When good isn’t good enough, how do you make it better?

Process changes boost outcomes in three months

Sometimes doing something well isn’t good enough, especially when you can do it better. That was the case with a Louisiana home health agency that refused to accept good wound care results and strove for something better. 

After Egan Healthcare Services of Metairie, LA, had revamped its procedures, it saw an increase in wound healing along with good control of utilization. 

The process started with home visits "to see what was going on qualitywise with wound healing and patient care," says Linda Rubino, RN, BSN, assistant administrator for clinical services for the agency, which serves an area within 50-mile radius that includes greater New Orleans. Egan Healthcare conducts 80,000 visits a year. 

Since revamping the program, the agency has had a five-percentage-point increase in wound cases that healed, from 80% to 85%. 

The agency achieved these outcomes while seeing patients with fewer home health visits than the state’s average for wound care patients, says Pamela Egan, RN, MSN, clinical specialist, adult nurse practitioner, director, and owner of the agency. 

"Our wound care utilization is 25% less than the other agencies across the state of Louisiana," Egan says. 

The process started in December 1996 when the agency conducted a baseline study of patients, primarily to see how many wounds healed within a three-month period. In March 1997 the scores were tallied again. "In 80% of the cases, there was definite improvement, and there was no deterioration," Rubino says. 

But that left the question of what was happening in the other 20%. "Why didn’t they respond the way the rest of them did? Was there something in the healing process? Was there something we needed to do but we didn’t do?" she asks. 

The agency formed a team to examine the data and work on ways to improve the process. The enterostomal therapist (ET) nurse led the team. Other members included field nurses, Rubino, and nurse managers. 

"We looked at everything about the processes involved in providing wound care, from documentation to doing a visit," Rubino says. 

"We wanted to make sure that not only was our care as good as it could be, but that this was reflected in our documentation as well," she adds.

Checking on care provided, and on documentation

The team decided to take a two-pronged approach: 

• The ET nurse specialist would visit the patients’ homes to make sure the nurses were performing wound care correctly and to see whether there were problems they were missing. 

• The team checked the case documentation to make sure the nurses’ wound care services were being reflected in the paperwork. 

"We did chart reviews to see if some nurses should have used preventive measures and weren’t using them, and what we found was we were providing wound care well within acceptable standards of practice," Rubino says. 

Still, the agency identified and implemented revisions that included the following: 

1. Develop a pressure sore risk assessment tool. 

Egan Healthcare’s ET researched existing assessment tools for wound care and jotted down what she thought was most important from them. "She added to them and enhanced them," Rubino says. 

Then she condensed it to one page, making it as concise as possible. 

"There’s a lot of paperwork in home care, and we didn’t want to keep adding reams of stuff, so our tool was designed to be concise and to the point," she says. 

The assessment is in check-off format, but it includes one category with space for the nurses to write down something that might need further detail. 

Some examples of the key categories the tool checked are as follows: 

• Is the patient incontinent? 

• What is the patient’s mobility status? 

• What is the patient’s nutritional status? 

Field nurses fill out the wound care assessment tool for every single patient on admission. The assessment would be redone every 60 days for those patients with identified risk factors. 

"Every patient has the possibility of developing some kind of wound, and if they have no risk then we will never do the assessment again unless their status changes significantly," Rubino says. 

Patients who are totally bedbound and incontinent would have a very high possibility of developing a wound, so these patients would be assessed every 60 days, she adds. Also, the first time a nurse conducts a high-risk patient’s assessment, the nurse will send the form directly to the ET. Rubino says some nurses will even call the ET before they return to the office that day. 

"That alerts the therapist that there’s some potential problem out there," she explains. 

Otherwise, the assessments are placed in the patients’ charts. 

2. Develop wound care referral criteria. 

Egan Healthcare asked all five specialists at the agency to write indicators or referral criteria for when they should be called in to see a patient. The five specialty areas are wound care, psychiatric home care nursing, diabetes education, cardiopulmonary rehabilitative service, and respiratory home care program. 

But because of the project, the process team helped to develop the wound care referral criteria as well, Rubino says. 

First the ET nurse was asked to choose three or four major categories that field nurses would easily remember. Then her suggestions were reviewed by the process team, and the team added to it. 

The team came up with these criteria: 

1. Wound or pressure area with delayed healing; 

a. no decrease in wound size or appearance. (Rubino says the criteria don’t lock the staff into a time frame because patients heal at differing speeds, and field nurses are expected to use their professional judgment.) 

b. any signs or symptoms of a wound infection. 

2. New ostomy from which the nurse needs to review or plan a specific plan of care. 

3. Need for any specialty equipment, supplies, or any recommendations for care; 

a. pressure-relieving devices. 

b. wound care or skin care products. 

Rubino says the last criterion allows the nurse to obtain a specialist’s help in learning how to use a wound care product. 

"Any time a nurse has a question about a wound, the nurse can fill out a formal consult sheet to consult with the therapist," Rubino says. "So there’s always somebody available who has the expertise and can be another set of eyes or make recommendations." 

3. Educate staff. 

Egan Healthcare Services gave its staff continuing education credits for an inservice on wound care. "The team decided it might be worthwhile for nurses in the field to have a series of educational programs on wound care, so we did that," Rubino says. 

Four 1.5-hour inservices were held once a month for four months. Nurses were given a post-test. 

4. Use a clinical pathway. 

The agency uses a commercial clinical pathway on wound care, and then added to that. The pathway asks if the wound is stage 1, 2, 3, or 4, and has the nurse describe what it looks like based on several examples. 

"We made it easy for the nurses so they can circle answers and write a couple of lines," Rubino says. 

5. Use the latest technology. 

The agency has hired a company to provide video imaging of complicated wounds. "The ET nurse usually goes with the imager to make sure everything goes right, and then we’ll bring it to the physician to let him see how a patient’s wound is healing," Rubino says.

Typically, the agency chooses to do this for patients who cannot visit the physician routinely and who have a difficult wound. Rubino says physicians responded well to this information. "It’s one more piece of information for them."