practice
Meeting the challenges of wound care in Danish home care Objective: To evaluate a community-based educational intervention to improve wound-care practice, and thereby reduce the costs of care, in four communities in Denmark. l Method: Annual wound care audits recorded patients’ ages, the number and types of wounds being treated, wound duration (days unhealed), frequency of dressing changes and nurse time per dressing change. Data were available at year 1 and year 3 post-intervention. A statistical analysis was performed, testing for changes in a range of variables between these years. l Results: In the post-intervention period, significant reductions were found in the proportion of chronic wounds, the proportion of wounds requiring a daily dressing change, mean frequency of dressing change, mean nurse time spent in wound care per week, and the total cost of wound care per week. l Conclusion: These results suggest that it is possible to improve wound-care practice and reduce the resource costs of wound care through a systematic programme of education and training, tailored to suit the needs of local communities. l Declaration of interest: S.F. Jørgensen and R. Nygaard are partners of KvaliCare ApS. J. Posnett was commissioned by KvaliCare ApS to undertake the analysis of audit data. l
H
ealth-care providers are facing significant challenges from a combination of demographic changes and constraints on the growth of health-care budgets. As populations become older, the rising demand for health-care services exceeds the growth of gross domestic product (GDP), so the proportion of GDP spent on health care is continually rising.1 Where demand grows faster than the resources to meet it, services must become more efficient. Community-based health-care services are particularly affected, as chronic conditions, which are primarily cared for in the community, are more prevalent in older populations. Wound care is a typical example. The majority of wound care is provided by community nurses, and caring for wounds is often the single most important use of community nurse time.2 Considering the strong correlation between the prevalence of chronic wounds and age,3 it seems likely that as the number of older people increases, so too will the number of patients with a wound.
The intervention An initiative, designed in 2006 to reduce the costs of wound care in Denmark, is currently running in 14 of the 98 Danish municipalities, namely: Aalborg, Aabenraa, Viborg, Langeland, Sorø, Ringsted, Slagelse, Holbæk, Høje Taastrup, Frederiksberg, Ringkøbing Skjern, Holstebro, Lemvig and Struer. By educating and training community nurses and local carers, this intervention aims to reduce heal540
ing times and improve wound prevention, thereby improving efficiency and reducing the costs of wound care.4 At the heart of this intervention is a series of e-learning modules, developed by a central training provider (KvaliCare ApS), which can be adapted to suit the specific needs of each community. The central training provider coordinates and implements the training programme, facilitates annual audits and provides feedback on improvements over time. The intervention has four components: l Baseline audit A point-prevalence audit is carried out to identify specific training needs and establish a baseline against which changes can be measured. Information is recorded on patient age, the number and types of wounds being treated, wound duration (days unhealed), frequency of dressing changes and the time taken per dressing change. During the week of the audit, all community nurses are asked to provide details of every wound-care patient on their active caseload. To maximise the response rates, non-respondents are sent reminders until a reply is received. The results of the audit are presented to the community team leaders and tissue viability nurses (TVNs) and a plan is agreed for the year, which aims to address any priority areas. l Wound-care organisation A manager is appointed within each community organisation, providing a link between the local nurses and carers and the central training provider. This role is to ensure that the training programme meets specific, local needs.
© 2013 MA Healthcare
S.F. Jørgensen,1 Tissue Viability Nurse, Partner of Kvalicare ApS; R. Nygaard,1 Tissue Viability Nurse, Partner of Kvalicare ApS; J. Posnett,2 BA, DPhil, Health Economist; 1 Kvalicare ApS, Sorø, Denmark 2 Heron Evidence Development, London, UK E-mail: [email protected]
ltd
wound audit; practice improvement; efficiency in wound care
j o u r n a l o f wo u n d c a r e v o l 2 2 , n o 1 0 , O c to b e r 2 0 1 3
ournal of Wound Care. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved
practice l E-learning modules The training provider has developed standard e-learning modules for nurses and carers that focus on the prevention and treatment of wounds. These modules are based on best practice and evidence-based guidelines, including European Pressure Ulcer Advisory Panel guidelines and European Wound Management Association documents, and are adapted to suit local procedures and the locally-available wound-care products. The training provider offers regular updates to ensure that teaching remains consistent with established guidelines. Local procedures are updated in cooperation with the wound-care manager. The training programme is agreed with local leaders and the community organisation, and is applied according to an annual calendar. Training is assessed, and the results are fed back to the local organisation. Where audits or other observations suggest that it may be beneficial, specific training needs can be met with classroom or bedside teaching. l Follow-up audits Wound-care audits are conducted annually to illustrate where improvements have been made and to indicate whether any further training is required. As a number of communities have been implementing this system for several years, local audits can also be used for benchmarking purposes.
This study set out to test a series of hypotheses regarding the effects of implementing the training programme in four municipalities in Denmark (Aabenraa, Aalborg, Frederiksberg, and Ringsted), which were chosen because annual audit data were available for at least 3 consecutive years. Four specific hypotheses were tested: l Chronic wounds, as a percentage of all wounds, will be reduced. More effective procedures for the prevention and treatment of chronic wounds are expected to result in a lower incidence of (new) chronic wounds, and shorter healing times. While the total number of wounds may increase as the population ages, a larger proportion would be expected to be surgical and trauma wounds (acute wounds), which are less susceptible to proactive prevention policies. l Mean/median wound duration will be reduced. The proportion of wounds that do not heal within 1 year will be reduced. Improvements in the diagnosis and treatment of wounds should lead to a reduction in the proportion of non-healing wounds, proxied by mean wound duration and the proportion of wounds that remain unhealed at 1 year or more. l Mean/median frequency of dressing change will be reduced, as will the proportion of daily dressing changes. More efficient wound-care practice is expected to result in reductions in both the averj o u r n a l o f wo u n d c a r e v o l 2 2 , n o 1 0 , O c to b e r 2 0 1 3
Indicator variable Description Chronic wounds Chronic wounds: leg ulcers, foot ulcers and (% of all wounds) pressure ulcers Acute wounds: surgical and trauma wounds Wounds whose aetiology was unknown (‘other’) were excluded from this analysis Mean/median wound duration Length of time the wound has been unhealed (days) during the week of the audit (in days) Proportion of wounds ≥ 1 year
Proportion (%) of all wounds that have been unhealed for ≥ 1 year in the week of the audit
Mean/median frequency Frequency with which dressings are changed per of dressing change (per week) week, identified for each wound under treatment Proportion of daily dressing change
Proportion (%) of all wounds that require a daily dressing change
Mean/median nurse time The nurse time required to change dressings per wound per week (mins) per wound per week, in minutes. This does not include travel or administration time. It is the mean/median time to change a dressing multiplied by the weekly frequency of dressing change Mean total cost per Mean total cost per wound per week: wound per week (Kr) the cost of nurse time plus the cost of dressings. Nurse time is valued at 450Kr/h Dressings are valued at 55Kr/dressing (average) Total wound care cost per The total cost per wound per week multiplied wound per week (Kr) by the total number of wounds under treatment in the week of the audit Total nurse time per Total nurse time per wound per week wound per week (hours) multiplied by the number of wounds under treatment in the week of the audit
age frequency of dressing change and the proportion of patients having daily dressing changes. l Mean/median nurse time per wound per week will be reduced, as will the total cost per wound per week. Effective prevention, diagnosis and treatment will be associated with shorter healing times and a reduction in the amount of, and cost of, nurse time devoted to wound care.
Method Anonymised patient-level data were available for each of the four communities at baseline (preintervention), year 1 and year 3 post-intervention. These data were collected during the baseline audit and at subsequent annual audits. The programme was initiated at different times in different municipalities, therefore the years are not necessarily the same for each of the four communities. In the primary analysis, data were aggregated across local communities to investigate differences in a range of key indicator variables between years 1 and 3. We tested the hypothesis that introduction
s
© 2013 MA Healthcare
ltd
Study aims
Table 1. Key indicator variables
541
ournal of Wound Care. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved
practice
Total number of patients with 220 a wound under treatment (n)
423
80
143
Total number of wounds under treatment (n)
298
527
114
164
Mean wounds/patient (n)*
1.35 ± 0.73 1.25 ± 0.52 1.43 ± 1.32 1.25 ± 0.79
Median wounds/patient (n)†
1.00 (1–5) 1.00 (1–5) 1.00 (1–11) 1.00 (1–7)
Mean patient age (years)*
75 ± 19.9
Median patient age (years)†
80 (10–106) 76 (19–101) 78 (10–98) 77 (5–99)
70 ± 21.3
71 ± 22.1
71 ± 21.2
* Results presented as mean ± standard deviation; † Results presented as median (range)
Table 3. Primary analysis of key indicator variables for aggregated community data Variable
Year 1
Year 3
p value
Total wounds under treatment (per week) 1103
1110
—
Chronic wounds (n)
706 (64%)
626 (56%)
0.001
Wound duration (days): l Median (range)
280 229 61 (1–14 600) 61 (1–9130)
0.180
Proportion of wounds ≥ 1 year (n)
169 (15%)
0.530
149 (13%)
Frequency of dressing change (per week): 3.53 3.22 0.013 Median (range) 3.00 (
Meeting the challenges of wound care in Danish home care Objective: To evaluate a community-based educational intervention to improve wound-care practice, and thereby reduce the costs of care, in four communities in Denmark. l Method: Annual wound care audits recorded patients’ ages, the number and types of wounds being treated, wound duration (days unhealed), frequency of dressing changes and nurse time per dressing change. Data were available at year 1 and year 3 post-intervention. A statistical analysis was performed, testing for changes in a range of variables between these years. l Results: In the post-intervention period, significant reductions were found in the proportion of chronic wounds, the proportion of wounds requiring a daily dressing change, mean frequency of dressing change, mean nurse time spent in wound care per week, and the total cost of wound care per week. l Conclusion: These results suggest that it is possible to improve wound-care practice and reduce the resource costs of wound care through a systematic programme of education and training, tailored to suit the needs of local communities. l Declaration of interest: S.F. Jørgensen and R. Nygaard are partners of KvaliCare ApS. J. Posnett was commissioned by KvaliCare ApS to undertake the analysis of audit data. l
H
ealth-care providers are facing significant challenges from a combination of demographic changes and constraints on the growth of health-care budgets. As populations become older, the rising demand for health-care services exceeds the growth of gross domestic product (GDP), so the proportion of GDP spent on health care is continually rising.1 Where demand grows faster than the resources to meet it, services must become more efficient. Community-based health-care services are particularly affected, as chronic conditions, which are primarily cared for in the community, are more prevalent in older populations. Wound care is a typical example. The majority of wound care is provided by community nurses, and caring for wounds is often the single most important use of community nurse time.2 Considering the strong correlation between the prevalence of chronic wounds and age,3 it seems likely that as the number of older people increases, so too will the number of patients with a wound.
The intervention An initiative, designed in 2006 to reduce the costs of wound care in Denmark, is currently running in 14 of the 98 Danish municipalities, namely: Aalborg, Aabenraa, Viborg, Langeland, Sorø, Ringsted, Slagelse, Holbæk, Høje Taastrup, Frederiksberg, Ringkøbing Skjern, Holstebro, Lemvig and Struer. By educating and training community nurses and local carers, this intervention aims to reduce heal540
ing times and improve wound prevention, thereby improving efficiency and reducing the costs of wound care.4 At the heart of this intervention is a series of e-learning modules, developed by a central training provider (KvaliCare ApS), which can be adapted to suit the specific needs of each community. The central training provider coordinates and implements the training programme, facilitates annual audits and provides feedback on improvements over time. The intervention has four components: l Baseline audit A point-prevalence audit is carried out to identify specific training needs and establish a baseline against which changes can be measured. Information is recorded on patient age, the number and types of wounds being treated, wound duration (days unhealed), frequency of dressing changes and the time taken per dressing change. During the week of the audit, all community nurses are asked to provide details of every wound-care patient on their active caseload. To maximise the response rates, non-respondents are sent reminders until a reply is received. The results of the audit are presented to the community team leaders and tissue viability nurses (TVNs) and a plan is agreed for the year, which aims to address any priority areas. l Wound-care organisation A manager is appointed within each community organisation, providing a link between the local nurses and carers and the central training provider. This role is to ensure that the training programme meets specific, local needs.
© 2013 MA Healthcare
S.F. Jørgensen,1 Tissue Viability Nurse, Partner of Kvalicare ApS; R. Nygaard,1 Tissue Viability Nurse, Partner of Kvalicare ApS; J. Posnett,2 BA, DPhil, Health Economist; 1 Kvalicare ApS, Sorø, Denmark 2 Heron Evidence Development, London, UK E-mail: [email protected]
ltd
wound audit; practice improvement; efficiency in wound care
j o u r n a l o f wo u n d c a r e v o l 2 2 , n o 1 0 , O c to b e r 2 0 1 3
ournal of Wound Care. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved
practice l E-learning modules The training provider has developed standard e-learning modules for nurses and carers that focus on the prevention and treatment of wounds. These modules are based on best practice and evidence-based guidelines, including European Pressure Ulcer Advisory Panel guidelines and European Wound Management Association documents, and are adapted to suit local procedures and the locally-available wound-care products. The training provider offers regular updates to ensure that teaching remains consistent with established guidelines. Local procedures are updated in cooperation with the wound-care manager. The training programme is agreed with local leaders and the community organisation, and is applied according to an annual calendar. Training is assessed, and the results are fed back to the local organisation. Where audits or other observations suggest that it may be beneficial, specific training needs can be met with classroom or bedside teaching. l Follow-up audits Wound-care audits are conducted annually to illustrate where improvements have been made and to indicate whether any further training is required. As a number of communities have been implementing this system for several years, local audits can also be used for benchmarking purposes.
This study set out to test a series of hypotheses regarding the effects of implementing the training programme in four municipalities in Denmark (Aabenraa, Aalborg, Frederiksberg, and Ringsted), which were chosen because annual audit data were available for at least 3 consecutive years. Four specific hypotheses were tested: l Chronic wounds, as a percentage of all wounds, will be reduced. More effective procedures for the prevention and treatment of chronic wounds are expected to result in a lower incidence of (new) chronic wounds, and shorter healing times. While the total number of wounds may increase as the population ages, a larger proportion would be expected to be surgical and trauma wounds (acute wounds), which are less susceptible to proactive prevention policies. l Mean/median wound duration will be reduced. The proportion of wounds that do not heal within 1 year will be reduced. Improvements in the diagnosis and treatment of wounds should lead to a reduction in the proportion of non-healing wounds, proxied by mean wound duration and the proportion of wounds that remain unhealed at 1 year or more. l Mean/median frequency of dressing change will be reduced, as will the proportion of daily dressing changes. More efficient wound-care practice is expected to result in reductions in both the averj o u r n a l o f wo u n d c a r e v o l 2 2 , n o 1 0 , O c to b e r 2 0 1 3
Indicator variable Description Chronic wounds Chronic wounds: leg ulcers, foot ulcers and (% of all wounds) pressure ulcers Acute wounds: surgical and trauma wounds Wounds whose aetiology was unknown (‘other’) were excluded from this analysis Mean/median wound duration Length of time the wound has been unhealed (days) during the week of the audit (in days) Proportion of wounds ≥ 1 year
Proportion (%) of all wounds that have been unhealed for ≥ 1 year in the week of the audit
Mean/median frequency Frequency with which dressings are changed per of dressing change (per week) week, identified for each wound under treatment Proportion of daily dressing change
Proportion (%) of all wounds that require a daily dressing change
Mean/median nurse time The nurse time required to change dressings per wound per week (mins) per wound per week, in minutes. This does not include travel or administration time. It is the mean/median time to change a dressing multiplied by the weekly frequency of dressing change Mean total cost per Mean total cost per wound per week: wound per week (Kr) the cost of nurse time plus the cost of dressings. Nurse time is valued at 450Kr/h Dressings are valued at 55Kr/dressing (average) Total wound care cost per The total cost per wound per week multiplied wound per week (Kr) by the total number of wounds under treatment in the week of the audit Total nurse time per Total nurse time per wound per week wound per week (hours) multiplied by the number of wounds under treatment in the week of the audit
age frequency of dressing change and the proportion of patients having daily dressing changes. l Mean/median nurse time per wound per week will be reduced, as will the total cost per wound per week. Effective prevention, diagnosis and treatment will be associated with shorter healing times and a reduction in the amount of, and cost of, nurse time devoted to wound care.
Method Anonymised patient-level data were available for each of the four communities at baseline (preintervention), year 1 and year 3 post-intervention. These data were collected during the baseline audit and at subsequent annual audits. The programme was initiated at different times in different municipalities, therefore the years are not necessarily the same for each of the four communities. In the primary analysis, data were aggregated across local communities to investigate differences in a range of key indicator variables between years 1 and 3. We tested the hypothesis that introduction
s
© 2013 MA Healthcare
ltd
Study aims
Table 1. Key indicator variables
541
ournal of Wound Care. Downloaded from magonlinelibrary.com by 137.189.170.231 on November 21, 2015. For personal use only. No other uses without permission. . All rights reserved
practice
Total number of patients with 220 a wound under treatment (n)
423
80
143
Total number of wounds under treatment (n)
298
527
114
164
Mean wounds/patient (n)*
1.35 ± 0.73 1.25 ± 0.52 1.43 ± 1.32 1.25 ± 0.79
Median wounds/patient (n)†
1.00 (1–5) 1.00 (1–5) 1.00 (1–11) 1.00 (1–7)
Mean patient age (years)*
75 ± 19.9
Median patient age (years)†
80 (10–106) 76 (19–101) 78 (10–98) 77 (5–99)
70 ± 21.3
71 ± 22.1
71 ± 21.2
* Results presented as mean ± standard deviation; † Results presented as median (range)
Table 3. Primary analysis of key indicator variables for aggregated community data Variable
Year 1
Year 3
p value
Total wounds under treatment (per week) 1103
1110
—
Chronic wounds (n)
706 (64%)
626 (56%)
0.001
Wound duration (days): l Median (range)
280 229 61 (1–14 600) 61 (1–9130)
0.180
Proportion of wounds ≥ 1 year (n)
169 (15%)
0.530
149 (13%)
Frequency of dressing change (per week): 3.53 3.22 0.013 Median (range) 3.00 (
