Successful Outcomes with the h.e.a.l. Program
The positive outcomes of standardized, evidence-based wound care protocols have been well documented.1–3 Beginning in March 2003, the Community Care Access Centre of Wellington-Dufferin (CCACWD) implemented the Healing Excellence with Advanced Learning (h.e.a.l.) approach for the provision of home-based wound care in the geographically mixed (urban/rural) counties of Wellington and Dufferin, Ontario, Canada. The process used to assess wounds, wound care, and provider needs; the rationale for selecting the h.e.a.l. program; and implementation challenges and preliminary outcomes are described.
What is the CCACWD?
The CCACWD coordinates and provides professional and support services to clients in schools, the home setting, and long-term care homes for inhabitants of two counties (Wellington and Dufferin) in south-central Ontario. The Community Care Access Centres (42 in the Province of Ontario) are not-for-profit organizations funded by the Ontario Ministry of Health and Long-Term Care. Each Community Care Access Centre (CCAC) is governed by an appointed Board of Directors and overseen by an Executive Director assisted by Directors, Managers, Case Managers, and support staff who provide access to and coordination of Ministry-funded services.
Community-based home care is provided by professional and support service staff on a contractual basis. The CCAC contracts with agencies that provide the client care. Registered nurses and registered practical nurses deliver nursing services. Between 4,000 and 5,000 clients receive service in the two counties; in 2005, of the 988 nursing care clients, 200 received wound care. The Ontario Ministry of Health and Long-Term Care funds the project — the CCAC provides the professional services and supplies required for wound care at no direct cost to the client. The geographic area covered is large, requiring driving times of up to 2 hours to reach rural client homes.
Why Was a Standardized Approach to Wound Care Needed?
When the author, an experienced hospital and community nurse, moved into CCACWD Management in 2001, she became increasingly aware of a number of issues facing clients, nurses, and healthcare administrators. As she addressed the challenges of wound care, including the concerns of front-line nurses and the nursing budget, it became evident that systems level improvements were needed. A statistical review indicated that the highest individual nursing expenditure was wound care provision. Three areas of concern emerged with regard to wound care: 1) knowledge deficits, 2) lack of standardization, and 3) no financial or clinical measurement of wound care interventions outcomes.
Knowledge deficits. Knowledge deficits primarily were related to a lack of evidence-based wound care for community-based clients. Access to expert advice from an enterostomal therapist (ET) was available for complex wounds but support for the development of standard general nursing expertise related to managing “regular” acute and chronic wounds in the community was not available.
Setting goals for care. The knowledge deficits for nonspecialized nurses encompassed several areas related to setting goals for wound care. First, nurses erroneously anticipated that all wounds would heal regardless of their etiology or the overall condition of the patient. Nurses became frustrated when wounds failed to heal, even though the chances of healing were slim. They have since learned to accept that wounds are multidimensional in origin. Treatment is not focused solely on the wound but also must include interventions related to the individual patient’s condition, including age,4 insufficient oxygenation, excessive and sustained pressure, underlying disease processes, curative therapies, nutritional status, stress,3 presence of bacteria,6 and whether a standardized type of wound care practice is offered to the client.1 Hence, not all wounds can be expected to heal.
Second, for wounds where complete healing was a reasonable goal of care, nurses lacked a comprehensive understanding of the phases of wound healing — ie, hemostasis, inflammation, proliferation/granulation, and remodeling/maturation.7 Nurses also lacked a working knowledge of wound assessment, particularly with respect to distinguishing normal from abnormal signs and symptoms of wound healing.
Dressing selection. Another knowledge deficit was the nurses’ inability to apply a rationale for appropriate dressing selection. Often, dressing selection was based on prior experience with a particular product, tradition, a specific client situation, or an educational session sponsored by a pharmaceutical company. In many cases, nurses would remember a product name but not its intended rationale for use. As a result, well-intentioned nurses tried “flavor of the month” dressing supplies in attempts to provide appropriate (hopefully) nursing care. Nurses trying to achieve positive client outcomes often were frustrated by their own knowledge deficits.
Additional concerns. Knowledge gaps were also evident among Case Managers and physicians. Case Managers had no experience with standardization or an evidence-based approach to wound care and, as a result, relied on nurse or physician direction to authorize service plans for clients, rendering visit frequencies and dressing supplies unmanageable. Many physicians, unfamiliar with the principles of moist wound healing, relied on past practices that were frequently inconsistent with best practice guidelines for wound healing.
Lack of standardization. A lack of standardization in wound care — both in practice and product usage — also was noted. Current literature indicates that when educated healthcare professionals utilize a standardized protocol for providing moist wound healing, positive client and financial outcomes result.1 In the CCACWD catchment area, community nurses frequently followed physician orders without question and were unable to sustain a consistent approach to wound care. Educational sessions were client- or condition-specific but no consistent, systematic approach to providing comprehensive wound care education was utilized.
Outcomes measurement. No measurement of care outcomes — clinical or financial — was documented. Client care outcomes were inconsistent. Some clients achieved healing goals and others received home care nursing for weeks, months, and even years without evidence of healing. Some clients healed after a period of care only to have wounds re-develop, requiring additional weeks or months of painful, costly treatment. For some clients, comorbid conditions and compliance factors accounted for inconsistent results. However, when comparing facility practices to information in the literature, it seemed that the lack of a standardized, evidence-based approach to wound care (eg, moist wound healing) was the key negative factor for many clients with nonhealing wounds. Although nurses documented wound care observations and actions for individual clients, this care often was not based on literature findings and nurses were not consistent in the care they provided. Wound care product use varied and was not based on solid principles that could be applied systematically throughout the region. Neither the CCACWD nor the nursing agencies possessed the tools to capture how many clients achieved positive outcomes or to ascertain which treatment protocols fostered healing.
Attempts to Improve
The confusion and uncontrolled spending for nursing visits and medical supplies needed to be addressed. A solution was not readily apparent until 2001, when insights gained from a presentation on the development of a standardized, evidence-based approach to wound care known as the Nova Scotia Protocol3 helped the author better understand what was required for the client population and the organization in the local region of Wellington and Dufferin Counties.
Five years earlier, a wound care committee comprised of community nurses, an ET nurse and Case Managers was formed. This group developed wound care guidelines and goals based on the principles of moist wound healing. However, this body of work was never fully implemented, in part because access to professional education for a large group of nurses who provided wound care to clients throughout the extensive geographic was limited. Additionally, at the time, only one ET was available to provide expertise for a group of approximately 100 nurses. Thus, the number of staff members with sufficient resources to manage wound care outcomes for the client population was limited. Consequently, nurses returned to more traditional wound care interventions — ie, wound care delivered before knowledge of evidence-based practice (saline and gauze dressing changed once or twice a day and widespread use of potentially wound toxic products such as Betadine® [The Purdue Frederick Company, Norwalk, Conn] and hydrogen peroxide).
In 2002, ET services in the more rural county were no longer available — the ET who consulted and provided care throughout the entire region found the workload overwhelming when faced with a drive of at least 2 hours (one way) in order to assess and treat clients in the rural areas of both counties. As a result, ET services became available in Wellington County only. Clients in Dufferin County received ET services only occasionally and in exceptional circumstances, causing great concern for local surgeons, physicians, and nurses. In response to this situation, ConvaTec, A Bristol-Myers Squibb Canada Company, stepped in and provided professional ostomy and wound care education with accompanying product samples for the community visiting nurses to help create a standardized, evidenced-based wound care approach.
Planning and Implementing the h.e.a.l. Program
The h.e.a.l. program is based on the principles followed in the Nova Scotia model3,8 (see Table 1). In 2002, the author spent considerable time investigating how populations similar to those served by the CCACWD (Peel and Waterloo regions) approached wound care and whether areas that already had implemented the h.e.a.l. program (Chatham-Kent and Niagara regions) were finding it appropriate to their issues and challenges. It was concluded that the key to the success of any wound care program was consistent staff access to education and the ability to measure outcomes. However, management representatives of the nursing agencies and the two ETs had reservations about the h.e.a.l. program. They expressed concern about potential conflict of interest because a vendor was providing both education and dressing supplies. Investigation demonstrated that the h.e.a.l. program was based on solid evidence from respected sources in the literature. Legal counsel was sought to ensure the soundness of the proposed agreement with the company. Following investigation and deliberation, Senior CCACWD Management decided the h.e.a.l. program would help meet the wound care goals of the clients and CCACWD; the program would be tried for 1 year.
The contractual agreement between the CCACWD and ConvaTec Canada included access to the h.e.a.l. program and the means to evaluate wound care outcomes. Education for direct nursing providers, CCACWD Case Managers, and others was promoted by an ET who provided evidence-based information on principles of moist wound healing, facilitated question-and-answer sessions, and assisted with community nursing rounds, serving as a consultant for the nursing team on challenging wound care. The ConvaTec sales rep provided information on dressing usage. In return, ConvaTec wound care products would be utilized as the first-line choice for dressings. Dressing products from other companies were available if required. This was not a marked change in practice; ConvaTec products had been the first choice of participating facilities for years.
The decision to proceed with the h.e.a.l. program was communicated to CCACWD staff and all contracted community agencies and stakeholders, including the physician group. The new program would begin in March 2003.
The Education Plan
To ensure maximal attendance and buy-in for the h.e.a.l. program by contracted nursing providers, the CCACWD agreed to financially compensate all nurses attending h.e.a.l. education sessions. The two participating nursing agencies identified several staff members who would be educated to complete the outcomes measurement exercise. The selected nurses were taught the value of 1) a comprehensive client assessment utilizing the reliable, valid Braden Scale9; 2) interrater reliability; and 3) outcomes measurement. Prevalence was defined as the number of clients with all types of wounds, divided by the number of clients visited and multiplied by 100 to obtain a percentage. In addition, nurses documented the gender and age of each client; the etiology, location, and type of each wound; the frequency of nursing visits; treatment products utilized; and the professional designation of the nurse. The baseline data, completed for 214 clients receiving wound care (information was not available on three wound care clients), was analyzed by Health Outcomes Worldwide Incorporated (Nova Scotia), an independent consulting firm. Following the outcomes measurement exercise, Clinical Educators provided a 6-hour basic wound care educational session for all community nurses. Appropriate use of the CCACWD formulary of wound care products was demonstrated by the professional sales representative. This education was not embraced wholeheartedly by all nurses. Many experienced nurses, who considered themselves expert providers, indicated feeling insulted when required to attend a basic wound care education session. However, pre-test and post-test results demonstrated a need for a basic instructional review.
All attendees received instruction on providing comprehensive wound and client assessments, collaborating with physicians in a more professional and accountable manner to determine the most appropriate treatment options, and participating in outcome measurement strategies that yield the supporting data for continued utilization of the h.e.a.l. program.
The CCACWD Case Managers attended a shorter, less clinically focused session to understand how to best negotiate and authorize service plans for wound care clients.
Throughout the remainder of 2003 and into 2004, the h.e.a.l. program’s Clinical Educators provided question-and-answer sessions to ensure nurses were comfortable with the basic principles. More advanced educational classes were available. Initially, it was anticipated that this education would be provided for a core group of resource nurses; however, the agencies determined that many staff nurses were interested in increasing their wound care skills. As a result, all nurses were invited to attend 2-hour specialty sessions focusing on the differential diagnosis and treatment of leg ulcers, wound bioburden, and surgical site management.
An Ontario physician who specializes in wound care has made three presentations to local physicians, supporting the principles of moist wound healing and the h.e.a.l. program. Education sessions for the nursing staff of physician offices also were held throughout the region.
The h.e.a.l. Program: 2005
In terms of ongoing education, the h.e.a.l. program provides all information sessions on a yearly basis in locations that meet the needs of urban- and rural-based visiting nurses. Additional classes are scheduled as required when specific knowledge deficits become apparent. The CCACWD continues to financially support the education of all nurses who attend h.e.a.l. education programs. The 2006 outcome measurement exercise should be completed (by March 1).
Publications and documents. Communication with physicians occurs via a quarterly CCACWD-provided physician newsletter that includes a section on the h.e.a.l. program. The medical adviser for the organization is aware of the h.e.a.l. program and provides support to the physician group and guidance for CCACWD staff who work collaboratively with physicians.
To support the standardized, evidence-based wound care approach, a resource for nursing documentation was developed. The resource includes a formulary for dressing selection and a tool for nurses to send information to physicians for follow-up client assessments. All forms were designed to provide consistency while supporting the principles of the h.e.a.l. program.
The Wound Assessment and Data Entry Form (see Figure 1) provides data related to the etiology of the wound, exact measurements, and treatment plans for each client receiving wound care. Nurses complete this form weekly and submit it monthly to CCACWD. This provides easy access to data for chart audits and outcome measurement.
The Product Selection List (formulary) (see Figure 2) is grouped according to wound care needs so nurses and Case Managers can readily determine the appropriate product for provision of moisture, moisture retention, exudate management, compression, and specialty products for management of odor or for the treatment of contaminated wounds. Any request for products not listed in the formulary is handled through an exception process to control and/or provide alternatives for wound care dressing selections. The formulary and process of exceptions help avoid the historical “flavor of the month” approach.
The Wound Care Communication Tool (see Figure 3) was developed so nurses would have a document, formatted according to the wound classifications of h.e.a.l., on which to chart progress notes, queries, or other information for the client’s physician. These notes commonly accompany the client to the physician’s office or to hospital.
A new Medical Order Form (see Figure 4) cues physicians to choose a wound care goal of either healing (for which the moist wound healing principles of the h.e.a.l. process are indicated) or maintenance (in which comfort measures are more appropriate). It is important for the multidisciplinary team to determine if healing is an appropriate and realistic wound care goal. If the wound appears unable to heal, a maintenance goal is selected so comfort measures, including pain control, can be implemented. It is anticipated that this form not only will serve the physician group well, but it also will provide more autonomy for community nurses.
Educational sessions and materials. In March 2005, a 1-day event aimed at professional providers (nurses and physicians) addressed a multidisciplinary approach to a variety of topics, including ostomy management, venous ulcers, the diabetic foot, the Nova Scotia experience of evidence-based wound care, a physician’s perspective on communication and management of wound pain, and an overview of the success of the h.e.a.l. program from a CCAC perspective. A sales representative reviewed appropriate use of the dressings available on the CCACWD formulary.
In November 2005, a respected American surgeon discussed surgical site management utilizing the principles of moist wound healing at a session attended by local surgeons, ETs, and other resource nurses specializing in wound care.
In addition, resource binders have been developed for use by all visiting nurses and CCACWD staff who work directly with physicians related to wound care medical orders. The binders contain information sheets related to specific wound care products and are arranged according to treatment goals — ie, hydration, moisture retention, and exudate management. The resource binders also contain a copy of the dressing formulary and an updated comprehensive clinical guideline for wound care.
Zip-lock® bags with small quantities of moist wound healing dressings have been prepared for all community visiting nurses and a supply of specialty dressings has been provided for the hospitals staffed by CCACWD Case Managers. This ensures that clients are discharged from the hospital with appropriate wound care products.
A quick-reference booklet has been prepared for distribution to all local physicians and surgeons in order to support their knowledge base related to moist wound healing. Similarly, a service planning guide has been distributed to CCACWD Case Managers to assist in the determination of nursing service plans for wound care clients.
Future educational opportunities will focus on the continued support of physicians, Case Managers, and nurses.
Outcomes are measured annually using the Prevalence Study data. A sample of nurses from each of the contracted agencies performs a comprehensive assessment of all clients over a 2-week period, documenting findings on a standardized assessment form. The etiology of each wound, pressure ulcer staging, treatment used, frequency of wound care, anatomic location of each wound, and the age, gender and diabetic status of each client are noted. All documents are analyzed by the database of Health Outcomes Worldwide Incorporated; results are returned to the CCACWD several weeks later.
According to the most recent Prevalence Study Analysis (March 2005), the number of clients requiring daily wound care decreased from 253 (46%) in 2003 to 236 (39%) in 2004 to 194 (29%) in 2005 (see Figures 5, 6, 7, and Table 2). Although nurses always have been expected to pursue continuing education as a professional development obligation, the general feeling is that the improved outcomes are the result of implementing the h.e.a.l. program — ie, a better educated staff is communicating better and more knowledgeably. Physicians have noted that nurses are exhibiting improved professionalism (eg, nurses now provide objective data related to wound appearance and characteristics as opposed to saying the wound is “draining a lot and not improving”). The additional education has been a factor in appropriate use of support surfaces and other pressure offloading devices.
Twice-daily wound care nursing visits have been reduced from 9% of all wound patients in 2003 to 4% in 2004 and to 3% in 2005 (see Figure 5), most likely because of the nurses’ enhanced ability to assess and treat more appropriately according to h.e.a.l. program principles. After completing the comprehensive assessment, nurses are better able to select products according to wound classification, which include better choices than previous saline and gauze options.
Improved knowledge of dry gauze dressings, not consistent with the principles of moist wound healing, has reduced the number of wounds treated with these products from 41% in 2003 to 36% in 2004 to 22% in 2005. While the goal of the program was to improve patient outcomes (eg, faster, more pain-free healing), focusing on the quality issue impacted financial aspects of wound care as well — ie, using moisture-rententive products meant fewer dressing changes and subsequently decreased costs. However, dry gauze remains the most prevalent product of choice for wound care. This factor underscores the ongoing need for staff, provider, and physician education.
Wound type and location. In Wellington and Dufferin counties, open surgical wounds (ie, wounds that require packing such as pilonidal sinuses, infected wounds, and dehisced wounds) are the most frequently encountered, which appears to be a national Canadian trend (see Figure 6). Because of the types of wounds (see Figure 6) and wound location data (see Figure 7), two potential key educational opportunities are the provision of pressure reduction strategies for clients at risk for the development of pressure ulcers and the application and continued use of compression therapy for clients with venous leg ulcers.
Visit frequency. Since 2003, the impact of reducing daily and twice-daily nursing visits has resulted in the opportunity to reallocate $1,572,480, the amount of money saved based on an average visit rate of $40.00 per nursing visit. This means administrators have the ability to not only re-align the CCAC nursing budget, but also to prevent lengthy wait times for clients eligible for nursing visits (see Table 2).
Impact of setting. Setting data were somewhat surprising. Originally, it was anticipated that acute care consistently would be the most prevalent referral source. No explanation for the dramatic increase in “home” for 2005 has been determined. Although providing care to such an extensive region still presents numerous challenges, rural clients are provided the same care as their urban counterparts.
In July 2004, patients who were able to access outpatient clinics or ambulatory care settings were no longer eligible for CCACWD inhome services, a change from previous practice that resulted in fewer clients with wounds (particularly surgical wounds) and impacted 2005 prevalence data. Most of the clinic care subsequently provided has been wound or intermittent IV (antibiotic) therapy. The observed increase in knee-ankle wounds may be attributed to the growing numbers of elderly but statistics to confirm this observation are not available.
As local hospitals, long-term care homes, and family health teams become aware of the local success of the h.e.a.l. program, it is anticipated that healthcare organizations can work collaboratively to develop a regional approach to standardized, evidence-based wound care throughout Wellington and Dufferin Counties. At this point, in addition to CCACWD clients, three hospitals in the area are utilizing the h.e.a.l. program and two hospitals are utilizing principles of moist wound healing.
Implementing a comprehensive, systematic, organized approach to wound care using the h.e.a.l. program has enabled two counties to improve wound care outcomes for patients as well as to redirect financial resources. The need for program-related education is on-going across many staff levels, confirming the fact that changing practices is not easy. With continued support from healthcare administrators and the persistence of care providers, patients in the two Canadian counties can anticipate better, evidence-based care. Further documentation of this and similar initiatives is warranted.
The author thanks Corrine McIsaac, BScN, RN, Med, Health Outcomes Worldwide Incorporated, for sharing the Nova Scotia Protocol as well as data, vision, and support while the h.e.a.l. program is developed regionally. A very special thanks to Anne Howarth, BScN, Regional Business Manager for ConvaTec, A Bristol-Myers Squibb Canada Company, and Andrea Russell RN, ET, a Clinical Educator, who provided the initial and ongoing education and tireless support that helped make the positive outcomes a reality that will continue. The following CCACWD management staff are acknowledged: Ross Kirkconnell, Executive Director; Rosslyn Bentley, Marg Donald, Glynis Williams, Directors of Client Services; and Suzanne Trivers, Manager Contracts and Quality, for the financial and professional support provided to initiate and sustain the h.e.a.l. program and for the encouragement to proceed with a regional approach to moist wound healing. The CCACWD staff of Case Managers and Client Services Assistants who have embraced h.e.a.l. principles are to be commended. Others especially deserving gratitude are the community visiting nurses of CarePartners, Saint Elizabeth Health Care, ComCare Health Services, and Bayshore Home Health, who have demonstrated professional growth, development, and excellence in the provision of evidence-based wound care.