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The Challenge we face

High mortality has been noted in patients with chronic wounds, and surgical site infections are associated with high morbidity and mortality.  Wound infections have been identified as a cause of avoidable hospital admission, with review of community records of the days / weeks leading up to admission often highlighting a progressive deterioration in wound signs and symptoms and overall patient condition. This is often accompanied by escalating concern from community nurses, however difficulties exist in the articulation of the level of alarm and a standardised approach to escalation and response is lacking; this may lead to delayed or ineffective treatment.  Systemic symptoms of infection or sepsis may then develop, requiring urgent hospital admission.  This can cause the patient significant fear and anxiety, which is compounded by the frequently poor quality of life reported by patients living with wounds.  Hospital admissions do not embody the transformation agenda of delivering health care in the community setting, however early signs and symptoms of infection may progress in the community setting between contacts if the patient (or staff) cannot recognise and act on them.

There is also the growing problem of antibiotic resistance, with inappropriate prescribing potentially exacerbating this.  There has been a noted connection in Clostridium Difficile cases occurring in patients with chronic wounds, through receiving repeated courses of antibiotics, often over a period of months or years.

Why does it matter?

Wounds represent a significant burden on the NHS with annual wound management costs to the NHS of around £5.3 billion (Guest et al., 2015) with £110 million just on prescription costs for advanced wound management products and antimicrobial dressings (NICE, 2016).  On any day, 27–50% of acute hospital beds are likely to be occupied by patients with a wound (Posnett et al., 2009). Prevention, early diagnosis and management of infection are fundamental in wound management (Jones, 2012).

Sepsis is the second biggest killer after cardiovascular disease, but in many cases, it could be avoided; early identification and prompt treatment being key to improving outcomes (NHS England, 2015).

Our opportunities?

Implementation of the National Early Warning Score has improved patient safety by standardising the recognition of acute illness severity within the NHS.  It has been recommended that clinical outcomes associated with the NEWS2 tool be evaluated in primary care, and community use of an early warning score is recommended by NCEPOD (2015) in suspected cases of sepsis.  However, recording of vital signs is not routinely undertaken by community nursing staff visiting patients at home for wound management; however, visual examination of wounds is.

Patient engagement is forefront in providing holistic, patient centred care; building on existing use of the Patient Activation Measure (PAM) may also identify patients who can, with education, contribute to their own care through early identification of signs of wound deterioration.

What do we propose 

Our project will address the challenge we face.  We aim to design and implement an early warning scoring tool for wound infection based on the signs and symptoms that are recorded as part of each holistic wound assessment.  Scores allocated to signs and symptoms and relevant co-morbidities would be calculated quickly and simply using a colour coded chart, similar to the one vital signs are currently recorded on (NEWS2).  The total scores would then be allocated a risk category with prompting of appropriate actions. This should improve the care of patients with a wound by facilitating timely recognition of infection and guiding treatment based on calculated risk levels, thereby delivering appropriate, timely care in order to reduce the risk of deterioration and admission to hospital.

Staff will benefit from improved education and awareness and will have a robust framework to support clinical decision making and collaboration between services.

It is anticipated that the risk tool should aid identification of patients that could have their wounds managed with topical treatments and advanced wound care, reducing the reliance on systemic antibiotics where they are not absolutely necessary.

Where would this take place?

On the Fylde Coast we have 12 multidisciplinary Neighbourhoods and are one of eight first wave integrated care partnerships. Working collaboratively as a health economy partnership we will bring together the expertise of primary and secondary care nursing and medical staff, GPs and commissioners.

The tool would be tested for use locally in both primary and secondary care settings, but has the potential for much wider use if robust efficacy data demonstrates validity and benefits to patient care.  These benefits could include reduced wound related morbidity and mortality, reduced hospital admissions, improved patient experience and reduction in inappropriate antibiotic prescribing.

How will this affect the Q community?

Many Q members will have contact with people with wounds either directly or indirectly, personally or professionally. If successful, this tool could be utilised across the organisations of the Q community.

 

How you can contribute

  • Input would be welcomed from Q members with experience in microbiology or antimicrobial stewardship, particularly in the primary care setting.
  • If Q members have experience of any similar projects they could collaborate
  • If the tool is shown to be beneficial locally, we may seek out Q members who would be willing to evaluate it within their own areas.

Comments

  1. If you think that some process mapping would benefit your project please let me know, I'd be pleased to help with that. Regards Tom

    1. Thanks Tom, all offers of help much appreciated, I will keep in touch

  2. Love this idea. Having been at the treatment end of many patients who have not had standardised community chronic wound assessments, this is the missing link. I would urge you to consider training in the taking of observations as well. Our patients are easily able to record their BPs, O2 sats and heart rates.I think the combination of Changes in wound appearance + Physiology would be a very strong contender for funding.

    1. Thanks Matthew, that’s really good to hear.  There is definitely scope to incorporate patient self monitoring of vital signs as this is likely to increase validity and reliability of the tool, so it’s definitely something we will look at including, kind regards, Nicola

  3. Hi Nicola and Tracy,

    couldn't agree more on the potential for improvement in tissue viability. It has such a huge impact in terms of people's pain and restriction in lifestyle. It's great to see your passion for this much needed work.

    Have you seen the work done by the West of England AHSN WEAHSN on NEWS and NEWS2. There's a great team at the AHSN and they have produced a whole range of helpful resources and videos.

    Also, when thinking innovation in TV have you seen the work of Cornwall Partnership on their PROMISE project? They are using intelligent pressure monitoring technology to improve wound outcomes. It's one of the Health Foundation's Scaling Up programmes.

    Also I notice some areas are starting to use a photo app to aid wound measurement and diagnosis. Have you got this in your area?

    Good luck

    best wishes

    Anna

    1. Hi Anna, I will have a look at those resources, thank you they may be helpful for us. Whilst there is some new technology coming out to support wound infection diagnosis that we will certainly consider building in at some point, we are hoping to create a tool that is an accurate predictor utilising only the visual / patient reported signs and symptoms.  This means that apart from increased clinician and patient education, there will be no requirement for additional resources, therefore hopefully reducing implementation barriers across organisations, for instance within Nursing Homes and other similar settings.

       

  4. Like the idea.

    The other important elements of the NEWS / NEWS2 work are communication - standardised (such as SBAR) and escalation policy - so need to have all stakeholders across the pathway engaged which it sounds like you are doing from description above.

    Also I wondered about self-management/assessment for these patients - opportunity for co-design here?

    1. Hi Jo, yes we definitely need to ensure all stakeholders are fully involved and on board, particularly around escalation, or it just won’t work. We would also like to encourage patients to be as engaged in their care as possible, this means they need to be involved from the start with the design process so we can ensure the tool also works from a patients point of view, so yes an opportunity for co-design. This might be an area we need to tap into other Q projects / members expertise, any help or suggestions welcome!

  5. Hi Nicola and Tracy

    Thanks for sharing your idea!

    I wondered if staff engagement and training would be included in this work? It strikes me that having a useful tool is step one but ensuring teams are engaged and using it effectively is also crucial  otherwise it becomes another form.

    We have a couple of microbiology clinicians in Q who may be able to help or direct you to others perhaps, check out the directory here:

    https://q.health.org.uk/community/directory/?members_search=Microbiologist&members_search_submit=

     

    Good luck,

    Dimple

    Q Programme Manager

    1. Hello, yes staff engagement will be key, it is envisaged that the tool will be built into existing wound assessment documentation to avoid any duplication of work. To be honest, the idea came when colleagues, both nurses and GPs, expressed uncertainty around when to treat infection and how aggressively, so the feeling is the tool will be welcome as an aid to decision making. We will likely select one or two neighbourhood teams to pilot the tool in the first instance, allowing staff to be fully engaged with the process, kind regards, Nicola

  6. Do you have 12 multidisciplinary Neighbourhood teams? Regards Tom

    1. Nicola, Please have a look at the 'Community Support' project. Our project is associated with our newly established neighbourhood teams. Maybe our two projects could collaborate by sharing ideas and techniques of working more closely in the community, particularly with GPs, if our projects are successful. Regards Tom

    2. Hello, yes we have 12 Neighbourhood teams across Blackpool, Fylde and Wyre. The teams comprise of Community Nurses, Long Term Condition Nurses, Allied Health Professionals and the 6 Blackpool Neighbourhood teams have social workers also.

      Kind regards

      Nicola

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