Standardizing Riverside’s wound and skin care formulary
Medline and Riverside concluded that the system’s challenges revolved around products, clinical education and protocols. Our team devised a plan to standardize wound care products used in every unit and reeducate providers on a consistent curriculum based on uniform treatment protocols to be used throughout the system.
One component of the assessment project was a closer look at the system’s usage patterns of wound and skin care products. The results were telling: in a one-year study, Medline and Riverside discovered the system used 113 different items and only 10 of those products were used at every Riverside facility. This included 25 different foam dressings, 14 different silver dressings and nine different gelling fiber dressings, among other products.
“When we looked at the number of products we were using, it was mind-blowing. To be honest, I didn’t have any idea the variation was to that extent.”
Senior vice president and chief nursing officer, Riverside Healthcare
The use of different products at different levels of care confused patients. “Patients said they did not like the products being switched,” said Rebecca Schiltz, director of rehabilitation services at Riverside. “There was lots of anecdotal information. The more we dug in, we discovered nurses had over 100 products they could order from 15 different suppliers.”
Riverside management realized that improving product consistency across the system would not only create a better patient experience, but also a better experience for nurses. Standardization would make nurses feel more comfortable in working across the continuum of care and increase their confidence in the patient’s treatment success as they transitioned from one care setting to the next.
So, together we set out to create a product formulary to be used across the system. After reviewing all wound and skin care products used at each facility across Riverside, we determined they were able to reduce the number of unique products used across the system by more than 50%, offering a significant opportunity to reduce product costs and standardize treatments and outcomes.
Mutterer also pushed for the health system’s 12 skilled nursing partners to adopt the same practices. Even though these providers weren’t part of the Riverside Healthcare organization, they made a significant contribution to the care continuum, he noted.
Teaching standardization in wound care
Education would also be key to ensuring all clinicians were treating patients properly and consistently. “In general, most nurses are not certified in wound care,” Mutterer said. “Their training for basic wound care can vary from A to Z. Standardizing training on a standardized product line helps them feel more confident and comfortable in assessing and treating wounds.”
Implementation of a formulary created a substantial learning curve as the system had to convince clinicians that moving to a standard line of products was good for both staff and patients.
“It was rough because we were taking away products that people knew,” Schiltz said. “At first, the teams did not understand all the new products. We had to get the teams to embrace them.”
As a part of the education program, registered nurses and certified nursing assistants from select units learned a standardized method for preventing skin damage such as pressure injuries, moisture-associated skin issues and skin tears. RNs received further training on wound care and the system’s new formulary of products.
“The fact that, from the top down, all staff got trained—even aides—shows a real commitment from
Riverside,” said Sue MacInnes, Medline’s Chief Market Solutions Officer. “Changing a protocol or a
formulary is a process. Changing the behaviors of people means those people want to know why: ‘What do I get out of this and how does it help my patients?’ The leadership of the organization hasto demonstrate both commitment and a passion for better patient care. Riverside never took their eye off the greater good for the patient and that filtered down to every staff member.”
The new training had a noticeable impact on patient satisfaction, in part because it improved treatment efficiency. For Schiltz, a major ‘aha moment’ came when, through education and changes in protocol, bedside rehabilitation nurses were empowered to triage wounds upon admission in the rehabilitation unit, instead of waiting for a specialty nurse to do so.
Medline and Riverside also devised a new, more consistent education platform for wound care patients. This was a crucial part of ensuring outcomes remained consistent even after patients were discharged from the hospital, Mutterer noted.
“Education is a means for us to teach patients to care for themselves once they leave our four walls,” he said. “Poor patient education can lead to poor outcomes.”
Nurses rated their comfort with staging a wound at three or higher on a five-point scale.
The biggest win for Schiltz came in the rehabilitation unit, where she was able to watch bedside nurses treat wounds on “day one,” which helped speed up the healing process. Because patients often come to the rehabilitation unit after major surgery, it’s a frequent provider of wound care.
“To see people go home from rehab with their wounds fully healed is amazing,” Schiltz said. “We never tried to heal before. We tried to stop them from getting worse.”
In 2015, Riverside’s wound center ranked just below the national average of 78 days to fully heal arterial ulcers. That number dropped consistently throughout 2016, and today those wounds take just 30 days to heal when treated at Riverside. Nationally, diabetic foot ulcers take an average of 86 days to heal, but Riverside’s wound center has lowered that number to 40 days. Meanwhile, Riverside is also healing venous leg ulcers faster than the national average.
“A health system that improves its standardization doesn’t just save money—it also improves its care. That is when things start to turn.”
Higher awareness of skin assessment on admission
Early attention to wound issues has also helped Riverside avoid hospital-acquired pressure injuries (HAPIs). In one notable case, nurses immediately identified two patients that were discovered to have a deep tissue pressure injury (DTPI) upon admission to the rehabilitation unit. Many of these DTPI wounds develop into full-thickness pressure injuries while a patient is in the hospital and must be reported to state authorities as a HAPI. But because the newly-trained nurses identified these wounds early on in the admissions process and addressed them accordingly, they were able to prevent a reportable HAPI.
“The keen eye and awareness of the rehab staff has proven to be beneficial for Riverside,” MacInnes said. “The staff indicated that those types of wounds, prior to their training and focus on skin health, would certainly have been missed.”
Increased number of wound center patients
By improving care quality, Riverside’s wound center was able to treat more patients. The system’s wound care volume rose by 32% to 451 patients in fiscal year 2016, and visits to the wound center increased 17%. The clinic closed 57% more wounds in 2016 than the year before, demonstrating its value within the health system and the entire community as a care resource and a revenue driver.
Riverside’s success can also be seen in avoided costs.
Healthcare costs related to HAPIs increase annually and are estimated to be between $44,000 and $128,000 per pressure ulcer, according to the AORN Journal. HAPIs have been reduced at Riverside as the result of provider training on proper skin assessments and early identification of skin issues during the Medline program.
Pharmaceutical costs for debriding wounds are almost a hidden cost. The new product formulary and provider education helped bring those costs down. Riverside was able to reduce the annual cost for an enzymatic debriding agent by 71% through training staff on alternative treatments that produce similar care outcomes.
“This is just one example of the staff’s knowledge and the ability to apply it to practice. Using the patient assessment skills combined with product knowledge, the staff was able to look for the best option for their patient. The staff demonstrated time and time again the value of empowerment,” said Margaret Falconio-West, Medline’s senior VP of clinical education and a member of the project team.
Nurses gave an overwhelming thumbs up to the transformation process. In a survey of nursing staff, 74% said they were “very satisfied” and 19% said they were “satisfied” with the education provided by Medline. Ninety-three percent said they were either very satisfied or satisfied with the Medline Remedy Skin Care product line included in the system’s new formulary, followed by 92% who were either very satisfied or satisfied with Medline’s advanced wound care products.
Perhaps most importantly, 87% of nurses rated their comfort with staging a wound at three or higher on a five-point scale. “Bedside nurses used to hate wounds,” Schiltz, said. “They would be very quick to put in for a consult from a specialty nurse. Now they enjoy changing the dressing and treating them. They’re empowered. They’re very excited.”