A leading vascular nurse consultant said she “could scream Hallelujah” after leg ulcers in community patients were included in a performance-related pay scheme for trusts.
Dr Leanne Atkin, who chairs the Legs Matter campaign, said the inclusion of leg ulcers in the Commissioning for Quality and Innovation (CQUIN) framework for 2020-21 could spare many people unnecessary suffering and distress.
“A lot of these patients are suffering because of failures in care”
The CQUN framework is a financial incentive scheme run by NHS England that means healthcare providers can earn more money if they achieve quality improvement goals.
Nurses have also welcomed the fact pressure ulcers in community hospitals and care homes are among this year’s CQUIN targets as part of efforts to tackle what is a hugely costly – yet mainly avoidable – problem for the NHS.
Lower leg wounds affect about 70,000 people in the UK. However, it is estimated less than a quarter currently receive appropriate assessment and treatment.
Dr Atkin, who is a practicing vascular nurse consultant and a lecturer at the University of Huddersfield, said she was delighted to see a focus on lower leg wounds in the CQUIN.
“Lower limb conditions have not been taken seriously for decades. There are many patients that are poorly treated with active and professional ignorance and a stigma attached,” she told Nursing Times.
“A lot of these patients are suffering because of failures in care,” she added.
She hoped that including lower leg wounds in the CQUIN would encourage trusts to focus on efforts to ensure early diagnosis and swift treatment.
“The beauty of the CQUIN is that because it is both a financial carrot and a stick it raises this issue right to the commissioners, to the trust boards and directors of service so they start to think ‘How can we improve practice?’,” she said.
Under the leg wound CQUIN, trusts must ensure at least 25% of patients with lower leg wounds seen by community nursing teams receive appropriate assessment, diagnosis and treatment.
Trusts must achieve a quarterly average of 50% or more in order to earn the maximum amount.
Community nurses will be expected to carry out a thorough assessment with patients receiving treatment within 28 days of a leg wound being identified.
Where appropriate patients should receive compression therapy and those diagnosed with a leg ulcer referred to vascular services to be assessed for possible surgery.
Dr Atkin said challenges included a lack of clarity on the treatment of leg wounds and loss of expertise and high turnover in the community nursing workforce.
“It does offer the opportunity to get a handle on the prevalence of leg ulceration”
She said confusion among nursing staff meant leg ulcers were not being identified with nurses continuing to change dressings for “months and months” rather than applying all-important compression to reduce swelling and help ulcers heal properly.
When patients came to her, Dr Atkin said many had been living with their wounds “for years”.
“Yet I am able to heal them by simple generalist nursing practice – nothing specialist. Just by getting compression on them and getting their edema reduced with some good wound care, I can get those patients to heal within a matter of weeks,” she added.
She hoped trusts would make use of a new clinical navigation tool developed by the National Wound Care Strategy that sets out how leg ulcers should be treated and states patients should be assessed by an appropriate healthcare professional within 14 days of wounding.
However, she said there was a need for a whole-system review of the way services were commissioned and delivered, which could include setting up new rapid response assessment units staffed by specialist nurses.
She also said she wanted to see nurses embrace the challenge and take action to eliminate chronic leg ulcers entirely.
“Chronic ulcers are a great burden to the nursing service – we could eliminate them by getting them right first time,” she said.
“Nurses need to stop making excuses – we need to strive for service-wide change to revolutionise the whole of leg ulcer care,” she added.
“We need to call this out as harm and need nursing staff to remember why they joined the profession.”
Tissue viability nurse specialist Alison Schofield, who works for Northern Lincolnshire and Goole Foundation Trust, said the leg wound CQUIN would be welcomed by specialist nurses around the country.
She has worked to improve leg ulcer care including developing a teaching programme that has been shortlisted for a national award.
She said the CQUIN would help identify gaps in care and encourage clinical commissioning groups to review services.
“The CQUIN will highlight areas where assessment, diagnosis and treatment are not being effectively managed,” she said.
While the CQUIN was only aimed at community services she said it was “a good starting point”.
However, she also raised concerns about the capacity of vascular services to cope with a potential increase in referrals.
“An element of the CQUIN is to ensure patients are offered referral to vascular services for assessment and treatment if appropriate,” she said.
“Many vascular services cannot cope with increased demand, but this will highlight gaps in the system we hope,” she added.
As well as improving diagnosis and treatment, she said there also needed to be a focus on prevention and self care.
Dr Una Adderley, Queen’s Nurse and director of the National Wound Care Strategy Programme, pointed out many patients were treated for leg ulcers in primary care but the CQUIN was only applicable to community nursing services.
“Although this means the picture will be incomplete, it does offer the opportunity to get a handle on the prevalence of leg ulceration in community nursing service and encourage more timely and evidence-informed care,” she told Nursing Times.
“People with leg ulcers who receive such care are likely to heal much faster and thus reduce the overall burden of wound care on community nursing services,” she added.
Meanwhile, trusts are also being asked to take steps to tackle pressure ulcers in care homes and community hospitals.
Pressure ulcers – which can be life-threatening – are a massive problem for the NHS with some estimates putting the cost at about £1.4m each day.
Under the CQUIN framework, trusts must ensure at least 40% of patients in community hospitals or NHS-funded residents in nursing homes receive a pressure ulcer risk assessment.
Providers must achieve a quarterly average of 60% or more to earn the maximum amount.
In order to hit the target, nursing staff will need to use a validated risk assessment tool such as Waterlow, Purpose T or Braden, which assesses mobility, skin, nutrition, continence and sensory perception.
Patients and nursing home residents will also be expected to have an individual care plan that records the results of risk assessment and any action taken as a result.
“Inclusion in CQUIN is expected to contribute to reducing the number of pressure ulcers nationally, improving standards of care for nursing home patients,” said the guidance.
“The risk of sepsis is present and we know it kills people”
Karen McEwan is a quality improvement matron at community and mental health provider Nottinghamshire Healthcare NHS Foundation Trust where she manages the trust-wide tissue viability team and is also the CQUIN lead.
She said she “absolutely applauded” the inclusion of pressure ulcers in the CQUIN framework and said she believed it could “save lives”.
“People in care homes are one of the most vulnerable groups and a high percentage in nursing homes are going to be at risk of pressure ulcers. The risk of sepsis is present and we know it kills people,” she said.
Nottinghamshire Healthcare was at the forefront of developing the React to Red pressure ulcer prevention programme for care homes and other healthcare providers – now available nationally.
She said she was confident her trust would be able to achieve the pressure ulcer CQUIN because of long-standing and ongoing work to address pressure ulcers across community services, including in community hospitals and care homes.
This had included the creation of a dedicated tissue viability team for care homes in the Bassetlaw area, which led to an 87% reduction in pressure ulcers.
However, Ms McEwan said her trust was “lucky” and acknowledged others may not have such a deeply embedded pressure ulcer prevention strategy.
“I was speaking at an event in London last month and people were coming up to me and saying ‘If only we could have a team like you’ because they have horrendous problems in their care homes,” she said.
“There are different models around the country but there will probably be areas that have still got nothing,” she added.
When her organisation first set out to tackle the problem, key challenges included a lack of knowledge and training for care home staff and the incredibly high staff turnover, said Ms McEwan.
“I don’t think those problems we encountered all those years ago are particular to our area – I think it is a common problem,” she said.
“There is just not the training and often owners won’t release staff to go on training even if they can find it,” she added.
While the CQUIN specifically relates to NHS-funded residents she said it would help to raise standards across the board.
“It is about that constant engagement with people, making sure they have the training they need and keeping it current,” said Ms McEwan.
“We are constantly thinking of new things to keep care homes engaged with the whole agenda because it is so important,” she added.
This content was taken from the Nursing Times website, click here to see the original article