Learning Zone

The small things that can make a big difference. Compilation of experience from me and my colleagues over the last 20 years in clinical practice:

• Support and education can empower your patient | This can ensure they become a stakeholder in their own healthcare. Patient passport documents and support groups such as ‘Legs Matter’ can provide simple but effective information, which can make a BIG difference.  

• Involve the family | Never feel you have got to do this on your own. Sometimes a relative, family friend or a career with a good relationship with your patient can be that firm but supportive helping hand.

• Peer support groups | These can help patients interact and support each other within a peer group experiencing similar challenges. ‘Leg Clubs’ established an effective model back in the early 90’s, bringing together socially isolated communities all experiencing problems of the lower limb. 

• Autonomy | Working with your patient and showing a willingness to compromise can help the patient feel they have some control in an otherwise vulnerable and confusing situation.

• Understand your patient holistically | Asking the patient what their priorities and challenges are can help work towards a realistic approach to success. Understanding their needs and priorities can help shape a regime and select the right product at the right time. For example, your patient’s goal may be to attend a family event without worrying about bulky bandages. Understanding this can help shape a treatment regime, whether temporary or longer term.

• Slow but steady wins the race | Don’t feel like you need to solve all challenges at the same time. Providing a solution to a patient challenge can sometimes solve a problem before it starts. Giving footwear advice for example can alleviate any anxiety around being able to wear suitable and aesthetically pleasing footwear.

• It’s not what you do it’s the way that you say it | Your thoughts and aims may be clinically accurate, however consider a joint approach. Starting a dialogue with ‘maybe you could’ or ‘perhaps we could’ or ‘shall we try’ can position a plan as a partnership decision. 

• Self-care | Delivering care in the current climate can be incredibly challenging. For many years we have been seeking to achieve a balance of self and shared care and COVID-19 has accelerated this process. We need to have a support process to identify those patients who can and are willing to self-care and those who still require regular intervention. When appropriate we should provide a plan of care that is easy to follow alongside support material to empower our patient, carer or family member. These should include hand hygiene, how to change a dressing, signs and symptoms of deterioration, how to raise concerns and realistic expectations of the patient/carer/family member.

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How to know what product to use, how and when:

• Long term and self-care management | Introduce your patient to hosiery as soon as possible and they are more likely to use their compression long-term and reduce the risk of recurrence.

• Evolution of Compression Therapy | Traditionally hosiery has been worn to prevent recurrence of venous leg ulcers, however more recently compression hosiery has also proven to be as effective as multi-component bandaging in healing venous ulceration. 

• Hosiery First Line* | Due to the cost economic benefits and the potential positive implications for the patient, hosiery kits should be used as the first compression option except in those patients who do not meet the criteria for hosiery kit use (*subject to local guidelines and full leg ulcer assessment).

• When not to use hosiery | Although compression hosiery is recommended as a first-line option, it may not be suitable for dysmorphic limbs, rapidly decreasing oedema or exudate levels not contained within the dressing. These characteristics and observations are usually managed using compression bandages before hosiery is commenced.

• Non-Concordance | The reasons for non-concordance can be grouped into two interdependent major categories, (1) wear-comfort factors and (2) an intangible sense of restriction. Work with available options to find the most suitable compression option (open toe, closed-toe, zippers, 2 layers, wraps).

• Non-Concordance – what to do? | If a patient cannot or will not wear the chosen compression therapy, don’t give up. Try to have a sample pack of options and always be positive. “If this doesn’t work, don’t worry we can try something new”.

• Application & Removal | It can sometimes be difficult to apply and remove hosiery, especially if patients have very painful ulcers or dexterity issues. Hosiery can also cause trauma to those patients with very fragile skin during the application and removal process. Many application aids are now on drug tariff. These can provide an effective solution for patients who wear compression hosiery with a closed and open-toe.

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How can the medical industry really help Trusts, Clinicians and Patients in management of the lower limb? Many commercial partners have access to a multidisciplinary team not too dissimilar to the NHS. Alongside product specialists, sales managers and clinical teams, there are also many other useful roles which can help in areas not typically falling within our expertise. These include:

• Health economists | These can help investigate how our resources are used and focus on the distribution, availability and effectiveness of our service. There is more and more pressure for us to provide functional information regarding service delivery (CQUIN). I have utilised this resource, helping to provide information on costs, cost-effectiveness and strategic planning to guide policy and service delivery. 

• Statisticians | By identifying statistical trends, health care providers can monitor local conditions and compare them to national and international trends. This guidance and collation of local data can assist in the allocation of public and private funds and possibly help fund a service redesign project (Doppler service, leg ulcer clinics & equipment). Another example of how to use this expertise is within everyday formulary decision making. It is important when we make formulary decisions that they deliver on the objective. Statisticians can help detail clinical scenarios to ensure a return on objective/investment is achieved.

• Business Managers | Ever thought of or been asked to consider how to make quality improvements? Whether it’s purchasing new equipment, expanding service centres and staffing levels or even a complete service redesign you will need a business plan. Nurses are under increasing pressure to up their business acumen to demonstrate service deliverables including impact, a return on investment and efficiencies. However, don’t despair! I have worked with industry partners to help build, guide and format plans to deliver successful business cases.

• Medical Writers | Before products come to market there are many clinical and regulatory hurdles industry have to overcome including research (safety and performance data), instructions for use and drug tariff applications. Companies will have expertise such as a medical writer who can apply the principles of clinical research and help develop clinical trial documents, describe research results, product use, and other medical information. MW’s can help present clinical findings, peer review posters, articles, conference presentations or information for patients, such as health advice leaflets and website material.

• Designers | Many industry partners either have onsite designers or have access to agencies for their marketing material. This service uses design methodologies and clinical collaboration to re-imagine the way that people interact with health care. This can be anything from creating visual tools that improve conversations between patients and clinicians to applying infographics to an otherwise text-heavy clinical pathway. I have many a time collaborated with different industry partners to help professionally deliver pathways, patient support documents and educational material.

• Medical Publication Agencies | Many publication agencies are working in the field of tissue viability and lower limb management. These agencies can be hugely supportive and can be seen as a 2^nd arm to industry partners. Their offering is diverse, running conferences, publishing research, generating easy to use guides and playing a pinnacle role in education. Through working with these, I have learnt how to write articles, generate case study posters and produce meaningful material which can help influence theory in practice.

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Proving the worth of our leg ulcer services. 

It is one thing to implement a best in class clinical service, but it’s another to accurately demonstrate it. We must be able to record the effectiveness as well as areas of improvement. With the upcoming CCG-14 CQUIN along with the published National Wound Care Strategy Group guidelines and recommendations, it is so important we can prove results from our leg ulcer services. Some great national examples of this exist already, however more can be done. 

Read this top-line plan from personal experience of a service redesign through targeting data:

1. Understand what operating system your Trust uses (SystmOne, Vision, EMIS etc.) and how or if reports are generated. Who reports on current CQUIN’s and who is your commissioner for CQUIN delivery?

• Clinical coding is not new, however the way we use this could improve our understanding. Many elements of our documentation are or could be coded to help populate an analytical script. Do you have a digital lead or template designer in the Trust? Where is the Trust Business Information Unit and who is the Trust Information Analyst?

• Undertake a service level audit and gap analysis. In my experience a service level audit examined criteria from four work-streams ‘The Patient’, ‘Education’, ‘Documentation’ and the ‘Clinical Infrastructure’. This includes clinical governance, practice, product selection and use, clinical settings and equipment. A gap analysis then compares performance data with potential or desired key performance indicators (KPI’s).  

• Ensure you documentation meets the minimum data set requirements according to National Wound Care Strategy Program Lower Limb Assessment Essential Criteria (LLAEC). The LLAEC has been compiled using all the criteria from the NHSE Leading Change Adding Value Framework Minimum Data Set 1 and the assessment criteria from the SIGN Guideline for Venous Leg Ulcers. 

• Collate all gathered information including change indicators, unknown factors and areas of success and populate a project management chart (eg GANTT). This highlights a project schedule, relationships between identified activities and current schedule status. This can then be the repository of all information needed to build a business plan for a service redesign.

I hope this inspires you to believe in change… remember ‘if you always do what you always did, you will always get what you always got’ (Albert Einstein). As highlighted in ‘Industry Partnerships’ a commercial partnership can help materialise a theory into clinical practice.

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What this will mean for the patient, for you and your Trust:

What

• CQUIN frameworks set out targets for service providers to improve the quality of patient care and encourage transformational change
• The Department of Health introduced the CQUIN framework in 2009. 
• It makes a proportion of a healthcare service provider’s income conditional on demonstrating improvements in the quality of the service it provides in key topical areas
• These frameworks supported the strategic aim of the Five-Year Forward View (NHS England, 2014)
• Click here for more information on CCG14, page 10

Theory into practice

1. All methods and interventions have been reviewed to ensure they are in line with current routine clinical practice and are simple and straightforward to implement. 
2. National programme teams (AHSN | NWCSP) are supporting implementation by making available practical tools, training and support

Description

• Denominator | Total number of patients treated in the community nursing service with a wound on their lower leg (originating between the knee and the malleolus)
• Numerator | The number where the following audit criteria for diagnosis and treatment are met within 28 days of referral to the service or, for a patient already receiving care from the service, within 28 days of a non-healing leg wound being identified and recorded
  • Documentation of a full leg wound assessment that meets the minimum requirements (NWCSP)
  • Patients with a leg wound with an adequate arterial supply (ABPI 0.8-1.3) and where no other condition that contra-indicates compression therapy is suspected, treated with a minimum of 40mmHg compression therapy
  • Patients diagnosed with a leg ulcer documented as having been referred (or a request being made for referral) to vascular services for assessment for surgical interventions

Potentially this is a big financial incentive to deliver for the Trust and ultimately a massive benefit to the patient who will have a team focused towards a truly first-class service. For more information on data collection in line with financial targets, see the article ‘Data Dilemma’.

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