Wound I.D. made easy: Using evidence-based nudges to achieve standardized wound assessment

Clinician with gloved hands measures a wound with the NE1 tool.

It’s 2008, and Nancy Estocado, PT, CWS, is midflight, with her overhead light on and seat tray down. She’s intently sketching out her idea for a new wound assessment tool. She doesn’t know it yet, but over the next two years and countless more drawings, her paper assessment tool will be implemented at her hospital, Sunrise Hospital and Medical Center in Las Vegas, Nevada. In 2010, her hospital’s parent corporation, Nashville, Tennessee-based HCA Healthcare, will recognize her ingenuity with its prestigious Innovators Award for Quality and Safety. Six years later, the tool will be used in most of HCA’s 179 hospitals nationwide.

Standardized processes make it hard for staff to make mistakes.

Estocado names the inverted L-shaped tool “NE1” because anyone using it at bedside will be able to assess wounds more accurately by matching them to one of a line of wound images on the tool. She states that the tool is easy and fast to use, reduces guessing by frontline staff and, most important, leads to better patient outcomes. Fast forward to early 2019. Sunrise is now part of the three-hospital Sunrise Health System. The system has phased in the use of secure mobile phones featuring a proprietary NE1 app. Frontline staff are taking time-stamped digital photos early, on admission, and uploading them for further assessment by onsite wound care specialists. From there, providers sign off on assessments, and cases are promptly coded. Estocado also is getting her first glimpse of data on NE1’s impact, specifically the number of coded pressure injury (PI) cases reported at the hospitals. The initial numbers on coding and reimbursable present on admission Stage 3 and 4 PIs are soaring — signs that transparency in reporting and a streamlined workflow in wound care are taking hold.

Nudges and results

How did Estocado convince her colleagues, from top HCA executives down, to adopt NE1 and her wound assessment methodology? Talk to her and there’s little doubt that she is passionate about NE1 and achieving accurate, universal wound assessment. But enthusiasm alone doesn’t lead to sustained, transformational change in healthcare facilities.

Hard data drives change, she says, and that means measuring performance continually and in real time. Throughout her 10-year journey to standardized wound care, she’s repeatedly turned to evidence and persistent staff training to instill long-term change. She’s faced major challenges along the way. According to Estocado, this is how she’s worked to overcome three main ones.

  1. Frontline staff often resort to an old habit — guessing on wound classifying and staging.
    —Nudges: Continually train and educate frontline staff on wound assessment. Train in real time and across the continuum.
    —Key Results: It builds frontline staff’s confidence in their ability to assess wounds correctly.
  2. Resistance from wound healthcare colleagues from top down. From frontline staff to physicians and executive leaders, there was resistance to transparent reporting of hospital acquired pressure injuries (HAPIs). Frontline staff, in particular, were afraid of doing something wrong, Estocado says.
    —Nudges: Provide evidence, including ongoing quarterly data on HAPI reporting, coding results, cost-savings and potential reimbursement cases. Partner with physicians, nurses, and others to achieve outcomes and improve quality of care.
    —Key Results:
    The HAPI rate at Sunrise Health System’s largest facility plunged 70% from Q4 2017 to Q4 2018.
    With real-time data, CNOs — and by extension the C-suite — stay current on what is happening in wound care at their facility.
    —Systemness was achieved by standardizing wound assessment, including treatment protocols, products and patient education. This led to lower costs of care, higher reimbursements and fewer penalties and 30-day readmissions, Estocado says.
  3. Lack of a consistent, fluid workflow. Consider wound photography and what happens when patients take photos of their wounds with their smartphones. It’s wise to get ahead of the problem.
    —Nudges: Have frontline staff across the continuum take digital photos early, on admission. When wounds are caused by the facility, encourage staff to report them early for just-in-time care. To make change fun, hold a facility-wide “PI reporting” contest.
    —Key Results:
    Digital photos serve as real-time audits, leading to better reporting and coding.
    Photos are great teaching tools. Discuss them with patients and their families throughout their care.
    Digital photos can protect the facility from risk and liability. They also help build patients’ trust in the facility.

The Methodology behind NE1

Illustrations of steps to use NE1 wound measurement tool.
Illustrations of steps to use NE1 wound measurement tool.
Illustrations of steps to use NE1 wound measurement tool.

Estocado’s evidence-based wound assessment methodology, called H-A-T-T, is designed to improve workflow around wound care. It also promotes teamwork at all levels in classifying wounds. Here’s how it works: Frontline staff are encouraged to participate in all four H-A-T-T steps — History, Anatomy, Tissue Type and Touch/view details. But their primary responsibility is to cover H and A by answering: What caused the wound? Is it due to pressure or other causes (i.e., burn or moisture)? On what body part is the wound located? Wound care specialists then zero in on the T and T. Using NE1, they assess worst tissue type and color and provide touch or view details. Once wounds are classified accurately with the involvement of providers, proper coding and billing complete the process.