Hillsborough District Nursing Service
Improving care for patients with lower leg wounds and reducing inappropriate visits
The Hillsborough District Nursing Team is based at Wardsend Road NHS Community Base in Hillsborough. The purpose of the team is to provide treatment, prevent deterioration and promote health education to Patients and Carers in a community setting.
On average, the caseload comprises of approximately 900 patients and almost 2000 home visits per month completed by a team made up 14 Registered Nurses, 2 Support Workers and 1 Clerical Officer.
We have been meeting hourly, once a week as a team since August 2016, using a structured approach to improvement using Microsystems improvement methodologies.
The team completed a review of the Microsystem using the 5 Ps assessments and the theme of a high workload was evident. This caused the team to feel stressed and to feel that they were not delivering good quality care to patients who really needed it, having to rush visits in order to go to the next patient. The highest volume of visit were for Patients with lower leg wounds making up more than 50 % of the total monthly visits and there was a feeling amongst that team, that many of these were inappropriate.
The Team collected their own data about the visits, to assess whether some visits were inappropriate and if so to establish some of the reasons why they were inappropriate and they found that
- Lots of patients in this group who were not housebound and therefore could have been seen by the Practice Nurse or at the dressing clinic
- Some were having unnecessary dressing changes due to the lack of standardisation of care for dressing lower leg wounds
- Most visits had been forward planned from within the team itself
The team also completed a fishbone diagram to assess the cause and effect further:
Many change ideas were generated from the data collection and the fishbone assessment:
The team decided that they wanted to standardise the care for patients with lower leg wounds and used the themes identified within the fishbone to generate further change ideas. They started to use PDSA cycles to introduce the changes. The changes they implemented were:
- Team Leader reviewed the whole caseload of existing patients and with the team managed any that were felt to be inappropriate
- Review of all new patients presenting with lower leg wounds and if non housebound refer to practice Nurse
- Developed a standardised dressing regime, which included the use of a consistent, more absorbent product, which could remain in situ for a week
- Developed laminated sheets for all the staff to have in their cars, listing the dressings to use and the regime for tests and investigations for this group of patients
- Discussed the group of patients at handover, 3 times a week, giving the opportunity to question, support and change according to the discussion
- Use of a standardised care plan template on the system for all patients with lower leg wounds
What we achieved
Since making the changes, the number of visits had reduced significantly and the time spent with patients has increased significantly. The team now feel that they are delivering a high standard of care and are visiting the patients who really need care in a community setting.
The team have now returned to the initial data, showing the number of visits and have completed a process map for patients who require a review for long term conditions, which is the second highest reason for visiting. The process map has revealed inconsistencies in the care for this group of patients and many of the team in general lack confidence in this area of nursing care. The team therefore have started to consider change ideas to make improvements in this area of nursing care.