Quality indicators for a community-based wound care centre: An integrative review

Standardized Wound Care: Patchwork Practices?

Standardized care is crucial in health care for ensuring consistent, safe, high-quality, efficient, and evidence-based practices. Care pathways that standardize procedures promote adherence to best practices, reduce variability in treatment, and encourage collaboration among health care teams. This approach ultimately improves patient outcomes, enhances safety, and boosts the overall effectiveness of health care services. However, despite these benefits being widespread across most of the U.S. health care system, wound care stands out as an area where standards can vary significantly. The inconsistency in wound care standards in the United States can be traced to several factors. These include limited structured clinical wound care education, the discretion of health care providers in different business environments, differences in wound care settings, varying access to advanced treatments and technology, patient demographics and socioeconomic status, as well as differences in state laws and regional or institutional practices. Addressing these disparities requires a comprehensive approach that considers the complex interplay of the abovementioned factors. Active measures are needed to improve access, equity, and the quality of wound care services for all patients, regardless of where they live, their socioeconomic status, their health care coverage, or the business interests of providers and their institutions as well as of vendors marketing wound care products inconsistent with evidence-based practice. By understanding and actively addressing these factors, we can work toward achieving more standardized, evidence-based, and patient-centered practices in wound care across the nation.

Key performance indicators to inform evaluation of wound care programmes for people with complex wounds: a protocol for systematic review

OBJECTIVE

The objective of the systematic review is to examine and summarise the available evidence in the literature of the use of key performance indicators (KPIs) to inform evaluation of wound care programmes and services for people with hard-to-heal (complex) wounds. The need for wound care is expected to grow with the continued ageing of the population and the resulting increased development of chronic conditions. This expected increase necessitates improvement of wound care programmes and services and their ability to deliver quality, evidence-based and cost-effective practice. The current literature lacks a systematic assessment of KPIs to inform evaluation of wound care services and programmes across various settings, and how the KPIs are used to improve the quality of wound care and achieve desired outcomes. This protocol sets out how the systemtic review will be undertaken.

METHOD

Primary studies will be screened from databases such as MEDLINE, CINAHL and Scopus, with unpublished studies and grey literature retrieved from Google Scholar and ProQuest Dissertations and Theses. The study titles and abstracts will be screened by two independent reviewers, using Covidence systematic review software to ensure they meet the inclusion criteria, who will then proceed with data extraction of the full-text using the standardised data extraction instrument. The reference lists of all studies selected for critical appraisal will be screened for additional publications. The two independent reviewers will critically appraise all studies undergoing full-text data extraction using the appropriate checklist from JBI SUMARI. At all stages, differences between reviewers will be resolved through discussion, with adjudication by a third, independent reviewer.

RESULTS

Data points will be analysed with descriptive statistics and grouped, based on programme characteristics and publication status. Grey literature and peer-reviewed publications will form separate analyses. To answer review questions, the data will be summarised in a narrative format. A meta-analysis is not planned. At the time of writing, this protocol has been implemented up to the preliminary literature search.

CONCLUSION

This review will address a current literature gap and systematically identify KPIs in wound care, allowing for programmes to evaluate their quality of care and improve their services in a methodical manner.

Community-Based Wound Care Programs for Unhoused Individuals

Wound care management for unhoused individuals is challenging due to the lack of healthcare infrastructure to handle the unique needs of this population. Therefore, we aimed to obtain insights for best practices and to establish a care clinic that is low threshold, community-based and meets the needs of unhoused people. We employed two approaches: (1) conduct a targeted narrative review of the literature of existing or proposed community-based program models that can address the wound care needs of unhoused individuals, and (2) assess cost-effectiveness and describe the results of a survey administered to unhoused clients and their health care providers at a community-based wound care program in Honolulu, Hawai'i. The literature search and screening yielded 11 articles relevant to the topic. Per the literature, existing community-based healthcare programs were successful when: (1) wound care services were incorporated into a broader social/health program, (2) cost-effective, and (3) comprehensive services were provided. Survey results in Honolulu found that the wound care program matched the needs of the targeted population and was cost-effective. Difficulty in following clients until wound closure and the sustainability of the program, particularly the lack of insurance reimbursement for street-based services, were perceived challenges. Additionally, the lack of insurance reimbursement for street-based wound care services continues to impact sustainability. Community-based programs can be successful in addressing the wound care needs of unhoused individuals if they address complex fundamental issues. This paper highlights existing gaps in logistics and policies that must be addressed to meet the specific medical needs of these vulnerable individuals.

The need for integration nursing theories into pressure ulcer care in the community

Pressure ulcers are injuries to the skin requiring integrated care, particularly when patients are at home. Pressure ulcers have been a nursing concern for years, and several strategies have been proposed for its prevention and management. Nursing theory, which is essential for nursing practice, recommends plausible approaches to health problems. However, literature describing steps to integrate nursing theory into pressure ulcer care has not yet been explored. For this reason, this article discusses the six steps on how to apply nursing theory in community practice. A case study is also discussed to help gain a better understanding of these steps.

In Vitro Wound Dressing Stack Model as a First Step to Evaluate the Behavior of Dressing Materials in Wound Bed-An Assessment of Mass Transport Phenomena in Hydrogel Wound Dressings

Wound dressings when applied are in contact with wound exudates in vivo or with acceptor fluid when testing drug release from wound dressing in vitro. Therefore, the assessment of bidirectional mass transport phenomena in dressing after application on the substrate is important but has never been addressed in this context. For this reason, an in vitro wound dressing stack model was developed and implemented in the 3D printed holder. The stack was imaged using magnetic resonance imaging, i.e., relaxometric imaging was performed by means of T2 relaxation time and signal amplitude 1D profiles across the wound stack. As a substrate, fetal bovine serum or propylene glycol were used to simulate in vivo or in vitro cases. Multi-exponential analysis of the spatially resolved magnetic resonance signal enabled to distinguish components originating from water and propylene glycol in various environments. The spatiotemporal evolution of these components was assessed. The components were related to mass transport (water, propylene glycol) in the dressing/substrate system and subsequent changes of physicochemical properties of the dressing and adjacent substrate. Sharp changes in spatial profiles were detected and identified as moving fronts. It can be concluded that: (1) An attempt to assess mass transport phenomena was carried out revealing the spatial structure of the wound dressing in terms of moving fronts and corresponding layers; (2) Moving fronts, layers and their temporal evolution originated from bidirectional mass transport between wound dressing and substrate. The setup can be further applied to dressings containing drugs.

An Innovative National Programme for Comprehensive Chronic Wound Therapy and Its Impact on Treatment Outcomes

BACKGROUND

Although the lifetime prevalence of chronic ulcers tends to be approximately 2.2-10 per 1000 population, no systemic solutions for this problem have been implemented in many countries. It is still not fully agreed whether treatment of chronic wounds requires hospitalization, which incurs high costs, or whether the therapy can be carried out entirely in an outpatient setting. Therefore, the aim of this study was to evaluate the 5-year activity and effectiveness of a national programme for the comprehensive treatment of chronic wounds based on hybrid care for patients. Treatment of nonhealing chronic wounds begins in the hospital, where necessary diagnostic actions are carried out, followed by surgical cleansing of the wound and selection of appropriate dressings. Then, the treatment is continued in the outpatient setting with a continuous patient education. The programme is divided into four subsequent stages. In addition, the present study compared the effectiveness of chronic wound treatment with that in the period before implementation of the programme.

METHODS

From January 2015 to December 2019, 383 patients were treated at a centre for chronic wounds. We analysed the outcomes in 227 individuals with chronic venous ulceration or diabetic foot syndrome.

RESULTS

The mean wound area at the time of introduction of treatment was 36 cm2 (1-290; SD 34). After three stages of treatment, wounds were completely healed in 139 patients (61.2%), 78 patients with venous ulcers (55.3%) and 61 patients with diabetic foot (70.9%). In an additional 67 cases (29.5%), a significant reduction in wound area and depth was achieved, and the treatment was continued beyond the actual treatment programme. No significant effect was achieved in 21 patients (9.2%). In the group of patients treated without systematic application of the guidelines of the programme, wound healing occurred only in 19 cases (26.8%), reduction in the wound area occurred in 27 patients (38.0%), and lack of any healing progress or even worsening of the wound status was found in the remaining 25 cases (35.2%); these differences were statistically significant (p < 0.001).

CONCLUSION

Treatment of chronic wounds based on a systematic dedicated programme using an experienced multidisciplinary team of professionals allows to obtain better results in terms of reduction in wound area and might be an effective procedure. The combination of frequent, scheduled outpatient visits, access to inpatient treatment, and regular education of patients based on a standard form improves treatment outcomes.

Quality indicators for a community-based wound care centre: An integrative review

The purpose of this review was to identify the role and contribution of community-based nurse-led wound care as a service delivery model. Centres increasingly respond proactively to assess and manage wounds at all stages - not only chronic wound care. We conducted an integrative review of literature, searching five databases, 2007-2018. Based on inclusion and exclusion criteria, we systematically approached article selection and all three authors collaborated to chart the study variables, evaluate data, and synthesise results. Eighteen studies were included, representing a range of care models internationally. The findings showed a need for nurse-led clinics to provide evidence-based care using best practice guidelines for all wound types. Wound care practices should be standardised across the particular service and be integrated with higher levels of resources such as investigative services and surgical units. A multi-disciplinary approach was likely to achieve better patient outcomes, while patient-centred care with strong patient engagement was likely to assist patients' compliance with treatment. High-quality community-based wound services should include nursing leadership based on a hub-and-spoke model. This is ideally patient-centred, evidence-based, and underpinned by a commitment to developing innovations in terms of treatment modalities, accessibility, and patient engagement.