OASIS Alert

Published on Fri Nov 28, 2008 PDF

Case study shows that you shouldn't overlook PT's role in wound outcomes.

If you try to solve an outcome problem without first looking carefully at the details, you may find yourself spinning your wheels.

Collecting accurate OASIS data is only one part of the outcome based quality improvement process. Use that data to help you focus on the real issues standing in the way of outcomes improvement, said Patti Johnson with KCI in Houston, TX, speaking at the November annual conference of the OASIS Certificate & Com-petency Board in Baltimore.

It's easy to make assumptions about the cause of an outcome problem, especially when you are in crisis management mode, Johnson said. She provided this illustration from her own experience:

Agency issue: Lower than desired results in the outcome "Improvement in status of surgical wounds."

Step 1. Johnson began with an intensive instruction program for the nurses to address knowledge deficits. She provided competency evaluations, classroom instruction in wound assessment and care and joint home visits.

Result: The agency showed minimal improvement.

Step 2. Better late than never, she began to determine which patients had surgical wounds that failed to improve, Johnson explained. Then she audited those records looking for common elements.

Payoff: The common element was that most of the patients were in PT-only episodes. As a nurse, when she thought about wound care she thought about nursing, Johnson realized. "Physical therapy was off my radar screen," she said.

Step 3. She began discussing the issue with the therapists and repeating for them the program already provided to the nurses.

Discovery: A large percentage of therapists did not understand the definition of "nonobservable" on M0488 (Status of most problematic [observable] surgical wound). One of the four possible answers to M0488 is NA - No observable surgical wound. Because most patients with recent orthopedic surgery had wounds covered with a dressing, the therapists thought that meant they were nonobservable.

Why this matters: An episode with M0488 marked NA is excluded from the outcome measures and cannot show improvement in the surgical wound, Johnson said. The patient needs to be able to show improvement between admission and discharge.

Step 4. The response-specific instructions for M0488 tell clinicians "'nonobservable' surgical wounds include only those that are covered by a nonremovable dressing or cast." Johnson began instructing PTs on removing the dressing, assessing the wound and replacing the dressing, so they could correctly answer M0488 on admission.

Tip: Be sure clinicians understand the difference between "fully granulating" and "early/partial granulation," Johnson said. Audits showed 66 percent of patients were assessed as fully granulating at both start of care and discharge. This was another pattern that didn't allow the agency to show improvement and often resulted from inadequate knowledge, she said.

Lesson learned: When addressing outcome improvement, it's crucial to start with an understanding of the specific outcome, what is being measured, what definitions are involved and how improvement in that outcome is measured, Johnson said. Audit for the factors in-volved in that outcome. To see improvement in surgical wounds, you must be able to observe the wound on admission.

In addition to clinician training, the agency explained to doctors that they needed to remove the dressing on admission to evaluate wound status. The doctors appreciated the opportunity to look for wound problems, Johnson said. The main referring doctors provided the agency with standing orders for the dressing removal and replacement. When a patient is admitted, the intake staff confirms that the standing orders apply to this patient and essentially they become verbal orders, she noted.

Bottom line: Clearing up PT misunderstandings allowed the agency to improve from 62 to 68 percent on this outcome, Johnson reported.