Download - Nhs West Midlands Chronic Wounds Toolkit
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[CHRONIC WOUNDS TOOLKIT] NHS West Midlands guide for quality in the commissioning and delivery of chronic wound prevention and treatment services
Chronic Wounds Toolkit 2010
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Contents
Glossary
1. Executive Summary
2. Introduction
a. Background
b. How was the toolkit developed?
c. Definition of chronic wound
d. Costs associated with chronic wounds
3. Requirements of commissioning services
a. How should the tool kit be used?
b. Structure of the toolkit
4. Quantifying the burden of chronic wounds
a. Identifying local priorities
b. Monitoring chronic wound prevalence management
c. Measurement of the effectiveness of wound care services
5. The right training at the right time
a. The value of education
b. Minimal skill sets and competency frameworks
c. Identifying the frequency of training
d. The role of care bundles
e. Commissioning expertise/developing experts
6. What can be done to prevent chronic wounds?
a. Can chronic wounds be prevented?
b. Services aimed at prevention
7. Clinical Pathways
a. Reducing variation in the management of chronic wounds
b. Rejecting tolerance of chronic wounds
c. The role of expert referral
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d. The role of innovation
e. Health Economy Working
8. Patient involvement
a. Patient information
Appendix 1 Chronic Wound Guidelines
Appendix 2 Members of Working Group
Appendix 3 Chronic Wounds Data Capture System
Appendix 4 Pressure Ulcer Productivity Tool
Appendix 5 Example multidisciplinary minimum skills set
Appendix 6 Chronic Wounds High Impact Intervention
Appendix 7 Heart of Birmingham PCT Pressure Ulcer Programme
Appendix 8 Wolverhampton City PCT Pressure Ulcer Prevention Bundle (in patient care) Appendix 9 Stoke on Trent Community Health Services Primary Care Foot Ulcer Pathway Appendix 10 Stoke on Trent Community Health Services Secondary Care Foot Ulcer Pathway Appendix 11 Stoke on Trent Community Health Services New Patient Referral Pathway Appendix 12 Example expert referral guidelines
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Glossary
Leg ulcer
Pressure ulcer
Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result
of pressure, or pressure in combination with shear.
Diabetic foot ulcer
A wound of the lower leg associated with the complications of diabetes
Non-healing surgical wound
A wound healing which fails to heal within the expected time frame post operatively
Wound healing by secondary intention
Wounds left open to allow the free drainage of exudate and the formation of granulation tissue
to fill the cavity left by removed tissue.
Recurrence
The presence of a wound on a previous site due to the same physiological cause
Prevalence
The proportion of a defined population who are affected by a disease.
Incidence
The rate at which new cases occur in a population during a specified period.
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1. Executive Summary
Chronic wounds have been identified as the sources of infection in as many as 40% of MRSA
bacteraemia cases within the West Midlands and are likely to be implicated in may other causes
of blood stream infection resulting in potentially avoidable harm to patients. The impact of
chronic wounds has not only debilitating implications but requires significant resources across
the health care system to treat the wound and the associated co-morbidities.
There is currently little data collected to give an indication of the number of chronic wounds
either across the West Midlands or within health economies or outcome data. This makes it
difficult to establish the resources required or indeed where there are gaps within in current
service provision.
The Chronic Wound Toolkit has been designed to support the commissioning and delivery of
services to understand the numbers of chronic wounds within the health economy, benchmark
current practice and align best practice to enable improved clinical outcomes. It will also
support provider organisations in the standardisation of services aimed at this important aspect
of patient safety.
This is achieved through:
Understanding the problem through effective data capture and monitoring
Consistent pathways of care with effective assessment and intervention, risk triggers
and timely escalation
Implementation of best practice as shared through service models and high impact
interventions.
This toolkit complements the Chief Nursing Officers High Impact Actions on Pressures Ulcers,
QIPP Safe Care work stream and the Diabetes UK ‘Putting Feet First’ campaign as well as NICE
and other national and international guidance on best practice. Whilst the high impact action
‘Your Skin Matters’ focuses on prevention of pressure ulcers, the chronic tool kit provides a
focus for assessment and management of chronic wounds including pressure ulcers.
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2. Introduction
a. Background
Currently 40% of MRSA bacteraemia cases reported to the West Midlands SHA have
their source identified as a chronic wound (West Midlands RCA data; 2009). The
prevalence of other organisms causing infection in chronic wounds is unknown but
these will be significant causes of blood stream infections as they migrate from the
wound to the circulatory system resulting in acute care admissions, complicated
antibiotic regimes and the associated risk of mortality.
Chronic wounds are complex in their cause, duration, management and
complications; infection being just one. The burden of chronic wounds on healthcare
services in the UK is significant as identified in the in the Chief Nursing Officer’s high
impact actions for nursing and midwifery which highlight the burden of pressure
ulcers, just one group of chronic wound but one which safeguarding boards are
increasing concerned with. The opportunity to improve on quality, productivity of
wound care services and prevention of disease in the West Midlands is likely to yield
substantial cost benefits and significantly improve the patient experience.
Despite the complexity of these wounds, focus on prevention, early intervention,
referral and specialist treatment pathways have been shown to be highly effective in
the timely healing and prevention of chronic wounds. Implementing a chronic
wound prevention and reduction strategy as a Quality Innovation Productivity and
Prevention (QIPP) initiative will have the following benefits:
Assisting organisations to deliver the forthcoming years MRSA Objective.
Reduce pressure on community provider services
Prevent admissions associated with chronic wounds and their complications
Reduce costs associated with wound dressings and associated technologies
Increase patient satisfaction
Improve quality of services
Prevent unnecessary associated morbidity and mortality
Deliver one of the Chief Nursing Officer’s high impact actions for nursing and
midwifery (No avoidable pressure ulcers in NHS provided care)
Supports the QIPP Safe Care work stream and the Energising for Excellence
Campaign
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National and international guidance and best practice principles exist for the
purposes of prevention, treatment and holistic care of chronic wounds (see
appendix 1) however, variability of their implementation is a recognised problem.
This variability has been attributed to:
Patient related factors (co-morbidities, compliance, environment and
psychosocial wellbeing);
Wound related factors (duration, size, condition, infection, wound location);
The skill and knowledge of the healthcare professional (competence in wound
assessment and measurement, triggers for expert referral);
Resources and treatment related factors (habitual behaviour, wound care
formularies, delayed innovation, improvement measures)
(Adapted from Vowden et al, 2008)
This document aims to identify how commissioners and providers can ensure that
chronic wounds are monitored and reduced through the use of a series of tools and
examples of good practice in the region. It has been developed with the assistance
of regional experts in the field.
b. How was the tool kit developed?
A workshop to identify the contributing factors to the variability in chronic wound
service provision in the West Midlands was held in Birmingham. Key experts in
infection prevention and tissue viability were invited from three West Midland
health economies thought to be particularly dynamic in this area. During the
workshop the following areas were considered:
What is a chronic wound?
What patient groups are likely to have chronic wounds?
Where are the patients?
Who looks after the wounds?
What components does a good wound care service need to have?
Results of the workshop revealed wide variation in the delivery of services. No
health economy provided consistent preventative and expert treatment and referral
services, education and patient information relating to chronic wound management.
Furthermore there was very little evidence of measurement of chronic wounds or
performance indicators aimed at rapid healing or appropriate care of the wound.
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Following the workshop a multidisciplinary working party was set up as a task and
finish group to develop guidance, pathways and best example case studies. These
are targeted at commissioners and providers and aim to drive down the numbers of
chronic wounds through ensuring expert referral pathways are in place and
measuring performance against key standards. Examples of best practice were
sourced from regional interest groups and their networks. Full details of members of
the working group are provided in Appendix two. The diagram below shows the
outline strategy developed.
c. Definition of chronic wound
Definitions of chronic wounds are based on either the aetiology or the duration of
the wound. For the purpose of this document a definition based on duration is taken
as it is likely to facilitate effective measurement of improvement.
IMPROVED QUALITY AND SAFETY
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A chronic wound is defined as any wound which has remained unhealed for longer
than 6 weeks (Cutting & Tong 2003).
Chronic wounds are likely to include the following:
Pressure ulcers
Leg ulcers
Diabetic foot wounds
Non-healing surgical wounds/wounds healing by secondary intention
Traumatic wounds.
d. Costs associated with chronic wounds
The costs of chronic wounds are largely unknown. This is mainly due to the diversity
of settings where they are treated and medical professionals to whom responsibility
for their management falls. The cost of pressure ulcers has been estimated as £1,064
for a grade one pressure ulcer rising to £24,214 for a grade 4 pressure ulcer (NHS
Institute for Innovation and Improvement, 2009). Venous leg ulcers have been
estimated as costing the NHS at least £168–198m per year (Posnett and Franks;
2008) and diabetic foot ulcers are estimated to cost an estimated £300m per year
(Gordois et al, 2003) with estimates that 50% of these will become infected at some
time (Lavery et al, 2003) and 2,600 will require lower limb amputation each year.
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3. Requirements of Commissioning Services
a. How should the tool kit be used?
It is recommended that commissioning services benchmark their services against
those explained in this toolkit. The local prevalence and resulting burden of chronic
wounds should be understood. Following this a gap analysis should be undertaken to
identify the necessary actions to ensure a comprehensive chronic wound service is in
place.
Key points are:
The local prevalence and burden of chronic wounds need to be understood along
with any priority areas
Local services should be compared to the recommended framework
A gap analysis should be undertaken followed by
A risk assessment to identify relevant action that needs to be taken.
b. Structure of the toolkit
The structure of the tool kit is designed to be user friendly and give easy access to
tools to assist with focus and improvement in this area. Cases studies and additional
tools will be added on a regular basis as experience develops and usage increases.
Individual tools are included as appendices to this document.
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4. Quantifying the Burden of Chronic Wounds
a. Identifying local priorities
The burden of chronic wounds is unknown in most health economies. From our
discussions we have found that that this is due to the wide variation in where
chronic wounds are managed, their definition, which health professionals their care
is managed by, and inconsistencies in data collection. Therefore there is a need to
collect data on all chronic wounds using a consistent methodology which is repeated
regularly or maintained as an ongoing surveillance system. Difficulty in comparing
and benchmarking data is externally experienced by many organisations due the
variances in socioeconomic backgrounds. It is therefore anticipated that
organisations set their own, regularly reviewed, ambitions for improvement in
ongoing prevalence data.
b. Monitoring chronic wound prevalence
The prevalence of all types of chronic wounds is needed to truly asses the extent of
the problem, to identify trends, effectiveness of services and monitor improvement
and cost and quality benefits. To facilitate this data collection and monitoring a
database has been developed by NHS West Midlands which is a simple, free to use,
secure, web based data entry system enabling PCO’s to download status reports.
However a commitment to data collection, entry and capture is required. See
appendix three for details of the data capture system developed by the working
group.
c. Calculating the cost of chronic wounds
Prevalence data can be used to calculate the financial cost of chronic wounds to
organisations. To assist with this the Chronic Wounds Calculator has been
developed. This tool relies on a number of assumptions and is detailed in Appendix
four.
d. Measurement of the effectiveness of wound care services
In order to decrease the burden of chronic wounds the change need to be owned at
Board level and the subsequent implementation of measures needs aimed at
reducing the prevalence of chronic wounds as well as improving the patient
experience, quality and safety. The clinical services involved (in which there are
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many) need to be engaged and bought into an ambitious strategy which creates an
expectation that the whole organisation will have a responsibility to contribute.
Local targets should be agreed against a range of measures which examine clinical
outcome and aspects of process. Suggested measures are listed below for the
intention of primary care organisations adopting a selection of these to measure
performance.
Suggested Outcome Measures
i. Time to heal
Number of new wounds healing with in 0-12 weeks, 12-24 weeks, 24-52
weeks, more than 52 weeks.
ii. Recurrence rates
Of the number of chronic wounds healed the percentages which recur in at
the same site within a 52 week period.
iii. Incidence of new onset of chronic wounds
iv. Patient satisfaction
Key questions should be asked of patients with chronic wounds to be able to
identify obstacles to rapid healing (e.g. access to services) and health status
(e.g. mobility).
Suggested Process Measures
v. Prevalence of chronic wounds expressed a rate per 10,000 population
(Include prevalence in care home setting)
vi. Percentage of patients with chronic wounds on a specialist pathway
vii. Number of hospital admissions with chronic wounds per 1,000 admissions
viii. Length of stay of patients with chronic wounds per 1,000 bed days
ix. The number of chronic wounds arising as a result of an inpatient care
episode
x. Training
NHS and private sector care settings can monitor the uptake of training and
maintaining knowledge and skills. See section 6 for appropriate training.
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xi. Compliance with relevant care bundles
Compliance being 100% and monitored at set intervals. Escalation plans to
monitor more frequently can be based on compliance scores and
maintenance of the agreed standards.
(See section 5d for more information on care bundles)
xii. Compliance with training requirements
(See section 5c frequency of training)
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5. The Right Training at the Right Time
a. The value of education
Good quality education is vital to improving services for those with chronic wounds.
Through appropriate training and education assessment of risk, interventions to
heal, reduce size or alleviate symptoms, as appropriate, and relevant referral of
chronic wounds to experts is more likely.
Education must be targeted at all those responsible for assessment and care of the
patient/client. It must include not only theoretical content relating to wound healing
and the skills required to undertake this but the ambition to reduce the burden of
chronic wounds and the triggers for referral to specialised services. In order that this
education is delivered consistently it should be multi faceted and inclusive. The
diagram below demonstrates where education should be targeted.
b. Minimal skill sets and competency frameworks
Education and training is required to be delivered in a practical manner, ensuring
that staff providing care and assessment gain practical knowledge to identify key
challenges relating to wound care and how to expedite the relevant care pathway.
•Multidisciplinary
•Consistent with clinical training/experiences
•Contemporary
Pre-registration
•Competency based
•Regular updates
•Monitoring of practice using care bundles
•Targeted education relating to performance/ audit results/initiatives
Post-registration
•Preventative
•Supportive of treatment
•Patient contracts
•Suport initiatives
Patient Education
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An example of a multi professional minimum skill set is developed by Birmingham
City University is provided in Appendix 5.
A minimum of 3 yearly updates is recommended for all staff with a responsibility for
the assessment or care of chronic wounds, this must include medical, nursing and
allied health professionals to ensure that patient safety is maintained.
See pages 18/19 for Dudley Primary Care Trust leg ulcer service solution to
education and competency assessment of district nurse’s leg ulcer assessment and
treatment skills.
c. Identifying the frequency of training
Organisations will need to identify all healthcare workers who have a role in chronic
wound management including relevant medical, podiatry, nursing and allied health
professionals. All should have competency assessment and at least 3 yearly update.
This should be monitored regularly for compliance with the training frequency.
Universities delivering pre and post registration training have a clear role to play in
strengthening the delivery of services. The provision of training should be both
classroom and placement orientated however, commissioners of training should
ensure that there is proof that expert clinical advice has been sought in influencing
the training programme to ensure that training is contemporaneous.
d. The role of care bundles
Care bundles link evidence and measurement thorough identifying key processes
aimed at reducing infection during a specific procedure or element of care. The
focus is on quality of care rather than research or judgment (Marwick & Davy, 2009).
High Impact Interventions are measurement tools based on this approach and
provide the opportunity through self or peer assessment to standardise key aspects
of clinical practice and a means of demonstrating compliance with a standard using
an agreed measurement. To succeed all elements of the care bundle must be
consistently undertaken.
A high impact Intervention focussing on chronic wounds has been developed by the
Royal Wolverhampton Hospitals NHS Trust and Wolverhampton City PCT (see
appendix 6). The Department of Health are also in the process of publishing a similar
document as part of the Saving Lives package. See link to the latest package of
initiatives below:
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www.dh.gov.uk/en/Publichealth/Healthprotection/Healthcareassociatedinfection/P
racticalsupport/SavingLives/index.htm
e. Commissioning expertise/developing experts
It is vital that clinical staff have access to experienced and trained tissue viability
experts to ensure timely healing of chronic wounds which are able to progress along
the healing continuum and overcome the many risks which potentially prevent this.
Tissue viability nurses, podiatrists, vascular and diabetic teams are often the source
of this expertise in the NHS, other organisations may subscribe to private providers
or commission additional services. Whichever system or combination is the
preferred, services should be able to offer:
Prevention services for leg ulcers, diabetic foot ulcers and pressure ulcers
Support to clinical staff dealing with non-healing or problematic wounds
Education and training to all healthcare workers and health professionals
Advice on current opinion, technologies and evidence in wound healing
Advice on local policy, wound care formulary and potential cost savings
Raise awareness of health lifestyles/disease prevention
Analysis of surveillance data to inform service priorities to meet the needs of
the given population
Audit of relevant services and practices.
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6. What can be done to prevent chronic wounds?
a. Can chronic wounds be prevented?
Preventative chronic wound services are essential and exist for many of the
categories of chronic wounds. As chronic wounds have varying causes the
preventative services differ. A summary and some examples of effective
preventative services/practices are listed below.
b. Services aimed at prevention
Diabetic Foot Ulcers
The 2008 prevalence of diabetes was 2.89% in England. It is estimated that 50% of
diabetic foot ulcers will be come infected with 2,600 cases per year requiring
amputation. Prevention is therefore essential for the safety of the patient and to
enable efficient use of resources. The Diabetes UK document Putting Feet First:
Commissioning specialist services for the management and prevention of diabetic
foot ulcers (2009) explains the role of acute trusts in the prevention of diabetic foot
disease in hospital inpatients. Community provider services should have suitable
podiatry services with the following emphasis
Education on foot care to all new patients with diabetes and their carers, focusing on prevention
Ongoing education of patients with diabetes and their carers
Education, advice, liaison, and outreach support to primary care diabetes teams. (British Diabetic Association, 1999)
In addition this service should actively seek out those at risk of diabetic foot ulceration, including younger people with diabetes and explore innovative ways of allowing them to access services (e.g. telemedicine). Leg Ulcer Prevention
The Royal College of Nursing Clinical Practice Guideline: the nursing management of
patients with venous leg ulcers (RCN, 2006) recommends that the clinical and
educational strategies should be available to prevent recurrence of venous leg
ulcers:
Clinical
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Life time compression hosiery
Venous investigation and surgery
Regular follow up to monitor skin condition for recurrence
Regular follow up to monitor ankle brachial pressure index (ABPI)
Patient education
Concordance with pressure therapy
Skin care
Discourage self treatment with over-the-counter medicines
Avoidance of accident or trauma to legs
Early self-referral at signs of possible breakdown of the skin
Encouragement of mobility and exercise
Elevation of the affected limb when immobile. (RCN; 2006)
NHS Gloucestershire has developed a ‘Look after Your Legs Programme’ including
exercise video’s and CD’s, patient ambassadors, education material, inspection
advice and care instructions aimed at reducing the risk of recurrence of leg ulcers
www.healthylegs.nhs.uk .
Dudley Primary Care Trust runs 6 leg ulcer clinics across the borough to enable easy
access to leg ulcer treatment and prevention services. These are led by a tissue
viability nurse with a group of specialist leg ulcer and district nurses. The service
provides:
Expert assessment and care planning of patients with leg ulcers
Treatment of leg ulcers with a key aim of preventing recurrence
Expert advice and support to patients with healed wounds
Expert education and support to district nursing services.
Patients with healed leg ulcers are fitted with compression hosiery and provided
with information and education on the hosiery, skin care and when to seek advice.
The patients are then reviewed 2-3 weeks later to ensure the hosiery is effective and
information and education refreshed. Following this the patients are recalled 6 to 12
monthly for further assessment (depending on other risk factors such as diabetes),
hosiery renewal and education.
A relationship between the service and the patients is developed which enables
patients open access to seek advice and treatment at a much earlier point should
their skin begin to ulcerate again, reducing healing times and recurrence rates.
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The clinics provide important advice and support to community nurses but
education of this group is challenging due to the numbers involved, geographical
spread and demands on community services. Rotation of community nurses through
these clinics means that the service is adequately staffed and district nurses skills
and competency can be assessed and maintained. This has been successful in one
area of the 6 covered by clinics and is now planned to rollout to other areas.
Pressure Ulcer Prevention
NICE guidance on pressure relieving devices (2003) recommends the following
multiple strategies in order to prevent pressure ulcers
Identification of vulnerable individuals through risk assessment
Regular skin inspection
Positioning of the patient
Use of seating aids and equipment
Use of pressure relieving devices (beds, mattresses and overlays)
A comprehensive education programme.
Heart of Birmingham Teaching PCT has incorporated pressure ulcer prevention into
a broader pressure ulcer treatment and prevention programme aimed at preventing
recurrence of healed pressure ulcers. Nurses have access to a series of supportive
tools and educational information (see appendix 7).
Wolverhampton City Primary Care Trust provider (in patient) service has developed
a comprehensive care bundle aimed at prevention of pressure ulcers. In addition to
the risk assessment and the care plan, medication, mobility and nutrition are
assessed by the relevant allied health professional and a daily intervention sheet is
used to document the condition of pressure areas and trigger referral to the tissue
viability service or reassessment. This links to a Care Standard Guideline for Pressure
Ulcer management. Documentation is available in appendix 8.
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7. Clinical Pathways
a. Reducing variation in the management of chronic wounds
The use of clinical pathways in the prevention and treatment of chronic wounds is
key to successful management. These must be contemporary and include room for
new and innovative therapies with clear triggers for referral and expert review.
Chronic wounds which fail to progress with current recommended therapy require
the patient to undergo regular re-evaluation to identify the factors inhibiting
progression.
Diabetic Foot Ulcers
An ideal diabetic foot ulcer pathway is provided in appendix 8.
Pressure Ulcers
NICE (2005) has published the management of pressure ulcers in primary and
secondary care: A Clinical Practice Guideline guidance as have EPUAP (2009)
Pressure ulcer treatment: quick reference guide.
b. Rejecting tolerance of chronic wounds
There has been an acceptance of chronic wounds both from health professionals
and those affected. Through the development of a strategy aimed at the prevention
and reduction of the number of chronic wounds costs and resources will be
released. Beliefs that chronic wounds cannot be healed need to be rejected by
healthcare professionals having contact with those affected. The following points
should be considered in strategy to assist in this element:
Create partnerships with service users
Gain board level champions who are aware of the necessary processes
Appeal to the core values of healthcare workers required to change
Ensure a whole organisation (grass roots to board) approach.
c. The role of expert referral
Clear guidance should exist to limit the duration of chronic wounds and allow
prompt expert intervention in wounds which fail to make progress. Local guidance
must make clear ‘triggers’ for referral. Appendix 9 gives the example of the referral
guidelines at Bradford Teaching Hospitals NHS Trust.
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d. The role of innovation
Recent years have seen an explosion of innovative wound dressings and
technologies. Innovations need to implemented and evaluated for their clinical
effectiveness, cost efficiency, user acceptability and their productivity. Clinical
pathways should allow for the introduction of innovation. Some examples of
innovations in wound care are listed below.
Platelet Leukocyte Gel (PLG)
Topical negative pressure wound therapy
o NICE guidance on the use of this technology for use in open
abdomens (2009) is available
Laser therapy
Larvae therapy
Antimicrobial dressings
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8. The Role of Health Economies
Experts are often available in NHS organisations though there may be more than one
service with an interest in chronic wounds as discussed earlier. Health economies should
look towards establishing wound care formularies with shared or seamless policies, referral
criteria, pathways, and innovations. This should include the private and social care sectors,
charitable organisations such as hospices, local authority, pharmacy, infection prevention
and control services and senior organisational leaders. Such groups should monitor a local
strategy and improvement while identifying key areas of concern or action and consider the
representation of an expert patient (see section 9).
In organisations where NHS experts are not available innovative solutions should be sought.
Private providers who may provide ‘whole solution’ wound care service from prevention to
education and policy to treatment are available with many NHS organisations offering
service level agreements with the private sector.
Heart of England, Birmingham East and North and South Birmingham Primary Care Trusts
have developed a joint service led agreement to provide care homes with a suitable Tissue
Viability Team to provide advice and support to the care homes in these health economies.
A link to a full case study for this programme can be found at
www.institute.nhs.uk/building_capability/hia_supporting_info/your_skin_matters.html.
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9. Patient involvement
a. Patient information
NHS Choices has a comprehensive library of information for patients on chronic
wounds including videos, written information and links to specialist resources.
b. Patient involvement
Patient user groups are one way of ensuring that the interests of patients with
chronic wounds are best met. Including patients in decision making to shape and
monitor services may add ambition, empower the patient and ensure that the
patient is the focus of the strategy. The Expert Patient Programme (Department of
Health, 2001) aims to tap into the previously underutilised knowledge of patients
with long term conditions to improve care, particularly in relation to quality of life
issues.
References
Cutting KF, Tong A; 2003; Wound Physiology and Moist Wound Healing; Medical
Communications LTD; Holsworthy
Department of Health; 2001; The Expert Patient: A New Approach to Chronic Disease
Management for the 21st Century;
www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/
dh_4018578.pdf 8th June 2010
Diabetes UK; 2009; Putting Feet First: Commissioning specialist services for the management
and prevention of diabetic foot disease in hospitals;
www.diabetes.org.uk/Documents/Reports/Putting_Feet_First_010709.pdf 8th June 2010
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel; 2009;
Pressure Ulcer Treatment; www.epuap.org/guidelines/Final_Quick_Treatment.pdf 8th June
2010
Gordois A, Scuffham P, Shearer A, Oglesby A; 2003; The healthcare costs of diabetic peripheral
neuropathy in the UK; Diabetic Foot; 6:62-73
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Lavery LA, Armstrong DG, Wunderlich RP, Tredwell J, and Boulton AJM; 2003; Diabetic foot
syndrome: evaluating the prevalence and incidence of foot pathology in Mexican Americans
and non-Hispanic whites from a diabetes disease management cohort; Diabetes care;
26:5;1453-38
Marwick C, Davy P; 2009; Care Bundles: the holy grail of infectious risk management in
hospital?; Current Opinion in Infectious Diseases; 22:4 364-369
National Institute for Health and Clinical Excellence; 2003; Pressure ulcer risk assessment and
prevention, including the use of pressure-relieving devices (beds, mattresses and overlays) for
the prevention of pressure ulcers in primary and secondary care;
www.nice.org.uk/nicemedia/pdf/CG7_PRD_NICEguideline.pdf 8th June 2010
National Institute for Health and Clinical Excellence; 2005; The management of pressure ulcers
in primary and secondary care: A Clinical Practice Guideline
www.nice.org.uk/nicemedia/pdf/CG029fullguideline.pdf 8th June 2010
National Institute for Health and Clinical Excellence; 2009; Negative pressure wound therapy for
the open abdomen; http://www.nice.org.uk/nicemedia/pdf/IPG322Guidance.pdf 8th June 2010
NHS Institute for Innovation and Improvement; 2009; High Impact Actions for Nursing and
Midwifery; NHS Institute for Innovation and Improvement;
www.institute.nhs.uk/images//stories/Building_Capability/HIA/NHSI%20High%20Impact%20Ac
tions.pdf 8th June 2010
Posnett J, Franks PJ; 2008; The burden of Chronic Wounds in the UK; Nursing Times; 104; 44-45
Royal College of Nursing; 2006; Royal College of Nursing Clinical Practice Guideline: the nursing
management of patients with venous leg ulcers;
www.rcn.org.uk/__data/assets/pdf_file/0003/107940/003020.pdf 8th June 2010
Vowden P, Apelqvist J, Moffat C; 2008; Wound Complexity and Healing: In European Wound
Management Association; 2008; Position Document: Hard to Heal Wounds: a holistic approach;
http://ewma.org/fileadmin/user_upload/EWMA/pdf/Position_Documents/2008/English_EWM
A_Hard2Heal_2008.pdf 8th June 2010
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Appendix 1 - Published Guidelines
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel; 2009;
Pressure Ulcer Treatment; www.epuap.org/guidelines/Final_Quick_Treatment.pdf 8th June
2010
European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel; 2009;
Pressure Ulcer Prevention; www.epuap.org/guidelines/Final_Quick_Treatment.pdf 8th June
2010
International Working Group on the Diabetic Foot; International Consensus on the Diabetic Foot &
Practical Guidelines on the Management and Prevention on the Diabetic Foot
www.iwgdf.org/index.php?option=com_content&task=view&id=87&Itemid=138 8th June 2010
National Institute for Health and Clinical Excellence; 2003; Pressure ulcer risk assessment and
prevention, including the use of pressure-relieving devices (beds, mattresses and overlays) for
the prevention of pressure ulcers in primary and secondary care;
www.nice.org.uk/nicemedia/pdf/CG7_PRD_NICEguideline.pdf 8th June 2010
National Institute for Health and Clinical Excellence; 2005; The management of pressure ulcers
in primary and secondary care: A Clinical Practice Guideline
www.nice.org.uk/nicemedia/pdf/CG029fullguideline.pdf 8th June 2010
National Institute for Health and Clinical Excellence; 2009; Negative pressure wound therapy for
the open abdomen; http://www.nice.org.uk/nicemedia/pdf/IPG322Guidance.pdf 8th June 2010
National Pressure Ulcer Advisory Panel; 2009; NPUAP-EPUAP Pressure Ulcer Prevention and
Treatment;
Royal College of Nursing; 2006; Royal College of Nursing Clinical Practice Guideline: the nursing
management of patients with venous leg ulcers;
www.rcn.org.uk/__data/assets/pdf_file/0003/107940/003020.pdf 8th June 2010
Chronic Wounds Toolkit 2010
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Appendix 2 Members of Working Group and Acknowledgments
Name Title Vanessa Whatley Programme Specialist (Healthcare Associated Infection)
NHS West Midlands Helen Shoker Lead Tissue Viability Nurse
Walsall Hospitals NHS Trust Anna Pronyszyn
Infection Prevention Nurse Consultant NHS Sandwell
Gillian Hiskett Modern Matron Heart of Birmingham Teaching Primary Care Trust
Maria Poole Tissue Viability Nurse Wolverhampton City Primary Care Trust
Sarah Hart
Principal Podiatrist Diabetes & Tissue Viability Community Services Warwickshire Community Health
Lorraine Thursby
Service Lead Manual Handling and Tissue Viability George Eliot Hospital
Pat Davies Senior Lecturer Birmingham City University
Acknowledgement to :
Carole Clive Consultant Nurse Infection Prevention and Control; NHS Worcestershire
Debbie King Head of Infection Prevention Solihull Care Trust
Dr Beryl Oppenheim Consultant Microbiologist Sandwell and West Birmingham NHS Trust
Dr Jane Povey Medical Director NHS West Midlands
Ingrid Craddock Infection Prevention Nurse Wolverhampton City PCT
Iris Fitzgibbon Professional Head for Rehabilitation Nursing
Wolverhampton City Primary Care Trust
Dr Itisha Gupta Consultant Medical Microbiologist Heart of England NHS Trust
Jane Taylor Programme Lead (HCAI) NHS West Midlands
Karen Mc Bride Tissue Viability Nurse Dudley Primary Care Trust
Dr Kathryn Vowden Consultant Nurse Tissue Viability Bradford Teaching Hospitals NHS Foundation Trust
Maria Poole Tissue Viability Nurse Wolverhampton City PCT
Susan Harper Infection Preventions Nurse Royal Wolverhampton Hospitals NHS Trust
Podiatry Diabetes Group Stoke on Trent Community Health Services
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Appendix 3 Chronic Wounds Data Capture System
http://www.monitoring.westmidlands.nhs.uk/Login.aspx?ReturnUrl=%2fDefault.aspx
For more details, user guide and registration enquires please email [email protected]
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Appendix 4 Pressure Ulcers Opportunity Estimator (Calculator)
An Excel based resource for estimation of the financial burden of pressure ulcers, the
opportunity estimator, has been produced and is available on the ‘Your Skin Matters’ high
impact intervention pages of the NHS Institute for Innovation and Improvement pages. The
selected text provides the link to the pages below.
www.institute.nhs.uk/opportunity_locators/calculators/pressure-ulcers.html
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Appendix 5: Example multidisciplinary minimum skills sets produced by Birmingham City
University
Untrained healthcare staff with clinical skills (e.g. Health Care Assistants)
Skin assessment
Equipment for pressure ulcers including repositioning
Wound Dressing
Bandage application
Aseptic / non-touch technique
Clean technique
Awareness of appropriate positioning techniques for patients with leg ulceration
Newly qualified clinical staff (e.g. Foundation year 1 doctors/nurses/Allied health professionals)
To be able to undertake a full skin Assessment
To be able to classify Pressure Ulcers correctly
To be able to risk assess patients for pressure ulcers using a recognised pressure ulcer risk assessment tool.
To be able to determine the appropriate equipment to use to prevent pressure ulcers including repositioning
To be able to determine the appropriate equipment to use to treat existing pressure ulcers including repositioning
To demonstrate an awareness of leg ulceration management
To demonstrate an awareness of the appropriate management of fungating wounds
To demonstrate an awareness of the appropriate management of open abdomen
To demonstrate an awareness of the appropriate management of the diabetic foot
To be proficient at aseptic / non-touch technique
To be proficient at clean technique
To demonstrates the ability to determine a wound infection and instigate appropriate management.
To be proficient in holistic wound assessment
To be proficient in determining appropriate wound management to include wound covering material.
To demonstrate proficiency in the taking of a wound swab from a non-infected wound and from an infected wound.
To have an awareness of the need for health promotion in order that patients become experts in their own wound management.
Demonstrates the ability to plan the appropriate care for a patient with a wound; including the use of appropriate treatment objectives to enable evaluation.
Clinical staff having completed foundation stage/preceptorship
To be able to undertake a full skin Assessment and be able to teach this to others.
To be able to classify Pressure Ulcers correctly and be able to teach this to others.
To be able to risk assess patients for pressure ulcers using a recognised pressure ulcer risk assessment
Chronic Wounds Toolkit 2010
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tool and be able to teach this to others .
To be able to determine the appropriate equipment to use to prevent pressure ulcers including repositioning and be able to teach this to others.
To be able to determine the appropriate equipment to use to treat existing pressure ulcers including repositioning and be able to teach this to others.
To demonstrate an awareness of leg ulceration management and be able to teach this to others.
To demonstrate an awareness of the appropriate management of fungating wounds and be able to teach this to others.
To demonstrate an awareness of the appropriate management of open abdomen and be able to teach this to others.
To demonstrate an awareness of the appropriate management of the diabetic foot and be able to teach this to others.
To be proficient at aseptic / non-touch technique and be able to teach this to others.
To be proficient at clean technique and be able to teach this to others.
To demonstrates the ability to determine a wound infection and instigate appropriate management. Is able to teach this to others.
To be proficient in holistic wound assessment and be able to teach this to others.
To be proficient in determining appropriate wound management to include wound covering material and be able to teach this to others.
To demonstrate proficiency in the taking of a wound swab from a non-infected wound and from an infected wound. Is be able to teach this to others.
Demonstrates the ability to plan the appropriate care for a patient with a wound; including the use of appropriate treatment objectives to enable evaluation and be able to teach this to others.
To be proficient at aseptic / non-touch technique and be able to teach this to others.
Specialist staff (e.g. Tissue Viability Nurse/Vascular nurse/Podiatrist):
In addition to being able to undertake the items below, is also able to assess and audit the completeness of the activities of others in relation to the aspects below.
To be able to undertake a full skin Assessment and be able to teach this to others.
To be able to classify Pressure Ulcers correctly and be able to teach this to others.
To be able to risk assess patients for pressure ulcers using a recognised pressure ulcer risk assessment tool and be able to teach this to others.
To be able to determine the appropriate equipment to use to prevent pressure ulcers including repositioning and be able to teach this to others.
To be able to determine the appropriate equipment to use to treat existing pressure ulcers including repositioning and be able to teach this to others.
To demonstrate an awareness of leg ulceration management and be able to teach this to others.
To demonstrate an awareness of the appropriate management of fungating wounds and be able to teach this to others.
To demonstrate an awareness of the appropriate management of open abdomen and be able to teach this to others.
To demonstrate an awareness of the appropriate management of the diabetic foot and be able to teach this to others.
To be proficient at aseptic / non-touch technique and be able to teach this to others.
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To be proficient at clean technique and be able to teach this to others.
To demonstrates the ability to determine a wound infection and instigate appropriate management. Is able to teach this to others.
To be proficient in holistic wound assessment and be able to teach this to others.
To be proficient in determining appropriate wound management to include wound covering material and be able to teach this to others.
To demonstrate proficiency in the taking of a wound swab from a non-infected wound and from an infected wound. Is be able to teach this to others.
Demonstrates the ability to plan the appropriate care for a patient with a wound; including the use of appropriate treatment objectives to enable evaluation and be able to teach this to others.
Ability to formulate plans of complex care.
Ability to advise staff on the management of patients with wounds.
Ability to devise policies and procedures to direct care relating to tissue viability within the organisation.
Evaluates the care of patients instigated by self and others within the organisation in relation to tissue viability.
32
Appendix 6 Wolverhampton Health Economy Chronic Wounds High Impact Intervention
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Appendix 7 Heart of England PCT Pressure Ulcer Programme Domain: District Nursing/ allied healthcare professionals
Area: Assessment and treatment of Pressure Ulcers where skilled district
nursing and allied health care professional intervention is required to
ensure effective treatment.
PCT Target: All adults and children with or at risk to pressure ulceration that require
intervention from the district nursing service. (See District Nursing
Referral Criteria)
PAS/Activity Code: PAS Codes required- see EB 399912005 – Pressure sore
D/N Contribution: 1. A holistic assessment of the Service Users status to determine the aetiology of the pressure ulcer utilising Tissue Viability Guidelines (See HOBtPCT Policy – Tissue Viability
Guidelineshttp://pctnet/services/tissueviability/documents.asp)
2. Development of an agreed plan of care in accordance with
service users and their carers.H:\templates\care plans\pressure ulcers\CARE PLAN pressure ulcers HOB.doc
3. Provision of evidence based, quality standardised service. (See HOB tPCT Policy – Tissue Viability Guidelines).
http://pctnet/services/tissueviability/documents.asp 4. Promotion of service user’s concordance and self management
http://www.NICE.org.uk/Guidance/B 5. Raise awareness of health lifestyles/disease prevention. (See
Programme of Care Healthy Lifestyles)
H:\templates\leaflets\Pressure ulcer prevention booklet.doc
6. To act as the coordinator of care where multi professional and multi agency services are required.
7. To ensure that the pressure ulcers have not occurred due to potential
neglecthttp://ncw.pctnet.wmids.nhs.uk/Policies_Admin/PoliciesList.aspx?PCT=hob&ID=347
Target population: All adults and children with or at risk to pressure ulceration that require
intervention from the district nursing service. (See District Nursing
Referral Criteria)
Team Target: All adults and children with or at risk to who require intervention from
district nursing services, in accordance with the District Nursing Referral
Response Times (See District Nursing Referral Criteria).
Intervention:
1. Following a first assessment (See Programme of Care – First Assessment), the service user will have a comprehensive assessment utilising standardised assessment documentation. (See HOB tPCT Tissue Viability Guidelines)
Chronic Wounds Toolkit 2010
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http://pctnet/services/tissueviability/documents.asp 2. Consent to be obtained in accordance with HOBtPCT Policy
and Procedures.
http://nww.pctnect.wmids.nhs.uk/Policies_Admin/PoliciesList,aspx?PCT=hob&ID=243
3. Record the outcome of assessment, plan of care, and evaluation in accordance with The Guidelines for Clinical Record Keeping
http://pctnect.wmids.nhs.uk/policies_Admin/Policieslist,aspx?PCT=hob&ID=466
4. Assess the requirement and/or use of pressure redistribution equipment in line with Tissue Viability Guidelines
http://pctnet/services/tissueviability/documents.asp
5. Initiate treatment using Wound Care Formulary
http://pctnet/services/tissueviability/documents.asp 6. Report all pressure ulcers that are Grade 3+ (European
Pressure Ulcer Advisory Panel – EPUAP
http://www.epuap.org) utilising the clinical incident form- 7. Care will be reviewed at each visit with formal evaluation and
reassessment of care taking place at a minimum of monthly intervals or earlier if condition changes
8. Ensure appropriate storage of prescribed treatments
http://pctnect.wmids.nhs.uk/policies_Admin/Policieslist,aspx?PCT=hob&ID=718
9. Ensure safe disposal of clinical waste products
http://pctnect.wmids.nhs.uk/policies_Admin/Policieslist,aspx?PCT=hob&ID=717
10. Correct procedure for hand washing is adhered to .
http://pctnect.wmids.nhs.uk/policies_Admin/Policieslist,aspx?PCT=hob&ID=718
11. Service users will be provided with relevant contact details of how to contact the district nursing service and MDT
12. Provide consistent information which ensures that service users are aware of and fully understand the nursing advice and intervention
13. Access interpreters as necessary via the BILCS
servicehttp://pctnet.wmids.nhs.uk/trustwide/corporate/bilcs/index.htm http://nww.pctnet.wmids.nhs.uk/trustwide/corporate/bilcs/index.htm
14. Access to specialist nurse as required via tissue viability service.
http://pctnet/services/tissueviability/documents.asp 15. Supporting written information should be provided using PCT
resources, and/or patient leaflets such as those available from
http://cks.library.nhs.uk/.
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Evidence base:
Royal College of Nursing and National Institute of Clinical Excellence
(2005) The Management of Pressure Ulcers in Primary and Secondary
Care. NICE Clinical Guideline September 2005 London, National
Institute for Clinical Excellence http://www.NICE.org.uk/Guidance/B
Tissue Viability Guideline (HOBCT)
http://pctnet/services/tissueviability/documents.asp
Competencies
required:
1. Every registered staff member is responsible for their own continual professional development (CPD) and will keep updated according to current recommendations. This will be monitored using the trust PCT competency
framework.H:\documentation\competency\Pressure Ulcer Competency BEN draft1.doc
2. All registered staff will have an up to date NMC registration, and will remain responsible for updating this as specified.
3. All staff to attend mandatory tissue viability training and complete practical competencies
http://pctnet/services/tissueviability/documents.asp
4. All grades of staff must provide evidence of competency at annual appraisal in line with the Knowledge & Skills Framework (KSF).
Resources required: 1. Access to training as identified in ‘Competencies required’ section
2. Protected time out of role to undertake training 3. Access to equipment necessary to undertake task 4. Access to Heart of Birmingham Policies and Procedures
Partnerships: Service User’s/Carers
Practice Nurses
General Practitioners
Social Workers
Assertive Case Managers( referral forms/ Advanced Nurse
Practitioners
Specialist Services
Occupational therapy( referral forms
Wheelchair services ( referral forms
Dieticians( referral forms
Audit trail: Heart of Birmingham Clinical Audit Programme audit programmes
Tissue Viability Prevalence and Incidence Audit H:\audit\audit
forms\Audit form pressure ulcer 2005.xls
Specific audits to be negotiated with the Director of Nursing Services
Chronic Wounds Toolkit 2010
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and Clinical Development
Standards audit H:\audit\standards audit\standard for pressure
ulcer audit apr 19 v1.doc
.3 monthly pressure relieving equipment audit
Chronic Wounds Toolkit 2010
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Appendix 8 Wolverhampton City PCT Care Bundle and Standard Operating Procedure
West Park Rehabilitation Hospital Directorate of Rehabilitation
Nursing
Subject: MOBILITY Date of Implementation: June 2010 Date of Review: July 2013
Care Standard Guideline Number 37 Standard Relating To: Pressure Ulcer management
Care Outcome To ensure the skin integrity is maintained and the risk of deterioration of pressure ulcer formation is reduced healing is optimised.
NURSING CARE
1. Complete care bundle for pressure ulcers.
2. Assess the risk using the Waterlow score, recording assessment in nursing risk record, state
frequency of re-assessment minimum weekly.
3. Record specific needs regarding moving handling the patient on the assessment sheet, avoid sheering force when handling patient.( Refer to physio goal setting care plan.)
4. Alternate position minimum 2 hourly, relieving pressure and observing skin. 5. Record skin condition daily noting any changes 6. Keep skin clean and dry, report any changes in skin condition and pressure areas in nursing records
and to team leader. 7. Ensure adequate dietary and fluid intake, refer to dietician following the nutritional assessment and
record in nursing risk record. 8. Use pillows to support limbs, nurse on appropriate mattress or bed according to risk assessment.
Record in nursing records when specialised pressure relieving methods are used e.g overlay, alternating pressure mattresss. Record time and date when used or changed.
9. Observe for pain on movement, or pain associated with certain positions. Use pain chart as appropriate.
10. Assist with hygiene needs and with any activity of daily living, when required. 11. Conduct regular positioning of patient Using turn charts to record movement 12. Care for wound according to care standard 40, mapping wounds on body chart and dressings required.
Reference:
Tissue Viability policy
Cost effectiveness of Pressure relieving devices for the prevention and treatment of pressure ulcers. Fleurence RL. 2005 Int J Technol Assess Health Care. 2005; 21(3):334-41
The Cost Of Pressure ulcers in the UK. 2004. Age Ageing. 2004;33(3):230-5
American Association of Infection Control Practitioners (APIC); 2001; Position Statement: Clean vs. Sterile: Management of Chronic Wounds; APIC News; March/April 2001;
20-31; www.apic.com; 24/01/05
Chief Medical Officer; 2003; Winning Ways: Working together to reduce Healthcare Associated Infection in England; Department of Health; London
Department of Health (2006). The Health Act 2006.Code of Practice for the Prevention and Control of Health Care Associated Infections.
41
Pressure Ulcer Care Bundle
Nurse to complete assessments and if any question is answered YES nurse to ask for dietician and physiotherapist to complete their section.
NAME SIGNATURE DATE
History poor skin integrity underlying predisposing condition? Yes / No
Pressure damage on admission.
Yes / No
If Yes complete care plan for wounds and map skin damage
Is the patient at risk nutritionally ? Yes / No
Has the patient got a High risk score on the Waterlow score /immobile? Yes / No
SECTION 1: TO BE COMPLETED by Nurse
Skin Assessment
Actions taken
Identify & treat underlying issues Cognitive
issues. Blood test, , TPR, current medicines. continence
Actions taken
Wound Care Chart Commenced Completed by
Commence repositioning chart using generic Completed by
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observation chart (obs)2
Environment & equipment review. Consider use of
Pressure relieving mattress/ cushions visibility by nursing staff
Actions taken
SECTION 2: TO BE COMPLETED BY PHYSIOTHERAPIST
Mobility review. Consider intervention required, and
mobility plan.
SIGNATURE DATE
Action taken
SECTION 3: TO BE COMPLETED BY DIETICIAN
Nutritional dietary needs. Consider food supplements ,
and vitamins, minerals , mechanical feeding .
SIGNATURE DATE
Action taken
43
Pressure Ulcer Prevention Daily Intervention.
Tick in each box to state action completed. Write in date, time and signature
in space provided .Record evaluation or changes on the on care plan.
Complete at least once per day
Patient Name. _____________________________________
DOB. ______________________________________
Hosp. No. ______________________________________
ACTION Date/
Time
Skin inspection daily
Refer to Tissue
Viability Review if
deterioration occurs
Wound chart
reviewed/Waterlow
risk
Pressure relieving
equipment in Use
State Mattress /
cushions in use on care
plan
Mobility regime –
adhered to as on care
plan
Skin condition checked
after sitting out on
care plan
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If wound reviewed
recorded changes on
wound chart
Indicate any further
areas of pressure
damage on care plan
Nurse Signature
45
Appendix 9 Example: Stoke on Trent Community Health Services Primary Care Foot Ulcer
Pathway
Foot ulcer identified by:
GP
Practice Nurse
District Nurse
Other HCP
Community Care Home Staff
REFER : 24 WORKING HOURS
Problem
Sudden Onset Cold Foot
New Hot Foot
and
Emergencies
Refer to Secondary Care Pathway
Primary Care
Community Podiatrists
Healed
Refer back to Community Podiatry
Deteriorated
Refer to Secondary Care Pathway
Complex Wound Clinics run by Advanced Podiatrists in Diabetes
Located at: Bentilee, Biddulph, Fenton, Hanley,
Kidsgrove, Meir, Milehouse, Smallthorne, Tunstall
OR
Multidisciplinary Complex Wound Clinics
Currently located at Leek, Biddulph, Milehouse and Cheadle
run by
TVNs and Advanced Podiatrists in Diabetes
Fast Track Access to Secondary care
OR
Consultant Led Multidisciplinary Complex Wound Clinics
at
Bentilee, Haywood Hospital and Longton Cottage Hospital
No progress after 4
weeks or deterioration
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Appendix 10 Example: Stoke on Trent Community Health Services Secondary Care Foot Ulcer
Pathway
Problem
Secondary Care - All
referrals must be VIA GP
Chronic Foot Ulcer
Not responding to community treatment
or deteriorating.
Tendon/joint/bone exposed
Sudden Onset Cold Foot
Ischaemic/Necrotic
ABPI <0.5 +
tissue damage
New Hot Foot
Red/hot/swollen
ie. Charcot arthropathy suspected
Emergencies
Severe infection
Spreading cellulitis
GP referral to:
Acute (Medical) Assessment Unit
Or Surgical Assessment Unit
– if debridement required
GP referral to:
Vascular Surgeons
Via
Surgical Assessment Unit - same day
GP referral to:
Vascular/Diabetes Team
Via COPD Urgent Appointment 1-2/52
GP referral to:
Via Diabetes Team for diagnosis then to
Orthopaedic Surgeons Same day
Shared care
to include;
Podiatry, Tissue Viability, Vasc.
Nurse Practitioner, Orthotists,
Biomechanics etc.
47
Appendix 11 Example: Stoke on Trent Community Health Services New Patient Referral Pathway
Triage
Daily – 24hrs
Formal Training
Experienced Staff
30mins per day
Urgent
Offered appointment
within 1-7 working days
Diabetes
Offered appointment/dom
within 1 month
Non-urgent
Offered appointment/dom
within 1 month
Assessed
(and treated if necessary)
Assessed
(and treated if necessary)
Assessed
(and treated if necessary)
Outcome
Discharge
Single treatment and
discharge
Short-course of treatment
Planned treatment
programme
Outcome
Low risk
(annual assessment
PN/GP)
Increased risk – no
podiatry need
(annual assessment
PN/GP)
Increased risk – podiatry
need
(treatment 3-6 months)
High risk
(treatment 1-3 months)
Ulcerated
(follow pathway)
New referral received at
Shelton Primary Care Centre
Norfolk Street
Shelton
ST
from
GP, Practice Nurse, District Nurse,
Tissue Viability, Allied Health
Professional
Outcome
Discharge
Single treatment and
discharge
Short-course of treatment
Planned treatment
programme
48
Appendix 12 - Bradford Teaching Hospitals NHS Foundation Trust & Bradford and Airedale Teaching Primary care Trust Referral Guidelines
Wound Management Policy
Referral Procedure The wound care and tissue viability service including the leg ulcer service and the diabetic foot clinic are
designed to optimise patient care and to achieve best outcomes for patients in a cost effective
framework. Although some wounds may require direct referral to the Wound Healing Unit at the
Bradford Royal Infirmary for the majority of wounds the process is based around an integrated service
with progressive referral pathway from the general nursing teams, through the community and hospital
Tissue Viability Nursing Service to the specialist Wound Care Unit. Progression depends on:-
Wound complexity and/or aetiology
Treatment outcome review
Treatment availability
Failure to manage symptoms such as pain, odour or exudate
Need to manage associated condition(s)
Patient choice
Referral Criteria The criteria for progression along the referral pathway are:
need, wound complexity, co-morbidity, response to treatment and existing National policies (e.g. NSF
relating to diabetic foot management)
Health care practitioners should refer a patient for specialist advice to the community Tissue Viability
Nursing Service or Hospital Wound Care Team if:
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The patient requires a more detailed assessment or management advice is required
A wound that falls outside the field of knowledge or experience of the practitioner
If there are problems with investigations such as Doppler ankle brachial pressures (ABPI)
For any patient where the wound fails to progress or infection, exudate, pain, odour or necrotic tissue is a management problem
For patients with pressure ulcers o The wound is a grade 3 or 4 pressure ulcer o The pressure ulcer is deteriorating or difficult to manage o The ulcer is on the heel and requires Doppler assessment o Where adult protection issues may require evaluation
For all patients with diabetic foot ulcers (including grade 3 and 4 pressure ulcers on the heel) o Co-ordinate care with Diabetic Foot Clinic in line with NSF and Local PACE guidelines
For patients with surgical wounds (in conjunction with the appropriate surgical team) o Progress to healing requires VAC therapy o Progress is delayed or is affecting patient quality of life
For patients who are receiving or require advanced therapy. (e.g. topical negative pressure or larvae therapy)
o Assessment of need/appropriateness o Assessment of progress and review of outcome
For patients with malignant fungating wounds o To review treatment options to maintain symptom control
Health care practitioners should refer a patient to the leg ulcer service for:-
A below the knee wound – no improvement/static after 4 weeks
Failure to control symptoms such as venous eczema, pain or exudate
Where diagnosis is uncertain
Where concordance issues affect care
Patient choice
Health care practitioners should refer directly to the Wound Healing Unit for:-
Failure to make adequate progress- no improvement/static after 12 weeks of appropriate treatment.
Failure to control symptoms (pain, odour, exudate) despite input from the tissue viability team or community leg ulcer service
Assessment for venous surgery to prevent recurrent ulceration
Requirement for specialist input related to wound complexity or co-morbidity
Wound requires care only available within a specialist centre
A patient with a leg wound and low ABPI (<0.8) or if assessment or symptoms suggests ischaemia
Referral indicated by National policy or framework
Referral to other specialist services may be appropriate when:-
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When contact dermatitis complicates care – referral for Dermatological opinion may be appropriate
When malignancy is suspected - referral to Plastic Surgery or Dermatology combined clinic.
51
Diagram of Referral Criteria to Tissue Viability Service
TISSUE VIABILITY SERVICE
Pressure Ulcers
The wound is grade 3 or 4 pressure ulcer
The wound is deteriorating or difficult to manage
The ulcer is on the heel and required Doppler assessment
Where adult protection issues may require evaluation
Surgical Wounds
Progress to healing requires vacuum therapy
Progress is delayed [compared to expected healing time]
Progress is affecting the quality of life [for the patient]
General - any wound where:-
Patient requires more detailed assessment [than is
available in the current setting/area of expertise]
Wounds falls outside the field of knowledge of the
practitioner
The ankle brachial pressure (ABP) gives cause for concern
Wound fails to progress OR
Infection, pain, exudate, odour or necrotic tissue is
unmanageable
All fungating wounds
Any patient requiring advanced therapy