Quality summary report: Tissue Viability CLCH Quality Report Jan Dec 2011 Service exact name Tissue Viability St. Charles Centre for Health and Wellbeing Exmoor Street London London W10 6DZ No. beds [N/A] Website www.clch.nhs.uk Main telephone 020 8962 4467 Completed by Sarah Dionissiou and Jane Flynn Tissue Viability Service Manager in Westminster and Kensington & Chelsea and Tissue Viability Service Manager in Barnet Approval Joanne Jones and Elizabeth Shillingford Associate Directors for Adults Services 2 and Assistant Director of Operations in Barnet
CLCH Quality Report 2011 Summary report for Tissue Viability Directorate Adults 2 Service area Tissue Viability Boroughs Barnet Kensington & Chelsea Hammersmith & Fulham Westminster CQC statement of purpose for this service The Tissue Viability service is a nurse-led specialist service whose aim is to promote the healing of compromised tissue. With extensive knowledge in management of acute, chronic and complex wounds we aim to provide a high quality service by managing wounds, providing advice and support for clinicians, patients, their families and carers. We advise and support wound care management in nursing, residential homes, wound care clinics and patients homes. We work closely with other healthcare professionals within primary and secondary care settings. We are a national research center and regularly take part in clinical trials for new therapies and dressings. The service is for anybody with a wound or those at risk of developing a wound who are registered to GPs in the boroughs of Kensington & Chelsea, Westminster and Barnet. Services offered are; Leg Ulcer Assessment and Management, Doppler Assessment, Compression Bandaging, Other Wound Management, Vacuum Assisted Closure/ Topical Negative Pressure Therapy, MIST Therapy, Primary Lymphoedema Management, Pressure Ulcer Assessment and Management, Prevention of Pressure Ulcer Development, Advice on wound Management e.g. wound bed preparation and dressing choices. The Tissue Viability Service is open from Monday to Friday from 8am 4pm and is closed on Public Holidays. We run several clinics all of which can be accessed via referral by a health or social care professional. GPs can refer via
Choose and Book. All referrals are triaged and an appointment letter will be sent to the patient by post. Patients who are referred will be seen within 21-days. Self-referrals are not accepted. Initial patient visits vary in duration, but we allocate 90 minutes for the patient to have a full leg ulcer assessment (including Doppler). Subsequent visits can take between 30 and 60 minutes depending on the complexity of the wound we are treating. The Complex Wounds Clinic at St. Charles manages the patient for a period of one month in an attempt to kick-start non-healing wounds. After one month they are referred back to the clinician who referred them but can be referred to the clinic again if the wound deteriorates. The Complex Wound Clinic does a lot of joint care with many other teams both in primary and secondary care. Patients in all of our clinics are asked to complete a PROMS questionnaire at their first visit followed by another 4 weeks later (or earlier if they are being discharged). They are also asked to complete a PREMS questionnaire after 4 weeks of treatment or upon discharge (if earlier that this time). Tissue Viability does not provide a clinical service to H&F. We currently have an educational contract only. Overall summary of quality performance and next steps Safety The Tissue Viability Service has made the care around pressure ulcers the main safety quality improvement priority of the past year. A Pressure Ulcer Working Group has formed to help improve the safety of care around pressure ulcers. The group has helped launch an audit into pressure ulcers and will implement the actions that have developed as a result.the service has also implemented a pressure ulcer prevalence form to monitor the reporting of pressure ulcers and through increased education it has improved the reporting of incidents from 15 in 2010 to 116 in 2011. Effectiveness The service undertook a comprehensive audit of the care around pressure ulcers in 2011. The action plan following the audit is currently being implemented and should help improve the effectiveness of the care around pressure ulcers. The
service has also increased the amount of wound care training available, both internally within the organisation and externally to other organisations, such as private nursing homes and social services. Experience The service an additional clinic in Barnet on Friday afternoons due to high demand. The service also ran the PREM in 2011 and will be making improvements to the experience of the service base don t he feedback received. Safety Overview We aim to make our service as safe as possible at all times. Our main priority regarding safety this year concerned the incidence/prevalence of pressure ulcers. The incidence of Category 3 and 4 pressure ulcers occurring within the Trust have been generally low, but recent patient safety reports highlighted an increase in the reporting of these ulcers. These ulcers can devastate lives as they are disabling and often lead to hospital admission. Therefore, the reduction of pressure ulcers was identified as a priority area. A Pressure Ulcer Working Group was set up in June 2011 to review and monitor issues related to pressure ulcer prevention and management. Audits have been conducted throughout CLCH looking at clinical practice in relation to Pressure Ulcer risk assessment (Essence of Care Audit). The results have prompted the group to work towards developing integrated policies, core care plans and increased training. We also conducted an audit on the reporting of pressure ulcers by District Nurses and Nursing Homes over a 5 month period. One of the findings was that nurses were having difficulty categorizing the ulcers as 42 out 171 PUs were categorized as unknown. Following this we did some extra training sessions on this topic and will update our current training programme to incorporate these findings.
Key achieveme nts this year We identified the following safety improvement actions in our 2010 Quality Report. This section outlines the progress we have made on each of them: 1) Audit of referrals and patients documentation to assess how many patients are referred to the service with pressure ulcers not mentioned on the patient s documentation: soon after this improvement action was designed our focus changed following the highlighting of the increase in pressure ulcer incidence reporting and the resulting CQUIN. Therefore this objective was not achieved. 2) PREMs to be handed out at all sites from which the Tissue Viability Service provides care from: this safety quality improvement action is ongoing, the PREMs were completed this year and next year the process will be improved so that responses are received from every site. As well as those safety quality improvement action identified in last year s quality report, the service has also implemented other safety quality improvement actions: 1) The identification of flaws in the categorizing system introduced by the European Pressure Ulcer Advisory Panel (EPUAP) in 2009: The NPUAP (US equivalent) use unstageable/unclassified to describe wounds covered with slough or necrosis. This is because the wound cannot be assessed accurately whilst it is covered with this non-viable tissue. Once debridement has occurred it is then staged/classified again. EPUAP do not have a category for wounds covered with thick slough or necrosis but instead have advised that stageable/unclassified Pressure Ulcers are to be grade as a IV. To use this method could mean that clinicians in CLCH are in danger of over grading pressure ulcers (eg documenting the ulcer as a Category IV when it is in fact a III). It was suggested that we use an adapted version of the NPUAP s unstageable but further investigation into adopting this failed as NHS London said there had been queries from other organisations too and there are issues around the coding of STEIS, the database used for serious incidents, which is holding it back from being implemented. However on a positive note, we can look at the current system in place and question all of the ulcers being categorized as IV to identify if this in fact the case or just a difficult ulcer to categorize. Meanwhile the EPUAP have been contacted about this and are reviewing their guidance next year.
2) The implementation of the Pressure Ulcer Prevalence form: Identified that District Nurses (with the exception of a few teams) were not consistent in reporting pressure ulcers. It also found that nurses were having difficulty in categorizing pressure ulcers (see statement above) leading the Tissue Viability Team to revise their current pressure ulcer training and introduce workshops to describe the categorization process to nursing teams. This remains an ongoing process. 3) The Wound Management Guidelines were implemented in 2010 but were omitted from this paper as an achievement last year. Key results Total incidents Jan-Dec 2011 by category There were a total of 116 incidents reported in 2011.
Incident Categories by Borough Barnet H&F K&C West Total Not Recorded 1 1 2 Environmental hazards and harmful substances - inc body fluids 1 1 Information 1 1 IT Network and Equipment 1 1 Medical devices & equipment 2 2 Pressure Ulcer - developed within CLCH service 2 2 4 Pressure Ulcer - developed within non-clch service 44 1 41 9 95 Problem with admission to service (inc new birth notifications) 1 1 Problem with appointment 2 2 Security of sites and property 1 1 Staffing Issue 1 1 Unwell/illness/illness 2 2 Violence /Harassment or Abuse - without understanding 1 1 Violence/abuse/harassment with intent 2 2 Total 49 4 52 11 116 Total incidents Jan-Dec 2011 by severity Blank Low Minor Medium High Catastrophic 0 4 44 67 1 0 Level of reporting: In this service, incidents are recorded in most cases. Near misses are recorded in some cases. The service is currently raising the awareness of the importance of reporting pressure ulcers, it is hoped that the amount of pressure ulcers that are reported will rise in future following the educational drive.
Themes arising Approximately 80% of incidents reported by the Tissue Viability service in 2011 regarded pressure ulcers that have developed outside of CLCH s services. This follows a large drive within the organisation to improve the care around pressure ulcers. Safety Action Expected Named Improveme completion lead nt Actions date for 2012 Implement Pressure Ulcer Actions from the Essence of Care Audit. For example, arrange training in the use of 2012 Service Lead high specification pressure relieving mattresses for District Nurses. Obtain information from Datix to detect where Category III and IV ulcers are occurring eg, acute sector or primary 2012 Service Lead care and act upon this. Follow-up categorizing system for Pressure Ulcers in use by keeping up-to-date with any changes announced by 2012 Service Lead EPUAP and NICE Effectiveness Overview We aim to achieve the best possible outcomes for patients. To do this, we regularly check to see that we are delivering care and treatment according to best practice standards, and we increasingly look to measure and improve clinical and patient reported outcomes. The service has carried out audits around adherence to the NICE and Essence Of Care guidelines to ensure that practice is following best practice. The service is also in the process of launching a Patient Reported Outcome Measure (PROM) to measure outcomes.
Key achievements this year We identified the following clinical effectiveness improvement actions in our 2010 Quality Report. This section outlines the progress we have made on each of them: 1) Clinical Outcomes audit on practice of discharging patients after 4 weeks to assess whether it is cost effective and whether the patients are happy with the policy: on-going. This effectiveness quality improvement action was not completed as audits dictated by the CQUIN took preference. However this is a future project for 2012. 2) Audit on referrals to see whether pressure ulcers are correctly documented: on-going. This effectiveness quality improvement action was not completed as audits dictated by the CQUIN took preference. However this is a future project for 2012 as the results from the Essence of Care Pressure Ulcer Audit found several issues regarding documentation, in particular the planning of care. For example only 53 out of 113 patients with Pressure Ulcers had photographs present in their documentation, 56 out of 113 patients with pressure ulcers did not have their pain level included in their care plan, out of 142 patients that had a care plan in place only 55 had a repositioning regime included in the care plan. All of this data is being looked at by the Working Group and action plans are currently being put in place to resolve these issues. For example, they will provide some recommendations to increase the amount of photographs that are taken of pressure ulcers and included in patients notes. Much of the issues regarding care plans will mean adaptations to our training systems but may also improve with the introduction of core care plans which are currently being developed. The service also implemented the following effectiveness quality improvement actions last year: A Tissue Viability documentation audit was conducted by the Tissue Viability team in June 2011 as it had been identified that there had been an increase in referrals to Tissue Viability and there had been an increase in cost of wound care products. The audit was conducted amongst 27 District Nursing Centres in K&C and Westminster.
Review of wound care documentation (in particular Pressure Ulcers) following the recent integration of services within boroughs. We hope to introduce our core care plans for Pressure Ulcers in 2012. Increased Tissue Viability training in Barnet: The Tissue Viability service in Barnet has started Tissue Viability training in over 40 residential homes and 25 nursing homes in Barnet. The service in Barnet has also started training external agencies on tissue viability, for example, the service now trains social services on safeguarding issues so that they are trained to identify signs of neglect. Key results Patient Reported Outcome Measures (PROMs) K&C and Westminster did PROMS for 2009/2010 but were advised to stop at the beginning of 2011. Therefore we do not have any data for this year. However we recommenced the PROMS in October 2011 so hope to have more robust data next year. The PROM currently used is a questionnaire for patients and is likely to be reviewed soon to identify any changes required to its format. Other measures of effectiveness We received funding 3 years ago for us to obtain a contract with a medical devices manufacturer to use their V.A.C pumps for patients requiring Topical Negative Pressure (TNP) Therapy. This was initiated by the Tissue Viability Team as we were experiencing difficulty getting GP funding for patients to receive TNP therapy due to the expense. However, since this project commenced things have progressed rapidly and patients are now being discharged from secondary to primary care with VAC with as little as 48 hours notice to the relevant teams. We are also able to commence VAC in the community now so patients with complex wounds can be treated at home rather than having to be admitted to hospital as would likely have been the case previously. We run a bandaging service for those with Primary Lymphoedema. We have found that patients referred to us experiencing Lymphoedema for several years can have the size of their limb reduced significantly enough to wear support hosiery within 14 days of intensive treatment by the Tissue Viability Team.
However we currently do not monitor the healing/reduction in limb size rate officially so will look into doing so in 2012. In 2012 we are intending to audit patients with leg ulcerations attending our clinics to look at levels of wound chronicity and length of time the patients have been treated by other disciplines before referral to tissue viability. Clinical Audit Local audits during 2011 This year our clinical audit plan has focused on the following audits: 1) Essence of Care Pressure Ulcer Audit (CLCH wide): These results are still being analysed and action plans are not in place for all recommendations yet. The audit results highlight several areas that need action. For example, not all grade III or above pressure ulcers that were not reported to a Tissue Viability Specialist in Westminster, Barnet and Kensington & Chelsea. The audit found that 74 out of 197 patients had been given patient information on pressure ulcers and 105 out of 197 patients had patient information discussed with them. The results regarding patient information was discussed at the Working Group and two contributory factors to the poor results were identified: There has been a change to the process for distributing patient information booklets. Previously NICE delivered booklets to services upon request, however, now booklets have to be downloaded and printed by services. Some services may not be aware of the new system or do not have the means to download and print them. Some patients do not have the mental capacity to discuss the patient information and there was no Not Applicable option for this question on the audit form, therefore, the No results may contain some patients with which it was not relevant to discuss the patient information. In response to this the Working Group will recommend a system to ensure that services that require patient information booklets can access them, possibly by printing them centrally and distributing the booklets internally.
2) Tissue Viability Audit (K&C and Westminster): The audit found that whilst care planning and evaluation was generally satisfactory, the number of photographs and wound measurements taken was low. It also identified that the risk assessment of those with pressure ulcers was 79% which is unacceptable. Only 50% of patients with leg ulceration had their ABPI (Doppler results) documented. The average duration for the healing of wounds was 24 weeks and ranged from 1 day to 258 weeks. The findings are about to be presented to the DN leads and we are recommending the following: 1) Doppler Assessment is absolutely essential for those with leg ulcers 2) Tissue Viability Nurses to keep a more thorough record of Doppler and Compression Bandaging competency for nurses than the one currently in use 3) Risk assessment must be carried for all patients with pressure ulcers and this will be monitored by DN team leaders 4) Nurse prescribers will be expected to adhere to the wound dressing formulary. Requests for any dressings required outside the formulary must be discussed first with the TVN. 5) In addition to this individual members of the TV team have been allocated DN teams to work alongside and visit monthly to reassess any patients with complex or chronic wounds (however we will visit sooner if necessary) providing continuity of care. 3) Pressure Ulcer Reporting Audit (K&C and Westminster): the main result from this audit was that nurses were having difficulty categorizing the ulcers. Extra training has been provided and sections of our rolling Pressure Ulcer Training programme are currently being reviewed. The service is also about to commence a Pressure Ulcer Risk Assessment audit
at a local nursing home. We are looking at this area because if a risk assessment is not completed or if a patient is assessed as high risk but no action is taken, the outcome for that person is likely to be quite different to that of someone who is assessed and the appropriate measures are then put in place accordingly. NICE compliance The following NICE guidance is either fully or partially relevant to this service: Pressure Ulcer (CG029) Requirements to report all pressure ulcers Category III and above (CG07) Diabetic foot problems (010) NICE are set to develop an evidence-based clinical guideline for the prevention and management of pressure ulcers in primary and secondary care and we have been invited to meetings to discuss and give our opinions on what should be included in this document. The service has implemented the following best practice guidelines: 1) EPUAP International Pressure Ulcer Guidelines 2) SIGN Guidelines 120: Management of Venous Leg Ulcers. The EPUAP International Pressure Ulcer Guidelines have proved difficult to implement due to issues surrounding categorizing and the likelihood of the current system to be inaccurate in the reporting of Pressure Ulcers. Research and innovation Clinical research undertaken over the past year is as follows: 1) Evaluation of the Efficacy and Safety of the K-Two versus Actico Compression System in the Management of Venous Leg Ulcers 2009-2010 2) We started a new clinical research study in October 2011 that is predicted to run for six months. We are hoping to publish the
results of this study. Product Evaluation is as follows: 1) Debrisoft debriding agent Lohmann and Rauscher Company March 2011 What the patients say about the outcomes of their care and treatment The results of your efforts are crisply and readily demonstrated by the exceptional degree of healing that have accompanied my attendances to your clinic From the moment I began my treatment you established a clear plan for my longterm health. All the advice given to me, particularly regarding my diet and its effect on the healing process has been so beneficial. Clinical Effectiveness improvement actions Actions Follow-up/Review for the Tissue Viability and Pressure Ulcer Reporting audits Expected Named completion lead date 2012 Service Lead Launch of new updated PROMs questionnaire 2012 Service Lead The development of an integrated protocol for leg ulcer management. 2012 Service Lead Experience Overview We care about treating everybody with kindness, dignity and respect at all times. The service ran a Patient Reported Experience Measure (PREM) for the last two years and uses the feedback gained to improve the experience of the
service. Key achievements this year We identified the following patient experience improvement actions in our 2010 Quality Report. This section outlines the progress we have made on each of them: 1) Future PREMS to be handed out to all sites from which the Tissue Viability Service provides service from: on-going. The service was advised to stop the PREMS at the beginning of 2011. However we recommenced them in October 2011 but are yet to be fully established into everyday practice again. More discussion is required amongst the Tissue Viability Team to identify how we are going to obtain future PREMS data as in the past it has been done via questionnaire or written comment. Perhaps the re-introduction of a comments box would be a practical option to consider. 2) Staff in the service to be trained on the referral routes into the service: This experience quality improvement action has been completed. All staff are trained and fully aware of referral pathways into our service and are able to assist others clinicians in the correct referral procedures into the service. In addition to those experience quality improvement actions identified in last year s quality report the service has also carried out the following action: 1) A new leg ulcer clinic on Friday afternoons has been launched in Barnet due to high demand. Patient survey results Patient surveys (known as Patient Reported Experience Measures PREMs) Summary of results for core patient experience measures (Aug-Dec 2011) Question Result for this service Trust-wide average % patients/carers rating overall experience good or excellent 100% 93% % patients saying they were definitely involved in planning their treatment 64% 56%
% patients saying they were always treated with dignity & respect 97% 92% % patients saying they definitely understood explanation 88% 88% % patients satisfied with waiting time 92% 74% Interpretation of PREM results The results from the PREM showed that 100% of patients that returned a PREM rated their overall experience of the service as either good or excellent. This is consistent with the PREM results from 2010 when 100% also stated their overall experience of the service as good or excellent. This shows that the service consistently provides a service that the service users are satisfied with. The lowest score was received regarding patients being involved with their treatment, with 64% of patients reporting that they were definitely involved with treatment. The service will aim to improve this aspect of the care it provides in future. PREM methodology The following table summarises the number of patients that responded to a PREM this year, and shows this as a percentage of all referrals during the survey period (August December 2011). Our aim was to achieve a representative view of patient feedback, so we set out to survey every patient that was prepared to return a completed response form. PREM volume targets Total (Aug-Dec 2011) Number of patients who responded to a PREM 61 Total new referrals 752 % of new referrals who responded to a PREM 8% Target % of respondents 15%
Target achieved? No Compliments and Complaints Patient user groups and focus groups Other qualitative feedback What the patients say Compliments and Complaints Number of compliments Jan 2011 Dec 2011: 0 Number of complaints Jan 2011 Dec 2011: 0 We do not have any specific patient focus groups. We have suggested it to patients in the past but have received poor responses to the idea. In 2010 we did regular PREMS but were advised to stop this in 2011. Since then the only feedback we have had from patients is via card, letter or through conversation. In the past we had a comments box but it was not well-utilised but may be something that we should consider reintroducing. You were extremely reassuring and efficient. You took charge immediately, expertly assessed my illness and consequently treating the wound. You always took care to explain how the treatment works and yourself and the other staff explained what I was expected to do in order to help with the healing process. Your treatment and advice has been invaluable in the healing process of this awful illness. I am deeply touched by the friendly, cordial but efficient mannerism with which you all delivered the high degree of service I have received. Patient experience Improvement Actions Action Recommence the PREMS questionnaires and look at prospect of adding an electronic format to give patients more choice Expected Named completion lead date 2012 Service Lead Audit Complex Wound Clinic looking at the pathway for this clinic and the possibility of making it more adaptable to individual patient needs. 2012 Service Lead