Agency’s efforts combine quality, education

QI program part of efforts to improve wound care

A recent wound care improvement program at HealthReach HomeCare and Hospice, based in Waterville, ME, is dovetailing neatly with the agency’s emphasis on wound care in its annual competency for nurses.

Both are steps in HealthReach’s ongoing efforts at improving wound care, which have included appointing a wound care consultant to work with nurses in the agency’s three offices in central Maine.

Jennifer Wing, RNC, HealthReach’s wound care consultant, was also named staff educator in last June. She says the decision to focus on wound care education was a natural fit.

"I could make myself available to the various offices in our agency throughout weekly visits to help them assess difficult wound care patients, so it tied in with that," she says.

Audits revealed problems with documentation

Judy Marshall, RN, quality improvement reviewer for HealthReach, says the decision was made to merge the selection of wound care as the nurses’ annual competency with this year’s quality improvement project.

She says chart audits showed problems with the documentation of wound care visits, particularly in the area of patient education.

"We weren’t really sure when we were teaching wound care whether the client was really ready to learn or understood what they needed to do," Marshall says. "It was because there was inconsistency in documentation. Nurses go over this with the clients, they go through the teaching process, but it just somehow or other doesn’t get documented consistently, so they can really say what the patient is learning."

It also can lead to communication problems between the patient’s primary nurse and per diem nurses who perform subsequent visits.

"The problem is that perhaps the right hand doesn’t know what the left hand is doing sometimes," Marshall says. "Something was discussed with a client or a change was made and it wasn’t written, so the next person coming in wasn’t aware of the change. If the change was written, perhaps the nurse didn’t read the last two notes and pick up on something new.

"Those are the kinds of things we’re trying to get people to think about to concentrate on," she adds.

Begin with education

After the chart audit, which looked at records from October through December 1999, the next step was Wing’s education program, held in January and February for all nursing staff.

Beyond the general overview of wound care — reviewing different types of wounds, including surgical, diabetic, and pressure ulcers — the education component also would look at documentation issues.

"[Wing] and I did meet and we did come up with some criteria, certain things we did want to look for, mostly on our documentation," Marshall says. "We wanted to have the nurses write a standard wound assessment, with wound descriptions. We want them doing certain things on every visit, such as taking a temperature."

Marshall says a wound measurement is to be done weekly by the primary provider, and that provider is responsible for making any changes in the plan of care.

"She would be responsible for calling the doctor rather than having per diems going out and seeing a patient and deciding that maybe a change needs to be made here. A per diem would have to go through the provider."

Another priority was measuring and documenting a client’s readiness to learn, which is accomplished through recording comments made by the patient and noting any necessary demonstrations. Responses such as "I can’t do that" or "I don’t feel comfortable taking care of that" would raise a red flag, requiring follow-up, Marshall says.

"We want the providers after every visit to make a follow-up plan and we’ll be looking to see whether the plan is followed on the subsequent visit in the clinical note," she says. "The nurse might document ongoing teaching and support, and four or five days later there may be a response in which the client says he or she might consider trying to do the wound care."

Wing says the emphasis on documentation composed the meat of her program. Most of the information was review for staff, including a discussion of sterile vs. clean techniques in wound care.

"Because a lot of our clinicians are coming from an acute-care facility where sterile technique is the gold standard, we did talk about that," Wing says. "In dealing with chronic wounds, it hasn’t been proven any more beneficial to use sterile technique over clean technique. In home care, it’s been pretty much the standard that we use clean, no-touch technique."

Wing distributed an educational packet that included nutritional handout, a glossary of terms, and a magazine article discussing sterile vs. clean technique.

The packet also included a list of various wound care products. Marshall and Wing say there are no plans to immediately change the types of supplies currently in use at HealthReach. That inventory was reviewed about a year ago, Marshall says.

Part of Wing’s role is to be available to nurses to consult on complex cases, Marshall says. If a wound hasn’t shown signs of improvement or the nurse has a question, Wing can accompany a nurse on a visit and offer suggestions.

Following up on education

With the new emphasis on documentation, revisions are under way to the clinical note to include a specific area for teaching, a place to record the patient’s response to teaching, and a space to note a plan for the next visit.

A post-audit also is planned to gauge how well nurses are responding to the education.

Marshall says supervisors will conduct assessments as part of the competency, visiting homes with nurses so they can demonstrate appropriate wound care, assessment, interventions, and patient education. "We’ll be looking to see if the procedure is explained to the patient and family. We’ll certainly be looking for hand washing — that’s a big thing."

Those assessments will continue through 2000, she says.

Although information isn’t available yet from postaudits, Marshall says she’s already seeing anecdotal evidence that HealthReach’s ongoing wound care efforts have been successful. "Overall, it’s been very beneficial for the nurses. I think that it’s certainly made a difference for some clients who have had some of the more severe chronic wounds."

Marshall says agencies looking to make changes in wound care should make efforts to tap expertise they have on staff.

"[Wing] has been a tremendous help to the clients and to us," she says. "She provides that direction that sometimes we need [when a nurse is unsure of the next step to take with a difficult case]. Now we know we can consult with her and she can really give us her professional opinion."

For her part, Wing hopes to revisit wound care on a yearly basis to keep staff up to date with rapid advances in wound care products. She’d also like to conduct a wound care vendor fair so that vendors could show staff newer products and how to use them.

"I think it would be beneficial to revisit that yearly because there are new products out there that we’re probably going to be using more and more, with the coming [prospective payment system]," she says. "We’d also try to tie it in with documentation, so we can continue to do thorough assessments and documentation."

Judy Marshall, Quality Improvement Reviewer, HealthReach HomeCare and Hospice, 212 Main St., Waterville, ME 04901. Telephone: (207) 873-6880. Fax: (207) 873-6888.

Jennifer Wing, Staff Educator and Wound Care Consultant, HealthReach HomeCare and Hospice, 32 Winthrop St., Augusta, ME O4330. Telephone: (207) 626-3435. Fax: (207) 626-3463.