keys to effective wound management in long - online the need –ft or pt ... critical component to...

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OHCA Annual Convention & Trade ShowSeptember 23, 2014

Lynn Peterson RN, BSN, CWOCN3M 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


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The ElderlyThe Elderly

An “At Risk” PopulationAn “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.


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Contributing Factors

Compromised skin barrier and

mechanical protection

Decreased pain perception

Delay in healing and immune

response

Inadequate hydration and

nutrition

Incontinence/ moisture

Physical and cognitive

limitations

Thin, dry skin

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Compromised Skin Integrity

Diabetic Foot Ulcers

Incontinence-Associated Dermatitis

Medical Adhesive-related

Skin Injury (MARSI)

Moisture Associated Skin

Damage

Pressure Ulcers

Skin Tears


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 Effective Skin & Wound

Management ProgramManagement Program


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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 re-hospitalizations

Cost containmentStaff

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


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� WOC nurse or Wound Care Specialist
















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


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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”


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� Multidisciplinary wound care team





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


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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

� Documentationhttp://www.myhousecleaningbiz.com/members/images/247.jpg


Key Components� Collaboration with Clinical Leadership


� WOC nurse or Wound Care Specialist







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


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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


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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 careLynn Peterson, 3M, September 2014

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


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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











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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 productcategory not brand specific� Antimicrobial� Alginate� Foam


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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


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Additional Formularies� Lower limb immobilizers

� NPWT systems

� Other therapy devices

� Support surfaces (bed, chair)

� Wheelchairs











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


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Product Guide (continued)

� Why

� Improve:

� Clinical competence

� Consistency

� Clinician comfort

� Resource efficiency and effectiveness




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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


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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


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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


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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 EditionSharon Baranoski, and Elizabeth A. Ayello

� Clinical Guide to Skin & Wound Care, Seventh EditionCathy 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


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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


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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


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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


References1. 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.

2. Chou R, Dana T, Bougatsos C, Blazina I, Starmer A, Reitel K, Buckley D. Pressure ulcer risk assessment and prevention: Comparative effectiveness. ComparativeEffectivenessReview 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


References4. 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-in-the-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.


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References8. 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-different-wound-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-ltc-establishing-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-inspiring-ltc-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-care-teams/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.


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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.


keys to effective wound management in long - online the need –ft or pt ... critical component to...

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