Optimising chronic wound care

Process optimisation is a major issue in any healthcare facility, say Ellen Schaperdoth, Claudia Roland, Rudolf Pape, René A. Bostelaar. Some organisations have already come a long way, others are just about to attempt the first steps

Process optimisation concerns all primary and secondary processes in a hospital. Case management is a tool that supports the implementation of comprehensive optimisation efforts.

The Cologne Case Management Model is designed as a process of interdisciplinary cooperation in patient care. It encompasses assessment, planning, documentation, coordination, organisation and evaluation of healthcare services. During assessment and during the extended process monitoring by the case manager the wound manager identifies patient needs and initiates agreed solution-oriented actions such as wound management.
At University Hospital Cologne central wound management has been implemented in the context of introducing case management.
There are several treatment strategies for the care of chronic wounds. New research highlights the complex processes involved in wound healing. Industry seems to exploit this trend to present ever more complex products. However, for the user it is increasingly difficult to gain an overview over the broad range of available wound care products. Moreover, clinicians adhere to different theories and practices regarding wound care, making this issue a bone of contention that leads to unnecessary distress. In everyday hospital life many patients are subjected to changing treatment methods, which means a lack of continuity of care. Different materials with widely differing time requirements, and above all uncontrolled costs, are applied with uneven success.
Wound management goals
l    Standardisation of wound care (following established guidelines),
l    Process optimisation
l    Economic use of products.
Wound managers’ tasks are to
l    advise and care for patients with chronic wounds
l    develop guidelines that ensure standardised and consistent wound treatment
l    reduce and standardise wound care products by removing unsuitable materials and medication
l    train medical and nursing staff
l    ensure the continuity of care by appropriate data collection and harmonisation of IT-based wound documentation.
Milestones achieved:
The hospital board adopted guidelines for the treatment of decubitus, diabetic foot syndrome and ulcus cruris. The stock of wound care products was updated and restructured in order to make all procedure-relevant materials immediately available to the staff. Pharmaceuticals of questionable effectiveness were removed. Consignment stock was established for vacuum therapy material.
The first training courses for wound managers began in November 2004 and were completed in February 2005. Additional courses took place from September 2006 to March 2007 and from April 2008 to July 2008. The course contents were supported by bedside teaching on wards. All new members of staff receive training for new products.
To improve and harmonise documentation, the internal IT system was modified and is currently being tested in some clinics.
The first wound manual was published in July 2006.

Responsibilities
Upon admission of a patient with chronic wounds, e.g. decubitus, diabetic foot syndrome, ulcus cruris or secondary healing wounds, wound management should be paged during assessment by the case manager(s). During joint wound assessment (case physician, the nurses and wound manager) photo documentation is created and the therapy concept designed. The agreed therapy is documented on the wound documentation form or the temperature chart.
Monitoring, changing of dressings and the concomitant documentation on the wound documentation form are the responsibility of the nurses and/or medical staff. Support and advice during treatment are the responsibility of the trained wound manager.
The treatment plan is reviewed in regular and previously agreed intervals by the physician in charge and the wound management team. The plan is modified as needed. The case manager is informed.
To facilitate scheduling, the different departments are offered a fixed ‘visit day’. Defined procedures facilitate treatment of chronic wounds and ensure continuity of care.
Further guidelines, for example regarding decubitus prevention, are currently being developed.
Roughly every six months a wound colloquium is scheduled where internal and external staff members present their results and undergo additional training.
Process optimisation ensures that problems are identified early and that appropriate solutions can be immediately initiated.
Further details: rudolf.pape@uk-koeln.de