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 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 Decreased pain perception Physical and cognitive limitations Compromised skin barrier and mechanical protection Contributing Factors Thin, dry skin 6 2
Diabetic Foot Ulcers Skin Tears Incontinence- Associated Dermatitis Compromised Skin Integrity Pressure Ulcers Medical Adhesive-related Skin Injury (MARSI) Moisture Associated Skin Damage Additional Statistics Pressure Ulcers 2 Affect 3 million adults in the US (2006 statistics) Prevalence 2-24% in LTC Diabetes 3 Leading chronic disease 370 million people globally 25% lifetime risk of diabetic foot ulcer development Incontinence-Associated Dermatitis 5.6% - 22.5% of LTC residents 4 Skin Tears 1.5 million/yr 5 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
Program Key Components Collaboration with Clinical Leadership Medical Director, Administrator, DON/ADON WOC nurse or Wound Care Specialist Evidence-based protocols/policy and procedures Interdisciplinary wound care team Standardized Formulary Skin & Wound Product Guidelines Education Program 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 Wound Care Specialist 6 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 Specialist 6 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
Program Key Components Collaboration with Clinical Leadership Medical Director, Administrator, DON/ADON Wound Care Specialist Evidence-based protocols/policy and procedures Multidisciplinary wound care team Standardized Formulary Skin & Wound Product Guidelines Education Program Evidence-Based Protocols 6,7 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 http://www.myhousecleaningbiz.com/members/images/247.jpg Examples: Skin assessment Pressure ulcer risk assessment Wound cleansing Wound assessment Wound treatment Pressure ulcer staging Documentation Key Components Collaboration with Clinical Leadership Medical Director, Administrator, DON/ADON WOC nurse or Wound Care Specialist Evidence-based protocols/policy and procedures Interdisciplinary wound care team Standardized Formulary Skin & Wound Product Guidelines 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 Program 10 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 Program 10 (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 Program 10 (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 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 11
Standardized Formulary 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 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 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
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 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 Learning 11 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 Competencies 12 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, 2010 13 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 PU Reduction Program (continued) 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 PU Reduction Program (continued) 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. Harris-KojetinL, SenguptaM, Park-Lee E, ValverdeR. Long-term care services in the United States: 2013 overview. Hyattsville, MD: National Center for Health Statistics. 2013. 2. Chou R, Dana T, BougatsosC, BlazinaI, StarmerA, 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. 3. 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. SackettDL. 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 Long- Term 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