The nurse-led chronic wounds service where lower limbs are the highest priority
‘Lack of priority given to leg ulcers is a scandal’: centre leader puts an impassioned case for how her team’s distinctive approach can transform patient outcomes
‘Lack of priority given to leg ulcers is a scandal’: centre leader puts an impassioned case for how her team’s distinctive approach can transform patient outcomes
- Management of leg ulcers is too often suboptimal, with catastrophic consequences for individuals
- Read how the distinctive approach of a nurse-led chronic lower limb wound and lymphoedema service is transforming lives
- Learn from the experts – find out how to make the most of compression therapy. Plus other tips for improving outcomes
When Hayley Turner-Dobbin reflects on the value of the service provided by her employer, there’s one particular patient who comes to mind. A woman who had incurable bowel cancer had come to Accelerate CIC, the London-based specialist service for wound and lymphoedema care, with leg ulceration.
‘She actually didn’t care about her cancer,’ says Ms Turner-Dobbin, who is now clinical delivery lead for the social enterprise. ‘It didn’t hurt her and she was comfortable. For her, the problem was her legs.’
Staff at Accelerate assessed her and she was started on compression therapy, which made a huge difference within the space of two weeks, Ms Turner-Dobbin explains.
‘She didn’t have long and it was horrible that the last bit of her life was so hard that she hadn’t even had time to think about her palliative care for her cancer because she was so concerned about the pain in her leg. It was sad, and I just feel so proud that we made her comfortable so that she could enjoy her family and her time.’
A nurse-led wound care service with a complex caseload
Accelerate, which has been an independent organisation since 2011, came about when the leg ulcer service at the then Tower Hamlets Primary Care Trust became a social enterprise. Specialist nurse Alison Hopkins led the drive that made this happen, and is the organisation’s chief executive. The team has grown from seven to around 35 people, and now provides lower limb management to patients from at least 30 clinical commissioning groups in London and beyond.
‘We have the luxury of time, I can’t deny that. When nurses elsewhere say they have a 40-minute turnaround to see a bilateral leg ulceration that’s dripping, you just think that’s cruel, not just for the patient but for the nurse’
Alison Hopkins, Accelerate chief executive
The caseload includes people with some of the hardest-to-treat complex non-healing wounds, as well as those who need help managing lymphoedema. In addition, it offers training, and advice on how others can promote excellent care.
- RELATED: Alison Hopkins – I know I am in the right place when I see the impact we're having on people's lives
For Ms Hopkins, it is part of a mission to improve management of leg ulcers that dates back to her early career as a district nurse more than three decades ago.
Back then, she was shocked by the lack of knowledge about this clinical area. She took time out to educate herself, and has become an authority. She believes patients are still being failed and argues that a different approach is urgently needed.
‘Knowing that someone actually cares for you as a person makes a difference’
Sharon Outhwaite, Accelerate patient
‘People talk about “complex” and “simple” leg ulcers,’ says Ms Hopkins. ‘But with complex leg ulcers, the only reason most are complex is simply because they don’t have the care they need early on. Duration is a significant problem – the longer you have a wound, the more difficult it is to heal, simply because the pain is worse, the gait, the biomechanics change, and so on. So the system simply propels people into chronicity.’
Staff went the extra mile for me
A knee replacement operation in her early 50s left nurse Sharon Outhwaite with a compromised blood supply that resulted in ulcerated wounds. The wounds would not respond to any treatment.
This meant that Ms Outhwaite had to leave the clinical duties she loved to take on a desk job (which she disliked) and ultimately led to her retirement on medical grounds at the age of 54. She is now 65.
‘They tried everything – different antibiotics, even maggots, but nothing worked,’ she says. ‘I was going back and forward [to hospital]; I’ve been on steroids for years and now I have osteoporosis. I couldn’t go upstairs, I had to stop driving; it’s taken away all my independence. I’ve got curvature of the spine because of the osteoporosis and I’m so conscious of that. It’s a funny thing to say but you still grieve for your old life.’
This treatment has improved my quality of life
Ms Outhwaite says she was eventually referred to Accelerate after what was essentially a tussle between a tissue viability service and the local community nursing service over where she should be treated. She is pleased with the outcome, and says that one leg has almost healed.
‘The difference with Accelerate is that they really go the extra mile,’ she says.
‘They’ve been using different compressions and trying different treatments. I’ve had so many different people in the past that don’t know how to bandage my legs, or don’t do what they should do.’
Ms Outhwaite says the worst thing about her condition is not being able to look after her grandchildren, aged three and two. But coming to Accelerate has made her life better, she says. ‘Not to the extent that I can run around, but just knowing that someone actually cares for you as a person makes a difference.’
Impact of leg ulcers is often underestimated
There is a lack of understanding about the enormous impact of leg ulcers, even among fellow health professionals, says Ms Turner-Dobbin. ‘People just say “oh, you’ve got a leg ulcer”, or “you’ve got a wound, and it will get better”. But I don’t think people actually recognise the impact it has on patients, such as how debilitating it is.’
She recalls working in the community and seeing a patient who went from juggling a full-time job and family to being unable to work. ‘She worried about going around with her children because her leg had a bad odour, and it really affected her life. Now I know if she’d had some really good compression and good care, her life might have been very, very different.’
‘I call light compression suboptimal – it’s as useless as a quarter of a paracetamol tablet’
Ms Turner-Dobbin has worked at Accelerate almost since qualifying as a nurse, treating people both in the community and at a treatment centre in east London. ‘I think that too often – especially in the acute sector – everything is very focused on pressure ulcers, and leg ulcers are forgotten.
‘The first thing that happens when people go into hospital is that they [clinical staff] whip off their bandages to look at their legs and give them loads of antibiotics. Then they forget about the legs. I suppose my message is not to forget about the legs.
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‘I left Accelerate for a little while and went to work in the acute sector for four months and it broke my heart. I walked round and could see patients sitting on a chair with their legs on inco [incontinence] sheets as a “bucket” for their legs to leak on to. I tried to change that culture, but there was too much focus on pressure ulcers and I was told that no, we don’t do that here. So I came back to Accelerate.’
What is the Accelerate approach and what makes the difference?
At Accelerate, patients – the vast majority of whom have not healed with local services – are assessed, with an open mind, then most are treated with strong compression. The multidisciplinary team includes specialists in dermatology, gait and biomechanics, psychology and lower limb, as well as wound care and lymphoedema. The process is thorough.
‘We do have the luxury of time,’ Ms Hopkins acknowledges. ‘I can’t deny that. When someone [a nurse who doesn’t work at Accelerate] says “I have to see a bilateral leg ulceration that’s dripping, with a 40-minute turnaround”, you just think that’s cruel, not just for the patient but for the nurse. That’s a tough ask.
‘Our appointments are longer. We spend more time on debriding the wound bed, ensuring the surrounding skin is well cared for – that really reduces bacterial burden. But it is fundamentally about creative compression and looking at the ulcer site as well as the diagnosis, and optimising compression to the wound bed, not just the leg. That’s where the strapping technique comes in. We use way more compression than others do. Ours are strong.’
‘Lack of priority given to leg ulcers is a scandal’
Ms Hopkins would like to see compression considered in the same way as treatments such as drugs, in as much as you can titrate or alter the ‘dosage’ depending on the needs of the patient. This can mean increasing the compression or reducing it – but she warns against making it so light that it is ineffective.
‘I don’t call it reduced or light compression, I call it suboptimal,’ she says. ‘Of course, there will be times I would use that, but the majority of patients are under-compressed. The way I describe it is if you’re giving paracetamol, and regularly giving a quarter or half of a tablet, then lovely, you’re giving paracetamol, but it’s useless. It’s the same with compression.’
‘My advice to any specialist nurse is not to wait for someone to ask for data – you need to have it at your fingertips. If no-one’s asking for healing rates, you should be doing it anyway’
She does not criticise individual nurses for poor service that she believes is due to system pressures, but a lack of understanding and knowledge of leg ulcers that means they are not seen as a priority. But that doesn’t mean she isn’t cross about it.
‘It’s a scandal, and why nurses don’t call it a scandal is because we don’t want to offend people who are working hard in their day job, and we’ve got a crisis in nursing, and community nursing in particular – the gaps are phenomenal there. This is why I talk about the “system” because people should acknowledge the harm at a system level.’
How earlier NHS intervention would lead to improved outcomes and efficiency
Taking wounds seriously at an early stage would ‘change their trajectory’, she says, transforming outcomes for individuals, but also saving health service resources longer term. ‘You have to have a different approach; you have to say a small wound will become a big one, so how can we stop it now?’
‘I’d like to help people to listen to the small voice in their heads that says “what’s happening isn’t right” and to take that on. Wherever they are, they should say “I’m not going to let this happen”’
Current guidelines aren’t helpful, Ms Hopkins says, because they create a ‘fear factor’ about when Doppler tests (to measure blood flow) and compression should be deployed. ‘We’ve created a fear factor around compression therapy that says you have to be fully trained and competent – whatever that means – to put compression on, and all it’s done is create more and more delay.
‘I’m not saying people shouldn’t be trained, but we’ve created an industry around something that should be quite straightforward for early intervention. The NICE guidelines are well out of date – they’re not helpful in today’s world of not having enough nurses.’
Look at the numbers for evidence of service effectiveness
So what does success look like? ‘You need to see the evidence in numbers,’ she says. ‘For me it’s having a low wound prevalence – a low number, today, of wounds in Tower Hamlets, or wherever we’re working. In the treatment centre is difficult because you don’t have the whole caseload, it’s individuals. So then we’re looking at how many people get into really decent compression, and a good 85% of our patients are in extra-high compression, and close to 100% are in some form of compression.
‘In lymphoedema you’re looking for – once they’re under our care – whether we impact on cellulitis and admissions, how do we demonstrate that?’
Certainly, the figures from Accelerate are impressive, showing for example an 83% reduction in cellulitis for Tower Hamlets residents and a 90% decrease in cellulitis-related hospital admissions in City and Hackney.
How to build a business case for service improvement
Ms Hopkins says nurses hoping to build a business case to improve their leg ulcer services should be proactive in collecting evidence. ‘My advice to any specialist nurse is not to wait for someone to ask for data – you need to have the data at your fingertips. If no-one’s asking for healing rates, you should be doing it anyway.
‘You should care enough about your population to ask “am I making a difference, is the team making a difference? Is there an issue with the system being good enough, and where do we need to change?”’
‘Compression is a powerful tool to reduce inflammation associated with venous disease and oedema but like all therapies, it has to be delivered at the correct dose’
Advice from Accelerate, see box below
One of the common misconceptions, she says, is that patients are non-compliant. ‘That’s a myth that takes some challenging. Because the issue is that the system is not good at delivering excellence, or good, or even modest to be honest, and that nurses don’t know to compress safely and well and creatively.
‘So of course you get people who struggle to keep on a bandage that from their point of view isn’t working – and why would they? They’re labelled as non-compliant. If we keep blaming the patients, we will never critique ourselves.’
Why nurses need to feel they can stand up for better care
Ms Hopkins and her team will continue to challenge the status quo, and are calling on other nurses to join them. ‘I’d like to help people to listen to the small voice inside their heads that goes “what’s happening isn’t right” and to really take that on. Wherever they are, they should take it on and say “I’m not going to let this happen”. We also need skilled people – and we don’t have enough of them. There’s not enough really good treatment-focused training around. It’s something that we’re looking it.
‘Compression is a powerful tool for reducing inflammation. Someone could have an inflamed leg and you could put compression on and within hours, you’re reducing it. Hardly anything works that fast. It’s such a powerful tool, but hardly anyone understands it. That needs to change.’
How you can improve patient outcomes – practical tips from the Accelerate team
- Treat leg ulcers at an early stage to prevent them becoming ‘chronic’
- Any wound on the lower leg will heal faster with compression, including surgical and traumatic wounds. They do not have to be classified as venous
- Compression is a powerful tool to reduce inflammation associated with venous disease and oedema but like all therapies, it has to be delivered at the correct dose
- Educate yourself about the value of compression. Good resources include:
– Wounds UK
– Legs Matter
- Ensure compression is strong enough to be effective – you wouldn’t give a quarter tablet of paracetamol and think that would do any good
- Ensure that compression therapy is consistently applied and at the right level. If it is still not delivering healing then look at your technique or type of compression. Are they having enough?
- Don’t blame patients for non-compliance – understand that patients who feel a treatment isn’t working will be reluctant to continue, and address that by making sure the compression is effective
- Know your stats – nurse specialists who want to make a business case for service improvement should routinely collect data on, for example, healing rates or delays in care, and have these figures at their fingertips
- Find out what is important to the patient – it might not be what you think
- Think ‘legs’ – don’t focus on pressure ulcers at the expense of leg ulcers. Leg wounds and conditions is where community nurses spend much of their time
- Recognise that most leg ulcers should heal; the longer the delays to effective compression, the greater the chance of non-healing and soggy legs
- Medical complexity such as vasculitis or ischaemia may prevent full closure but you can diminish the impact