Decision Making in Wound Management & the Use of SMART Objective Setting in Treatment Planning to Improve Patient Outcomes Francine Nutt Community Practice Teacher (Shropshire England)

This is me!

Session content  What factors influence our clinical decision making?  Treatment planning – how well do we do it?  SMART objective setting in treatment planning  How can we ensure a consistent approach to clinical treatment for our patients?  Wound management decisions

What influences our decision making in wound care?  Our personal level of knowledge/ understanding/confidence/experience  What’s available within the care environment  Access to wound management information (i.e. Wound formularies? Product info leaflets?)  Custom/Practice/Culture of the organisation  Time available  A clear treatment plan

Treatment plans – are they useful?  Treatment Plan A  Problem  Wound on L leg  Treatment Objectives  To heal  Treatment Plan  Hydrogel  Absorbent Pad  Stockinette  Evaluation  Static

Treatment Plan B  Problem  8 week history of wound above L ankle - 4cm x 5cm tenacious slough  with moderate exudate levels - bilateral leg oedema with dry skin plaques.  Treatment Objectives  Ascertain suitability for compression therapy.  Remove slough to reveal wound bed  Rehydrate dry skin areas and protect wound margins from further breakdown  Manage exudate levels.  Treatment Plan  Vascular assessment with doppler test within 7 days (repeated 3 monthly)  Re-measure/photograph next visit and thereafter every 4 weeks  Re-dress twice weekly  Wash legs using dermol soap substitute. Remove loose skin plaques.  Cavilon film to proximal skin. Cetraben emollient knee to toe (3 pumps per leg)  Actiform cool to sloughy wound bed both backing films removed –trimmed to provide 1cm overlap to wound margins  Cover with 10 x 10cm Eclypse pad held with actifast blue line toe to knee  Compression system – (K-Two)  Evaluation  Vascular Assessment confirms suitability for full compression therapy.  (Commenced K-Two)

How can we ensure a consistent approach?  Thorough Assessment Documentation  Clear treatment objectives which are SMART (specific, measurable, achievable, relevant, timed)  Patient in full agreement with treatment plan  Professional respect for other team members decisions  Timely evaluation of treatment provided, to ensure you are on track to achieve set treatment goals

KEY ELEMENTS OF AN OBJECTIVE  An objective:  Is a specific and measurable description of the required treatment  Describes the intended result – the ”how much or what by when”  Is jointly agreed and prioritised between the service user and the nurse.  Should be set at the beginning of the care episode.  Should be reviewed regularly to ensure relevance to care needs  Provides a framework of measurable performance standards for care interventions within an agreed timescale.

BENEFITS OF OBJECTIVE SETTING  It provides clear direction for all nursing team members and the patient  It allows progress to be monitored and measured by the team.  It helps build good relationships between the patient & the nursing team and improves overall communication  Helps to focus on a specific task  Helps to prioritise care interventions  Promotes regular and meaningful evaluation of care interventions  Enables success to be measured

SMART OBJECTIVES All Objectives should be able to meet these key criteria S Specific Ensure there is no ambiguity in the objective – it has a specific outcome to be accomplished. The outcome is stated in a clearly defined manner. M Measurable Is there a form of measurement in the objective? If it cannot be measured it will be difficult to assess/evaluate. A Achievable Is it actually possible to achieve the objective within the time frame set, are the necessary resources available? R Relevant Does the objective meet the service user’s needs and medical status? T Timed This means clearly stating when the objective should be achieved.

Let’s decide what to do with this…

Clinical Decision Making Process When Selecting Woundcare Treatment  Holistic Assessment to optimise treatment for co-morbidities and to accommodate patient’s personal assessed needs  Wound Assessment  Define and prioritise treatment objectives  Ensure patient’s preferences are fully considered  Identify performance criteria required from dressing/products and select the most appropriate that meet all identified requirements  Timely Reviews as treatment objectives will invariably alter as wound progresses/ deteriorates

What are our priorities here? Identify and maximise treatment for any co-morbidities, think how these may affect treatment options. Utilise a systematic wound assessment process (i.e. TIME) What are the treatment priorities and what is the patients perspective on these Consideration of what wound management options best meet the identified criteria to achieve treatment objectives Patient information re course of action Setting review date

How about this?  Pressure/friction relief  Pain relief  Debride?  Protect surrounding skin  Manage exudate  Risk Assessment esp. mobility issues

Where shall we start?

And this?  Malignancy – palliative  Patient’s preferences  Dignity issues  Body image  Malodour  Exudate management  End of life planning

Justifying our decisions  How comfortable are we in detailing the rationale for our treatment decisions?  How do we feel when colleagues question our decisions?  Do we actively strive to improve our knowledge of how wound care products work and how they can interact with each other

Decision making is a complex skill  Be your own critic…. question yourself  Take time to reflect on decisions you have made… could the outcome have been different - better/worse  Embrace a student……  There is never only one course of action/intervention  A ‘good’ decision can only be reached if all the component issues are actively considered

Finally…….  Thanks for listening and remember….. effective decision making can be empowering  I would like to share with you a decision I made recently

Some decisions are difficult to make but can be life enhancing!