Cath Lab Digest

C hronic wounds increase home care (HC) costs, stressing an already overburdened system. More severe wounds are significantly more expensive to manage than less severe ones.¹ In addition to these recognized economic costs, clients are burdened with the pain, suffering, and loss of independence commonly associated with chronic ulcers.²

The Clinical Issues Committee of the Nova Scotia (NS) Department of Health (DOH) recognized increasing challenges within its province as a result of a growing nursing shortage, an aging population, and budgetary restraints. To address these challenges and proactively reduce the growing burden of wound care in the home, the Clinical Issues Committee, a multidisciplinary team of HC professionals, and a team of HC nurses decided to address this issue. The team applied the principles of outcomes management³ — identifying opportunities for improvement, developing interventions, implementing practice standards, and testing outcomes achievement to assess, define, and improve home wound care outcomes in the Province of NS.

Methods

Study design overview. The Outcomes Management Model (see Figure 1) was used as the paradigm for a program of research using four phases to improve outcomes of care. In Phase I, the NS DOH, Continuing Care (Clinical Issues) Committee (the Committee), defined the scope and nature of the chronic ulcer challenges facing HC professionals in NS using a descriptive retrospective chart review. During Phase II, a multidisciplinary team at Cape Breton University conducted a literature search to identify evidence-based wound care practices, which were subsequently incorporated into a comprehensive protocol of wound care, the Nova Scotia Protocol (NSP). The NSP included validated, reliable client⁴ and wound⁵ assessment tools for wounds encountered in home health care as well as assessment-based validated wound care protocols⁶ adapted for the Province of NS home health care agencies. In Phase III, the NSP was disseminated to all 20 NS HC nursing offices with programs to educate professionals in its use. A prospective, quasi-experimental, descriptive study design was used to measure the effects of the NSP in Phase IV of the program. Specifically, wound care outcomes before and after implementing the NSP were obtained.

Phase I. Assessing the situation: population wound prevalence, care, and outcomes. To assess the NS HC baselines for wound prevalence, practices, and outcomes, the Committee commissioned all administrators and staff from the 20 nursing offices in NS to gather wound prevalence data on the total home care population (N = 548) during a 2-week period in November 1999. One resource nurse at each participating agency trained participating HC nurses to assess wound prevalence, using the standardized Provincial Wound Care Data Collection©⁷ tool. This data collection instrument contains the following variables: office identification (agency/branch/region of NS); date; client identification information; wound etiology and location; length of time client was on wound care caseload; dressing change frequency; type of treatment (1 = normal saline/gauze dressing; 2 = moist wound healing (eg, using hydrocolloid dressing; 3 = compression therapy; 4 = wound irrigation; and 5 = other); level of care provider (RN or LPN); ratio of RN to LPN visits; presence/absence of client self care; potential for client self care; and comments.

To explore the quality and consistency of recent baseline wound care practices for the Phase I situational assessment, several case managers also conducted a retrospective chart review of HC practices and outcomes for selected clients with wounds that had consistently recorded data from 1995 to 1999.