms around my neck and put his head on my shoulder. It is rewarding to see a teenager look at her stoma for the first time without crying. There are more happy stories than sad in my scope of practice.”