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 2nd most frequently billed procedure in GP [BEACH study]

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

5 year Mortality -International Wound Journal 2007

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 ReportKaren 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

� Reluctance for GP to refer for more specialised care

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

Prof Helen Edwards -Wound CRC program 3 leader

Financial SupportProblem 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 1Wound 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 ”

� “I now suggest to my GPs what I would like to use “

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 3Financial 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 3National 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

22

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

A change of Practice

and an opportunity

arises

GP Wound Clinic Commenced March 2012

Aimed at secondary level of care to provide an advanced level of

assessment and management which is open to the community but

preferably by GP referall

The essentials to offer General Practice at this level:

� Assessment and Diagnosis

� Wound bed preparation- U/S Debridement

� Management of oedema with compression

� Management of wound-dressing products

� Advanced therapies-NPWT

� Multi disciplinary collaboration

� On site training and education

GP Wound Clinic

Receiving referrals from :

-GPs

-community-Nurses, Pharmacies

-Gold Coast Hospital vascular clinic

-Private Hospital Physcians and Surgeons for USWD to inpatients

Financial SustainabilityHow does a private clinic survive ?

� The support of Healthscope-owners and managers of Bundall Medical Centre

� Practice Nurse Incentive Payments-to support the expanded and enhanced roles for practice nurses to cover the diversity of nurse activities , including but not specifically wound management . Replaced previous item number 10996

� Working smarter-using Medicare item numbers

� Patient contribution to cost of products

Reducing the incidence of VLU by 50% in 5 years with

the General Practice Team

The Outcomes of Reducing the incidence of VLU?

Wellbeing for All-Especially the Patient