Leading change

Tissue Viability Nurses at Nottinghamshire Healthcare NHS Foundation Trust led on the development and implementation of a new standardisation approach to venous leg ulcers within the community. This programme of work has addressed unwarranted variation in venous leg ulcer treatment and management in order to deliver better outcomes, experience and use of resources within the organisation.

Where to look

NHS Benchmarking (SIGN 2010) has highlighted that 39% of district nursing clinical time is spent in wound care, with additional research suggesting that 20% of this work relates to venous leg ulcers. In essence approximately 8% of the whole district nursing workforce time is spent on venous leg ulcers with 2.1 million visits annually (Barratt et al 2013).

In the 2017- 2019 commissioning guidance NHS England has identified a need for community services to place a greater emphasis on wound care leading to better patient and system outcomes. The goal, to increase the number of full wound assessments for wounds which have failed to heal after 4 weeks with 75% of leg ulcers healed within 20 weeks. The Tissue Viability Nurses identified unwarranted variation in patients with venous leg ulcers, as they were taking more than the anticipated period to heal and so were concerned that best practice was not being implemented and reporting may not be consistent.

What to change

The Tissue Viability Nurses undertook a review of existing service provision and clinical practice in order to establish a baseline as well as to identify areas for development and improvement. This review highlighted that practice differed between the Trust’s services and that knowledge regarding best practice with venous leg ulcers varied between practitioners. This provided an opportunity to standardise training, clinical pathways and support available to staff to ensure they delivered high quality leg ulcer care.

How to change

The Tissue Viability Nurses led on the development and implementation of a number of key areas including:

• Redesigning the leg ulcer assessment and management templates on the Trust’s digital system.
• Providing specialist education and training to all staff caring for patients with venous leg ulcers to support a focus on best practice outcomes
• Re-energising the Trust’s leg ulcer co-ordinator forum to provide regular meetings and a forum for clinical supervision. This forum provides opportunities for clinicians to bring challenging case studies into an arena to aid learning, consistency in the way the clinics operate across the area and equity across services to minimise further unwarranted variation in practice.
• Developing an e-learning tool to support awareness and practical training for all staff at the Trust.
• Redesigning information literature available to patients.
• Redesigning the hosiery formulary to ensure consistency of practice. Research identifies that compression hosiery is an important element in the prevention of recurrence of venous ulceration (RCN, 2000)
• Implementing a staff lower limb handbook and accompanying leg ulcer care policy.

Adding value

The immediate impact of the change has been measured in a number of ways including through venous leg ulcer healing rate data, clinical audits of practice and feedback from patients receiving care and clinicians providing care.

Better outcomes – Since the implementation of the new standardised approach to venous leg ulcers, the Trust has seen improvements in the support available to staff, healing rates and referral rates.  In excess of 90% of leg ulcers heal within the 20 week period.

Better experience – Feedback regarding the service is extremely positive and the leg ulcer link co-ordinator meetings have proved popular with staff.

Better use of resources – The new approach has led to increased consistency in venous leg ulcer care across the Trust and improved healing rates have meant a reduction in time under services for a number of patients with leg ulcers. It is anticipated that the Trust will save in excess of £19000 annually following the implementation of the online training packages.

Challenges and lessons learnt for implementation

• Initial data is extremely important but can be challenging to access at times. Having this has however been key to evidencing the impact of the changes in the longer term.
• It is essential to engage with clinician stakeholders early in the process, in this case those managing venous leg ulcer clinics were key to success and work collaboratively with them has been extremely positive.
• Developing the digital e-learning tool has proved to be a huge success and it has resulted in a sustainable model of training that is gaining interest from other service providers.

For more information contact

Alison Thompson, Tissue Viability Specialist Nurse, Nottinghamshire Healthcare NHS Foundation Trust
Alison.thompson@nottshc.nhs.uk

Annabel Wilson, Tissue Viability Nurse, Nottinghamshire Healthcare NHS Foundation Trust
Annabel.wilson@nottshc.nhs.uk

Kimberley Bignall, Tissue Viability Nurse, Nottinghamshire Healthcare NHS Foundation Trust
Kimberley.bignall@nottshc.nhs.uk