A pilot trial of the clinical and cost effectiveness of consultations with remotely situated expert wound nurses for healing of pressure injuries (bed sores) among residential aged care patients.

Consultation with a remote expert wound nurse. The intervention is “consultation” which involves the provision of expert clinical advice, education and support to patients (in the case of this trial, specifically aged care residents), nurses, personal care workers and family members. The intervention includes the development, facilitation, implementation and evaluation of care plans for residents. The speciality associated with the consultation is wound management and specifically, as applies to the trial, with a focus on the clinical issue of pressure injury. The content and outcomes of the consultation are based on the evidence and recommendations in the International Guideline (prevention and treatment of pressure ulcers/injuries in clinical practice https://www.internationalguideline.com) and are tailored according to the individual needs of the resident, local processes, and the resources, skills and abilities of the nurses in the aged care settings who provide the direct care (wound management) to residents. Recommendations that will be made by the Wound Management Clinical Nurse Consultants include wound dressing selection, pressure redistributing strategies (repositioning schedules and equipment to facilitate), skin care, activity and nutrition advice and referrals to allied health. Tailoring could include for example, education to residents who have capacity to understand (this education not provided to residents who do not have capacity), care planning for residents to reposition their body themselves if physically able (care planning for health care providers to reposition if the resident is unable to reposition their body themselves), support of family members if engaged in the consultations (not provided if not engaged), wound dressing selection in line with individual resident characteristics including for example consideration of skin allergies. The expected time commitment required by the participant to follow recommendations in between consultations will vary in line with the complexity of the pressure injury and the characterises of the resident. Wound treatment (cleaning and redressing the pressure injury) can take between 20 and 60 minutes. This time is time that the resident would usually spend having the dressing attended and is therefore not in addition to use care time. The “expert wound nurse” is one or more Wound Management Clinical Nurse Consultants (CNCs). These nurses usually have relevant post graduate qualifications (or are working toward) and/or relevant experience working in the field of wound management. In Victoria, these nurses are typical employed in a Grade 4 position. “Remote” refers to the location of the CNC. The CNCs provides consultation from outside the residents aged care facility (referred to as their Home) in the trial. The consultations occur via videoconferencing supplemented by the provision of pressure injury images. Images are taken by the treating nurse with an iPad or digital camera (facility owned and operated) immediately prior to the consultation and uploaded to a secure folder for access by project staff and the CNC. These images are then uploaded by the CNCs to an application that automatically calculates wound size and quantifies healing rate. Participation in the consultations occurs over 12 weeks and in the study 24 weeks. The consultations occur at baseline, 4, 8, and 12 weeks. For residents who have complex wounds (more severe pressure injuries) an additional consultation is provided at week 1 to provide for additional monitoring and reinforcement of wound management policies and procedures and trial processes. After the 12 week consultation the consultations cease and status of the residents pressure injury is checked at 24 weeks. Consultations take between 30 and 60 minutes. Nurses are provided with a clinical intervention manual (pdf file) to guide the consultation process. This manual was purposed designed for the study. The intervention is personalised to the individual needs of the participants of the consultation. No adaptation of the intervention is planned as the intervention was evaluated and was refined in a feasibility study prior to the commencement of the trial. Intervention adherence is monitored via fidelity checking of the CNC consultation process and outcomes (trial CNCs independently consulting and comparisons made by a different CNC) as well as checking of the similarity of intended care plans for the pressure injuries and the actual/applied care plan (via unannounced on site checking of the dressings in use by the research team) in the participating Homes.