Hurry up and heal
Hurry up and heal
QI improves wound outcomes in 3 months
Sometimes the best new QI project really is a revision of an old one.
At least, that’s what a Louisiana agency discovered this year when it took a fresh look at its wound care process.
Egan Healthcare Services of Metairie, LA, has always had a QI plan for wound care. But last year, the agency decided to change it to more closely reflect performance improvement.
"We actually did some home visits to see what was going on quality-wise with wound healing and patient care," says Linda Rubino, RN, BSN, assistant administrator for clinical services for the agency, which serves a 50-mile radius that includes greater New Orleans. Egan Healthcare conducts 80,000 visits a year.
Since revamping the QI program, the agency has had a five-percentage-point increase in wound cases that have healed. The baseline percentage of wounds that healed was 80%, and the new figure is 85%, Rubino says.
Also, the agency has achieved these outcomes while seeing patients with fewer home health visits than the state’s average for wound care patients, says Pamela Egan, RN, MN, clinical specialist, adult nurse practitioner, director, and owner of the agency.
"Currently, our wound care utilization is 25% less than the other agencies across the state of Louisiana," Egan says.
The agency conducted a baseline study of patients last December, primarily to see what percentage of wounds were healed within a three-month time frame. In March the scores were tallied again. "In 80% of the cases, there was definite improvement, and there was no deterioration," Rubino says.
"So we wanted to know what was the problem with 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 adds.
The agency formed a process team to examine the data and work on ways to improve the wound care outcome. 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 level was reflected in our documentation as well," she adds.
The process 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 wanted to improve the wound care outcomes, so the team implemented the revised QI program. One quarter after changes were made, the percentage of patients whose wounds healed properly had increased to 85%.
Rubino offers these guidelines on how quality managers can set up a QI program to improve wound care:
1. Develop a pressure sore risk assessment tool.
Egan Healthcare’s enterostomal therapist researched existing assessment tools for wound care and jotted down what she thought was most important from these. "She added to them, enhanced them, and did a little more work," 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," Rubino 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?
• Is the patient bedbound, or what is the mobility status?
• What is the patient’s nutritional status?
Field nurses fill out the wound care assessment tool for every single patient on admission. Then for those patients with identified risk factors, the assessment would be redone every 60 days.
"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 enterostomal therapist. 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 QI 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 doesn’t lock the staff into a time frame because patients heal at various speeds, and field nurses are expected to use their professional judgment);
b. any signs or symptoms of a wound infection.
2. New ostomy (operation that forms an artificial opening) 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 call in a specialist anytime the nurse wants to learn how to use a new wound care product.
"Anytime 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 and the latest techniques.
"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 basically asks if the wound is a stage 1, 2, 3, or 4 wound and asks the nurse to 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 to show pictures 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 the physicians have responded very well to receiving this information. "It’s just one more piece of information for them."
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