By Catherine T. Milne, APRN, MSN, BC-ANP, CWOCN-AP
Editor's Note: This letter originally appeared in the 19th edition of WoundSource™, published July 2016.
From Nike's "Just Do It" ad campaign to Google's corporate "Don't be evil" code, I've always been struck by the many marketing campaigns that remind us to pay attention to our conscience. A similar focus should apply to health care. In 2000, the Institute of Medicine (IOM) published a scathing report showing that the number of people who died from medical errors surpassed the combined total of those who died from breast cancer and car accidents.1 To make matters worse, this was likely a low estimate. In 2013, the Journal of Patient Safety reported that adverse events from preventable harm may affect between 210,000 and 440,000 hospital patients each year.2 As clinicians, we've all taken an oath, a pledge or a vow to "do no harm." Why is the reality so far from the ideal?
The IOM report has changed health care corporate culture, and that's a good thing. The emphasis on patient safety has resulted in "time-outs," "SBARs," "huddles" and relentless requests of the patient to regurgitate his or her birth date. I've had many annoyed patients wonder why we keep asking for personal information verification. We still are uncomfortable trying to explain to patients who entrusted their life to us that because of human error, we have unwittingly done things that have led to injury or demise of our fellow human beings.
Hand hygiene compliance rates have been abysmally low—around 30%.3 How sad it is when we have to post signs, as some facilities do, to remind our patients to nag us if they did not see us wash our hands. That's no way to instill confidence in their care! Why do we need to be told to do no harm? Technology via video or chip-embedded sensor badges now oversees our actions. When did our conscience and our commitment to patients go on permanent vacation? We've documented the problems—lack of supplies, ignorance of low adherence rates and time constraints, to name a few.4 Why can't we do the right thing?
Like beauty, "the right thing" may be in the eye of the beholder. As providers, we educate our patient with a diabetic foot ulcer to control blood sugar levels, offload the foot, and perform local dressing changes. That's the right thing. For our patient—who is already straining to pay the mortgage, and who stands all day at work to earn money to pay for the mortgage, medicine and wound dressings—life is a struggle. Oh yes, the patient stops at the local fast food place because the glucometer said the blood sugar was getting too low. The patient is doing the right thing, too. It may not be in his or her best interests, but it is the patient's perception of the right thing at that moment.
The Components of Evidence-Based Wound Care
In the original definition of evidence-based practice, Sackett5 outlines three intertwined components: (1) best available literature, (2) individual clinician expertise and (3) patient preferences. As with a three-legged stool, each element is dependent on the others. When one leg is broken, short or absent, outcomes are compromised. In the worst scenario, the patient's safety is at risk. What is the best available evidence? Well, it may depend on clinician expertise. When I entered the wound care specialty, I wasn't reading about molecular and cellular interactions in the wound bed. I was trying to find out the difference between a hydrocolloid and a calcium alginate. I was a novice. I was reading the best available literature for my level of expertise. As expertise increases, our lifelong effort to seek out the best available evidence— which can be a moving target as science makes new discoveries—must also change.
Patient preferences can be very different from what we wish. Patients want to see their granddaughter get married, even if that means sitting on that pressure ulcer for a three-hour plane ride in the middle seat! We are afraid of lawsuits and poor peer approval if we allow our patients to dictate their care. After all, they came to us for help. So what is the "right thing"? We face these moral dilemmas daily.
Is it still the "right thing" when a quick decision needs to be made and a cursory review (never mind an exhaustive review) of the literature for the best practice can't be accomplished? What about the provider who does not know what she doesn't know? I suspect many adverse events in health care occur because one thinks one is doing the right thing, but is actually doing the wrong thing. For example, the majority of wound care in the United States is provided not by modern wound care dressings, but by wet-to-dry dressings.6 In Armstrong and Price's study, less than 25% of the clinicians used modern wound care dressings, even though they were readily available.7
Where Intervention and Outcome Meet
The concept of performance improvement8 may have gotten its start because the "right thing" was not done. Even the IOM has said, "to err is human."1 At its core, committing to the "right thing" means we must have interventions that have been shown to have a desired outcome. Although specific wound care treatments have been shown to have variable efficacy, it takes the clinician's critical thinking to apply this knowledge to the particular patient situation and preference. The same goes for appropriateness, defined as a specific intervention to meet the patient's needs. Sometimes that does not mean weekly visits for the 92-year-old who depends on the goodwill of a dwindling circle of friends to provide transportation.
Instead of the admonishment, "well, do the right thing," perhaps "do the right thing well" is more appropriate. Thirty percent of acute care service payments are reimbursed on patients' perception of satisfaction. As health care continues to evolve, this method will expand to other settings and providers. Combining the emotional human component with technical aspects of safety and care coordination raises expectations for health care consumers and clinicians alike. The shift toward pay for performance has already begun. Does this mean when we tell our wound patients to lose weight, use compression stockings despite 90-degree heat, and stop smoking, they will give us poor satisfaction ratings? Yes, they may. Nonetheless, it is the "right thing." Working with patients to have them think that changing their behavior is their idea is "doing the right thing well." Everyone benefits.
"Doing the right thing well" also means providing timely care. When you are managing a wound, time is tissue. Obtaining a working diagnosis, collaborating with non-wound care providers to manage comorbidities, ensuring adequate wound bed preparation, treating infection, and managing the underlying wound etiology while the patient moves through a variety of settings and ever-changing insurance requirements is difficult. Whew! Timeliness takes a lot of time. When done well, it saves time. Fewer visits, decreased cost, less pain, better patient satisfaction, more favorable reimbursement. Paid for the performance.
Calibrating the Process of Care
Unfortunately, the wound care community lacks clear and comprehensive data about the effectiveness of the many therapies it administers. We are frequently criticized by our non-wound care colleagues for not having heterogeneous groups in our studies, for low numbers of study participants, for poor research designs and for comparison of the study product to wet-to-dry dressings. Effectiveness, not to be confused with efficacy, is defined as "the degree to which care and services are provided in the correct manner, given the current state of knowledge, to achieve the desired or projected outcome for the patient."8 Sounds like the definition of evidence-based practice. We are getting better in this area.
Ultimately, we aim for "doing it right the first time." Avoiding errors avoids wasted time, effort and cost. For example, over one and a half million people board commercial aircraft every day in the United States. The airlines get this right the first time. Yes, we complain that our seat is too small and we hate the packages of pretzels thrown our way. But we land safely. Are there near misses in this business? I'm sure there are, just as in health care. The difference? The airlines are not having us arrive at our destination maimed, or worse, dead. They have fine-tuned their processes to simultaneously meet productivity, financial and quality measures. We're still trying to get there.
As Clinical Editor of WoundSource™, I want all our readers to "do it right the first time well." Need to brush up on a certain wound product category? Afraid technology has changed and you've moved into the "don't know what you don't know" realm of practice? Want data to be prepared for the value analysis committee to make a change in a restricted formulary? Nothing is more convenient than accessing WoundSource™ in either hard copy or digital format. Bring up the product category and compare features. If you, the reader, can articulate (using your clinician's expertise) a feature of that device or dressing (using the best available evidence) that meets the patient's goals for acceptability, availability and outcomes (preferences), then you are adhering to an evidence-based practice model. It is the Right Thing, Done Well, the First Time. Who can argue with that?
1. Kohn LT, Corrigan J, Donaldson MS (Institute of Medicine).To err is human: Building a safer health system. Washington, D.C.: National Academy Press, 2000.
2. James JT. A new, evidence-based estimate of patient harms associated with hospital care. J Patient Saf. 2013 Sep;9(3):122-128.
3. Healthcare worker hand-washing compliance rate remains frustratingly low. June 13, 2013. Available at: www.safepatientproject.org/posts/4569. Accessed April 2, 2016.
4. Rodak S. Why does low hand hygiene compliance still plague healthcare? April 4, 2013. Available at: www.beckershospitalreview.com/quality. Accessed March 15, 2016.
5. Sackett DL. Evidence-based medicine. Seminars in Perinatology. 1997;21(1):3-5.
6. Fleck CA. Why "wet to dry"? J Am Col Certif Wound Spec. 2009;1(4):109-113.
7. Armstrong MH, Price P. Wet-to-dry dressings: Fact and fiction. Wounds. 2004;16(4):56-62.
8. Joint Commission on Accreditation of Healthcare Organizations. 1997 Automated CAMH: The official handbook. Oakbrook, IL: JACHO, 1997, p. 3.
About the Author
Catherine T. Milne, APRN, MSN, BC-ANP, CWOCN-AP, is the Clinical Editor of WoundSource™, and the co-owner of Connecticut Clinical Nursing Associates, a practice focusing on direct patient care, consultation, education and research in the fields of wound, ostomy and continence care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.