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Pressure Ulcers/Injuries -Coordination of Care

Pressure Ulcers/Injuries -Coordination of Care

Pressure Ulcers/Injuries -Coordination of Care

ABSTRACT

Pressure ulcers/injuries (PUs/PIs) pose a large burden to affected individuals, caregivers and healthcare systems. PUs/PIs have been identified by the Centers for Medicare and Medicaid Services (CMS) as one of the 14 hospital-acquired conditions (HACs) that are reasonably preventable using evidence-based guidelines.[1] Patients at risk or with existing PUs/PIs often present with multiple comorbidities and are treated at different care settings that may not have access to all patient information needed to ensure proper care. Furthermore, roles that each clinical department/service should take in caring for patients with or at risk for PU/PI may be unclear, leaving room for gaps in care. This topic provides practical examples on best practices of care coordination for management and prevention of PUs/PIs.

CLINICAL

Overview

This topic provides practical examples on best practices of care coordination for management and prevention of pressure ulcers/injuries (PUs/PIs). For a list of guidelines and quality measures related to PUs/PIs, see topic "Pressure Ulcers/Injuries - Overview". For an introduction and assessment of PUs/PIs including epidemiology, risk factors, etiology, pathophysiology, history, physical examination, diagnosis, differential diagnoses, documentation and ICD-10 coding, see "Pressure Ulcers/Injuries - Introduction and Assessment". For management of PUs/PIs, see topics "Pressure Ulcers/Injuries - Treatment"For a systematic approach to identifying patients at risk for developing pressure ulcers/injuries (PUs/PIs) and developing specific care plans, primarily based on the latest evidence-based clinical guidelines, see "Pressure Ulcers/Injuries -Prevention".

Background

  • PUs/PIs pose a large burden to affected individuals, caregivers and healthcare systems. PUs/PIs have been identified by the Centers for Medicare and Medicaid Services (CMS) as one of the 14 hospital-acquired conditions (HACs) that are reasonably preventable using evidence-based guidelines.[1] 
  • Patients at risk or with existing PUs/PIs often present with multiple comorbidities and are treated at different care settings that may not have access to all patient information needed to ensure proper care. Furthermore, roles that each clinical department/service should take in caring for patients with or at risk for PU/PI may be unclear, leaving room for gaps in care.
  • To ensure efficient coordination of care, it is important to hold the belief that "the problem of PUs/PIs belongs to no one group of healthcare professionals, and that all on the healthcare team must work together to diminish the incidence and severity of PUs/PIs.[2][3]

Care coordination for treating or preventing pressure ulcers/injuries

  • 2CWe suggest healthcare services develop and implement care coordination programs to treat and prevent PUs/PIs (Grade 2C)
    • Rationale: studies on the impact of care coordination for preventing or treating PU/PI published to date have design biases that lead to uncertainty around whether care coordination programs help prevent or treat PUs/PIs.[4] While additional research is required to strengthen this evidence, it still makes sense to develop and implement care coordination programs. Despite the establishment and implementation of prevention guidelines, avoidable PUs/PIs continue to occur.[5] Reasons are multifactorial and many of them may stem from the wide variations in clinical conditions under which patients at risk for PU/PI are admitted to a healthcare facility and receive care. When not adequately accounted for, these variations can lead to challenges in care coordination that result in avoidable PUs/PIs. Lack of care coordination often results in wasted time and resources that may delay healing or contribute to the development of PUs/PIs, thus the importance of tight care coordination within and among healthcare teams.

Care coordination to manage patients with existing pressure ulcers/injuries

Healthcare services may face several obstacles when managing patients with PU/PI. Table 1 below illustrates some of these issues and potential solutions.

Table 1. Care coordination to manage patients with pressure ulcers/injuries - problems and solutions

ProblemsSolutions
Education-related
  • Healthcare professionals (nurses, physicians, etc) may lack adequate PU/PI-related knowledge [6]
  • Clinical guidelines have not been implemented due to barriers such as lack of time, lack of resources [6]
  • Mandatory PU/PI education at employee orientation and on a yearly basis (similar to fire safety, hand washing, etc)[6]
  • Clinical mentorship with inter-professional wound care experts [6][7]
  • Easy access to online guidelines and protocols for assessment and management of PU/PI [7]
  • Team-based approach to delivering PU/PI care. Best practice suggests that wound care is ideally delivered by an inter-professional team (e.g., nurse, physician, dietician, physical therapist, occupational therapist, pharmacist)[6][8] 
  • Peer-to-peer case-specific discussions have been cited as a common method for obtaining education at the point-of-care.[9] For customized answers to clinical/reimbursement questions, refer to WoundReference Curbside Consult
Operations-related
  • Care that PU/PI patients receive across different settings is inconsistent due to differences in processes of care, regulatory or financial constraints, and clinical protocols [10]
  • Facilities may use different wound measurement techniques and PU/PI classification/staging definitions - documentation can be misinterpreted, resulting in inadequate care plans [10]
  • Use of case managers to: assist in patient transitions from one setting to another within a healthcare network, help identify/locate documentation about the condition of patients as they move through the healthcare continuum, reduce waste in duplicative workup/therapies, assist patients/caregivers in modifying lifestyle and behavior according to care plans [10] 
  • Development of a Provider Order Sheet with standardized interventions and treatments for basic types of PUs/PIs. Ideally, these sheets are customizable to individual patient and can be used in all care settings [10][7]
Clinicians are required to use their facility’s selection of products (formulary) and/or may have strong preference for a specific product brand, not realizing that other brands can accomplish similar function. Difficulty in identifying similar wound care products under various branding [10]
Product formularies can be shared across facilities so that clinicians from the referring service can learn upfront which products are available at the receiving service. Clinicians might opt to use the Product Navigator to see different brands of each product type, and develop a local wound formulary.
Transition of care across settings results in wasted effort/resources. When a PU/PI patient is received at a hospital, nursing home or home health agency, clinicians start care process disregarding workup/interventions that have already been done for the patient, either due to lack of information from the previous care setting, or because clinicians need to follow rigid local protocols [10]
Use of a "Transition of Care Provider to Provider Wound Communication Form", that can be utilized to communicate  important information about the patient, including wound etiology, significant medical history, results of any wound  diagnostics that have been conducted, specifics regarding current wound care goals and treatment regimens.

Care coordination to prevent pressure ulcers/injuries

PU/PI is considered a preventable hospital-acquired condition by the Centers for Medicare & Medicaid Services, and as a result hospitals do not get reimbursed for PUs/PIs that occur during a hospital stay. Most hospitals have implemented care coordination programs that have successfully reduced incidence of PUs/PIs. Table 2 summarizes best practices that have been in place at the Queen of the Valley Medical Center in Napa, California.  

Table 2. Care coordination to prevent pressure ulcers/injuries in an acute setting 

Queen of the Valley Medical Center is a non-for-profit healthcare facility with 208 beds in Napa, California. At this hospital, wound care specialists work in conjunction with other clinicians as follows: 
  • At each hospital ward, nurses complete a PU/PI risk assessment (Braden Scale for Predicting Pressure Sore Risk, or "Braden") for every patient in each 12 hour shift, and log results into the patient's records on an electronic medical record system. Preventive measures are implemented according to each patient's individual needs based on the Braden subscales.
  • The Wound Care Office receives alerts to low Braden scores (<14), and scores are recorded in a log by the wound care team.
  • Once a patient has 3 cumulative low Braden scores during the hospital stay, patients are placed on the wound care team rounding list for skin assessment and review of preventive care plan to ensure appropriate measures are in place. In summary, plan includes pressure redistribution, repositioning (i.e. use of proper turning equipment and technique), management of excessive moisture and shear (e.g. limit layers under the patient to only one and keep it wrinkle free, protect the skin from exposure to excessive moisture with moisture barrier products, incontinence management, prophylactic dressings, etc), and nutrition optimization if poor nutritional status. See details of PU/PI prevention interventions in topic "Pressure Ulcers/Injuries - Prevention"
  • Depending on the patient's acuity, follow-up visit by the wound care team is scheduled for once or twice a week, unless patient develops a PU/PI, in which case visits are completed on a more frequent basis.
  • Patients continue to be on the wound care team rounding list until their Braden scores indicate they are no longer at risk for PU/PI. 
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NOTE: This is a controlled document. This document is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

REFERENCES

  1. Centers for Medicare and Medicaid Services . Hospital-Acquired Conditions .;.
  2. Ayello EA, Sibbald RG et al. Pressure Injuries: Nursing-Sensitive Indicator or Team- and Systems-Sensitive Indicator? Advances in skin & wound care. 2019;volume 32(5):199-200.
  3. Abruzzese R.. Editorial. Decubitus 1998. 1998;volume 1(7):.
  4. Joyce P, Moore ZE, Christie J et al. Organisation of health services for preventing and treating pressure ulcers. The Cochrane database of systematic reviews. 2018;volume 12():CD012132.
  5. Association for the Advancement of Wound Care. Proceedings of the Association for the Advancement of Wound Care’s First Annual Pressure Ulcer Summit. February 9–10, 2018 Atlanta, Georgia Ostomy Wound Management. 2018;volume 64(4 April 2018):.
  6. Suva G, Sharma T, Campbell KE, Sibbald RG, An D, Woo K et al. Strategies to support pressure injury best practices by the inter-professional team: A systematic review. International wound journal. 2018;volume 15(4):580-589.
  7. Carson D, Emmons K, Falone W, Preston AM et al. Development of pressure ulcer program across a university health system. Journal of nursing care quality. 2012;volume 27(1):20-7.
  8. Baker TL, Boyce J, Gairy P, Mighty G et al. Interprofessional management of a complex continuing care patient admitted with 18 pressure ulcers: a case report. Ostomy/wound management. 2011;volume 57(2):38-47.
  9. Papermaster A, Champion JD et al. The common practice of "curbside consultation": A systematic review. Journal of the American Association of Nurse Practitioners. 2017;volume 29(10):618-628.
  10. Thomas ME. The providers' coordination of care: a model for collaboration across the continuum of care. Professional case management. 2008;volume 13(4):220-7.
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