Wound care and tissue viability manual

1 Introduction

Tissue viability and wound care (TV and WC) is the focus on reducing pressure ulcer, improving wound assessment and reducing unwarranted variations in the care of lower leg wounds.

The management of chronic wounds has been identified as a national problem and evidence of an increasing number of chronic wounds and the associated financial burden (Wound UK 2018).

NHS England responded to this new evidence with the development of a clinical reference group, which developed into a project board to oversee a number of ongoing work streams, as part of the leading change adding value programme (NHS 2016a).

The work streams aimed to address some of the failings highlighted and included:

an economic case study analysis resulting in the publication of “Betty’s story” (NHS England 2017)
development of a frame work for lower leg management, moved forward to “Leg Matter Campaign “(2018)
quality indicators for wound assessment 2017-19(CQUIN framework NHS England 2016b)
minimal data set (MDA) for wound assessment (Coleman et al. 2017)
advice for commissioners when commissioning for wound care services
recommendations for minimal level of education for practitioner involved in wound care, moved forwarded to Pressure ulcer core curriculum (NHS Improvement June 2018)
stop the pressure (May 2017)
react to RED evaluation of pilot (Lisle, J, Collins, J, May 2017) This followed the development a training package to promote a collaborative approach to pressure ulcer prevention (five year forward view NHS England 2014) and RDaSH was a pilot site
pressure ulcers; revised definition and measurement (NHS Improvement June 2018)
NICE (2020) Leg Ulcer Pathway
National Wound Care Strategy Programme (2020) Lower Limb Recommendations for Clinical Care.

The work of the national wound care strategy programme identified significant variations in wound care approaches. Local scoping in 2019 confirmed that this is the case in Doncaster. A wound care alliance has been created in Doncaster with the aim to reduce variations in care. The Doncaster wound care alliance consists of the following parties:

Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust (DBTH)
Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH)
NHS Integrated Care Board (ICB), Doncaster CCG
Primary Care Doncaster
Fly Coast Medical Service Ltd. (FCMS)

A joint Doncaster wound care formulary has been developed by the Skin Integrity team, DBTH, tissue viability and lymphoedema services, RDaSH, podiatry foot protection service lead, RDaSH, RDaSH and senior medicines management, NHS Integrated Care Board (ICB) Doncaster CCG.

To access the Doncaster wound care formulary please follow the link: Doncaster wound care formulary (opens in new window).

The Doncaster wound care alliance includes a universal structured competency based educational programme for healthcare professionals undertaking wound care interventions, to ensure a consistent and cohesive approach for wound care interventions is provided that reflects the current evidence, local policy and pathways, whilst incorporating the national agenda. The educational programme provides three different levels of education and learning outcomes based on the complexity of the wound management required (tier 1, tier 2 and tier 3). The complexity of the wound is divided over 4 tiers (Doncaster Wide Formulary 2021).

Tier 1, patients with wounds less than 14 days with positive healing (for example, 100% granulation tissue), including removal of sutures or clips.
Tier 2, patients with wounds that are not healing under the care of Tier 1 service within 14 days and are presenting with 50% or less slough or necrotic or devitalised tissue in the wound bed.
Tier 3, patients with wounds that are more complex in their nature but can be dealt within the GP practices with shared care following the overarching management plan from a tier 4 service and are presenting with more than 50% slough or necrotic or devitalised tissue in the wound bed.
Tier 4, patients with wounds that are more complex in their nature and are managed by the specialist teams only (for example, consultants, tissue viability and lymphoedema services, Skin Integrity team, podiatry foot protection service, local burns services, dermatology).

1.1 Definition of wound

A wound may be defined as the interruption of continuity in a tissue, usually following trauma. Skin is the organ predominantly affected although any tissue, whether nerve, bone or internal organ, may be wounded.

Acute wound definitions
Term	Definition
Abrasions (grazes)	Abrasions (grazes) are superficial wounds, generally caused by friction as a result of brief or indirect contact between the skin and a harder or rougher surface. Abrasions are generally confined to the outer layers of the skin
Lacerations (tears)	Lacerations (tears) are more severe than abrasions and involve both the skin and the underlying tissues
Penetrating wounds	Penetrating wounds maybe caused by knives, bullets or may result from accidental injuries caused by any sharp or pointed object. Internal damage can be considerable depending upon size and depth of penetration, and, or the velocity of the bullet or missile
Bites	Bites caused by animals, insects or humans may become infected by a range of pathogenic organisms including Spirochetes, Staphylococci, Streptococci and various gram positive bacilli. If untreated these infections may have serious consequences, involving fascia, tendon and bone

Chronic wound definitions
Term	Definition
Chronic wounds	Chronic wounds are the hard to heal wounds which are often linked to patients with multiple co-morbidities as defined below
Pressure ulcers	Pressure ulcers which are usually caused by the sustained application of surface pressure over a bony prominence, which inhibits capillary blood flow to the skin and underlying tissue. If the pressure is not relieved it will ultimately result in cell death followed by tissue necrosis and breakdown
Lower leg wounds	Lower leg wounds, which maybe venous, ischaemic, mixed aetiology or traumatic in origin
Diabetic foot ulcers	Diabetic foot ulcers may require urgent referral to appropriate healthcare professional
Dermatological conditions	Dermatological conditions, which may include skin conditions such as venous eczema, dry skin conditions or more complex condition such as pyoderma gangrenosum.
Malignant or fungating wounds	Malignant or fungating wounds, which develop when cancer that is under the skin breaks through the skin and maybe the result of a primary cancer or metastasis to the skin from a tumour

2 Purpose

The purpose of this manual and the linked procedures is to provide clear and concise guidance in areas of tissue viability and wound management for all Rotherham, Doncaster and South Humber NHS Foundation Trust (trust) staff whether in direct or indirect patient care role, regardless of the care environment. It is acknowledged that some staff work in premises over which they have little or no control (for example, patients’ own homes) therefore in some instances staff will have to use their own professional judgement in the interpretation of certain procedures.

The contents of the manual and linked procedures are based on sound tissue viability and wound care principles and national guidance.

3 Scope

This procedure is intended for use predominantly in the community, Tickhill Road Hospital site in-patient services and provides guidance for other patient areas covered by the trust. However, it may also be relevant for all other in-patient services and the need for a pressure ulcer risk assessment will be determined by the physical assessment on admission, in line with the physical health policy.

In the North Lincolnshire and Rotherham localities tissue viability and wound care services is provided by North Lincolnshire and Goole NHS Foundation Trust and Rotherham NHS Foundation Trust. The tissue viability and wound care services provided are a combined hospital and community service.

4 Responsibilities, accountabilities and duties

4.1 Chief executive

The chief executive is accountable for having policies and procedures in place to support best practice, effective management, service delivery, management of associated risks and meet national and local legislation and, or requirements. This responsibility is delegated to the executive director of nursing and AHPs.

4.2 Board of directors

The board of directors is responsible for having policies and procedures in place to support best practice, effective management, service delivery, management of associated risks and meet national and local legislation and, or requirements.

The board of directors also monitor incidents of pressure ulcers as reported from the Performance team data and incidents.

4.3 Director of nursing and allied healthcare professionals

The director of nursing and allied healthcare professionals has the executive authority and responsibility for ensuring strategies are implemented to prevent avoidable pressure ulcers, providing Board assurance and to provide leadership, information and guidance at all levels of the organisation in relation to:

all incidents requiring systematic review with root cause analysis investigation
the organisations’ performance in relation to pressure ulcers and providing regular reports
actions taken in response to new and updated legislation, national policies and guidance ensuring effective policies are in place and audited in relation to TV and WC issues

4.4 Clinical nurse specialist in tissue viability

The role of the clinical nurse specialists includes:

providing expert professional advice on tissue viability and wound care to other professionals, multi-disciplinary groups, patients and carers
advising on complex issues relating to tissue viability and lymphoedema and treatments and interventions, delegating responsibility to trust staff as appropriate
to report any breaches in policy compliance through the trusts electronic reporting system and to the health safety and security committee
leading in the investigation of identified breaches of tissue viability and contributing to serious incidents (SIs) reports as required
managing the TVALS team of registered nurses and health care assistant

4.5 Tissue viability and lymphoedema services (TVALS)

Registered nurses and healthcare assist who deliver tissue viability, wound care and lymphoedema management to patients in their preferred place of care.

4.5.1 Tissue viability and lymphoedema service (TVALS)

Wound care and lymphoedema advice can be obtained from the TVALS. The normal hours of service are 8:30am to 4:30pm Monday to Friday. The service can be contacted via phone on 01302 566 999.

Referral to the service can be processed through SystmOne by completion of the TVALS referral form. Referral can be made by any healthcare professional or social care professional.

4.6 Service managers or modern matrons

The role of the service managers or modern matrons includes:

ensuring that all staff are aware of the manual and adhere to policies, procedures and guidance
identifying training needs and ensuring staff are appropriately trained in tissue viability and wound care issues
ensuring staff have protected time to attend training and educational sessions in tissue viability and wound care
ensuring compliance with the audit requirements of the policy

4.7 Registered nurse or clinicians

Registered nursing staff must only work within their competency.

It is the registered nurses’ responsibility to:

undertake initial and ongoing assessment of risk status to pressure ulcer injury
undertake initial and ongoing assessment of wound, surrounding pri-wound tissue and associated conditions
plan and prescribe care and record in the appropriate documentation
pressure ulcers category 2 or above to be documented on the trust electronic Safeguard IR1 system
monitor wound progress by observing the wound at least once a week. If a wound is being re-dressed weekly, then the wound should be re-dressed by a registered nurse on alternate weeks
provide support to healthcare assistants or support Workers through the competencies for skin assessment and wound care
continue to ensure support and education as required to ensure safe practice

4.8 Healthcare assistant or support worker

The initial and ongoing assessment of risk status to pressure ulcer injury, wound assessment and dressing changes must be carried out by a registered nurse. Skin checks and dressing changes may be delegated to healthcare assistant or support worker in line with their area of practice.

Wound care of complex wounds should not be delegated to healthcare assistant or support worker. The definition of a complex wound is:

category 3 and category 4, un-staged pressure ulcer or deep tissue injury
any cavity wound
fistulae and sinus wounds
tier 4 wounds
lower leg wounds that require anything but conservative or palliative care
infected or dehisced surgical wounds

Wound care should not be delegated to healthcare assistant or support worker if the wound requires:

wound bed preparation
presents with a significant risk of developing a complicated such as pain or risk of haemorrhage

4.9 Doncaster locality, Doncaster adult mental health and LD care group or children’s care group staff

All clinical staff who is involved with the care of a patient within the inpatient services and community must comply with this manual and procedures.

It is the responsibility of each individual member of staff to adhere to the requirements set out within this policy.

4.10 Rotherham or North Lincolnshire localities, Rotherham care group or North Lincolnshire adult mental health and talking therapies care group and children’s care group staff

The principles of the tissue viability and wound management policy and procedures are upheld within the trust care setting but the localities’ tissue viability and wound care services is provided by Rotherham NHS Foundation Trust and North Lincolnshire and Goole NHS foundation Trust.

4.11 Tissue viability link nurses

Received extra training provided by TVALS and supporting education programs from the wound alliance.
Support staff within their clinical areas.
Provide extra education to individual staff in their clinical area as required.

5 Procedure or implementation

6 Training implications

6.1 Registered clinical staff, ABPI and compression bandaging

Length of training: 4 hours.
Delivery method: Practical and face to face.
Training delivered by whom: Community practice educators.
Where are the records of attendance held: Electronic staff records system (ESR).

6.2 Non-qualified staff, Medi ABPI

Length of training: 4 hours.
Delivery method: Practical and face to face.
Training delivered by whom: Community Practice Educators with Medi nurse advisor.
Where are the records of attendance held: Electronic staff records system (ESR).

6.3 Non-qualified staff, wound care

Length of training: 6 hours.
Delivery method: Face to face.
Training delivered by whom: Community practice educators.
Where are the records of attendance held: Electronic staff records system (ESR).

6.4 Registered clinical staff, wound care

Length of training: 6 hours.
Delivery method: Case scenarios and wound products face to face.
Training delivered by whom: Community practice educators with appropriate clinical advisors from wound care.
Where are the records of attendance held: Electronic staff records system (ESR).

6.5 Registered clinical staff, pressure ulcer grading, photography purpose T

Length of training: 6 hours.
Delivery method: Practical and face to face or via Microsoft Teams. Video for wound photography on intranet.
Training delivered by whom: Community practice educators.
Where are the records of attendance held: Electronic staff records system (ESR).

6.6 All staff, new starters and update existing staff, pressure ulcer prevention and wound management

Length of training: 7 hours.
Delivery method: Face to face or Microsoft Teams.
Training delivered by whom: Community practice educators.
Where are the records of attendance held: Electronic staff records system (ESR).

It is each person’s professional responsibility to ensure their knowledge is updated accordingly as part of his or her personal professional development plan. Training should be updated on at least 3 yearly basis.

As a trust policy, all staff need to be aware of the key points that the policy covers. Staff can be made aware through a variety of means such as:

all user emails for urgent messages
one to one meetings or supervision
continuous professional development sessions
posters
daily email (sent Monday to Friday)
practice development days
group supervision
special meetings
intranet
team meetings

7 Monitoring arrangements

7.1 Non-adherence to procedures

How: Via IR1 reporting system.
Who by: Managers or matrons.
Reported to: Care group directors.
Frequency: Bi-monthly.

7.2 Safeguarding IR1 reporting of pressure ulcers category 2 and above

How: Via IR1 reporting system.
Who by: Managers or matrons.
Reported to: Care group directors.
Frequency: Monthly.

7.3 Trust RCA log for trust acquired category 3 or 4 pressure ulcers

How: Via RCA reporting system.
Who by: Managers or matrons.
Reported to: Care group directors.
Frequency: Monthly.

8 Equality impact assessment screening

To access the equality impact assessment for this policy, please email rdash.equalityanddiversity@nhs.net to request the document.

8.1 Privacy, dignity and respect

The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi’s review of the NHS, identifies the need to organise care around the individual, “not just clinically but in terms of dignity and respect”.

As a consequence the trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided).

8.1.1 How this will be met

No issues have been identified in relation to this policy.

8.2 Mental Capacity Act (2005)

Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals’ capacity to participate in the decision-making process. Consequently, no intervention should be carried out without either the individual’s informed consent, or the powers included in a legal framework, or by order of the court.

Therefore, the trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act (2005). For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act (2005) to ensure that the rights of individual are protected and they are supported to make their own decisions where possible and that any decisions made on their behalf when they lack capacity are made in their best interests and least restrictive of their rights and freedoms.

8.2.1 How this will be met

All individuals involved in the implementation of this policy should do so in accordance with the guiding principles of the Mental Capacity Act (2005) (section 1). No issues have been identified.

9 Links to any other associated documents

10 References

British Lymphology Society (2018) Best Practice, Leadership. Support Position paper for Ankle Brachial Pressure Index (ABPI).
Coleman, S., Nelson, E. A., Vowden, P. et al. (2017) Development of a Generic Wound Care Assessment Minimum Data Set. Journal of Tissue Viability. 26 (4) 226-40.
European Pressure Ulcer Advisory Panel (2019) Prevention and treatment of pressure ulcers: Clinical Practice Guideline.
Furlong W (2015) Recommended frequency for ABPI review for patients wearing compression hosiery. British Journal of Nursing.
Guest JF, Ayoub N, McIlwraith T. (2015) Health economic burden that wounds impose on the National health Service in UK BMJ Open 5 (12).
Guest JF, Vowden K, Vowden P (2017) the health economic burden that acute and chronic wounds impose on an average clinical commissioning group or health board in UK J Wound Care 26(6) 292-303.
International Wound Infection Institute (2016) Wound Infection in Clinical Practice.
National pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance (NPUAP or EPUAP or PPPIA) Prevention and treatment of pressure ulcers: quick reference guide. Cambridge Media: Osbourne Park Australia (opens in new window)
National wound care strategy program (2020) Lower limb recommendations for clinical care.
NHS England (2016) A Framework for nursing, midwifery and care staff, Leading Change, Adding Value.
NHS England (2016) Commissioning for Quality and Innovation (CQUIN) Guidance for 2017/2019.
NHS Improvement (2018) Pressure ulcer; core curriculum.
NHS Improvement (2018) Pressure ulcers: revised definition and measurement.
NHS Right Care scenario (2017) The variations between sub-optimal and optimal pathways; Betty’s story: Leg ulcer wound care.
NICE (2014) Pressure ulcers: prevention and management. Clinical guidance CG179.
Wounds International (2016) Wound Infection in Clinical Practice: Principles of best practice.
Wounds UK (2018) Best Practice Statement; Improving holistic assessment of chronic wounds.
Wounds UK (2020) Best Practice Statement: Management of lower limb skin tears in adults. Wounds UK, London.
Wounds UK (2108) Best Practice Recommendations for the prevention and management of skin tears in aged skin.
World Union of Wound Healing Society (2016) Position document, local management of diabetic foot ulcers.
Wounds UK (2017) Recognising, managing and preventing deep tissue injury (DTI).

11 Appendices

11.1 Appendix A Skincare protocol for incontinence associated dermatitis (IAD) primary care

Appendix A Skincare protocol for incontinence associated dermatitis (IAD) primary care (staff access only) (opens in new window)

11.2 Appendix B Purpose T

Appendix B Purpose T

11.11 Appendix K Preparation for taking images of wounds

Explain to the patient why you wish to take a digital image and seek their verbal consent. Document consent in their notes.
Before starting, ensure everything necessary is to hand and if assistant is needed there are sufficient staff.
Ensure the imaging device is functioning correctly and has sufficient power and storage capacity or memory.
Make sure the patient is in a comfortable position, with the entire wound visible but private and personal body parts (for example, genitals, breasts) and identifiable features (such as face, tattoos or birthmarks) covered. If there are previous images, seek to replicate the previous positions.
Where possible use an uncultured pale or neutral background, ideally non-reflective and neutral grey or surgical drape or sterile sheet with no personal identifying items or other people visible. Ambient natural light is ideal. Avoid extremes of light or dark and minimise shadows. If flash is used document use.
Decontaminate your hands, put on a disposable apron from the wound care dressing pack, remove the dressing and cleanse the wound, surrounding skin and any skin or clothing that will be visible in the digital image unless this is needed for legal or safeguarding purposes. Remove gloves and decontaminate your hands.
Decide how many images will be needed. The recommended minimum is an image of the wound plus an image of the site of the wound, for example, leg, abdomen. Instructions for taking images of wounds
Use a single-use disposable measuring scale or an auto-scale (if available on the device).
If the digital imaging device does not automatically immediately upload the image to the patient’s digital clinical record, a patient identifier, for example, the patients initials or NHS number should be visible either within the image or at the beginning and end of the image sequence.
Scales with colour control patch to take account of variation of skin tones are recommended.
Aim to take a clear, close-up photograph of the wound. Hold the camera or device at a distance so that you can photograph the whole wound if possible:
- if the wound is long, you may need to take more than one image to capture the whole wound
- for some sites, for example, the heel, it may be easier to use a mirror to view the wound (do not use the camera flash if a mirror is used)
- gentle tension on excess body tissue or the separation of skin folds may be necessary to reveal the depth of a cavity or you may need to lift the leg to photograph the heel or separate toes
Where possible, point the camera or device directly at the wound, for example, straight in front of the wound and not at an angle.
Allow the device to focus on its own (auto-focus). If needed, focus manually. This can usually be done by tapping the screen or pressing down the button slightly. You may need to move the camera or device further away if it cannot focus.
Check the images on the display screen. It should be in focus, unblurred well-lit and ideally with no shadows over the wound. You can try taking a picture with and without the flash (if available) to see what looks best. It is very important that the photo does not show any identifiable features, such as patients face, tattoos etc. If you need to take another photo until you are happy that you have a clearest photo possible.
Delete unsuccessful photos as you go along so you are only left with the ones that you want.
Decontaminate your hands and equipment before and after taking the photos.

Document control

Version: 2.4.
Unique reference number: 493.
Approved by: Clinical policies review and approval group.
Date approved: 21 February 2024.
Name of originator or author: Clinical nurse specialist, tissue viability.
Name of responsible individual: Clinical nurse specialist, tissue viability.
Date issued: 5 March 2024.
Review date: March 2025.
Target audience: All trust clinical staff.

Page last reviewed: November 15, 2024
Next review due: November 15, 2025

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