Tissue Viability
What we do
Top left to bottom right: Helen, Penny, Ana-Faye, Fran, Kay, Martha, Lauren, Ger
The Tissue Viability service provides specialist advice and support to healthcare professionals who are managing complex wounds within the community of Oxfordshire.
The nurse-led team works in partnership with patients, their carers and healthcare professionals to provide expert wound care advice, specialist healthcare equipment and education that is aimed at preventing needless skin breakdown.
The team aims to improve and support high standards of practice through clinical consultations, regular audits, development of guidelines and polices and by delivering formal educational training to healthcare professionals.
Tissue_Viability_Service leaflet (pdf)
Useful information
You can contact the Tissue Viability Service by telephone, fax, email or post, Monday to Friday 8.30am-4.30pm.
We are based in the Admin building at Abingdon Community Hospital and our address is:
Tissue Viability
Administration Building
Abingdon Community Hospital
Marcham Road
Abingdon.
OX14 1AG
Phone: 01865 904 959 or 90 4271
Messages can be left on our answerphones.
Email: tissueviability@oxfordhealth.nhs.uk for clinicians using Oxford Health email
Or tissueviabilityadmin@oxfordhealth.nhs.uk for referral forms
Seeking Advice from the Tissue Viability Team
Step 1. If you have a general query about dressings, treatment pathways, equipment provision etc, there is a wealth of information on this website which is designed to help you with your clinical decision making.
Step 2. If the information you need is not here, contact your Tissue Viability Resource Nurse (ReN), or a more experienced colleague. ReNs have had additional training from the TV team and so may be able to advise you.
Step 3. If your query cannot be answered by the above, you should email the TV team. When your email is delivered to the TV team inbox, you will receive an ‘out of office’ reply that states the email has been received. If you do not get this, the email has not arrived and therefore, you should resend it.
Step 4. If you are with the patient and discover something serious that needs immediate advice and guidance, or there is a sudden deterioration in a patient you have emailed about you should ring the team administrator on 01865 904959/ 904271. Please do not ring in with routine queries; you will be redirected to our email service.
Step 5. Tissue Viability Referral – This should be submitted when the plan of care that has been implemented following the assessment, is not progressing as expected. This form includes referrals for complex wounds, chronic oedema, skin problems and pressure damage problems associated with seating and posture. You should only complete the section(s) that apply to your patient. If requesting equipment, you will need to complete a separate equipment request form.
Patients can be referred by their GP, community nurse or any other health care professional.
We do not accept referrals from patients directly. Referrals for advice on wound care should be made using the tissue viability referral form. The Tissue Viability Service referral process guidance and TV referral pathway guides will help you identify when and how to refer to us.
Referrals for equipment should be made using the equipment request form
Referral forms should NO LONGER be faxed to the team but should instead be emailed to our referrals email address: tissueviabilityadmin@oxfordhealth.nhs.uk. We no longer have an nhs.net email address.
All referrals should accompanied by a medical summary printout and digital photographs of the wounds.
Equipment
Identifying the correct piece of equipment for a patient can be complex. The Tissue Viability Team deals with advice and guidance for clinicians regarding equipment for tissue viability purposes only. Equipment required for functional or health reasons are not sourced through our team. Refer to an occupational therapist for functional need or contact the nursing staff for a health need.
The following guidance documents are provided to assist clinicians in decisions around the provision of equipment.
Guidance on Prescribing Equipment
- Criteria for the supply of riser recliner chairs
- Criteria for the supply of hospital beds into residential care homes
- Dermis Plus Prevent
- Frequently requested information on pressure relieving equipment
- Pressure relieving equipment formulary (Adults) – A guide for community clinicians
The previous versions of the Mattress selection guide, cushion selection guide and Guide to heel protectors have now been amalgamated into the’ Pressure Ulcer Equipment Formulary (Adults: A guide for clinicians’ and can be found at the back of this document.
Once supplied, it’s important that equipment is set up correctly. Many pieces of equipment will be set up by Millbrook on delivery. It is the prescriber’s responsibility to make sure they are correctly set up and are regularly checked to monitor this. The following guides may be helpful:
- Tally Quattro mattress guide to changing comfort settings
- Setting up a Starlock cushion
- ROHO competency
If you require any further help please do contact our equipment nurse on 01865 904003.
Training
We offer a comprehensive programme of training courses which are free for Oxford Health staff. These courses are also open to other staff groups such as practice nurses and nurses working within nursing homes but incur a charge. Please email Learning & Development at learn@oxfordhealth.nhs.uk for further information
We are pleased to announce that the 2022 Tissue Viabilty Training Program will return in the main, to Face-to-face training. A summary of the program is available in the link below.
We are running the following courses:
- Wound Prevention, Assessment and Management – full day
- Pressure Damage Prevention & management – ½ day
- Fundamentals of Leg Ulcer Management – 2 full days
- Chronic Oedema – full day
- Hosiery Workshop – ½ day
- Tissue Viability 2023 Training Schedule
- Tissue Viability 2024 Training Schedule
If possible, we would recommend attending these courses in the order they are listed, as each course, to some extent builds on previous courses.
Videos from our virtual training program are now available on a separate Tab on this site. These are an additional resource but will not count as attendance on the above courses.
Oxford Health staff – please book on via Learning & Development Portal
NON-Oxford Health staff – please book on via email to Learning & Development –
CPDExternalCandidates@Oxfordhealth.nhs.uk
Videos
We have a playlist of training videos on wound assessment and management our the Trust YouTube channel.
Go to: Tissue Viability training playlist
Conditions and treatment
Assessment is the foundation of all clinical practice; without a robust holistic assessment it is difficult to achieve a clear management plan. This section provides information and tools to aid clinicians in clinical practice and to support them to develop clear and achievable management plans.
The following guidelines are available to assist clinicians:
- Oxfordshire Guidelines for Managing Bacterial Loads in Wounds
- Wound management standard V7 FINAL Feb 2019
Wound prevention, assessment & management
We advocate the use of TIME principles to provide a systematic approach to the assessment and management of wounds. TIME is based on assessment and intervention in four clinical areas with the aim of producing a well vascularised wound bed that facilitates the effectiveness of other therapeutic measures.
The objectives underpinning TIME are:
- T – Tissue – assess for and treat any non-viable or deficient tissue
- I – Infection or Inflammation – identify and treat
- M– Moisture Imbalance – restore balance
- E – Epidermal Margin non advancing or undermined – identify and optimize wound edges
This framework should be used in addition to obtaining a complete and in-depth medical history and discussion with the patient (and relatives/NOK if appropriate). Regular assessment and review of wound surface area, depth and undermining are also crucial when formulating a management plan. Wound photography is an invaluable tool to monitor progress or deterioration in the wound. Wound photography and mapping are both also fantastic tools in encouraging active participation with patients and can provide a real boost to patient morale.
The following tools and documents are available to assist clinicians and can be found under the resources Tab:
- Abbey pain scale progress sheet
- AMBLE Tool – Assessment/management of bacterial loading in wounds
- Calculating wound surface area/size reduction
- Leg ulcer assessment form
- Lower limb assessment form
- Pain assessment and management leaflet
- Pathway for the treatment of skin that is damaged and excoriated by moisture
- Potassium Permanganate Procedure
- Protocol for the use of Topical Steroids in Wound Care
- Removal of foam dressings
- Wound assessment and evaluation form
- Wound healing pathway/risk tool
Skin Tears
Skin tears are acute, traumatic wounds caused by the mechanical forces of shear, friction or trauma, including the removal of adhesives, resulting in a partial or complete separation of the outer skin layers from the inner tissue (ISTAP, 2018). They can occur anywhere on the body but are most commonly seen on the hands, arms and lower legs. 70–80% of skin tears occur on hands or arms. Skin tears can be painful and distressing for the patient.
It is estimated that prevalence of skin tears may be underreported and in fact be greater than pressure ulcers. To date, no prevalence data is available for the UK, so the cost to patients and the NHS is not fully known. The ageing population means that incidence of skin tears is increasing (elderly patients have fragile skin and are at increased risk)
Skin must be protected in at-risk patients and skin tears managed to avoid further damage and prevent progression from an acute to a more chronic, potentially hard to heal wound.
- Skin Tear Pathway (with stock list)
- Skin Tear Pathway Training Presentation
- Skin Tear Pathway Training video is available on YouTube on the Tissue Viability training playlist
Management of Skin Tears in Residential Homes
The following resources are available to support Care Leaders in Residential Homes in providing 1st Aid to a skin tear:
Skin Tear Pathway V2 for Care Leaders in Residential Homes
Skin Tear Pathway V2 Training Presentation – Care Leaders in Residential Homes
Skin Tear Pathway Competency Checklist for Care Leaders in Residential Homes
Oxfordshire Wound Management Formulary
It is important that within the NHS we are able to justify our clinical decisions and expenditure on wound management products. In Oxfordshire we currently spend £1.8 million annually on dressings, bandages and tapes; therefore the wound management formulary has been developed with the explicit aims of:
- Promoting evidence based practice by providing a framework within which it is safe to practice
- Promoting continuity of care
- Promoting rational prescribing
- Encouraging safe, effective and appropriate use of dressings
- Promoting cost effectiveness
Product selection should be based upon a comprehensive and holistic assessment of the patient and their wound. Once the wound aetiology and the intended treatment outcome have been confirmed, an appropriate product can be selected. If a patients wound fails to progress as expected then a referral to tissue viability should be considered.
Pressure ulcers are caused when an area of skin and the tissues below are damaged as a result of being placed under pressure sufficient to impair its blood supply. The European Pressure Ulcer Advisory Panel defines them as:
“An area of localised damage to the skin and underlying tissue caused by pressure, shear, friction and/or a combination of these.” (EPUAP, 1999)
Typically they occur in a person confined to bed or a chair by an illness and as a result they are sometimes referred to as ‘bedsores’, or ‘pressure sores’. All patients are potentially at risk of developing a pressure ulcer. However, they are more likely to in people who are seriously ill, have a neurological condition, impaired mobility, impaired nutrition, or poor posture or a deformity (NICE, 2014).
A leg ulcer is defined as ‘the loss of skin from the knee to the ankle, which takes more than 6 weeks to heal’. There are several reasons why people get leg ulcers, the most common one (approx. 60 – 80%) being due to venous insufficiency arising from faulty valves in the veins and/ or poor calf muscle pump action. A smaller percentage of ulcers (10 – 20%) are caused by poor circulation in the arteries or as a result of other diseases such as diabetes or rheumatoid arthritis.
It is estimated that approximately 1% of the population in the United Kingdom will suffer from leg ulceration at some point in their lives with the experience often impacting negatively on their quality of life. Without correct treatment, ulcers can remain unhealed for many months or sometimes years, resulting in episodes of infection, pain and immobility.
To improve the healing rates of venous leg ulcers in Oxfordshire a venous leg ulcer treatment pathway has been introduced (click on venous leg ulcer pathway tab) which supports evidence based practice and has contributed to more ulcers being healed within 24 weeks. All clinicians delivering leg ulcer care are expected to use this pathway.
The resources found within this site will assist nurses with their clinical decision making when managing a patient with a leg ulcer.
Please see the following guidelines for further information:
- SIGN Guidelines for the Management of Venous Leg Ulcers (2010)
- Varicose Eczema Pathway
- Doppler procedure and interpretation
- OHFT Best Practice Statement for lower limb cleansing in people’s homes or community inpatient settings
Chronic Oedema Pathway
Chronic oedema is an umbrella term for swelling that does not respond to elevation or diuretics and which has been present for three months or more. It can occur in the limbs and/or the trunk, head and neck or genitalia. There are a number of possible causes including;
- Dependency’ oedema: associated with immobility
- Venous oedema: e.g. resulting from venous disease such
as post-thrombotic syndrome or severe varicose veins
- Oedema associated with obesity
- Lymphoedema: primary and secondary
- Oedema related to advanced cancer
- Oedema due to heart failure
Left untreated chronic oedema of the lower limbs can progress and cause skin changes such as discolouration, eczema, dry skin plaques and hardening of the tissues. The risk of developing leg ulcers increases as the tissues become more vulnerable to injury and wounds fail to heal properly. The tissues become prone to infection and can require hospital admission. In the advanced stages the limbs change shape developing skin folds with hard cobblestone skin. They can begin to leak fluid profusely as the skin is unable to contain the fluid.
Chronic oedema can have a significant impact on a person’s quality of life. It is also costly to the health service in terms of time, resources and staffing. The key to managing chronic oedema is early intervention to prevent disease progression. The main interventions include compression therapy, skin care, exercise and elevation. Managing chronic oedema complicated with ulceration, lymphorrhoea (leaky legs) or infection can prove a challenge. However, with appropriate management strategies, these factors can be reduced.
Compression therapy
Correctly applied compression therapy is recognised as the mainstay of treatment for both the preventative and therapeutic care of venous disease, with high compression bandaging now established as the treatment of choice for venous leg ulceration. Compression therapy is mainly delivered through the application of bandaging or compression hosiery.
Compression therapy aims to reverse the effects of venous hypertension by:
- Decreasing the capacity of and pressure within the superficial veins
- Assisting venous return by increasing the blood flow velocity in the deep veins
- Reducing oedema and subsequent wound exudate levels
- Minimising or reversing skin changes that impact on wound healing.
Compression therapy should not be applied before the arterial status of the limb has been established (Doppler test) and should be applied in line with local policy and guidelines.
Please refer to the following Hosiery Booklet and Hosiery Formulary for guidance on the selection and application of compression hosiery in Oxfordshire:
- Oxfordshire Compression Hosiery booklet
- CHROSS checker tool- A4 form
- CHROSS checker tool – picture cards
- Alternative compression options to bandaging
- Hosiery prescription guidance V2
- Compression and heart failure monitoring form
- Heart failure and compression therapy pathway
- Oxfordshire Compression Hosiery and Wrap Formulary
Lower Limb Wound Pathway 2023
Leg ulcers are wounds on the lower leg (below the knee) and above the malleolus that are slow to heal. It is estimated that approximately 1.5% of the adult population in the UK is affected by active leg and foot ulceration, which equates to 730,000 patients. There is considerable variation in practice and outcomes which increases care costs and extends healing times. The biggest proportion of leg ulceration is due to venous insufficiency. However, many ulcers do have a mixed aetiology with either an element of arterial disease or be purely arterial. This revised guidance brings the care pathways for the various aetiologies together into one simplified document which we hope clinicians will find more accessible.
We have developed and made available a range of documents and guidelines to assist and inform clinicians within Oxfordshire.
Page last reviewed: 21 November, 2023