Oxfrdshire CCG Service Specificatin 2017-18 Management f Venus and Mixed Aetilgy Leg Ulcers Requiring Cmpressin Therapy 1. Backgrund Current best practice and natinal guidelines recmmend the use f high cmpressin therapy fr patients wh have leg ulceratin due t venus disease. In many cases, fllwing a rbust assessment, it is als pssible t manage patients with mixed aetilgy disease (venus and arterial causes) with mdified cmpressin. It is recgnised that the treatment f this grup f patients requires a specialist level f knwledge and skill and can be time cnsuming. Under this specificatin, GP practices will be ffered payment fr treating patients wh have venus leg ulceratin which is suitable fr high cmpressin therapy r wh have leg ulcers f mixed aetilgy (arterial and venus) which are suitable fr mdified cmpressin therapy. As part f essential services in the GMS cntract, practices shuld cntinue t identify and prevent, as far as pssible, the develpment f leg ulcers in all patients cnsidered t be at high risk. This wuld include patients with previus leg ulcer histry and thse shwing signs and symptms f venus disease (as per CEAP classificatin tl) such as varicse eczema, varicse veins and dependant edema. 2. Aims The aim f the service is t apprpriately manage the care f patients with new and existing leg ulceratin wh wuld benefit frm cmpressin therapy. The bjectives f the service are t: T prvide nursing assessment and diagnsis f leg ulcer aetilgy fr ambulant patients T prvide n-ging treatment and evaluatin up t healing T prvide supprt fr aftercare and preventin f reccurrence f ulceratin T prvide educatinal advice t supprt patients in the management f their skin 3. Service descriptin The service will prvide: A full and hlistic assessment f a patient with leg ulceratin t assess their suitability fr high cmpressin therapy r mdified cmpressin therapy. This will include the use f Dppler ultrasund as a diagnstic tl. Onging cmpressin therapy in 12 weekly cycles with reassessment every 12 weeks. Reassessment appintments will be paid at the higher rate. Fr venus leg ulcers, an individualised treatment plan based n the lcal Tissue Viability Service Venus Leg Ulcer Pathway (attached at Appendix 4) which reflects natinal guidelines and evidenced best practice as set ut at http://www.sign.ac.uk/pdf/sign120.pdf. Versin 1 2017-18 1
Regular dressings and cmpressin therapy accrding t an individualised treatment plan and in line with Oxfrdshire s wund dressing frmulary Onging review and reassessment and referrals where apprpriate t specialists, e.g. Specialist Tissue Viability service, Dermatlgy r Vascular services. Supprt frm the Specialist Tissue Viability service at Oxfrd Health NHS Fundatin Trust fr advice and specialist assessment (see referral frm at Appendix 2) as fllws: Venus Leg Ulcers If the venus leg ulcer des nt appear t be respnding t the management plan/ cmpressin therapy after 6 weeks f treatment (apprx. 40% reductin in wund area), the patient shuld be discussed with the cmmunity Specialist Tissue Viability Nurse via email service, xfrdhealth.tissueviability@nhs.net (NHS net t NHS net emails are secure.) If the leg ulcer des nt appear t be respnding t cmpressin therapy after 12 weeks f treatment (apprx. further 40% reductin in wund area), the patient shuld be referred t the Specialist Tissue Viability Nurse, r jintly assessed with the cmmunity Specialist Tissue Viability Nurse (See referral frm, appendix 2) Between 12 and 24 weeks f treatment practices shuld cntinue t manage the leg ulcer, seeking advice frm the cmmunity Specialist Tissue Viability Nurse as required. It is anticipated that apprximately 70% f venus leg ulcers will be healed at 24 weeks, with a further 20% prgressing well twards healing. A minrity f wunds, apprx. 10%, can be expected t be slw t heal and will need nging management. Mixed Venus & Arterial Leg ulcers If the leg ulcer des nt appear t be respnding t a management plan/ mdified cmpressin therapy after 6 weeks f treatment (apprx. 10-20% reductin in wund area), the patient shuld be discussed with the Specialist Tissue Viability Nurse via the tissue viability email service, xfrdhealth.tissueviability@nhs.net If the leg ulcer des nt appear t be respnding t a management plan/ mdified cmpressin therapy after 12 weeks f treatment (apprx. further 10 20%% reductin in wund area), the patient shuld be referred t the cmmunity Specialist Tissue Viability Nurse, r jintly assessed with the Specialist Tissue Viability Nurse (see referral frm Appendix 2). Frm 12 weeks, practices shuld cntinue t manage the mixed aetilgy leg ulcer, seeking advice frm the cmmunity Specialist Tissue Viability Nurse as required. Due t the nature f the disease, this grup f patients will be slwer t heal and may require vascular interventin. Cmmunity tissue viability will advise practices n this. Patient educatin and lifestyle management with written supprt fr patients and carers. The service prvider will ensure that: Versin 1 2017-18 2
Patients with leg ulceratin receive a cmprehensive hlistic assessment that includes the use f Dppler ultrasund as a diagnstic tl. Patients receiving treatment are regularly reassessed every 12 weeks. Essential Dppler ultrasund equipment is available within the practice, and maintained accrding t manufacturer s instructins. All clinicians prviding the service have cmpleted the relevant training curse and are prficient and cmpetent in the care f peple with leg ulceratin, including the use f Dppler and cmpressin bandaging. Premises are suitable fr the prvisin f treatment t patients with leg ulcers, including the implementatin f the standards fr infectin cntrl and the safe dispsal f cntaminated waste. The service cntinues t be prvided during perids f staff absences thrugh illness r annual leave. Practices must make their wn arrangements fr cver ensuring it meets the criteria set ut in this specificatin. Accurate and clear recrds are maintained. This must include the treatment and quantity f the dressings rdered fr the patient. A patient lg t be kept by all prviders f the service This service is nly available t patients wh are registered with the prvider s wn practice. Accreditatin The Prvider will ensure that all clinical staff prviding this service have cmpleted relevant training in the management f leg ulcers, and are prficient and cmpetent in the care f peple with leg ulceratin, including skills in the use f Dppler and cmpressin bandaging. Nurses wh have nt cmpleted such training as at 1 st April 2014 are required t undertake the 2-day training curse n the management f leg ulcers prvided by Oxfrd Health via their Learning and Develpment Department by 31 st Octber 2014. Evaluatin and audit f primary care leg ulcer services will be undertaken regularly t ensure that quality and standards, within the cntext f clinical gvernance, are being maintained. Supply f dressings Please nte that all dressings must be used in line with the wund care frmulary (attached at Appendix 3) which has been prduced jintly with Oxfrd Health NHS Fundatin Trust. Dressings used in the delivery f this service must be rdered via the ONPOS system except as indicated in the Frmulary. Any additinal prescribing csts fr this will be taken int accunt when mnitring the practice's prescribing budget. 4. Payment Practices will be paid fr the fllwing:. 1. First assessment (includes treatment) @ 30 per leg 2. Further appintments fr up t 11 weeks @ 15 per treatment per leg 3. If nt healed, reassessment at 13 weeks (includes treatment) @ 30 per leg 4. Further appintments fr up t 11 weeks @ 15 per treatment per leg Versin 1 2017-18 3
5. If nt healed, reassessment at 25 weeks (includes treatment) @ 30 per leg 6. Further appintments fr up t 11 weeks @ 15 per treatment per leg 7. If nt healed, reassessment at 37 weeks (includes treatment) @ 30 per leg This is based n a reassessment after each 12 week cycle if a patient s leg ulcer has nt satisfactrily healed; the practice may make a secnd & third claim, but may be expected t prvide additinal details. It is anticipated that many patients will need nce-weekly treatments, hwever, where treatment is required mre than nce a week, the practice may claim fr each appintment. The practice clinical lead fr this service will be expected t mnitr the frequency f treatments t ensure that they are clinically apprpriate. Practices wh have higher than average levels f multiple appintments may be asked fr further infrmatin t clarify reasns fr this. Practices are expected t recrd when cmpressin therapy finishes (including mdified cmpressin therapy) using the cdes shwn in Appendix 1 belw. If a patient has leg ulcers n bth legs, the practice may claim fr tw separate payments. In rder t maintain skill levels, practitiners will be expected t care fr a minimum f 12 treatments requiring cmpressin therapy per year. These payments d nt include the cst f dressings which are btained via the ONPOS system and medicatin which is n prescriptin 5. Mnitring Practices are asked t submit a quarterly reprt using QUEST f actual activity t the CCG by the 15 th f the mnth fllwing the end f each quarter during the year. The quarterly activity reprts will frm the basis f payments. Read cdes t be used fr this service are shwn at Appendix 1 belw. 7. Terminatin This service will terminate n 31 st March 2019. Any change t the service r earlier terminatin f the agreement must be agreed by bth Cmmissiner and Prvider. Versin 1 2017-18 4
Appendix 1: Read Cdes fr Leg Ulcer Care 2017-18 Search Ppulatin Item Patients with a Venus Leg Ulcer Patients with a Mixed Venus and Arterial Leg Ulcer Read Cde and Descriptin M2715 Venus ulcer f leg M2714 Mixed Venus and Arterial ulcer f leg Fr payment @ Level 1 30 (Initial assessment) Fr payment @ Level 1 30 (Reassessment) Initial assessment in primary care leg ulcer clinic and cmpressin therapy started Re-assessment at 12-week intervals, seen in primary care leg ulcer clinic and cmpressin therapy cntinued 8CV2. Leg ulcer cmpressin therapy started 38C4. Leg ulcer assessment Fr payment @ Level 2 15 (Onging care) Seen in leg ulcer clinic fr nging cmpressin therapy 9N0t. Seen in primary care leg ulcer clinic Fr infrmatin Leg ulcer cmpressin therapy finished 8CT1 Leg ulcer cmpressin therapy finished Versin 1 2017-18 5
Appendix 2: Cmplex Wund Referral Frm Office Use Only : Received: Respnded: Visit: COMPLEX WOUND REFERRAL FORM Please cmplete in blck capitals and give as much infrmatin as pssible. Date f Referral PATIENTS Name N.H.S N. D.O.B PATIENTS Address Pstcde Tel. N. Address if different frm abve G.P Name Surgery address GP Tel. Inc.STD Referred by Name Jb Title Tel. inc. STD Fax N. E.mail Reasn fr referral Is referral due t a serius incident requiring investigatin? Y N Lcatin f wunds and number f wunds Type f wunds Pressure Ulcer Diabetic Ulcer Traumatic wund Burn / scald Surgical wund Fungating lesin Leg ulcer Other please state Wund duratin Days.. Weeks... Years. Versin 1 2017-18 6
Factrs which culd delay healing Immbility / Seating Diabetes Pr Nutritinal status Old Age Dehydratin Incntinence Infectin. Anaemia Misture Ischaemia If leg ulcer ABPI L Leg R Leg ABPI = ABPI = Date f ABPI Lcal wund bed Systemic (Cellulitis) Current Blds Hb... Glucse... Date Wund Assessment Wund size in cm2 Length in cm.. Width in cm Depth in cm/mm Wund bed tissue type Black % necrtic Green % infected Yellw % slugh Red % granulating Pink % epithelialising EXUDATE levels Nne Lw Mderate High Cntinued. Aut Immune Cnditin i.e. Rheumatid Arthritis. Smking Allergies- (please state) Nn Cncrdance Drug Therapy e.g. Sterids, Immunsuppressant, Anticagulant, Anti- inflammatry analgesics. (please state).. End f life/palliative Care Other (please state). Current dressing regime cmmenced date Primary dressing used Secndary dressing used Cmpressin bandages (if applicable). Frequency f dressing change.. Hw lng used?... Surrunding skin Oedema Erythematic Macerated Healthy / Intact Wund Odur YES NO Pain scre 0 2 3 4 5 I I I I I Exudate type Serus Haemserus Purulent Versin 1 2017-18 7
Has a wund r Leg ulcer assessment been cmpleted: W. assessment Y N L.U. assessment Y N Wund traced/measured Y N Phtgraphed Y N Up t date Dppler (if LU) Y N Key Reasn fr Referral, List key Management challenges IF REFERRAL RESULTS IN A TV VISIT WE WOULD EXPECT A NURSE WHO UNDERSTANDS THE PATIENT CASE TO BE PRESENT DURING THE CONSULTATION Please cmplete frm fully and send t Tissue Viability either by email t tissueviability@xfrdhealth.nhs.uk r if frm a GP practice/nhs.net accunt please use xfrdhealth.tissueviability@nhs.net r fax t 01235 205788. N. B. Frms that are cnsidered illegible r incmplete will be returned t sender. Versin 1 2017-18 8
Appendix 3: Wund Management Advice and Prescribing Guidance Versin 1 2017-18 9
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Appendix 4: Venus Leg Ulcer Standard and Cmplex Pathways Venus Leg Ulcer Pathway 1 (Standard) 24 week healing target (Please refer t the guidance n the reverse f this pathway algrithm) Initial leg ulcer Assessment Diagnsis f venus ulceratin (ABPI 0.8 1.3) Enter assessment cde & venus leg ulcer cde n RIO Free frm devitalised tissue and infectin Wund slughy but nt lcally infected Lcal wund infectin (with r withut slugh) Treat with Urgclean, absrbent pad and apprpriate cmpressin until wund bed clean. If debridement nt achieved within 2 weeks then refer t Tissue Viability fr advice Treat with Antimicrbial as per frmulary, absrbent pad and apprpriate cmpressin fr 2 weeks. Refer t T.V if wund still appears infected after 2 weeks Treat with Atrauman, absrbent pad & apprpriate cmpressin Re assess every 6 weeks Map and measure wund surface area in cm² Fllwing expected healing prgressin (Has achieved at least a 40% reductin in wund surface area) Nt fllwing expected healing prgressin (<40% reductin in surface area f wund in 6 weeks) Cntinue with VLU Pathway 1 Healed Enter healed cde n RiO and cmmence patient n healed leg care plan Mve t VLU Pathway 2 (Cmplex) Refer t tissue viability if supprt required at this pint Versin 1 2017-18 11
Guidance fr Standard venus leg ulcer pathway (See criteria fr pathway allcatin) All f the supprting dcumentatin can be accessed/ dwnladed frm the tissue viability prtal n the intranet (insert link) N Actin t be taken Dcuments/Guidance/ tls t supprt actin 1 Venus aetilgy shuld be established by carrying ut a full Leg ulcer plicy & guidelines leg ulcer assessment which shuld include a Dppler Leg ulcer assessment frm assessment. Make sure yu have traced the ulcer/s and Wund prgressin chart wrked ut surface area in cm² Guide t measuring wund surface area Dcument assessment findings in patients ntes Lwer limb assessment frm Dppler assessment frm *Allcate t this pathway if the patients ulcer is less than 6 Wund healing pathway/ risk tl mnths ld, ulcer/s size ttals less than 100cm² and ulcer is NOT a recurrence 2 Dppler assessment - Ensure ABPI is between 0.8 1.3 befre Guide t carrying ut a Dppler implementing pathway NB Cnsider falsely elevated readings in Guide t interpreting ABPI elderly pts, particularly with diabetes & renal disease. 3 Enter assessment cde & venus leg ulcer cde n RiO Standard perating prcedure fr entering leg ulcer cdes n RIO Allcate patient t PSAG (Pt Status at a Glance) bard. Advice sheet - PSAG 4 Assess wund bed fr signs f lcal wund bed infectin Guidance fr the assessment & management f bacterial lading in wunds AMBL tl fr assessing fr lcal infectin 5 Urgclean prduct guide If wund bed is clnised/ slughy the primary dressing Gd prescribing guidelines shuld be Urgclean. This prduct has hydr-deslughing fibres that trap slughy residues. It prvides an nn adherent / atraumatic cntact layer. Use fr up t 2 weeks nly. If wund is nt deslughing, cntact tissue viability fr advice. 6 If wund bed is lcally infected cmmence 2 weeks curse f a Antimicrbial frmulary tpical antimicrbial treatment. Antimicrbial frmulary summary sheet 1 st line Hney Inf sheet Patients guide t Hney 2 nd line Cadexmer idine These prducts need prescribing (Nt available frm ONPOS). Prduct Inf sheets Dressings (T include PIP cdes fr prescribing) Only prescribe the number f dressings required fr a 2 week Gd prescribing guidance. curse. Dcument start and stp dates f treatment in patient s ntes. 7 If wund is free frm slugh and/ r lcal infectin cmmence Atrauman as yur primary cntact layer Prduct guide t Atrauman 8 Chse an absrbent pad as a secndary dressing based n the level f exudate present in the wund. NB If yu have t step up t Srbin, this is 2 nd line s will need t be prescribed. *Remember t STEP DOWN when exudate under cntrl. 9 Select the cmpressin bandage system t be used based n yur patients level f mbility. Guide t absrbent pad selectin Guide t cmpressin bandage selectin Prduct guide K Tw Prduct guide - Actic Versin 1 2017-18 12
10 6 week re- assessments Every 6 weeks trace/ map wund and wrk ut surface area in cm². Wrk ut % reductin ver past 6 weeks. If the wund has nt reduced by 40% then mve patient t the cmplex leg ulcer pathway and refer patient t tissue viability Once healed enter healed ulcer cde n RiO and cmmence patient n a healed leg care plan Guide t wrking ut surface area f wunds Tissue viability referral frm Cmplex leg ulcer pathway algrithm Tissue viability referral frm Standard perating prcedure fr entering leg ulcer cdes n RIO Versin 1 2017-18 13
Venus Leg Ulcer Pathway 2 (Cmplex) 24 week healing target (Please refer t the guidance n the reverse f this pathway algrithm) Initial leg ulcer Assessment Diagnsis f venus ulceratin (ABPI 0.8 1.3) Enter assessment cde & venus leg ulcer cde n RIO Ulcer present fr mre than 6 mnths If free frm devitalised tissue and/ r infectin Wund slughy (Refer t AMBL tl fr guidance) If lcal wund infectin present (with r withut slugh) Refer t AMBL tl Treat with Antimicrbial dressing as per frmulary, absrbent pad & apprpriate cmpressin fr 2 weeks. If debridement nt achieved within 2 weeks then refer t Tissue Viability fr advice Treat with Antimicrbial dressing as per frmulary, absrbent pad & apprpriate cmpressin fr 2 weeks. Refer t T.V if wund still appears infected after 2 weeks Treat with UrgStart cntact, absrbent pad & apprpriate cmpressin 6 week assessment Has there been a wund area reductin f 20% r mre since initiating Urgstart? YES NO Cntinue with Urgstart Discntinue Urgstart cntact and change t Atrauman Reassess at 12 weeks Discntinue Urgstart and change t Atrauman *If <40% wund reductin since last measurement, refer t tissue viability Refer t Tissue Viability Reassess at 18 weeks - cntinue with Atrauman *If <40% wund reductin since last measurement, refer t Tissue Viability Week 24 week assessment Cntinue with current treatment regime until healed. If wund fails t prgress r becmes static then refer t tissue viability. Once healed, enter healed cde n Ri and cmmence well leg care plan. Versin 1 2017-18 14
Guidance fr cmplex venus leg ulcer pathway (See criteria fr pathway allcatin) All f the supprting dcumentatin can be accessed/ dwnladed frm the tissue viability prtal n the intranet. Actin t be taken Dcuments/Guidance/ tls t N supprt actin 1 Venus aetilgy shuld be established by carrying ut a full leg ulcer assessment which shuld include a Dppler assessment. Make sure yu have traced the ulcer/s and wrked ut surface area in cm² Dcument assessment findings in patients ntes Leg ulcer plicy & guidelines Leg ulcer assessment frm Wund prgressin chart Guide t measuring wund surface area Lwer limb assessment frm Allcate this pathway if ulcer is greater than 6 mnths ld, ulcers ttal mre than 100cm²in size and there have been at least 3 episdes f lcal infectin in 6 mnths. 2 Dppler assessment - Ensure ABPI is between 0.8 1.3 befre implementing pathway NB. Cnsider ptential fr falsely elevated readings In the elderly & pts with diabetes r renal disease. Dppler assessment frm Wund healing algrithm/ risk tl Guide t carrying ut a Dppler Guide t interpreting ABPI 3 Enter leg ulcer assessment and venus leg ulcer cde n RiO Standard perating prcedure fr using leg ulcer cdes n RiO Allcate patient t PSAG (Pt Status at a Glance) bard PSAG advice sheet 4 Assess wund bed fr signs f slugh r lcal wund bed infectin Guidance fr the assessment & management f bacterial lading in wunds AMBL tl fr assessing fr lcal infectin 5 If wund bed is slughy r lcally infected cmmence 2 weeks curse Antimicrbial frmulary f a tpical antimicrbial treatment. Antimicrbial frmulary summary sheet 1 st line Hney Inf sheet Patients guide t Hney 2 nd line Cadexmer idine Prduct Inf sheets Dressings These prducts need prescribing (Nt available frm ONPOS). Only Gd prescribing guidance. prescribe the number f dressings required fr a 2 week curse. Dcument start and stp dates f treatment in patient s ntes. 6 If wund is free frm slugh r infectin cmmence Urgstart cntact. Urgstart advice sheet This is a prtease inhibitr that reduces the high level f harmful Guide t MMPs MMPs (enzymes) that are cmmnly ccurring in chrnic wunds. This prduct needs prescribing (Nt available frm ONPOS) 7 Chse an absrbent pad as a secndary dressing based n the level Guide t absrbent pad selectin f exudate present in the wund. NB If yu have t step up t Srbin, this is 2 nd line s will need t be prescribed. 8 Select the cmpressin bandage system t be used based n yur Guide t cmpressin bandage selectin patients level f mbility. Prduct guide K Tw Prduct guide - Actic 9 6 week re- assessment Guide t wrking ut surface area f wunds At 6 weeks trace/ map wund and wrk ut surface area in cm². Wrk ut % reductin ver past 6 weeks. If the wund has nt reduced by 20% then stp the Urgstart cntact, change t Atrauman and refer patient t tissue viability. If 20% + has been achieved cntinue with Urgstart cntact. Tissue viability referral frm 10 12 week assessment Re assess wund and trace/ map and wrk ut surface area in cm². Stp Urgstart cntact and change primary dressing t Atrauman(Urgstart cntact shuld nly be used fr 12 weeks maximum) If the wund has nt prgressed by 40% refer t tissue viability 11 18 week + re- assessments Cntinue t re-assess wund/s every 6 weeks, wrking ut surface area in cm². If the wund/s fail t prgress r becme static then refer t tissue viability. Once healed enter healed cde in RiO and cmmence patient n a healed leg care plan Guide t wrking ut surface area f wunds Atrauman prduct guide Tissue viability referral frm Guide t wrking ut surface area f wunds. Tissue viability referral frm Standard perating prcedure fr using leg ulcer cdes n RiO Versin 1 2017-18 15