best practice wound care

ORIGINAL ARTICLE

Best practice wound careMelissa L O’Brien, Joanna E Lawton, Chris R Conn, Helen E Ganley

O’Brien ML, Lawton JE, Conn CR, Ganley HE. Best practice wound care. Int Wound J 2011;doi: 10.1111/j.1742-481X.2010.00761.x

ABSTRACTThis article describes the barriers, changes and achievements related to implementing one element of a woundcare programme being best practice care. With the absence of a coordinated approach to wound care, clinicalpractice within our Area Health Service (AHS) was diverse, inconsistent and sometimes outdated. This was costlyand harmful, leading to overuse of unhelpful care, underuse of effective care and errors in execution. The majoraim was to improve the outcomes and quality of life for patients with wound care problems within our community.A collaborative across ten sites/services developed, implemented and evaluated policies and guidelines based onevidence-based bundles of care. Key barriers were local resistance and lack of experience in implementing structuraland cultural changes. This was addressed by appointing a wound care programme manager, commissioning of astrategic oversight committee and local wound care committees. The techniques of spread and adoption were used,with early adopters making changes observable and allowing local adaption of guidelines, where appropriate.Deployment and improvement results varied across the sites, ranging from activity but no changes in practice tomodest improvement in practice. Evaluating implementation of the leg ulcer guideline as an exemplar, it wasdemonstrated that there was a statistically significant improvement in overall compliance from 26% to 84%.However, only 7·7% of patients received all interventions to which they were entitled. Compliance with the eightindividual interventions of the bundle ranged from 26% to 84%. Generic performance was evaluated against thewound assessment, treatment and evaluation plan with an average compliance of 70%. Early results identifiedthat 20% of wounds were healed within the target of 10 days. As more standardised process are implemented,clinical outcomes should continue to improve and costs decrease.

Key words: Bundle • Clinical practice guideline • Evidence-based practice • Spread • Wound care

INTRODUCTIONThe purpose of this article is to describe anddiscuss issues and achievements related to thebest practice care element of a wound care pro-gramme. Programme evaluation (1) shows ouraccountability in reporting on the expenditureof public funds, validating programme objec-tives and the degree of implementation andachievement of clinical goals.

Traditionally, the medical profession hasdirected the care of wounds. However, over

Authors: ML O’Brien, MN, Quality & Risk Management Unit,St Vincent’s Hospital, Sydney, New South Wales, Australia; JELawton, MN, Quality & Safety Unit, Launceston General Hospital,Launceston, Tasmania, Australia; CR Conn, ME, MN, Quality &Risk Management Unit, St Vincent’s Hospital, Sydney, NewSouth Wales, Australia; HE Ganley, MQIHC, Clinical GovernanceUnit, Northern Sydney Central Coast Health, Sydney, New SouthWales, AustraliaAddress for correspondence: HE Ganley, MQIHC,Vanderfield Building, Royal North Shore Hospital, St. Leonards,NSW 2065, AustraliaE-mail: [email protected]

the past 30 years, wound management decision Key Points

• wound care is high volume, highrisk and high cost

• an un-coordinated approachto wound care is costly andharmful, leading to overuseof unhelpful care, underuse ofeffective care and errors inexecution

• spread and adoption tech-niques can be used tostandardise processes, reduceresistance to change andenhance collaboration

making has gradually been incorporated intothe nurse’s scope of practice (2). More recently,wound care is being delivered by a vast arrayof people including clinicians, patients and/orcarers, in a variety of settings, and often inisolation (3).

In 2005 Northern Sydney Area HealthService (AHS) amalgamated with the CentralCoast AHS to become Northern Sydney CentralCoast Health Service (NSCCHS). Covering2500 km2, NSCCHS serves a population of1·1 million, using approximately 10 000 staffacross seven major sites as well as domiciliarycare.

Historically, each facility within NSCCHShad undertaken a number of quality improve-ment activities to develop wound managementpractices, but these were usually self-generatedand not part of a collaborative approach.Subsequently, most sites, workgroups andprofessionals believed that their system wasindependent and autonomous, and specific

© 2011 The Authors© 2011 Blackwell Publishing Ltd and Medicalhelplines.com Inc • International Wound Journal • doi: 10.1111/j.1742-481X.2010.00761.x 1

Best practice wound care

to the disparate patient conditions that eachclinician/group dealt with. For instance, thosemanaging leg ulcers were autonomous in theirtreatment which was quite different to clini-cians preventing surgical site infections.

It was recognised that the autonomy ofeach of the two AHSs prior to amalgamationcould be a significant barrier to the project.In addition, previous efforts to improvewound care were un-coordinated becauseof professional, geographical and personalpriorities along with a lack of leadership acrossthe sites. This showed itself in seeminglyintractable problems with little coordinationof what and how to change and improvethis growing clinical problem. So, in thiscontext, the issue of cultural change wasconsidered to be a defining intervention withthe standardisation and incorporation of thecontinuum of care into clinical guidelines beingthe lever for this change.

Other best practice programmes were inplace across the AHS, such as for pressureulcer management. So there was no shortageof innovators and opinion leaders (4) to agreethat a wound care programme led andsupported by early adopters would allowfor a critical mass to observe and agree onthe implementation possibilities and positiveoutcomes that a wound care programme coulddeliver.

Wound care is generic across all patientpopulations:

• Approximately 270 000 people in Aus-tralia have a chronic wound (5);

• 12·1% of patients’ surgical wounds healedby secondary intention (6), which extendsthe healing time and wound care resourcesrequired;

• Treatment of infected surgical wounds canadd up to 10 days of hospital care to thelength of treatment (7);

• 15·9% of surgical sites have iatrogenicinfections in acute care; 28·1% skin and softtissue infection in non acute settings (8);

• Prevalence of chronic leg ulcers rangesbetween 1·1 and 3·0 per thousand adults inwestern countries (9) with treatment costsper patient approximating A$12 000 perannum;

• Cost to treat is estimated to be A$3 billionper annum for the management of legulcers (10).

PROBLEMArguably, wound care is a high volume,high risk, high cost and unreliable healthcare activity. Delayed healing and infectionsrelated to inappropriate treatment results inpreventable pain and reduced quality of life.

New South Wales has yet to conductepidemiological studies appropriate to thetopic. However, the high volume of woundsis evidenced by a prevalence study in WesternAustralia (11) of 3000 patients which confirmedthat:

• 48% of patients had at least one wound;• 28% of patients had acute wounds;• 9% of patients had pressure ulcers;• 11% of patients had skin tears.

It was identified that the AHS required thata wound care programme should not just beisolated to acute settings. This was becausejust one of our two domiciliary home nursingservices provides around 100 000 home visitsa year for wound care (2004–2005) of whichapproximately half are related to the treatmentof leg ulcers.

AIMThe aims of the proposed changes were to:

• Improve the outcomes and quality of lifefor patients with wound care problemswithin the NSCCHS ‘community’;

• Empower clinicians and patients throughthe development of a wound care pro-gramme that enables delivery of best prac-tice, innovation and cost-effective care.

STUDY QUESTIONSThe primary improvement-related questionwas ‘What needs to happen to ensure thatpatients with wounds have optimal healing?’Secondary to implementation of changes, anevaluation would include seeking answers tothe following questions:

• How effective has the generic and site-specific deployment plan been?

• What patient, organisational and staff pro-cesses and outcomes have been affected?

Because it was our intention that theprogramme would evolve over time, ourimprovement-related questions were not set

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in concrete. As the programme took shape,the reaction to performance and emergingcomplexities were mirrored in the change andscope of indicators we monitored.

METHODSThe wound care programme had an execu-tive sponsor with tactical support from thePatient Safety Manager. The project leaderwas the Clinical Nurse Consultant StomalTherapy/Wound Care seconded, initially, toundertake a gap analysis.

To give a balanced view of the state of woundcare across the AHS a number of differentsources of information were explored. Theelements that formed the gap analysis were:

1. A literature review to establish interna-tional best practice standards in woundcare;

2. Interviews were held with key stakehold-ers in wound care;

3. A visit to a tertiary referral wound careclinic identified to have best practicemodels;

4. A small audit sample provided documen-tation across the breadth of all woundtypes. Each medical record was thenmapped against international best prac-tice standards for leg ulcers, non com-plicated surgical wounds and woundsconsidered complicated through infectionor wound breakdown.

During this process it was identified thatwound care was being delivered by a vastarray of people including clinicians, patientsand/or carers, in a variety of settings, andoften in isolation. Care was sometimes notin keeping with current local, national andinternational best practice guidelines, and therewas no standardisation in practice betweenstaff and between sites. With the absence of acoordinated approach to wound care acrossNSCCH, practice was diverse, inconsistentand sometimes outdated. This was costlyand harmful, leading to overuse of unhelpfulcare, underuse of effective care and errors inexecution. Although no data were available,there was consensus that re-admission andpatient harm were linked to a lack of continuityof care for patients on discharge.

Cost ineffectiveness and inappropriate useof the vast array of wound care products

were also linked to a lack of standardisationand outdated staff wound care knowledge.Clinicians were concerned about the increasingcosts of products, especially those associatedwith antimicrobial dressings. Costs were notjust measured in product use. Inappropriateindirect costs were being generated throughlack of knowledge and skill, as well as extendedclinical time. Additionally, there was nomonitoring system to track patient outcomesin relation to length of stay, treatment,cost, improved quality of life and analgesicuse.

One of the high volume, high risk andproblem areas identified was the clinicalmanagement of wounds. A gap analysisidentified that fewer than half of the auditedclinical areas had guidelines in place to ensurebest practice information guided nursinginterventions. Only 20% of clinical guidelinesaddressed the whole continuum of care (i.e.included general practitioners and communitynurses). Half of the clinicians identified thatthey required assistance to develop andimplement guidelines. It was highlightedthat assistance may include direction from adedicated wound care CNC/specialist and/orclinical nurse educators. Most clinicians soughtto access guidelines via our Intranet; however,existing information technology support didnot make this always available.

There were also examples of good woundcare practice and initiatives, specifically that allclinical areas had guidelines for pressure ulcerprevention, the majority of which addressedthe continuum of care.

Eight elements of a wound careprogrammeDevelopment of a strategic plan defined thevision and necessary structure, resources,procedures and actions to achieve the futureand incorporated the following eight elements:

1. Best practice care;2. Models of care;3. Health promotion by prevention;4. Education;5. Care management;6. Information management;7. Research and innovation;8. Cost effectiveness.

This article describes the issues and achieve-ments of the best practice care element.

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SOLUTIONSThe following objective was agreed: Personswith wound care issues will receive safe, appro-priate and effective care. This will be achievedby developing, implementing and evaluatingevidence-based guidelines for all major cate-gories of acute and chronic wounds. Subse-quently, approximately 30 policies/guidelineswere identified as requiring standardisation orinitial development.

Framework for developing,implementing and evaluating policiesand guidelinesAn agreed framework for developing woundcare policies/clinical guidelines included:

• A process for policy/guideline develop-ment designed so that local Wound CareCommittees could develop/modify theirown;

• A system developed for determiningthe ‘level of complexity’ of the poli-cies/guidelines developed and the imple-mentation requirements for each;

• Ensuring relevancy across the care con-tinuum by including general practitionersand community care;

• Publishing one page policy summariesbased on the key principles;

• Developing a method to monitor theclinical application of guidelines.

Structures and processesThe programme included a number of struc-tures including:

• A wound care programme manager wasappointed to guide the multidisciplinaryArea Wound Care Committee and otherkey stakeholders to develop and imple-ment the wound care programme withinthe 2-year timeframe and ensure it wassustainable;

• The Area Wound Care Committee rolewas to develop strategies and operationalplans to achieve the programme goals,provide governance and oversight of thesystem for wound care monitoring andlink to the management board regardingprogramme performance;

• The best practice working party role wasto action the strategic plan through for-mulating and overseeing the development

of around 30 policies, processes andevidence-based guidelines.

• Local wound care committees and clinicalnetworks as shown in Figure 1 had therole of reviewing and providing feedbackon newly developed or standardisedevidence-based guidelines as well asimplementing strategies and operationalplans. Each site wound care committeechair was a member of the area woundcare committee.

Standardisation can be reviled in oneorganisation and revered in another. Thekey is to only standardise processes whereabsolutely necessary. To work, changes mustbe not only adopted locally but also adaptedlocally (12). On the basis that people do notresent change, but do resent being changed,the overriding principle was that users woulddevelop the guidelines. No one will disagreewith a decision/action they have put forward.Thus policies were allowed to be adapted bylocal wound care committees. For example,the wound swabbing guidelines suggest thatin community health it may be beneficial andwill provide a more accurate swab result ifthe wound swab is collected by the pathologyservice.

Once implemented, we were aware of theneed to treat guidelines as living, breathingdocuments that can and must be constantlyimproved and maintained in line with currentbest practice. We developed a process forthe spread of our guidelines which waspartly a technical process and part leadershipprocesses, and in this capacity was able toshow and/or emulate leadership processes.When a group takes on this leadership mantleit produces synergy which is a powerfulway to effect positive change. Each localcommittee chair was supported by the woundcare programme manager who used situationalleadership by supporting, coaching, delegatingor directing, dependent on the need of thecolleague (13).

DeploymentUnderstanding that the success of adoption ofchange lies in people being able to adapt it atthe local level (12), we developed an executivesteering group with membership of each ofthe site chair persons, programme managerand the programme sponsor who were able



Figure 1. Local wound care committees and clinical networks.



to consider site-specific implementation needsand variations to the guidelines. Guidelinesare more likely to be effective if they takeinto account local circumstances and aredisseminated by an ongoing educational andtraining programme. A two-pronged approachto deployment was developed which involvedcommunication and notification as well aseducation and training according to thestratified complexity of the guideline. Thecategories of complexity were defined, by theauthor, as straight forward, Intermediate orcomplex.

Guidelines are a means to capture and retainorganisational knowledge and as such wereposted on our Intranet; for those with limitedcomputer access the local wound care commit-tees also made these available in a printedformat in a resource folder. The one-pagesummaries provided clinicians with a snap-shot view of the principles and essentials ofcare related to that patient group/key associ-ated risks. General practitioners and medicalstudents along with allied health profession-als (podiatrists and occupational therapists)were invited to wound care seminars and alsoprovided with documentation of the new pro-cesses so that they were aware of their role andthat of other stakeholders. Patients and carersare able to access guidelines from the internet athttp://www.nsccahs.health.nsw.gov.au/services/wound.care/index.html.

A formal communication plan documentedwhich stakeholder groups required what com-munication message and the most appropriatevehicle for reaching them. For instance, therewas weekly e-mail information to membersof the Area Wound Care Committee, eachsite Director of Nursing and the clinical net-works. A bi-monthly wound care programmeNewsletter provided highlights of recentlyendorsed guidelines/policies and this wasreplicated on the wound care programme web-page.

RESULTSThere are many purposes of evaluation includ-ing enlightenment, accountability, programmeimprovement, clarification or developmentand symbolic reasons (1). One of our majorobjectives was accountability, being the obli-gation to report on the expenditure of publicfunds, validate the programme objectives and

degree of implementation, and achievement ofclinical goals.

Generic evaluation questions were:

1. Is the programme reaching the targetpopulation?

2. Is the programme being implemented inthe ways specified?

3. Is the programme effective?

4. How much does the programme cost?

5. What is the cost of the programme relativeto its effectiveness?

At this stage, we have assessed immediateoutcomes (1 and 2) concerning deployment.

Using the Institute for Healthcare Improve-ment Assessment Scale for Collaboratives (14)the eight sites were rated as:

• 2·0: Activity, but no changes – one tertiaryreferral hospital;

• 2·5: Changes tested, but no improve-ment – one tertiary, three district hospitalsand domiciliary care;

• 3·0: Modest improvement – one districthospital;

• 3·5: Improvement – one district hospital.

A survey of the 35 staff involved in thewound care programme found that 97%stated the programme was achieving its goals,positively influencing clinical care and theclinician’s ability to provide best practiceand supporting change locally. In addition,staff reported that guidelines enhanced theirmorale through empowerment and access toinformation. Along with participation in ourextensive education and training programme,this increased professional knowledge.

Of the approximately 30 policies and guide-lines identified as in need of development orrevision, half were completed over a period of17 months.

Various wound care interventions weremonitored as bundles of care and analysedappropriately (15) using MINITAB™ statisticalsoftware (16). ‘Bundles’ comprise a smallnumber of proven interventions, often three tofive, and known to improve clinical outcomes.Performance related to leg ulcer managementguidelines is provided as exemplars of bundlemonitoring.

Composite compliance indicators monitorthe proportion of all care that was given. Lessthan 100% means patients received some care



Figure 2. Composite compliance: proportion of leg ulcer bundle implemented – March 2006 and March 2007.

Figure 3. Historical control chart. Composite compliance: proportion of leg ulcer bundle implemented – March 2006 and March2007.

bundle interventions but not all. Credit is givenfor incomplete or partial care.

Figure 2 shows a control chart with thefirst audit achieving 26% compliance andthe second audit achieving 84%. Statisticalsignificance is identified by at least one, andin this case two, datum being outside of theupper control limit (UCL) and or lower controllimit (LCL) which is set at three standarddeviations (SD) from the mean (green line),being the red horizontal lines. Control chartsare dissimilar from classical biostatistical tests.Three SDs are the default for control charts inmost statistical software packages as the aim isto be sensitive enough to quickly signal whena special cause exist, that is the data are notrandom. Using three SDs also means that thechart should rarely signal a ‘false alarm’ whenthe data are random. Whilst Figure 2 producedan average compliance of 57%, the process

exhibits special cause variation, being one ormore points outside of the red control limits,making calculation of the summary statistics atright inaccurate.

Figure 3 shows how a control chart shouldbe split so that only common cause variationis displayed in the second part of the chartalong with appropriate summary statistics, atright. This is called an historical control chart.The 2007 process shows a performance of 84%and can be predicted, unless there is significantchange to the fundamental process, to achievebetween 68% and 100% in future audits.However, with only one datum, predictionshould be extremely cautious.

A more sensitive indicator than compositecompliance is the proportion of patients whoreceive all elements of the care bundle orthe perfect process. Figure 4 shows that onaverage only 7·7% of patients received the



Figure 4. Perfect process: proportion of patients receive full leg ulcer bundle – March 2006 and March 2007.

Figure 5. Pre- and post-audit of leg ulcer guidelines – March 2006 and March 2007.

perfect process compared with 84% compositecompliance in Figure 3. Measuring the perfectprocess monitors the provision of all carethe patient is eligible for which more closelyreflects the interests and likely desires ofpatients and their families.

Each intervention in the care bundle shouldbe monitored separately, as in Figure 5, to givedirection to specific areas of non compliance.In this case, ‘referral to specialist’ is the lowestachieving indicator at around 20%. As the nexthighest bundle intervention of Ankle BrachialPressure Index (ABPI) performs at 57%, referralto specialist is clearly special cause variationwhich should be addressed.

One district hospital achieved a result of 20%of patients attaining wound healing within thegoal of 10 days.

Ongoing improvements to the wound careprogramme continue to be implemented overtime. A wound assessment, treatment andevaluation form was implemented in early2009. Figure 6 shows that five of the eight keydocumentation requirements are achieving ator above the intermediate goal of 75%. In thiscase, simple data display as with bar graphsis deemed appropriate, for wards and the areawound care committee.

There were six wound care committeesacross ten sites and a good evaluation includescomparisons, where appropriate. A bar graphis not the appropriate analysis when comparingthe sites to determine who is performingdifferently from the rest. Figure 7 shows that,as expected, half the sites are performing aboveaverage and half are below the average of 70%as shown by the green horizontal line. But the



Figure 6. NSCCHS wound assessment, treatment and evaluation plan audit – May 2009.

Figure 7. NSCCHS wound care assessment and treatment plan evaluation (n = 169) – May 2009.

graph also shows that all six sites are withinthree SDs of the system average as representedby the red horizontal control limits which are ofvarying height because of the disparate numberof audits conducted at each site. This meansthat whilst each site is performing numericallydifferent from another, there is no statisticallysignificant difference in performance with thedata provided. The goal then becomes tochange, upward, the performance of all sites.

DISCUSSIONEarly results have showed that the aim ofproviding appropriate and effective care has

begun. But much more needs to be performedand achieved.

Evaluations of multi-faceted programmessuffer from the difficulty of disentangling theimpact of programme activities from that ofexternal influences. However, the indicatorsmonitored included a series of intermediateresults in the cause and effect chain. Monitoringof health outcomes was also conducted wherepossible.

Our goal was also to effect positive changeon population health, and this can be attainedby encouraging and facilitating an increase inhealth education. External community shar-ing and easy access to guidelines for the



community and public were enabled by pub-lishing the guidelines on the internet. Theseassist other key partners involved in woundcare to improve patient outcomes, continuityof care and share the great work of our woundcare programme.

This article sought to publish a generictemplate of structures and processes whichcan be used to achieve wound healing. Whenthere is a generic patient care problem, itmakes sense for there to be a collaborativeapproach, involving all salient professional andpatient/carer groups, to work together. Evenat this early stage of evaluation, we are surethat safe, consistent, appropriate care is beingprovided across the patient journey.

A well-implemented project has been devel-oped into a programme which is demonstrat-ing limited success at this early stage.

ACKNOWLEDGEMENTSWe acknowledge the clinical teams whichparticipated in developing and implementingthe programme. We thank Sharon McKinley,Professor of Critical Care Nursing – Universityof Technology, Sydney and NSCCHS for herassistance in reading and editing this article.

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