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.
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 904959 or 904271
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 for staff with Oxford health emails, and oxfordhealth.tissueviability@nhs.net for staff with nhs.net email.
All referrals should accompanied by a medical summary printout and digital photographs of the wounds.
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
- Cushion selection guide
- Guide to Heel Protectors
- Mattress selection guide
- Aderma advice for nursing homes
- Frequently requested information on pressure relieving equipment
- Pressure relieving equipment formulary (Adults) – A guide for community clinicians
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.
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
As a result of the Covid-19 outbreak we have had to design a new training programme using a combination of videos, virtual training via Microsoft Teams and local, small group practical training sessions.
To start with we would like to offer the following courses all of which can be booked through the Learning and Development Department:
- Introduction and core tissue viability modules
- Pressure damage prevention and management
- Wound assessment and management
- Fundamentals of lug ulcer assessment and management
Previously we also offered:
- Chronic oedema – we will offer this later in the year
- Hosiery workshop – we will offer this later in the year
- Skills day – we will not be offering this in 2021 but may again from 2022
Oxford Health staff – please book on via Learning & Development Portal
NON-Oxford Health staff – please book on via email to Learning & Development – learn@oxfordhealth.nhs.uk
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 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
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)
- Lower Limb Wound Pathway
- Doppler procedure and interpretation
Venous Leg Ulcer Pathway
In 2012, In order to optimise the healing potential of venous leg ulcers, two treatment pathways were designed and then
piloted in clinical settings across Oxfordshire. These pathways are evidence based and focus on good wound bed preparation, managing infection, correct application of compression, monitoring of progress over 6 weekly periods and timely referral to a specialist if the ulcers fail to improve. The pilot proved that more ulcers heal within 24 weeks when a treatment pathway is implemented.
The pathways have now been implemented across all care settings within the community with an expectation that all clinicians providing leg ulcer care should be using this best practice model. The guidance on allocating a patient to a venous leg ulcer pathway should be viewed first in order to ensure the correct treatment is delivered.
- Allocating a patient to a venous leg ulcer pathway
- Standard venous leg ulcer pathway
- Complex venous leg ulcer pathway
- Varicose eczema pathway
Further supporting documentation can be found under the RESOURCES Tab on the homepage.
District nursing teams use a Patient Status at a Glance board to monitor progress of patients on the pathways.
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 mont
hs 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:
We have developed and made available a range of documents and guidelines to assist and inform clinicians within Oxfordshire.
Page last reviewed: 29 July, 2021