Practice nurse transforms pathway for leg ulcer care
A nurse studied her practice’s leg ulcer care and devised a new pathway that improved healing
A nurse studied her practice’s leg ulcer care and devised a new pathway that improved healing
- Pathway creates better patient experience
- It frees up time for community and practice nurses
- Reduced spending on dressings is saving £1,000 a month
Like many general practices across the country, Angel Hill Surgery had a large cohort of patients attending for leg ulcer dressings for many weeks before they had a Doppler scan and received compression bandaging. Healing rates were poor and patient satisfaction was low. Consequently, the nursing team was dispirited.
Practice nurse manager Emma Williamson transformed management of leg ulcers at the practice in Bury St Edmunds, increasing the number of healed wounds, improving patient experience and freeing up time for community and practice nurses.
Four weeks after she took on the role she agreed to find a way to alleviate pressure on district nursing and take on their Doppler service, which was being provided to 120 patients.
‘My award is a win for primary care’
Ms Williamson won the Wound Prevention and Treatment category of the RCNi Nurse Awards 2019.
‘I am so proud of my team and everyone at the surgery. It has been due to their support and encouragement and belief in me that I have been allowed to explore ideas. We were up against some big trusts and great contenders who had also done fantastic work. This award feels like a bit of a win for primary care, not just me.’
What the judges say
Judge Kate Hancock, BBI Europe's vice-president of marketing, said: ‘BBI were delighted to co-sponsor this award, highlighting aspects of nursing care that are often under the radar. Emma’s passion and dedication to improving the quality of life of her patients was an important element contributing to her success.’
Arjo strategic marketing director UK Martyn Elcocks added: ‘Arjo is proud to have had an opportunity to publicly recognise the important contribution that nurses make every day to wound prevention and treatment, making a positive impact on clinical outcomes, reducing costs and, most importantly, easing a patient’s suffering. The holistic approach and the real evidence of clear benefit to her practice alongside the physiological and psychological patient benefit meant Emma’s entry really stood out.’
The Wound Prevention and Treatment category of the RCNi Nurse Awards 2019 was sponsored by Arjo and BBI
After a review of related literature Ms Williamson realised that a standardised pathway, supported by a Doppler service with new equipment and a proactive approach to wound management treatment and prevention, would make an enormous difference.
‘I could see that instead of two community nurses coming to the clinic to perform a Doppler scan, a new machine could be used by one healthcare assistant, making it cost-effective by reducing nursing time,’ she says. ‘Training was included with the price of the machine.’
‘Everyone was shocked at how quickly we were healing patients and getting them out of the door’
Over a three-month period she reviewed every patient receiving annual Dopplers and found that only 25% of those on the list had a clinical need for annual testing. Addressing this saved more than 100 appointments of 30 minutes each in a 12-month period.
But a significant number had wounds that were not healing despite multiple trips to the surgery.
‘There was no coherent care pathway,’ says Ms Williamson. ‘The practice nurses had different levels of knowledge and were using different methods.
‘One nurse would look at a leg wound in clinic and take a swab. The next week a different nurse would look at it and think it might be pre-diabetes and do bloods to send off.’
There was no structured approach to identifying risk factors for leg ulcers and supply costs were high. Nurses were having back problems due to high numbers of leg dressings. ‘The whole team was also demoralised by the poor healing rates and patient experience,’ says Ms Williamson.
Ms Williamson says nurses love the holistic approach and it has rippled into all aspects of their work:
- Nurses are more proactive and are making more referrals to smoking cessation and weight loss services
- The clinic gives nurses time to treat the whole person
- Patients are better-educated in self-management, and fewer leg treatments have been ineffective
- Patients who had been visiting the practice for years with leg ulcers are now healed
- Not only has money been saved on travel expenses, but patients have gained positive psychological effects from being treated
- Patients are making progress in losing weight, stopping smoking and with pain control
- Patients are comfortable and their mobility has improved, while falls have been reduced
Patients with a leg ulcer were invited to attend a new one-stop shop holistic clinic, run by a nurse and a healthcare assistant. Time is allocated for a Doppler study and a swab for infection, and bloods are taken and the leg washed and creamed.
They address pain and oedema, give lifestyle advice such as on footwear, and refer patients to smoking cessation, weight loss and dermatology services. They also arrange occupational health assessments if needed.
‘At the initial assessment the nurse has time to look at every factor that could be preventing the wound from healing, and we do it holistically,’ says Ms Williamson. ‘The next nurse to see that patient will know all those factors have been checked and can focus on where the wound is on that day.
‘To be able to offer the Doppler scan in clinic and immediately put patients into compression bandages is a game changer. We all know that compression bandaging helps patients to heal more quickly, and now this is done very early so we have patients in the right dressings.’
The nurse prescribes the stockings and patients’ legs are measured by the pharmacist.
Savings give team more scope to try new dressings
‘People were being prescribed medium stockings but one leg was more swollen than the other,’ says Ms Williamson. ‘The pharmacy provides the right stocking for each leg. This has saved money. Previously, a patient might need more than one prescription because the stockings were uncomfortable, or they had given up wearing them and the wound had broken down, so the practice team would see them again and again until it had healed.’
Ms Williamson set up monitoring systems to audit the clinic’s impact. Of the long-term leg ulcer patients, more than half were fully healed after two months, with nearly all healed after six months. The clinic has seen 56 new patients in the past nine months, with the majority healed within two weeks.
The changes have saved more than 16 hours of nursing time a week and reduced monthly spending on dressings by £1,000.
When looking at costs, people find it challenging to take a long-term view of the time it saves and the benefits through the results’
‘Within six to eight weeks the nurses started feeling the benefit,’ says Ms Williamson. ‘Everyone was shocked at how quickly we were healing patients and getting them out of the door.’
The savings in time and money have given Ms Williamson and her team more scope to try new dressings when they come on to the market, and as a result they are developing their own formulary.
‘With our wound and medicine management team we have done clinical trials on some alternative dressings that work more quickly. They are more expensive but prove more cost-effective,’ says Ms Williamson.
‘We have used some wound pads that cost more but are used for a much shorter period of time – three weeks rather than three months. We can justify using them because we have proved that it saves money and improves patient care. They are more comfortable as well – sometimes the cheaper dressings are clumpy.’
Ms Williamson’s approach has attracted attention from other practices. ‘It is completely transferable and I don’t feel there are any negatives to it,’ she says. ‘But when looking at costs, people find it challenging to take a long-term view of the time it saves and the benefits through the results.
‘It paid for itself within months. I would argue that it is absolutely worth investing in and juggling clinics around, and someone has to do that. Our leg clinic has gone from four mornings to one morning a week, and it is such a pleasure seeing our patients all healed.
‘The nurses are happy as they have been able to allocate admin time to promote cervical cancer screening, for example, which has gone up as a result. The time saved means I can send my nurses on more training. We have more slots for calls. Everyone is happier.’
‘Her one-stop shop clinic provides continuity between nurses’
This includes the GPs at her practice. Partner Laura Leach says: ‘Emma has revolutionised nursing at our practice. It is difficult to believe she qualified just four years ago.
‘She was able to use her research and vision to show that this would result in better ways of working and better experiences for patients, as well as freeing up time for community and practice nurses to carry out other work.
‘Her one-stop shop clinic provides continuity between nurses, expanding their knowledge and giving effective, positive outcomes for the patient pre and post leg ulcer.’
From problem patient to poster boy
A man weighing 141kg presented with multiple wounds below the knee that were not healing.
He had a family history of type 2 diabetes and worked full-time, so could only attend evening appointments and sometimes failed to do so due to social engagements. His left lower leg had become macerated, consistently leaked fluid and, due to the shape of the leg, two-layer dressings would slip out of position and the area would become infected.
Initially the patient was reluctant to attend the new clinic but a nurse explained there would be extra time and they could do diagnostic tests that would be of benefit to him. He arranged time off work so he could attend the first available appointment of the day.
Following the holistic care pathway
The nurse followed all the elements of the holistic care pathway including bloods, a swab and a referral to the local exercise and weight loss programme.
The Doppler showed he was suitable for compression bandaging, which would stay in place better than two-layer bandaging.
The following week he was told his swab had come back positive and his bloods showed he was pre-diabetic. This came as a shock to him. The nurse gave him information and helped him understand the benefits of losing weight. An appointment was made with the diabetes specialist nurse.
He lost 9kg, and following six weeks of regular dressings the wound had healed and his blood glucose level had improved. This boosted his confidence and he went on to lose more than 20kg, becoming the poster boy for the local weight loss and exercise programme.
The woman who escaped an amputation
A woman in her eighties presented with a painful wound just below the knee.
She had been treating it at home, but it had started to deteriorate quickly and the pain had become too much for her to manage with-over-the counter analgesia. After an appointment with her GP in which her pain was addressed she was booked in for nursing team review.
The nurse dressed the wound and booked a follow-up appointment in the wound clinic three days later. In the clinic and following the care pathway it was noted that her right leg and toes were cold. Her right leg also showed hair loss and her capillary refill time showed a delay of five seconds in her toes.
Evidence suggested arterial disease
The patient reported that her pain was worse on elevation and eased when she dangled her legs off the side of her bed or chair. She had been smoking 20 cigarettes a day for 40 years, and the evidence suggested arterial disease.
The Doppler showed that her left leg was within normal parameters but her right leg displayed extensive arterial damage (ABPI 0.48) and required an urgent referral to a hospital vascular team.
Within seven weeks of the patient wearing the correct footwear, having dressing changes and the vascular team reviewing and then referring her to the pain management team, she was healed and her condition was stable.
The vascular team reported that the swift referral meant the patient had avoided losing her right lower leg to amputation.