Case study: Improving wound dressing procurement at Wirral NHS trust

Exploring how the clinical partnership between NHS Supply Chain and procurement managers at Wirral University Teaching Hospital NHS Foundation Trust is delivering improved patient outcomes and reduced costs through standardisation

woundcare case study

Background

Wirral University Hospital NHS Foundation Trust (WUTH) is one of the largest and busiest acute trusts in the North West of England.

Providing a comprehensive range of high-quality acute care services, the 5,785-strong workforce serves a population of approximately 400,000 people across Wirral, Ellesmere Port, Neston and North Wales.

The challenge

Challenge

In achieving the balance of quality patient services delivered in a financially-sustainable way, one of the key focus areas in the trustís quality strategy is to deliver consistent care leading to reduced length of stay, re-admissions and mortality.

Woundcare is one area of care that can have a major impact on the success of this strategy.

It is for this reason that the procurement team formed a partnership with tissue viability nurse, Bernadette Harwood; and specialist IV access nurse, David Wynne, to deliver a work plan to standardise clinical practice and the range of consumables used, reducing risk for nurses and delivering savings.

The workplan is focusing on the following categories:

  • Barrier creams
  • IV dressings
  • Film dressings
  • Film and pad dressings

These categories have been defined based on their feasibility for standardisation and recurrent savings over 2014/15 and 15/16 without placing too much of a time burden on Harwood and Wynne, distracting them from their core responsibilities.

This case study will focus not only on how they have worked with nursing teams across the trust to reduce variation and deliver recurrent savings, but also how procurement processes were critical in driving through changes in clinical practice, leading to better outcomes for patients and more protection for nurses

The need to adopt clinical best practice for dressing catheter sites

When choosing a dressing for a catheter site, the most-important consideration is protection from infection. UK evidence-based guidelines for preventing healthcare associated infections used globally, state that dressings must be permeable to water vapour in order to prevent the growth of local microflora.

Itís about keeping the standards high - having quality products, maintaining education for staff and saving money

This can be measured through the moisture vapour transmission rate (MVTR), which represents the amount of moisture that passes through a membrane such as a dressing during a given time period. The higher the MVTR, the more effectively moisture is removed, preventing the accumulation of pools of moisture under the membrane.

In reviewing clinical practice Wynne discovered that while infection rates for catheter sites were at an acceptable level across the trust, a range of five non-standardised film dressings were being used, which was not consistent with UK evidence-based guidelines. This was creating unnecessary variation and risk around the care nurses were giving patients and also leading to unnecessary usage.

Objectives of woundcare workplan

  • To deliver average savings year on year of 4% across all selected woundcare categories
  • To ensure clinical practice for dressing catheter sites is in line with UK evidence-based guidelines
  • Standardise ranges in all categories to reduce stock levels and reduce variation for nursing teams
  • Ensure all nurses are trained appropriately on clinical good practice and the agreed ranges

Results so far

  • £45,370 (53%) projected savings (annualised) so far
  • Improved consistency of woundcare practice across the trust with support for a standardised range
  • Agreement on adoption of clinical good practice for dressing of catheter sites, embedded using key procurement processes such as product masking
  • Standardised ranges have led to increased proportion of spend with small to medium enterprises (SMEs), supporting achievement of government requirements

Solutions

The delivery of this workplan is being facilitated by Karen Hudson, clinical nurse advisor at NHS Supply Chain and supported by suppliers through training and education of nursing teams across the trust.

With her background as a theatre nurse, Karen is saving time for Harwood and Wynne, providing them with product range analysis using trust spend data to demonstrate opportunities for standardisation, as well as potential saving options by moving to comparable products.

For dressings, itís about standardisation. Thereís a minefield of dressings out there. Itís not bad practice, but itís about choices we make and sticking to formulary

In approaching the project, the first stage across all categories was always to understand where it was feasible to standardise within the existing formulary and agree the best approach to ensure the same dressings are being used for the same purpose. Procurement would then mask all products outside the core range of products to prevent them being ordered and ensure consistency.

Once this was achieved and embedded, the next stage was to test and evaluate the full range of savings options from comparable products on the national frameworks, not just what was on the formulary.

Having agreed the shortlist of feasible options from Hudsonís analysis, Harwood and Wynne, supported by infection prevention nursing teams in the relevant areas, agreed the criteria on which the new products should be evaluated.

Evaluations are then run across a mixture of high usage and more-specialist area for 4-6 weeks. Suppliers assist nurses with on-site training and ongoing support to ensure they are comfortable using the products correctly. Added to this, the team has set up a training day on dressings with a number of the trustís suppliers, to give nursing teams access to the latest clinical practice.

Feedback from the evaluation is a mixture of forms, observation and discussion, to ensure any major issues are resolved.

However, the process wonít stop here, categories will be constantly reviewed as new products arrive on the market and the team will ensure nurses have access to the best=value products

Adopting clinical good practice

In addressing this specific challenge within the overall workplan, Wynne used his experience from his previous trust where highly-permeable IV dressings were used. Taking an evidence-based approach, he reviewed research comparing infection rates of a range of IV dressing methods.

Using the range of suppliers available through the national framework a shortlist of IV dressings products were developed, with suppliers providing training and support for the nursing teams over the course of two weeks, though there is a programme in place to attend on ad-hoc basis to capture staff that were previously missed.

Feedback revealed that not only was the IV dressing acceptable, it was far easier to apply than the current dressings.

This project only works because of the cross-functional working between clinical and procurement. Itís a partnership with common goals

However, one challenge that has caused a delay in implementation is the trustís formulary, which has not been updated due to postponement of meetings with members of the trust board to agree and sign off changes.

Overcoming this, Harwood and Wynne have obtained the buy-in from all the nursing teams and have agreed that procurement will go ahead and mask all non-compliant products from the NHS Supply Chain catalogue over a four-week period.

Coinciding with this will be a number of training days from the supplier on an ad-hoc basis as and when required.

Timescales

So far the project has been running six months and has delivered £7,000 in savings. However, much of the time has been on set up eg analysis, product evaluation etc, so progress and savings delivered should increase exponentially over the coming months.

Conclusions and learnings

  • Consider how existing processes eg product masking can be used to support changes in clinical practice
  • In specialist areas like woundcare, effective standardisation has to be done area by area in the first instance. It cannot be a trustwide initiative
  • When developing workplans, ensure the scope does not overburden clinical resource in your trust
  • Make the most of support resources already available through procurement organisations and suppliers eg clinical and implementation specialists, product training
  • Do not commit on early savings from specialist areas like woundcare to enable yourself to build a network of supportive stakeholders who will enable you to deliver savings on a recurrent basis
  • Delivering recurrent savings requires a cyclical approach - analyse/ standardise/adopt best-value/analyse
  • Understand timings of trust processes ie timescales for board sign off of trust formulary
  • Consider the whole care pathway when scoping the project, not just the four walls of your organisation
  • Consider all stakeholders that can impact the implementation process for the project eg pharmacy, not just those who are impacted directly by the project eg nursing teams
  • Ensure impacts of packaging design on usage are tested during the evaluation stage
  • Once a stanadardised range has been agreed by all relevant areas, ensure there is ownership for ordering or communicating changes to materials management teams to avoid product availability issues

Next steps

  • Secure agreement on changes to the formulary
  • Extend standardisation of IV dressings across the care pathway to ensure continuity of care
  • Move to lower-cost comparable products on film dressings and film and pad dressings
  • Expand the scope to other categories where standardisation is feasibility, within the limits of clinical resource available to support