Wounds affect more than those afflicted. How well a skilled nursing facility prevents or treats pressure ulcers is a fundamental indicator of quality clinical care. If not addressed, this issue causes tremendous stress for both patients and family members.

 

A select group of skilled nursing centers in New Jersey and Pennsylvania has come together to rethink the way it approaches building a true interdisciplinary team around wound care.

 

The initial driver for meeting was the high utilization of wound care products in the group’s regional division.

 

“This particular cluster of centers has one of the highest rates of patients admitted with wounds within Genesis, although their participation does not imply bad care in any way,” says Jeanine Maguire, senior director of skin integrity and wound management for Genesis HealthCare, Kennett Square, Pa.

 

“These buildings have the most experience in wound care and may offer the best leadership ability and knowledge. We knew that we had something to learn from this group.”

The group, comprised of operations and clinical leaders, wound specialists, center-based directors of nursing and nurse practitioners, therapists, and center-based and regional food and nutrition managers, held its first meeting in late 2014 in Trenton, N.J. Its goals: Take a fresh look at how all center inter-professionals collaborate, standardize product utilization, and reduce spending, all while ensuring quality clinical care.

“Our individual disciplines talk about wound care and product selection but never as a truly complete wound team,” says Flora Petillo, vice president of clinical practice for Genesis Physician Services. “We never hear the message at the same time, so we weren’t developing a vision statement as a team for how to re-educate clinicians and develop a plan for improving outcomes.”

The meeting included a review of standard wound care products, as well as discussion of debridement options, with the goal of standardizing usage of both.

“A lot of wound care is driven by personal preference for certain products. Often they are not the best, just the most familiar,” says Maguire. “We needed to bring people together to educate staff, while at the same time breaking some old habits. If the center leadership does not support and promote the same products and approach as the nurse practitioner or unit manager, it doesn’t promote team cohesiveness. We needed to say, ‘This is the way our organization does it.’”

The day itself was a model of collaboration, as each participating nursing center’s staff met as a team to brainstorm, starting with a statement of their current approach and then setting a goal for where they would like to be. For example, centers may only be using one method of debridement out of habit and comfort, may not be using standard tracking tools to measure outcomes, or may not recognize the benefit of an interdisciplinary approach to wound care.

Following the centers’ team meetings, the whole group convened to compare notes. The results were
illuminating.

“There were many ‘aha!’ moments,” says Maguire. “Clinicians were beginning to put the picture together to make choices that were the best clinically for the patient, rather than sticking with their habitual practices. Additionally, having rebab and nurse practitioners attend gave the team the opportunity to come together and brainstorm ideas of how this could happen in their center.”

Adds Petillo, “They were already brainstorming before the meeting happened, but we saw great team collaboration.”

By the end of the day, every center had a goal to improve communication by having nursing, rehab, and the nurse practitioner conduct rounds together, says Maguire.

Kelly Repka, PT, Genesis rehab regional clinical director, says that the meeting was a unique opportunity for all of the pilot centers to get together and assess their wound care programs, with an eye to establishing protocols that can be replicated throughout the company.

“We meet as center teams but not with other centers, normally,” she says, adding that the rehab group plays a big role in wound care.

“Rehab teams have become more involved in both wound rounds and wound care. They are getting more comfortable with wound care. We realized that we needed to provide more education for them. It really opened our eyes.”

To support ongoing process improvement, the Genesis Skin Integrity and Wound Management program is rolling out new and revised skin and wound guidelines. Selected pilot centers will be receiving a live demonstration of a Closed Pulse Irrigation treatment, a type of debridement from vendors that use pressurized saline directed at the wound bed to promote mechanical debridement. Additionally, half of the group will evaluate a new Food and Drug Administration (FDA)–approved wound debriding wash.

In addition to rethinking how the various disciplines collaborate, the group’s other desired outcome is to have their nurse practioners and physician assistants more directly involved in center-based wound programs.

As these two specialists become more integrated with their nursing, rehab, and dietary team members, their expertise will grow even more valuable, says Petillo.

The meeting members recently participated in an update call to report progress toward their self-set goals and any other findings. Most of the centers reported improvement in wound outcomes, improvement with use of wound care standard guidelines, and a better approach to debridement options.

Centers that participated in the trial of the new FDA-approved wound wash had overwhelming success, leading to a new approved product for all centers to use.

A great example of the success of the interdisciplinary approach was noted by Director of Nursing Edna Lynn Esconde and Director of Rehab Lydia Spevack, Waterview Center, Cedar Grove, N.J. They reported two major pieces to improve wound rounds: the ongoing attendance of a physical therapist or therapy assistant and routine attendance by the unit manager.

Another major finding was incorporating the nurse practitioner into the routine skin assessment of new admissions, potentially improving accuracy in determining any wound issues, wound type, and pressure ulcer staging.

Post-acute settings strive to improve the fundamental indicator of quality of clinical care: skin. When not addressed successfully, stress for patients, family members, and center staff is high, sometimes resulting in survey issues and litigation.

As demonstrated by this core group of centers, guideline standardization, interdisciplinary group education, and a center-level interdisciplinary approach are key factors in improving wound prevention and management.

Ultimately these actions improve the cost associated with negative outcomes and non-structured approaches to product use, Genesis project leaders concluded.