Key learning points:
– Most people with wounds are cared for in the community
– Community nurses are dealing with more complex wounds than ever before
– Nurses must adapt their practice to overcome the challenges of providing evidence-based care in settings outside of hospital
Nurses working in community settings care for 1.45 million people with wounds each year,1 and 39% of those wounds will not have healed after 12 months.1 Caring for people with acute and chronic wounds in the community can be more challenging than in hospital.
This article aims to explore the type of wounds that community nurses encounter in clinical practice, the importance of appropriate infection control, and how to overcome challenges.
What type of wounds do community nurses encounter?
The NHS spends around £5 billion pounds a year managing an estimated 2.2 million wounds.1 Around 47% of wounds are acute, 28% leg ulcers and 21% pressure ulcers, and approximately two out of three people with wounds are cared for in the community.2 Many people with wounds have co-morbidities such as diabetes and nutritional problems that affect healing.
Managing wounds and co-morbidities requires around 18.6 million practice nurse visits, 10.9 million community nurse visits, 7.7 million GP visits and 3.4 million hospital outpatient visits.1 Wound care is predominately a nurse led discipline and community nurses spend 25-50% of their time dealing with leg ulcers.3,4
Caring for the person with an acute wound
There are two main types of acute wounds: surgical and traumatic. Surgical wounds are incisions. An uncomplicated surgical wound has clean edges and is usually closed with sutures, staples or adhesives. Traumatic wounds are injuries to the skin and are underlying. They are often classified according to how the injury was sustained, Table 1 provides details.
Many traumatic wounds are minor in nature and people who sustain minor wounds normally care for them without seeking professional advice. The nurse may be required to provide wound care if the person with a minor wound is unable to care for it because of infirmity, or if the person is at risk of complications.
The principles of caring for the person with an acute wound are to reduce the risk of infection with standard principles and a protective dressing, to remove sutures or clips when indicated, to educate the patient on when to seek urgent advice and to monitor the wound for complications.
Although ageing and increasing comorbidities heighten the risks of healthcare-associated infection (HAI), infection rates have fallen in recent years.5
Standard principles (previously known as standard precautions) are evidence-based guidelines that aim to help staff prevent healthcare-associated infections.6 The latest guidance categorises infection control strategies into five parts:7 hospital environmental hygiene, hand hygiene, use of personal protective equipment, safe use and disposal of sharps, and principles of asepsis.
The acute wound should be dressed using an aseptic technique. This can be challenging in a person’s home environment, however it is important that nurses adapt and do their utmost to maintain asepsis despite these challenges.8,9 Lightly exuding wounds should be protected with a vapour permeable dressing. Moderately exuding wounds should be protected with an absorbent perforated dressing, an adhesive border if the skin is not friable. Sutures on the head should be removed within three to five days, 10-14 days if they are over a joint, and seven to 10 days on other sites.10
The nurse should inform the patient of potential red flag symptoms such as increased pain, redness and swelling, fever and feeling unwell. These symptoms may signal infection, and if they occur the patient should contact the nurse or his/her doctor for assessment and treatment.
Caring for the person with a chronic wound
The chronic wounds that are most commonly managed in the community are leg ulcers and pressure ulcers. The basis to managing chronic wounds is to maintain standard principles, to identify, treat and manage factors affecting wound healing and to use dressings and treatments to encourage healing, and reduce the risk of complications.
It is important to use a holistic approach and to understand and manage factors that affect wound healing and quality of life.
The person with a leg ulcer for example may have conditions such as anaemia, diabetes, poor nutrition and oedema that affect wound healing. Assessment can enable the nurse to identify co-morbidities that impact wound healing and to work with others to treat or manage these conditions.
The person with a pressure ulcer may have mobility problems and may benefit not only from pressure relieving equipment, but also input from physiotherapists and occupational therapists to improve mobility and independence.
Chronic wounds are commonly colonised by bacteria and the community nurse should use a clean technique rather than an aseptic technique when dressing wounds. Leg ulcers can be cleansed with tap water. The nurse should use clinical judgement and be guided by local wound formularies when choosing dressings.
The importance of infection control
At the beginning of the 21st century the UK had one of the highest rates of healthcare-associated infections (HAIs) in Europe. Despite the increasing vulnerability of an ageing population, the UK has succeeded in achieving impressive declines in HAIs in recent years. Improved anti-microbial stewardship and hand hygiene have resulted in a 69% reduction in methicillin-resistant staphylococcus aureus (MRSA) bacteraemia rates and a 59% reduction in clostridium difficile infections over the last five years.11 The barriers to best practice in hand hygiene are a lack of time, equipment, and inadequate education, and a culture that enables suboptimal hand hygiene to persist. The nurse working in a clinic will have little difficulty maintaining good infection control, however this can be more difficult in some patients’ homes.
The community nurse providing care and treatment in a person’s home does not normally have access to liquid soap and paper towels to wash their hands. In some homes the nurse may not even have access to hot water. In such circumstances the nurse must adapt their practice to reduce infection risks.
On the first visit to the patient’s home the nurse should assess the hand washing facilities. If facilities are not ideal this should be recorded so that other nurses are aware of challenges and how they can be overcome. The nurse may wash her hands in either the bathroom or the kitchen. Ideally the home will have liquid detergent and kitchen towel that can be used to dry hands. If the nurse is faced with cold water, filthy towels and dirty bar soap then alcohol gel should normally be used. The hands can be washed thoroughly in the home of the next patient visited before care is given. When hand washing facilities are poor, alcohol gels can help prevent infection. These do not remove dirt, debris or physical contamination from the hands. Instead, they destroy most micro-organisms and reduce the bio-burden of micro-organisms on the hands. Alcohol gels are very effective at removing certain organisms such as rotavirus but do not remove clostridium difficile.
The nurse should carry out a risk assessment and work out the risk of infection based on the care required. If the procedure is one that carries a high risk of infection, the nurse can suggest that the patient provide liquid soap and kitchen towel. If the patient is not willing or able to do this, the nurse may have to bring liquid soap and paper towels. If the procedure is not high risk then the nurse can adapt their practice. A clean bar of soap stored in a dish with drainage holes can be used. Washing up liquid can be used to wash hands and clean cotton towel can be used to dry hands thoroughly.
If facilities are very poor and it is not possible to decontaminate the hands thoroughly, it may be possible for the nurse to reduce the risks of infection by scheduling the visits at certain times. If possible the nurse should schedule the visit as the last visit of the morning or afternoon so they can return to base and thoroughly decontaminate their hands.12
Good practice when dressing wounds
When dressing wounds the nurse should practice good hand hygiene. He/she should use personal protective equipment appropriately and wash hands before and after removal. The nurse should use the appropriate dressing technique. This will normally be a full aseptic technique for acute wounds and a clean technique for leg ulcers.
Additionally, nurses should use appropriate dressings that take into account of the type of wound, exudate, and – when relevant – the condition of the wound bed. Care should be taken to not damage fragile skin. If for example the patient is an older person with a skin tear then the skin is often friable and easily damaged. In such circumstances, adhesive dressings and tapes are contra-indicated and dressings should be held in place with cotton or tubular cotton bandages.
Although dressings are intended for single use and only sterile until opened, they may be cut to size. Sometimes the un-used proportion of the dressing is returned to the sterile wrapper and saved for the next dressing change. This is done in an effort to prevent waste. There is little research on the safety of such practice, however one article found that dressings ‘saved for later’ in such a way became colonised with bacteria within seven days. In fourteen days the bacterial count was high enough to harm patients.13
Nurses working in the community provide most of the wound care in the UK, however many are not woundcare specialists and although they do an excellent job, more could be done. In around 30% of cases it is unclear why the person has developed a wound.1 If we are to improve woundcare practice in the community then greater numbers of nurses are required.
1. Guest JF, Ayoub N, McIlwraith T, Uchegbu I, Gerrish A, Weidlich D, Vowden K, Vowden P. Health economic burden that wounds impose on the National Health Service in the UK. BMJ Open 2015;7(5):12. ncbi.nlm.nih.gov/pmc/articles/PMC4679939/ (accessed 7 February 2016).
2. Vowden KR, Vowden P. A survey of wound care provision within one English health care district. Journal of Tissue Viability 2009;1:2-6.
3. Simon DA, Dix FP, McCollum CN (2004) Management of venous leg ulcers. British Medical Journal 328(7452): 1358-1362.
4. Chamanga E, Christie J, McKeown E. Community nurses’ experiences of treating patients with leg ulcers. Journal of Community Nursing, 2015. jcn.co.uk/files/downloads/articles/12-2014-community-nurses-experiences-of-treating-patients-with-leg-ulcers.pdf (accessed 7 February 2016).
5. Nazarko L. Standard Principles of Infection control: Infection control series part 2. British Journal of Healthcare Assistants 2014;8(5):226-233.
6. Pellow C, Pratt R, Loveday H et al. The epic project updating the evidence base for national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England; a report with recommendations. Journal of Hospital Infection 2005;59(4):373-4.
7. Loveday HP, Wilson JA, Pratt RJ et al. epic3: national evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. Journal of Hospital Infection 2014;86(Suppl 1):S1-70. his.org.uk/files/3113/8693/4808/epic3_National_Evidence-Based_Guidelines_for_Preventing_HCAI_in_NHSE.pdf (accessed 7 February 2016).
8. Unsworth J, Collins J. Performing an aseptic technique in a community setting: fact or fiction? Primary Health Care Research & Development 2011;12(1):42-51.
9. Unsworth J. District nurses’ and aseptic technique: where did it all go wrong? British Journal of Community Nursing 2011;16(1):29-34.
10. NICE. Lacerations. London, 2015. cks.nice.org.uk/lacerations#!scenario (accessed 7 February 2016).
11. Public Health England. Healthcare Associated Infections. hpa.org.uk/hpr/infections/hcai.htm. Staphylococcus aureus: guidance, data and analysis. hpa.org.uk/webc/HPAwebFile/HPAweb_C/1278944283762 (accessed 7 February 2016).
12. Nazarko L. Potential pitfalls in adherence to hand washing in the community. British Journal of Community Nursing 2009;14(2):64-8.
13. Canadian Agency for Drugs and Technologies in Health (2012). Use of Single-Use Sterile Dressings from a Previously Opened Package in the Community Setting: Safety, Harms, and Guidelines. Canadian Agency for Drugs and Technologies in Health.