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Managing Wound Care Outcomes—Part 1
Chronic wounds increase home care (HC) costs, stressing an already overburdened system. More severe wounds are significantly more expensive to manage than less severe ones.1 In addition to these recognized economic costs, clients are burdened with the pain, suffering, and loss of independence commonly associated with chronic ulcers.2
The Clinical Issues Committee of the Nova Scotia (NS) Department of Health (DOH) recognized increasing challenges within its province as a result of a growing nursing shortage, an aging population, and budgetary restraints. To address these challenges and proactively reduce the growing burden of wound care in the home, the Clinical Issues Committee, a multidisciplinary team of HC professionals, and a team of HC nurses decided to address this issue. The team applied the principles of outcomes management3 — identifying opportunities for improvement, developing interventions, implementing practice standards, and testing outcomes achievement to assess, define, and improve home wound care outcomes in the Province of NS.
Methods
Study design overview. The Outcomes Management Model (see Figure 1) was used as the paradigm for a program of research using four phases to improve outcomes of care. In Phase I, the NS DOH, Continuing Care (Clinical Issues) Committee (the Committee), defined the scope and nature of the chronic ulcer challenges facing HC professionals in NS using a descriptive retrospective chart review. During Phase II, a multidisciplinary team at Cape Breton University conducted a literature search to identify evidence-based wound care practices, which were subsequently incorporated into a comprehensive protocol of wound care, the Nova Scotia Protocol (NSP). The NSP included validated, reliable client4 and wound5 assessment tools for wounds encountered in home health care as well as assessment-based validated wound care protocols6 adapted for the Province of NS home health care agencies. In Phase III, the NSP was disseminated to all 20 NS HC nursing offices with programs to educate professionals in its use. A prospective, quasi-experimental, descriptive study design was used to measure the effects of the NSP in Phase IV of the program. Specifically, wound care outcomes before and after implementing the NSP were obtained.
Phase I. Assessing the situation: population wound prevalence, care, and outcomes. To assess the NS HC baselines for wound prevalence, practices, and outcomes, the Committee commissioned all administrators and staff from the 20 nursing offices in NS to gather wound prevalence data on the total home care population (N = 548) during a 2-week period in November 1999. One resource nurse at each participating agency trained participating HC nurses to assess wound prevalence, using the standardized Provincial Wound Care Data Collection©7 tool. This data collection instrument contains the following variables: office identification (agency/branch/region of NS); date; client identification information; wound etiology and location; length of time client was on wound care caseload; dressing change frequency; type of treatment (1 = normal saline/gauze dressing; 2 = moist wound healing (eg, using hydrocolloid dressing; 3 = compression therapy; 4 = wound irrigation; and 5 = other); level of care provider (RN or LPN); ratio of RN to LPN visits; presence/absence of client self care; potential for client self care; and comments.
To explore the quality and consistency of recent baseline wound care practices for the Phase I situational assessment, several case managers also conducted a retrospective chart review of HC practices and outcomes for selected clients with wounds that had consistently recorded data from 1995 to 1999.
The Committee reported results to HC office management and to the Provincial authorities involved before being authorized to begin Phase II of the outcomes management research project.
Phase II. Developing and pilot-testing interventions: the standardized protocol. The Director of the Eastern Region of NS Continuing Care DOH authorized six nurses in this region to review existing literature and reach consensus on best evidence-based wound care practices. These nurses applied their varying expertise and specialties to MEDLINE® and CINAHL® searches of the literature covering all aspects of wound care relevant to HC in NS. Searches were supplemented with materials from educational volumes on wound management and current journal publications. The nurses agreed on protocols of home wound care based on the best available evidence found in the literature. Together, they used this evidence to develop a Provincial Standardized Home Care Wound Management Protocol©. The resulting NSP incorporates existing reliable, validated client4 and wound5 assessment and data collection tools to guide wound care decisions through an adaptation of a protocol of care previously validated in the US.6 A multidisciplinary team of wound experts from Cape Regional Breton Hospital, including dietitians, physicians, nurses, and physical therapists, reviewed the NSP; feedback from more than 500 healthcare professionals also was integrated into the final NSP. The final NSP consists of the wound assessment/progress tool and a standardized protocol of care.
Standardized wound assessment/progress (WAP) tool. The wound assessment/progress tool includes a pressure ulcer risk scale and wound assessment instrument. Each client’s risk of developing pressure ulcers was assessed using the reliable, valid Braden Scale©.4 Subsequent reassessment was recommended monthly or whenever a significant change in the client’s condition was observed. The latter enables each nursing office to monitor changes in risk level of their clientele and proactively address shifts in risk factors such as mobility, incontinence, or nutritional status.
The status of each wound was assessed on admission and associated outcomes of care were monitored weekly until discharge using the WAP Tool adapted from the Pressure Sore Status Tool (PSST©).8 Wound features measured on the WAP Tool guided wound care according to previously validated algorithms.6 The WAP Tool also documented wound outcomes, such as wound healing. Estimated area (wound length x width) was used as a simplified method to monitor wound status rather than the total PSST score because percent reduction in this estimate of wound area is reportedly a reliable predictor of wound healing outcomes.9-12 Although items in the PSST had been validated and reliability-tested for pressure ulcers only, the multidisciplinary team deemed the items relevant to and adapted them for assessment of all types of wounds encountered in NS HC. The resulting standardized WAP Tool differed from the original PSST in three ways based on NS HC user feedback for use on wounds of all etiologies: 1) necrotic tissue type (PSST) was replaced with WAP Tool Ulcer Base (N = necrotic, G = granulating, P = pink, W = white/grey, NA = nonadherent slough, LA = loosely adherent slough, A = adherent soft black eschar, FA = firmly adherent black eschar); 2) skin color surrounding wound (PSST) was replaced with WAP Tool periwound skin; and 3) limb color (pale, pink, cyanotic, hemosiderin stained) was added to the assessment.
Additional WAP Tool variables include:
• wound dimensions (length, width, and depth in cm, or as wound depth is described on the WAP Tool — eg, 1 = reddened skin; 2 = partial-thickness wound; 3 = full-thickness wound; 4 = muscle, tendon, or bone involvement; 5 = “unstageable”) and AHCPR Stage13 for pressure ulcers
• pedal pulse, ankle-brachial index (ABI) in affected limb(s), leg and/or foot edema (recorded on a four-point ordinal scale ranging from +1 for slight to +4 for pitting edema), diabetic status, and glycosylated hemoglobin (HgbA1C) if measured
• wound etiology, location, pain, infection status, and confirmation (yes/no, culture or biopsy),associated antibiotic use and pressure ulcer stage
• standard principle(s) of care applicable to this wound, treatment choice, frequency of dressing change, number of minutes per dressing change, and nurse initials.
Before NSP implementation across NS, pilot research using the WAP Tool was conducted to confirm the tool was user-friendly, relevant for use in this wound care environment, and reliable as a metric for wound characteristics guiding care decisions and monitoring wound outcomes. Feedback from 10 NS HC agency staff members who used the WAP Tool for 12 weeks was obtained and suggestions to improve ease of completing the form and ensure uniform coding of product usage were incorporated. The same two NS HC agencies conducted inter-rater reliability studies on the WAP Tool using a test-retest paradigm. After staff had used the tool to evaluate a successive sample of 20 clients (18 with open wounds, two with wounds which were recorded as healed on the WAP Tool), an experienced wound care nurse blinded to the prior assessments used the tool to assess the same clients. Agreement between the novice nurse and the expert nurse on 95% of the wound assessment observations on the same wounds was perfect. At the same time, an enterostomal therapist trained in wound care performed a similar exercise in the Province of Ontario using a sample of 20 clients with 15 wounds. The expert and novice nurses achieved perfect agreement on 97% of wound assessment observations.
Standardized protocol. Wound care was based on client and wound assessments, adapted as described above, and guided by the Solutions® (ConvaTec, a Bristol-Myers Squibb Co. Solutions® is a registered trademark of E.R. Squibb and Sons, L.L.C.) protocols of care previously validated in the US.6 In addition to completing the WAP Tool, HC professionals recorded the generally accepted Principle14 guiding each element of wound care. The guiding principles of wound care utilized are:
1. Risk assessment and prevention, with the Braden Scale scores focusing attention on alleviating risk factors for development of pressure ulcers15; and ABI, edema, pedal pulse, diabetic status, and glycosylated hemoglobin recoded when available to address other chronic wound etiologies
2. Complete client history and wound assessment
3. Debridement of necrotic tissue
4. Identification and elimination of infection (including microbial culture and biopsies)
5. Elimination of dead space
6. Absorption of excess exudate
7. Providing an environment for moist wound healing
8. Providing thermal insulation
9. Protection of wound healing.14
Management type was recorded using the following coding scale and caregivers could include more than one: 1 = normal saline/gauze; 2 = moist wound healing — eg, use of hydrocolloid dressing on formulary; 3 = compression therapy; 4 = wound irrigation recommended applied at a pressure 4 to 15 pounds per square inch; 5 = other (specify).
Change in management was documented with rationale — eg, no reduction in estimated wound area after 2 to 4 weeks of care.9-12
Care provider was specified as RN or LPN. If extra documentation was warranted (eg, for a complex wound), notification was added to “See nurse’s progress notes.”
Phase III. Implementing practice standards. The NSP was introduced throughout NS HC as a quasi-experimental intervention in January 2000, when the Clinical Issues Committee formally named the NSP a “Standard of Care.” The NSP was presented first to regional HC Directors and then to local Supervisors and Case Managers who established processes and protocols for implementation. In June 2000, the NS DOH issued a directive to participating HC offices to engage at least 80% of their nursing staff in NSP education. Resource nurses educated staff members on wound and client assessments and the use of assessment variables to guide care decisions within the NSP. Ten educational sessions describing use of the draft NSP were organized. Participants comprised 510 HC staff members, as well as acute and long-term care staff members, including enterostomal therapists, physical therapists, occupational therapists, physicians, and other professionals who asked to attend. At these educational sessions, audiences informally validated the principles and documentation tools and provided feedback that was incorporated into the final NSP to improve its functionality.
Senior nursing staff at each agency served as NSP champions through regular conference calls between staff and a Committee member responsible for communicating outstanding issues and concerns to the Committee. Physician communications were standardized by the Clinical Issues Committee through the creation of a Physician Information Booklet, which was distributed to general practitioners and specialists in the province likely to be involved in wound care.
Adherence to the NSP was assessed for each participating HC office and determined to occur if the following four conditions were met: nursing staff: 1) used the standardized Wound Assessment/Progress (WAP) Tool, 2) applied the NSP for wound and skin care interventions following algorithms based on the best available evidence for wound management, 3) standardized wound prevalence and client evaluation methods and data collection, and 4) applied the Nine Standard Principles of Wound Management from published literature14 adapted for specialized use in the HC environment.
The Clinical Issues Committee formally named the NSP a “Standard of Care” in in the Community in NS in January 2000. After use of the NSP confirmed its clinical and economic benefits, the NS DOH Continuing Care Branch issued a Policy Directive on July 1, 2002 that the NSP be formally implemented under the title of Wound Management Protocol.
Phase IV. Measuring outcomes achieved by NSP use. Selected data generated by NSP use were entered into a database established to monitor outcomes of its usage within NS HC. To date, the Committee and multidisciplinary panel of professionals have entered, analyzed, and reviewed the variables that reflect healing, quality of life, quality of care, and economic outcomes, as well as professional experiences associated with use of the NSP. The Committee and multidisciplinary panel are currently deriving implications for effects of the NSP on wound care quality improvement within the scope of NS home wound care.
Standardized prevalence studies. The Committee used a descriptive cohort design to conduct prevalence studies for all wounds in all participating HC agencies 1 year and 2 years following implementation of the NSP. The Provincial Wound Care Data Collection tool7 that had been used in the November 1999 prevalence study was used in both follow up studies. Wound prevalence was recorded in November 2001 on 600 home wound care clients and on 2,281 clients in the agencies’ HC service in December 2002. In the 2002 survey, acute wounds were surveyed as a separate category after earlier analysis showed this to be a major etiology of wounds managed in NS’s HC settings.
Healing. The weekly wound variables recorded using the WAP Tool are being entered into the database for later analyses and are not reported here. Wound healing times from 1999 through 2003 reported here are defined as length of time between a client’s wound admission to care and his/her date of discharge if healed or to the date when the wound was deemed sufficiently healed to discharge the client to family care (length of time on the wound care case load).
Client quality of life. Client-reported quality-of-life responses were recorded on an ongoing basis using unstructured open-ended interviews and pain was measured on a five-point rating scale. Clients were asked about their wound-related experience while on the agencies’ caseloads; their responses, collected systematically from 2002 forward, will be categorized and tabulated in future reports of this study.
Economic outcomes. First, a pilot, parallel-group, non-randomized controlled study was conducted to compare the combined labor and materials costs of wound care between two similar home care offices — one used the NSP and the other did not fully implement the NSP. All wound care costs were recorded in Canadian dollars from April to July 2000. Second, all labor and materials costs were recorded during 10 months of home wound care in 10 DOH agencies using a sample of 50 typical clients with the same or similar wounds stratified across etiologies before NSP use (March through December 1999) and after NSP implementation (March through December 2001). Costs of care were calculated based on recorded material use and ratios of LPNs to RNs administering wound care. Labor costs were based on NS average costs of $30.66 per LPN visit and $41.47 per RN visit. Materials used were based on wound treatment data recorded during the prevalence studies with corresponding hospital formulary costs recorded for each wound care product used per week. The nursing visits for wound care were reduced from seven visits per week before implementing the NSP to a range of two to three per week for different agencies after NSP implementation, conservatively estimated at three wound care visits per week for cost calculations.16
Quality of care. Quality of care was assessed as the frequency of wound dressings. Less frequent dressing changes were associated with higher quality of care because this implied less use of gauze-type dressings that are associated with delayed healing, increased infection rates, and increased wound-related pain.17-19
Professional experiences. A multidisciplinary panel of wound care professionals selected by their management in HC, acute care (AC), and long-term care (LTC) settings evaluated NSP ease of use and outcomes satisfaction. The panel, including physicians, enterostomal therapists, physical therapists, LPNs, and RNs, described their experiences in January 2002 after using the NSP for up to 2 years by completing the Wound Management Protocol Survey (the Survey). The Survey comprised a standardized eight-item questionnaire, with “Yes-No” questions related to familiarity with and usage of the NSP in practice and preference for a standardized list of supplies. A checklist for types of wounds applicable to the NSP also was included. Respondents were asked to describe reasons for use and non-use of the NSP and what the respondent liked most and least about it. All responses were anonymous.
Analyses of Variance (ANOVA) compared healing time measures across time for venous ulcers (initially the slowest to heal) and surgical wounds healing by secondary intention (initially the fastest to heal). Statistical significance of results was selected as ± = 0.05. Chi-square tests assessed the significance of temporal trends in pressure ulcer prevalence or percentages reported for the different wound etiologies. Descriptive data, such as client-reported quality of life comments or professional NSP user comments, were categorized and tabulated.
(Continued in Part 2)
