Don't let wound care scar your case management program
Early identification, daily monitoring keys to healing
Pressure ulcers are a common problem that can lengthen a patient's stay and add unnecessary treatment costs. Yet many hospital case management programs haven't addressed this problem proactively because the extent of the problem isn't always immediately obvious.
For example, what was thought to be an isolated case of a pressure ulcer led to the discovery that the problem was occurring more frequently and was more costly than caregivers ever realized at Fairfield Medical Center in Lancaster, OH. "The problem of mushy heels [a partial loss of epidermal thickness] was first brought to my attention in May 1995. When we started going through the charts, we found over 30 cases of the same type of problem," says Doris Moffat, MBA, CNAA, RN, vice president of nursing at the 195-bed facility.
A multidisciplinary effort to address the problem led to the creation of a risk assessment tool and a critical pathway for monitoring skin care. Moffat and the pathway development team incorporated the pressure ulcer staging guidelines from the Agency for Health Care Policy and Research (AHCPR) into the pathway to categorize wounds. Moffat can find no direct reasons for the problem, but says the assessment and pathway should prevent it from occurring again.
In fact, since December 1995, no cases of mushy heels have been reported at Fairfield, except for two cases where patients were transferred from another hospital and admitted with that problem. The pathway is part of Fairfield's Skin and Tissue Observation Project, which was developed with help from a medical supply company and a hospital bed manufacturer. (To see how Fairfield monitors patients for wound care, see the related story, p. 36.)
Pressure ulcers are surprisingly common. The federal AHCPR, located in Rockville, MD, estimates that one in 10 hospital patients and a quarter of all nursing home patients have pressure ulcers. AHCPR researchers estimate that 65% of elderly patients admitted to the hospital with hip fractures will likely develop pressure ulcers. As a result, the AHCPR released treatment guidelines in December 1994 to accompany guidelines first published in 1992 on preventing pressure ulcers.1
Baptist Medical Center in Little Rock, AR, took a similar approach to addressing pressure ulcer problems by first developing critical paths. But Baptist now is turning to outside experts to help with outcomes management. Using the services of Bates-Jensen & Associates, a Seattle-based networking and benchmarking firm, and managing patients on its two existing wound care pathways, hospital caregivers are working to improve outcomes, reduce costs, and justify the expansion of an existing outpatient wound care center.
"We are just now starting this program. One of the things we are looking at is cost of supplies and cost of care. The hard part is figuring out what we are paying for in supplies," explains Cindy Kitchens, RN, BSN, CETN, an enteral therapy (ET) nurse for the 736-bed facility.
To help identify the costs, Kitchens enlisted the help of the central supply department. Staff in that department are reviewing what "we are spending for wound care supplies. Right now, I am just trying to collect data and get it into the computer so that we can monitor that area," explains Kitchens.
The majority of the hospital's wound care patients have chronic pressure ulcer problems and are admitted for that condition. Their care typically is monitored by ET nurses and plastic surgeons, says Kitchens. The ET nurses, along with the plastic surgeons, conduct rounds on wound care patients and collect data on a special documentation form. Included on this form is a wound assessment that tracks patient status by determining the stage of the patient's wound.
Data are collected weekly and entered into a database program, purchased from Bates-Jensen. The data are then sent to Bates-Jensen for analysis. "They send us monthly and yearly data that tells us what we are doing compared to what everybody else is doing -- such as costs, which products are working better than others, and how much each facility is spending on total wound care," explains Kitchens.
Evolution into outcomes managers
Because the program is still new, case managers are not heavily involved in collecting the data. As case managers expand their role toward managing patients beyond the hospital walls, however, they'll take on more responsibility for data collection, Kitchens predicts.
"What we are envisioning is the case managers' role moving towards an outcomes managers' role. They will be using information from this database to work with the clinicians and to assist in the full continuum management," adds Jim Novak, RN, BS, clinical systems development coordinator.
"We are seeing case coordinators getting very broad [in job descriptions], and data being the basis to establish interdisciplinary consensus. That is the focus of where we are headed," says Novak.
Other patient groups already are being incorporated into the full continuum management model. For example, Baptist has a project in development for congestive heart failure patients. The home health nurses and the case managers will work together in managing the patients.
Multiple paths help manage wound care
To help in the data gathering process for Bates-Jenson, the hospital is using its two wound care pathways -- a well care path, called pathway A; and a skin graft path, called pathway B. Pathway A is used for patients needing to be debrided, while pathway B is used strictly for those patients undergoing skin grafts, Kitchens explains.
Several factors have helped Baptist reduces its length of stay (LOS) for wound care patients from an average of 12 days to an average of three to four. First, patients are transferred to the hospital's wound care unit immediately following surgery, where case managers track their care. Another contributing factor to the LOS reduction was a new policy providing for alternative care for patients needing additional care beyond the recommended five-day LOS.
For example, if wounds aren't clean by the fifth day and need more debridement or more care, the physician determines if patients need an alternative care setting to complete their care. Case managers then begin searching for an appropriate alternative site, such as a nursing home or home health care.
Otherwise the LOS could creep back up to 12 days or more, Kitchens says. Once this policy was put in place, LOS quickly declined to six days before reaching its current rate. One exception to the new policy is if a physician requests a skin graft. Skin grafts must be done by the fifth or sixth day of hospitalization, provided the patient does not need additional wound care, Kitchens explains. Skin grafts conducted after the fifth or sixth day could add extra days to the overall LOS.
All disciplines document on the pathways. Variance documentation is built into the pathway but is not yet captured in a database, Kitchens says. "The [variance information] is profiled in the case management department and is then presented to an interdisciplinary team and the medical staff sections. What we are finding is the medical staff is becoming extremely interested in outcomes data. They are realizing that it's significant in terms of their managed care negotiations," Novak explains.
Although the hospital does not yet have results back from Bates-Jenson, Kitchens says he hopes the findings will help the hospital provide more efficient care across the continuum and give the hospital a good opportunity to market its outcomes to managed care organizations.
"We hope [the results] will help us achieve better outcomes for our patients, which of course is what managed care is looking at," Kitchens says. "We also hope it will help us achieve better outcomes in terms of managing the patient from home and other places besides an acute care setting."
[Editor's note: For more information on the AHCPR guidelines or to order a copy of the pressure ulcer treatment guidelines, which cost $6 per copy, contact: AHCPR Publications Clearinghouse, P.O. Box 8547, Silver Spring, MD 20907. Telephone: (800) 358-9295.
For more information about Bates-Jensen & Associates services, write: 119 First Ave. S., Suite 110, Seattle, WA 98104. Telephone: (800) 893-1887.]
Reference
1. Bergstrom N, Bennett M, Carlson C. Treatment of Pressure Ulcers: Clinical Practice Guideline No. 15. Rockville, MD: Agency for Health Care Policy and Research; Pub. No. 95-0652; December 1994. *
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content