Case studies

Perley Health is a designate Long-Term Care Best Practice Spotlight Organization® (BPSO®) which demonstrates a strong commitment to providing evidence-based care. During the pandemic, the team identified skin and wound infection as a clinical concern among their residents. Consistent with the literature, residents at Perley Health experiencing comorbid medical conditions such as frailty, diabetes, and arterial and venous insufficiency were at increased risk for chronic wound infections [1]. Chronic wounds are a prime environment for bacteria, including biofilm, making wound infection a common problem [2] [3]. Managing biofilm, which can affect wound healing by creating chronic inflammation or infection [3], becomes crucial as up to 80 per cent of infections are caused by this type of bacteria [4] [5].

To adopt and integrate best practices, the team at Perley Health decided to implement the Assessment and Management of Pressure Injuries for the Interprofessional Team best practice guideline (BPG). To support a systematic approach to change, four of the action cycle phases of the Knowledge-to-Action Framework, from the Leading Change Toolkit [6] are highlighted below.

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Identify the problem 

Perley Health’s wound care protocol was audited and the following gaps were identified based on current evidence:

• Aseptic wound cleansing technic could be improved, as nonsterile gauze was used for wound cleansing.
• Wound cleaning solution was not effective to manage microbial load in chronic wounds
• Baseline wound infection data were collected on the number of infected wounds within the organization each month over three years and is ongoing

Adapt to local context

The project was supported by key formal and informal leaders within the organization including the Nurse Specialized in Wounds, Ostomy and continence (NSWOC), the Director of Clinical Practice, a team of wound care champions, the IPAC team and material management. Staff was motivated to improve resident outcomes by lowering infection rates which facilitated the project but many continued to use old supplies so as to not waste material. Providing the rationale for the change and associated best practices improved knowledge uptake, as did removing old supplies to cut down on confusion. Barriers the team encountered included staff turnover and educating new team members.

Select, tailor, implement interventions

The interventions listed below were selected, tailored and implemented based on the evidence that was adapted to the local context. They were purposely chosen to support the clinical teams’ needs on busy units and to creatively overcome staffing challenges. Interventions included:

• use of a wound cleanser containing an antimicrobial
• use of sterile equipment for wound care, including sterile gauze
• creation of a wound-cleansing protocol was created to reflect best practice
• updating and approval of a policy by the Risk Assessment and Prevention of Pressure Ulcers team in collaboration with the director of clinical practice

Perley Health also created and delivered education in two formats designed to be accessible to front-line staff:

• Just-in-Time education was provided on every unit, on every shift, to registered staff by the NSWOC on all shift sets, over a one-month period. Wound care champions were available on each shift to aid in learning and answer additional questions to support the team’s needs.
• A continuing education online learning module was created and uploaded onto Perley Health’s Surge learning platform. Training is included in new hire onboarding and mandatory for yearly education.
  
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 An RPN demonstrating how to cleanse a wound using wound cleanser at Perley Health

Evaluate outcomes

Evaluation indicators were selected to determine the impact of the implementation interventions when compared to baseline data, including the rate of wound and skin infections per 1,000 days.  A 50 per cent reduction in wound infections was identified following the implementation of the identified change strategies and education above. 

This graph represents four years of data collection on wound infections at Perley Health. Three years of baseline data and one year of post-implementation data are highlighted in red.

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References

1. Azevedo, M., Lisboa, C., & Rodrigues, A. (2020). Chronic wounds and novel therapeutic approaches. British Journal of Community Nursing, 25 (12), S26-s32.
2. Landis, S.J. (2008). Chronic Wound Infection and Antimicrobial Use. Advances in Skin & Wound Care, 21 (11), p 531-540.
3. Registered Nurses’ Association of Ontario (2016). Clinical best practice guidelines: Assessment and management of pressure injuries for the interprofessional team (3rd ed.). Registered Nurses’ Association of Ontario: Toronto, ON.
4. Jamal, M., Ahmad, W., Andleeb, S., Jalil, F., Imran, M., Nawaz. M., Hussain, T., Ali, M., Rafiq, M., & Kamil, M.A. (2018). Bacterial biofilm and associated infections. J Chin Med Assoc. 81(1): 7-11.
5. Murphy, C., Atkin, L., Swanson, T., Tachi, M., Tan, Y.K., De Ceniga, M.V., Weir, D., Wolcott, R., Ĉernohorská, J., Ciprandi, G., Dissemond, J., James, G.A., Hurlow, J., Lázaro MartÍnez, J.L., Mrozikiewicz-Rakowska, B., & Wilson, P. (2020). Defying hard-to-heal wounds with an early antibiofilm intervention strategy: wound hygiene. J Wound Care, (Sup3b):S1-S26.
6. Registered Nurses’ Association of Ontario (2022). Leading change toolkit: Knowledge-to-action framework. https://rnao.ca/leading-change-toolkit Registered Nurses’ Association of Ontario: Toronto, ON.

Spectrum Health Care (Spectrum), an RNAO Best Practice Spotlight Organization® (BPSO®), is a home health organization with more than 200 nursing staff across three locations in the province of Ontario, Canada.

Spectrum chose to implement the 2015 Person- and Family-Centred Care (PFCC) Best Practice Guideline (BPG) to enhance person- and family-centred care and to reduce complaints regarding care. Members of the senior leadership team at Spectrum Health Care led implementation together with Spectrum’s Patient and Family Advisory Council.  

To support the practice change, Spectrum used the following implementation interventions:

• Conducting a gap analysis to determine the knowledge/practice gap;
• Holding education sessions for staff on person- and family-centred care best practices;
• Revising their care processes to include review of care plans with the person and/or members of their family
• Surveying staff members on their attitudes about person- and family-centred care via surveys
• Developing staff education on communication strategies to support the assessment of a person’s care needs and care plans.

After implementing these interventions, Spectrum assessed the number of complaints received from persons receiving care per 1,000 care visits and compared that to their baseline. 

They found a decrease of 42 per cent of complaints from persons received over an 18-month time period at one of the sites that was implementing the PFCC BPG at Spectrum Health Care. 

At another site, an 80 per cent reduction in complaints was found following the staff education intervention.    

Data analyses overall indicated that the implementation of the PFCC BPG was highly successful in reducing persons' complaints regarding care.

Read more about Spectrum Health care’s results of implementing the PFCC BPG here: Slide 2 (rnao.ca)

A major acute-care hospital in Toronto, Ontario, Humber River Hospital (now Humber River Health) has used continuous monitoring to determine the impact of their BPG implementation and staff performance.

These tiles, displayed on large screen monitors in a Command Centre (pictured above), are integrated into the daily delivery of care to support physicians, nurses, and other clinical staff. Each row within the tile represents a patient, followed by where they are located. By clicking on a patient, staff can see more information regarding the clinical criteria that put them on the tile.

With every patient, there is an expected time in which the issue should be resolved based on a service level set by the hospital. If the system detects that the process is taking longer than expected, the icon will escalate to amber and then to red, indicating a higher level of alert.

Tiles also include several quality monitoring indicators based on RNAO's best practice guidelines (BPG) related to fall risk intervention, wound and skin management, pain management and delirium management. By centralizing data in the Command Centre, the monitoring indicators empower clinicians so that they can intervene in a timely manner to ensure that best practices are followed. 

Read more about this innovative quality monitoring approach here: https://www.hrh.ca/2020/08/04/cc-risk-of-harm/