Wound care program saves $142K, wins award
System gets lower LOS and improved outcomes
Ask any physician or nurse from a large health care system and you’ll hear the same thing: Wound care is always a problem. It is no different at the North Shore Long Island Jewish Health Care System, a group of 13 institutions, two nursing homes, four home care agencies, and some 100 ambulatory care sites in Great Neck, NY.
"I’ve been in this business for 20 years, and wound care is always an issue," explains Yosef Dlugacz, PhD, senior vice president for quality management for the system. But with a large database, he was able to determine that across the system that nurses were using different methodologies to deal with pressure wounds. In some institutions, care seemed to work better. "The variation between institutions was too big to ignore," he adds. It put wound care at the top of an annual list of quality improvement projects.
Fewer days, fewer dollars
The resulting project was able to help the system decrease median length of stay (LOS) for those patients by one day, improve patient outcomes, and save more than $100,000 in costs associated with the specialty beds that patients with advanced pressure wounds use. And the project won recognition from the Joint Commission for Accreditation of Health Care Organizations (JCAHO), which awarded the system the Codman Award for the project last November.
"It was a problem that occurs a lot with the elderly," explains Dlugacz. "It costs a lot, patients are in the hospital a long time. They often have gait deterioration. Although they don’t usually die from their wounds, they have a high mortality rate, and the decubiti can’t help."
While the project didn’t measure pain, he adds that there is probably some pain associated with those injuries, as well. For patients who have to have surgery on their wounds, there is post-surgical pain at the very least.
"We wanted to create an organized way of providing care to the patients across all the institutions," he says. "The challenge was enormous. But this gave us a unique opportunity to bring the system together through a particular task. This is a tangible thing for administrators, medical staff, and nurses to do. And as the demographics of the patient population changes and they grow older, this will be an increasing problem."
Bringing the team together
Lori Stier, RN, EdD, assistant director of quality management, put together a team in August 1996 that included nutritionists, physical therapists, physicians, and nurses. Nursing education and quality management staff were also involved. "We wanted to look at all policies and procedures and see what we could standardized and where we could use the AHRQ [Agency for Healthcare Research and Quality] guidelines," she explains.
The group also wanted to standardize the way they measured wounds, the definitions used, and what products they used. "When we inventoried our products, we found we used about 160 different ones." That was eventually reduced to 24 products that all facilities could use.
The team members, says Dlugacz, reflected different specialties and leaders of the system’s various organizations. Nurse executives from the nursing council gave legitimacy to the process.
The system created a uniform standard of skin care across the continuum. Team members developed a risk assessment methodology with a score given to patients based on wound size and depth. It provides nurses and other members of the care team with an objective measurement that can be related to specific interventions. Stier says they went one step beyond teaching nurses simply to quantify wounds in terms of depth, size, and color. "What made it even better is that we attached outcome. If there is redness and the wound scores a one, we incorporated it into care map: How do we get rid of the redness?"
Another goal for the team was to adopt best practices and measure patient outcomes. That in turn would be measured against internal and external benchmarks. Using AHRQ guidelines, Stier says the system didn’t do too badly — AHRQ has a rate of 2.7%, while the incidence in the system was about 2.2%. "But when we looked internally at our more aggressive benchmarks, we didn’t do as well. And we found that some of our hospitals were doing better than the system average, and some had room for improvement."
The goals were primarily to improve quality and improve care processes, Stier says. "This was not a cost-cutting program. Saving money was just a secondary benefit."
Using external guides as a template
Stier explains that using existing guidelines as a template helped save time. "There were some practices that we used across the system, though, that shouldn’t be scratched. We incorporated them with other guidelines. We wanted to merge what was out there together and create our own guide."
One benefit of that process was the ability to adapt the guideline to other parts of the system. For example, AHRQ doesn’t have different pathways for nursing homes and acute care facilities.
Creating their own guideline also enabled the health system to incorporate practical aids, such as the well-known Braden scale of wound risk into their care map. "AHRQ may give us numbers and supporting literature," says Dlugacz, "but we brought the practicality to it."
The resulting program includes the following steps:
• complete a risk assessment on all patients;
• determine appropriate stage for patients with skin breakdown;
• perform chart review for relevant data;
• record data (using palmtop computer);
• conduct benchmark prevalence studies compared to national statistics to identify strengths and weaknesses;
• complete follow-up prevalence studies to identify areas for improvement and analysis.
The program was implemented through a teleconference program that allowed the staff to learn about the new program in the most efficient way. Using a train-the-trainer scenario, the team introduced the new guidelines to system educators, wound specialists, and some nurse managers. They, in turn, took it to their own people.
The new program puts everyone in charge of intervening in a wound case, says Dlugacz. "Where there was a wound specialist in every department who would be in charge of intervention, education, and data collection, now there is no such sacred cow. Now, intervention is universal. Everyone can help take care of the patient."
And, adds Stier, the system has provided the staff with the tools, material, and resources to make the program a reality. "Before, there were some units that had programs in place, while others were rudimentary. This elevates the standard of care across the system."
No such thing as a good wound rate
The results of this particular project were impressive: annual savings for use of specialty beds were nearly $142,000. Length of stay (LOS) decreased from 13 days to 12 days. Stage III pressure injuries decreased from 7% to 5%; and Stage IV wounds declined form 5% to 1%. Staff competency has improved, and the system has standardized guidelines and measurements to use.
But the program still has further to go, Dlugacz says. "We think we can reduce LOS further if underlying diseases don’t interfere. We are going to do a new study to see if nutritional supplements help these patients."
Other steps for the future include improving surveillance, communication, and transfer of patient information across the continuum of care, monitoring readmission of patients with pressure injuries, and establishment of a demonstrated best practice within the system.
Dlugacz says the biggest obstacle in implementing the program was convincing 12 hospitals to do it. "The nurses felt that a 4% or 5% wound rate was OK. We had to convince them it was not."
The key to getting buy-in was to give them a sense of ownership. There was some solid data that showed the system needed to provide better patient education; since New York has a higher LOS than other parts of the country, there was pressure from managed care organizations to reduce that number.
Dlugacz knows that having a commitment to quality from the chairman and the board is vital to making a project like this one work. "This takes money, time, and resources to work. You have to have trust between your administration and your quality staff so that quality is always on the agenda. Some people think quality is just about JCAHO accreditation. But it is a permanent topic for us, part of our culture."
"One of the things that has been helpful for us is a strong communication structure among our facilities," says Stier. "Initiatives like this have the opportunity to be recognized throughout the system. We can keep the leadership informed of our progress so that our committee is known to do work and people understand that we are getting somewhere with the time we have invested."
She also believes that having the right people on your project team is vital for success. "Everyone involved has to have a voice in the decision making," she warns. "If you try to it do top down, it doesn’t really work."
• Yosef Dlugacz, PhD, Senior Vice President of Quality Management, and Lori Stier, RN, EdD, Assistant Director of Quality Management, North Shore Long Island Jewish Health Care Systems, Great Neck, NY. Telephone: (516) 465-2600.