Impact of: a specialist wound clinic on patients who develop complex wounds post cardiac surgery Presented by: Penny Gowland ANP Pascaline Njoki Thanks to: Mr S Datta and Jenifer Dalloway RGN

Introduction Background to setting up the wound clinic Evolution of the clinic Impact on service delivery Impact on patients Evidence based practice Ongoing plans

Surgical Sight Infection (SSI) Cardiac surgical patients have high risk factors for developing SSI. Health Protection Agency data for 2012: SSI rates for cardiac surgery range from 0.49% to 18.8%, With the average SSI rate in the UK 4.4% The Manchester Heart Centre had had an increased incidence of SSI and this was impacting on service delivery and patient care

Not just dealing with the problem work done to optimize care and reduce SSI

Where we started: Median discharge in SSI patients56 days Incident Forms specific to wound problems 4 Follow up clinic over running due to wound management problems 16% Specialist Care post discharge0% Readmissions24%

Paradigm shifts What are we doing for an inpatient with an SSI Is it feasible to manage them at home Is it safe to manage them at home Can the patient engage with an outpatient treatment plan Utilizing advanced wound care management in the outpatient setting e.g. Vacuum Assisted Closure devices

The objectives for the wound clinic facilitate early discharge offer specialist outpatient care reduce readmission rates facilitate timely readmission if appropriate. enhance the quality of care given to outpatients with SSI

The initial impact on service delivery 1/2/07 to 1/6/08 30/6/08 to 30/1/09 Median discharge in SSI patients56 days35 days Incident Forms specific to wound problems 40 Follow up clinic over running due to wound management problems 16%0 Readmissions24%0% Specialist Care post discharge0%100%

Seamless service Aims: Establish communication with the community staff Empowering patients to self care or seek help for wound care. Actions: Altering information given at pre and post surgery Writing to district nurse as well as GP. Developing a website for access by primary care staff. Alterations to the Discharge Notification Form to include information on wound care and follow up. Writing an information leaflet to educate patients how to care for their surgical wounds on discharge.

Measuring Patient Satisfaction Jan – May 2011 Were the patients getting the correct information? Were we helping the patients to get continuation of care between the primary care team and the wound clinic by communication and ensuring the patients have dressings and medications? Were we meeting the needs of our patients? What were their experience of the wound clinic? Could we do anything better?

Questions asked were: About themselves About the wound clinic / department About the staff About their treatment And, overall rating of the care provided Response rate was 100% A patient satisfaction questionnaire administered to 21 patients by post or hand delivery after their clinic visit

Gender distribution

n=10 (48%) were offered information leaflet on discharge n=8 (38%) via liaison team. n=21(100%) knew where to attend the clinic n=13 (62%) good signage to department Patients were asked to indicate about information made available to them.

Why appointment was made

n= 18 (86%) were seen at appointment time n= 3 (14%) ambulance issues-1 Were you seen at your appointment time?

n=17 (81%) rated the reception staff very good n=21 (100%) rated the nursing staff very good n=17 (80%) rated the medical staff very good n=19 (90%) rated the ANP very good n=21 (100%) had confidence and trust in doctors / nurses treating them Please rate how you felt you were dealt with by the following staff during your visit:

n=15 (71%) had dressing regime changed n=8 (39%) got a a prescription of either antibiotics/dressings or both n=21 (100%) understood the next steps of their treatment n=18 (86%) got a note for their district nurse About treatment

Decision making 90% of patients said they were happy with their involvement in decision making. Overall rating of care

Very little time spent waiting (2) good advice (2) Care and attention of all staff (3) Felt staff were interested and capable and had time to talk (1) Care given-keep up the good work (1) reassurance (1) The professionalism and friendliness and warmth of the staff (2) What do you like best about our clinic?

Reduced Length of stay Given specialist care post discharge Reduced Readmission Rates Stopped over running of general clinics due to wound care interventions Achieved good satisfaction rates with their clients The wound clinic has had an impact:

Objectives 100% of patients to receive information leaflet on discharge Signage to out patient department was being reviewed by management Developing a cardex for wound clinic to have a continuous audit of -Activity in the wound clinic -how frequently we see patients -treatments given -time to wound to closure -Clinical and cost effectiveness of treatments

Changes to the wound clinic in the interim Twice a week availability, two clinics in two different locations Changes to the way patients were discharged from hospital Changes to the working patterns of the Cardiac Liaison Team

Re-audited Patient Satisfaction Jan-June questionnaires were given to patients attending wound clinic or by post 24 were returned completed (69% response rate) Asked the same questions about the patient demographics and their experience

Demographics Remained similar between the two audits

n=6 (25%) were offered information leaflet on discharge n=3 (12.5%) via liaison team. n=22(92%) knew where to attend the clinic n=13 (54%) good signage to department Patients were asked to indicate about information made available to them.

Why appointment was made Change in trend: more patients being given appointments on discharge and More GP and DN referrals and less from Liaison Team

n= 21 (88%) were seen at appointment time n=3 (12%) Were you seen at your appointment time?

n=21 (88%) rated the reception staff very good n=21 (88%) rated the nursing staff very good n=20 (83%) rated the medical staff very good n=20 (83%) rated the ANP very good n=24 (100%) had confidence and trust in doctors / nurses treating them Please rate how you felt you were dealt with by the following staff during your visit

About treatment n=21 (88%) had dressing regime changed n=14 (58%) got a a prescription of either antibiotics/dressings or both n=21 (88%) understood the next steps of their treatment n=5 (20%) got a note for their district nurse n=23 (96%) patients had advanced wound care n=18 (75%) had Deep wound cleaning n=4 (17%) had VAC therapy n=1 (4%) had platelet gel therapy

Decision making 92% of patients said they were happy with their involvement in decision making. Overall rating of care

Listening (5) Information Given (10) Treating me as a person (2) Care and attention of all staff (19) Given reassurance (2) The professionalism and friendliness and warmth of the staff (7) What do you like best about our clinic?

What we could improve on? Information on discharge (3) Communication between reception staff and medical team (1) Too frequent visits (1) Signage at MRI generally (1) Location of clinic (3) Prefer to have this type of treatment nearer home (1) More staff needed (1)

“I have found all my treatment on the cardiothoracic wound clinic extremely satisfying. Every member of staff has been very efficient, considerate, helpful and polite. I have found getting appointments, even in an emergency, very quick. All in all, I have received a very good service from the department and staff.”

Conclusions and action plans second round of patient satisfaction audit Continue to get good feedback Getting good engagement from Primary care team Revisit the information given in the Discharge Notification Letter and How To Look After Your Surgical Wounds leaflet to reflect the current wound clinic and information about where the clinics are held. Work with the new discharge process to ensure that the patients get given the information

Developing a data base Real time information about outpatient management and trends in the wound clinic Generate automatic reports where new infections are diagnosed To be able to evaluate clinical and cost effectiveness of treatments

Database to give real time data