Prakesh Dhoonmoon, community service lead, and Caitriona O’Neill, director of community services and lymphoedema, Accelerate CIC, describe how they have adapted wound management to provide optimum care while observing strict infection control measures including physical distancing during the era of Covid-19.
How do you ensure that patients are continuing to receive the care required?
We carried out significant continuity planning for many weeks leading up to lockdown to ensure we were prepared. Guidance released by NHS England just before official lockdown indicated that the priority for acute services was to free up space, while for the community it was preparing to deal with additional discharges to help free up acute beds.
We created a risk assessment process for all contacts, identifying those patients aged 70 and over, those shielded and those with Covid-19. Our approach to clinical RAG rating is outlined below and was based on continuing face-to-face appointments if there was a concern about deterioration.
High risk – those we need to see with critical deterioration in condition, leaking, palliative, cellulitis, new pressure ulcers, complex surgical wounds
Medium risk – patients that we may need to see to minimise the risk of deterioration, undertake a one-off review or assessment or where we are the sole provider (eg, those on a routine leg ulcer clinic)
Low risk – those we do not need to see, where self-management is embedded, and treatment can be reviewed via teleconsultation, with face-to-face review deferred.
The key focus is to keep patients safe and manage any impact further along the NHS healthcare system chain. Every referral received is triaged and a telephone pre-assessment booked to ensure patients are seen in a timely manner based on their risk RAG rating.
The pre-assessment over the phone allows us to gather information in advance, including to screen for any signs and symptoms of Covid-19. Complex cases are prioritised and we are implementing self-care strategies where possible to maintain continuity of care.
How have you incorporated self-management into your process?
Patients being involved in their own care and providing direct care with support of their relatives has always been encouraged and is embedded within our team ethos.
During the pandemic, some patients have been avoiding face-to-face contact with clinicians, despite appropriate PPE being in use. Where there were no clinical concerns or red flags, we reviewed patients with consent, and agreed a plan for self-care.
Patients self managing wounds are supplied self-care packs and the required dressings, including bulk orders where required. We teach patients face to face initially, offering additional support and information on aseptic techniques and hand hygiene leaflets to help minimise risk of infection and contamination.
The use of British standard hosiery kits and compression wraps has proved very beneficial for people with lymphoedema and leg ulceration, where the wound was deemed to be self-manageable within this framework. We also provided a hosiery service for garments direct to patients’ homes. This was agreed with commissioners and has been particularly well received by patients, and health professionals alike.
Our experience so far has demonstrated that self-care could be introduced more widely to reduce face-to-face visits, with virtual reviews a positive way forward in the delivery of care to patients.
However, the key to success is that this must be supportive self-management – patients do well in this context, but they should not be left to fend for themselves; regular checks on progress are required.
How have you increased your online and virtual care?
The bulk of our routine reviews have converted to telephone consultations, including multidisciplinary teams for the more complex. For some this is a conversation on progress, talking through the care plan. For more complex patients, photos are sent in prior to the consultation to assist the remote review and advice. We set up a new dedicated email to receive photographs.
We did not have the ability to do direct video consultations at the beginning of the pandemic, and the teleconsulting approach has on the whole been working very effectively. We are, however, now in the final stages of testing a full comprehensive digital consultation platform.
We implemented pre-assessment for all new referrals, with a view to capturing all generic medical history and the background of the condition. This also allowed us to identify where a patient could be deferred or needed to be seen face to face where there were clinical concerns.
Where face to face appointments are deemed necessary, the generic component of the pre-assessment helps to reduce the appointment time and make the consultation more focused, whether conducted in the home or in clinic, to help minimise the risk of exposure and of course appropriate PPE is worn.
We developed the self-care component of our website at a rapid pace to support virtual care. Key components include: managing your leg ulcer at home, managing your lymphoedema at home, optimising lower limb compression and staying well. We have also just launched a direct chat line open to all; this has mainly been used by professionals to date. Patient feedback to date has been very positive.
Compression is a key part of lower limb wound management strategies – how have you continued this treatment in the pandemic?
Compression therapy remains the key component of management of lower limb conditions. To prevent and reduce the risk of further deterioration, compression therapy is vital. In short, a greater focus on compression facilitates a reduced length of time to healing.
Recognising that resources are stretched during this period, it is still essential to keep this focus during the pandemic as high therapeutic compression will aid healing and avoid the risk of clinical infection and cellulitis which may, if not averted, result in a hospital admission.
As clinicians we have a critical role in motivating our patients to understand how beneficial compression is and that a therapeutic dosage is required to create improvement. This applies to both compression bandaging and garments.
With both time and resources stretched, we have adopted a pragmatic approach to the assessment around suitability for compression. Where required this is completed as per best practice, using an automated Doppler ultrasound machine to save time. However, in some patients it is possible to proceed to compression based on the clinical examination and medical history alone, rather than delaying and potentially increasing harm. The British Lymphology Society position statement on vascular assessment provides guidance on this approach.
Lower limb exercises are also emphasised in wound management strategies. How can this be approached in patients who are isolated and immobile?
We commonly see decreased mobility and a limited ankle range of motion, compounded by inappropriate footwear, in our patient group. This significantly impacts on leg ulceration and lower limb lymphoedema. Poor mobility means the calf muscle does not fulfil its usual ‘pump’ function to support venous and lymphatic return to aid drainage away from the limb. This exacerbates problems with circulation that are necessary for healing. Keeping a good blood flow through the legs is paramount to improving their condition.
Our team puts a great emphasis on lower limb exercises such as ankle rotation, leg elevation and raising the heel, which can be easily done by sitting on the chair. During the pandemic we have released these short videos via our website – chair-based exercises, the use of TheraBand, and footwear.
For our wider lymphoedema groups, exercise is also a key component of management. Exercise in all its forms is encouraged but needs to be gradual depending on the person’s own fitness level. It is also essential that any ill effects are noted and exercises adjusted accordingly. The Cancer Research UK lymphoedema exercise videos have been invaluable during this period. Whilst completing virtual reviews we have noted that generally all patients are very aware of the importance of keeping well and mobile and recognising the value of exercises during the limitations of lockdown.
British Lymphology Society. Position paper for ankle brachial pressure index 2018
Farrelly I. Ten top tips: improving mobility in people with wounds. Wounds International 2017; 8: 14-18
O’Neill, C. Mythbuster: patients with lymphoedema must be managed by a specialist service. Nursing in Practice. 19 November 2019
Tissue Viability Society – Coronavirus (Covid-19) and wound care: https://tvs.org.uk/covid-19/
Legs Matter – Covid resources: https://legsmatter.org/search/covid
Academic Health Science Network – Covid-19 resources for health professionals: https://www.ahsnnetwork.com/covid-19-healthcare-professionals