Presentation Objectives

Identify the components and implementation process of our Skin Health & Wound CARE Program Skin Health & Wound CARE Protocol
National Case Managers Conference April 24/2009

Consider how this protocol may lead to improved client outcomes and cost containment Describe the benefits of FREMS technology related to wound care and pain management

Agenda
Introductions Wound Care Today Wound CARE Protocol
Education Standardized Documentation Wound Care Fundamentals Sustainability Evaluation

Wound Care Today

Approximately 40% of our business is wound careand growing.
Pressure ulcer prevalence study: 25 % in acute care, 30 % in non-acute care, 22 % in mixed health-care settings, 15 % in community care

The mean prevalence overall was 26 %

Woodbury and Houghton (2004)

Remote Wound Assessment FREMS

Prevalence of skin ulcers due to various etiologies in the community setting 35.5%
Woodbury and Houghton (2004)

Wound Care Today

Wound types commonly seen in the community:
Acute/Non-Healing Surgical Wounds Venous/Arterial Leg Ulcers Diabetic Foot Ulcers/Neuopathic Ulcers Skin Tears Hospice Palliative Wound Care

First step to evidence informed care

Needs Assessment Survey results revealed:

- Varying knowledge base (nurse/physician) - Product selection a challenge (inconsistency) - Need for point of care resource

Skin Health and Wound CARE Program

Wound CARE Protocol Program Components Key Elements: 1) 2) 3) 4) 5) Education Standardized Documentation Wound Care Fundamentals - point of care decision support tool Evaluation Sustainability

What is Wound CARE?

Client centred, Assessment, care planing

& treatment

Reassessment Evaluation

Protocol Components 1) Education

CAWC S-Series, IIWCC, CAET, WOCN Bayshore Baseline Nursing Wound Care Education Program Regular Monthly Inservicing Unregulated Care Provider Skin Health Education Program

Protocol Components cont 2)

Standardized Documentation
Initial Wound Assessment (CLE116) Nursing Care Plan Wound Care (CLE115) Interim Wound Care Assessment (CLE117) Wound Care Flow Sheet revised (CLE34) Home Support Assessment - Care Plan (CLE13) Home Support Charting Sheet (CLE12)

Initial Wound Assessment (CLE116)

Nursing Care Plan Wound Care (CLE115) Completed upon admission Reassess q visit Update as nursing diagnosis and outcomes change Additional nursing diagnosis added as required Measures goal outcomes

Completed upon admission Provides a holistic assessment of the client; not simply the wound Completed once Guides clinician in developing plan of care Local Wound: Assesses for Infection, Debridement, Moisture Balance and Edge

Interim Wound Assessment (CLE117)

Protocol Components cont 3)

Completed q 2 weeks Provides a holistic re-assessment of the client; not simply the wound Guides clinician in developing plan of care Local Wound: Assesses for Infection, Debridement, Moisture Balance and Edge Provides clarity as to progress of wound towards primary goal (FUN Criteria)

Wound Care Fundamentals Guide

Point of care, decision support tool Based on the most current, best practices in wound care: CAWC BPR, RNAO BPG, Woundpedia, Pepid, Best Evidence for Nursing

NextA Framework for Implementation

Protocol Components cont

Implementation Steps:
1) Assess Branch readiness 2) Establish Wound CARE Implementation Team 3) Receive Wound CARE Protocol education 4) Participate in evaluation 5) Establish Sustainability plan

4) Sustainability
Establish a Local Wound CARE Team: Field Clinicians Branch Mentorship Network Clinical Managers Regional Mentorship Network

Ongoing Team Support

Local Branch Team: Administration Community Clinical Consultants National Service Center Clinical/Quality Response Team National Clinical Advisory Council National Care Team Clinical Consultants

Knowledge Transference

Knowledge Transference

Front-line Change Agents

Knowledge Transference v.s. Knowledge Translation

Little knowledge is a dangerous thing With knowledge comes power

Translating new knowledge into practice is most likely to occur within an empowered workplace environment:
One that values the contributions of individuals Has decentralized decision-making A shared vision Provides access to information, support & resources Provides growth and movement within organization
(Edgar, Herbert, Lambert, MacDonald, Dubois, Latimer, 2006)

Protocol Components cont

Remote Wound Assessment

5) Evaluation
Focus Groups - Collaborative monthly feedback teleconference Chart Audits Electronic Data Collection Collaboration is essential; constant feedback supports evolution of protocol

Goal:

To offer access to advanced skin health & wound care assessment in remote locations through the Wound Consultation Network.

Response time: 48 hrs.

Remote Wound Assessment

Obtain informed consent Complete assessment documentation Obtain digital wound images Forward via secure internet access to advanced wound care clinician for review Live voice follow up with on site nurse Follow up every 2 weeks

Partnership at work

FREMS
What is it? How does it work? Who will it benefit? Next steps

FREQUENCY RHYTHMIC ELECTRICAL MODULATION SYSTEM

FREMS Therapy

FREMS
FREMS is the result of a research dedicated to realizing a nonnonpharmacological system able to treat vascular and neurological diseases such as diabetic neuropathy
Traditional Electrical Stimulation has normally a very limited effectiveness on patients affected by chronic pathologies, basically because they are unable to properly stimulate biological control systems and because they exert a very rough fiber stimulation..

The Gate Control Theory: Wall & Melzak (TENS)

FREMS: applications
Peripheral neuropathy Peripheral vasculopathy Ulcers and wounds Edematous states Muscle injuries Contractures Tendonitis Orthopaedic conditions

Pain reduction for a short period of time

FREMS Therapy Working Principles

Vasomotion: Vasomotion: smooth muscle cells relaxation mediated by NO Angiogenesis: Angiogenesis: release and production of vascular endothelial and fibroblast growth factors (VEGF; bbFGF) AntiAnti-inflammatory: cytokine immunomodulation (TNF- IL- IL(TNF-, IL-2, IL-6 , IL-10) IL-10) Neuromodulation: Neuromodulation:
Of sensitive afferent fibers through:
Inhibition of nociceptive fibers

Of efferent moto-neurons: motomodulation of arch reflex ..> Inhibit/Excite H-reflex H-

DIABETIC NEUROPATHY
FREMS

LASTING EFFECTS

Comparison of measurements at the 4-month follow-up with those at baseline revealed that a significant benefit persisted for all measures that showed an improvement at the end of treatment, with an additional improvement in quality of life evaluated by the Short Form-36 questionnaire (all p<0.05).
Bosi et al. Diabetologia (2005) 48: 817823.

Direct Cost Analysis

NONNON-HEALING ULCERS: DOMICILIARY ULCERS: ASSISTANCE INCLUDING ELECTRICAL NEURO-STIMULATION. NEURO-STIMULATION. CLINICAL OUTCOME AND COST REDUCTION
G Veneziano1, L Calcara1, S Vitello1, P Di Salvo1,G Albano1, G Di Silvestre1, G Dalia1, G Messineo1,LJ Dominguez2, E Putignano2, R Toscano3, M Barbagallo2, G Oddo1
1Departmental Service for Sociohealth Integration of the Aged and Integrated Home Care AUSL 6, Palermo, Italy; 2Geriatric Unit Department of Internal Medicine, University of Palermo, Italy; 3 LORENZ Research Center, Department of Medicine, Luigi Sacco Hospital (Vialba)-University of Milan. ITALY

CONTROL GROUP Mean Cost: 5.966,92

FREMS GROUP Mean Cost: 4.095,20

(FREMS cost: 1.186,94 included)

COST REDUCTION: 31% Days assistance: 414 Days assistance: 173 TIME ASSISTANCE REDUCTION: 58% Wound stage: 3- 4

CLIENT ADVANTAGES
Reduced pain Reduced time to healing Improved quality of life Relatively short treatment time

Caregiver Advantages
Automated software On-screen diagrams of electrode Onpositioning Floor or portable model in wheeled case for easy transport Can be done at time of dressing change Quick set up Battery back-up back-

Administrative Advantages
Reduced time to healing, resulting in reduced overall costs Bayshore will be among the first in Canada to adopt the latest technology in electrical stimulation Revenue generation Many applications, therefore can be utilized not only in wound care

THANK YOU!!

In Summary We have the tools. Seamless implementation is our ultimate goal Through collaboration in this initiative we will make a difference!

Thank you For more information, please contact me at:

Katherine Grant-Brown RN, BScN, CVAA, IIWCC kgbrown@bayshore.ca