Guideline for the Referral of Patients to the Tissue Viability Service

Guideline for the Referral of Patients to the Tissue Viability Service

Guideline for the Referral of Patients to the Tissue Viability Service Document Type Unique Identifier Document Purpose Document Author Clinical Guidelines CL-180 To ensure core standards of good practice Professor & Consultant Nurse in Tissue Viability, Tissue Viability Nurse Specialist, Tissue Viability Nurse Target Audience Responsible Group(s) WHCT staff, other health care professionals, patients and carers who require intervention of the Tissue Viability Service Clinical Policies Group Date Ratified 8 th January 2015 Expiry Date 8 th January 2018 The validity of this policy is only assured when viewed via the Worcestershire Health and Care NHS Trust website (hacw.nhs.uk.). If this document is printed into hard copy or saved to another location, its validity must be checked against the unique identifier number on the internet version. The internet version is the definitive version. If you would like this document in other languages or formats (i.e. large print), please contact the Communications Team on 01905 760020 or email to communications@hacw.nhs.uk Guideline for the Referral of Patients to the Tissue Viability Service Page 2 of 17

Version Circulation Date Job Title of Person/Name of Group circulated to Brief Summary of Change 01 25/11/2014 WHCT Tissue Viability County Team Remove staff members, WHCT Tissue Viability Link identifiable Nurses, Associate Director of Nursing, Director of Quality, Consultant Nurse information, NMC reference added, Infection Prevention and Control, correction of Paediatric Lead, Clinical Services Locality grammatical errors. Manager, Practice development and Service Lead- Mental Health, Community Hospital Matron, Clinical Services Operational Lead, Head of Quality Governance 02 16/12/14 Clinical Policies Group Amendments to section 6.1, Education & Training expanded Amendment to Appendix 1 Accessibility Interpreting and Translation services are provided for Worcestershire Health and Care NHS Trust including: Face to face interpreting; Instant telephone interpreting; Document translation; and British Sign Language interpreting. Please refer to the intranet page: http://nww.hacw.nhs.uk/a-z/services/translationservices/ for full details of the service, how to book and associated costs. Training and Development Worcestershire Health and Care NHS Trust recognise the importance of ensuring that its workforce has every opportunity to access relevant training. The Trust is committed to the provision of training and development opportunities that are in support of service needs and meet responsibilities for the provision of mandatory and statutory training. All staff employed by the Trust are required to attend the mandatory and statutory training that is relevant to their role and to ensure they meet their own continuous professional development. Guideline for the Referral of Patients to the Tissue Viability Service Page 3 of 17

Contents Page Number 1. Introduction 5 2. Purpose of this policy/procedure 5 3. Scope 6 4. Ownership and Responsibilities 6 4.1 Support and Advice 6 4.2 Role of the Tissue Viability Link Practitioner 6 4.3 Role of the individual staff member 6 5. Standards and Practice 7 5.1 Making a Referral 7 6. Tissue Viability Referral Criteria 7 6.1 Pressure Ulcers 8 6.2 Traumatic Wounds 8 6.3 Fungating Wounds 8 6.4 Leg Ulcers 8 6.5 Paediatrics 8 6.6 Foot Ulcers 9 6.7 Sharp debridement 9 6.8 Surgical Wounds 9 7. Dissemination and implementation 9 8. Education 9 9. Appendix 9 10. Audit 9 Guideline for the Referral of Patients to the Tissue Viability Service Page 4 of 17

1. Introduction This Tissue Viability Referral Guideline provides guidance on criteria for referral to the Tissue Viability Team. It is the responsibility of every practitioner caring for patients with tissue viability needs to possess skills in essential skin care, aseptic technique, pressure ulcer prevention & management utilizing the Worcestershire NHS Wound Management formulary. The role of the Tissue Viability team is to support the development of knowledge and skills, to provide advice and support as required and is not designed to be used as an urgent wound management service. The Tissue Viability Link Nurse Team aims to support health care practitioner to provide professional, evidence based and clinically confident and competent Tissue Viability care through the provision of education, clinical leadership and promoting evidenced based care. The Link Nurse members have specific responsibilities (See appendix 1) and can be contacted as a first resource. Referrals to the tissue viability service are accepted Monday to Friday 9am 4.30 pm from all allied Healthcare professionals, General Practitioners, Medical Consultants, Nursing Home Staff, Acute Hospital Trusts and self-referrals All referrals received by the Tissue Viability Service will be prioritized according to the information provided by the referrer on the completed referral form. Relevant policies and procedure guidelines are available and staff should be aware of these and their contents. Education and training in Tissue Viability is available across the trust to support the prevention and management of wounds. For patients who may be appropriate for Negative Pressure Wound Therapy, please refer following the NPWT guidelines. A first line approach is to contact a member of the County Tissue Viability team or link nurse. The County Tissue Viability Team/link nurse aims to support health care practitioners to provide professional, evidence based and clinically confident and competent Tissue Viability care through the provision of education, clinical leadership and promoting evidenced based care. 2. Purpose of this Guideline/Procedure The aim of this guideline is to provide advice for clinicians on accessing Tissue Viability services. This guideline incorporates all patients across the Worcestershire Health and Care NHS Trust with tissue viability needs. 3. Scope The referral guideline applies to all staff caring for patients with wounds, who recognise that specialist tissue viability advice will enhance management of the patient. It is designed to ensure patients requiring tissue viability intervention are seen in a timely manner that promotes optimum treatment and management of their tissue viability needs. Guideline for the Referral of Patients to the Tissue Viability Service Page 5 of 17

4. Ownership and Responsibilities The Tissue Viability team consists of a Professor & Consultant Nurse in Tissue Viability, 1 Tissue Viability Specialist, 2 Tissue Viability nurses and an administration Secretary. They will triage referrals and respond in a timely manner. Referrals will be accepted via email and an initial response will be returned within five working days. This will usually be by a telephone call to the referring clinician or by email. The aim of this is to provide support either through advice and or intervention to ensure optimum wound management. 4.1 Support & advice The Tissue Viability service will provide support and advice where intervention can aid clinical diagnosis and healing. The Tissue Viability service provides policies, procedures and guidelines, based on the best available evidence. Tissue Viability offers a comprehensive education programme and is accessed through professional development. The Tissue Viability team provide an advisory service; patients will not be routinely reviewed by the team and responsibility for the care of the patient remains with staff in the clinical setting. The Tissue Viability service is supported by a network of link practitioners, who provide support within their own clinical areas. 4.2 Role of the Tissue Viability link practitioners The role of the Tissue Viability Link Nurse is outlined in Appendix 1. 4.3 Role of individual staff member Clinical staff must be able to put into action an appropriate plan of care to assess the needs of the patient and form an appropriate aim of treatment (NMC, 2008) until the patient can be reviewed by a County Tissue Viability link nurse or a Tissue Viability specialist. Staff responsible for assessment of patients with leg ulceration is required to complete the accredited leg ulcer course. All staff should be able to access education and relevant procedures, policies and guidelines to support clinical decision making. Accesses to these are available via the Trust intranet site. 5.0 Standards and Practice All patients with category 3 or 4 pressure ulcers must be referred to Tissue Viability. A referral to Tissue Viability service may be requested to provide Advice on holistic assessment to identify variables influencing healing/skin integrity. Liaison with other health professionals within and in the wider multidisciplinary team. Advice on clinical management of the wound and/or skin integrity Fungating wounds associated with uncontrolled symptoms e.g. Bleeding, odour, pain Advise on pressure relieving equipment Guideline for the Referral of Patients to the Tissue Viability Service Page 6 of 17

Education and support in the management of complex tissue viability issues. Undertake debridement including sharp debridement 5.1 Making a referral Prior to making a referral to the Tissue Viability service the referrer should gain the consent of the patient or undertake a best interest decision. A holistic assessment of the patient and a specific wound assessment should be undertaken and documented using the wound assessment form. A referral form should be filled out and emailed to the tissue viability team. (Appendix 3) Where a staff member is unsure of what action is required in normal circumstances the Tissue Viability link nurse should be asked to review the patient first. Referrals will be triaged by the Tissue Viability team and an initial response will be made within 1-2 working days either are via email or telephone. If the referral is considered to be Urgent the patient should be seen within 1 5 working days in agreement with the referrer. If the referral is Non-urgent or routine the patient should be seen within 5 10 working days of the initial discussion with Tissue Viability All referrals should be made using the Tissue Viability referral form. This should be completed via email. Please ensure all sections are completed otherwise the referral will be returned and this will delay action. 6.0 Tissue Viability referral criteria The following list of referral criteria should not be seen as an exhaustive list but as a guide to aid the clinician making the referral. Chronic or complex wounds that are not listed but are failing to respond to intervention should be referred to the Tissue Viability Team (EWMA, 2008, Dowsett & Aayello, 2004, EWMA, 2008). 6.1 Pressure ulcers The Tissue Viability Service will give advice regarding all grades of pressure damage/ulcers. Referral to the Tissue Viability team must be made for all grade 3 and grade 4 pressure ulcers, or the deterioration of existing pressure damage (NPUAP & EPUAP, 2014). Please ensure that a Ulysses report has been made and that all pressure ulcers have an up to date wound assessment (using the TIME acronym (Falanga, 2004), SSKIN assessment and Water low risk assessment. For further guidance on the Prevention and Management of Pressure Ulcers please refer to the Trust Prevention and Management of Pressure Ulcers guidelines. 6.2 Traumatic Wounds Please note that all serious acute traumatic injuries with extensive skin loss must be referred directly to the nearest accident and emergency department. The Tissue Viability Team will review patients with complex non-healing wounds; this includes burns, skin tears, lacerations, malignant wounds (if appropriate) and those wounds inflicted as a result of mental health issues. Please also consider referral to safeguarding if appropriate Guideline for the Referral of Patients to the Tissue Viability Service Page 7 of 17

For guidance on Wound Management and Skin Tears please refer to the Trust guidelines. 6.3 Fungating wounds Fungating wounds associated with uncontrolled symptoms e.g. Bleeding, odour, pain. 6.4 Leg Ulcers A differential diagnosis including a holistic assessment, leg ulcer assessment and a Doppler Ultrasound should be taken prior to referral to the Tissue Viability Service (SIGN, 2010, Moffatt et al, 2007, RCN, 2006, WUWHS, 2008). A referral to the Vascular clinic may be required if the patient has significant arterial disease or, requires intervention for the treatment of varicose veins. For the management of leg ulceration whether arterial, venous or mixed aetiology the clinician should refer to the Trust guidelines to ensure that the correct line of treatment has been negotiated. 6.5 Paediatrics Patients requiring Tissue Viability advice concerning wound management or the prevention of pressure ulcers should be referred to Tissue Viability. 6.6 Foot Ulcers Please consider a referral to the Podiatry service for diabetic patients with foot ulceration. All other foot ulcers that are not responding to intervention can be referred to the Tissue Viability service for advice concerning management. 6.7 Sharp Debridement The decision for sharp debridement will be made by the Tissue Viability team upon referral. 6.8 Surgical wounds In the case of surgical wound dehiscence please consider the appropriateness of referral to the Tissue Viability Service. It may require referral or liaison with the surgical team in the first instance. 7. Dissemination and implementation The referral process will be disseminated to the Tissue Viability Link practitioners and also available to all via the Tissue Viability website. 8. Education and training All staff have access to education and further professional development. Access to this is available through the Professional development unit via the Trust intranet site http://nww.hacw.nhs.uk/a-z/services/training-development/ 9. Appendices Appendix 1 - Role of the Tissue Viability Link Nurse. Appendix 2 - Referral process flow chart. Appendix 3 - Referral form. Guideline for the Referral of Patients to the Tissue Viability Service Page 8 of 17

10. Audit A quarterly audit of all patients referred for NPWT and all patients with category 3 or 4 pressure ulcers. An annual report of all referrals to Tissue Viability. 11. References Dowsett, C. & Aayello, E. (2004) TIME principles of chronic wound bed preparation and treatment. British Journal of Nursing. (Tissue Viability supplement) Vol 13, No 15 p s16-21 EWMA (2008) Hard to heal wounds an holistic approach. http://ewma.org/fileadmin/user_upload/ewma/pdf/position_documents/2008/englishe WMA_Hard2Heal_2008.pdf Accessed November 2014 Falanga V (2004) Wound Bed Preparation http://www.woundsinternational.com/pdf/content_49.pdf Accessed November 2014 Moffatt, C. Martin, R. Smithdale, R (2007) Leg ulcer management. Oxford, Blackwell Publishing Ltd Nursing and Midwifery Council, (2008) The Code. NMC London. NPUAP and EPUAP (2014) Prevention and Treatment of Pressure Ulcers: A quick Reference Guide http://www.epuap.org/wp-content/uploads/2010/10/quick-reference-guide-digital- NPUAP-EPUAP-PPPIA-16Oct2014.pdf Accessed November 2014 Royal College of Nursing (RCN, 2006) Clinical practice guidelines, The nursing management of patients with venous leg ulcers. London, RCN. Scottish Intercollegiate Guidelines Network (SIGN, 2010) Management of chronic venous leg ulcers, a national clinical guideline. Edinburgh, SIGN. World Union of Wound Healing Society (WUWHS, 2008) Principle of best practice: compression in venous leg ulcers. A consensus document. London, MEP Ltd. Guideline for the Referral of Patients to the Tissue Viability Service Page 9 of 17

Appendix 1 Tissue Viability Link roles and Responsibilities The Tissue Viability link aims to support health care practitioners to provide professional, evidence based and clinically confident and competent Tissue Viability care through the provision of education, clinical leadership and promoting evidenced based care. The link needs to be flexible, proactive and to respond to individual needs of those being cared for. Role of the Tissue Viability Link 1. Role: The role of the Tissue Viability Link is to act as a resource in their clinical area and to liaise with the Tissue Viability Team. To act as a role model for their colleagues and ensure compliance with set standards. To act as a lead for their clinical area in initiating/undertaking specific Tissue Viability related activities to meet the needs of the Trust. They are not a replacement for an adequately resourced Tissue Viability service. 2. Background Experience: At least 6 months post registration experience To have management support for the role 3. Responsibilities: To act as a resource for their clinical area in relation to Tissue Viability Issues, within their own capabilities and competencies. To update colleagues on new Tissue Viability policies, guidelines procedures and changes in practice and ensure these are implemented, within their own capabilities and competencies. To assist in the education of staff and patients in their clinical area in the principles of Tissue Viability as it relates to their area, within their own capabilities and competencies. To ensure compliances with Tissue Viability policies and guidelines in their clinical area. To provide a two way communication on issues related to Tissue Viability between their clinical area and the Specialist. To develop and update resource packs and a teaching board for their area to disseminate and share information. To assist in developing audit and outcome measures that may be used to evaluate practice. To undertake evaluation of dressings, hosiery and pressure reducing equipment within clinical practice. To challenge poor practice and initiate the clinical risk reporting process when necessary. Guideline for the Referral of Patients to the Tissue Viability Service Page 10 of 17

To take the lead role in their clinical area in co-ordinating audits with support from the Tissue Viability Nurse team. To encourage members of their clinical area to use the Wound Formulary and to encourage colleagues to complete wound evaluation forms on any new products tried. To raise the profile of the Tissue Viability Link. To work pro-actively as a team to promote issues in Tissue Viability. To support the annual audit of beds, bed bases and cushions and the implementation of the results where appropriate. Undertake Root Cause Analysis following training where appropriate. 4. Professional Responsibilities: Tissue viability links will attempt to attend all meetings and will negotiate the time for this with members of their team or to arrange a replacement from their area if they are unable to attend. Tissue viability links will take a proactive approach to their own tissue viability training needs and will attempt to maintain their own knowledge and will share this with other team members. Tissue viability links will all hold a qualification in Tissue Viability. I.e. an accredited course in Tissue Viability, leg ulceration or pressure damage and prevention. Tissue viability links will act as a resource and will organise ways of disseminating knowledge and evidence based practice within their own area. Tissue viability links will be aware of the role of the Tissue Viability Team staff and will support them. A Tissue Viability link will be present at all local meetings with pharmaceutical industry. 5. Trust Responsibilities: For clinical areas to recognise and support the role of the Tissue Viability Link. To allow the tissue viability links the time and opportunity to attend Link meetings and training. To ensure tissue viability links have regular opportunities to feedback information to their clinical areas i.e. at team meetings, provide a notice board to display information. For each tissue viability link to discuss the role of the link during their SDR on an annual basis with their manager. Guideline for the Referral of Patients to the Tissue Viability Service Page 11 of 17

Please note that incomplete referral forms with be sent back to the referrer. Tissue Viability Referral form Patients Name: Referrer s Name: NHS Number: Designation: Address: Base: Tel: Mobile: Tel No: Date of Birth: or if no phone please indicate Has consent been gained for this referral? Is patient in nursing or residential care? Y N Email address: Date of Referral: All referrals will initially be followed up by telephone to enable appropriate response from the Tissue Viability Service Ethnicity: Other requirements: (e.g.: Interpreter, keycode number etc) Next of Kin: Address: Tel No: GP Name: Allergies/Hypersensitivities: Address: Tel No: Past Medical History: Guideline for the Referral of Patients to the Tissue Viability Service Page 12 of 17

Medication: Reason for referral (please place a cross in all boxes that apply) Pressure Ulcer+ (Please state grade and site) Non Healing Surgical Wound (Please specify site) Traumatic Wound (e.g. Burns, skin tears, please state) + Ensure referral to Ulysses is completed Mental health wound care (Please state type) Paediatric wound care/ advice (Please state type) Leg Ulcer Venous Arterial Mixed Sharp debridement (specify site and wound type) Sharp debridement (specify site and wound type) Foot Ulcer+ Diabetic? + Consider referral to podiatry Refer to Diabetic Foot Pathway if Diabetic Y N Patient Name Date of Birth Current Treatment and frequency of dressing change: Guideline for the Referral of Patients to the Tissue Viability Service Page 13 of 17

Leg Ulcers ABPI Date completed LT = RT = (If not done within the last 3 months please complete prior to referral unless unable to perform/or contra-indicated. Consider referral to vascular clinic if appropriate Waterlow Score +Please ensure SSKIN assessment is completed Pressure ulcers if applicable Type of mattress in use (please name) Type of cushion in use (please name) Other equipment in use (please state) Fluid/Nutritional Intake/ Weight Loss/Gain Incontinence Sensory Impairment Mobility Co-morbidities Recent Infection/ or Acute Illness Mental Health Has Capacity been assessed? Social RISK FACTORS Yes No Comment Any other relevant information: (please place a cross in boxes and complete as appropriate) E.g. Malnutrition Universal Screening Tool. Please e-mail completed forms to whcnhs.tissueviability@nhs.net Guideline for the Referral of Patients to the Tissue Viability Service Page 14 of 17

Equality Analysis Title of Policy/Function (Function Includes: Services; Projects; Strategy; Processes; Systems; Practices; Procedures; Protocols; Guidelines; Care Pathways etc..) Guideline for referral to Tissue Viability New New Existing/Revised Short description of Policy/Function (aims and objectives, is the policy/function aimed at a particular group if so what is the intended benefit): This document has been produced to support Registered Healthcare Professionals working within Worcestershire Health & Care NHS Trust; it should be referred to for the recommended best practice for referral to tissue viability. The guideline will support appropriate referral to Tissue Viability. The role of the Registered Health Care Professional will be defined in this guideline, outlining their responsibility and accountability for the appropriate referral to Tissue Viability. Name of Lead/Author(s) Job Title Contact details Professor Jackie Stephen- Haynes Rosie Callaghan Professor & Consultant Tissue Viability Nurse Tissue Viability Specialist Nurse j.stephen-haynes@nhs.net 07775 792775 rosie.callaghan@nhs.net 07717 543046 Monique Maries Tissue Viability Nurse Monique.maries@nhs.net Suzy Tandler Tissue Viability Nurse Suzanne.tandler@nhs.net When the policy/function involves patients/staff/partners/stakeholders etc. please where possible include them in the Equality Analysis to demonstrate openness, transparency and inclusion and particularly by those who this policy/function is most likely to have impact. Does this Policy/Function have any potential or actual impact that is positive(+), neutral (N) or negative (-) impact on the following protected characteristics please indicate: + N - Please provide a rational/justification for each of the following regardless of impact Age N This policy encompasses all ages. Disability N Reasonable and appropriate adjustments will be made to ensure that any person who has a disability/ learning disabilities will not be discriminated against as will no person with mental health issues. Equally, consideration for careers and family members who have either a disability/learning disability or mental health issue to avoid associative discrimination. Gender Reassignment N This policy is relevant to any persons who are undertaking or have under taken gender reassignment Guideline for the Referral of Patients to the Tissue Viability Service Page 15 of 17

Pregnancy & Maternity N in the same way as those who have not undertaken or who are undertaking gender reassignment. This policy is relevant to any person who may be pregnant or receiving post natal care. It is not relevant to the unborn child. Race N This policy is relevant to any race. Religion & Belief N All patients will be treated equally; this is regardless of their religion or belief. Sex N This policy is relevant to any gender and applies to both sexes equally. Sexual orientation N This policy is relevant to any sexual orientation/preference. Marriage & Civil Partnership N This policy is relevant to marriage & civil partnership equally. Other Groups who could experience inequality, e.g. carers, homeless, travelling communities, unemployed, people resident within deprived areas, different socio/economic groups e.g. low income families, asylum seekers/refugees, prisoners, people confined to closed institutions or community offenders, people with different work patterns e.g. part-time, full-time, job-share, short-term contractors or shift workers - Access, location and choice of venue, timings of events and activities. Support with caring responsibilities This policy is relevant to all groups equally. Analysis conducted by: (minimum of 3 people) Name Job Title Contact details 1 Jackie Stephen-Haynes Professor and Consultant Nurse in Tissue Viability j.stephen-haynes@nhs.net 2 Suzy Tandler Tissue Viability Nurse Suzanne.tandler@hacw.nhs.uk 3 Monique Maries Tissue Viability Nurse Monique.maries@nhs.net Start date of policy/function Review date of policy/function December 2014 December 2017 Period valid for : 24 months Service Delivery Unit: Reference/Version: Date Equality Analysis completed: D D M M Y Y If you have identified a potential discriminatory impact on the policy/function please refer it to the author together with suggestions to avoid or reduce the impact. A copy of the completed Equality Analysis must be attached to the policy/function and a copy sent to: Patrick McCloskey Equality Inclusion Practitioner Guideline for the Referral of Patients to the Tissue Viability Service Page 16 of 17

Isaac Maddox House, Shrub Hill Road, Worcester, WR4 9RW Tel: 01905 761324 Patrick.mccloskey@hacw.nhs.uk Guideline for the Referral of Patients to the Tissue Viability Service Page 17 of 17