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Under Pressure

March 1, 2006
by Peggy Cronin, RNC, MS, CPHIMS
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NCH Healthcare System, Naples, Fla., implemented a clinical information system to reduce wound rates.

Bringing a clinical information system (CIS) online can have serendipitous outcomes. As part of our design process, we involved clinical disciplines and specialties, studying workflow and how various specialists received consults. The question we looked at was, when the paper goes away, how will consults be communicated?

The answer was through automating clinical triggers. Coincidentally, in 2002 our hospital was part of the Hill-Rom Pressure Wound Prevalence Survey, which is conducted every six months. As part of the process, experts examine every adult inpatient, except for new mothers and behavioral health patients. At the time, our hospital-acquired pressure wound rate was at 12.8 percent, while the national average was 8.5 percent.

The pain and suffering of patients, the average national cost of $50,000 for treatment of hospital-acquired pressure ulcers, the increased length of stay, and the potential for lawsuits all contributed to our organization's commitment to reducing our pressure wound rate. Clearly, we had a problem, and we intended to address it. Thus, in bringing our CIS online, we focused on wound care early in the process.

As a subject matter expert, the wound care nurse worked with the clinical informatics team to design electronic documentation with required fields and specific triggers built into the system. The day we went live, a flood of automatic referrals were triggered quickly, which brought to our attention how many patients we had been missing. Since going live in January of 2002, we have demonstrated sustainable improvement and remain below the national average for hospital-acquired pressure wounds.

'Heel'ing wounds

Since June 2000, hospital-acquired pressure wound prevalence rounds have been conducted, and hospital-acquired heel pressure wounds consistently account for greater than 50 percent of all of our hospital-acquired pressure wounds. In addition, there was data to support that mechanically ventilated and chronic hemodialysis patients were at higher risk than other patients to develop heel pressure wounds. This led us to Phase 2, "The Heel Initiative."

In September 2003, a multidisciplinary task force was formed with a risk manager, critical care physician, podiatrist, chief medical officer, chief nursing officer, wound care nurses, clinical informatics analysts and managers from critical care, operating room, education and central distribution. As a result of the task force recommendations, additional clinical alerts were built into the system, which linked mechanically ventilated and hemodialysis patients to an automatic order set to the central distribution department, nursing and the wound care nurses. It triggered central distribution to deliver a smooth, foam, one-size-fits-all boot for the patient. It triggered the staff nurse to apply the boot, and it triggered the wound care nurses to monitor compliance.

At our next wound pressure prevalence rounds in January 2004, our hospital-acquired heel pressure wound rate decreased from 3.2 percent to 1.9 percent, at which time we purchased new mattresses for the hospital and new critical care beds. In July 2004, the rate was decreased further to 1.3 percent when an additional trigger was added for boots for all patients with a Braden score less than 13. (Braden scores are required on all adult patients at the time of admission and then daily after that.)

As required fields are completed, the score is automatically totaled. Our January 2005 survey showed a further decrease to 1 percent and our most recent survey in July 2005 indicated an all-time-low rate for nosocomial heel pressure wounds of 0 percent.

The Wound Care Initiative is an example of efforts supporting our primary goal to improve patient safety. One of our guiding principles is to eliminate memory-based practice and to embed evidence-based practice into our electronic workflow design. This basic informatics principle, and the efforts of a dedicated multidisciplinary team, working collaboratively with the informatics team, has been effective in improving patient care and has resulted in a case study in bedside evidence-based practice.

Using technology as a tool and evidence-based practice as a guideline, a 10-step paper-based process with five potential points of failure led to a simplified four-step automated, behind-the-scenes, rules-driven referral practice. In addition to the introduction of evidence-based practice, our organization experienced a documented decrease in hospital-acquired heel wound rates along with an overall decrease in our hospital-acquired pressure wound rate.

The success we experienced using technology to improve clinical and patient care spurred on our efforts, increasing requests to improve our clinical practice by developing automated triggers for many clinical departments. The journey continues.

Paper vs. Automated Referral Process

Memory-based Referral Process (old) Automated Referral Process (new)

Wound care nurse referral need identified by RN during admission assessment

Wound care nurse referral automatically triggered from nursing assessment

RN notifies the unit secretary either verbally or in writing on paper to enter a wound care consult into the order communication system

Referral automatically generated to wound care nurses activities list

Unit secretary remembers to enter the consult

Wound care nurse completes referral and documents online

Paper requisition prints in the education department

Wound care nurse completes the activity and charge automatically drops

Someone in the education department notices the paper requisition and pages the wound care nurse

Wound care nurse goes to the education department and picks up the paper requisition

Wound care nurse goes to nursing unit and searches for the paper chart to review

Wound care nurse performs consult and writes treatment plan in the paper chart

Wound care nurse stamps a charge slip and returns it to the secretary in the education department

Charge is entered into system

Peggy Cronin, RNC, MS, CPHIMS, is director of clinical informatics, NCH Healthcare System, Naples, Fla.

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