Wound Awareness
The Challenges
The Solutions
Everyone Deserves Intact Skin and the Sense of Wellbeing
Reducing the incidence of VLU
by 50% in 5 years
SIMPLY-It wont happen without General Practice
General Practice is at the coal face of VLU management
General Practice is the gatekeeper for our medical system
KPMG report –are 42,600 VLUs at any one time
86% of the time GPs are involved in the care of a chronic VLU
Wound related procedures are the 2
ndmost frequently billed
The Basic Principles for Management of
Chronic Wounds
1.
Evaluation of Ulcer Aetiology
2.
Treatment of Underlying Cause
3.
Management of the Wound
4.
Monitoring and maintenance
of healing of Wound
To reduce the incidence of VLU by 50% in 5 years the
potential lies in General Practice
broad skills and training of GPs and practice nurses
the vital and expanding role of the practice nurse with improved trust and collaboration with GPs
emphasis on chronic disease management [Medicare funding]
access to a multidisciplinary team of allied health professionals and specialist care [Medicare funding]
long standing collaboration with community nursing and aged care
long standing relationships with patients engender trust , caring and empathy and allow assessment of wellbeing and ensure wellbeing is the principal focus of care
Problem 1 -Wound Awareness
The Human and Financial Cost
The financial cost-KPMG study
The human suffering:
-mortality associated with chronic wounds similar to many cancers in our community
-affecting society’s most vulnerable –wounds are disproportionately represented in the elderly and in the lower socio-economic community
-more than 25% of residents in Aged Care have a wound
Problem 2
Practising Evidence Based Wound Care
Education and Expertise
• Failure to make a diagnosis of cause of wound
• Lack of expertise and confidence in performing eg ABPI and compression bandaging
• Lack of access to equipment in or out of surgery –eg U/S doppler
Lack of skills and knowledge of wound dressings, compression bandages, stockings and devices
“Venous leg ulcer management in general practice” -Dr Carolina Weller ,Sue Evans 2012
Wound CRC Education Project Report Karen Innes –Walker -Project Manager
“Identifying health services pathways promoting evidence based management of patients with VLUs”
Finlayson,Edwards et al 2012
Practising Evidence Based Wound Care
Problem 2
Education and Expertise
• Lack of time to assess patient, perform wound care• Patients have complex medical needs
University medical training –lack of dedicated wound management education
Limited access for GPs and PNs to guidelines and pathways and education resources
Limited access to wound clinics and clinicians and advanced therapies, eg NPWT , in many areas
Time-The Perennial Problem
Wound CRC Education Project Report
Results of Provider Study
GPs acknowledge wound management is a gap in their knowledge and skills
Need for more wound management education and training
Identified particular topics of need: -using wound investigations
-understanding wound products , pharmaceuticals, and devices
Occupational groups with the highest needs are those working in primary care-practice nurses, GPs, aged care workers
Skin tears are the most commonly managed wound
Least confidence is in management of mixed venous/arterial leg ulcers
Preferred methods of receiving education is face to face training and short inservices
Karen Innes –Walker -Project Manager
Financial Support
Problem No.3
• Major costs of wound dressings,compression bandages, stockings and devices
Lack of support from all levels of Government –can not see the Elephant in the Room
Current Medicare subsidy
arrangements do not encourage best
practice wound care-will the PNIP succeed in wound care?
Medicare rule preventing charging for dressings if consultation is bulkbilled
Solutions : Problem 1
Wound Awareness
•
Increase wound awareness in general community
•
Recognise “Woundol0gy” as a speciality
•
Continuing active role of AWMA, Wound CRC
•
Awareness and support from the medical community
•
Support from all professional bodies-RACGP, AMA,
Nursing and Allied Health
Solutions :Problem 2
Education and Expertise
• Wound CRC education project –developing Wound Education Hub, a plan for effective delivery of wound care education and training to medical and nursing students, providers and patients
• Improve early intervention and reduce recurrence by:
-implement NHMRC Australian and New Zealand Clinical Practice Guidelines for Prevention and Management of VLUs and Pressure Injuries
-implement specific wound pathways - QUT ihbi, Hunter New England Health Pathways
• Service provision in the community- Medicare Locals
-business model for nurse run wound clinics being developed by Sth Melbourne medicare local
-Gold Coast practice nurse wound project. To be expanded next year to GPs, community and aged care nurses
Gold Coast Medicare Local/GPGC
Practice Nurse wound training project January-July2013
Transfer of learning survey
The training has had no impact on my wound management practice
The training has had a slight impact on my wound management practice
The training has had a moderate impact on my wound management practice
42.8%
The training has had a major impact on my wound management practice
57.2%
Q3. Overall what impact has the training you attended had on your wound management practice ?
Gold Coast Medicare Local/GPGC
Practice Nurse wound training project
Transfer of learning survey
Strongly disagree
Disagree Agree Strongly agree
Neither agree nor disagree
As a result of the wound training program, I am now more confident to make clinical decisions regarding the wound management of the patients at my practice
28.6% 64.3%
As a result of this training I am now more confident to participate in the wound management decision making process with the GP(s) at my practice
21.4% 71.4%
I would recommend this training to other GP Practice Nurses
14.3% 78.6%
Gold Coast Medicare Local/GPGC
Practice Nurse wound training project
Transfer of learning survey
“We have found a reduction in wound healing time using compression which in turn has increased patient compliance, self esteem & confidence “
“Would love ABPI at work to feel more confident with compression – also would like Doctors to be more positive using it. They never want to just because the patient may not like the idea.”
“I had no confidence at all. I know I can now look at wound and see the stage and know what dressing to use”
“Wound healing times and patient confidence has in turn allowed us to order new dressings and to initiate new policies regarding dressings “
“GPs have loved learning from what I have learnt and started using different dressings and asking for my opinion ”
Gold Coast Medicare Local
Practice Nurse wound training project
Transfer of learning survey
Q 1 : Do you currently use the three layer tubular bandage compression system?
Yes 42.8% No 50% No response 7.2%
If no what compression system do you use? “None”
“Have not had any PT’s who have had ABPI done so unable to apply compression therapy”
“Compression stocking”
“We do not do compression other than support bandaging/tubigrip” “There is no compression system to be used in my practice”
“Only tubigrip one layer”
“Slowly implementing compression therapy into practice”
Solutions :Problem 2
Education and Expertise
If compression is the answer to treating VLUs –then make it easier !!
Three layer tubular bandage system good results regarding healing and quality of life
readily accepted by GPs , nurses and patients-improves compliance
less expertise required
layers can be removed to improve comfort and compliance
bandages readily available and cheaper
Dr Carolina Weller et al
“Randomised clinical trial of three-layer tubular bandaging system for venous leg ulcers” Wound repair and Regeneration 2012
Solutions :Problem 3
Financial support
Review of PNIP
Work smarter-make better use of case
conferencing, care planning
Specific Medicare item number for wound management
Recognise woundology as a specialty to allow eg
teleconference billing
Change of policy from DOHA regarding bulkbilling and
paying for products
Private Health Funds-more support for outpatient wound
care
Solutions :Problem 3
National Subsidy scheme for reimbursement of
compression therapies and products
• Implementation similar to national diabetes scheme -diagnosis of VLU and national registration
-access to compression devices through pharmacies -access to efficacious application via:
General Practices Wound clinics
Community clinics-eg Leg Clubs
This will require clinicians to provide proof of competancy to maximise safety and efficacy of these devices
Once we have done all that then find time
The
Problem on the Gold Coast
Gold Coast Health services District Wound Management
Model-Carramar Report 2009
“The management of patients with chronic wounds in the GCHSD is fragmented and inefficient”
“There are a range of services available but these are poorly coordinated and may not offer optimum levels of efficacy and efficiency ”
Recommendations of Carramar report
“That a high priority be given to establishing an Interdisciplinary Wound Clinic at the secondary level so that there is an opportunity for referral of chronic wounds in a community setting”
“This service is required to assist those at the primary level to treat hard to heal wounds. It will bring together the necessary expertise form a nurse practitioner, a range of allied health professionals with advanced practise standing, and include review by a medical specialist when necessary”
Referring to a community based chronic wound management model based on 3 tiers or levels reflecting the escalation in complexity of chronic wounds and the assessment and care that can be provided
