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Legs at Lakes: Improving documentation of care for clients with leg ulcers

Central Coast Local Health District
Project Added:
23 May 2016
Last updated:
9 June 2016

Legs at Lakes: Improving documentation of care for clients with leg ulcers

Summary

Central Coast Local Health District (CCLHD) standardised the process of documenting care for clients with leg ulcers within the ComCare system.

Aim

To ensure 100% of clients have a personalised care plan documented in the electronic medical record (eMR) that aligns to CCLHD Leg Ulcer Guidelines, within six months.

Benefits

  • Supports introduction of a new information management system (ComCare).
  • Standardises documentation of care plans.
  • Supports the development of personalised care plans based on best practice.
  • Improves client care through scheduling and documentation of care reviews.
  • Improves continuity of care and interdisciplinary care.

Background

Chronic wounds are a significant health issue to the Australian population, with 400,000 people estimated to be living with one at any given time. Caring for clients with chronic leg ulcers is estimated to cost the health system more than $234,000 each year.

While the CCLHD community nursing service has an excellent reputation for providing leg ulcer care at home and in collaboration with vascular surgeons, the documentation of this care was affected by the introduction of a new information management system (ComCare). It required clinicians to document care differently from the old system. Both the functionality of ComCare and the process of completing point of care documentation was a significant change, resulting in confusion about what information to document and how to write a care plan in ComCare. As a result, there were significant variations in record keeping for clients with leg ulcers, which did not demonstrate that care was delivered in accordance with the CCLHD Leg Ulcer Guidelines.

CCLHD Leg Ulcer Guidelines state that establishing the cause of the ulcer – including an assessment of vascular status, co-morbidities and psycho-social status – is crucial for developing the most appropriate management plan and referring the client to a vascular surgeon if required. While 80% of leg ulcers are due to venous disease and should heal within 12-16 weeks, clients whose leg ulcers do not heal as expected need to be referred to a wound nursing practitioner (NP), clinical nurse consultant (CNC) or vascular surgeon. As such, accurate documentation is essential in evaluating ongoing care for clients.

An audit conducted in May 2015 revealed a lack of documented care plans, with minimal goals of care or dates for review. Information in ComCare was absent or difficult to find, often requiring extensive time to locate. The audit also revealed the following results:

  • 57% of clients were identified as having an ulcer of undiagnosed cause, with no corresponding care plan in place to address the wound
  • 19% of clients had vascular information recorded, which was located in a number of different places
  • 35% of clients had documented evidence of a care plan, including clear goals
  • 35% of clients had been referred to a wound NP or CNC.

It was anticipated that improving documentation in ComCare would ensure the CCLHD community nursing team had the information to deliver safe and effective care, with the client receiving care based on an assessment of their individual needs.

Implementation

  • Monthly meetings were implemented with the project team, to complete ‘Plan, Do, Study, Act’ cycles.
  • The project team standardised what information needed to be documented and where it needed to be documented in ComCare.
  • Short-term goals were documented in the patient’s wound care plan and education was provided to all nursing staff, to ensure they understood the wound care module in ComCare and were confident developing short-term goals with clients. Education was reinforced at each monthly meeting, using examples from clients’ eMR to illustrate successes and highlight where improvements could be made.
  • The name of the vascular surgeon, any vascular investigations and the date of review were documented in ComCare, to ensure all members of the interdisciplinary team were across the patient’s care plan. Nurses were encouraged to communicate proactively with vascular surgeons, particularly those running the weekly leg ulcer clinic.
  • The Doppler Lower Limb Assessment Clinic was re-established, to conduct vascular assessments and determine the cause of the ulcer. Nurses received additional training to provide lower limb assessments and measure the Ankle Brachial Pressure Index (ABPI), which determines the presence of vascular disease. Nurses initiated compression therapy for uncomplicated venous ulcers with normal ABPI measurements. Clients with abnormal ABPI measurements were sent back to their general practitioner for referral to a vascular surgeon.
  • The monthly NP clinic – established for clients whose leg ulcer fails to progress within three months despite best practice – was actively promoted to appropriate clients. A monthly audit determined which clients were suitable for the clinic but had not received care from a wound NP or CNC.

Project status

  • Implementation - the initiative is ready for implementation or is currently being implemented, piloted or tested.

Key dates

  • May 2015 – February 2016

Implementation site

  • CCLHD Community Nursing, Lakes Sector

Partnership

  • Clinical Leadership Program, Clinical Excellence Commission

Results

  • Monthly audits showed an increase in the number clients with accurate documentation of care and a personalised care plan completed, from 35% in May 2015 to 65% in December 2015.
  • Each audit was posted on a staff noticeboard, which allowed the team to celebrate successes and see improvements each month.
  • Anecdotal evidence suggested that team engagement improved as a result of the project, with increased participation and ownership of the ComCare system.
Documentation type

Pre-implementation
26 clients with leg ulcers

Post-implementation
65 clients with leg ulcers

Standardised documentation of APBI in eMR339
Standardised documentation of vascular surgeon in eMR1020
Documented evidence of referral and review by wound NP/CNC556
Documented care plan with short-term goals in eMR943

Due to implementation of a new data retrieval system, the total number of clients with leg ulcers post-implementation was deemed to be a more accurate identification of the total number of clients with leg ulcers. These figures have been reflected in subsequent audits and it is now recognised that pre-implementation results show under-reporting.

comparison showing increase in documentation post implementation

Lessons learnt

  • A period of staff shortages and leave meant that staff often missed meetings and were unaware of project actions to be completed. The team proposed a flowchart to indicate what was expected, however this was trialled for a month and deemed unsuccessful. Promoting the project on the staff noticeboard and discussing actions at staff meetings was more effective. Monthly audits were also helpful in identifying staff who did not document care according to the new process.
  • It is important not to underestimate the impact of changing from a paper-based documentation system, to a digital platform.
  • Engaging teams can be challenging, as time and energy is required for critical reflection, so changes in approach can be made.
  • Clinicians respond positively when they understand the benefits to themselves as well as the clients.

Further reading

  • Central Coast Local Health District. Leg Ulcer Management Guidelines (GE2008_013). 2015.
  • Harding K, Dowsett C, Fias L et al (2015). Simplifying venous leg ulcer management: consensus recommendations. Wounds International 2015.
  • Graves N, Zheng H. Modelling the direct health care costs of chronic wounds in Australia. Wound Practice & Research: Journal of the Australian Wound Management Association 2014: 22(1); 20-24, 26-33.

Contact

Frances McNulty
Clinical Nurse Consultant, Community Health
Central Coast Local Health District
Phone: 02 4367 9600
frances.mcnulty@health.nsw.gov.au

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