There’s a new article out published open source (you can download it free) about the “DIME” approach to wound management (Debridement/devitalized tissue, Infection or inflammation, Moisture balance, and wound Edge preparation/wound depth) in relation to the currently available quality measures.
You can see that we have some “gaps” where quality measures are concerned. Maybe this article will help clinicians see how challenging it will be to take clinical guidelines, turn them into “actionable items” by a clinician and then turn those actions into a quality measure. Here’s an example: We all agree we need to debride necrotic material. How much necrotic material in a wound should trigger a recommendation to perform a debridement, and what kind of debridement(s) meet the guideline? For quality measures, we need precise definitions of things. Does a wound need debridement as long as there is ANY non-viable tissue? Or only if there is, for example, more than 10%? Do we “count” the autolytic debridement performed by certain dressings as a debridement for that specific visit, or only encounters with techniques like sharp, maggots, ultrasonic, etc.?
If a clinician performs a sharp debridement but the wound still has non-viable tissue in the bed, did they fail the measure today? Surely not. How often will we perform this measure, at every visit? Imagine that you are evaluating the documentation in an EHR and you have to establish specific criteria to say when a wound is necrotic and needs debridement, and when the quality measure of “doing” debridement by some means has been achieved. What are those exact definitions going to be?
It’s easy to say, “wounds with necrotic tissue should undergo debridement.” It’s quite another thing to create the clinical decision support for that in an EHR, and then develop a way to measure whether that has been done.
I mention this for those of you who develop clinical practice guidelines. If precise language is not provided regarding what constitutes vascular assessment (for example), or the frequency of intervals, or specifically how we are to identify patients who have infection (erythema? fever? induration?), then the guidelines will not be able to move to the next stage of “life” for them — which is to be incorporated into EHRs as clinical practice suggestions and then become quality measures.
Always interested in your thoughts – share them in comments, or connect with me via Twitter.com/CarolineFifeMD
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Caroline Fife, MD
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