Standardization cuts costs of wound care program

Standing orders, quicker debridement effective

Standardization of care, products, and staff education resulted in an 56% decrease in the number of wound-care visits from the first quarter to the fourth quarter for Centura Home Care & Hospice in Denver.

The decrease in the number of visits translated to a 63% decrease in the cost of budgeted supplies, or a savings of $8,160, for one pod of managed care business, says Susan A. Flow, RN, BA, BS, MSN, project manager for the wound, ostomy program and Denver-area Medicare case manager for Centura.

Because Centura Health System comprises multiple hospitals and their affiliated home health agencies, wound care techniques and supplies differed from place to place, Flow says. The hospitals and home health agencies worked together to develop a protocol for wound care that would be used in both the acute care and home health setting. "We also conducted product trials to allow physicians and staff members to evaluate different supplies."

The 17-month process resulted in a standardized set of products and protocols that reflected national standards, she explains.

Physician and staff education was an important part of the process, Flow admits. Staff members attended inservices that addressed three specific topics: principles of wound healing, pressure ulcers and surgical wounds, and venostasis and arterial ulcers. "We also held a product fair after each inservice that enabled staff members to get hands-on experience with the products we discussed in the inservice," she adds. The inservices were mandatory for nurses, but Flow found that all of the physical therapists, occupational therapists, and some speech therapists attended the sessions as well.

Physicians received information about wound care protocols in a mailing that explained the basis for the protocol. They were asked to give permission for the hospitals and home health agencies to begin treatment of wounds according to the protocol upon admission by signing standing orders. "The first mailing went to 90 of our referring physicians in the Denver area, and we received a 60% response rate, which meant that 54 of the physicians signed the standing order," explains Flow. These standing orders mean that there is no delay in treatment as the nurse waits for physician orders, and that means fewer visits and better outcomes, she adds.

New techniques, fewer visits

Many home health agencies are looking carefully at their wound care programs primarily because of changes that result from the prospective payment system (PPS), says Corena LeGalley, RN, CWOCN, enterostomal therapy (ET) field nurse for the Visiting Nurse Association of Houston.

"We’ve had to return the day-to-day responsibility for health care to our patients, while nurses are serving more in a teaching and advisory role," she explains. "We have to select treatments and products that can be easily used by caregivers between our visits."

"We’ve moved away from traditional wet-to-dry wound treatments and use techniques such as vacuum-assisted wound closure as well as foams," LeGalley says. "We also chemically debride sooner than we might have in the past, and we will send a patient back to a physician for a sharp debridement in a shorter timeframe if needed." These techniques all result in faster-healing wounds, she adds.

Two studies performed by Centura Home Care show that the use of newer techniques improves healing time. "When we compared four patients who had been treated on our standardized protocol using vacuum-assisted closure to four patients who had similar nonhealing wounds on conventional treatment, we saw . . . the total number of visits drop from 580 visits over 325 days for the conventionally-treated patient group to 68 visits over 182 days for our protocol-treated group," Flow says.

"The costs for treating the conventional patients totaled $60,000, while the vacuum-assisted, closure-treated patients costs totaled $7,300 in nursing time and supplies," she adds.

Flow points out that vacuum-assisted wound therapy is not appropriate for malignancies, wounds that open into a body cavity, wounds with active bleeding, or wounds for which the cause is unknown.

The other study compared the differences between patients with venostasis disease who were treated with and without compression boots. "The three patients treated with a multilayer compression boot required a total of 40 visits over 199 days for a total cost of $4,300, while the patient group treated without compression boots required 120 visits over 130 days for a total cost of $13,000," Flow says.

Another high-tech treatment that can reduce the number of nursing visits required is noncontact normothermic wound therapy, says Joan E. Halpin-Landry, RN, MS, CWCN, clinical support therapist for Eden Prairie, MN-based Augustine Medical, manufacturer of the technology. Nurses place a wound cover over the wound, insert the warming card into the cover, and activate the temperature-control unit; nurses don’t have to return for three days, she explains.

"Nursing visits for a patient undergoing Warm-Up wound therapy average 1.6 times per week, with costs running between $10 and $13 per day," Halpin-Landry adds.

While the therapy is effective on most wounds, it is not indicated for third-degree burns, some arterial ulcerations, and any wound for which the cause is unknown, she explains.

Flow points out that a key to a successful wound-care program is having an expert on staff. "While we have trained all of our nurses to assess and treat wounds, we use our ET nurses as staff experts to consult on difficult cases or offer advice when a wound is not responding to treatment."

LeGalley agrees that it is important to have a certified wound care specialist oversee your program, either as a staff member or as an outside consultant. "Someone who is interested and knowledgeable in this area will be able to focus upon and keep up with new techniques and new products that can improve care for all patients."

[For more information about cost-effective wound care programs, contact:

  • Susan A. Flow, RN, BA, BS, MSN, Project Manager for Wound, Ostomy Program and Medicare Case Manager for the Denver Area, Centura Home Care & Hospice, 2420 W. 26th Ave., Suite 200D, Denver, CO 80211. Telephone: (303) 561-5000. E-mail: susanflow@centura.org.
  • Corena LeGalley, RN, CWOCN, ET Field Nurse, Visiting Nurse Association of Houston, 2905 Sackett, Houston, TX 77098. Telephone: (713) 630-5547. E-mail: legalleyc@msn.com.

For information about guidelines and clinical protocols, contact:

  • Wound, Ostomy and Continence Nurses Society, 4700 W. Lake Ave., Glenview, IL 60025. Telephone: (888) 224-9626 or (866) 615-8560. Fax: (866) 615-8560. Web site: www.wocn.org.
  • American Academy of Wound Management, 1255 23rd St., N.W., Washington, DC 20037. Tele-phone: (202) 521-0368. Fax: (202) 833-3636. Web site: www.aawm.org.
  • Agency for Healthcare Research and Quality Publications Center, P.O. Box 8547, Silver Spring, MD 20907-8547. Telephone: (800) 358-9295 or (410) 381-3150. E-mail: ahrqpubs@ahrq.gov. The agency offers a series of booklets related to the treatment of pressure ulcers: Pressure Ulcer Treatment. Quick Reference Guide for Clinicians (AHCPR 95-0653); Treatment of Pressure Ulcers. Clinical Practice Guideline Number 15 (AHCPR 95-0652); and Treating Pressure Sores. Consumer Guide (AHCPR 95-0654) Spanish-language booklet (AHCPR 95-0655). You must include both the title and publication number in your request. Single copies are free.

For more information about products, contact:

  • Augustine Medical, 10393 W. 70th St., Eden Prairie, MN 55344. Telephone: (800) 733-7775 or (952) 947-1214. Fax: (952) 918-5214. Web site: www.augustinemedical.com. Manufacturer of Warm-Up therapy for wound management.
  • KCI, P.O. Box 659508, San Antonio, TX 78265-9508. Telephone: (888) 275-4524 or (210) 524-9000. Web site: www.kci1.com. Manufacturer of the V.A.C. for vacuum-assisted wound closure.]