[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

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
2

Chronic Wounds Toolkit 2010

d. The role of innovation e. Health Economy Working

8. Patient involvement a. Patient information Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 Appendix 8 Appendix 9 Appendix 10 Appendix 11 Appendix 12 Chronic Wound Guidelines Members of Working Group Chronic Wounds Data Capture System Pressure Ulcer Productivity Tool Example multidisciplinary minimum skills set Chronic Wounds High Impact Intervention Heart of Birmingham PCT Pressure Ulcer Programme Wolverhampton City PCT Pressure Ulcer Prevention Bundle (in patient care) Stoke on Trent Community Health Services Primary Care Foot Ulcer Pathway Stoke on Trent Community Health Services Secondary Care Foot Ulcer Pathway Stoke on Trent Community Health Services New Patient Referral Pathway Example expert referral guidelines

Chronic Wounds Toolkit 2010

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.

Chronic Wounds Toolkit 2010

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.

Chronic Wounds Toolkit 2010

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 Officers 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 Officers 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

Chronic Wounds Toolkit 2010

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.

Chronic Wounds Toolkit 2010

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.
IMPROVED QUALITY AND SAFETY

BEST PRACTICE PRINCIPLES

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.

Chronic Wounds Toolkit 2010

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 168198m 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.

Chronic Wounds Toolkit 2010

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.

10

Chronic Wounds Toolkit 2010

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 PCOs 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
11

Chronic Wounds Toolkit 2010

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.
12

Chronic Wounds Toolkit 2010

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)

13

Chronic Wounds Toolkit 2010

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.

Multidisciplinary Consistent with clinical training/experiences Contemporary

Postregistration
Competency based Regular updates Monitoring of practice using care bundles Targeted education relating to performance/ audit results/initiatives

Preventative Supportive of treatment Patient contracts Suport initiatives

Preregistration

Patient Education

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.
14

Chronic Wounds Toolkit 2010

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 nurses 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:

15

Chronic Wounds Toolkit 2010

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.

16

Chronic Wounds Toolkit 2010

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
17

Chronic Wounds Toolkit 2010

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 videos and CDs, 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.
18

Chronic Wounds Toolkit 2010

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.

19

Chronic Wounds Toolkit 2010

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.
20

Chronic Wounds Toolkit 2010

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

21

Chronic Wounds Toolkit 2010

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 .

22

Chronic Wounds Toolkit 2010

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

23

Chronic Wounds Toolkit 2010

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

24

Chronic Wounds Toolkit 2010

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

25

Chronic Wounds Toolkit 2010

Appendix 2 Members of Working Group and Acknowledgments
Title Programme Specialist (Healthcare Associated Infection) NHS West Midlands Lead Tissue Viability Nurse Walsall Hospitals NHS Trust Infection Prevention Nurse Consultant NHS Sandwell Modern Matron Heart of Birmingham Teaching Primary Care Trust Tissue Viability Nurse Wolverhampton City Primary Care Trust Principal Podiatrist Diabetes & Tissue Viability Community Services Warwickshire Community Health Service Lead Manual Handling and Tissue Viability George Eliot Hospital Senior Lecturer Birmingham City University

Name Vanessa Whatley Helen Shoker Anna Pronyszyn Gillian Hiskett Maria Poole Sarah Hart Lorraine Thursby Pat Davies Acknowledgement to : Carole Clive Debbie King Dr Beryl Oppenheim Dr Jane Povey Ingrid Craddock Iris Fitzgibbon Dr Itisha Gupta Jane Taylor Karen Mc Bride Dr Kathryn Vowden Maria Poole Susan Harper Podiatry Diabetes Group

Consultant Nurse Infection Prevention and Control; NHS Worcestershire Head of Infection Prevention Solihull Care Trust Consultant Microbiologist Sandwell and West Birmingham NHS Trust Medical Director NHS West Midlands Infection Prevention Nurse Wolverhampton City PCT Professional Head for Rehabilitation Nursing Wolverhampton City Primary Care Trust Consultant Medical Microbiologist Heart of England NHS Trust Programme Lead (HCAI) NHS West Midlands Tissue Viability Nurse Dudley Primary Care Trust Consultant Nurse Tissue Viability Bradford Teaching Hospitals NHS Foundation Trust Tissue Viability Nurse Wolverhampton City PCT Infection Preventions Nurse Royal Wolverhampton Hospitals NHS Trust Stoke on Trent Community Health Services

26

Chronic Wounds Toolkit 2010

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 hcai@westmidlands.nhs.uk

27

Chronic Wounds Toolkit 2010

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

28

Chronic Wounds Toolkit 2010

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 29

Chronic Wounds Toolkit 2010

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. 30

Chronic Wounds Toolkit 2010

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.

31

Appendix 6

Wolverhampton Health Economy Chronic Wounds High Impact Intervention

32

Chronic Wounds Toolkit 2010

33

Chronic Wounds Toolkit 2010

34

Chronic Wounds Toolkit 2010

35

Chronic Wounds Toolkit 2010

Appendix 7 Heart of England PCT Pressure Ulcer Programme
Domain: Area: District Nursing/ allied healthcare professionals 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 Codes required- see EB 399912005 Pressure sore 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.a sp) 2. Development of an agreed plan of care in accordance with service users and their carers.H:\templates\care

PAS/Activity Code: D/N Contribution:

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 users 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/Policie

sList.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) 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). 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)

Team Target:

Intervention:

36

Chronic Wounds Toolkit 2010

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/Policies List,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,as px?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 form7. 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,as px?PCT=hob&ID=718
9. Ensure safe disposal of clinical waste products

http://pctnect.wmids.nhs.uk/policies_Admin/Policieslist,as px?PCT=hob&ID=717
10. Correct procedure for hand washing is adhered to .

http://pctnect.wmids.nhs.uk/policies_Admin/Policieslist,as px?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/.

37

Chronic Wounds Toolkit 2010

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). 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 Service Users/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

Resources required:

Partnerships:

forms\Audit form pressure ulcer 2005.xls

Specific audits to be negotiated with the Director of Nursing Services

38

Chronic Wounds Toolkit 2010

and Clinical Development Standards audit H:\audit\standards audit\standard for pressure

ulcer audit apr 19 v1.doc

.3 monthly pressure relieving equipment audit

39

Chronic Wounds Toolkit 2010

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.

40

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 Yes / No Yes / No If Yes complete care plan for wounds and map skin damage Is the patient at risk nutritionally ? Has the patient got a High risk score on the Waterlow score /immobile? Yes / No Yes / No DATE

History poor skin integrity underlying predisposing condition? Pressure damage on admission.

SECTION 1: TO BE COMPLETED by Nurse

Actions taken

Skin Assessment
Actions taken

Identify & treat underlying issues Cognitive issues. Blood test, , TPR, current medicines. continence

Wound Care Chart Commenced Commence repositioning chart using generic

Completed by Completed by

41

Chronic Wounds Toolkit 2010

observation chart (obs)2 Environment & equipment review.
Consider use of Actions taken Pressure relieving mattress/ cushions visibility by nursing staff SECTION 2: TO BE COMPLETED BY PHYSIOTHERAPIST Action taken

Mobility review.
mobility plan.

Consider intervention required, and

SIGNATURE

DATE Action taken

SECTION 3: TO BE COMPLETED BY DIETICIAN

Nutritional dietary needs.

Consider food supplements ,

and vitamins, minerals , mechanical feeding .

SIGNATURE

DATE

42

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 ACTION Date/ Time

Patient Name. DOB. Hosp. No.

_____________________________________ ______________________________________ ______________________________________

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

43

Chronic Wounds Toolkit 2010

If wound reviewed recorded changes on wound chart Indicate any further areas of pressure damage on care plan Nurse Signature

44

Appendix 9 Example: Stoke on Trent Community Health Services Primary Care Foot Ulcer Pathway

Problem

Primary Care

Foot ulcer identified by: GP Practice Nurse District Nurse Other HCP Community Care Home Staff REFER : 24 WORKING HOURS

Community Podiatrists

No progress after 4 weeks or deterioration

Complex Wound Clinics run by Advanced Podiatrists in Diabetes Located at: Bentilee, Biddulph, Fenton, Hanley, Kidsgrove, Meir, Milehouse, Smallthorne, Tunstall OR

Sudden Onset Cold Foot New Hot Foot and Emergencies

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

Refer to Secondary Care Pathway

OR Consultant Led Multidisciplinary Complex Wound Clinics at Bentilee, Haywood Hospital and Longton Cottage Hospital

Healed Refer back to Community Podiatry

Deteriorated Refer to Secondary Care Pathway

45

Chronic Wounds Toolkit 2010

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

GP referral to: Vascular/Diabetes Team Via COPD Urgent Appointment 1-2/52

Sudden Onset Cold Foot Ischaemic/Necrotic ABPI <0.5 + tissue damage

GP referral to: Vascular Surgeons Via Surgical Assessment Unit - same day Shared care to include; Podiatry, Tissue Viability, Vasc. Nurse Practitioner, Orthotists, Biomechanics etc.

New Hot Foot Red/hot/swollen ie. Charcot arthropathy suspected

GP referral to: Via Diabetes Team for diagnosis then to Orthopaedic Surgeons Same day

GP referral to: Emergencies Acute (Medical) Assessment Unit Or Surgical Assessment Unit 46 if debridement required

Severe infection Spreading cellulitis

Appendix 11 Example: Stoke on Trent Community Health Services New Patient Referral Pathway
New referral received at Shelton Primary Care Centre Norfolk Street Shelton ST Urgent Offered appointment within 1-7 working days Assessed (and treated if necessary) Outcome Discharge Single treatment and discharge Short-course of treatment Planned treatment Outcome programme from GP, Practice Nurse, District Nurse, Tissue Viability, Allied Health Professional Triage Daily 24hrs Diabetes Offered appointment/dom within 1 month Low risk Assessed (and treated if necessary) (annual assessment PN/GP) Increased risk no podiatry need (annual assessment PN/GP) Formal Training Experienced Staff 30mins per day Non-urgent Offered appointment/dom within 1 month Increased risk podiatry need Assessed (and treated if necessary) (treatment 3-6 months) High risk Outcome (treatment 1-3 months) Discharge Ulcerated Single treatment and (follow pathway) discharge Short-course of treatment Planned treatment programme

47

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:

48

Chronic Wounds Toolkit 2010

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:-

49

Chronic Wounds Toolkit 2010

When contact dermatitis complicates care referral for Dermatological opinion may be appropriate When malignancy is suspected - referral to Plastic Surgery or Dermatology combined clinic.

50

Diagram of Referral Criteria to 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 vac Progress is delayed [compared t Progress is affecting the quality

TISSUE VIABILITY SERVICE

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

51