Introduction to the Lower Extremity Wound Pathway. Current challenges for nurses. Pathway proposes 3/21/2016

Transcription

1 Introduction to the Lower Extremity Wound Pathway Carolyn Morin, Enterostomal Therapy Nurse, Saskatoon Health Region Michelle Heidel, Skin & Wound Consultant, Prairie North Regional Health Authority Current challenges for nurses Incomplete info/orders from primary care Lack of standardized wound care protocols, product formulary Capacity for wound care not always available in the homecare team Sometimes difficult to access wound resource nurse/ physicians/ specialists for advice Wound care takes many homecare hours Pathway proposes Wound care referral form for family physicians and nurse practitioners Standardized wound care protocols & product formulary (no orders required) T2 Capacity building for homecare team Forms to record & share information with wound resource nurse/ physician/ specialist Tools to support better wound measurement and tracking, faster healing 1

2 Slide 3 T2 delete collect, replace with record Tessa, 3/1/2016

3 How does the Pathway work? T3 Step 1: primary care referral Primary Care Referral Form 2

4 Slide 4 T3 Are we still proposing "tertiary clinic"? May want to change to "Tertiary care" Tessa, 3/1/2016

5 Primary Care Triage Contact on call vascular surgeon and fax this form for URGENT REFERRALS (red flags) FAX REFERRAL to nearest Regional Wound Care Team for initiation of treatment according to wound pathway protocols FAX REFERRAL to BOTH Regional wound team AND specialist office for all DIABETIC FOOT ULCERS. Regional wound team will initiate care; specialist assessment/consult takes place within three weeks Step 2: limb/wound assessment Standardized assessment form Should be completed ASAP after admission Assessment flow through Assists to identify probable etiology Please refer to printable copy 3

6 Clinical Signs and Symptoms of Wound Infection in Diabetic Foot Ulcers (DFU) In this immunocompromised population, infection needs to be recognized and treated early. Infection is a serious complication within the foot; the various compartments, tendon sheaths and neurovascular bundles favor the spread of infection¹ and can be rapidly limb threatening. If any of these signs/symptoms are present contact the wound clinician nurse, family physician/np. The presence of infection is defined by 2 or more classic findings of inflammation or purulence ² > 2 cm of redness ² ⁴ Local inflammatory response (warmth, Increased pain ³ ⁴ swelling) ² ⁴ Wound breakdown ³ Foul odor ² ³ Friable granulation tissue ³ Probe to bone ² ³ ⁴ Increased amount of exudate ² ³ Clinical Signs and Symptoms of Wound Infection in Venous Ulcers Increased Bacterial Bioburden Localized Infection Systemic Infection Non healing (minimal change in wound measurements after 3 weeks of care) Pale pink, non pebbly tissue Friable(bleeds easily) or hypergranulation (raised, deep/bright red, friable) tissue New areas of necrotic slough (yellow/grey/cream colored tissue) Increased amount of exudate Change in characteristics of exudate from watery and serous to purulent (thickened, greenish or yellow/white fluid) Odour after wound cleansing Onset of wound pain or increasing pain Peri wound induration (firm edema) greater than/equal to 2cm Peri wound erythema (redness) greater than/equal to 2cm Increased peri wound warmth Increased wound size and / or the development of sinus tracts and / or satellite wounds next to the original wound Purulent exudate (thickened, greenish or yellow/white fluid) Increased dysreflexia(abnormal response to physiologic stimuli) or spasticity in clients with spinal cord injury General malaise (predominantly in clients who are elderly, immunocompromised & children) Fever (may be muted in clients who are elderly or immunocompromised) Rigor / chills Change in behaviour or cognition (especially in elderly clients) Unexplained high blood sugar (in clients who are diabetic) Septic shock potentially leading to multi organ failure Wound probes to bone If 3 or more signs/symptoms present add a topical antimicrobial to the wound dressing and contact the wound clinician nurse If 3 or more signs/symptoms present swab the wound for C&S, add a topical antimicrobial to the wound dressing and contact the wound clinician nurse and physician/surgeon If any of these signs/symptoms are present contact the physician/ surgeon for review of the patient immediately or activate EMS Interpretation of ABI/TBI in Determining Compression ABPI Value Interpretation/Clinical Significance Compression Therapy* >1.3 Abnormally high range, renders ABPI test TBI Incompressible arteries indicated, contact wound clinician Normal High compression Borderline to mild obstruction/peripheral arterial High compression disease Mild to moderate obstruction/ peripheral arterial Modified compression disease <0.7 Contact wound clinician or /physician/np. Contra indicated unless ordered by specialist TBI Value Interpretation/Clinical Significance Compression Therapy >0.7 Normal High compression Mild to moderate peripheral arterial disease Modified compression <0.4 Severe ischemia contact wound clinician or /physician/np Contra indicated 4

7 Communication to referring provider Step 3: initiate treatment according to protocol Standardized treatment protocols Based on wound etiology Evidence based standardized care If wound fails to follow wound healing trajectory or if concerns with protocols, contact wound resource nurse. Wound team may vary by region identify local wound resources and coordinate care Please refer to printable copies 5

8 Diabetic Foot Ulcer Venous Leg Ulcer Non healable wound 6

9 Suggested formulary Sealant/barrier: Cavilon No Sting, Skin Prep Alginate: Biatain Hydrofibre: Aquacel Absorbent cover dressing: Mesorb, Mextra, Mepilex foam Compression: Coban 2/Coban 2 lite Antimicrobial dressing if indicated: Acticoat Flex 3, Iodosorb, Silvercel Ag (alginate), Aquacel Ag (hydrofibre) Step 4: monitor wound progress NISS Wound Record electronic version or app may be available to calculate % change in wound area Wounds that do not decrease in size by 50% within 4 weeks are not on track 7

10 What happens in specialty care? Who is part of the multidisciplinary team? Patient & family Primary care provider Community nurse Wound resource nurse Podiatrist Diabetes educator Physiotherapist Occupational therapist Nutritionist Social worker Orthotist Vascular specialist What nurses need to know: Takes a team approach to heal a wound Access wound resource nurses with any concerns If vascular surgeon is directing local wound care treatment, they will review regularly and follow up Investigate possibility of telehealth 8

11 Capacity building & resources NURS 1684 Care of the Patient with Lower Extremity Wounds SK Polytechnic Nurses still need certification as per regional policy Pathway web pages (search sask wound pathway) for documents & links In summary: The purpose of the pathway is to improve patient outcomes through early optimal wound management: Better healing times Reduced hospitalization and amputation In summary: Improvements for providers include: Standardized tools and protocols Better communication and teamwork Improved patient outcomes = reduced provider hours/products 9

12 The LEW Pathway is still in development. Objectives for this year are: Support wound care capacity building for nurses and primary care Introduce and build familiarity with standardized wound care forms & protocols Work on electronic versions of tools and forms Improve access to vascular specialist and other wound services Questions and Suggestions Lower Extremity Wound Pathway Contact: Lori Latta, Project Manager , 10