Wound management: An innovative approach
Prompted by unacceptable delays in the treatment of complex wounds, in 2007 Southend University Hospital NHS Foundation Trust began a trust-wide review of wound management.
Realising that the standard of wound management was inherently poor throughout, with only a low profile, the Trust decided to set up a Wound Management Team (WMT). This is a nurse-led team formed by the merging of two specialist nurse teams – vascular and tissue viability – which, with the addition of a vascular surgeon, has produced an effective blend of wound management expertise from both nursing and medical backgrounds.
Prior to the review it had not been uncommon for patients with a variety of wounds – eg acute diabetic foot, pre-tibial lacerations and leg ulcers – to be distributed throughout the Trust under different disciplines such as orthopaedics, plastics, medicine and general/vascular surgery. Treatment was frequently delayed, and for the diabetic foot this would often lead to amputation. The added value of including a surgeon in our team was that it facilitated the ordering of investigations and access to theatre for surgical wound management.
Our first action was to set up a single point for patients to be referred to us. Once this was in place we began twice-weekly, safari-style ward rounds of the whole hospital: first to assess these patients and then to go back to each of them to treat them. This turned out, however, to be very labour intensive and inefficient, since on some wards the nurses had limited expertise and interest in wound care.
As our patients were already occupying a bed, we agreed a strategy with the executive to cohort them into a single ward; thus the Wound Management Unit (WMU), was born. Initially the unit comprised 12 beds within a medical ward, but we now occupy our own ward of 22 beds. Within this space are housed the team members, rehab staff, and a gym (a side room with two beds) for early mobilisation.
The criterion for admission to our unit is a wound that is keeping the patient in hospital. The ward has its own junior staff, and there are two consultant-led, multidisciplinary ward rounds a week including CNSs (both wound management and diabetic), rehab staff and senior ward staff. Also we have daily consultant board rounds. The unit is supported in Outpatients by two CNS-led clinics per week running alongside the consultant clinics; any medical co-morbidities are overseen by a dedicated consultant physician.
Originally the driver for setting up the WMU was to tackle the management of acute diabetic foot and its complications. Our remit has now been extended to include all complex wounds. We have created a pathway to allow rapid access to the unit from the community for all people with an at-risk diabetic foot. We have a dedicated phone line, affectionately known as the ‘Batphone’, the number of which is published on the pathway that has been distributed to all community healthcare personnel (podiatrists also have a Batphone, and they form an integral part of our team). This allows patients to be referred directly to us, to be seen either on the same day or within 24 hours, in line with the guideline published by NICE and the recommendation published by Diabetes UK. We see patients in the WMU or they may be admitted directly to the surgical assessment unit, thus bypassing A and E and without the need of GP referral.
We believe that this rapid access has been the main factor in the reduction, by 60%, of major lower limb amputations in the last three years. Our unit has been the recipient of a number of awards – Quality in Care Diabetes 2013, the James Purdie Prize at the Society of Vascular Nurses Annual Meeting 2009, and the Mölnlycke Health Care Wound Academy Team Award 2009.
The unit’s success in terms of good practice and multidisciplinary activity was noticed by the Director of Nursing, who suggested that our ward should be used to develop the concept of a Model Ward – a concept intended to be a beacon of excellence in nursing and medical care, and a vehicle by which new ideas can be tried, tested and, if found to be valuable, extended across the Trust. The Model Ward project has now been running for 12 months; multidisciplinary, it involves medical and nursing staff and all other supporting professional groups, and has a focus on quality improvement and an emphasis on patient safety/satisfaction.
At present, our team consists of four CNSs: Susan Edwards, Nicola Stone, Gina Sommerville and Helen Sanderson , Paula Fish, a specialist community podiatrist; and consultant vascular surgeons James R. Brown and Mike Salter.
In the future, we hope that the barriers between primary and secondary care can be breached, to provide a ‘service without walls’ and thus to improve the care of wound patients on leaving hospital. This would bring all staff under the management of a single team. The resulting education and enhancement of skills will further reduce the risk of amputation and its devastating effects on quality of life. As a team, we are represented on our own local diabetic network, and also on the regional East of England Diabetic Foot network, and thus we hope to influence the future development of services to improve the outcome of these patients.
Helen Sanderson is Lead CNS, Southend University Hospital NHS Foundation Trust