CCME CNE Course Announcement

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1 CCME CNE Course Announcement Activity Title: NoCVA Pressure Ulcer Webinar The Carolinas Center for Medical Excellence (CCME) is accredited as an approved provider of continuing nursing education by North Carolina Nurses Association, an accredited approver of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. This activity has been designated by CCME for 1.0 contact hours of Continuing Nursing Education (CNE) credit CCME utilizes industry accepted mechanisms to identify and resolve conflicts of interest. The planners, faculty, and speakers for this activity have no unresolved relevant financial relationships with commercial interests that could be perceived as a conflict of interest CCME has received no commercial support related to this educational activity In order to obtain credit, you must register, attend webinar, complete survey evaluation questions before you leave the webinar and complete attendance attestation through SurveyMonkey tool by October 3, 2014, the expiration date for awarding contact hours. We will then provide you with an attendance certificate for your records.

2 Data Overview For the 2014 Pressure Ulcers Learning Network, hospitals are no longer being asked to manually submit data. In order to encourage participation in the learning network, NoCVA is utilizing the data available from the CMS (claims-based) data set. Measure follows PSI-03 definition The data is available for >90% of NoCVA hospitals and account for conditions that are present-on-admission (POA) Using this data source means a reduced burden on hospitals to collect and submit data The downside to claims-based data is a reporting lag (approximately 6-9 months)

3 Outcome Measure PSI 03 (Claims Data)

4 Summary of Data # of Hospitals Below 40% Reduction Target (Rate < 0.36) 2013Q3 92 (88.4%) 2013Q4 91 (87.5%) The Learning Network Pressure Ulcer rate rose nearly 50% from 2013Q3 to 2013Q4. However, rates continue to be low across a majority of hospitals, despite an increase of 11 Pressure Ulcers (16 in 2013Q3 vs. 27 in the most recent quarter).

5 LifeCare Hospitals of NC Long-term acute care 50 beds and medical staff of more than 40 physicians Specializes in the treatment of medically complex patients who require extended hospitalization

6 Admission Report Sheet

7 General Information

8 Detail Information - Wounds

9 Our Wound Care Journey A Community Hospitals Toolkit

10 Augusta Health 250 bed Not-for-profit community hospital Local Board of Directors Rural area 35 miles west of the University of Virginia Wound Clinic with full time Surgeon CWON on Staff (that s me!) CWON is also a Nursing Administrator (Why do nurses wear so many hats?)

11 History Surgical floor had the most exposure to Wounds so they were the in house resource Physical Therapy was providing wound care in the P. T. department if ordered by an MD Wound care was still mostly surgically driven with wet to dry dressings being used Hospital did not have 24/7 wound coverage so nurses need a guide or toolkit

12 Evolution of Wound Care Service CWON started getting consulted by Surgeons and Hospitalist Negative pressure wound therapy started being ordered frequently Hospital started seeing more complicated wounds with addition of vascular surgeons Obesity contributed to more wounds Wounds were becoming more complex

13 A little more history: Hospital is located at the intersection of two major interstates, often we get travelers off the interstate. Large diabetic population High Obesity Rate Many patients lack a PCP

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16 Fistula

17 Wound Care Team evolution Set up a system for physicians to formally consult Wound Care Nurse Set up protocols for Wound Care Nurse to use Set up meetings with MD s to review how to consult, what to consult for, communication and protocols. Partnered with Smith and Nephew to develop evidence based wound care protocols for the floor nurses. Partnered with IT to set alerts for nurses

18 Protocols Easy to follow Accessible information Product boards developed with all the toolkit products displayed for ease of reference assembled by Smith and Nephew Product boards placed on the units Roving in-services for staff on protocols Auto alerts from documentation to Wound Nurse

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21 Clinician Consultant Role Record Review: Review pertinent data including labs, medications, past medical history, past surgical history, current medical condition that resulted in hospital stay, social history, wound healing history. Detailed wound assessment: Inconsistencies were noted with wound assessments. Wound assessments were simplified and standardized. Common terms were used as much as possible, (red, yellow black, ulcer, abrasion,)

22 Detailed Wound Assessment Very important because physicians were staging venous stasis ulcers, staging pressure ulcers incorrectly and mislabeling wounds. Improper wound diagnosis can impact reimbursement. (If a diabetic foot wound is called a pressure ulcer, it can impact reimbursement and treatment.)

23 Wound Clinicians Role Plan the wound care for the patient to include follow up care : specific supplies needed, home health, Wound clinic Follow up All chronic wound patients are offered follow up in the Wound Center. Provide acute care nurses written management instructions for wound care. Wound Clinicians also follow all ostomy patients

24 Pressure Ulcer Care Any patient with a pressure ulcer present on admission generates a consult to the wound care nurse. Wound Care nurse guides off-loading and treatment plan Braden Scores that are high risk generate a consult Nurses participate in the NDNQI quarterly pressure ulcer survey

25 Our Toolkit ALLEVYN THIN 4X4 ALLEVYN FOAM 3X3 ALLEVYN FOAM 5X5 ALLEVYN HEEL REPLICARE 4X4 REPLICARE THIN 3X5 ACTICOTE ABSORBENT 4X5 ACTICOTE BURN 4X4 COVERSITE 4X4 COVERSITE PLUS 6X6 SKIN PREP WIPES PROFORE VENOUS wrap KIT PROFORE LITE 4X4 SOLOSITE HYDROGEL MOISTURIZER CREAM DERMAL WOUND CLEANSER IODOFORM ½ IODOFORM 1 IODOFORM 2 KERLIX ALLEVYN NON ADHESIVE 4X4 HYPAFIX TAPE IODASORB ADAPTIC 4X4

26 Stage III (shallow) Wound Nurse Consult Dermal Wound Cleanser Skin-Prep*and/or Calmopseptine Cleanse wound, pat dry. Apply to periwound skin and allow to dry. Minimal to Moderate Drainage Solosite gel Coversite Apply to wound bed. Cover with dressing, change every 2 days or PRN. Moderate Drainage Solosite or Algisite (2x2/4x4) or Iodasorb gel Apply to wound bed. Allevyn/ Allevyn Adhesive/ Choose cover dressing. Change daily or PRN. Moderate to Heavy Drainage Algisite (2x2/4x4) or Iodasorb gel Apply to wound bed Allevyn/ Allevyn Adhesive/ Exudry Choose cover dressing. Stage III (deep) or Stage IV***** Wound Nurse Consult Dermal Wound Cleanser Skin-Prep* (if needed) Change daily or PRN. Cleanse wound, pat dry. Apply to periwound skin and allow to dry. Minimal to Moderate Drainage Solosite Iodasorb gel Apply to all wound surfaces. Loosely pack with Solosite-Impregnated gauze. Or Idodasorb impregnated gauze for exudative wounds Coversite/Kling Choose cover dressing. Change every 2 days or PRN. Moderate Drainage Algisite/ or Iodasorb and 4x4 s Loosely pack wound cavity. Moderate to Heavy Drainage Algisite (Iodasorb and 4x4 s) Loosely pack wound cavity. Allevyn/ Allevyn Adhesive/ Choose cover dressing. Change daily or PRN.

27 Other Initiatives: Wound of the Month: Each month a wound is featured as the Wound of the Month for staff education. The wound is featured with the care plan and matching protocol. Primary nurses are encouraged to go with the consulting wound nurse to see wounds and the nurse does on the spot education. All new hires spend a day with the Wound Nurse Nurse Residents spend a day in the clinic

28 June 2012 Wound of the Month Necrotizing Fasciitis What is necrotizing fasciitis? Necrotizing fasciitis is a term that describes a disease condition of rapidly spreading infection, usually located in fascial planes of connective tissue that results in tissue death that is often associated with sepsis and widespread organ failure. Fascial planes are bands of connective tissue that surround muscles, nerves, and blood vessels. Fascial planes can bind structures together as well as allow body structures to slide over each other effectively., The majority of cases begin with an existing infection, most frequently on an extremity or in a wound, it can occur in almost any area of the body. Although many cases have been caused by group A beta-hemolytic streptococci, most researchers now agree that many different bacterial species, either alone or in combination can cause this disease. Fungal species are also known to cause necrotizing fasciitis. Important in understanding necrotizing fasciitis is the fact that whatever the infecting organism(s), once it reaches and grows in connective tissue, the spread of the infection can be so fast (research has shown some organisms can progress about 3 centimeters per hour) that the infection becomes difficult to stop even with both antimicrobial drugs and surgery. As an example mortality rates have been reported as high as 75% for necrotizing fasciitis associated with Fournier's (testicular) gangrene. Patients with necrotizing fasciitis have an ongoing medical emergency that often leads to death or disability if it is not promptly and effectively treated. Treatment Immediate treatment is needed to prevent death and/or disability. Treatment includes: Powerful, broad-spectrum antibiotics given immediately through a vein (IV) Surgery to drain the wound and remove dead tissue Donor antibodies to help fight the infection in some cases Supportive measures such as insertion of a breathing tube, intravenous administration of fluids, and drugs to support the cardiovascular system Skin grafts after the infection goes away to help your skin heal and look better Amputation if the disease spreads through an arm or leg 100% oxygen at high pressure (hyperbaric oxygen therapy) for certain types of bacterial infections From sinus abscess From Bath Salts injection From a Bee Sting References:

29 Augusta Wound Center and Hyperbarics Full service wound clinic with a full time surgeon, 6 Registered nurses, 2 Licensed Practical Nursing, 1 Patient Care Technician and our Administrative Support Staff 2 Certified Hyperbaric Technicians 2 Certified Hyperbaric Registered Nurses

30 Wound Clinic and Hyperbarics Serve patients that come from a 100 mile radius visits per month Sharp debridement is done almost every visit Advanced wound care products Multi-layer compression wraps Off-loading Diabetic Wounds Total contact casting HBO Multi-disciplinary approach to care

31 On the Horizon Computer Order Entry Sets for wound care protocols Special are just for wound care consults by Wound Care Team (sometimes they get buried in the EMR) Physician/Nurse Collaboration and rounding on Wound Care patients

32 Thanks to: Smith and Nephew for their assistance with protocols and product selection Augusta Health Wound Nurses for their commitment to patients Augusta Health Wound Clinic for 6 years of success!

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