The NWCSP acknowledges that there are unwarranted variations in wound care services across the UK, which offers major opportunities to improve care provisions, clinical outcomes and spend (NWCSP, 2020). An area that the NWCSP has produced recommendations for is Lower Limb wounds, those on the lower leg (below the knee) and foot that are slow to heal. It is estimated that approximately 1.5% of the adult population in the UK is affected by active leg and foot ulceration, which equates to 730,000 patients (Guest et al, 2015). There is considerable variation in practice and outcomes (Gray el at, 2018) which increases care costs and extends healing times (NHS Right Care, 2017).

      The Skin Integrity Team at Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (DBTH) identified the need to implement the NWCSP Lower Limb recommendations for the diagnosis and treatment of leg ulceration in a secondary care environment. DBTH worked with services in the Doncaster Place Wound Care Alliance collaboratively through system leadership to develop lower limb clinical pathways to meet the recommendations and reduce variation in care. A main element of the recommendations was the use of compression therapy in secondary care, however the skin integrity team were mindful that some would argue many nurses have difficulty with maintaining compression bandaging skills in hospital setting (secondary care), which Anderson (2006) agreed with. Because of this historically at DBTH compression was discontinued on admission, following the removal of the bandages to enable a skin inspection and wound assessment to be undertaken, despite evidence showing compression therapy doubles the chances of venous leg ulcers (VLU) healing (O’Meara, 2012).

      Therefore, it was crucial for the skin integrity team that a compression therapy system was available that aided safe and correct application, reduced the risk of complications, allowed continuity of care and could be supported by education and competencies within a secondary care environment. The implementations of the clinical pathways would be a huge change to DBTH requiring time to establish and embed into practice. Standards were set in line with the NWCSP recommendations, including the red flags being clearly identified at the start of the pathway, to ensure there were clear and measurable outcomes that would enable the process to be reviewed, adapted and measured.

METHOD Development and Implementation of new clinical pathways

      The stakeholders that included the specialists wound care services within the Doncaster Place Wound Care Alliance and Medicine Management at the Clinical Commissioning Group (CCG) worked corroboratively to review national guidance and recommendations and brainstorm ideas of developing and implementing standardised pathways for the guidance, prevention, assessment, management and treatment of lower leg wounds based on the NWCSP 2020 recommendations. Key stakeholders included:

The Skin Integrity Team, Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

Tissue Viability and Lymphoedema Service, Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH)

Doncaster Medicine Management (CCG)

Foot Protection Service/Podiatry Service Rotherham Doncaster and South Humber NHS Foundation Trust.

Vascular Nurse Specialist Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust

District Nurse Educator, Rotherham Doncaster and South Humber NHS Foundation Trust.

The NWCSP key proposals to improve the care of lower legs includes (NWCSP, 2020):

Change the model of care provision to allow more people with chronic lower limb wounds to receive equitable care

Deliver care in a clinic setting, where possible

Encourage supported self-care, where possible

Increase the delivery of evidence-based care for chronic lower limb wounds

Undertake a lower limb assessment with 14 days of identification

For arterial leg offer offloading/casting for pressure relief

Rapid access to specialist vascular services for vascular reconstruction

Optimisation of comorbidities including disease management

For VLUs use strong multilayer compression therapy

For VLUs refer for endovenous ablation surgery

Post-healing compression therapy

Improve data and information to support clinical decision making and enable quality improvement to be monitored.

      In addition to ensuring the clinical pathway met the needs and recommendation of the NWCSP the collaborative group also ensured it enhance the quality of care, guided the healthcare professional through evidence-based decision-making, was cost effective, improve patient access to care and their quality of life.

      To ensure that the pathways were beneficial to the healthcare professionals providing patient care, the process was split into sections in line with the current Doncaster Wound Care Alliance tired service model. As a result four clinical pathways were developed with three supporting appendices:

Lower Leg Wound Guidance

Lower Leg Wound Pathways in Primary Care

Lower Leg Wound Pathways in Secondary Care

Lower Limb Assessment Pathways.

      Clinical pathways were also developed for wounds of the foot, however this did not include an assessment pathway as the key stakeholders identified the large amount of changes and implementation that was needed, so made the decision to develop and implement these over a phased approach to ensure they were embedded into practice and sustainable. Therefore the wound of the foot assessment pathway development was under creation during the implementation phase of the below pathways, with the plan to launch the full guidance for the wounds of the foot in 2022. Pre and post data will be collected for this using the same methods as the lower leg wound pathways.

      The Lower Leg Wound Guidance (Figure 1) was developed to establish possible wound type for wounds below the knee to the malleolus (ankle) supporting the healthcare professional to follow the most suitable plan for treatment and referrals. This then enable the healthcare professional to use the Lower Leg Wound Pathway for either the Primary Care (Figure 2) or Secondary Care (Figure 3) environment, supporting them through identification of red flags, immediate and necessary care recommendations as highlighted by the NWCSP, wound bed preparation, wound assessment, management and referrals as per the suspected wound type.

      The referrals included:

 The Skin Integrity Team at DBTH/Tissue Viability and Lymphoedema Service at RDaSH/ Community or Practices Nurse Service in line with the Doncaster Wound Care Alliance tiered service model for a lower limb assessment for diagnosis and treatment to be undertaken and commenced, such as compression therapy

The Vascular Service at DBTH for investigations and consideration for underlying causation treatment such as surgical/ endovenous interventions

Dermatology opinion

Community Tissue Viability and Lymphoedema Service at RDaSH for lymphoedema management care in line with the International Lymphoedema Framework Recommendations

Community or Practices Nurse for ongoing wound interventions.

      A Lower Limb Assessment Pathway ( Figure  4) was developed to ensure that assessment was undertaken based on minimum data set and that the process was consistently followed throughout the Doncaster Place Wound Care Alliance. There were three supporting appendices to this pathway to assist with documentation, scheduled follow up and compression therapy options.

      For the skin integrity team is was crucial that within the compression therapy options there was a first line option for secondary care to use that aided safe and correct application, as ward and department staff were not familiar with compression therapy and did not have the knowledge, skills or competencies for safe application. Historically compression is discontinued in secondary care despite evidence showing compression therapy doubles the chances of VLUs healing (O’Meara, 2012). Some would argue that this is because many nurses have difficulty with maintaining compression bandaging skills (Anderson, 2006). Compression therapies were reviewed and it was identified that the multilayer compression bandage system to use was UrgoKTwo. Young et al (2013) stated that UrgoKTwo benefits from PresSure system that has shown to aid the safe and correct application of the therapeutic pressures from the first application, reducing the risk of complications and potential for variation between health professionals, allowing for continuity of care and enabling education and competencies in the application to be achieved. A hosiery system was consider however due to the procurement and cost of these, with multiple sizes, fabrics and colour it was identified by the key stake holders and secondary Care Procurement it was not suitable as a first line product in secondary care.

      A training programme was launched at DBTH providing education, skills and competencies around lower limb aetiology, wound causation and development and interventions to enable health professionals to follow and implement the clinical pathways. A key factor in reducing unwarranted variation in the assessment and treatment of wounds is ensuring that healthcare professionals have relevant and up-to-date evidence-based knowledge and skills to deliver the care effectively, timely and in the right place where an appropriate clinician is available; while overcoming barriers.

      Figure 5 shows the UrgoKTwo competency document which is used to confirm healthcare professional competence before enabling them to start applying the treatment following a diagnosis and treatment plan.

RESULTS

      Following the development of the clinical pathways data was collected before the implementation to establish a baseline in relation to the NWCSP recommendations. It was acknowledged that it would take time to embed and sustain all the recommendations at once, therefore it was decided that for the first 12 months the following areas would be monitored and measured be to quantify the outcomes achieved in a secondary care environment by implementing the NWCSP recommendations through clinical pathways:

Change the model of care provision to allow more people with chronic lower limb wounds to receive equitable care — pathway development and implementation

Deliver care in a clinic setting — number of lower leg wounds referred to the skin integrity team (acute wounds versus chronic)

Increase the delivery of evidence-based care for chronic lower limb wounds — the number of patients with a chronic wound that required a lower limb assessment versus having the assessment undertaken

Undertake a lower limb assessment within 14  days of identification (a decision was made by the skin integrity team that during the first phase of implantation the assessment pathway, due resources and time supporting the implementation of the other pathways throughout the Trust, would be complete for chronic within 14 days and acute within 21 days if wound is still present and transitioned to a chronic wound, with the plan to increase the acute wounds to 14 days in the future)

For VLUs use strong multilayer compression therapy — the number of patients that were suitable and had a lower limb assessment to be undertaken by the skin integrity team

Post-healing compression therapy

Improve data and information to support clinical decision making and enable quality improvement to be monitored.

The second phase of the implementation (post-12 months) will include recommendations around:

Encourage supported self-care, where possible

For arterial leg offer offloading/casting for pressure relief

Rapid access to specialist vascular services for vascular reconstruction

Optimisation of comorbidities including disease management

For VLUs refer for endovenous ablation surgery.

      The preclinical pathways implementation data (May and June 2021) identified that none of the NWCSP recommendations that were being measured were achieved (Table 1). Whereas the post-implementation data from July to December 2021 (Table 2) showed there was an increase in all recommendations being achieved, thus improving practice (Figure 6):

For DBTH inpatients 96% being scheduled for a lower leg assessment within 14 days for a chronic wound and within the next 28 days for an acute wound that transitioned to chronic; if the patient remained an inpatient

100% of inpatients suitable for a lower leg assessment receiving one within the scheduled time frame; if the patient remained an inpatient.

100% of patient that received a lower leg assessment has a diagnosis documented.

94% of patients receiving recommended treatment ± compression in line with the diagnosis.

DISCUSSION

      The NWCSP Lower Limb recommendations signpost to relevant clinical guidelines or outline evidence-informed care that will improve healing and optimise the use of healthcare resources (NWCSP, 2020). The recommendations outline care interventions with the aim of promoting a rapid diagnosis, fast access to appropriate interventions for treatment or service provision. The skin integrity team felt this could be achieved by developing and implementing clinical pathways, which was also a recommenations from the NWCSP (2020) and Wounds UK (2016).

      Kiyama et al (2003) stated clinical pathway implementation aligns clinical practice with guideline recommendations in order to provide high-quality care within an institution. There is evidence that shows they serve as useful tools to reduce variations in clinical practice, thereby maximising patient outcomes and clinical efficiency. This includes work by Fletcher et al (2018) and Adamina et al (2011) who expand stating they improve cost-effectiveness through standardisation of practice. Hegarty et al (2014) identified a consistent finding from 28 clinical pathways that they all contribute to better clinical outcomes compared with usual or standard care processes with 8 resulting in a reduced length hospital stay (Adamina et al, 2011; Allen et al, 2008; Barbieri et al, 2009; Chen et al, 2014; Kul et al, 2012; Leigheb et al, 2012; Lemmens et al, 2009; Van Herck et al, 2010).

      However in contrast Carthey et al (2011) states that in an effort to reduce variance in practice there is a propensity to try and specify every conceivable aspect of care which may lead to multiple guidance on the same area and in many cases very complex guidance. Hegarty et al (2014) agrees stating adherence to clinical pathway remains suboptimal, which in turn contributes to preventable harm and suboptimal patient outcomes. Then again Kiyama et al (2003) suggests that despite this they still they have the capacity to promote safe, evidence-based care by providing locally oriented recommendations for the management of a specific condition, while contributing to the reduction of complications and treatment errors. This is supported by Wounds UK (2016) who states a structured treatment pathway should be used in the management of all VLUs.

      NHS Improving Quality (2019) published the National Evaluation of the Department of Health’s Integrated Care Pilots 2012 results which stated there is a lack of common definitions of concepts underlying integrated care working. As a consequence, many terms including 'integrated care', 'coordinated care' and 'collaborative care' are used resulting in inevitable variations. Despite this The Department of Health (2012) state that a collaborative approach can improve communication, save time, reduce duplication of effort, improve working relationships and provide a better experience for people who use health and social care services. Therefore it can be suggested that by enabling organisations and teams to work together and respect other perspectives in healthcare it empowers and assists stakeholders to work more effectively as a team to address current challenges to help improve patient outcomes.

      Compression therapy has been considered the gold standard of care for venous hypertension and leg ulcers since the late 1980s (EWMA, 2003) and as research has translated into clinical practice, bandage application practices have changed and improved, reducing healing times and increasing patient comfort and wellbeing (Young et al, 2013). Wounds UK (2015) confirmed that compression should be first-line treatment to optimise healing and can benefit patients both acute and chronic management. However, it is vital that the healthcare professional has established that compression is safe to use for the individual. Therefore, a lower limb assessment and diagnosis is required to ensure early, safe and effective management can be commenced.

      Wounds UK (2016) highlight a number of patient factors that should be considered in relation to the suitability for compression and the type of compression required. They also provide advantages around hosiery kits over bandages, however this then limits the recommendations for areas in practice where hosiery kits are not feasible or cost effective; such as in a hospital setting in secondary care. Therefore, the skin integrity team identified that a multilayer compression bandage system would be the most suitable for that environment as firstline.

      A multilayer compression bandage system was selected as part of the NWCSP recommendations following a Cochrane review on compression that concluded that multicomponent bandage systems are more effective than single component bandage systems in healing VLUs (O’Meara, 2012). UrgoKTwo was selected for use at DBTH and across the Doncaster Place Wound Care Alliance due to Benigni et al (2007), Sanderson et al (2012) and Hajjar et al (2007) all finding that the product effectively supported wound healing in patients with VLUs. In addition, Jünger (2009) identified that it effectively provided sub-bandages pressures after seven days and both Hanna et al (2008) and Weindorf et al (2012) stated this was achieved despite people with varying skills applying the bandage system. Therefore it can be suggest it is a safe and easy to apply bandaging system.

Next steps

      Data will continue to be collected and analysed for the first implementation stage that remains from January to June 2022. This includes healing rates for all patients from May 2021 at 12 weeks, 24 weeks and 48 weeks. During this time the clinical pathways will be enhanced to include an interactive primary dressing to establish if this will enhance the healing rates further when compared with the first 12 months with compression alone.

      From July 2022 additional data will be collected when additional pathways are developed and launched around supported self-care, arterial leg offer offloading/casting for pressure relief, rapid access to specialist vascular services for vascular reconstruction, optimisation of comorbidities including disease management and VLU referrals for endovenous ablation surgery. The current pathways will also updated taking into consideration skin tone and diverse populations in relation to terminology, language and images. Education is to continue throughout the process to ensure the clinical pathways continue to be embedded onto standard practice. Work is also underway to implement a Foot Ulcer Assessment Pathway to work on the same principles as the clinical pathways for the lower leg to improve practice for the care of foot wounds.

CONCLUSION

      The recommendations published for lower limb care by the National Wound Care Strategy Programme (NWCSP) (2020) seek to improve in the care of patient with wounds. The Skin Integrity Team at Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (DBTH) identified the need to implement the NWCSP Lower Limb recommendations for the diagnosis and treatment of leg ulceration in a secondary care environment.

      A collaborative group developed clinical pathways in line with the NWCSP lower limb recommendations to reduce variations and implement best practice, which was support by education and training cover all aspects, knowledge, skills and competencies within the pathways.

      An increase was seen in adherence to all recommendations being measured within the first phase of implementation suggesting improving practice had been achieved.

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ACKNOWLEDGEMENTS:

      Kelly Moore wound like to thank the patients at DBTH, The Skin Integrity Team, Tissue Viability and Lymphoedema Service, Doncaster Medicine Management Clinical Commissioning Group, Foot Protection Service/Podiatry Service, Vascular Nurse Specialist , District Nurse Educators.

DECLARATION OF INTEREST

      Kelly Moore won the 2021 Urgo Medical Rising Star Award for Recognising new and emerging talent in wound care based on the abstract for this practice development work. Urgo Medical support the educational programme the Skin Integrity Team deliver to staff at DBTH.

This article is excerpted from the Wounds UK | Vol 18 | No 2 | 2022 by Wound World.