Best Practice: Assessment & Intervention for Patients with Wounds in Home Health What can Physical Therapists do to Create Change? Mitchell Brotsky, Kira D Annunzio Advisor: Tony D Alonzo Arcadia University 2017 Purpose Develop best practice exercise guidelines Encourage multidisciplinary approach to wound care Patient centered goals with positive outcomes Utilize evidence based best practices More effective rehab Less costly episode of care & earlier discharge Possible decrease in hospital readmission rates 1
Capstone Evidence based literature review on most effective exercises for venous leg ulcers, pressure sores, diabetic foot ulcers Developed Best Practice Exercise Guidelines Delivered presentation to home health PTs Analyzed metrics over 5 months Education Delivery PowerPoint Presentation Delivered July 15th & July 22nd, 2016 2 Philadelphia branches of a national home health agency Delivered as a staff inservice Staff received 1.5 CEUs Total of 18 Staff 14 PTs 4 OTs Provided guideline booklet for quick reference out in the field 2
Content Provided general overview of most common wounds Identified unique pathology of venous leg, pressure, & diabetic foot ulcers Suggested guidelines for treatment Practiced specific exercises and skills Discussed application to case studies Summary & discussion Guidelines Delivered 3
General Screening Guidelines Check for new wounds on every visit Dermatomal sensation screening Pressure relief / off-loading education Promote personal hygiene Education about nutrition, activity levels, and risk factors Screen for DVT s with Well s Clinical Prediction Rule Measure Ankle Brachial Index (ABI) value Ankle Brachial Index (ABI) Value Important predictor for: Presence of Peripheral Artery Disease Activity tolerance Likelihood of development of ulcers Wound healing Take ABI on first eval Report abnormal values to doctor 4
Pressure Sore Development Poor UE/LE strength Insufficient bed mobility Lethargy, inactivity, painful movement Poor hygiene Pressure Sore Exercises Transfers & unweighting of wounds UE Strengthening & bed mobility Reduce shearing during transfers Bridging, gluteal strengthening Functional independence 3-way single leg raises, ankle pumps, sit-to-stand, heel raises, marching Gait training with unweighted ambulation Off-loading boots, assistive devices (Hambrecht et al,1998) (Hammad et al, 2015) 5
Venous Stasis: Insufficient Calf Muscle Pump Chain of pumps from foot to upper thigh; synchronize during walking 1. Dorsiflexion empties the distal calf pump 2. Weight bearing empties the foot pump 3. Plantar flexion empties the proximal calf pump Ejection fraction directly related to contraction strength Insufficient valves hypertension Hypertension muscle atrophy Atrophy malfunction of the CMP Malfunction leads to chronic ulcers (O Brien et al, 2012) Tip-Toe Exercises Stage 1: Seated heel-rises (both legs) Begin 10 reps, 3 sets, 3x/day, for 3 consecutive days Advance by 5 to 25 reps, 3 sets, 3x/day, for 3 consecutive days Stage 2: Standing heel-rises (both legs) Begin 10 reps, 3 sets, 3x/day, for 3 consecutive days Advance by 5 to 25 reps, 3 sets, 3x/day, for 3 consecutive days Stage 3: One legged heel-rises Begin 10 reps, 3 sets, 3x/day, for 3 consecutive days Advance by 5 to 25 reps, 3 sets, 3x/day, for 3 consecutive days (O Brien et al, 2014) 6
Diabetic Foot Ulcers Poor blood flow to LEs Diabetic Neuropathy Poor patient self management Berger Allen Exercises 1. Elevate feet at 45-90º angle. Hold until feet turn white/blanched, about 2-3 minutes 2. Place feet below body & perform until blood/color returns to the feet: ankle pumps supination/pronation toe flexion/extension 3. Rest patient in supine cover feet to ensure warmth 7
Staff Feedback Staff Feedback 8
Staff Feedback Cont Outcomes 9
Outcomes Baseline of Same Season Baseline of Same Year Post Inservice Aug 15 - Dec 15 Jan 16 June 16 Aug 16 Dec 16 Number of Episodes 125 146 97 Average Nursing Visits per Episode when PT is also provided 12.5 11.8 10.8 Avg PT visit count 8.7 9 8.1 Hospitalization Rate 29.6% 28.7% 18.6% Avg. Length of Episode with PT 51.5 50.9 47.8 Episodic Gross Margin 63.6% 64.1% 66.4% Ongoing Recommendations 10
What Would We Do Differently Larger sample size of staff and longer duration Included more branches Increased nurse involvement Earlier reinforcement of participation Keep PTs more engaged and motivated Are PTs effectively, appropriately, and consistently utilizing the guidelines? Track actual, not just reported, participation through documentation Detailed documentation review Track specific diagnoses, cause of hospitalization, & pt demographic breakdown What was the exact exercise prescription, what other exercises did they do etc. Limitation: many variables could have contributed to improved outcomes! Thank You 11