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Picture this: photos improve wound management

A surveillance nurse’s project to add photos of wounds to electronic records and give patients a copy at discharge is helping to cut surgical site infection rates
Melissa Rochon

A surveillance nurses project to add photos of wounds to electronic records and give patients a copy at discharge is reducing surgical site infections and their impact

Harefield Hospitals clinical nurse specialist in surveillance Melissa Rochon introduced Photo at Discharge (PaD) to reduce the impact of surgical site infections (SSIs).

The project, in which nurses take photos of wounds to help patients monitor infection once they leave hospital, is reassuring patients, reducing readmission rates and saving money.

Melissa, who was highly commended in the Innovations in Your Specialty category at this years RCNi Nurses Awards, explains: The early detection of SSIs is critical to reduce the severity of infection and its impact, and prevent readmission, of which it is the most common cause.

Relying on memory

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A surveillance nurse’s project to add photos of wounds to electronic records and give patients a copy at discharge is reducing surgical site infections and their impact

Harefield Hospital’s clinical nurse specialist in surveillance Melissa Rochon introduced Photo at Discharge (PaD) to reduce the impact of surgical site infections (SSIs).

The project, in which nurses take photos of wounds to help patients monitor infection once they leave hospital, is reassuring patients, reducing readmission rates and saving money.

Melissa, who was highly commended in the Innovations in Your Specialty category at this year’s RCNi Nurses Awards, explains: ‘The early detection of SSIs is critical to reduce the severity of infection and its impact, and prevent readmission, of which it is the most common cause.’


Melissa Rochon, right, explains the system to colleague Marie Dupree. Picture: David Gee

Relying on memory

She says 60% of SSIs arise after discharge, the majority within the first two weeks. ‘They are largely due to bacteria/host response, treatment delay or fragmented communication between acute and community care.

‘Our trust spent £1.6 million on readmission for SSIs after cardiac surgery over a three-year period.’

Her root cause analysis indicated that delay in seeking treatment and lack of communication between acute and community care may have contributed to the duration and severity of SSIs.

‘Infection prevention literature given to the patient was generic and not patient-centred,’ Melissa adds. ‘Patients were asked to rely on memory to determine if the wound appearance had changed.’

Preferred approach

Under PaD, nurses take a photo of the surgical wound, which is uploaded on the electronic record and given to the patient; this makes it easier to spot changes in the wound's appearance that may indicate infection.

‘With cardiac surgery, quite often the first time we take the wound dressing off is at discharge, and even then the patient’s vantage point isn’t good,’ says Melissa, who works for Royal Brompton & Harefield NHS Foundation Trust. ‘If they notice a change at home, they can see a community clinician – an approach preferred by patients – or come to our wound clinic for review.’

The scheme ensures a consistent and standard approach to wound assessment at discharge and handover to the community teams, who receive a clear baseline to detect deterioration.

Hospital clinicians, who may not have seen the wound previously, can review the electronic patient record and readily determine whether the wound is improving or deteriorating. This can affect the decision on whether antibiotics should be prescribed.

‘We thought it might lead to more people being readmitted – an increase in people bouncing back as they noticed the changes – but it has not been an issue’

Melissa Rochon

‘As a surveillance nurse, the photo helps me determine trends, or highlight patients needing extra resources at discharge’ Melissa says. ‘Having that photo helps me in supporting the multidisciplinary team.’

She first trialled the concept with one surgeon, before extending it to other teams. Once she had a working process and the main content for the forms, she trained her surveillance colleagues Natalie Gott and Carlos Morais, before testing the initiative with 500 patients.

She collected outcome data and patient feedback to gain the medical director's support in developing a database to create the PaD forms.

‘We modified out trust’s existing system to create, store and report compliance for PaD forms. This addressed key information governance issues, standardised the form and kept costs down to a minimum. A colleague in IT wrote bespoke code so the form could be uploaded to the electronic patient record.’

Terrific feedback

Melissa then created and delivered a training package for surgical staff nurses using photography, covering clinical governance issues, consent, privacy and dignity.

Compliance feedback is provided to the wards on a monthly basis, with staff achieving more than 90% from January to December 2016.

‘Patient feedback has been terrific,’ says Melissa.  ‘We thought it might lead to more people being readmitted – an increase in people bouncing back as they noticed the changes – but it has not been an issue. Giving patients this tool has not led to over-reporting.

‘And the positive feedback really drove the project forward and helped overcome any resistance.’

New skill

The surveillance team delivered the training to the discharge team and ward nurses at the end of 2015.

‘Making it a nursing skill to use the photo upload has been crucial,’ says Melissa. ‘When only the surveillance team took pictures, the numbers fell when they were on leave or absent. Our excellent uptake rate is largely because we gave nurses a different skill set, to take and manage the pictures.

‘In other trusts, policies and governance called for medical illustrators to come to the bedside to take the picture. Potentially, this is bringing in a risk to the wound, which might be exposed waiting for someone to come along. Nurses used to handwrite wound charts with drawings. This makes their job easier.

‘They quickly picked up what they needed to do in terms of photo quality. Poor images, because they were too small or upside down, were infrequent and easily rectified. It was a real credit to the nursing staff. It is exciting that nurses are able to do this.’

‘PaD appears such a simple initiative, but it has already had a significant impact on care and patient outcomes, and in substantial savings to the hospital’

Margaret Sneddon

For sister Sian Jenkinson, PaD has brought wound management at discharge into the 21st century. ‘Patients and staff both love it,’ she says. ‘By providing personalised wound advice and photographs, it empowers patients to gain expert help promptly when changes occur.

‘The system is simple to learn and use, and has been easily incorporated into the discharge process.’

Sister Samantha Derland agrees, adding that it is also popular with patients. She says: ‘Sometimes patients remember little about what is said to them at the time of discharge, so this acts as a reminder of how to look after their wound. We have found that it has resulted in fewer patients returning with wound infections.’

The scheme has impressive results in terms of both patient experience and outcomes.

When a self-addressed postal questionnaire was sent to patients, about one third reported using the photo to review the wound with a community healthcare worker.

Around two thirds of respondents said the photo provided extra reassurance and information during recovery.


The system of providing personalised advice and photographs has proved popular with patients. Picture: David Gee

Cost avoided

The innovation reduced SSIs. Melissa adds: ‘We have calculated that the “cost avoided” by the reduction of SSIs is £196,202. Our readmission SSI rates are reduced to and maintained at below the national benchmark.

'The guidance on economic assessment I received from Chih Hoong Sin at the Office of Public Management and RCN research and innovation adviser Ann McMahon as part of an innovations course at Buckinghamshire New University has been invaluable in presenting the cost avoided by PaD.'

RCNi Nurse Awards judge Margaret Sneddon, honorary senior research fellow at the University of Glasgow School of Medicine, Dentistry and Nursing, says: ‘PaD appears such a simple initiative, but it has already had a significant impact on care and patient outcomes, and in substantial savings to the hospital.

‘Its effectiveness has come from the thorough, systematic way it has been implemented, monitored and disseminated locally, which is to be commended. The outcomes speak for themselves and deserve wide dissemination.’

Great initiative

Public Health England deputy director of nursing Joanne Bosanquet praises its contribution to antibiotic stewardship. ‘This is a great initiative delivered with tremendous insight,’ she adds. ‘There is an opening to share with other specialty types.’

This has already been seen at Harefield, where nurses are using their new skills more widely for other wounds.

The tissue viability nursing team has developed a registry for its referrals, based on the PaD system, so that a consistent approach and single system is used for wound care.

The invasive cardiology team and cardiac physiologists have also adopted the approach. Now all new implant devices have a photo uploaded in a registry copied from PaD, and implant device wounds are also added.

Tablet trial

Melissa has supported other hospitals to implement similar schemes (see box).

Looking to the future, she says PaD’s success shows how a surveillance app would work in practice. The hospital is currently trialling the use of a tablet to streamline the process further, as it can offer access to the database, camera and print feature.

Melissa would also like to see more trusts increase their nurses’ skills so they can deliver similar improvements in patient care.

‘The RCNi Nurse Awards has been a fantastic opportunity to gain national nursing endorsement for PaD and raise the profile of this innovation to reduce SSIs, improve patient experience and enhance nursing practice,’ she adds. ‘We look forward to sharing our experience with colleagues in other hospitals.’

Get the picture: advice on joining PaD

The RCNi Nurse Awards judges praised the Photo at Discharge scheme's simplicity and effectiveness – and its transferability.

Having already extended PaD from cardiac surgery to tissue viability and implant devices at Harefield Hospital, project lead Melissa Rochon is keen to share what she has learned with other trusts. St George’s Hospital in south London and Barts Health NHS Trust in east London have started to implement a similar approach.

‘It is a simple innovation but anything in the NHS has to satisfy requirements, so you won’t hit the ground running,’ says Melissa. ‘It is readily transferable but needs planning.’

Key to success

‘We did not spend a lot. Different centres will have different rules and regulations, but we used our in-house team to update our electronic record system and others could do the same. This is the approach being taken by both St George’s and Barts.’

There are also practical challenges. Nurses need access to a computer, a camera and a printer.

‘The key to its success has been the patients, and trialling the scheme to make the information better for going home,’ says Melissa

She invites any nurses thinking of implementing a similar scheme to get in touch.

Quality monitored

‘We can share our standard operating procedure and nurse training so they don’t spend time reinventing the wheel,’ she says, adding that tips are given on taking a good photo. ‘We monitor photo quality, make sure we document issues and retake the photo if necessary, but that has been rare.’

Trusts with PATS Dendrite site-wide licences can have the database at no cost, she says.

Those interested in adopting the approach are advised to secure support from the nurse or medical director. ‘They can really drive it forward at times of delay,’ says Melissa.

‘I experienced a delay when senior managers did not realise the benefits of bedside nurses being trained in this skill – until I had executives in the audience during one of my presentations.’ 


Elaine Cole is managing editor of Nursing Standard

 

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