Posted 24 July 2023 - 11:15
Posted 24 July 2023 - 11:15
Analysis
Chronic wound care: improving record-keeping and communication
New NHS standards target assessment and consistency in wound care. Learn more about the national wound care strategy at Nursing Live, RCNi's unique event
New NHS standards target assessment and consistency in wound care. Learn more about the national wound care strategy at Nursing Live, RCNi's unique event
- The wound care standards will help nurses deliver best practice and tackle non-healing wounds
- Chronic wounds are incredibly costly; strong multidisciplinary teamwork and educating patients in self-care could improve lives and reduce costs
- Addressing communication issues among teams, common errors when caring for wounds, and the aims of the National Wound Care Strategy Programme
This article was updated on 11 October 2023
New standards on record-keeping and documentation in wound care should be available for use by nurses later in the year.
23 - 24 October 2024, ACC Liverpool
Register for updates about this unique nursing event and make a note in your diary to join us later in the year.
The standards are part of an ongoing programme of work aiming to improve wound care. We look at what nurses need to know about the current issues and the expected changes.
The challenges in wound care, and why new standards are needed
In wound care, one of the key challenges is a lack of documentation, record-keeping and continuity of care – about a quarter of wounds go unrecorded or undiagnosed, according to a BMJ Open study.
Salford University adult nursing lecturer and tissue viability specialist Matthew Wynn says: ‘This is a real problem. You see patients with compression socks to help wounds heal go into hospital and staff take them off and their wounds open up because the staff are not aware of why they have them on.
‘Or I have seen patients who have reported having wounds for years, but there are little or no records on what treatment and approaches have been tried.’
To address this, the National Wound Care Strategy Programme has commissioned the Professional Record Standards Body (PRSB), which is responsible for the development of standards for clinical record-sharing, to draw up a wound care information standard.
Draft standards were published in May and the PRSB is now waiting for endorsement from NHS England before making them available to front-line staff.
Comprehensive record-keeping: what the standards cover
The six domains are:
- Wound assessment and treatment, including the cause of the wound.
- The treatment plan, including an escalation pathway.
- Self-care information provided to the patient.
- Patient details.
- General health information and relevant history.
- Contact details for those involved in the person’s care.
PRSB chair Maureen Baker says she hopes this will ensure best practice is spread across the system.
‘Wound care is a complex area of healthcare. Sharing and recording information consistently with the right professionals is key to ensuring that people receive the best wound care possible,’ she says.
‘Communication is an issue’: challenges in primary care
RCN professional lead for primary care Heather Randle says nurses working in community settings face several challenges when it comes to wound care.
‘Communication is definitely an issue,’ she says. ‘The information we get from hospital discharge is not always as good as it should be.
‘Nurses in primary care do provide wound care to patients, although the most complex cases where patients are housebound will be picked up by district nurses. The problem is we are not investing and valuing the general practice nurse role. The new nurses coming in are not getting enough training and they are so overwhelmed with other tasks.
‘What’s really important is having access to a good tissue viability service – they can provide advice and look at pictures of wounds to help nurses decide what is best and some will run clinics in the community that we can refer patients to. But there is some variation in what is available.’
What common errors do nurses need to look out for?
National Wound Care Strategy Programme director Una Adderley says nurses working in the community in areas such as general practice and district nursing are in a difficult position because they are ‘pulled in so many different directions’.
‘Carrying out an assessment takes at least 40 minutes and usually more, and when you have so many competing priorities and you are treating patients who are in great pain or may be dying, you can see how wound assessment gets neglected.’
But Dr Adderley says even when assessments are done, there are common mistakes then being made in terms of treatment.
‘One is to place too much emphasis on dressings – we do need good quality dressings, but we also need to identify what the cause of the wound is.
‘Most lower limb wounds are related to venous disease or arterial disease. Sometimes there are other causes, but they are the main ones and they need the right therapy, such as compression and surgical interventions. But if the underlying cause is not being diagnosed and dealt with you’re going to struggle to get the wound to heal.’
And when that happens, she says, the common assumption that is made is that it is because of an infection.
‘Sometimes this is the case, but more often there are other causes of non-healing. This is one of the reasons why we find patients struggling with wounds for a long time and that affects quality of life.
‘There are specialist tissue viability services, but we don’t think it necessarily needs a tissue viability specialist to diagnose and treat leg ulcers. A nurse in the community with the right training and skills and enough time and practice can do it.’
But, she says, many nurses struggle to access training because they cannot take time away from their day jobs.
‘There are a lot of free education materials available online, but if nurses can’t get time away to study and train and get the necessary face-to-face education to complement the online learning, it is hard to develop the knowledge and confidence needed.’
The cost of wound care
The total annual cost of wound care to the NHS is estimated to be around £8.3 billion a year, according to the most comprehensive research on the issue. To put that in context, it is nearly the same as the cost of managing arthritis.
The BMJ Open study, published in 2020, involved researchers modelling the cost and prevalence of wound care in 2017-18. It estimated about 3.8 million people – 7% of the adult population – received care for wounds, a rise of 71% in five years.
Most of the cost – £5.6 billion – was accrued managing unhealed wounds and worked out as an average of £3,700 per person – 2.5 times the cost of managing a healed wound.
About 80% of the costs come in the community, with district nursing and practice nursing teams playing a key role, along with specialist tissue viability services. Dr Adderley adds that the cost is not just to the NHS, pointing out the poor management of wounds is having a ‘debilitating’ effect on people’s lives.
Other research has found one in 50 people in the UK is living with a chronic wound that reduces their quality of life, causing pain and loss of mobility. Half report suffering from depression.
‘Wound care does not get the priority it deserves,’ says Dr Adderley. ‘Although wound care involves many different types of wounds, lower limb wounds, such as leg and foot ulcers, form the largest proportion.
‘Diabetic foot ulceration probably has the highest profile, but only constitutes around 10% of wound care. If you look at the figures in relation to spend, caring for leg ulcers accounts for over half of the total. There are a lot of people with diabetic foot ulcers, but what we've discovered is there are at least as many people with foot ulcers who do not have diabetes.
‘More than half of all major limb lower limb amputations are in people that do not have diabetes.
‘The healthcare needs for both groups are very similar, but people without diabetes find it difficult to access the care that reduces the risk of amputation and death.’
Hear about NHS England’s national wound care strategy programme at Nursing Live
Programme director Una Adderley will outline proposals for improving timely care of people with leg and foot ulcers, pressure ulcers and surgical wounds.
She will be among the guest speakers at Nursing Live – a unique, free event brought to you by RCNi.
What can patients do for themselves?
There are several important steps patients can take to help with healing. Advice from the NHS is that patients should stop smoking, as it is proven to delay the healing of wounds.
Good nutrition, particularly eating foods rich in vitamin C to promote collagen, is also important. Keeping active will help with healing as it increases blood flow.
Certain drugs, such as anti-inflammatory medication, should be avoided, and patients can even get involved in their own wound care.
Dr Adderley says: ‘Supported self-care is really important. If they can manage it, patients don’t want to be always going into the GP practice or waiting for the district nurse to come.
‘Just as we expect people with diabetes to usually manage their own insulin injections, some patients with wounds can do some of their own wound care, such as changing dressings and managing their own health.’
What else needs to change?
Society of Tissue Viability vice-chair Sarah Gardner, who has worked as a specialist nurse and now runs the Wound Matters consultancy, says the national programme is ‘working hard’ to address the challenges, but she says there needs to be a ‘huge culture change’ to make more progress.
‘What we need is for those who commission services to take this seriously and to place an importance on wound healing. We need to break down silos and work more collaboratively. This is not just a nursing problem. It’s a multidisciplinary one.’
She says there needs to be greater collaboration across the whole system – community and hospital teams and specialist vascular, dermatology and podiatry services.
‘We need more one-stop-shop multidisciplinary clinics where patients get diagnostics, assessment and treatment plans agreed in one session.’
Salford University’s Mr Wynn says there needs to be much greater use of new technologies.
‘Not many nurses or even doctors realise this, but there is no objective way of diagnosing an infection. You cannot do a test. It’s a clinical diagnosis made by looking at the wound.
‘Wounds need to be colonised with a healthy level of bacteria to help them heal, and working out the difference between an unhealthy level and a healthy level is a challenge.’
But he says devices that can help nurses see bacteria, such as MolecuLight, are not being widely used.
Nor, he says, are smartphone apps that can take a scan of a wound to help the health professional and patient work out if a wound is healing.
‘It can be very hard to work out if a wound has got smaller or bigger – they are not a nice rectangular shape. They change and it can be very hard to notice with the human eye.
‘There are digital technologies that can help, but we don’t use them. ‘Smartphone apps can tell you if it has changed even by a few millimetres.
‘That could make all the difference. Patients could use them to send wound pictures to nurses, and staff who are not specialised in wound care could send them to wound specialists for advice.
‘As a specialist viability nurse, you want to see the wounds that are not healing, not the ones that are.’
What is the National Wound Care Strategy Programme?
Launched in 2018 by NHS England, the National Wound Care Strategy Programme has brought together a range of experts to help drive through improvements in care.
Its focus is on three types of wounds – lower limb ulcers, pressure ulcers and surgical wounds.
The most work has been done on lower limb ulcers, given they are responsible for more than half the overall wound care costs.
Recommendations have been developed for treatment and assessment, and the programme is working with some pilot sites to pioneer more joined-up care between community teams and specialist services.
Alongside this, it has produced education materials and information leaflets for patients as well as commissioning the information standards.
Further information
- National Wound Care Strategy Programme
- Wound Care Draft Information Standard
- BMJ Open study on costs
Nick Evans is a health journalist