Managing Wound Care Outcomes—Part 2

Results

Client demographics, wound prevalence, and pre-NSP wound care practices. Characteristics of the sample and results of the prevalence studies are presented in Table 1. The number of clients increased in 2002, while the proportion of clients with wounds decreased (P Acute surgical wounds were included in the “Other” category in 1999. As a result of this research program, surgical wounds were counted separately in 2001 based on increasing awareness of the challenge they offered NS HC. These were broken down into open (healing by second intention) and closed (healing by primary intention) surgical wounds in order to track the magnitude and source of this challenge. In 2002, 277 (12.1 %) clients had surgical wounds healing by secondary intention.
The retrospective chart reviews identified substantial gaps in healing outcomes, as well as in quality and consistency of practice, resulting in poorly met client wound care goals and a growing challenge to the Provincial budget. Wound care practices were often outdated. For example, among clients who had venous insufficiency ulcers for which the cornerstone of care is either multilayer, high compression bandaging or stockings, few received adequate compression. The case studies (see Figure 2) contrast typical client outcomes achieved by worst-case venous ulcer clients observed from August 1995 through January 1999, with similar client outcomes obtained for a similar wound after implementing the NSP. These retrospective chart review results were pivotal in the Provincial government’s decision to move forward to improve NS’s wound care practices.
Wound healing outcomes. After implementing the NSP, wound healing times declined for all wound types recorded. Healing times recorded from sporadic observations in the retrospective chart review in 1998 ranged from 4 to 5 years. These were tracked prospectively from 1999 forward for increasing numbers of wounds. In 1999, diabetic foot ulcers took longest to heal (174 weeks or 3.3 years), diminishing to 10 weeks in 2003. Average venous ulcer healing time diminished from 105 weeks in 2000 (the first year systematically recorded) to 6 weeks in 2003. Pressure ulcers averaged 3.3 years to heal in 1999, declining to 7.3 weeks in 2003. Surgical wound healing times were shortest, declining from 29 weeks in 2001 when first systematically recorded to 3 weeks in 2003 (see Figure 3.) The percentage of clients discharged to family care was highest in 1999, with two out of six clients (33%) discharged, stabilizing at 12.8% in 2002 to 17.2% in 2003.
Client-reported quality of life. Client-reported unstructured quality-of-life statements were generally positive for most wounds experienced by the HC clientele. For example, “My daughter has had these pressure ulcers for years. You have truly made a difference in her quality of life.” One client with venous ulcers noted, “You nurses are angels. I have suffered for over 5 years with these ulcers and now they are healed.” Another client with a diabetic neuropathic foot ulcer, remarked, “I have tried everything in the last 2 years to heal this wound. I cannot believe it is finally closed.” The typical comment for acute wounds in which a moist environment was maintained per the NSP was, “The wound was so painful and now it feels so good with the treatment you are using.”
Economic outcomes. Immediately before implementation of the NSP, wound care clients received five to seven wound care-related visits per week. This declined to between two and 4.7 visits per week in 2001 and to between 1.8 and 2.8 in 2002 with nursing offices who consistently implemented the NSP exhibiting the lowest number of wound care-related visits per week (see Table 1). Sample pre-NSP product use for one client over 4 years of ulcer care with minimal progress is presented in Table 2 to illustrate pre-NSP cost sources.
Use of the NSP in the prospective parallel group pilot study reduced costs by an average of $2,039 per client per month when compared to wound care labor and materials costs in an office that did not consistently use the NSP. The nursing offices providing NSP-guided care served an average of 4.7 wound care clients per month for a total 4-month cost of $7,208 ($383 per client per month); whereas, the nursing offices that did not consistently implement the NSP provided care to an average of 3.7 clients per month at a cost of $2,422 per client per month for a total of $35,842.
These results were confirmed in the 10-month cohort study (n = 50). Labor costs were about eight times material costs pre-NSP and five times material costs following NSP implementation (see Figure 4). The average number of visits decreased from 20 to 25 per client per month pre-NSP to 7 to 13 visits per client per month after NSP implementation. The corresponding costs of labor and materials in this sample declined from $1,487.02 per client per month pre-NSP to $540.38 per client per month after NSP implementation. Nursing labor comprised 89% of pre-NSP costs and 84% of costs when using the NSP. Materials costs decreased from $158.33 per wound care client per month pre-NSP to $84.13 using the NSP. Based on these calculations, offices consistently using the NSP were able to reallocate to other services prior wound care costs of $946.63 per client per month. Totaling these reduced costs of wound care for all 50 clients served using the NSP during their 10 months of home wound care, these offices were able to reallocate $473,316 to other urgent client HC needs.
Quality of care. Table 2 illustrates the lack of consistency of product usage before implementing the NSP, which streamlined this list to five functional categories: wound cleansers (eg, saline or non-ionic wound cleanser); wound hydration (eg, amorphous gel, such as DuoDERM® Hydroactive® Gel); moisture-retentive dressings (eg, DuoDERM® CGF® dressings or composite dressings); exudate management (eg, alginate or AQUACEL®* Hydrofiber®* dressing); and compression (eg, two- to four-layer elastic compression wraps, such as SurePress® or Profore®); with specialty dressings used to meet specific wound needs, such as controlling minor wound bleeding or wound odor management. (DuoDERM Hydroactive Gel, DuoDERM CGF, AQUACEL, HYDROFIBER, and SurePress are registered trademarks of E.R. Squibb & Sons, L.L.C.; Profore is a registered trademark of Smith & Nephew, Inc., Largo, Fla). In 1999, 42% of clients were receiving once-daily wound care primarily with five to seven gauze dressing changes per week; an additional 10% were receiving every-other-day wound care administered by LPNs (57% of the time) and RNs (43% of dressing changes). Less than half of clients received the benefits of a moist wound environment, which the literature search shows to be associated with less frequent care,²⁰ less pain,²¹ faster healing,^20,22 and fewer infections than gauze.²³ In the offices where full implementation took place by 2002, this trend was reversed, with many clients consistently receiving the research-based NSP of care; number of visits per week ranged from 1.8 to 2.8.
Professional experiences reported. Of the 143 clinical professionals responding to the Survey, 14 were in AC, 35 in LTC, and 94 in HC distributed across eight Districts. Of these, 140 were familiar with the NSP and 133 were using it - 130 on chronic wounds and 118 on acute wounds. Most (n = 117) said they would find a standardized list of supplies beneficial. Respondents were generally satisfied with the NSP, its ease of use, and outcomes achieved, with the most frequent unstructured comment being, “Wound management protocol is fantastic/Really like the protocol” (n = 11). The second most common comment received (n = 6) related to physician reluctance or refusal to follow protocol. Forty specific recommendations were made. The most frequent recommendations, which will be addressed, were: Physicians need to be aware it is “Policy and compliance standardization” (N = 26), “yearly inservice/updates/training needed for physicians and nurses” (N = 17) and “need for more training now” (N = 9).
Respondents’ structured responses (see Table 3) most frequently cited their ability to “treat using appropriate procedures without having to contact a physician with each change” as the most liked feature about using the NSP. Other positive features mentioned included “simple and easy to follow” “consistency,” “decreased dressing changes,” “increased client comfort” (N = 11): “wound healing” (N = 11); and providing “resource for wound management” (N = 10). Least-liked features cited were related to physicians not following the NSP and concerns about the selection of suppliers. Ten respondents indicated that the WAP Tool needs to be more user friendly. Several respondents indicated they were not using the NSP because they “follow doctor’s orders,” “use evidence-based wound care and most of what is in protocol is already being implemented in acute care,” or “do not give direct care.” The predominant themes in the survey were satisfaction with the NSP and pleas for increased physician usage and increased educational initiatives.
Once the NSP was established and wound care outcomes were inspiring local users, the NSP was presented to provincial health authorities, with appropriate briefings, along with evidence that it could improve client outcomes. As a result of these communications, the NSP was issued as a policy for Community Care in the Province of NS on July 1, 2002.

Discussion

Home care agencies implementing the NSP improved the quality and consistency of wound care outcomes and clients’ reported quality of life while reducing the frequency of client visits. The NSP reduced wound care costs by $946.63 per wound care client per month or $11,359.58 per client per year. If all 891 clients with wounds served in 2002 had received NSP care (consequently decreasing the frequency of dressing changes), approximately $10,121,389 could have been reallocated to other urgent healthcare needs in NS and unprecedented benefits for wound care clients might have been provided.
Wound healing times and stage or depth on admission were sporadically recorded in 1999 before the NSP was implemented and during its early implementation in 2000. Although interpretation of the relative improvement of healing outcomes in the current study is limited, it clearly shows the improvement in NS’s awareness of and capacity to manage its home wound care burden once the NSP was implemented and wound data were systematically recorded.
Because of improved wound care outcomes, the NSP was accepted as the Standard of Care for the Province of NS in 2001. It was incorporated into NS’s Provincial Policy in 2002 with recommendations that all Home Wound Care Offices follow this protocol as best available practice. In 2003, the Province issued a policy mandating the NSP based on best available evidence. Although the Protocol remains to be universally implemented for wounds in NS HC, 20 NS HC provider offices using the NSP served 2,281 clients with 891 wounds in 2002. Among healthcare professionals involved in the program, even those originally skeptical, general satisfaction was expressed regarding the consistency of protocols and outcomes derived from applying the NSP.
Implementing the NSP in these offices took 1 year, with a resource nurse within each office serving as an NSP champion and agency coordinator. Each office was mandated to educate 80% of their wound care staff on its implementation; most agencies cooperated. Processes were streamlined as time progressed and physicians and wound care staff sought increasing involvement as the benefits to clients became more evident. Additional annual costs of implementing the NSP included Resource Nurse costs ($30 per hour for four 8-hour sessions = $960 for each of 20 offices or $19,200) for nursing education; nursing staff time off to engage in wound care education ($30 per hour for one 8-hour session plus 1 hour of travel = $270 for each of 400 nurses for a total of $108,000); printing costs of the educational materials ($15,000 provided as an unrestricted educational grant); data entry and management ($28,000); and Clinical Consultant costs ($13,000) to communicate and disseminate the results. These provincial costs totaling $183,200 were offset by the economic benefit from caring for as few as 17 clients at $11,359.58 per client per year conserved for other healthcare priorities. The cost to implement and maintain the NSP was a small price to pay to restore funds to the healthcare budget.
Trends. Recent research suggests that these findings may be part of a global trend. For example, researchers in a US home telemedicine setting reported reduced healing times for wounds of all etiologies treated²⁴ with fewer HC visits, applying the same validated protocol of care from which the NSP was derived. Their subsequent findings²⁵ established unprecedented wound outcomes for full-thickness pressure ulcers and venous ulcers healing in a mean of 57 days or 62 days, respectively, and corresponding etiology partial-thickness ulcers healing in approximately half that time. Cost savings and improved clinical results also have been reported in the hospital setting in Japan²² using a similar standardized protocol of care applying the same products used in the NSP as compared to a standardized protocol of care using gauze and ointments or no standard protocol of care. These findings suggest the value of exploring the capacity of this standardized protocol of care using best evidence-based dressings to improve clinical and economic wound care outcomes for clients in other settings around the world.
Future considerations. Important factors for successful protocol implementation included getting management buy-in before implementing the NSP and working closely with professional staff to implement the NSP and train wound care staff — key elements of any outcomes management program.³ To chart future outcomes, the client quality-of-life measurement could be improved by using a standardized measure rather than open-ended qualitative assessment of effects of the NSP on client-reported activities of daily life, communication patterns, or affection displays pre- and post-NSP. More consistent use of the Braden Scale would be encouraged to further improve the efficiency of pressure ulcer care by focusing care on the clients’ most salient risk factors for developing pressure ulcers.¹⁵
Another facet of the outcomes management research program that could be improved relates to communication with opinion leaders in different settings in NS and throughout Canada. While the focus of this endeavor was primarily on improving HC wound outcomes in NS, it (unexpectedly) aroused interest of authorities in other settings and other provinces seeking similar client and professional benefits. The success of the NS initiative arose from years of cooperation between Provincial authorities and professionals who served HC clients. The professionals — physicians, enterostomal therapists with wound expertise, advance practice nurses, and other wound care professionals — continued to encounter resistance when trying to convince their HC agency management that quality wound care was a worthy investment. These professionals played a vital role in alerting the DOH Continuing Care Committee to the growing wound care problems that spawned the NSP project. They also remained actively involved during the educational, validation, implementation, and evaluation phases of the project. This cooperation worked well within the Province of NS, enabling HC wound care professionals to implement quality wound care and conserve resources.
Earlier involvement with similar AC professionals (AC constitutes approximately 80% of the healthcare budget of NS) as well as LTC and other branches of wound care policy within Canada is recommended. These professionals may have the potential to benefit more clients earlier in the outcomes management process. Following the steps in Figure 1 and involving multidisciplinary wound care professionals every step of the way is crucial to the success of improving client wound care outcomes as the NSP is considered for implementation in other settings as well as in HC agencies in seven provinces across Canada.

Conclusion

This outcomes management study established the effects of implementing the NSP on clinical, humanistic, and economic wound care outcomes. The purpose was to apply best available published wound care evidence using the only available wound care algorithms with published content validity⁶ for HC to meet clients’ wound care needs. Clinicians worked to implement evidence-based validated protocols of care and reliable, objective outcomes measurement as a standardized NSP and assess the impact of the NSP on client outcomes using the Outcomes Management paradigm for continuous quality improvement in home wound care —not to establish a consensus statement or an opinion-based clinical practice guideline; these are developed according to different paradigms involving available literature plus expert opinion consensus. Although the NSP may fit the broad definition of a guideline as “systematically developed statements to assist practitioner and client decisions about appropriate healthcare for specific clinical circumstances,”²⁰ and meets many published guideline criteria,^20,21 the Province of NS DOH Continuing Care Committee remains focused on using the NSP to improve measured client outcomes by adapting reliable, valid tools for wound assessment and home wound care to its clients’ needs.
The outcomes reported here evolved from use of the NSP protocols of care and procedures that maintain moist wound environments, avoid dry necrosis,²³ address delayed healing¹⁷ and wound trauma and pain,¹⁸ and reduce the infection rates¹⁹ and frequent dressing changes¹⁷ associated with use of gauze or other drying environments. These considerations were coupled with appropriate pressure ulcer offloading and skin care,¹³ diabetic foot ulcer offloading,²⁶ or elastic high compression for venous ulcers.²⁷ By achieving measured outcomes for clients and sharing them with other clinicians, home wound care professionals and their clients throughout the world will have an example to follow to improve wound care practice and outcomes.

Acknowledgment

The authors gratefully acknowledge the NS DOH for supporting the content development for The Evidence-Based Wound Management Protocol© (Copyright NS DOH-Community [now Continuing] Care) and for providing data collection and funds for data management, both in compliance with Canadian client privacy regulations. Special acknowledgment is due Murray Nixon, MD, CCFP, PCFP, CHE, for his leadership as the Provincial Medical Advisor for Continuing Care NS and Chairman of the Clinical Issues Committee of the NS DOH. A very special recognition to the field team for their patience, support, and endurance: Paulette Larade, Marilyn Mac Neil, Marilyn Richards, Isabel Eisenhauer, and Jackie Morrissey. Others deserving gratitude include Evelyn Doyle, RN, and Marguerite Miller, RN, Team Leaders, NS DOH, who championed the field validation of the Wound Assessment /Progress Tool; Ron Fuller Database/IT expert, DOH and Community Care, NS, Canada; the Clinical Nurse Specialist Working Group, who used the tool in the field; and the Cape Breton Hospital Wound Care Team who applied their multidisciplinary expertise to hone the NSP. Portions of this project, including its publication and hosting of the first series of Province-wide educational seminars, were funded by an unrestricted Educational grant from the Canada office of ConvaTec, a Bristol-Myers Squibb Co.