Can your trust afford not to employ a Tissue Viability team?

Demographics

At a time when the demographics of the United Kingdom are changing as more elderly are living longer than ever before, the NHS is facing the reality that more patients with long term conditions and multiple co-morbidity will be requiring expert care for associated tissue viability problems.

(Office of National Statistics 2006)

Specialism

The last year has seen several high level discussions about the value of specialist nurses and whether their input does lead to improved cost-effective outcomes for patients. Questions in the House of Commons regarding government endorsement of specialist nurses were answered by Ann Keen MP, Parliamentary under-secretary of State for Health stating that “specialist nurses were a valuable resource in the treatment and management of long-term conditions, supporting patients to maintain stability, improve quality of life and prevent frequent admissions to hospital and reduce length of stay”

(Hansard 2007). However, despite the government saying “that they were committed to the continued development of these roles” it was left to each NHS organisation to decide on their own local need for such nurses. Heated debates on this subject in the House of Commons and the House of Lords (Masham 2007) led to tissue viability associations in particular to pull together to find evidence to support their speciality and prove their worth (White 2007) (Beldon 2007).

Clinical audits looking at incidence and prevalence of pressure damage have been historically used to monitor quality care. But further more sophisticated data on health improvements and quality of life outcomes are often not within our grasp, due to lack of time to collate it, the technology to record and analyse it.

Back to Basics

2007 was a mixed and somewhat confusing year for tissue viability nurses. Several in the UK have lost their jobs or been demoted. On one hand the government and Department of Health was urging us to embrace a patient- focused approach to quality patient care, which is at the heart of clinical governance. Trusts were instructed to implement in full ‘Essence of Care’ (DoH 2001). Implement and monitor NICE Guidelines on pressure ulcer prevention and management (NICE 2005) and ensure that we could meet the recommendations of the NSF’s for older people (DoH 2001), those with diabetic foot complications (NICE 2004) and other long-term conditions

The aim appeared to be to keep experienced staff at the grass roots providing quality care. As a consultant nurse my job description states that, 50 % of my working day should be spent at the bedside giving expert care and advice, I usually manage 20%.

Yet at the same time the DoH were requesting clinical data from trust’s specialist nurses who then had to spend non-clinical time calculating figures to demonstrate their clinical effectiveness, perform ongoing audits to give quantifiable evidence and produce accountancy skills out of a magic wand to reduce our budgets. Increasingly I spend my time auditing outcomes, trying to find qualitative data from patient documentation on improved pain levels, quality of life or healing times. I constantly re-vamp the formulary to keep tight reign on the use of expensive dressing products, and avoid the pit that others have been made to jump into, being forced to adopt inferior products with less wear time to reduce financial deficits.

The role

Unlike many other nurse specialists who are disease specific and often attached to a medical or surgical team, most tissue viability nurses run nurse led services. Although they work closely with vascular, dermatology, surgical and plastic teams they work independently and are typically accountable to senior nursing management. This can make them vulnerable as often the role is not fully understood and can be at risk of being deemed expendable.

As experienced autonomous practitioners, we give advice, training, management, and care to all compromised tissue viability patients from birth to death crossing differing disease processes. My own team have input to a maternity unit, paediatric unit, mental health, surgical, medical, and outpatients and as an Integrated Community/Hospital Service, a community population of 250,000.

Risk levels

As our older population present with COPD, circulatory diseases, diabetes and other long-term conditions, their vulnerability to development of associated pressure damage whether it be diabetic foot ulcers, leg ulcers or pressure damage increases. At any one time in the UK there are estimated to be about 200,000 people suffering from chronic wounds (Posnett & Franks 2007) Pressure ulcers already affect approximately 1:5 of the hospital population and 50% of non- traumatic amputations of the lower limb occur in people with diabetes, 85% of which will previously have had foot ulceration (Pecoraro et al 1990)

As surgical intervention and technology improves we are seeing more complex post-surgical wounds, which need expert management. Wound care litigation for inappropriate wound care leading to amputations, prolonged hospital stay, pain and loss of function are on the increase (Tingle 1997, NAO 2001). Figures from the NHS Litigation Authority (2004) suggest that over £167, 32992 has been spent over the last 10 years on litigation related to pressure ulcers alone, and this figure is rising. As I go round wards, nursing homes and patients homes the increasing dependency and co-morbidity of the patients we care for is staggering.

Wound Audit A wound audit conducted in our PCT during summer 2007 showed that over the course of a week our district nurses conducted dressings on 496 wounds in 489 patients on their caseloads, 34% of these wounds were considered complex. This is in contrast to 131wounds on 349 hospital patients during the same week, 15% of these wounds were considered complex. Only a small percentage of the hospital patients with wounds (13%) were unable to be discharged because of their wound condition. This indicates that we are managing to get these patients home quickly and provide a seamless service. However Commissioners in primary care need to understand the impact on community nurses of early discharge and how that can be facilitated in the best interests of the patient. The need for ongoing training in tissue viability and support for staff and patients with complex wounds by an experienced TV team should not be underestimated.

Although pressure ulcer prevalence has been maintained at 4.5% in our health community area, and has dropped in our acute sector from 16% to 6.9% in 6 months. Continuing high patient dependency levels means prevention requires on-going reinforcement.

Costs

The cost of treating specific wound types has been researched nationally and impacts on all trust budgets.

Pressure ulcers in the UK in 2000 were estimated to cost £1.4-2.1 billion (Bennett et al 2004). 4% of the NHS budget is spent on the care of pressure ulcers with an extrapolated figure for 2008 and beyond is more than 2-billion (Clark 2007).

It is estimated that £112 million is spent per annum on equipment for Pressure Area Care (PASA 2005).

Venous leg ulcers alone cost £240-400 million 15 years ago (Bosanquet 1992) although research based treatments to improve healing rates using tissue viability specialist led services have reduced some costs and improved patient outcomes ( Ellison et al 2001).

Diabetic peripheral neuropathy, including foot ulcer complications are estimated to cost £252 million per year (Gordois et al 2003).

More than £631 million per annum is spent on the provision of medical consumables items to Primary and Secondary care, this includes dressings, incontinence aids, stoma appliances and chemical reagents (PASA 2006) An estimated £373.4 million of this is spent on dressings alone.

These costs will continue to rise in line with our aging population. We need to work together to develop and deliver prevention and management strategies across healthcare boundaries. Keeping experienced nurses at the grass roots, providing expert care, leadership and training for the next generation of nurses.

Strategiesfor prevention and management

The Department of Health should openly recognise the part played by Tissue Viability Specialists, in preventing tissue damage, as they have infection control nurses in reducing infection. Patients can acquire severe sepsis in wounds, however prompt assessment by a tissue viability team and a planned strategy of using effective anti-microbial dressings can often prevent widespread systemic infection. But as yet there is no DoH recommended quota per population for tissue viability nurses; in fact many Trusts do not provide a tissue viability service at all.

Unlike MRSA and C Diff figures reported monthly to the DoH there is still no legal requirement on trusts to report the prevalence of pressure ulcers regularly, despite the high morbidity associated with their development, even though NICE guidelines recommend that all pressure ulcers grade 2 or above should be reported. By insisting on a statuary reporting system the profile of prevention would be raised.

Part of the strategy for the NHS should be an investment in wound- care research looking at what treatments, dressings and alternative therapies are cost-effective, and have the greatest impact on healing. One way of achieving this would be to establish a wound healing research unit either centrally or in each strategic health authority working collaboratively with each other and the Universities to determine and disseminate best practice.

Thirdly we need to have an integrated electronic health record system across the UK, which will record the data we laboriously collect manually. This would significantly reduce the time spent on audits, and demonstrate outcomes linked to inputs in terms of clinical effectiveness.

And lastly we should employ Health Economics Accountants in each trust to do the number crunching for clinicians, and collate and analyse health data painlessly. Advising on cost benefits, patient outcomes and health trends so we can target where to use our budgets and skilled staff while retaining high standards of care.

In conclusion I would ask all chief executives to spend time with their nurse specialists, especially in tissue viability. Understand their role and the part they play in the multidisciplinary team. Because looking at the current figures and associated costs, your trusts are going to need all the tissue viability specialist nurses they can get in the future.

References Baroness Masham. Questions to the House of Lords on specialist nurses. 1 st May 2007. www.theyworkforyou.com/lords. 01b.1033.2

Bennett G, Dealey C, Posnett J. (2004) The cost of pressure ulcers in the UK. Age and Aging. Vol 33, No 3, p 230-235

Beldon P (2007) Politics: specialist nurses. Tissue Viability Association. Aberdeen .Available at www.tvna.org.uk

Bosanquet N (1992) Cost of Venous Ulcers: from maintenance therapy to investment programmes. Phlebology Supplement 1, p44-46.

Clark M. (2007) Pressure Ulcers: Skin Breakdown the Silent Epidemic. The Smith & Nephew Foundation. 6. p 33-37.

Department of Health (2003) The Essence of Care. Patient Focussed Benchmarks for Clinical Governance. Revised. HMSO London.

Department of Health (2001) National Service Framework for Older People. London. DOH.

Ellison DA, Hayes L, Lane C, Tracy A, McCollum CN. (2001) Evaluating the cost and efficacy of leg ulcer care provided in two large health authorities. Journal of Wound Care. 11(2):47-51

Gordois A, Scuffman P,Shearer A, Oglesby A. 2003. The healthcare costs of diabetic peripheral neuropathy in the UK. The Diabetic Foot. 6(2): 62-73.

Hansard 26 th July 2007. Written Reply, by Ann Keen MP.

NICE (2004) Type 2 Diabetes: Prevention and management of foot problems. London. The National Institute of Clinical Excellence.

NICE (2005) The Prevention and management of pressure ulcers. RCN. Clinical Guideline 29.London.

National Audit Office. (2000/2001). Handling Clinical Negligence claims in England. Report by Comptroller and Auditor General, HC 403 Session. London. Stationary Office.

NHS Litigation Authority ( 2003-4) Clinical Negligence Claims Audit Report .London.

NHS Purchasing and supply agency (PASA) ( 2006) nww.pasa.nhs.uk

NHS Purchasing and supply agency (2005) nww.pasa.nhs.uk

Office of National Statistics (2006). London. http://www.statistics.gov.uk/cci/nugget.asp?id=949

Pecoraro RE, Reiber GE, Burgess EM, (1990) Pathways to diabetic limb amputation. Basic for prevention. Diabetes Care . 13 (5) 513-521.

Posnett J, Franks P.(2007)The costs of skin breakdown and ulceration in the UK. Skin Breakdown: The Silent Epidemic. The Smith & Nephew Foundation.6-12

Tingle J. (1997) Pressure sores: Counting the legal cost of nursing neglect. British Journal of Nursing. 6: 757-758

White R (2007) The fight is on to protect investment in tissue viability. Wounds UK. Vol 3 No 4 p8.