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How a rural home care team implemented best practices to improve wound management

  
https://www.infirmiere-canadienne.com/blogs/ic-contenu/2022/11/07/soins-a-domicile-traitement-des-plaies

Alberta staff recognized need to address inconsistencies in care delivery

By Cheryl Grady & Celine Feagan
November 7, 2022
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The Cochrane Home Care team recognized the need to improve the delivery of wound care after identifying inconsistencies in various practitioners’ knowledge, attitudes, and practices related to wound management.

Cochrane is nestled at the foot of the Rocky Mountains, and the Cochrane Home Care (CHC) team is part of the Calgary Zone within Alberta Health Services (AHS). The CHC team provides services to rural clients in the town of Cochrane and the surrounding area, with a population of more than 40,000. Home care services are based on assessed needs and are mainly delivered in the client’s home or in a clinic setting within the Cochrane Community Health Centre.

Clients with wounds can be seen in the clinic or at home, depending on whether they have transportation and are ambulatory. Wound care is provided by a multidisciplinary team consisting of 10 registered nurses (RNs), five licensed practical nurses (LPNs), two occupational therapists, one physical therapists, one social worker, one therapy assistant, 20 health-care assistants, and two support staff. Professional team members have about 425 active clients on their caseloads. An average of 600 new referrals are received annually.

Delivery of wound care

In 2015, CHC recognized the need to improve the delivery of wound care after identifying inconsistencies in various practitioners’ knowledge, attitudes, and practices related to wound management. The Canadian Home Care Association (2012) reported that a large proportion of daily client interactions involve wound management and prevention. Baich, Wilson, and Cummings (2010) claim that “one third of all home care and community care clients have wound care needs.” Further supporting the high need for wound care in the community, we also know that “50% of care delivered by home care in Canada involves the management of wounds” (McIsaac, 2007).

Drivers for change were the direct care staff who knew there was the potential to improve delivery of patient care but did not know where to start. Although all staff were generalists, many had differing skill levels and knowledge related to delivering patient-centred wound care. By initiating a consistent approach to education and care delivery — such as standardizing use of validated tools and outcome measures, improving product knowledge, and ensuring consistent appointment scheduling — it was hypothesized these measures would translate into improved client outcomes and cost savings for the health-care system.

Education, mentorship, and support

For the proposed practice change to be achievable and sustainable, there were three critical elements: access to education, access to mentorship, and support from management. The initiative was led by a physiotherapist with 15 years of specialization in wound management. She completed the International Interdisciplinary Wound Course (IIWCC) in 2006 and joined the CHC team in 2015, bringing with her a wealth of knowledge and expertise and a willingness to spearhead the project.

Drivers for change were the direct care staff who knew there was the potential to improve delivery of patient care.

The physiotherapist was able to deliver education initially to the RNs and LPNS, and subsequent new staff attended the Calgary-based courses. This education ensured that everyone had the foundational wound knowledge incorporating assessment tools, wound bed management, dressing selection, and documentation methods. The project principles aligned with the Wound Prevention and Management Cycle (WPMC) adopted by Wounds Canada (Orsted et al., 2017).

The initiative has enabled CHC to establish skin and wound education programs for new hires. As each program is completed, staff members progress through more advanced courses.

Transition to bedside practice

Although didactic education is important, its transition to bedside practice is more difficult. The team reinforced classroom teachings at morning report, formal weekly wound rounds, informal desk chats, and bedside collaboration. The physiotherapist sought to engage the staff in the learning process by making it fun and memorable, such as the “Christmas wound Blitzen,” which consisted of daily Advent calendar tasks to engage the staff.

In conjunction with staff mentoring, the team secretaries were instrumental in devising the booking system to standardize appointment times. This ensured staff had time for their clinical wound interventions as well as client support and education, documentation, case management, and communication. Staff education posters and client teaching packages were collated from the existing pool of AHS-approved handouts and made readily available.

The educational packages were available for staff to print for their own learnings and to share with clients. This helped reinforce learnings for both staff and clients to know signs and symptoms of wound management. The secretaries also had packages prepared so staff could save time and just “grab and go” with the information at hand.

Referrals and rounds

Wound referrals were now triaged to the most appropriate RN or LPN, based on the type of wound and case management needs. For example, new clients with lower-extremity wounds were assigned to designated health professionals with experience in lower-limb assessments, whereas a new upper-extremity injury may go to an LPN.

Weekly formalized wound rounds focused on keeping everyone on task with their case management goals, identifying barriers to healing, and monitoring the progress of the client. These rounds progressed over the years from “what should I put on the wound?” to the present tenets of the WPMC.

Assessment, dressings, care pathway, and followup

Conducting the initial assessment
While there is a myriad of wound products available, and our team is fortunate to have access to many of these items within the AHS contract, it is of the utmost importance to understand the wound’s pathology and healability prior to choosing a dressing. By understanding the product form and function, staff became better informed and selected dressings tailored to their client’s goals and wound presentation.

Choosing the dressing
Choosing a proper topical wound dressing and encouraging client and family involvement in dressing changes are important. All dressing supplies were removed from the clinic rooms so that staff would have time to think critically about the specific form and function of the product that would meet the goal of care.

Adhering to the care pathway
Consistent use of the program’s wound care pathway and assessment tools was reinforced to ensure that staff were not changing products unless there was a clinical reason. The supply cart was organized systematically, from cleansing to toppers.

Following up
Whenever possible, clients are followed in the home care wound management clinic by the professional team members; otherwise, they are seen in their home. Seeing clients in the clinic allows the team to be efficient and see more clients rather than travel to outlying areas. Cochrane is a rural town, and travel can be time-consuming. Some clients can live more than an hour away in very remote areas.

Courtesy of Cheryl Grady
The physiotherapist sought to engage the staff in the learning process by making it fun and memorable, such as the “Christmas wound Blitzen,” which consisted of daily Advent calendar tasks to engage the staff.

Supplies and costs

In rural communities, the costs of supplies to clients are covered by AHS. Only enough dressings are supplied to the client for a few dressing changes, as unused supplies cannot be returned to stock. As a result, product quantities, expiry, and waste have been significantly reduced, and homebound clients are not left with an excess of unused supplies. This practice reduces the costs associated with dressing supplies.

The manager reviewed the budget allocated to the team for supplies. In the first year, reducing just the number of products on the supply carts resulted in a small savings to the budget. This outcome was determined by reviewing the actual amount spent divided by the initial starting cost.

The year 2014 was the baseline, showing a 5% reduction in costs. The following year, 2015, there was a further reduction in costs by 10%. By 2016, wound rounds were well established, and their practice had significantly changed, resulting in savings of 40%. The manager would calculate the amount spent each fiscal year divided by the allotted budget to determine whether there were actual savings.

Number of clients

The other factor to consider was the number of clients seen. The CHC program continued to grow, and referrals increased.

According to the 2022 federal Census, Cochrane’s population growth is up by 24.5% over the past five years. By 2020, savings had decreased because the allotted budget for the CHC team also decreased, because the funds could be utilized elsewhere (see Table 1).

Table 1

Year Dressing supplies: % saved (end of fiscal year/allotted budget)
2014 5%
2015 10%
2016 40%
2017 59%
2018 60%
2019 69%
2020 30%

Data collection

CHC has an electronic health record, but staff were not always using it to properly track diagnosis or length of time spent with clients. Staff soon began to realize the power of information to measure outcomes. Staff started to enter diagnosis codes, end-dating them when a wound closed. This practice gave them a rudimentary look at length of healing time from beginning of the referral diagnosis to when a wound had healed.

Although the goal of the CHC project was not just about collecting data, it did provide the team with information such as the type of wounds seen, and the length of time from the start of care to the closure of a wound. The team was interested in this information because it demonstrated that they were making a difference to their client’s care.

Initially, team members discovered that they had to spend a bit more time with clients, but over the course of treatment, time spent would gradually decrease. The number of visits changed, clients took an interest in their care, products were being used more efficiently, and wounds were healing. It would be interesting to set up a research project with sound methodology to collect such information accurately.

Conclusion

The most exciting aspect of this project for CHC was improving outcomes for our clients. After seven years, we are still going strong. From an implementation perspective, it took a solid four years of consistent support, education, reinforcement, and evaluation to get to where we are now, working together as a well-oiled machine.

The information collected provides real-time feedback to our staff, showing how skilful they are becoming at documenting information in an electronic system. Everyone takes pride in their wound knowledge, client interactions, and delivery of care. Having a team “wound champion” has ignited many to pursue additional educational and conference opportunities in hopes of fostering succession planning for the next wound leaders.

It is the individual practitioners’ interest and enthusiasm that drives them to establish their specialty in wound management and further their career goals with opportunities beyond the AHS curriculum. The manager has shared the team’s findings with other teams in the CHC program in Calgary Zone with the understanding that they too can implement similar practice changes to become more efficient and improve outcomes.

Word travels fast in a small town like Cochrane, and there is no better compliment than when local physicians, urgent care and acute care units, pharmacists, and former clients call us to “fix” their patients’, friends’, and families’ wounds!

All of this could not have been achieved without the amazing staff at Cochrane Home Care.

References

Baich, L., Wilson, D., & Cummings, G. (2010). Enterostomal therapy nursing in the Canadian home care sector. Journal of Wound, Ostomy and Continence Nursing, 37(1), 53–64. doi:10.1097/WON.0b013e3181c68d65

Canadian Home Care Association (2012). Evidence-based wound care: Home care perspective. [Based on Baich, Wilson, & Cummings (2010).

McIsaac, C. (2007). Closing the gap between evidence and action: How outcome measurement informs the implementation of evidence-based wound care practice in home care. Wounds 19(11), 299–309.

Orsted, H.L., Keast, D.H., Forest-Lalande, L., Kuhnke, J.L., O’Sullivan-Drombolis, D., Jin, S., et al. (2017). Best practice recommendations for the prevention and management of wounds. In: Foundations of Best Practice for Skin and Wound Management. A supplement of Wound Care Canada. Retrieved from www.woundscanada.ca/docman/public/health-care-professional/165-wc-bpr-prevention-and-management-of-wounds/file

Statistics Canada Federal Census. (2022). Cochrane population. Retrieved from https://www.cochrane.ab/Civic Alerts

World Population Review. (2022). Cochrane population 2022. (From Canadian Federal Census). Retrieved from https://worldpopulationreview.com/world-cities/cochrane-population


Cheryl Grady, RN, MN, was the former area manager in Alberta Health Services’ seniors, palliative, and continuing care program.
Celine Feagan, PT, BScPT, is a physical therapist in Alberta Health Services’ Cochrane integrated home care program.
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