Give wound care a boost with new clinical pathway
January 1, 2000 5 minutes read
Give wound care a boost with new clinical pathway
A careful review of wound care guidelines at a southern California home health agency has led to more consistent documentation and improved care for patients.
Assisted Home Care/Home Hospice of Thousand Oaks, CA, received the coveted accreditation with commendation standing in its last JCAHO survey. And that was before the new guidelines, says Lois Anne Meeker, RN, MSN, CPHQ, vice president for clinical integration and quality.
The agency’s focus on wound care was prompted by frequency — it’s one of the top 10 diagnoses — and by concerns raised during routine chart audits, Meeker says.
"Through a survey, we found inconsistencies in documentation by the staff," she says. "Some people would use a wound care flow sheet, some people wouldn’t. There were some inconsistencies in how often, or with what frequency, people would measure a wound. We found inconsistencies in when they would call in an enterostomal therapist. Some would always call them in right away, some would wait for a month."
Tailoring guidelines to fit local needs
With that information in hand, Assisted Home Care convened a quality improvement team that included Meeker, the agency’s staff development coordinator, the clinical director of nurses, and other physical therapists and nurses.
At key points, the committee also enlisted the help of nutritionists and enterostomal therapists.
As the committee set out to develop its own guidelines, members did a literature search on the Internet and asked for guidelines from other local home care agencies, as well as using a clinical pathway from Gaithersburg, MD-based Aspen Publishers as a reference. As a starting point, they looked at Stage 3 pressure ulcers.
In comparing the different sets of guidelines, the Assisted Home Care group found some characteristics that seemed particular to the agency.
Because some of their wound cases are referred from infectious disease physicians, the wounds can be more acute and complex than a normal wound. As a result of that acuity level, the doctor is less likely to prescribe a normal saline solution and more likely to call for Dakin’s solution or acetic acid.
"We did develop our own guideline based upon the type of patients that we had and also the preference in terms of our own physician base and what they used, which was a little bit different from the clinical standard for pressure ulcers," Meeker says.
The guidelines included a program to implement the Braden scale for assessing wounds to predict the likelihood of pressure ulcers. The use of the scale is a preventative measure with patients who may be prone to such wounds.
The committee developed a clinical pathway for wound treatment and designed a special wound care packet that is given to a nurse whenever she is assigned to a patient with wounds. (See pathway, inserted in this issue.)
It includes a flowchart that outlines treatment during each week of a patient’s care. Also included are guidelines for care and an explanation of the Braden scale.
The guidelines take into account not just wound dressings, but also the physical therapy, patient education, and nutritional aspects of wound care.
Meeker says the committee also standardized the agency’s use of wound care products. As an example, she noted that some staff preferred to use one type of hydrogel dressing while others used a different brand. "We didn’t [call for] different wound care products, but more consistency. We’ve standardized some wound care products in our medical supply cabinet. We have some calcium alginate dressings, some hydrogels, some hydrocolloids that we keep on a consistent basis."
She adds there is always room to add a particular product if a physician expresses a preference for it. Patient education materials focus on preventative issues, including diet, supplemental vitamins, standard precautions, and when to report skin problems.
The agency kicked off the new guidelines with staff inservicing. "The staff was familiar with the pathway mode because we had done one recently on hip replacement," Meeker says.
Since the changes, which were introduced last summer, Meeker says she’s seen marked improvement in documentation.
"What I’ve noticed is more consistent use of a wound care flow sheet to document all areas of the wound, in terms of size and whether there’s a change," she says. "There’s been more consistency in patient education, and the use of the Braden scale, which we hadn’t previously used."
One point in the new pathway that hasn’t been explored as much as Meeker had thought was the use of electrical stimulation or ultrasound in promoting wound healing.
"We found in our literature search that the use of electrical stim or ultrasound for some wounds had been beneficial, but we haven’t found that our physicians are quite open to that," Meeker explains. "We still figure that we’ll suggest it."
Don’t mix the two
Although the changes were not in place at the time of Assisted Home Care’s JCAHO survey, Meeker says the agency had prepared a storyboard outlining how they used the chart audits and the initial improvements to documentation.
The agency’s quality improvement committee is tracking results from the new guidelines, and Meeker keeps the entire staff up to date in the agency’s monthly newsletter and through other lines of communication.
Meeker’s advice to agencies seeking to update their own guidelines? "Don’t do it when OASIS is coming!" she says with a laugh. In seriousness, though, she says trying to undertake such a large project while preparing for OASIS was a stumbling block for her agency.
Other important points to remember before embarking on improvements:
1. Make sure the effort is valued by management. Meeker says she discussed the wound care survey with nursing directors and others on the agency’s clinical operations committee she chairs.
"I bring that information forward, we discuss it, and choose whether it is a priority for us," she says. "So I more or less got their blessing to proceed with the clinical pathway. It was based on our chart audits, based on a survey, and those inconsistencies. I really thought we needed to move forward on this."
2. Invite broad input, but recognize time constraints. Among those the wound care committee consulted in drawing up the guidelines were dietitians, physical therapists, and enterostomal therapists (ETs). That broad base of information was important, but it did create some scheduling problems, Meeker says.
"People who we needed as consultants; people like the ET whose time is very, very valuable, couldn’t make every meeting," she says. "Although their input would have been valuable, I know we wouldn’t have gotten them there at every meeting."
So the committee would give the specialists plenty of advance notice about the meetings at which they were most needed. "To the dietitian, we’d say, We’re going to be talking about dietary issues on X date,’ so that they weren’t always coming every week," Meeker says. "Don’t set yourself up for failure. If you know certain people are not going to be there every time, then you make those allowances within your group."
3. Make the guidelines user-friendly.
The handy wound care packet sent out with a nurse to a patient’s home has been a vital part of the guidelines’ success, Meeker says.
"We hand it out to them upon admission, along with their referral," she says. "They don’t have to go searching for the pathway. I make it very readable for them, and make it clear that it’s only to be used as a guideline. If they vary from it, it’s all coded, so it’s very easy to note that."
• Lois Anne Meeker, Vice President of Clinical Information and Quality, Assisted Home Care/Home Hospice, 468 Pennsfield Place, Suite 100, Thousand Oaks, CA 91360. Telephone: (805) 371-9988.
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