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Debridement in the patients home setting

Discussion in 'United Kingdom' started by anthony watson, Feb 27, 2014.

  1. anthony watson

    anthony watson Active Member


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    hi guys

    Just reading some posts and was wondering what level of debridement would you be happy with in the patients home.

    I was reading a reply to a post where the Pod suggested that all debridement should be done in a specialist team setting.


    Its just for me working closely with the Community Nursing teams debridement and TNP are done routinely in the home setting.

    Usual sterile field and guidelines are followed.

    What do you think?

    Thanks Anthony
     
  2. perrypod

    perrypod Active Member

    What you need is bundles of confidence and then you will know exactly what to do!
     
  3. anthony watson

    anthony watson Active Member

    indeed

    But also working in a good team with support is the key.
    Making good friends with the TVN and Community nursing has helped me massively.

    Thanks
    Anthony
     
  4. perrypod

    perrypod Active Member

    We all have our own path to walk, I hope that yours will be a happy one Anthony!
     
  5. PostMortem

    PostMortem Active Member

    Debride what needs to be debrided to get the wound to heal, within your scope of practice. If the wound needs to be debrided it is most definitely not sterile and if it not debrided effectively it will not heal therefore you are wasting your time with partial debridement.

    If you are confident in your debridement skills and have an evidence based rational for your treatment, then what is stopping you?
     
  6. anthony watson

    anthony watson Active Member

    yep
    removing the slough and biofilm is crucial for healing and only surgical wounds are "sterile"

    We do see a number of ischemic foot ulcers and as you will agree only do very limited debridement.

    evidence base for debridement is well documented.
    Usually we follow a dressing protocol but of course have leeway.
    hi perrypod not sure what you meant but thanks.
     
  7. PostMortem

    PostMortem Active Member

    The ischaemic ulcer is one of the most frustrating and frightening ulcers to manage in the home, as has been discussed in another thread, an inadvertant slip with the debridement could lead to loss of limb. For those who can't have the plumbing re-done, slow and steady, minimal debridement and lots of pain relief :)
     
  8. anthony watson

    anthony watson Active Member

    yep
    I still use hydrogel like intrasite on them for help in debriding.
    also a little more comfortable for the patient.

    What do you guys think of use of flaminal hydro in ischemic patients.

    Thanks
    Anthony
     
  9. davidh

    davidh Podiatry Arena Veteran

    If I read this right these are patients who are being treated at home. Is there a good reason for that (i.e. - cannot get out of the house)?

    You won't get too far with any topical dressing unless the ischemia is dealt with.
    Drug companies are experts when it comes to selective reporting of the effects of one of their products - glossy brochures and a pretty rep do not an effective product make (paraphrased, but I can't think of the original for now).
     
  10. anthony watson

    anthony watson Active Member

    hi David
    yep a pretty rep always helps!
    but sadly no longer seen very often in the NHS

    you're right the vascular compromised patient should always be assessed by the vascular team for appropriate intervention (surgical) if appropriate.

    The patients I see are mainly those how have been assessed and deemed not suitable for surgical/balloon insertion.

    Usually at home with MDT team input and unless infection or major deterioration happens seems to be no need to bring them to clinic.

    They are usually waiting for the ischemia to become critical and we know what happens then?

    Dressings use to me is more based on comfort and pain control, as for example the osmotic effect of honey can be painful for some.
    Avoidance of dressings that may stick is an obvious one.

    no not Tonywatson12 seem to know a lot about me! bet its one of my mates having a laugh.
    As we talk about the arena a lot.
    Never quite know why mark is so rude!!!
    Have had a dig back but seems to have gone down like a lead balloon!!!

    Thanks
    Anthony
     
  11. Ros Kidd

    Ros Kidd Active Member

    I am truly amazed that given the OH&S implications pertaining to the health worker, the risk of iatrogenic injury to the patient, the cost/time of travel to the patients' home, that there is any advantage or benefit in this method of health care delivery. But clearly there must be, so what is it? Can't help feeling that if there was a cost advantage that the bean counters I've had to deal with would have let me know PDQ. Is the "risk" aspect being sold off to be borne by the health worker in some way? So what am I missing?
    Ros
     
  12. davidh

    davidh Podiatry Arena Veteran

    Hi Ros,
    From a Primary Care management point-of-view it is cheaper to send health professionals out to people in their own homes than it is to see them in a fully staffed and maintained clinical facility.

    Clearly, in some situations the health professional has to decide if what they are asked to do is merely not best clinical practice, or if it could constitute actual clinical negligence, either in whole or in part. I rather suspect this may be one of them. Iatrogenic is a great word, and I'd like to see more Podiatrists using it!
    I think if it could be proven that a high-risk (and in this scenerio all these patients are at high-risk of increased morbidity or mortality) patient had contracted an infection because of being treated at home a case would run. Individual circumstances would dictate how far, and whether it was actually proven or not.

    In most cases the risk of being sued for Clinical Negligence is passed squarely on to the Heath Professional concerned. The NHS Trust will have rapped knuckles if a case comes to Court and is proven, but they will say that "lessons have been learned" and move on. In my experience the NHS are very good at pulling up the drawbridge after them, and the Health Professional can expect little help from that quarter. If a case is proven they will be sued, and then may be disciplined or struck off. They do have the option of suing the NHS Trust, but good luck with that.
     
  13. anthony watson

    anthony watson Active Member

    hi
    can I just jump in here.

    for many many years community nursing teams have managed high risk wounds.
    And TVN (tissue viability nurse specialist) spend a lot of time in community advising on wound dressing / planning.

    I think is is a little misdirected in my view to think this is a cost saving as it usually is done with the patient and his/her wishes as main consideration.

    Way back I think Ali Foster at Kings and the diabetic team started sending patients home with IV antibiotics.
    Although I have not seen this much it is done to help patients remain at home.

    Ros, I understand your questions about Health and safety factors but it is assessed as part of the risk assessment (usually a nursing model is followed) as all patients seen at home by them have "patient held notes" for the MDT to use.

    I think a post on here suggested bone removal in the home setting.
    to me it would depend on the wound presentation and why the bone needed to be removed, but I think I would be comfortable to remove loose sequestra from a neuropathic wound during dressing and wound cleaning.

    David what do you make of the NHS policies and PGD'S developed to allow this type of work to be done. Do they hold any legal water?

    thanks
    anthony
     
  14. Ros Kidd

    Ros Kidd Active Member

    Yes, indeed some antibiotics can be delivered by a CVC allowing the patient to remain functional at home and not occupy a hospital bed for days on end. But Ali Foster did not debride the wound in a patients home she did that in a hospital/clinic setting.
    A the end of the day it is the individual podiatrist who must decide the best and safest treatment plan for their patient which may well be beyond the scope of a nursing model of risk assessment used.
    Ros
     
  15. davidh

    davidh Podiatry Arena Veteran

    It really doesn't matter what I make of them. Its what you make of them.
    You must do as you think fit.

    Please be aware that if a legal case is made against you, you saying that you thought the NHS policies were correct will hold no water.
     
  16. anthony watson

    anthony watson Active Member

    hi david
    bit confused.

    so your saying that if I work in the NHS and follow the policies and procedures of the Trust I have no legal support.

    We are bound by the policies and procedures at work and would be disciplined if not followed !:confused:

    The Nursing care plans I have seen are usually better than any podiatry ones!

    I think the debridement issue is decided on clinical presentation and factors such as environment and lighting.

    thanks
    Anthony
     
  17. Ros Kidd

    Ros Kidd Active Member

    Anthony, just try this, write to your first line manager and ask him'her what happens when you come across a patient whom you believe would receive better care and improved outcomes if they were treated in a clinic. Mention OH&S, lighting, your bad back and possibly policies not written to include sharps debridement of ulceration. Policies are meant to be revised and reflect the changing needs of the patients not be cast in stone for all eternity (or until someone is sued, hung out to dry) then the NHS says sorry got it wrong lets make a policy!
    Ros
     
  18. davidh

    davidh Podiatry Arena Veteran

    Anthony,

    I've had over 40 years in the profession, four of which have been spent involved in medico legal, both Personal Injury and Clinical Negligence in the UK. I do have wide experience of how these things work.

    I understand that this is all a bit of a game to you, right up to the point at which the solicitors letter arrives. If that happens, you will be deep in the mire if you still believe the NHS will come to your aid.

    Your best bet, I suggest, would be to contact your professional body if you have concerns.
    Get their stance on this, in writing of course, so that you have something to fall back on if the worst happens. They may wriggle, so get them to be specific.

    If you don't believe Ros or myself, then there really isn't a problem (in your universe) and you can happily carry on as before.
     
  19. Podess

    Podess Active Member

  20. anthony watson

    anthony watson Active Member

    I do know what it is like to have solicitors letters and the stress it causes.
    Its no game to me.
    Litigation is a nightmare to live though and makes you somewhat cynical.

    I started treating every patient as if each treatment would result in a claim it really plays on your mind.

    I can tell you that the support from the line managers and NHS was excellent and lead to the claim been unfounded.
    I do believe that applying policy and following the protocols played a major part.

    I think (even in my universe) this sort of thing helps any case become more defendable.

    David I respect your knowledge in this and massive experience.
    and I can only talk within my limited experiences of NHS support in litigation which was good for me.

    Space cadet
     
  21. davidh

    davidh Podiatry Arena Veteran

    Support from Line Managers and the NHS would not result in a claim being unfounded.

    I thought this an interesting document.
    Notice how people distance themselves from the "scandal"?
    As seems to be the norm in the NHS, managers and above are simply moved around. Lowly front-line workers seem to be the ones who are disciplined and/or struck off.
     
  22. anthony watson

    anthony watson Active Member

    i have limited understanding of legal procedures and the NHS litigation authority.

    but the managers do the investigating and the letters in response.
    and my experience this was the main factor in the claim made against me.

    I don't pretend to understand what happens in the legal world but feel a lot safer in the NHS and its policy and procedures.

    not sure what role the HCPC have in all this, is it not just the discipline part?

    Don't we tend to follow the minimal standards from the SOCP?

    Again your knowledge is much greater and I make note of your opinions

    Thanks
    Anthony
     
  23. Ros Kidd

    Ros Kidd Active Member

    No Anthony you are being simplistic. Patients can simply go straight to a lawyer without making any complaint to the AHA. The notes are sequestrated under the FOI act. Then its just down to expert testimony. Certainly I have been asked for the paperwork relating to policy but again judgement falls to the individual podiatrist.
    Like driving a car in a 60kph area in poor weather, 60 may be far too fast for the conditions, you are still the driver of the car and responsible for the accident.
    Best of Luck
    Ros
     
  24. Podess

    Podess Active Member

  25. davidh

    davidh Podiatry Arena Veteran

    If you are suggesting that the podiatrist cannot be named as defendant, with all the consequences that entails, because of vicarious liability then yes, you are incorrect.

    If you are suggesting that the employer is liable for the mistakes of the podiatrist (and by this I mean liable in terms of carrying indemnity insurance for mistakes made by their staff) they may or may not. That is outwith the expertise of a witness, and one for the lawyers to argue over. I rather think though, that the podiatrist will end up paying any damages from their own professional malpractice insurance. That is why it is there after all.

    I was involved in several podiatry Clinical Negligence cases last year where the defendant was named. The question of vicarious liability did not arise, at least not in the documentation I examined. It may have come up with the question for damages liability after settlement.

    It's a good point though.
     
  26. Podess

    Podess Active Member

    David H,
    I asked the question because of advice given to me by an NHS Podiatry Manager years ago. We were told that in the event of a claim by a patient then we were covered by the Vicarious Liability of the insurer and the claim would be made against the AHA/Trust, because basically that was were the money was.

    I knew several pods then who had no professional liability insurance because, to quote one " they can't sue me for what I don't have" ( ! ) At that time, it wasn't a condition of employment. I presume that now prospective pods are required to show evidence of this.

    I took advice from the SCP, at the time, who told me that it was nonsense, as although a sucessful claim could be settled by the employer initially, (usually out-of-court) there was nothing to stop them turning around and sueing the podiatrist to recoup their losses. Personally, I don't know of this ever happening.
     
  27. davidh

    davidh Podiatry Arena Veteran

    It was certainly a condition of my first NHS employment back in 1971, so I presume some NHS AHA's were simply badly advised.
     
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