When good isn’t good enough, how do you make it better?
Process changes boost outcomes in three monthsSometimes 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.
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.
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.
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 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
"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.
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.
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.
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.)
"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."
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.
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.
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."