Quality Indicators in Wound Care

Wound care is an interdisciplinary area of medicine that relies on the collaborative expertise of physicians, nurses, nutritionists, physical therapists and social workers. Moving forward, healthcare professionals will need to ensure that all patients with wounds are offered consistently high-quality care. The Centers for Medicare & Medicaid Services (CMS) began to display new quality measures in early 2012. The aim of these guidelines is to increase the incentive for facilities to strengthen their wound care programs.

Members of the wound care program at Baylor Specialty Hospital in Dallas, Texas, know that effective wound care is dependent on many aspects of the care process. The facility’s multidisciplinary team provides an advanced healing environment for adult patients with acute, chronic or complicated wounds that result from diabetes, pressure, peripheral vascular disease, infection and complications of trauma or surgery.

Led by the medical director of wound care, the team consists of an enterostomal therapy nurse, a physician assistant, registered nurses and physical therapists. Team members use advanced technology and medications to offer an aggressive and holistic wound care program. Patients receive individualized care designed to restore their health and physical capabilities.

The team’s physician and PA address systemic medical conditions and medications that lead to the creation of wounds or poor healing, while the physical therapists detect aggravating or inciting causes such as poor mobility, inability to offload or ill-fitting shoes.

Treatment Plans

The Baylor Specialty Wound Care program covers care for patients at Baylor Specialty Hospital, a 52-bed long-term acute care hospital, and Baylor Institute for Rehabilitation, a free standing 90-bed rehabilitation hospital. The team sees up to 25 patients in each hospital depending on the hospital census.

“Our program is founded on evidence-based standardized wound care protocols established for general floor nursing,” shares Jean M. de Leon, MD, Wound Care Associates of HealthTexas, and medical director of wound care at Baylor Specialty Hospital. The program at Baylor Specialty Hospital was first established in 1998 and is held to strict standards of care.

The protocols adopted by the hospital direct the timing of wound care consultations by de Leon and her team. The wound care team typically sees all open post surgical wounds, deep-tissue injury wounds, Stage III and IV wounds and those they are unable to stage. The team also treats venous stasis ulcers, diabetic foot wounds and arterial wounds.

Upon admission, the floor nurses complete a patient assessment that includes a digital photo and measurements of the wound. De Leon and her team meet with the patient to determine a treatment strategy.

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Physical therapist Michelle Fudge prepares platelet-rich plasma gel for topical wound application on a patient at Baylor Specialty Hospital.

The team members make recommendations for strategy changes, alert the physician of declines, and perform modalities or debridement of the wound as needed.

While receiving wound care in the long-term acute care and rehab settings, patients continue to participate in all appropriate therapies. Physical therapists work closely with the nurses on the wound care team to provide initial assessments, dressing changes and re-evaluations.

The physical therapists at Baylor Specialty Hospital use negative pressure wound therapy, contact and non-contact ultrasound, radiofrequency and platelet rich plasma gel. The wound care team is proficient in excisional debridement with scissors, forceps, scalpel or ultrasound. The clinicians are trained to control bleeding with pressure, silver nitrate sticks or battery operated electric cautery.

“The PTs bring an additional focus of function to the treatment strategy,” shared Michelle Fudge, MSPT, physical therapist III, wound care, Baylor Specialty Hospital. “Dressings and modalities must be applied to patients so that function and mobility are not hindered during regular therapy sessions.”

When the negative pressure wound therapy machine is used with a patient, for example, there are some potential dangers to the patient including a tube that hangs from the machine. “Knowing how to work with patients so they don’t trip on the tubing or let it get in the way during their therapy sessions is important,” Fudge observed.

As a PT specializing in wound care, Fudge is available to communicate with clinicians who are working with the patients on other aspects of their recovery. “I insist on having open communication with the treating PTs,” Fudge explained. “I meet with them to discuss the cases so they are comfortable with the approach for each patient. If it helps to show them the patient’s wound, then I will.”

Another example Fudge shared with ADVANCE is that the tendons in a patient with a foot wound are more fragile, and therefore, specific limitations need to be followed.

The facility uses dressings and modalities designed to maintain a moist wound bed and decrease the number of painful dressing changes. Excisional debridement of unhealthy tissue can be provided as needed with each dressing change to maximize healing rate. The facility also relies on the use of advanced wound dressings such as bio-engineered tissue products, specialty support surfaces and modalities.

Because the wounds are typically complex in the long-term care hospital, dressing changes are often performed by the PT, nurse and physician together.

According to de Leon, having a multidisciplinary team that functions very closely with the physician or physician assistant allows for very timely treatment with adequate pain medications for the patient, including additional medications in the treatment strategy such as antibiotics and antiseptic rinses. Having PTs on staff ensures timely orders for equipment recommendations such as bracing, splints, offloading devices, cushions and wheelchairs.

“Having a PT who is aware of the wound and the treatment strategy provides valuable insight into the equipment needs and better advice on activity restrictions,” shared de Leon.

Educating the Patient and Family

According to de Leon, education of the patient, family and staff is imperative. Education begins during the assessment with pictures of all wounds being shown to the patient and present family members. Throughout the patient’s stay, staff members have easy access to pictures each week in the patient’s chart.

“We educate from the moment we enter the room for the first time to the day they leave our facility,” explained de Leon. The patients need to know how and why they got the wound, what it looks like, the timeframe that it will take for it to get better, what they will need to do to go home, and the purpose and mechanism of the dressings.

The team teaches patients about the risks involved if they don’t follow instructions, for example, if they don’t offload and if they continue smoking and eating poorly. “Each of these factors affects their progress and the healing of the wound,” de Leon stated.

De Leon is confident that once patients are discharged, they are prepared for the next steps and what to expect because the team has addressed every possible scenario and answered all questions.

In the rehab setting, many patients discharge home and continue with outpatient therapy. In these cases, family members and patients are educated on performing their own dressing changes at home.

Additionally, patients are educated on the importance of nutrition. Upon admission, each patient who is identified as having a wound is automatically evaluated by nutritional services. Tests to measure Prealbumin and C-reactive protein levels are given during admission and on an as-needed basis to monitor progress.

Many wound patients are hindered by medical factors, such as diabetes, poor blood flow, poor nutrition due to decreased appetite or inability to swallow, and by generalized weakness which limits them to the bed or the chair for extended time periods. Each of these comorbidities-and more-make healing wounds a challenge.

“The entire patient must be focused on in order to heal wounds,” explained Fudge. “In a perfect world, all patients would have proper nutrition, no medical comorbidities, and be functionally independent.”

While this can be very challenging for clinicians, there is a significant amount of gratification when these difficult patients improve, Fudge told ADVANCE.

On the Horizon

According to de Leon, the team is constantly evaluating new technology and seeking education on current research. The team presents and attends at least one national meeting each year and attends different lecture tracks in order to bring back the most information to the team.

Wound care has several areas of growth, reported de Leon. From a technology standpoint, the use of stem cells and growth factors to stimulate wounds is constantly evolving.

“More attention is now being aimed at modalities that affect the wound healing process at the cellular level whether to remove proteases that inhibit healing or to stimulate the fibroblast cell and up-regulates the cellular functions to produce more growth factors and collagen,” she said.

Assessment of blood flow and deep-tissue injury is another area that continues to grow. “More ultrasound type devices are emerging to help the clinician identify early damage to deep tissue or to allow more accurate bedside or clinic setting evaluations of blood flow,” said de Leon.

Industry experts are beginning to recognize how the microclimate between the skin and surface of beds or cushions can affect the prevention and treatment of pressure ulcers, de Leon shared.

Finally, and perhaps most importantly, de Leon indicated that there is increasing interest in wound care as a quality indicator by CMS. “Health care settings have to take on more responsibility for documenting wounds, not creating new wounds, and for not allowing current wounds to worsen,” she said.

According to de Leon, CMS is supporting measures set by the National Quality Forum. One of the new quality indicators will measure the number of new Stage II, III and IV pressure ulcers created in long-term acute care and acute rehabilitation facilities. Worsening of pressure ulcers during a patient’s stay will also be measured.

Ultimately, the quality indicators will have financial implications for all healthcare settings. Accurate staging of the wounds and appropriate and effective treatment will be important for all wound care professionals.

Rebecca Mayer is senior regional editor of ADVANCE and can be reached at rmayer@advanceweb.com.

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