Running head: Quality Improvement for Wound Care 1

Quality Improvement for Wound Care

Patricia Beemer
Ferris State University
NURS 440



2
Wound Care


Abstract
A quality improvement plan for a facility is needed to provide a patient with an optimal level of
care. The plan should be developed by multiple disciplines in order to capture all areas of
concern. Included in this team is a facilitator, member from information technology, nursing
information, quality improvement, and a wound care certified nurse or wound care expert. The
use of a Braden scale upon admission and on a routine basis is important to track those at risk for
skin breakdown. An evaluation process will involve continued auditing of patient charts by the
team to track areas for improvement.

Key words: Quality Improvement, Wounds, Braden, skin breakdown













3
Wound Care


Quality Improvement for Wound Care
As healthcare is in a state of transition and many cuts are taking place for reimbursement,
it is imperative to provide Quality Improvement measures within a health care facility. Skin
breakdown can be detrimental to a facility budget if not managed in an effective manner. To
provide a strong system to follow a patient with skin breakdown or those at risk for skin
breakdown, a quality improvement plan is needed. Monitoring pressure ulcer outcomes allows
organizations to assess their patient quality of care and examine processes and institutional
structures that may influence these outcomes. (NDNQI, 2014)
There is a clinical need for a consistent system for prevention of skin breakdown and care
to pre-existing breakdown. It not only important for the patient but also with the changes in
healthcare coverage, it is crucial to provide a thorough skin assessment for a patient at the time
of admission. Facilities are responsible for thorough documentation on a skin assessment. In the
event there is an area of breakdown, or suspected breakdown, it is important for a facility to
document this with measurements and pictures. It is also a need to provide an interdisciplinary
approach to prevention and healing. In order to follow whether these areas are being addressed,
a tracking system should be implemented as a quality improvement measure. The National
Database of Nursing Quality Indicators (NDNQI) is a program of the American Nurses
Association to assist with this tracking through patient clinical data included in their Electronic
Healthcare Record (EHR).
Some factors impeding wound healing that should be recognized and monitored by
facility are:
Local Factors
Inadequate blood supply
Increased skin tension
4
Wound Care


Poor surgical apposition
Wound dehiscence
Poor venous drainage
Presence of foreign body and foreign body reactions
Continued presence of micro-organisms
Infection
Excess local mobility, such as a joint over

Systemic Factors
Advancing age and general immobility
Obesity
Smoking
Malnutrition
Deficiency of vitamins and trace elements
Systemic malignancy and terminal illness
Shock of any cause
Chemotherapy and radiotherapy
Immunosuppressant drugs, corticosteroids, anticoagulants
Inherited neutrophil disorders, such as leucocyte adhesion deficiency
Impaired macrophage activity (Grey, 2006)

In order to provide an overall plan for wound care prevention and management, it is
necessary to involve a multidisciplinary team. Team members may include:
A facilitator
Information technology staff
Nursing information staff
Quality improvement staff
Wound care certified nurse or wound care expert
The facilitator will assist in gathering the information needed for monitoring and provide
that to the team. Information technology will use their knowledge to develop an assessment to
ensure nursing covers all areas needed in their documentation. They may also develop a report
to pull information needed for the quality improvement project. Nursing information staff will
5
Wound Care


follow requirements of wound assessments, documentation and make sure all preventative
measures are implemented. Quality improvement staff will define areas that need to be
monitored and a time frame to have them completed. Wound care certified nurse or wound
specialist to provide knowledge from a specialized area for completed assessments and proper
documentation. This team will work together for any skin concerns and monitor patients
identified as a risk for skin breakdown. There are multiple tools to assess a patients risk for
breakdown.
Upon admission, nurses will use a pressure ulcer risk assessment scale to identify those
patients at risk for breakdown. Once it is determined they have a skin concern or they are
considered at risk for skin breakdown, data is collected by the team. The scale that will be use is
a Braden Scale, used in predicting pressure sore risk. The following will be assessed using this
scale:
Sensory perception
o Ability to respond meaningfully to pressure-related discomfort
Moisture
o Degree to which skin is exposed to moisture
Activity
o Degree of physical activity
Mobility
o Ability to change and control body position
Nutrition
o Usual food intake pattern
Friction and Shear (Braden, 1988)

Within the team, charts will be reviewed and follow up provided in those areas that need
improvement. Obtaining information on areas missed will provide an opportunity for the team to
improve quality of care within the facility.
The team will provide weekly rounds with a Wound Care Certified nurse for all patients with
pressure ulcers. During these rounds, assessments will be completed and all areas of
6
Wound Care


documentation will be put into EMR. Monthly audits will then be completed to track all areas
defined within the wound care quality improvement plan. NDNQI defines the purpose of
tracking as follows:
1. Determine the incidence of pressure ulcers using clinical data from the EHR.
2. Determine the rate and time in of skin and pressure ulcer risk assessment performance
and prevention using clinical data from the EHR.
3. Explore the relationships among nursing assessments performed, intervention plans in
use, and pressure ulcer development. (NDNQI, 2014)
Centers of Medicare and Medicaid Services (CMS) made changes affecting hospitals in
October 2008. Since this change went in to affect, it is important for hospitals to evaluate their
current systems for quality improvement which as a result will provide proper payment from
CMS.
American Journal of Nursing states, The CMS will cease paying the additional costs of
treating selected preventable complications, such as pressure ulcers that arise during a patients
hospitalization. (AJN, 2008)
Facilities need to find a way to monitor areas of concern and develop systems to provide
a quality improvement plan. It takes many disciplines to complete and follow through on such
an extensive task. As a solid system is developed, a facility should see a decrease in cost of
wounds, better patient outcomes and a better reputation.




7
Wound Care


References
Braden, B., & Bergstrom, N. (1988). Braden ScaleFor predicting Pressure Sore Risk.
Retrieved from: http://www.in.gov/isdh/files/Braden_Scale.pdf on April 14, 2014.
Grey, J., Enoch, S., & Harding, K. (2006). ABC of wound healing. Wound Assessment.
Volume 332, pg. 285.
Kurtzman, E., MPH, RN, & Buerhaus, P., PhD, RN, FAAN. (2008) American Journal of
Nursing. New Medicare Payment Rules: Danger or Opportunity for Nursing? Volume
108. 6. pg. 30-35.