Lower Leg Wound CareAn ‘outside in’ approach – studying what matters to patientsDr Darunee Whiting

John’s Story

The problem from the ‘inside out’

Too many lower leg wound swabs being sent to the microbiology lab – seem to be ‘low value’ swabs

Problem identified from ‘Inside out’

Let’s study it from the ‘Outside in’, using our enduring points of leverage:

‘Clean in’, ‘Clean through’, ‘Clean out’

1)‘Clean in’ (Necessary/ Maximally appropriate/ sufficient)

Necessary: Infection Limit Unnecessary: Study demand/ InputsMDT review and audit of patient care/ Interviewing patients

Main finding: Wounds taking too long to heal in primary care and infection repeatedly seeked as cause of delayed healing (one year vs 80% should heal in 3months)

What matters to patients is: ‘I want my wound to heal quickly’Therefore the problem from the outside in/ the citizen is a problem of wound healing- not a problem of wounds swabs…..if we had NOT looked ‘outside in’ we would risk solving the wrong problem

Studying what matters to patients: Why are wounds taking so long to heal?

1. Not identifying root cause of wound. Need early ABPI in primary care

is this wound venous? needs compression.

2. Is this wound arterial? needs earlier referral

3. No early ABPI- takes 20-30 minutes time upfront but saves weeks/ months!

4. not enough time invested upfront- due to workload pressures

5. Leads to ‘quick fixes’- swabbing wounds and treating for infection

6. lack of continuity of nursing staff

Costs of this….

Key Solution: Early ABPI

if no ABPI- leads to: Poor outcomes and increased cost/ work in the system

Wrong dressings and delayed healing times (average heal rate 12 months!- 80% should heal within 3 months). morbidity/ depression/ Workload in primary care

Increased wound swabs to lab, increased unnecessary antibiotics

Increased referrals to tissue viability

Admissions for wound care/ cellulitis

?delayed vascular referrals ?Amputations rates

Focus on key problems and Actions: Working together to design improvement

Problem: Identify cause of wound and treat appropriately:

Action> ABPI within 2 weeks

Problem: No time in nurse timetable to enable ABPI (Need to understand system conditions/ limits)

Action> enable 30minutes upfront

Problem: lack of continuity of nursing staff causing delay in ABPI

Action> Template to record wound care, so that each nurse knows when ABPI should be done, has been done, duration of dressing

Problem: lack of understanding of use of wound swab

Action: Education

2) ‘Clean Through’

Without error/ With known variation/ On time

problem:

Previously looked for all organisms , even if not pathogenic as ‘clean in’/ clinical question not clear. Drove unnecessary antibiotic prescribing

Action:

> With understanding of ‘clean in’/ clinical question, can now process without error

"I am starting an antibiotic for cellulitis - is there any evidence that typical pathogens could be resistant."

Only look for pathogenic organisms/ resistance

3) ‘Clean out’

Understood/ Helpful/ Reflective of ‘what is normal for me’

Problem:

Non specific reporting

Action:

> Helpful reporting, answering clinical question/ ‘clean in’

ie: facilitating management of response to treatment

Lets look again at what was happening

From ‘fixes that fail’ to doing what matters

When we look inside out we risk solving the wrong problems

Understanding this, takes us out of the lab and out of the transactional context of the request for testing that the lab receives.

It takes us to where citizens are and to what difference they want us to help them make in their lives.

When we do this we see different and better problems and find different and better solutions

In this case it took us out to primary care, where citizens go to have their wounds dressed.

Looking ‘outside in’ showed us that this was not a problem of wounds swabs, it was a problem with wound healing that mattered to citizens

The points of intervention therefore turned out to be an early ABPI in primary care, rather than more education on wound swab requesting and infection.

Looking ‘Outside in’, studying what matters to patients

Acting on this meant:

Better outcomes for the citizen (heal rates/ depression/ social isolation/ less antibiotics/ ?amputation rates

More purposeful work for those working in the system*

Less demand into the system (Nurse appointments, tissue viability referrals, vascular referrals)

More capacity to do even more good things/ creates a virtuous cycle/ taking the time to understand and do what is really necessary, creates more time to understand and do what is really necessary.

Further system improvement

Wound pathway should improve care for 80% of patients

20% more complex

- need more bio-psychosocial input

- Often socially isolated, in part due to mobility and chronic wounds

Leg club: provides social environment for care. improved satisfaction, wellbeing, can keep up nurse education in shared environment. diabetes services, vascular services can join in