Post-Cardiothoracic Surgical Infection Prevention Program

 Care Coordination 
 Team 

Agency:
Visiting Nurse Service of New York, New York.
 
Agency Description:
For 120 years, the Visiting Nurse Service of New York (VNSNY), the largest not-for-profit home- and community-based health care organization in the country, has been committed to meeting the health care needs of New Yorkers. Today, VNSNY provides care throughout all five boroughs of New York City, Westchester, Nassau and Suffolk counties, and upstate New York. VNSNY employs 2,445 nurses, 525 rehabilitation therapists, more than 11,560 home health aides, 525 social workers, and 160 other clinical professionals.
 
Population Impacted:
VNSNY in collaboration with Mount Sinai Hospital (MSH) identified the need to develop a home care program for eligible and appropriate patients to go home in lieu of sub-acute rehab. It was identified that patients going to sub-acute rehab had an increase in 30-day hospital readmissions for sternal wound infection.
 
Strategic Partners:
VNSNY worked in collaboration with MSH in New York City. The collaborative workgroup consisted of:

VNSNY:
  • Clinical education developed educational tools and materials for field nursing staff.
  • Clinical operations trained field nurses in all geographical service areas. Rehab department developed an intensive cardiothoracic home care rehab program for patients to go home in lieu of sub-acute rehab. The rehab department provided training and education to all field physical therapists and occupational therapists.
  • Intake education developed and implemented teaching/training materials for the VNSNY intake staff at MSH.
MSH:
  • VP, Nursing, Mount Sinai Heart
  • Nurse Director, 7W, Cardiothoracic Inpatient Unit
  • Medical Director, Mount Sinai Cardiomyopathy Program
  • Surgical Site Infection (SSI) Workgroup
  • Department of Rehabilitation
  • Department of Infection Control
  • Social Work Department
  • Case Management Department
  • Department of Quality Initiatives
 
Project Description:
The VNSNY/MSH workgroup was created in September 2012 and met monthly. The workgroup's first step was to match the teaching tools developed and used on the 7W inpatient unit to the teaching tools that would be used to continue the teaching in the home (transitional care) by the home care RN. Next steps were to develop the training materials for the VNSNY field nurses, physical and occupational therapists, and intake team. The program went live on March 4, 2013.
 
Results:
The project generated a renewed focus on nursing interventions and patient teaching to prevent surgical site infections for the home care patient. The focus was on the impact of blood glucose control and the impact on wound healing and basic infection control practices.

MSH recommended use of the Joint Commission "Speak Up: Five Things You Can Do to Prevent Infection" pamphlet to teach patients and care givers the importance of hand hygiene. Nurses were instructed to demonstrate and ask for a return demonstration on hand-washing technique to highlight the importance of this basic strategy to reduce SSI.

As a result of this project, VNSNY added the Joint Commission tool "Speak Up: Five Things You Can Do to Prevent Infection" into their clinical orientation program and into the VNSNY Wound Care Protocols resource tool for clinicians.

The OASIS C assessment tool requires the clinician to document the healing status of surgical wounds on admission to home care. In the reporting of outcomes data, 33.6 percent of the surgical wounds were reported as "not healing." This definition required clarification for MSH regarding clarification of reports on outcomes related to wounds and OASIS.

In home health care, the Outcome and Assessment Information Set–C (OASIS-C) requires the clinician to assess and document the healing status of surgical wounds on admission to home care. The Wound Ostomy and Continence Nurses Society Guidance on Oasis-C Integumentary Items (2009) provide the definitions for healing status choices and guides the clinicians’ assessment and documentation.

OASIS-C differentiates between surgical wounds healing by primary intention and wounds healing by secondary intention.  There are two options for a wound healing by primary intention: “newly epithelialized” or “not healing”.  The clinician selects “newly epithelialized” if the assessment matches the definition:
  • wound bed completely covered with new epithelium
  • no exudate
  • no avascular tissue (eschar and/or slough)
  • no signs or symptoms of infection
A wound that is healing by primary intention but does not completely match that definition is described as "not healing." For surgical wounds that are healing by secondary intention, the healing status includes "newly epithelialized, fully granulating, early/partial granulation and not healing."
All patients were asked permission to have their surgical wounds photographed upon admission to home care as part of wound consultation. A Certified Wound and Ostomy Care Nurse (CWOCN) reviewed patient wound photos and assessed them for evidence-based topical treatment options. The photos were transmitted via secure email to a nurse practitioner (NP) or physician at MSH.
 
Outcome Measures:
From the beginning of March to the end of May 2013, this program used unified treatment approaches, from hospital to home, for 131 MSH patients with sternal wounds. For 10 of these patients, we were able to avoid skilled nursing home admissions with the VNSNY Intensive Rehab Program. When evaluated against the Centers for Medicare and Medicaid (CMS) Outcome-Based Quality Improvement (OBQI) outcome measures, patients surpassed six out of seven national quality benchmarks for essential quality of life functions, including the patient’s pain frequency when moving, ease of breathing, and ability to walk, bathe, take medicine, and get in and out of bed. Even more impressively, 100 percent of the VNSNY-MSH patients who took part in intensive rehab showed wound improvement.
 
Barriers to Implementation:
A number of barriers to implementation occurred during this project. Social work coverage was inadequate and the current social work staffing model was unable to identify all appropriate patients for the sternal wound program. Physicians and physical therapists were reluctant to send patients home with home care in lieu of sub-acute rehabilitation. Staff at VNSNY discovered the need for ongoing teaching, training, and education for field professional staff and also for MSH staff. Furthermore, a lack of standardized outcome measures were a barrier to implementation for this program.