Wound care: treating the cause rather than simply covering it with a dressing
How to challenge the perceived inevitability associated with chronic wounds
How to challenge the perceived inevitability associated with the treatment and outcomes for chronic wounds
- Many wounds considered to be chronic can be healed with appropriate and timely nursing interventions
- Forthcoming national strategy will tackle unwarranted variation and enhance treatment outcomes
- Advice on what you can do right now to boost patients' chances of recovery
Una Adderley was one week into her first community nursing post when she met the patient who would shape her career. The woman had leg ulcers, and it was the horror of what the young nurse saw – and the helplessness she felt – that ignited her passion for wound care.
‘I had never seen legs like it,’ she recalls. ‘I didn’t know legs could look like this. They were terrible – there were open sores from the knees down, they were weeping, and they were infected. The patient was ill and living in deprived circumstances. And what shocked me was that it wasn’t clear what we could do. She actually died from leg ulcers – she developed septicaemia and died a week later. It made a lasting impression on me.
‘This woman was an extreme example, but I then realised there were many other people – maybe not as serious – whose wounds just weren’t getting better. And as I got to read more, I realised there was a lot that could be done that wasn’t being done, and what breaks my heart now is that I still see that.’
A national strategy for wound care
All this could be about to change. Today, as director of England’s National Wound Care Strategy Programme, Dr Adderley hopes to inspire others to recognise how serious wounds can be. The Academic Health Science Networks (AHSN) programme, funded by NHS England, is developing a strategy for improving care in three main areas: pressure ulcers, lower limb ulcers, and surgical wounds.
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The idea is to improve the quality of wound care in England, eliminating unwarranted variation, improving safety and optimising outcomes and patient experience. It will also address access to education for practitioners and robust data-gathering so that we know what is happening on the ground, and will be able take action accordingly.
Such a strategy is much needed, says Dr Adderley, who believes nurses should be central to achieving the strategy's aims.
‘It’s unglamorous, unsexy and it’s not been the sort of thing that’s attracted attention,’ she says, matter-of-factly.
The hidden epidemic of chronic wounds
‘Wounds are seen as something that you just stick a dressing on and cover up. Generally, people don’t die from leg ulcers, so it’s not seen as a priority. It’s seen as a taboo – patients are embarrassed by it – a bit like continence. But these topics are fundamentally nurse-related. What is more nurse-related than wound care or continence? And yet they are neglected.’
‘We need a whole-system change, to look at these wounds with fresh eyes and review their healing potential from day one – rather than allowing them, even expecting them, not to heal’
Leanne Atkin, vascular nurse consultant and chair of Legs Matter
This neglect may be behind what some have called a hidden epidemic. According to the campaigning coalition Legs Matter, the annual cost to the NHS of managing wounds and comorbidities is around £5.3 billion, comparable to the estimated cost of managing obesity. What is more, NHS England says sub-optimal care of leg ulcers can cost ten times more than optimal management. Financial cost aside, wounds that don’t heal as expected cause patients intense pain and discomfort, psychological distress, social isolation and embarrassment.
‘It's not reinventing the wheel – it just works’
Emma Williamson, practice nurse manager at Angel Hill Surgery in Bury St Edmunds, Suffolk, is proof that nurse leadership can transform wound care in general practice. The winner of wound prevention and treatment category in the RCNi Nurse Awards 2019, she set up a comprehensive wound service for people with leg ulcers, leading to hugely improved treatment times and outcomes. Most patients’ below-the-knee wounds heal within six weeks.
When Ms Williamson came to set up the practice’s leg ulcer service, she looked at best practice guidance (including from NICE and the RCN) and found that while her nurses were following most of it, there were inconsistencies.
‘What we do now is see patients as if they are brand new – and make sure we have ticked every box, every time,’ she says. ‘I’ve not reinvented the wheel, but it’s just worked.’
Having worked in the community before becoming a practice nurse, Ms Williamson was aware that wound care wasn’t always what it should be. ‘There was nothing formalised about how we heal these people or prevent them from getting an ulcer in the first place,’ she says. ‘The best bit is nipping problems in the bud.’
Challenging defeatist perceptions of what ‘chronic wound’ means
For Leanne Atkin, vascular nurse consultant with the Mid Yorkshire Hospitals NHS Trust and chair of Legs Matter, part of the problem lies with the terminology.
‘When people view a wound as chronic, what does the “chronic” mean? It means long-term, non-healing. But many of these wounds, particularly on the lower legs, do not have to be chronic wounds,’ she says.
‘They can be wounds that heal within a normal healing trajectory, if the underlying pathophysiology is addressed.’
She gives the example of a patient who has a supposedly chronic wound that could be caused by a variety of conditions.
‘If you have underlying venous disease and then you have venous ablation and compression therapy in place, those wounds are going to heal,’ she says.
‘With arterial wounds, if you have devascularisation, those wounds will heal. There is no requirement for these wounds to become chronic, and that’s what the beauty of this job is.
‘Unfortunately, once many patients get to see me, they’ve suffered for a number of months and they view me as a bit of a miracle worker that these wounds – in my hands – go on to heal. And it’s not because I’ve done anything special. It’s simply because I have appropriately assessed them, diagnosed their underlying pathophysiology, and treated it. So that’s treating what’s caused the wound in the first place, what’s gone wrong with the body, whereas many clinicians simply focus on how to manage that wound. That’s the wrong way round.’
Transforming outcomes by eliminating inconsistency
Dr Atkin warns that even clinicians often believe that chronic wounds will not heal. ‘We need a whole-system change, to look at these wounds with fresh eyes and review their healing potential from day one – rather than allowing them, even expecting them, not to heal.’
She is optimistic that the wound care strategy – she is leading on the lower limb workstream of the programme – will help make this transformation happen.
‘We talk about the National Health Service but in wound care there’s no “national” standardisation of wound care process at all,’ she says. ‘It can be provided by multiple specialties, for example in nursing or podiatry. It can be in multiple locations such as walk-in centres, community nursing centres, specialised leg ulcer services and so on. And each of those individuals will be looking at different pathways of care.’
‘We try to send patients out on the treatment pathway and the district nurses ignore it; so much so that we have to stop the pathway completely or manage the patient ourselves’
Jacky Edwards, consultant nurse, Manchester University NHS Foundation Trust
The new strategy intends to provide clear clinical navigation tools to show exactly what should happen to the patient at each stage, and who should be assisting the patient in terms of what their core capabilities, their underlying education and level of knowledge should be, she adds.
‘We’ll never be able to standardise [completely] because of commissioning arrangements, but the individual assessing the patient should have this minimum set of core capabilities.’
My ulcers were so shockingly painful they took over my life
As he approached his 50th birthday, John Hellings noticed an ulcer developing, just above his ankle.
He already had eczema on his legs, but this took things to another level, not least because of excruciating pain.
Unfortunately, this ulcer – which was quite small at the time – was to change his life.
‘In retrospect, I know it was brought on by a blood circulation problem, and the eczema was an early warning sign,’ he says. ‘At that time I was healthy, fairly fit, and going to work, without any medical problems. But the impact of this was colossal.’
The ulcer was to be the first of three covering his lower legs. Soon Mr Hellings, a journalist, was unable to go to work or to lead any kind of normal life.
‘It was shockingly painful,’ he says. ‘It was like having a blow-torch on your legs. I was completely pole-axed. I couldn’t sleep, couldn’t stand up, sit down or lie down. It took over everything.’
‘They told me to take paracetamol, which was like trying to treat a burn by fanning some cool air on it’
Repeated visits to his GP, then a private consultation with a dermatologist before going back to the NHS, did not resolve the issue. The analgesia on offer gave him no relief.
‘They told me to take paracetamol, which was like trying to treat a burn by fanning some cool air on it,’ he says.
Years of anguish dominated by dressing changes
The ulcers became infected and treatment with dressings and antibiotics did not work. Mr Hellings was, he recalls, ‘having dark thoughts’.
‘I wrote them down in a diary and they make grim reading.’
His life was dominated by clinic visits to have dressings changed. He went three times per week in an ambulance, and, as he says, he had ‘long since forgotten about work’.
Mr Hellings endured this punishing regime for four years, until there was a change of personnel at the London hospital where he was being treated. A new consultant took his case history and referred him to Accelerate, a social enterprise in London that specialises in complex wounds and lymphedema.
Fresh assessment led to a new treatment regimen – and eventually, healing
From then on things started to look up. Clinicians there embarked on a programme of high compression, which – although it took a year and a half – finally led to healing.
By this time, he was also receiving morphine sulphate, which at last meant the pain was bearable.
‘I don’t blame the health professionals that came before. But I hope that the health professionals of the future will think differently’
‘I had two one-hour appointments on Mondays and Thursdays and I usually saw the same nurse. We’d measure the ulcers and see them getting smaller, millimetre by millimetre,’ he says.
Since then, he has had recurrences, but these have been brought under control quickly – and he knows he has a part to play in preventing ulcers, including wearing compression hosiery and not standing or sitting for too long.
The importance of acting quickly
Mr Hellings is now a patient partner with the Legs Matter coalition. He hopes that by speaking out, he might be able to prevent other people going through the same experience as him.
‘I know I was an extreme case, and I don’t feel bitter about what happened or didn’t happen to me in the past. I don’t blame the health professionals that came before. But I hope that the health professionals of the future will think differently about this, and recognise the importance of acting quickly, and of proper pain relief.
‘It does make a difference.’
Psychological toll of chronic wounds
The psychological impact of wounds should not be underestimated, says Jacky Edwards, a consultant nurse in burns at Manchester University NHS Foundation Trust, who chairs the surgical wound stream of the programme.
Her service is unusual in that it has a set pathway, which is followed consistently for all patients, and because psychologists are an important part of the multidisciplinary team. Patients are referred for the level of psychological support they require – some people will be struggling to come to terms with scars, while others may be experiencing post-traumatic stress disorder as a result of electrical burns, for example.
She believes the absence of a national pathway – and the lack of shared understanding about wounds and their impact – has contributed to inconsistencies in treatment. ‘Even locally, we try to send patients out on the treatment pathway and the district nurses ignore it, so much so that we have to stop the pathway completely or manage the patient ourselves.
‘We try to do shared care to keep the patient as close to home as possible because our cohort comes from geographically quite a large area,’ she says. ‘A national pathway would improve that shared care.’
Greater consistency in wound care is an urgent issue for at-risk groups
People with diabetes are among the biggest group affected by wounds that do not heal and are 20 times as likely to have to undergo amputations.
Head of care at Diabetes UK and diabetic nurse specialist Dan Howarth, says: ‘Most foot ulcers can be treated successfully but many just aren’t treated at all. Around the UK, there simply aren’t the foot protection services there should be.’
Lesley Carter, clinical lead, professionals and practice for Age UK wants to raise awareness of the issue, which disproportionately affects the frail and older population. ‘People have assumptions and think wounds are inevitable in older people. Older people and their relatives don’t understand about it and they don’t know how important it is to keep an eye on those little nips and cuts and strange coloured spots – particularly in people with diabetes. It seems not to come on to people’s radar.
‘People are also reluctant to go to the GP with something they think is so small, but then if they do get a diagnosis there can be a problem because professionals don’t recognise it sometimes, and there’s a whole lack of standardised treatment. Where you’ve got a dedicated wound care team, I hear that the care is brilliant, but that’s not everywhere – they are few and far between.’
This is something that has a profound effect on the lives of older people, adds Ms Carter, who is a nurse. ‘These people have lived with these wounds for a long time, and of course they the wounds are smelly, they’re painful, and they leak; people can’t walk, they can’t sleep, and they get depressed.’
She welcomes the forthcoming national wound care strategy.
‘We need standardised treatment,’ she adds. ‘We can’t have older people not going places, and not doing things, because they have a wound that smells.’
The 6 things you can do to help patients with wounds
What you can do in practice now to help people with wounds – from Una Adderley, director of the National Wound Care Strategy Programme:
- It is essential to diagnose the underlying cause rather than simply reaching for a dressing
- If you don’t know what’s causing the wound, signpost or escalate to someone who does, without delay
- Develop skills in wound care that are appropriate to where you work. Skin is the largest organ in the body and all clinicians should know the basics of how to look after it, how to clean wounds, and how skin heals
- Make sense of the research evidence. Don’t assume everything you are told is right – develop a healthy scepticism and don’t take everything at face value. Unbiased reports in plain English (such as plain language summaries of Cochrane reviews) are useful
- Prioritise treatments for which there is strong evidence of benefit, such as compression therapy for venous leg ulcers, rather than reaching for treatments for which there is little evidence, such as antimicrobial dressings
- Develop good relationships across your local health and care economy and have a shared understanding of the local wound care pathways and protocols. This may prevent people ‘falling through the gaps’
Jennifer Trueland is a health journalist