Keys to Effective Wound Management in Long

Transcription

OHCA Annual Convention & Trade Show
September 23, 2014
Lynn Peterson RN, BSN, CWOCN
3M Health Care
Disclaimer
Lynn Peterson RN, CWOCN is an employee of
3M Critical & Chronic Care Solutions Division
Lynn Peterson, 3M, September 2014
Objectives
Describe essential elements of a successful wound
management program
Identify key steps to improve quality and consistency
in wound care
Define how a well executed wound management
program improves clinical outcomes
1
The Elderly
An “At Risk” Population
Long Term-Care (LTC) Statistics (2012)1
8 million people received LTC services
Adult day care centers
Assisted living communities
Home health agencies
Hospice agencies
Nursing Homes
1.3 million long-term care residents
70% - 75 and older
42% ≥ 85 y.o.
28% 75-84 y.o.
Delay in healing
and immune
response
Inadequate
hydration and
nutrition
Incontinence/
moisture
Physical and
cognitive
limitations
Decreased pain
perception
Compromised
skin barrier and
mechanical
protection
Contributing
Factors
Thin, dry skin
6
2
Diabetic Foot
Ulcers
IncontinenceAssociated
Dermatitis
Skin Tears
Compromised
Skin Integrity
Medical
Adhesive-related
Skin Injury
(MARSI)
Pressure Ulcers
Moisture
Associated Skin
Damage
Additional Statistics
Pressure Ulcers2
Affect 3 million adults in the US (2006 statistics)
Prevalence 2-24% in LTC
Diabetes3
Leading chronic disease
370 million people globally
25% lifetime risk of diabetic foot ulcer development
Incontinence-Associated Dermatitis
5.6% - 22.5% of LTC residents4
Skin Tears – 1.5 million/yr5
Effective Skin & Wound
Management Program
3
Challenges
Lack of:
Evidence-based practice standards
Resources (staff turnover, workload management)
Wound care specialist to direct care
Consistency in care
Staff education and training
Staff satisfaction
Benefits
Evidence-based
skin and wound
management
Standardized
treatment goals
and plans
Quality
improvement
Improved clinical
outcomes
Reduction in
wound related rehospitalizations
Cost containment
Staff
education/job
satisfaction
Patient
safety/satisfaction
Program Key Components
Collaboration with Clinical Leadership
Medical Director, Administrator, DON/ADON
Wound Care Specialist
Evidence-based protocols/policy and procedures
Interdisciplinary wound care team
Standardized Formulary
Skin & Wound Product Guidelines
Education Program
4
WOC nurse or Wound Care Specialist
Education Program
Education Program
Wound Care Specialist6
Certification as a wound care specialist
Important to success of program
Expertise in full range of skin and wound issues
Pressure Ulcer Prevention
Incontinence Associated Dermatitis (IAD)
Tube site care
Ostomy related cares
Complex fistula management
5
Role of Wound Specialist6
Coordinate and lead interdisciplinary team
Consultant/Expert for evidence-based wound care
Control wound related costs
Educator – staff, patient, family
Manage pressure ulcer prevention program
Program coordination
Quality improvement activities
Quality Improvement Activities
Opportunities for:
Correction of deficiency from audit
Improve resident or staff satisfaction
Cost savings
Examples
Prevalence and incidence studies
Chart audits
Educational sessions
Considerations
Assess the need – FT or PT
Number of facilities
Number of residents
Options
Responsible for one facility or multiple facilities
Consultant arrangement
Wound “Champion”
6
Multidisciplinary wound care team
Education Program
Evidence-Based Protocols6,7
“The integration of best research evidence with clinical
expertise and patient values to facilitate clinical decision
making”8
Use for prevention & treatment protocols
Guidance for consistency in care
Improve resident outcomes
Improve staff satisfaction
Assist with cost containment
Prevention & Treatment Guidelines
Wound, Ostomy, and Continence Nurses Society
www.wocn.org
National Pressure Ulcer Advisory Panel, NPUAP
www.npuap.org
National Guideline Clearinghouse
www.guideline.gov
7
Policy and Procedures
Guide delivery of care
Meet standards for
licensing bodies and state
health departments
Examples:
Skin assessment
Pressure ulcer risk
assessment
Wound cleansing
Wound assessment
Wound treatment
Pressure ulcer staging
Documentation
http://www.myhousecleaningbiz.com/members/images/247.jpg
Key Components
WOC nurse or Wound Care Specialist
Education Program
Interdisciplinary Team
What: A group of health care professionals from diverse fields
who work in a coordinated fashion toward a common goal for the
patient. 9
Goal
Collaborative communication and care planning
Ensure all aspects of care are represented
Fosters best practice
Improved resident outcomes
Cost containment
Improved staff satisfaction
8
Interdisciplinary Team
Critical: “support” from administration
Invite administration to be a part of the team development
Team goal: Identify wound prevention and treatment as a
care priority
Determine mission and objectives
Clearly stated roles & objectives for each team member
Establish meeting times and goals
Meeting format (onsite, virtual, conference call)
Team task/responsibilities
Collaborate on prevention & treatment plan of care
Education:
Clinicians/caregivers
Resident & family
Develop P&Ps and protocols
Member of a product/DME selection team
Plan and implement quality or process improvement
activities
Rounding
Interdisciplinary team members
Administrator/DON/ADON
Medical director/primary care physician
Wound Care Specialist/Wound Champion
Nursing
CNA
Rehab staff (PT, OT, ST)
Dietician
Infection control
Social Service/Discharge planner
Nurse Educator
9
Certified Nursing Assistant (CNA)
Extremely important team member
Spends the most time with the residents
“Eyes and Ears” of licensed professional
Provides 90% of care
May be the first to recognize a problem area
Consider inclusion on wound round team
Implementing a Wound Care Resource
Nurse Program10
“The overall goal of this program was to support a
collaborative atmosphere among this group of nurses by
promoting best practice and expertise in the prevention
and management of Stage I and Stage II pressure ulcers
and to develop a peer resource system.”
Additional objectives:
Participate in research
Promote cost-effective practice
Remain aware of new developments in chronic wound care
Resource Nurse Program10 (continued)
Designed and lead by the Skin and Wound Care Clinical
Nursing Leadership Team (SWCCNLT)
Obtained organizational support
Built on Evidence-based, best practice recommendations
Offered to nurses wanting to increase knowledge and skills
in wound care
Four 8-hour educational sessions, self study & reading
Knowledge assessment pre and post
10
Resource Nurse Program10 (continued)
The role of the Wound Care Resource Nurse
Function as a clinical expert, role model, resource and change agent
Collaborate with interprofessional team, patients and families
Participate in:
Quality improvement activities,
Pressure ulcer prevalence and incidence surveys,
Implementation of hospital pressure ulcer risk assessment tool,
Wound Care rounds
More information: Ostomy Wound Management 2007;53(8):46-53
Breakout discussion
Education Program
11
Provide appropriate skin and wound care products
Guide clinicians/physicians on product/supplies
availability
Provides for effective and efficient use of resources
Foundation for Skin & Wound Product Guides
Guides care and clinical competence
Direct product utilization
Make wound care second nature for staff
Steps to formulary development
Consult with multidisciplinary team members
Determine most common skin and wound conditions
admitted or treated in facility
Review and organize current supplies
Assemble into product categories (alginates, foams,
hydrogel)
Remove expired product (can use for education)
Conduct a product evaluation
Steps to formulary development
Develop skin and wound care guidelines
Staff Education
Create an approval system for products not on formulary
Review annually
Products on formulary should be labeled by product
category not brand specific
Antimicrobial
Alginate
Foam
12
Skin Care Formulary
Skin cleansers
Therapeutic moisturizing products
Liquid skin protectants
Moisture barriers
Antifungals and antimicrobials (topical)
Wound Management Formulary
Alginate Dressing
Antimicrobial Dressing
Collagen Dressing
Composite Dressing
Compression Wraps
Contact Layer
Foam Dressing
Hydrocolloid Dressing
Hydrogel
Wound Formulary (continued)
Gauze, ABD pads, gauze wraps
Prescriptive agents
Debriding agents
Growth factors
Topical steroids
Superabsorber Dressing
Tapes
Transparent Film
Wound cleansers
13
Additional Formularies
Lower limb immobilizers
NPWT systems
Other therapy devices
Support surfaces (bed, chair)
Wheelchairs
Education Program
Skin & Wound Product Guide
Who
WOC Nurse / Wound care specialist
Skin & wound care team
Vendor supported
What
Evidence-based dressing recommendations to promote
wound healing
Options based on wound characteristic and clinical
assessment
14
Product Guide (continued)
Why
Improve:
Clinical competence
Consistency
Clinician comfort
Resource efficiency and effectiveness
15
Education Program
Staff Education
Critical component to successful program
Delivery of staff education challenging
Providing care to residents
Work long hours, difficult to sit in class room setting
Successful LTC staff development improves:
Clinical outcomes
Consistency in care
Staff job satisfaction
Resident satisfaction
Thoughts on education
Engaging & stimulating
Everything You Need to Know about Learning11
You remember approximately …
10% of what you read
20% of what you hear
30% of what you see
50% of what you hear and see
90% of what you do
16
Staff Competencies12
Upon hire and annually.
Retained written documentation of competency for each
employee
Skin assessment and care competencies
Wound assessment and care competencies
Accurate pressure ulcer staging or descriptive and correct
identification of skin and wound
Risk assessment
Facility skin and wound care guidelines, understanding and
implementation
Staff Competencies (continued)
Mechanisms for CNA and staff nurses to train and
round with wound care specialists
Introduction of critical thinking exercises
Staff nurses to contact primary care providers and their
extenders for skin and wound care orders
CNA staff to report significant findings to nursing staff
for follow-up
Educational Recommendations
Patient Safety
Skin Care
Pressure Ulcer Prevention
MARSI – Medical Adhesive-related Skin Injury
MASD – Moisture-Associated Skin Damage
Skin Tear Prevention & Treatment
Topical Wound Management
17
Styles
Class room style
Web-based
Webinar
Pre-recorded on Intranet
At the bed-side
Program Example
“Making Bedside Wound Management Decisions in
Long-Term Care”, Pearls for Practice, OWM, 201013
Interdisciplinary, hands-on, bedside education
Optimal resident outcome – nurses and CNAs must
Focus on pressure ulcer prevention
Provide accurate and timely wound assessment
Initiation appropriate interventions
Bedside education
Interdisciplinary, hands-on, bedside education:
Wound assessment/characteristics
Pressure ulcer staging
Identification of anatomical structures
Possible treatment options
Support surface selection
Other important skills
18
Results
Staff reported increased comfort managing complex wounds
Improvement in:
Outcomes in nursing documentation
Wound product selection
Wound healing times
Incidence in facility acquired pressure ulcers
Teamwork skills
Improvement in resident satisfaction
Staff communication
Additional resources
Wound Care Text Books
Wound Care Essentials, Practical Principles, Third Edition
Sharon Baranoski, and Elizabeth A. Ayello
Clinical Guide to Skin & Wound Care, Seventh Edition
Cathy Thomas Hess
Website resources
NPUAP - www.npuap.org
WOCN - www.wocn.org
National Guidelines Clearinghouse http://www.guideline.gov/
Additional resources (continued)
Vendors
Customized wound/product guides
Illustrated pocket guides i.e. Pressure Ulcer Staging Cards
Wound measuring guides
In-services and educational offerings
Web-based
Webinar
On-site
19
Breakout discussion
One additional
program example
Pressure Ulcer Reduction Program
LTACH Corporation – Pilot program
Identified problem:
22 facilities had higher than corporate target HAPU rates
Rates 4.10
Goal:
Determine causative factors
Reduce HAPU occurrence
HAPU rates < 0.75
20
PU Reduction Program (continued)
1.5 day session root cause analysis
Participants – VP of Clinical Services, Facility Certified
Nursing Office (CNO), 2-3 staff RNs, WOC Nurse,
2-4 CNAs, and members of the 3M team.
Process Map
Admission to discharge
Pressure ulcer prevention process
Identified disconnects
Developed improvement plan
Prevention policies updated
Developed multidisciplinary teams
Improved communication from shift to shift
Education modules created
Not on My Shift – Skin Saver Program
Prediction and Prevention; Avoiding Pressure Ulcers: Braden
Risk Assessment Tool
The Importance of Pressure Ulcer Prevention
Updated Policies and Procedures - Pressure Ulcer Prevention
Data collection to evaluate program and changes
67% decrease in HAPU rates
Identify ongoing needs for continued improvement
21
Thank You
Did I meet the objectives for this session?
Describe essential elements of a successful wound
management program
Identify key steps to improve quality and consistency in
wound care
Define how a well executed wound management
program improves clinical outcomes
Questions
References
1.
2.
3.
Harris-Kojetin L, Sengupta M, Park-Lee E, Valverde R. Long-term care services in the
United States: 2013 overview. Hyattsville, MD: National Center for Health Statistics.
2013.
Chou R, Dana T, Bougatsos C, Blazina I, Starmer A, Reitel K, Buckley D. Pressure ulcer
risk assessment and prevention: Comparative effectiveness. ComparativeEffectiveness
Review No. 87. (Prepared by Oregon Evidence-based Practice Center under Contract
No. 290-2007-10057-I.) AHRQ Publication No. 12(13)-EHC148-EF. Rockville, MD:
Agency for Healthcare Research and Quality. May 2013.
www.effectivehealthcare.ahrq.gov/reports/final.cfm.
International Best Practice Guidelines: Wound management in diabetic foot ulcers.
Wounds International, 2013. Available from: www.woundsinternational.com
References
4. Gary, M. (2014). Incontinence associated dermatitis in the elderly patient:
Assessment, Prevention and Management. New Journal of Geriatric Care
Management, Spring 2014. Retrieved from
http://www.gcmjournal.org/2014/05/14/incontinence-associated-dermatitis-inthe-elderly-patient-assessment-prevention-and-management/.
5. Leblanc, K., Chrisensen, D., Cook, J., Culhane, B. Prevalence of Skin Tears in a
Long-Term Care Facility. J Wound Ostomy Continence Nurs. 2013;40(6); 1-5.
6. Bryant,R. A., Nix,D. P. (2012). Principles for practice development. In R. A. Bryant &
D. P. Nix (Eds.), Acute & Chronic Wounds; Current Management Concepts, Forth
Edition (pp.2-20). St. Louis: Elsevier.
7. Stevens, K., (May 31, 2013) "The impact of evidence-based practice in nursing and
the next big ideas" OJIN: The Online Journal of Issues in Nursing. Vol. 18, No. 2,
Manuscript 4.
22
References
8. Sackett DL. Et al: Evidenced-based medicine: how to practice and teach EBM,
London, 2000, Churchill Livingstone.
9. http://medical-dictionary.thefreedictionary.com/interdisciplinary+team
10. Tully, S., Ganson, C., Savage, P., Banez, C., Zarins, B. (2007). Implementing a
wound resource nursing program. Ostomy Wound Management, 53(8):46-53.
11. Hebert GR, Oakley J. (2012). Pressure ulcer prevention education: creative ways to
engage staff. Annals of Long-Term Care: Clinical Care and Aging. 20(7):37-38.
12. Krasner, D.L. (2013). Skin and wound care programs for LTC. Retrieved from:
http://www.ltlmagazine.com/article/skin-and-wound-care-programs-ltc.
13. Porterfield, S. (2010). Making bedside wound management decisions in Long-Term
Care. Ostomy Wound Management;56(5):44–52
Additional Resources
Become a specialist: wound care specialists are highly valuable, but in short supply (Aug
1, 2009). Retrieved from www.mcknights.com
Beyond the bedsore: recognizing different wound types in long-term care. (2010).
Retrieved from: http://www.mcknights.com/beyond-the-bedsore-recognizing-differentwound-types-in-long-term-care/article/176218/.
Fenner, S.P. Developing and implementing a wound care program in Long-term care.
(1999). JWOCN ; 26(5) 254-260.
Flannagan, M. Barriers to the implementation of best practice in wound care. Wounds
International. Available from: www.woundsinternational.com/pdf/content_87.pdf, 74-82.
Erwin-Toth, P. (2013). Evolution in LTC: Establishing evidence-based skin and wound care
protocols. Retrieved from: http://www.medipurpose.com/blog/entry/evolution-in-ltcestablishing-evidence-based-skin-and-wound-care-protocols
Additional Resources
Erwin-Toth, P. (2014) “Vigilance” is key to inspiring LTC wound management success.
Retrieved from: http://www.medipurpose.com/blog/entry/vigilance-is-key-to-inspiringltc-wound-management-success.
Hess, CT, (2011). Skin care formulary checklist, Advances in Skin & Wound Care, 24(8),
384.
How to do it…Multidisciplinary wound care teams. (February 1, 2013).
http://www.mcknights.com/how-to-do-it-multidisciplinary-wound-careteams/article/279284/
Howe, L. Education and Empowerment of the Nursing Assistant: Validating their
important role in skin care and pressure ulcer prevention, and demonstrating
productivity enhancement and cost savings. (2008). Advances in Skin & Wound Care,
21(6); 275-281.
23
Additional Resources (continued)
Lundgren, J. (2013). How to set up an effective wound care formulary and guideline.
Wound Care Advisor, 2(4), 29-30.
Kottner, j. Lichterfeild,A., Blume-Peytavi, U. (2013). Maintaining skin integrity in the
aged: a systematic review. British Journal of Dermatology, 169,528-542.
Maguire, J. (2014). Wound Care Management. Today’s Geriatric Medicine. Vol. 7 No. 2 P.
14.
McConnell,E., Lekan, D., Corazzini, K. (2010). Assuring the adequacy of staffing of LongTerm Care, strengthening the caregiver workforce, and making Long-Term Care a career
destination of choice. NC Med J, 71(2), 153-157.
Scarbough, P. Understanding your wound care team. (2013). Retrieved from:
www.woundsource.com/.
Stefanacci, R. (2014). Determining the future of Long-Term Care. Annuals of Long-Term
Care: Clinical Care and Aging. 22(5);24-27.
24

Keys to Effective Wound Management in Long

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