Wound Management Model Redesign Journey
Hunter New England Area Health Service
Abstract
In 2005, 2006 and 2007 the Greater Newcastle Cluster (GNC) conducted a point prevalence study across six community health centres. Data collected investigated the number of clients with a wound, the type and healing rate. Changes in wound care practices and service delivery were implemented, resulting in improved health outcomes for clients with a non healing wound rate falling from 44 per cent to 11 per cent.
The 2007 study also identified the co-morbidities which delayed or prevented the healing of wounds. Further changes have been implemented identifying clients with high-risk delay wound healing and initiating earlier proactive interventions with referral to specialised care. While wound care referrals have increased, consumable and staff cost per patient have decreased significantly improving productivity.
Download the presentation given at the 2008 NSW Health Expo (1.2 MB).
Download the audio file of the presentation given at the 2008 NSW Health Expo (11.5 MB).
Presented by Margo Asimus.
Aim
Implement an evidence based wound management model across community health sites in Greater Newcastle Cluster which identifies high-risk clients and further reduces the number of clients suffering from chronic wounds.
Nature of the Problem
A review of wound management practices across six community health centres in 2005 identified a number of clients with chronic wounds. Clients with wounds which were delayed in healing can experience pain, infection and associated anxiety which results in social isolation due to wound odour and excessive exudate. These clients are regularly prescribed antibiotics and endure the inconvenience of frequent dressings in an attempt to avoid repeated hospitalisations. Chronic wounds commonly affect the elderly with existing co-morbidities, further complicating clients with chronic disease and increasing the burden on a diminishing health dollar.
Extent of the Problem
In 2006, a wound management model had been introduced in all six centres. This followed a point prevalence study in 2005 which identified that 44 per cent of clients assessed had a wound which was not healed within 12 months. Following practice changes this was reduced to 15 per cent when the study was repeated a year later.
Despite the reduction of clients with chronic non-healing wounds a large percentage of the community health resources were being used to manage clients with these chronic wounds. A number of the clients which remained non-healing were observed to have similar factors. It was anticipated that if earlier detection of client factors which contributed to delay in wound healing could be identified at the first assessment, improvement to overall outcomes may result.
Analyses of the data collated from the cross sectional study formed the evidence to create a criteria for high-risk client referral.
Strategic Importance
The NSW State Health Plan has identified early intervention and better access to community-based health services will reduce avoidable hospital admissions. The wound management model has developed criteria which identifies high-risk clients earlier and directs them to specialized services. Six wound management clinics including service by a Wound Management Nurse Practitioner were established. These promote high-risk early diagnosis, intervention and hospital avoidance in a client population which due to chronic disease complicates their wound healing.
The project has identified wound management has a high community profile with 60-70 per cent of clients requiring wound care.
Planning and Implementing Solutions
Following the 2005-2006 point prevalence studies and objectives based on the research were established. Clinical practice changes were implemented and improvement strategies with time lines determined.
2005 Objective
Collect baseline data to instigate clinical change and measure improved wound-healing outcomes attained from introducing evidence base practice.
Practice Changes
- Enhance clinical education and staff mentoring opportunities within the wound clinics.
- Standardised practice through the introduction of best practice algorithms and consistent product usage
- Purchase equipment and adjunct therapies to promote wound healing
- Introduce wound measurement system and digital photography consultation
2006 Objective
Reduce the number of clients with wounds open longer than 12 months by 25 per cent from the 2005 study. Assess client’s wounds as healable or non-healable and provide most appropriate care.
Practice Changes
- Clarification in the classification of clients with healing and non-healing wounds. Development of a non-healing algorithm to guide practice.
- Collaborate with equipment service to provide maintenance wound products to clients with non-healing wounds.
- Initiate regular teleconferencing wound education across the six community centres
2007
Wound management model project team was selected and monthly meetings commenced.
Objective
- Identify high-risk client for delayed healing potential on admission to community nursing service and refer to Nurse Practitioner.
- increase the healing outcomes in the high-risk group with prompt proactive interventions.
Activities
- Improved clinical review process
- Cross sectional study
- Analyse data
- Develop early referral criteria of high risk client group
Practice Changes
- Nurse Practitioner facilitates clinical review process of current clients, referring to the best practice algorithms
- At first assessment community nurses are guided by the high risk referral criteria
- Nurse Practitioner assesses clients in high-risk clinics
- Advanced wound technologies and practices are implemented to increase the healing rates.
Outcomes and Evaluation
Development of wound management clinics, best practice algorithms which guide management of clients with wounds enhanced clinical education and mentoring for community nurses.(Figure 1.)
The point prevalence study in 2006, indicated a reduction in the number of clients with a wound that had not healed within 12 months had reduced from 44 to 15 per cent. (Figure 2.)
The Nurse Practitioner reinforced a clinical review process that emphasized the best practice algorithm. In 2007, clients with non-healing wounds reduced again to a low 11 per cent.
Figure 1. Healing Rates for Generalist Community Nursing Service Clients with a wound in the Greater Newcastle Cluster
Figure 2. Percentage of GNC Community Health Clients with a non-healing wound greater than 12 months
The 2007 study provided evidence of risk factors which have the potential to delay wound healing and high-risk wound clients are now being referred to the Nurse Practitioner for proactive interventions. Innovative wound treatments will be utilised early to improve the wound healing outcomes in this group to reduce wound chronicity even further in 2008. (Figure 3.)
This improvement has enhanced the quality of life for the client and the morbidity associated with lower limb ulceration but has a dramatic impact on health expenditure. Analysis of expenditure on consumables associated with wound care has demonstrated decreased costs despite increasing referrals, which have been absorbed without any increase in staffing due to improved healing times and better product usage resulting in fewer dressing change requirements.
Figure 3. Wound referrals, percentage of wound related visits, consumables |
||||
| 2004-2005 | 2005-2006 | 2006-2007 | 2007-2008 | |
| Wound Referrals | 3198 | 3380 | 3420 | 3624 |
| % Wound Related Visits | 72.48% | 77.19% | 73.28% | 61.83% |
| Consumables | $260,355 | $270,478 | $264,725 | $262,634 |
Sustaining Change
The six community nursing teams involved in the study now routinely use the established wound algorithm and referral process with all clients with wounds. Education of nursing staff and referral criteria to identify clients at risk of reduced wound healing during the initial assessment will ensure early referral to wound clinics. A weekly clinical review process reinforces routine practice where nurses are able to review the progress of clients with wounds in an environment supported by the Nurse Practitioner. The wound management model rollout to other community health sites within HNE Health region also supports the sustainability of this project.
Future Scope
A wound management model has been refined to proactively treat clients with wounds at high risk of non-healing. This model can be introduced into all community health centres in NSW and has the ability to be modified to direct best practice within acute environments in the future.
HNE Health plans for this model include:
- Establish procedural clinics for community nurses to attend technical wound management procedures
- Evaluation of the healing rates for the high risk clients
- Provision of online wound management education
- Rolling out the wound management model into other HNEH community nursing, rehabilitation and podiatry teams.
References
- Berquist. S & Frantz.R. Pressure Ulcers in Community-Based Older Adults Receiviing Home Health Care Prevalence, Incidence and Associated Risk Factors. Advances in Woundcare. 1999 Sep.
- Carville K.& Lewin G. Caring in the Community: A Wound Prevalence Survey. Primary Intention. 1998 June;6(2):54-62
- Carville K.& Smith J. A report on the effectiveness of comprehensive wound assessment and documentation in the community. Primary Intention. 2004 Feb;12(1): pp 41-4, 46-9.
- Clarke-Moloney M. Keane N. Kavanagh E. An exploration of current leg ulcer management practices in an Irish community setting. Journal of Wound Care. 2006 Oct 15(9):p 407-10.
- NSW State Health Plan
http://www.health.nsw.gov.au/pubs/2007/pdf/state_health_plan.pdf - Piper. B, Templin.T, & Jacox A. Wound Prevalence Types, and Treatments in Home Care. Advances in Woundcare. 1999 April, 12,3 p117
- Walker N. Rodgers A. Birchall N. Norton R. MacMahon S. The occurrence of leg ulcers in Auckland: results of a population-based study. New Zealand Medical Journal. 2002 Apr 115(1151):159-62
- Walker NK. Vandal AC. Holden JK. Rodgers A. Birchall N. Norton R. Triggs CM. MacMahon S. Does capture-recapture analysis provide more reliable estimates of the incidence and prevalence of leg ulcers in the community?. Australian & New Zealand Journal of Public Health. 2002 Oct.26(5) p451-5,
- Wong I. Measuring the incidence of lower limb ulceration in the Chinese population in Hong Kong. Journal of Wound Care. 2002 Nov; 11(10)pp 377-9.
Project Team
Margo Asimus : Project Leader, Nurse Practitioner-Wound Management, Greater Newcastle Cluster.
Team Members
- Helen Kendall: Senior Manager Community Health & Director of Community Nursing, Greater Newcastle Cluster
- Sue Ayre : Manager, Practice Support Unit, Greater Newcastle Cluster, Primary & Community Networks
- Ron Hicks : Statistician, Greater Newcastle Cluster
- Jenny Simpson : Project Co-ordinator, Greater Newcastle Cluster
- Belinda Stewart : Executive Assistant to Senior Manager, Greater Newcastle Cluster
Contact
Nurse Practitioner Wound Management, Greater Newcastle Cluster
Hunter New England Area Health Service
Phone: 02 4924 6100
