In order to achieve high quality care within a patient-centred service it is essential to explore new and innovative ways of working. Joint working between industry and a publicly funded healthcare service is one of a range of options available to meet the needs of patients and achieve clinical excellence.
Recently published NHS guidance states: “The development of effective and clinically appropriate joint working with external stakeholders can contribute to building an NHS that is truly a beacon to the world.”
The quoted guidance states that a partnership approach should be considered against the following criteria:
- Meeting patient and NHS needs
- Enhancing accessibility
- Providing sustainable clinical benefits
- Being cost effective
The experience gained from previous partnership projects has confirmed that joint approaches to working may result in tangible benefits to patients whilst simultaneously supporting the strategic objectives of both delivery partners.
One area in which commercial companies and the NHS currently interact is the field of wound management. Often this interaction will be purely transactional in nature. In this instance there is an opportunity to establish a more relational approach, in which the company and the NHS body do not merely transact but instead work together towards mutual objectives.
Wound management, in common with many NHS services, is subject to increasing financial pressure. There has been a progressive increase in the scrutiny of the resources employed and the resultant costs incurred. At the same time, both life expectancy and the prevalence of chronic disease are rising, leading to an increased incidence of chronic wounds.
It has been estimated that the NHS spends £2.3-3.1 billion per annum on wound management. Given these circumstances the cost of treating wounds is, and will increasingly become, a key consideration when selecting treatments - the challenge facing wound management services in the NHS is to maintain or improve clinical outcomes while reducing cost per patient.
Advanced wound management products are effective when used appropriately in creating favourable local conditions for wound healing. Optimising the decision-making process, i.e. selecting the correct intervention for the appropriate wound, plays a key role in maintaining the best conditions for healing, while at the same time reducing the resources used for each patient.
This can be achieved through availability of appropriate dressings, education and training to inform dressing selection, and clear decision-making guidelines.
In wound management, clinical outcomes are determined not solely by the product but also by how it is used in practise. Within the NHS clinical staff are responsible for administering wound management interventions. To ensure that these interventions are directed to best therapeutic effect, it would seem appropriate to work collaboratively with the wound management companies, who possess a high degree of expertise in the most appropriate clinical applications for their products.
Implementing collaborative working
In NHS Hull antimicrobial dressings, and in particular silver dressings, have constituted a large part of total dressing expenditure, approximately £298k per annum. The challenge of seeking to reduce silver dressing expenditure without compromising patient care is ideally suited to a collaborative approach between the NHS and industry.
A project was instigated within Hull Teaching PCT provider arm with the aim of optimising the appropriate usage of antimicrobial dressings through a package of measures, including training, education and audit.
By focusing on appropriate usage (the correct product, used on a suitable wound for an appropriate time period) the collaborative approach seeks to reduce the overall number of individual dressings used while maintaining or improving clinical outcomes.
In terms of scope the project aligned with three of the four criteria recommended by the Department of Health (2008):
- Meeting patient and NHS needs
- Providing sustainable clinical benefits
- Being cost effective
Methodology - collaborative approach
After an initial meeting between the relevant Hull PCT and Smith & Nephew personnel during which the scope of the collaborative working project was defined a working group was established.
In order to gain the commitment required for the project to be effective it was essential that the working group included staff from all levels within both organisations. The group thus included a range of individuals from NHS service managers and clinicians to commercial managers and clinical support staff.
The initial focus of the collaborative approach centred on current practice in the use of silver dressings. The first step was the development of guidelines for optimised decision-making and appropriateness of use of antimicrobial dressings.
An initial baseline audit was conducted to assess current practice as regards decision-making and use of antimicrobial dressings. The initial audit encompassed a sample of 19 district nursing teams and treatment rooms. A bespoke audit tool was created and used to collect data for all patients receiving wound treatment on 6 February 2008.
The audit tool captured details of the wound management products removed and subsequently applied or re-applied, and explored the decision-making process of clinicians regarding their initiation, continuation or cessation of antimicrobial dressings.
A series of local study events were set up, at which the newly completed guidance for the management of wound infection was introduced and the rationale behind this development explained. The educational focus of these events was the need for an effective informed approach to the management of wound infection and the usage of silver antimicrobial dressings. Guidance was given as to the clinical signs and symptoms associated with critical colonisation and infected wound states.
The necessity for regular re-assessment of the wound and requirement for usage of an antimicrobial was also stressed. In line with the recently developed guidelines it was recommended that once initiated the use of topical antimicrobial treatments should be reviewed at two-weeks.
As stated in the guidelines at re-evaluation after two weeks if the antimicrobial agent had been effective in reducing bacterial burden and the wound had improved, use may be continued until evidence of critical colonisation/local infection resolves or for up to a maximum of four weeks. Between February and April 2008 a total of 159 frontline PCT clinical staff attended antimicrobial training events.
In order to assess the impact of the training and education central to the collaborative project a follow-up audit was performed on 29 October 2008. The second audit encompassed a sample of 17 district nursing teams and treatment rooms.
Table 1 summarises the results from the two audits.
Scope of the audit process
The returned audit forms reported on 214 and 240 cases in February 2008 and October 2008 respectively. The distribution of healthcare setting was similar in both audits: approximately 75 per cent of the cases were from community care, 20 per cent from treatment rooms and the remainder from other settings such as minor injuries units.
The distribution of wound types was also quite consistent across the two audits. About 40 per cent of the wounds were lower limb ulcers, with 15-20 per cent pressure ulcers, approximately 15 per cent surgical and 11 per cent trauma wounds (Figure 1).
Signs of infection
44 per cent of patients had at least 1 sign of clinical infection, compared with 57 per cent in the previous audit.
In general, the most commonly observed signs of infection were pain, erythema, and for the earlier audit, “increased exudate”. However, the number of patients reported with “increased exudate” had fallen from 20 per cent to just under 10 per cent, comparing the February and October audits.
Administration of antimicrobial treatment
At the time of the October 2008 audit, 35.3 per cent of patients were already receiving antimicrobials, compared with 48.6 per cent in the February 2008 audit. For those which recorded the duration of antimicrobial treatment (47 forms), the percentage where the duration of treatment was more than 28 days was 8.5 per cent in the later audit, compared with 33 per cent previously (Figure 2).
Of these 189 forms, an antimicrobial treatment was applied in 35.4 per cent of cases, compared with 46.4 per cent of cases in the February audit.
Respondents were asked to list the dressings removed on the day of the audit, and to specify in particular whether antimicrobial dressings had been removed or applied, and if so, to give details of the dressings. A diverse range of dressings was used. Though gauze was the most common non-antimicrobial dressing removed in both audits (used in 22 per cent of cases in the first and 18 per cent of cases in the second), modern wound dressings were used widely (predominantly hydrofibre and foam products).
At the time of the earlier audit, the most common antimicrobial dressing applied was Aquacel Ag hydrofibre. Results from the later audit showed that Acticoat use had increased from 5 per cent to 25 per cent, whereas Aquacel Ag use had fallen from 26 per cent to 8 per cent (Table 2).
In the later audit, respondents were asked to indicate the reason for the dressing change. 98.1 per cent of forms gave a response. Of these responses, 87.1 per cent gave the only reason as “planned visit”.
Time since last dressing change was also reported on 87.9 per cent of forms. The most common dressing change interval was 2 days, the mean being 2.3 days (February) and 2.7 days (October). The medians were 2 days in both cases.
There is broad consensus on the appropriate usage of silver antimicrobial dressings based on the presence of recognisable clinical indicators. Likewise there is consensus as to the clinical signs and symptoms associated with excessive wound bacterial burden. However, in many cases there may be a gap between theory and practice.
The challenge to achieving best practice is aligning what is currently done with a best practice approach.
Possible obstacles to achieving best practice include:
- Clinical knowledge gap
- Clinicians’ ability to recognise and understand key physiological changes through observation of clinical signs and symptoms
- Clinicians’ ability to use this to inform treatment decisions
- Product knowledge gap
- How the product works
- What the product does/doesn’t do
- The most appropriate clinical circumstances in which to use
- Practice tends to be based on habitual behaviour, and requires agents of change to breach the theory-practice gap
The objective of the collaborative approach was to engender a change in clinician wound management practice, specifically the appropriate use of silver antimicrobials. In order to evaluate the success of this approach, the clinical audit cycle was applied, by conducting two audits, one before and one after the antimicrobial training events.
The distribution of primary wound types highlighted by the audit (Figure 1) was very similar to that observed in a recent study carried out across several NHS trusts in the same region. The high degree of consistency between these two separate audits lends support to the conclusion that this pattern of wound types is representative of those treated in this region.
The structure and form of the audit questions allowed some insight into the decision-making processes with regard to the administration of antimicrobial treatments.
In particular the clinician’s decision to initiate antimicrobial treatment and subsequent review of this intervention was scrutinised.
These two key decisions had been identified as critical steps in clinical practice around antimicrobial usage, and the collaborative educational programme had reflected this. It was felt that it is at these two points that any theory-practice gap would be most detrimental to effective antimicrobial use and hence patient care.
The educational programme therefore gave more prescriptive guidance on the circumstances in which silver antimicrobials should be administered and the time scale for reappraising their use. All guidance given was based on consensus documentation.
The audit process allowed the impact the collaborative education programme had on practice to be scrutinised. If the programme were successful this should be evident in a more targeted and clinically informed decision-making approach to antimicrobial usage.
The results from the audit tend to support the conclusion that the programme has been effective in altering practice in line with the desired standards specified in the guidelines issued. For example, reductions in the proportion of patients receiving antimicrobial treatment and the proportion of patients receiving treatment for more than 28 days were both observed. The latter showed a particularly noteworthy change (33 per cent reduced to 8.5 per cent).
Although the initial focus was the use of antimicrobial dressings it was anticipated that, if successful, this collaborative education-based strategy would be extended to other areas of wound management.
One area of practice where it was felt a theory-practice gap might exist and hence might serve as the focus for any subsequent extension of the programme, was decision-making around the frequency of non-antimicrobial dressing change. In order to clarify current practice around dressing change and determine whether this would be a suitable topic for future education input, an additional question regarding reasons for dressing change was included in the follow-up audit in October 2008.
In general nurses plan their visits following an assessment of the patients’ needs which includes wound care. The additional audit question explored the drivers for dressing change but did not take into account other aspects of care that may be required for each individual patient. This gives some limited insight into whether the impetus for dressing change is clinical necessity, the dressing performance or non clinical consideration i.e. patient request or logistical consideration.
In 3 per cent of cases the sole reason recorded for dressing change was “to assess wound”, whereas in 87 per cent of cases, the sole reason recorded for dressing change was “planned visit”. In a proportion of cases where “planned visit” was specified it may be that the dressing change was not the primary reason for this patient contact.
Further collaborative working will therefore focus on education in the area of non-antimicrobial dressing change.
The Department of Health endorses joint working between industry and publicly funded healthcare services as an innovative way of meeting the needs of patients and achieving clinical excellence.
The field of wound management is one area where opportunities exist for collaborative working between healthcare services and industry. This approach has been shown to be effective in achieving substantial improvements in a targeted aspect of practice, namely antimicrobial usage.
Although the benefits arising as a result of this approach are chiefly patient centred, there are also advantages for both of the collaborating parties:
- Movement toward a best practice approach in antimicrobial dressing usage.
- Increased apparent transfer of theoretical understanding into practical application.
- Ensuring that the product that they supply is being used in the most appropriate way thereby maximising their clinical benefit.
- Building and improving relationships with customers helps industry better understand their needs and enables a more responsive customer-centred approach.
Margaret Fletcher is a tissue viability nurse practitioner at City Health Care Partnership, email@example.com. Lynda Whincup is deputy director service & professions at City Health Care Partnership, firstname.lastname@example.org. Alistair Bielby is clinical project manager at Smith & Nephew Healthcare Ltd, email@example.com. Richard Searle is health economics manager at Smith & Nephew Healthcare Ltd, firstname.lastname@example.org
Margaret Fletcher, Lynda Whincup, Alistair Bielby, Richard Searle