Quality indicators for a community‐based wound care centre: An integrative review

Abstract

The purpose of this review was to identify the role and contribution of community‐based nurse‐led wound care as a service delivery model. Centres increasingly respond proactively to assess and manage wounds at all stages – not only chronic wound care. We conducted an integrative review of literature, searching five databases, 2007–2018. Based on inclusion and exclusion criteria, we systematically approached article selection and all three authors collaborated to chart the study variables, evaluate data, and synthesise results. Eighteen studies were included, representing a range of care models internationally. The findings showed a need for nurse‐led clinics to provide evidence‐based care using best practice guidelines for all wound types. Wound care practices should be standardised across the particular service and be integrated with higher levels of resources such as investigative services and surgical units. A multi‐disciplinary approach was likely to achieve better patient outcomes, while patient‐centred care with strong patient engagement was likely to assist patients' compliance with treatment. High‐quality community‐based wound services should include nursing leadership based on a hub‐and‐spoke model. This is ideally patient‐centred, evidence‐based, and underpinned by a commitment to developing innovations in terms of treatment modalities, accessibility, and patient engagement.

1. INTRODUCTION

Although the prevalence of chronic wounds has escalated with an increasing demand for wound care owing to aging populations,1 patient health care outcomes have improved. The establishment of wound care centres with multidisciplinary care have led this change.2, 3

Globally, wound care centres are established at various levels of the health care system; in academic hospital‐based medical centres, as primary care community‐based centres, or stand‐alone wound clinics.

Kim et al4 report that a multidisciplinary approach to wound care has resulted in up to 50% improvement in patient outcomes, including a reduction in complications and amputations resulting from complex wounds. The development and use of standardised treatment protocols based on research evidence is another important factor in the effort to improve patient outcomes.5, 6

A universal benchmark in the management and treatment of wounds is the length of time it takes to reduce wound size or to heal the wound.7 In Europe, a peak body integrally involved in clinical standard‐setting is the European Wound Management Association (EWMA) that has membership from across countries in Europe and Scandinavia.8 In the UK, the National Institute for Health and Care Excellence (NICE)9 has a plethora of guidelines and care protocols for the prevention and treatment of wounds. In Canada, Health Care Toronto10 has published care protocols. Wounds Australia is the Australian equivalent, which has also produced care guidelines in conjunction with the New Zealand Wound Care Society.11

The most common wound types are those that arise because of tissue pressure3 and others caused by diabetes, venous pathology, and surgery.10 A substantial amount of evidence‐based guidance for wound treatment has developed as an outcome of research. For example, in 2017, Pruim et al2 cite clinical guidelines from six countries in Europe. A recent review of systematic reviews of interventions to treat complex wounds reported that numerous interventions were found valuable for treating various types of complex wounds, yet few treatments were found universally successful, suggesting that further high‐quality trials are needed to rank the effectiveness of all treatments.7

Established wound centres deliver care in many industrialised countries including, for example, the UK,12, 13 the USA,14, 15 The Netherlands,2 Canada,10, 16 and Australia.17, 18 Wound care is a costly business, however, with snowballing costs reported in the UK,19 the USA,1, 14 Singapore,20 and Australia.17 The management of pressure ulcers is a significant burden on the health system because costs increase with ulcer severity, and the time to heal becomes longer with a higher incidence of complications in more severe cases.21 A retrospective analysis of the records of 2000 UK NHS patients with wounds of different types in 2012–2013 examined the total NHS cost of patient management.19 The patients were predominantly managed in the community by general practitioners and nurses. The annual NHS cost varied between £1·94 billion for managing leg ulcers and £89.6 million for managing burns and the associated comorbidities. This high cost underscores the importance of effective wound management, in an effort to help reduce the cost burden of wound care.

The purpose of the current study was to explore the literature on the contribution of nurse‐led community‐based wound care as a service delivery model.

2. REVIEW METHODS

The aim of this study was to systematically review the evidence regarding nurse‐led and community‐based models of service delivery for care of wounds and their effectiveness.

Thus, the review focuses on program evaluation as well as research that reports effectiveness measures such as wound care outcomes.

An integrative review method was chosen because this is a broad type of literature review that allows for the inclusion of both experimental and non‐experimental research, to more fully understand a phenomenon.22 This method has been extensively utilised in nursing research to explore quite complex topics that are difficult to define because of variability in research designs. The integrative review method is applicable for the current review to describe diverse literature and to have the potential to inform the development of recommendations for service delivery. The phases of an integrative review as proposed by Whittemore and Knafl22 include: (a) problem identification, (b) literature search, (c) data evaluation, (d) data analysis, and (e) presentation of findings.

After an initial electronic search to determine the breadth of literature, the authors developed criteria for inclusion and exclusion of publications (Table 1).

Table 1.

Inclusion and exclusion criteria

Inclusion criteria	Exclusion criteria
Studies representing current knowledge – published in English in the years 2007–2018.	Medicine‐led wound care studies (eg, surgery).
Nurse‐led programs or programs with nurses as coleaders or providers.	Studies of hospital‐based inpatient wound management or infection control.
Studies that report aspects of wound care delivered by a Wound Care Centre: ie, a community‐based centre or a hospital‐based ambulatory care (outpatient) clinic.	Studies of patient assessment, diagnostic testing, or instrument development.
Studies of any type of acute or chronic non‐healing wound or pressure ulcer.
Peer reviewed or non‐peer‐reviewed studies of any design that describe a model of care for patients regarding wound management.

2.1. Literature search

A four‐phase search strategy was used to identify studies with potential for inclusion. The searches that were conducted aligned with the idea that, for an integrative review, there should be a comprehensive search of publications to identify the maximum number of eligible primary sources, using at least two to three strategies.22 A broad search of the Internet and Google Scholar was initially made to determine the breadth of available literature across peer reviewed and non‐peer reviewed publications; for example, research reports, guidelines, or position papers.

A systematic literature search strategy was developed using Medical Subject Heading (MeSH) keywords and derivatives of ‘nursing’ (Population); ‘model of care’ or ‘treatment’ (Intervention) ‘wound care’ (Concept) and ‘effectiveness’ or ‘impact’ (Outcome). Searches were conducted of the titles and abstracts in five health care databases utilising expanded searches with Boolean techniques. These were PubMed, CINAHL plus, OVID Medline, SCOPUS, and The Cochrane Library. However, it is also recognised that computer‐based searches of electronic databases may fail to identify a proportion of research because of inconsistent search terminology and indexing issues.23 Multiple open text searches were also conducted using Google Scholar and PubMed.

Searches were also made of the websites of key wound care organisations such as the European Wound Management Association, Wounds Australia, and NICE UK. A hand search was made of key wound care journals: The Journal of Wound Care and Wound Repair and Regeneration over the previous 5 years, for studies that may not have previously been identified. The reference lists of the included studies were similarly scanned. This broad search strategy was underscored as being necessary because of a dearth of studies around wound care service delivery models as a topic, and difficulty in identifying studies with a focus that met the inclusion criteria.

2.2. Data extraction

Of a total of 106 articles, 18 were found to meet the inclusion criteria and were included in the review. The study selection process is described in Figure 1.

Figure 1.

Flowchart of the literature selection process

2.3. Data evaluation

Articles that potentially met the inclusion criteria were grouped in an EndNote database. The broad nature of the topic showed a wide‐ranging literature sample including empirical studies, literature reviews, reports, and clinical guidelines/protocols. To facilitate collation of information, the study variables of interest were tabulated, including study design and objective; the type of wound centre; types of wounds managed; organizational staff mix; nature of centre collaboration; measures of effectiveness/cost implications and general findings. A single researcher prepared the table of eligible studies, and the final sample was agreed by two additional researchers who audited the sample. Owing to the diversity in study designs, a simple rating process was used to assess the quality of studies. Studies were ranked based on a suggested scheme using a 2‐point scale (2 = high; 1 = low).22 Two researchers rated: (a) methodological or theoretical rigour and (b) relevance of study data in the current review. The scores were agreed by consensus. As a result of this process, one study was excluded as it lacked relevance in regard to the study setting.

2.4. Synthesis

The primary source details that were extracted and tabulated were divided into two groups: primary studies, and other articles selected as examples of evidence‐based practice guidelines. Data reduction was achieved by organising each of the variables in summary form and systematically comparing the sources on a specific issue. In line with the aim of the review, the key quality characteristics of the included studies were identified as those pertaining to staffing mix and how wound care was delivered – and these were made a major focus of the synthesis. Three authors collaborated to develop the narrative around the main themes.

3. RESULTS AND DISCUSSION

As presented in Tables 2 and 3, the 18 included studies represent a wide range of research designs that included reports and descriptive articles, ranging in levels of research evidence from Level 1 experimental designs (such as randomized controlled trials), to Level 4, observational descriptive studies.24 Of the primary studies, three were randomized controlled trials25, 26, 27; three were observational studies18, 28, 29; two were descriptive designs4, 30; two others were a mixed method evaluations2, 31; one was a case study32; and one was an economic evaluation.17 Further evidence was provided in three recent reviews of literature.33, 34, 35

Table 2.

Summary of key quality of care characteristics from included studies: staffing and care delivery

Study/origin	Research design/sample	Type of wound centre/type of wounds	Organisational staff mix and lead	Nature of centre collaboration/follow‐up	Evidence‐based care/protocol use	Provides patient education	Measures of effectiveness/cost implications	General findings
Abrahamyan et al (2015) Structure and characteristics of community‐based multidisciplinary wound care teams in Ontario: an environmental scan. Wound Repair Regen 23(1): 22–29.   (Canada)	Observational survey (environmental scan) of service models of 44 of 49 wound centres in Ontario, Canada.	Hospital outpatient clinics (n = 27) free‐standing clinic n = 9; other n = 8 (mostly chronic wounds of all types).	N = 11 (25%) were nurse‐led (nurse or advanced nurse), commonly a physician (general practitioner/specialist) teamed with a nurse/advanced nurse (n = 30 teams), or a combination of a physician, a nurse, and a chiropodist (n = 9 teams). Seventy percentage of teams comprised ≥3 disciplines (mean team size 6).	Referrals made to multiple medical diagnostic or supportive specialty disciplines, on‐site, off‐site or distant. Follow‐up: Outreach follow‐up services to patients were provided by (84%), eg, telephone calls from teams (n = 20), telephone support lines for patients to call teams (n = 10); self‐monitoring with phone follow‐up (n = 12).	Yes	Yes (93%) provided unstructured and 27 teams (61%) structured education (eg, videos, written materials) for patient education	All team leaders mentioned: (a) supportive team dynamics and mutual respect; (b) advanced wound care knowledge with emphasis on clinical education for team members; and (c) multidisciplinary aspect of treatment.	Availability of multidisciplinary wound care in Ontario varied substantially across regions. Early detection of wounds and collaboration with other wound care expert/s seen as necessary.
Abu Ghazaleh et al (2018) A systematic review of community Leg Clubs for patients with chronic leg ulcers. Prim Health Care Res Dev 1–10.	Systematic review of 14 studies of Leg Clubs re‐ulcer healing, psychosocial outcomes, patient safety, cost, and patient experiences.	The Leg Club is a community‐based social model of care in 30 UK locations and 9 overseas, for treating patients with chronic leg wounds.	Not reported, however, usually nurse‐led.	Not reported	Yes	Yes	Wound Healing, level of pain, patient Quality of Life, satisfaction, and wound care nurses' views.	The Leg Club model has a positive impact on ulcer healing and recurrence, mood, sleep, quality of life, and pain. Patients and nurses projected positive views about the Leg Clubs.
Anissimova et al (2018) Scoping review of clinical outcomes related to advanced training in wound care. Surg Technol Int 1;33. pii: sti33/1064.	Scoping review of literature to summarise literature (n = 8 articles) on impact of different health care professionals with advanced wound care training and effect of clinical outcomes.	All types of wounds	Five main themes were identified from studies of nurse care: wound improvement, cost savings, influence on other nurses, wound recurrence rate, and advanced education.			N /A	No universally accepted definition for advanced training in wound care; 7 of 8 articles focused on nurses with a specialisation in wound healing/their impact on wound healing outcomes.	A minimum level of advanced training or education would be beneficial to ensure consistency in the provision of advanced wound care by professionals practicing wound care.
Study/origin	Research design/sample	Type of wound centre/type of wounds	Organisational collaborations or staff mix	Nature of centre collaboration/follow‐up	Evidence‐based care/protocol use	Provides patient education	Measures of effectiveness/cost implications	General findings
Bobbink et al (2018) Evaluation of needs and treatment benefits in outpatient care for leg ulcer patients: a pilot study. J Wound Care, 27(8), 527–533.   (England)	A descriptive, cross‐sectional pilot study of n = 32 patients of a university hospital outpatient clinic.	Hospital outpatient clinic, leg ulcer patients.	Clinician‐patient collaboration was important to patients	Patients mentioned that their therapy benefitted most from confidence in the treatment given, decreased pain, and being able to continue living normally.	Yes	Yes	The PBI‐w mean score was 2.93 (SD = 0.75) on a scale of zero (‘did not help at all’) to four (‘helped a lot’).	A clear diagnosis and therapy objectives, rapid wound closure, and confidence in the therapy given are the most important treatment objectives for patients. Patients perceived that they benefitted from the treatment they received.
Cheng et al (2018) Cost‐effectiveness analysis of guideline‐based optimal care for venous leg ulcers in Australia. BMC Health Services Research 18:421.   (Australia).	Economic evaluation to estimate cost‐effectiveness of guideline‐based care for VLUs that includes public sector reimbursement for compression therapy for affected individuals in Australia.	Treatment of Venous leg ulcers	N/A	N/A	Yes	N/A	Guideline‐based optimal prevention and treatment were modelled, then compared with usual care in each State and Territory in Australia.	Guideline‐based optimal care incurred lower total costs and improved quality of life of patients in all States and Territories in Australia. Provision of free compression therapy products would increase national costs but save $ in the longer term.
Edwards et al (2009) A randomised controlled trial of a community nursing intervention: improved quality of life and healing for clients with chronic leg ulcers. J Clin Nurs. 18(11):1541–9.   (Australia)	A randomised controlled trial of a community nursing intervention for clients with chronic leg ulcers (Intervention group n = 34), control group n = 33) using the Lindsay Leg Club model of care.	Chronic leg ulcers – trial of Leg Club versus traditional community nursing model consisting of individual home visits by a registered nurse.	Club emphasised socialisation and peer support; control group was traditional community nursing model.	Leg Club facilitated by wound care nurses.	Yes – standardised research protocols used by all nurses	Yes	Leg Club participants demonstrated significantly improved quality of life (P = .014), morale (P < .001), self‐esteem (P = .006), healing (P = .004), pain (P = .003), and functional ability (P = .044) at 24 weeks.	Use of standardised care protocols across intervention and control groups was required. In this sample, in Australia, the Leg Club model of care shows potential to improve the health and well‐being of clients who have chronic leg ulcers.
Goh & Zhu (2018) Exploring patient and caregiver perceptions of primary health care sector home care for simple acute wounds. Adv Skin Wound Care 31; 8: 348–360.   (Singapore)	Descriptive interview study exploring patient and caregiver perceptions of home wound care (self‐care) for patients with simple acute wounds in Singapore.	Simple acute wounds – burns, lacerations, (n = 4) surgical wounds (Chinese and Malay participants)	N/A	N = 9 face‐to‐face semi‐structured interviews were held with polyclinic patients. Interviews took place during the wound healing phase with participants who had performed wound dressing changes before without help of their caregivers.	N/A	N/A	Fear, lack of knowledge about wound care and difficulty in performing care (on specific skin sites) led to some patients avoiding self‐wound care. Those that did dressing changes wanted follow‐up clinic review as a check. Age, educational level, and cost did not have much impact.	Participants with some first aid knowledge and those who appreciated the flexibility of self‐wound care were more likely to embrace this concept. Participants suggested that written resources/brochures, telecommunications and mobile nurses could assist them.
Study/origin	Research design/sample	Type of wound centre/type of wounds	Organisational collaborations or staff mix	Nature of centre collaboration/follow‐up	Evidence‐based care/protocol use	Provides patient education	Measures of effectiveness/cost implications	General findings
Gottrup et al (2018) Wound centres – how do we obtain high quality? The EWMA wound centre endorsement project. J Wound Care, 27(5), 288–295.   (Europe)	Mixed method study: evaluation of quality of different types of wound centres across/outside (a) Europe to develop quality criteria for centre endorsement and (b) pilot projects were performed in two in‐patient centres in China and one outpatient centre in Brazil.	Mainly hospital‐based wound centres providing care to both inpatients and outpatients; Centre must accept referrals from hospitals, nursing homes, home care, general practitioners (GP), hospice, or other organisations.	The ultimate team concept should include all types of personnel with professional competencies relevant to wound healing and care. A team approach and collaboration between all health professionals is key to facilitation of high‐quality holistic care.	Collaboration between wound clinic staff as required, as well as with other health services staff to deliver team‐based care.	Yes	N/A	Endorsement evaluated (a) centre information; (b) physical facilities; (c) procedures & equipment; (d) clinical staff & collaboration with other hospital departments; (e) organisation and referrals; (f) research and education.	Endorsement systems focusing on the minimum requirements for a wound management centre are required to support the development of high‐quality wound centres which provide health‐care services according to recent evidence of current best practice.
Harrison et al (2008) Nurse clinic versus home delivery of evidence‐based community leg ulcer care: a randomised health services trial. BMC Health Serv Res. 2008;8:243.   (Canada)	A prospective, randomised trial to evaluate the effectiveness and efficiency of community leg Ulcer clinics (intervention) with care delivered through home visiting (usual care).	Leg ulcers: N = 126 patient participants: Home‐based nurse care (n = 61) or centre‐based care (n = 65) using the same evidence‐based treatment protocols.	Nurses provide treatment. The same nursing team delivered care in both the home and clinic settings.	Home‐based nurse care or centre‐based nurse care.	In both arms, care was delivered by specially trained nurses, following an evidence protocol.	Yes	Primary outcome: 3‐month healing rates. Secondary outcomes: durability of healing (recurrence), time free of ulcers, HRQL, satisfaction, resource use.	No difference in 3‐month healing rates: clinic 58.3%, home care 56.7% (P = .5); the organisation of care not the setting where care is delivered influences healing rates. Key factors are delivery of evidence‐based recommendations and a trained nursing team.
Innes‐Walker et al (2018) Improving patient outcomes by coaching primary health general practitioners and practice nurses in evidence‐based wound management at on‐site wound clinics. Collegian. doi:10.1016/j.colegn.2018.03.004   (Australia)	A longitudinal, pre‐post design to develop and trial a Cooperative Wound Clinic model of care in General Practice in Australia, using a nurse‐led, interdisciplinary, holistic approach; the study intervention was the model of care	Wounds of any type. Four Cooperative Wound Clinic pilot sites and nine nurse‐led wound clinics were established in General Practices across three Australian states.	Nurse‐led, interdisciplinary, holistic approach; an expert trainer was most often a nurse practitioner who was involved in initial training of health professionals within each clinic and then attended the clinic once/fortnight to coach and mentor staff in clinical practice and engage patients and carers in care.	Follow up attendance at clinical appointments by the wound expert nurse, in conjunction with the health professional staff, ensured repetitive coaching (of staff and of patients).	Yes	Yes	Pre and post survey data were collected over 24 weeks from medical records, clinical assessment and surveys of wound management practices, health professional confidence in evidence‐based wound management, patient health, well‐being, & healing outcomes.	Utilisation of a repetitive coaching model over a 6‐month period empowered the decision‐ making process and assessment of staff knowledge. A positive impact was seen on patient outcomes for a variety of wound types. There is potential for expanding this model of nurse‐led clinics.
Study/origin	Research Design/sample	Type of wound centre/type of wounds	Organisational collaborations or staff mix	Nature of centre collaboration/follow‐up	Evidence‐based care/protocol use	Provides patient education	Measures of effectiveness/cost implications	General Findings
Jeffcoate et al (2018) Current challenges and opportunities in the prevention and management of diabetic foot ulcers. Diabetes Care, 41(4):645–52.	Review of literature to review the state of management for diabetic foot ulcers (includes large number of recent citations for specialist care and cites many protocols, etc.]	Leg ulcer in people with diabetes (DLU).	Wide variation seen in DLU outcomes, suggesting a lack of optimal care. There is little evidence to justify some products and procedures currently promoted for use in clinical practice.	Very considerable improvements can accompany structural changes in the way care is delivered by using evidence‐based guidance.	Required. Structural changes should be made in the way that care is delivered by using evidence‐based guidance.	N/A	Structural changes should focus on 1) clear pathways to enable early assessment of DFUs by a specialist multidisciplinary service; 2) the provision of structured surveillance and care for those who have had a DFU and are in remission.	Specialist multidisciplinary services are needed for care for DFUs, plus better evidence for treatment practices. Care of the foot needs to metamorphose from a subspecialty to a ‘super‐specialty’ of diabetes.
Kim et al (2013) Critical elements to building an effective wound care centre Journal of Vascular Surgery 57; 6.   (USA)	Descriptive article on elements necessary to build an effective wound care centre, using an example of one USA hospital with emphasis on academic/medical lead & specialist delivery model.	All types. The multidisciplinary approach to wound care has led to a greater than 50% improvement in patient outcomes.	The necessary multi‐disciplinary team includes physicians, nurse practitioners, physician assistants, physical therapists, nutritionists, wound nurses, orthotists/prosthetists, social workers, medical assistants, and administrators.	A multidisciplinary team reflects the different pathologic processes involved in chronic wounds. (N = 21 staff specialties are listed, n = 14 are medicine‐based, n = 4 allied health, n = 2 nurses (wound nurse and nurse practitioner/physician assistant) (for Pre‐/postop care, wound care, discharge planning, patient education.	Yes	Yes	Wound healing measures, amputation rates.	The ideal wound centre model within a regional geographic area involves a community‐based wound care centre that treats routine wounds and refers unresponsive complex wounds to a central tertiary facility with operative capabilities.
Study/origin	Research Design/sample	Type of wound centre/type of wounds	Organisational collaborations or staff mix	Nature of centre collaboration/follow‐up	Evidence‐based care/protocol use	Provides patient education	Measures of effectiveness/cost implications	General Findings
Pruim et al (2017) Assessing and comparing the quality of wound centres: a literature review and benchmarking pilot. Int Wound J, 14(6), 1120–1136.   (The Netherlands)	Mixed method: (a) literature review of international centres' quality and effectiveness (n = 25 studies) and (b) pilot study of quality benchmarks in 8 Dutch hospital centres.	All types of wounds; different levels of wound centre: medical specialist, primary care and community.	Wound centres comprise multidisciplinary teams and include experienced wound care nurses.	Collaboration is required between Services – primary care organisations (home care organisations home care nurses, GPs, podiatrists, physiotherapists) and medical specialist centres.	Yes Integrated wound care pathway, including agreements with primary care providers on standardised follow‐up programmes, guidelines & protocols	No (Education of staff was the only benchmark suggested)	Multidisciplinary collaborations and standardisation of the organisation of care were key to effective care. Benchmarking: Structure, process and outcome measures were identified from literature. 14 quality indicators were trialled.	Benchmarking: not all of 14 quality indicators trialled were found valid for comparison. However, multidisciplinary collaboration and standardisation of care are necessary to achieve effective and cost effective wound care.
Shiu et al (2012) Exploring the scope of expanding advanced nursing practice in nurse‐led clinics: a multiple‐case study. J Adv Nurs 68: 8.   (Hong Kong)	A multiple‐case study design with 6 nurse‐led clinics representing 3 specialties: continence (2), diabetes (2) and wound care (2), using non‐participant observation of nursing activities (9 days), nurse interviews (n = 6), doctor (n = 6) and client (n = 12).	Sample Included two Wound centres led by advanced practice nurses (APN).	Wound centres led by advanced practice nurses (APN).	Good APN involved themes of ‘holistic nursing care’; ‘Client‐ and family‐centred care’; ‘Integrated teamwork’; ‘Community–hospital interface’; ‘Evidence‐based practice’ & ‘Innovative practice’.	Yes	??	Cross‐case analysis demonstrated six elements of good APN in nurse‐led clinics‐ Professional preparation, Professional attributes and clinical expertise, and Organisational culture.	Cases identified themes that describe good advanced nursing practice. The proposed model provides directions for expanding such practice in Hong Kong and beyond.
Terry et al (2009) Feasibility study of home care wound management using telemedicine Advances In Skin & Wound Care 22: 8.	Randomised controlled study to evaluate the effectiveness of telemedicine (TM) with digital cameras in treating wounds in a home care setting for n = 103 patients.	A metropolitan Visiting Nurse Agency; n = 160 subjects with pressure ulcers (PrUs) or non‐healing surgical wounds.	Subjects randomly assigned to 3 groups. Group A (n = 40): weekly visits with TM and wound care specialist (WCS) consults; group B (n = 28): weekly visits with weekly consults with WCSs; and group C (n = 35): usual and customary care.	Follow‐up was the intervention.	Yes	Yes	Outcome measures: time to heal, costs, length of stay (LOS), nursing visits, wound status, and change in wound size.	Group A had disproportionally > PrUs and larger non‐healing surgical wounds, needing more time to heal, >LOS, costs, and visits compared with groups B and C. Nearly 90% of wounds improved or healed. TM is a useful communication tool in wound management.

Table 3.

Selected examples of practice guidelines for evidence‐based practice that can underpin standardised wound care

Study/origin	Research design/sample	Type of wound centre/type of wounds	Organisational collaborations or staff mix	Nature of centre collaboration/follow‐up	Evidence‐based care/protocol use	Provides patient education	Measures of effectiveness/cost implications	General findings
National Institute for Health and Care Excellence (NICE), UK. Pressure ulcer prevention and management (Guideline 179) (2013)   Diabetic foot problems: prevention and management (NICE guideline 19) (2018).   (England)	National Clinical Guideline 179 (pressure ulcer guideline). NG 19 diabetic foot problems.	All types. GL 179: pressure ulcers. NG 19 diabetic foot problems. There are n = 122 documents on ‘team ‐based wound care' on the Website.	Nurses are multidisciplinary team members. Protocols refer to patient‐centred care by health care teams (clinician disciplines are not mentioned). Foot care: The multidisciplinary foot care service should be led by a named health care professional and consist of specialists across a range of disciplines (lengthy list).	Collaboration/links across all levels of health care are recommended. There should be a ‘foot protection service’ for preventing diabetic foot problems, and for treating and managing diabetic foot problems in the community.	Yes	Yes	Time to healing.	Protocols describe clinical care based on patient‐centred care and team‐based care, links across all health care settings are recommended. Nurses are a member of health care teams.
Orsted et al & Wounds Canada, (2017). Foundations of Best Practice for Skin and Wound Management: Best Practice Recommendations for the Prevention and Management of Wounds.   (Canada)	Protocol for best practice for skin and wound care, [including visual format flow charts, forms and EB statements].	Applicable to all types of centres.	Team‐based care.	Described in detail in protocol.	Yes	Yes	Evaluate outcome: documentation determines whether care goals were met because it verifies progress from assessment to discharge. Reassess patient, wound, environment & system if goals are partially met or unmet.	Use of the Wound Prevention and Management Cycle will take all factors into account and will result in a more complete, patient‐focused, sustainable process.
Wounds Australia. (2016) Standards for Wound Prevention and Management. 3rd edition. Cambridge Media: Osborne Park, WA.   (Australia)	Report: best practice standards for Wound Care in Australia, developed through best evidence in previous iterations and a recent review of literature and extensive stakeholder review and input.	Applicable to all types.	Seven core standards address key components of wound prevention and management, including working in collaboration, clinical decision making, documentation, education and corporate governance.	STANDARD 1 SCOPE OF PRACTICE Safety and wound healing potential of the individual is enhanced by practice that respects and complies with legislation, regulations, scope of practice, service provider policies, current evidence and ethics (including evidence‐based practice).	Yes	?	Standard 2: COLLABORATIVE PRACTICE Wound prevention and management is delivered using a collaborative approach between the individual, interprofessional team, health care workers and informal carers.	Standards contribute to ensuring that care delivery is of a consistent high level and that unwarranted variation is reduced. Standards play a role in improving safety of the individual and promoting positive outcomes of care.

The primary studies were conducted in eight countries: Australia (3), Canada (2), USA (2), England (1), Hong Kong (1) Europe (1), Singapore (1), and the Netherlands (1). The majority of studies had been published in the last five years and can thus provide current evidence for the best approaches to care of acute and complex wounds by wound centres in technologically developed countries.

The key themes derived from the findings of these studies relevant to nurse‐led and community‐based models of service delivery for care of wounds, and their effectiveness were: multidisciplinary team care, nurse‐led clinics, evidence‐based standardized care, and patient engagement.

3.1. Multidisciplinary team care

Wound care centres are established and operational across the range of health care services for ambulatory care; from hospital outpatient clinics, to community‐based primary care and home nursing services, to independent free‐standing clinics.2, 18, 28, 33 Almost all studies concurred with the ideal that patients be managed by a multi‐disciplinary team. No single discipline was thought able to independently meet the multiplicity of needs for individuals presenting with wounds.31 In Canada, Abrahamyan et al28 suggested that care should comprise:

a team having a minimum of two members with advanced training and/or more than five years of experience in wound care, representing a minimum of two different clinical disciplines (eg, a physician, a nurse, a dietitian, a physiotherapist, an occupational therapist, and a chiropodist), who share responsibility for the community‐based patient with a chronic wound (p. 6).

Almost three‐quarters of the teams surveyed in Canada were composed of at least three disciplines, although the team composition could be dictated by the local availability of specialists and type of patient population served. In this model, each discipline provides care expertise according to their skills/knowledge and actively collaborates with the other.28 This fits with the concept that interdisciplinary teams are becoming a common feature of health care across the care sectors36 and can enhance many aspects of care through better decision‐making.37

Regarding team care, the reviewed studies were unclear whether the ‘team’ were colocated or were made available on demand across local or distant centres. Certainly, studies recommended that care be based on a collaborative care model. There were a mix of organisational ‘team’ models, as hospital outpatient clinics, for example, can include a multi‐ disciplinary group of practitioners who provide part‐time services to the outpatient wound clinic and in this situation, would have immediate access to multiple hospital‐based diagnostic and surgical specialties.4 Other clinics situated in the community may need to refer on to more distant specialist or tertiary centres that manage complex wounds.18, 28 Hence, a patient could be managed in a primary care clinic by a GP (or GPs) practice nurse and a nurse practitioner (NP), a podiatrist, or differing appropriate combinations of such individuals. However, adherence to evidence‐based guidelines/best practices for wound care should be consistent across these specialties.

It is claimed that a multidisciplinary approach to wound care has led to a greater than 50% improvement in patient outcomes.4 Quality of care measures using health care outcomes have been proposed as, firstly, a primary outcome of the three‐month healing rate, and other secondary outcomes such as durability of healing (recurrence), time free of ulcers, health‐related quality of life, patient satisfaction, and resource use.2, 26

Practice protocols for wound care refer to the ‘health care team’ as providing wound care, inferring the need for staff collaboration9 or they prescribe collaborative practice.6, 38 Few studies specified the nurses' actual role. Nonetheless, given that in the community setting nurses may often be a key wound care team member, this evidence regarding the importance of multidisciplinary collaboration in wound care makes consideration of this aspect a useful quality indicator.

3.2. Nurse‐led clinics

Qualified nurses are key members of a wound care team and may be the team leader. A study of 44 wound centres in Canada reported that one quarter of services were nurse‐led (by a nurse or advanced nurse), but more commonly were led by a physician (general practitioner/specialist) teamed with a nurse or advanced nurse. Another combination was a nurse, a physician and a chiropodist.28 Shui et al32 described wound care clinics in Hong Kong that were led by advanced practice nurses. In developing benchmarks for evaluation of the quality of wound centres for accreditation Pruim et al2 described multidisciplinary staffing and suggested that the number of specialist nurses in the service with ‘more than 5 years of experience in treating wounds’ was an indicator of quality. Overall, we found there was very limited literature that focused on wound centre management, administration, the staffing composition, or described which discipline led the team.

It is reasonable to assume that appropriately trained nurses are well qualified to lead and coordinate wound care teams. In a recent Australian wound care study Innes‐Walker et al18 successfully developed satellite wound centres in conjunction with general medical practices and general medical practitioners. They trained and mentored practice nurses used in the clinics to manage wound care treatment locally. The training and mentoring of staff was provided by advanced practice nurses who were mainly NPs. In other situations, wound care might be delivered in a centre‐based care setting where the client travels to the nursing service,33 or in a traditional community nursing model consisting of individual home visits by a registered nurse, which is a common community‐based model in Canada, 26 the UK,39 and Australia.40

According to the earlier definition the appropriate qualification of a specialist wound care nurse is one who has either advanced training and/or more than 5 years of experience in wound care.2 Of interest, there is no universal definition of what comprises advanced training in wound care.34 However, as can be seen on the Wounds Australia website (http://www.woundsaustralia.com.au/pages/courses.php) higher education short courses and post‐graduate degree coursework in wound management (including distance education) are available to prepare nurses for more specialised wound care. Notwithstanding, nurses are equipped to lead wound care teams owing to their wide‐ranging competencies.41 The key elements of a USA wound care centre in a hospital were described as including two nurses: a wound nurse and NP/physician assistant).4 The role of the NP was managing pre‐operative and post‐operative patient care, wound care, discharge planning, and patient education: thus, a nurse who is a clinician and a leader. While the evidence found for nurse‐led clinics was not sufficient to guide specific quality indicators for that model of care, these current studies demonstrate that there is potential for nursing leadership in wound care services, although further research is needed.

3.3. Evidence‐based practice, standardised care

The need for evidence‐based practice and standardised care protocols across services were key themes throughout this review. Evidence‐based care and the use of clinical pathways were the preference of all the studies related to quality wound care practice. Clinical practice protocols for the various wound types have been produced widely and Pruim et al2 cite those from seven countries in Europe. The National Institute for Health and Care Excellence (UK) offers a wealth of practice resources, with (n = 122) practice‐related documents on ‘team‐based wound care’ on their website (https://www.nice.org.uk). Thus, evidence‐based protocols for wound care are readily available and should be available for the many categories of wounds.

To implement such care, Orsted et al and Wounds Canada6 developed a Wound Prevention and Management Cycle based on clinical evidence and, taking into account all relevant factors, claim that use of the guide would result in a more complete, patient‐focused, sustainable management process.

Although the best evidence for practice may be known, the science of translation into practice is, however, difficult to achieve.42 Some recent studies have identified that variation in general wound care management persists.13, 15 In a records review of US Veterans with lower limb ulcers, Karavan et al15 detected that only a minority of Veterans received the components of evidence‐based ulcer care in at least 80% of visits. However, in a Randomised Controlled Trial of two treatment settings Edwards et al43 ensured that standardised care protocols were used by all nurses, whether delivering care at home or in a clinic. It appeared, however, that the only way for services to achieve comparable patient outcomes was to share treatment protocols and adhere to treatment and follow‐up practices. We suggest that well‐developed referral procedures, referral into, referral onwards, and communication systems that link primary providers and tertiary providers may be key. These may include shared electronic medical records, for example.

The literature under review has a focus on the care of diabetic foot ulcers (DFUs) (n = 6 studies), perhaps because this ulcer type is a common complication of diabetes, these patients have complex needs, and the standard of care may be in need of improvement. In a review of literature on the prevention and management of DFUs, Jeffcoate et al35 reported that wide variation seen in the outcomes (such as time to healing) suggested a lack of optimal care. They recommended a change in care delivery through the use of evidence‐based guidance, and better continuity of care. This included the need for clear pathways to enable early assessment of DFUs by a specialist multidisciplinary service and the provision of structured surveillance and care for those who have had a DFU and are in remission.

One care model that appears to meet these requirements is the Leg Club community‐based social model of wound care33, 43 led by wound nurses in the UK and in other locations, where patients regularly meet together sharing therapy information and engaging socially. This model has been successful in significantly enhancing patients' ulcer healing, reducing pain, and recurrence, as well as improving patients' mood, sleep, and quality of life.43

3.4. Patient engagement

Patients who were interviewed about their leg ulcer therapy29 mentioned that they benefitted the most from a gain in confidence in the treatment being given, decreased pain, and being able to continue to live normally. What patients wanted was a clear diagnosis and therapy objectives, rapid wound closure and confidence in the therapy. This infers, also, that patients should be provided with education so that they may understand the complexity and importance of treatments – as in the study of home care where patients were taught to replace wound dressings at home.30 Patient engagement is likely to have contributed to the positive change in quality of life and other outcomes for the small group therapy sessions for Leg Clubs.33 We noted that the notion of patient‐centred care and patient involvement in clinical decision‐making was also a priority in wound management protocols cited in Table 3,6, 9 being described especially well in the Canadian guidelines by Orstead et al.6

This current evidence signals the importance of a patient's engagement in their wound care, and the potential for further investigation of the effect of their engagement as an indicator of quality care.

In conclusion, the limitations of this review are recognised. There was a scarcity of published literature related to the topic and the levels of research evidence were low. Literature on wound centre management and nurse leaders was lacking. The reviewed literature, however, includes 10 studies published within the last 2 years and hence reflects very recent research. Overall, this enabled synthesis of current research related to best practice of care delivery in a community‐based wound centre. The findings provide a basis for future research more closely focused on how nurse‐led community wound care services may meet patient needs, and the development of quality indicators for these specific wound care services.

3.5. Recommendations

A community‐based wound care service should consider adopting the recommendations (seen in Table 4) that arise from this review of literature. Unequivocal evidence shows that shorter time to wound healing decreases costs and burdens for patients and health systems. Thus, the recommendations each have a role to play in improving care and decreasing the cost of wound care.

Table 4.

Eight care quality recommendations for a community‐based wound care service based on findings in this review

Indicator	Recommendation
The ideal model of community‐based wound care	An appropriately staffed interdisciplinary or multidisciplinary community‐based wound centre that treats routine wounds according to EB practice protocols and has well‐established pathways/links to refer non‐responsive more complex wounds to a central tertiary facility, or hub, with enhanced diagnostic, treatment, and surgical capabilities.
2. Team‐based care	Wound care requires a multidisciplinary team‐based structure, whether providers are colocated or positioned at independent centres. Structured referral and communication channels should be developed, together with agreed or shared EB protocols for treatment and follow‐up (frequency, timing).
3. Nurse leaders	Nurses are appropriate team leaders and should be formally qualified in wound care through a postgraduate degree course to enable them to lead, mentor, and educate other nurses and health care providers.
4. Evidence‐based practice	Consistent use of evidence‐based (EB) practice protocols for each of the wound types is likely to enhance patient outcomes. A model Wound Prevention and Management Cycle (Orsted, 2017) may assist this plan. The NICE UK website offers a significant number of EB wound care resources
5. Patient‐centred care	Informed patients who take responsibility for their wound care and are involved in the decision‐making process are likely to be more satisfied with care. Written materials are helpful. Patient/carer education is a component of care protocols.
6. Nurse‐led patient therapy in small groups	Following the success of leg clubs in improving diverse health outcomes of diabetes WC patients, consideration should be given to developing a new model of patient‐centred small group therapy sessions/program for sufferers of similar or mixed wound types.
7. Quality of care indicators and standard setting	The European Wound Association lists over 40 quality of care indicators for a Wound Centre; centres may benefit from choosing a set of these items to act as benchmarks for quality of care (eg, time to heal, 3‐month healing rates, time free of ulcers, HRQL, patient satisfaction, and resource use) to track performance.
8. Innovation	Telephone follow‐up, a patient help‐line, and telemedicine options were suggested and could be innovative and effective additions to service delivery.

4. CONCLUSIONS

A community‐based wound care centre that provides centre‐based and outreach services (such as in‐home care) is an appropriate model for best practice of wound care. Community clinics require advanced practice nurses with wound care qualifications (such as NPs) or nurses with wound care skills and experience, to facilitate the assessment and management of patients in accordance with evidence‐based best practice protocols. As per best practice recommendations, at least two disciplines should be involved in team‐based wound care, and there is a need to achieve this by having well‐developed collaborative principles for practice accepted across disciplines and across health care sectors. There is a need for patients to have confidence in the treatment provided, which may best be assured through the provision of education of patients and carers.

The quality indicators developed in Europe by Pruim et al (2017)2 for assessing a wound care service for accreditation go some way towards setting performance benchmarks. We recommend that service administrators and/or leaders adopt core descriptors to evaluate performance in order to determine the overall outcomes of wound care.

CONFLICT OF INTEREST

The authors declare that they have no conflict of interest.

Seaton PCJ, Cant RP, Trip HT. Quality indicators for a community‐based wound care centre: An integrative review. Int Wound J. 2020;17:587–600. 10.1111/iwj.13308