Kumal Rajpaul17th September 2013
Kumal Rajpaul is Senior Tissue Viability Lead Nurse, King's College Hospital, London
I have recently been appointed as Senior Tissue Viability Lead Nurse having previously worked as a clinical nurse specialist in tissue viability at King’s College Hospital NHS Foundation Trust, London for the past seven years. King’s College Hospital is a large inner London teaching hospital based in south east London seeing patients from Lambeth, Southwark, Lewisham and further afield. King’s has around 1000 beds and is a major trauma centre, a centre of excellence for stroke care, has the largest haematology department in Europe, and has several intensive care/high dependency departments including medical, surgical, liver, paediatric, neonatal, cardiac and neurosciences. This means the team gets referrals from a variety of specialities. I start my day at 8.30am and finish around 5.30 or 6.00pm, depending on how the day has gone.
First thing each morning I check my calendar to see what meetings I have that day. If possible, I tend to plan meetings early in the morning or the afternoon, as the morning period is reserved for reviewing patients. It is a priority to look at the referrals that are made to the service. These can be sent to the team through an electronic referral system, by telephone or a pager from across the trust.
New patient referrals are allocated to members of the tissue viability team by choice wherever possible, or if they have seen the patient during a past admission. There are four tissue viability nurses in the team with a wealth of nursing backgrounds including trauma, orthopaedics, burns, plastics, general surgery, oncology and vascular. Once this is done, it is time to get out onto the wards to assess new patients and review patients already assessed by the team, putting care plans in place or re-evaluating as necessary. Ideally, the nurse caring for the patient will accompany us for each patient’s review so that they are aware what interventions and care plans are initiated and can update the bedside wound care plan/charts.
Some patients may have complex care needs and require other interventions from members of the multidisciplinary team such as plastics, dermatology, stoma team, general or vascular surgeons or the diabetic foot practitioner. In these situations, joint reviews are organised.
It is expected that the nursing staff will change the patient’s dressings, though I will support and supervise dressing changes if it is a complex case (for example, an open abdomen, polytrauma patient with wounds that need different interventions or leg ulcer management). The team has seen an increase in trauma patients referred to the tissue viability service since becoming a trauma centre in April 2010.
The review and assessment of a patient is used as an opportunity to teach and inform the nursing staff how to assess wounds and select dressings based on the assessment.
At Kings, the nursing and allied health professional staff are encouraged to learn and develop in aspects of wound care. Therefore, any opportunity to impart knowledge on wound care is welcomed.
The team have to be out of the wards by 12 noon as the trust has a protected mealtime policy for patients. If I haven’t managed to get through my list of new referrals and reviews, I go back again later in the afternoon.
Afternoons are, on the whole, dedicated to meetings and paper work associated with the role. These meetings may be with industry or with King’s Health Partners. At present, we are trying to standardise products and services throughout King’s Health Partnership. This standardisation is not only for the wound dressing formulary, but also extends to bed and mattress services and other services which have cost benefits for the trusts involved.
As the tissue viability lead I am involved in the Academic Health Science Centre (AHSC), of which King’s is a part, together with King’s College London, South London and the Maudsley NHS Trust, and Guys and St Thomas’s NHS Foundation Trust Together, we make up just one of five such AHSCs in the UK (http://www.kingshealthpartners.org/info/about-us). This is a great opportunity, especially when members of staff move within the partnership, since they will have all received the same tissue viability training so can hit the ground running. We have regular meetings to discuss the aims of the tissue viability service and training, and we develop shared study days, as well as streamlining guidelines, policies and procedures. We provide four study days a year, where we try to get between 70 and 100 nurses to attend. The nurses will usually get a certificate of attendance and the presentations from the day to take back to their clinical areas to share with colleagues. One I recently initiated concerned documentation, legal, ethical and professional issues in wound care and nursing practice, which included a simulation of a coroner’s court. The nurses received lectures on documentation and confidentiality, as well as legal, ethical and professional issues in wound care and the wider nursing practice from the trust’s legal team. I delivered a presentation on pressure ulcer classification, prevention and treatment. In the afternoon, a retired coroner delivered a short presentation and, with the help of nurses from the audience and organising staff, went on to re-enact true coroner’s case as it would have occurred in a ‘coroner’s court room’. The patient and nurses in the case had been anonymised to protect their identity. The case highlighted the lack of nursing documentation and nurses’ accountability in wound care. It also highlighted areas of my own practice which I could improve on, e.g. inserting time in EPR notes to reflect the time I saw patient’s, as the electronic patient notes will record the time you documented the notes and it is not always possible to document immediately after assessing the patient due to case load.
The team contributes to the nursing and midwifery inductions fortnightly, where new starters to the trust get time with the tissue viability team to discuss pressure ulcer grading, prevention and treatment. They are also issued with a wound care pocket guide that was designed and developed by the team and I, with the help of industry. It was designed to be an easy tool to assess wound types, goals of treatment and appropriate wound care products to select, with pressure grading listed at the back. I feel that there is a valid partnership to be had with industry, as they play a vital role in helping inform and educate with the resources available to them. The concept of the pocket guide has been adapted by other clinical areas including the IV and continence teams.
Another aspect of my role, which I sometimes have to fit into my day, is my position as a visiting tutor for King’s College London. This means that some days I will be delivering talks on the tissue viability module and evidence-based wound care course for post registration nurses. On the pre-registration curriculum, I contribute to the pre-surgical midwifery training, delivering talks to student nurses on wound assessment, dressing selection and pressure ulcer training. King’s feels that this is an integral part of my role and supports me in undertaking this as part of my job. The pre-reg students are our future nurses, so we need to play a part in ensuring that they come into the workforce with the knowledge and skills they require. I really enjoy teaching, but do find that there are times when there are just not enough hours in the day.
I am currently Chair of the Tissue Viability Nurse Forum South, so I also set up and attend quarterly meetings with TVNs from London and the south east. This involves setting the agenda with the group, producing minutes and sourcing speakers as required. One of the activities the group has undertaken was to develop and produce an in-house wound debridement course for TVNs within the forum. This was successfully run earlier this year with 15 attendees, with another cohort of TVNs due to start in December 2014.
If the afternoon is not taken up with meetings, I will usually spend it doing paperwork, although, of course, the patients are always the priority. It’s important when discharging patients to ensure that I contact the community TVN to maintain consistency of care where applicable. If a patient is going to need negative pressure wound therapy (NPWT) in the community, more support will be needed, which is provided by our colleagues in primary care. On occasions, I may also be asked to see patients at follow-up outpatient appointments, which is factored into the working day. Other strategic and operational aspect to my role is working with commissioners on reducing pressure ulceration; managing the bed contract and ensuring patient’s receive appropriate pressure-relieving equipment, etc.
Once the day is over, my journey home takes about 50 minutes, involving two trains and a walk across Barnes Common. This helps me to unwind after a busy day.