Tissue Viability Service in Bolton

The Tissue Viability Team in Bolton provides a specialist service to patients with pressure ulcers, leg ulcers, traumatic injuries, superficial burns, abdominal wounds, dehisced wounds and complex non-healing wounds such as pyoderma gangrenosum or necrotising fasciitis. Bolton Tissue Viability Service is quite unique in that it provides a service for Bolton PCT and Bolton Acute Trust. Whilst this is demanding, it provides seamless treatment in wound management to the people of Bolton. The wound care guidelines were produced in collaboration with the Royal Bolton Hospital, Bolton PCT, Bolton Hospice and a local private sector Hospital, and have provided all health care professionals with access to evidence based care, thus enabling them to deliver the same high standard of wound care throughout Bolton.

The presence of a pressure ulcer has a huge impact, not only physically and clinically but also psychologically, including a decrease in quality of life to the patient, carers and families (Hagelstein and Banks, 1995; Franks et al, 1999; Franks et al,2002) (Benbow,1996; Elliottet,1999). Clinicians working in a variety of clinical and non-clinical setting, including primary and secondary care, face challenges when providing holistic, person-centred services for the management of pressure ulcers. These challenges include decisions on methods of assessment and treatments to be used for individuals with an existing pressure ulcer. The Tissue Viability specialist nurse is able to direct health care professionals to the most appropriate treatment and equipment thus enhancing best practice in wound management.

The presence of pressure ulcers has been associated with a two-to-four-fold increase of risk of death in older people in intensive care units (Thomas et al, 1996; Clough, 1994, Bo et al, 2003).

The financial cost to the NHS is considered to be substantial (Bennett et al, 2004). Recent data suggested that the cost of treating ulcers varies from £1,064 for a grade 1 ulcer to £10,551 for a grade 4 ulcer, with total costs in the UK estimated at between £1.4-£2.1 billion annually, equivalent to 4% of the total NHS expenditure (Bennett et al, 2004).

The tissue viability service in Bolton monitors the prevalence and incidence of pressure ulcers in accordance with the NICE 2005 guidelines on the prevention and treatment of pressure ulcers.

There have been significant advances made over the past two decades in the delivery of effective services for patients with leg ulceration. Treatment costs, however, remain high and the development of strategies to ensure future provision of health care is important. Leg ulceration is a common, difficult and expensive health problem, affecting 1-2% of the population, and representing a significant challenge to the health service.

A third of patients develop their ulcer before the age of 50 (Cullum et al,1985) and 2% of those over 80 years of age are thought to suffer with this condition (Buxton,1987). Recurrence rates are high; 26% after one year and 31% after 18 months of healing, for venous leg ulcer patients. The cost burden to the NHS has been estimated at around £400million per annum (Franks et al, 1995) and numerous studies have identified the negative impact on patient quality of life (Persoon et al, 200; Lindsey, 2004, Ballard & Wilson, 2005, Jones 2007).

Prevalence of leg ulceration and the associated demands on the service provision are likely to remain a challenge, due not only to these high recurrence rates but also as a consequence of an ageing population and the rise in chronic conditions such as diabetes and obesity.

Bolton PCT Tissue Viability Service in 1995 developed a leg ulcer service around the needs and profile of their patient groups. Bolton’s population is around 280, 000, therefore Bolton PCT might expect to have between 420 and 840 patients under treatment at anytime. Annually treatment costs are estimated to be £1200-£1500 per patient for treatment with usual care. This implies that Bolton PCT faces a total treatment cost in the range of £0.5m to £1.3million per year. The benefits of the leg ulcer clinics in Bolton are that the patients receive appropriate assessment and management by clinicians who are trained in leg ulcer management. This has had a phenomenal affect on how leg ulcers are managed in Bolton. It has been recognised both locally and nationally and the service is actively involved in research studies with York University.

Tissue viability teams in 2008 face a major challenge as there is a renaissance in the biology of wound care which has resulted in the development of a range of advanced therapeutic products. The tissue viability service has to ensure that these advanced products are used cost effectively to improve the healing in difficult to treat, complex wounds. Without resources and commitment to the service the ability to deliver a high level of education, assessment, treatment and prevention and support to clinicians in the every day management of complex wounds would be severely compromised.

Jacqui Ashton is Specialist Tissue Viability Nurse at Bolton PCT

References

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Benbow M (1996) Pressure Sore Guidelines patient /carer involvement and education. British Journal of Nursing, 5(3), pp.182, 184-7.

Bennett G, Dealey C and Posnett J (2004) The Cost of Pressure Ulcers in The UK.Age and Ageing, 33, pp230-235.

Bo M, Massaia M et al (2003) predictive Factors of in Hospital Mortality in Older Patients Admitted to a Medical Intensive Care Unit Journal of the American Geriatrics society,51 (4):529-33.

Buxton P K (1987) Leg Ulcers.Br Med Journal 295 (6612) 1542-5.

Callam M J, Ruckley C V, Harper D R, Dale J J (1985) Chronic Ulceration of The Leg: Extent of the problem and provision of care. Br Med Journal (Clin Res Ed)290 (6485):1855-6.

Clough N P (1994) The cost of pressure area management in an intensive care unit. Journal of Wound Care 33-35.

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Elliottet T R (1999) Social Problem-Solving Abilities and Adjustment to Recent-Onset Spinal Cord Injury. Rehabilitation Psychology (4) pp 315-322.

Franks P J, Winterberg H et al (2002) Health Related Quality of Life and Pressure Ulceration Assessment In patients Treated In The Community. Wound Repair and Regeneration,10 (3),pp 133-40.

Franks P J, Moffatt C J (1999) Focus On Wound Management. Quality of life Issues In Chronic Wound Management. British Journal of Community Nursing,4 (6),pp 283-4.

Franks P J, Oldroyd M I, Dickinson Dishware J, Moffatt C (1995) Risk Factors for Leg Ulcer Recurrence .A Randomized Trial of Two Types of Compression Stocking. Age Ageing, 24 (6) 490-4.

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Hagelstein S M, Banks V (1995) Maintaining Quality of Life for Elderly Patients In Residential Care. Journal of Wound Care (8) 347-8.

Lindsey E (2004) The Lindsey Leg Club Model for Evidence-Based Leg Ulcer Management. Br Journal Community Nurse (supp) S15-20.

Nelzen O, Berbqvist D, Lindhagen A, Hallbrook T (1991) Chronic Leg Ulcers: An Underestimated Problem In Primary Health Care Among Elderly Patients. J Epidemical Community Health:45 (3) 184-7.

Persoon A, Heinen M M, Vandervleuten C J, DeRooij M J, Van de Kerkhof P C, Van Achterberg T (2004) Leg Ulcer: A Review of their daily impact on life. J Clin Nurs,13 (3) 341-54.

Thomas D R, Goode P S, Tarquine P H, Allman R M (1996) Hospital Acquired Pressure Ulcers and Risk of Death. Journal of American Geriatric Society,44,pp 1435-40.