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The Nursing in Practice wound care survey

It has been estimated that at any one time approximately 200,000 people in the UK are suffering from a leg ulcer, pressure ulcer or diabetic foot ulcer. And this doesn't include the number of surgical or traumatic wounds. In fact, the total cost of wound care in the UK is about 3% of total NHS spend - in the range of £2.3bn-3.1bn (at 2005/06 prices).1

And this is set to rise. The population of the UK is forecast to increase between 2005 and 2025 by 3.4 million, and in the same period the population aged 65 and older is forecast to increase by 3.5 million, from 9.5 million to 13.0 million.1

Despite this, wound care is seriously underfunded. The government has attached no Quality and Outcome Framework (QOF) points to delivering wound care despite the significant amount of resources it takes up. It receives little media attention and a small proportion of research funding.

The majority of wound care is provided by nurses, and it is one of the most challenging areas of modern healthcare. Despite the existence of national guidelines and frameworks, many practitioners do not have a clear expectation of their standard of knowledge, assessment capabilities and treatment delivery.2

Education provision for clinicians can also be haphazard with little if any information on wound care delivered in prequalification programmes, and access to postqualification programmes being restricted by availability and funding.2

Advances in technology and the ever-present focus on the cost-effectiveness of treatments have highlighted the need to re-evaluate the traditional delivery of wound care, with more and more of this service being delivered outside the acute setting.

This latest survey by Nursing in Practice wanted to find out more about what wound care was taking place in the world of general practice and the community. With such a dearth of information and resources, we wanted to find out just how much wound care you are doing, your knowledge and experience, and how comfortable you feel working in this field.

Background
The majority of respondents are providing wound care within GP practices (67%) followed by 26% providing care in patients' homes, presumably as part of district nursing teams (see Table 1). Most respondents (79%) provide wound care to at least three patients per week, and 35% saw over 10 patients with wound care problems per week (see Table 2).

[[Tab 1]]

Leg ulcers, postsurgical wounds and traumatic wounds were the types of wounds most commonly seen by respondents.

Respondents were asked to indicate what wound care education they had received within the last two years. Eighteen percent had never received any tissue viability education. The majority - 47% - had received this education through visits from company representatives and 36% from study days sponsored or delivered by pharmaceutical companies that manufacture dressings. "This is worrying," commented Una Adderley, a community tissue viability prescribing nurse from North Yorkshire and York PCT. "Such education is less likely to be generic and unbiased."

A total of 8.6% had undertaken a specific module/degree at university and 7.6% had attended a study day at an academic institution. Una felt this was a poor result: "This represents very few nurses, yet these courses are more likely to provide generic wound education with an evidence-based practice slant." However, she was encouraged that 41% have attended education provided by a tissue viability specialist nurse.

Most respondents - 85% - had access to a tissue viability nurse, and of those who did not, 71% said that they wished they did. As one practice nurse from south Wales put it: "Working in a primary care GP practice there is no immediate advice on hand when needed, and referral to a local wound clinic can mean months on a waiting list, even as an urgent referral."

Research
A recent report, Skin Breakdown: The Silent Epidemic,1 highlighted the huge discrepancy between the economic social burden of skin breakdown and the small amount of research money currently invested in this field. It cited the "urgent need for new research on skin breakdown to be commissioned" and described how the "shortcomings of the current evidence base reflect the low priority given to skin breakdown by those responsible for research funding, part of a wider picture in which wound care remains a Cinderella service."

Very few respondents had ever been involved in wound care research - just 17%. Of those who have taken part in research, 29% were involved in a randomised controlled trial, 35% in a survey, and 17% in a case study. The most common reason given for never having been involved in research was that they had never been invited to (83%).

Marilyn Eveleigh, Consultant Editor of Nursing in Practice, feels that this is a missed opportunity: "With so much nurse activity and funding going on in wound care, some effective coordination is needed here," she said.

Leg ulcers
A leg ulcer occurs where the skin breaks down allowing air and bacteria to get into the underlying tissue. This is usually caused by a problem with the underlying vasculature. For example, sustained venous hypertension causes swelling, restricted blood flow and damage to the skin and other tissues, leading to venous leg ulcers.

At any one time it is thought that between 70,000 and 100,000 people have a leg ulcer in the UK,1 and about 500,000 people experience recurrent leg ulcers.3 The risk of ulcer increases with age, probably due to decreased mobility and changes in the skin that make it more susceptible to damage.

Most of the respondents to this survey were practice nurses, yet they perceived district nurses (40%) and specialist leg ulcer services (44%) as having the most knowledge and skill regarding leg ulceration.

Despite the respondents' shortage of unbiased education and perception of superior knowledge and skills in other teams, 62% routinely treated leg ulcers and 71% of these felt confident treating leg ulcers. "Anecdotal evidence suggests that many practice nurses deliver leg ulcer care without being formally commissioned to do so," said Una Adderley. "However, the survey results suggest that when leg ulcer care is commissioned, a large minority of care is being commissioned from practice nurses rather than from the perceived experts."

This result could be seen as worrying, given that nearly half (46%) said that they did not use a handheld Doppler to screen for arterial disease, despite this being recommended by the RCN clinical guidelines as an essential part of differential diagnosis for leg ulceration.4 "It is really worrying that despite 71% of respondents stating they are confident about leg ulcer care, 46% do not use handheld Doppler," commented Una Adderley, "which is an essential part of assessment. Inadequately assessed leg ulceration can lead to dangerous or ineffective treatment with associated patient suffering."

Compression bandaging is the gold standard treatment for venous leg ulcers. Nearly half (48.3%) of respondents had had their compression bandaging technique assessed within the last two years, and in 50.5% of cases this was done by a specialist nurse. However, almost a third of nurses (30.4%) had never had their compression bandaging technique assessed.

Figure 1 shows the time that respondents allocate for assessment and treatment of a leg ulcer. "Answering 'As long as it takes' is not really helpful on a practical level," says Marilyn Eveleigh. "Does this mean that leg ulcer care is 'fitted in' to historical nursing hours. It would be more useful for practices to use leg ulcer data to determine the number of nursing hours required?"

[[Fig 1_wound]]

Alison Hopkins, Clinical Nurse Specialist in Tissue viability at the East London Wound Healing Centre in Tower Hamlets Primary Care Trust, is concerned at the number of practice nurses managing leg ulcers: "Can they deliver the care that is required when short appointment times and lack of QOF point work against this? Good leg ulcer management also requires soaking of limbs; how many practice nurses can provide this? Often the reason why some PNs provide leg ulcer care and others don't is based on historical reasons."

She is also concerned at the lack of use of Doppler: "If you link this to the lack of specialist support and compression bandage competency, you have a situation that puts patients at risk of either compression damage or lack of effective care. Both will be costly."

Pressure ulcers
A pressure ulcer (previously known as bed sore or pressure sore) is an area of damage to the skin and underlying tissue caused by pressure, shear and/or friction forces that restrict blood flow, leading to tissue damage and cell death. Pressure ulcers are common, affecting up to one in five patients admitted to hospital for acute care. Pressure ulcer care has an estimated annual cost of £2bn.1

Optimal management of pressure ulcers is prevention in the first place. To this end correct identification of those at risk is vital, leading to successful primary prevention. Since the late 1980s pressure ulcer prevention practice has tended to follow local policies or guidelines.5

In our survey only a third of respondents (32.4%) routinely treated patients with pressure ulcers. However, most of those (72.5%) felt confident treating these patients. In addition, 88% said their patients had access to pressure-relieving mattresses and pressure-relieving cushions provided by the NHS/Social Services, as recommended by NICE guidelines.6

Diabetic foot ulcers
Patients with diabetes are prone to the development of foot ulcers. This is due to the development of peripheral neuropathy and the resulting loss of sensation, which renders the foot susceptible to trauma. Once an ulcer has developed, repetitive stress, increased susceptibility to infection and a higher probability of peripheral vascular disease mean that healing can be impaired. In some instances this can result in gangrene and amputation.

Almost half of our respondents (48.2%) routinely treated patients with diabetic foot ulcers, and two-thirds (68.4%) felt confident in doing so. Nearly all patients with diabetic foot ulcers (90.5%) had access to a diabetic podiatrist, as recommended by NICE guidelines.7 However, 35% of respondents felt that their patient should have more frequent access to a podiatrist. And Alison Hopkins thinks that 9.5% of patients who don't have access to a podiatrist is unacceptable: "Again, nurses need to understand that this is an unacceptable risk. Correct footwear, offloading and vascular review (see poor use of Doppler) are cornerstones of care to prevent amputation. What can practitioners do to be true advocates when they know more is required?"

Dressing selection
Appropriate care of wounds not only benefits patients, but can also significantly decrease the overall cost of care. One of the most important parts of optimal wound care is choosing the correct dressing for the wound in question. To do this the health professional needs to have sufficient training, knowledge and expertise in this area, or have access to someone with the correct training. In addition, the practitioner needs to have access to the correct dressings.

A recent document produced by Wounds UK on optimising wound care,2 describes how over the last 30 or 40 years wound care has changed significantly with developments in scientific research and clinical knowledge. This has led to an explosion of dressing materials and therapies, but has also resulted in many wounds being managed without clear care/treatment goals or referral pathways, and dressings and therapies used without considered supporting rationale.

In our survey, an encouraging 92% of nurses replied that they had access to the dressings they regarded as essential to everyday wound care practice. These were mainly obtained by prescription (63.4%) although 28% of respondents were also accessing dressings via a central stock.

Three-quarters (73.2%) used a dressing formulary, and of these, 79% were mainly PCT wide, although a small proportion (18%) worked from an inhouse/GP formulary.

A total of 83.2% of respondents decide themselves which dressing will be applied to a wound. Only 2.1% of GPs made this decision. Figure 2 shows some of the other factors that respondents considered important when choosing a dressing.
Figure 3 shows the percentage of nurses who use wound care products other than "modern" dressings.

[[Figs 2-3_wound]]

Conclusion
Several things can be concluded from the results of this survey:

  • Wound care appears to form a substantial part of primary care and community nursing.
  • Wound care falls within the responsibilities of the nurse rather than the doctor.
  • There appears to be a willingness to deliver research-based practice and participate in research. However, there appear to be gaps in knowledge around evaluating and implementing evidence-based wound care.
  • A significant minority of respondents show a worrying lack of awareness around the clinical needs of patients with leg ulceration.
  • There is a recognition that district nursing teams and specialist leg ulcer services are more likely to be capable of delivering higher quality leg ulcer care, but this recognition is not necessarily being reflected in how leg ulcer care is being commissioned.
  • There is a lot of experience but relatively little investment in wound care education at an advanced and unbiased level (eg, nonmedical prescribing qualifications, education provided at universities).

"The findings echo what I see in clinical practice," commented Trudie Young, Chair of the Tissue Viability Society, "with tissue viability being a Cinderella service and not on the top of GPs' agendas or government targets."

References
1. Smith and Nephew Foundation. Skin breakdown: the silent epidemic. Hull: Smith and Nephew Foundation; 2007.
2. Wounds UK. Best practice statement: optimising wound care. Aberdeen: Wounds UK; 2008.
3. Leg Ulcers Website. Available from: http://www.legulcers.co.uk
4. Clinical Knowledge Summaries (formerly Prodigy). Leg ulcer - venous. Available from: http://cks.library.nhs.uk/leg_ulcer_venous
5. Watts S, Clark M. Pressure sore prevention: a review of policy documents. Final report to the Department of Health. Guildford: University of Surrey; 1993.
6. National Institute for Health and Clinical Excellence. The use of pressure-relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care. Clinical Practice Guidelines. London: NICE; 2003.
7. National Institute for Health and Clinical Excellence. Type 2 diabetes - footcare. CG10. London: NICE; 2004.

We asked what you thought about the survey results. Your comments: (Terms and conditions apply)

"I think that wound care and proper techniques are a global issue. We can really learn from each other. I know that sounds a little corny but there is a wealth of knowledge that we can share. For example the use of silver on wounds is showing great improvements (healing properties)" - Robert Dixon

"This survey proves that most of the care is delivered by practice nurses who have minimal training and work to local PCT/GP formulary guidelines. Accessing training in today's climate seems to be the difficulty and local tissue viability nurses are so busy even though they are incredible helpful when accessed. Perhaps there could be a move to use online training sometime in the future." - Hazel Randall, Hemel Hempstead