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Clinical PRACTICE DEVELOPMENT
Clinical PRACTICE DEVELOPMENT
Treatment and prevention of
recurrence of venous leg ulcers
using RAL hosiery
Advances in technology over the last ten years have allowed for greater choice of compression therapy.
Leg ulcer services need to provide up-to-date, high quality services that ensure safety, effectiveness and
improvements to the patient experience.This includes monitoring and reporting on leg ulcer healing rates
and prevention of recurrence.This paper discusses a redesign in a community leg ulcer service, including the
introduction of RAL compression hosiery. Healing rates improved from 36% at 12 weeks to 72%, and from
40% at 24 weeks to 100%. Recurrence rates for venous leg ulcers also reduced from 18–20% to 5.8%.
Caroline Dowsett
Venous leg ulcers are the most improvements in venous ulcer services,
KEY WORDS common leg ulcer aetiology and such as the availability of tissue viability
Venous leg ulcers are the result of a complex chain of and leg ulcer specialist nurses, more
RAL compression hosiery events resulting from venous valvular patients have their ulcers healed in
incompetence and subsequent a timely manner and the challenge is
Community leg ulcer service superficial venous hypertension (Chen to prevent recurrence. In some areas,
Healing and Rogers, 2007). Over half of venous prevention or well-leg clinics have
Recurrence ulcers are due to slowly progressive been established that focus solely on
primary reflux disease that begins as health promotion and prevention of
varicose veins, and the remaining ulcers recurrence of leg ulceration (Dowsett,
develop after deep vein thrombosis 2010).
L
eg ulceration affects (DVT) and are prone to advance more
approximately 580,000 rapidly to the ulcer stage in periods Leg ulcer services
individuals at any one time in from six months to several years post Many parts of the UK have followed
the UK, causing increased morbidity DVT (Kistner, 2010). Venous disease is a model of leg ulcer care based on
and reduced quality of life (Callam progressive and recurrent ulceration is ‘nurse-led’ community leg ulcer clinics.
et al, 1985; Moffatt et al, 1992). frequently accompanied by new venous Rates of healing of venous leg ulcers
As well as associated patient costs pathology, such as the development of have been shown to improve, with
such as pain and suffering, the cost new varicosities, new locations of reflux, costs reduced when a coordinated
to the NHS is between £300–600 or new incompetent perforating veins. service has been introduced
per annum (Bosanquet, 1992; Simon (Moffatt et al, 1992). However, these
and McCollum, 2004). The majority Compression therapy is the core improvements are only sustainable
of these ulcers are of venous origin, intervention in venous leg ulcer with regular training and suppor t
requiring an average of 24 weeks to treatment (Cullum et al, 2006). from specialist services such as tissue
heal; approximately 15% never heal Reported healing rates of venous viability and leg ulcer specialist nurses,
and recurrence is found once or leg ulcers treated with compression and should be monitored and audited
multiple times in 15–71% of cases therapy vary greatly, from 37–46% at to ensure improved outcomes and
(Kurz et al, 1999). 12 weeks and 55–68% at 24 weeks improvements to service quality in
(Iglesias et al, 2004). The majority line with current policy directives.
of these patients, up to 80%, are Audit not only measures outcomes
cared for in the community setting for patients, but can also identify
by community nurses and/or their areas where good practice or policy
general practitioner (Moffatt et al, is not being adhered to (Vowden and
1992). Many patients are cared for in Vowden, 2010).
nurse-led community leg ulcer clinics,
Caroline Dowsett is Nurse Consultant Tissue Viability, often organised by district nurses with The care of patients with venous
East London NHS Foundation Trust, Community Health, specialist input from tissue viability leg ulcers has improved over the last
Newham or leg ulcer specialists. With recent ten years (Dowsett, 2010). Advances
Wounds uk, 2011, Vol 7, No 1 115
Clinical PRACTICE DEVELOPMENT
in technology have led to a greater the community nursing service with two dedicated leg ulcer coordinators
choice in compression therapies. specialist input from the tissue viability from the community nursing service
Bandages, hosiery kits and hosiery are team. Over time, variations in practice who would take sole responsibility for
now used in the treatment of venous were noted across the localities and the nurse-led leg ulcer clinics and the
leg ulcers. Early referral to leg ulcer some clinics appeared to have better well-leg clinics. Following approval, the
services often means that the patient patient outcomes than others. two coordinators worked alongside
presents with a small leg ulcer and the two clinical nurse specialists in
therefore compression hosiery kits or tissue viability to drive up quality and
compression hosiery can be offered as Patients are more likely to improve outcomes in the leg ulcer
a first treatment choice. comply with compression treatment and prevention clinics.
therapy that is easy to
A recent meta-analysis of studies use and reduces pain and A number of service developments
that compared a variety of bandages discomfort. followed, including:
with specifically designed stockings 8 Education and training of the leg
for venous leg ulcer management, ulcer coordinators
found that stockings were easier to A comparative audit of the leg 8 Increased use of hosiery kits for
use and that patients using stockings ulcer clinics for 2007 and 2008 treatment of venous leg ulcers
experienced less pain (Amsler et showed that care was not consistent 8 A move to using RAL compression
al, 2009). Additionally, a greater across the localities and aspects of hosiery in the prevention
proportion of ulcers healed in best practice were not being sustained. of recurrence of venous leg
patients treated with stockings than in Nurses were failing to measure ankle ulceration.
those treated with bandages (62.7% circumferences that determined
versus 46.6%; P<0.01).The average the amount of compression to be Traditionally, British class hosiery
time to healing (seven studies, 535 used, and many patients did not has been used in community leg
patients) was three weeks shorter have up-to-date Doppler readings. ulcer clinics, as this was available on
with stockings (p=0.001) than with Patients reported varying levels of prescription (FP10). However, the
bandages (Amsler et al, 2010). satisfaction depending on which levels of compression vary significantly
clinic they attended. Following the from RAL hosiery (Table 1) which is
Patients are more likely to comply audit a business case for change now available on FP10. Additionally,
with compression therapy that is was proposed by the tissue viability RAL offers more available sizes and
easy to use and reduces pain and service, including the appointment of has an extra wide calf size.
discomfort. Developments in hosiery,
such as improvements to fabric,
range of available sizes and colours Table 1
have lead to improvements in patient Compression hosiery pressures
concordance, with wearing hosiery
leading to a reduction in recurrence
rates. In a study that followed 113 Title Available Strength Features
patients over 15 years, ulcer healing
was 97% in patients who adhered to Support Retail shops Less than 10mmHg Non-medical
treatment and 55% in those who did hosiery
not. Mean time to ulcer healing was Anti-embolism Hospitals for DVT 16–18mmHg For patients, pre, peri and
5.3 months. Ulcer recurrence was stockings prophylaxis post surgery
29% in five years. In the non-adherent
group, all ulcers recurred at 36 months Travel socks Over the counter 20mmHg For travel on planes, trains, car
(Maybury et al, 1991).
British FP 10 prescription Class 1 14–17mmHg Clinically effective for up to three
standard Class 2 18–24mmHg months, four sizes
Redesign of leg ulcer services hosiery Class 3 25–35mmHg
In Newham, four nurse-led community
leg ulcer clinics were set up in 1996, RAL standard Only available from Class 1 18–21mmHg Clinically effective for up to
resulting in improvements to the hosiery hospital appliances in Class 2 23–32mmHg six months
management of patients with venous the past Class 3 34–46mmHg Seven off-the-shelf sizes as well as
leg ulcers (Dowsett, 1997). Following Now available on FP10 Class 4 over 49mmHg custom-made
the success of the leg ulcer clinics, Comprehensive range of styles
three additional well-leg clinics aimed and colours
at preventing recurrence of venous Upper and lower limb garments
leg ulceration were established. These
clinics were organised and run by
116 Wounds uk, 2011, Vol 7, No 1
Clinical PRACTICE DEVELOPMENT
2009 2010 active leg ulcers. Care across the
120 four localities shows an improvement
in continuity and consistency in
100
practice. A re-audit of best practice
% of patients
80 in the clinics shows an increase in the
number of patients with full leg ulcer
60
assessments, measurement of ankle
40 circumference, current ankle brachial
pressure index (ABPI) readings, wound
20
measurements taken, and up-to-
0 date care plans. Data comparison for
t nce PI PI n e red m
sm
en
ere AB AB pla dat asu ure
d
t fo
r
2009/10 is outlined in Figure 1.
t re in
ses m
as r mf r ren Ca pla
n me eas en
rcu Cu LU m
nd ate ses
sm
LU fo le ci Ca
re
ou in d nd as
A nk W u Patient treatment outcomes have
Wo also improved, with healing rates for
Figure 1. Leg ulcer clinic data comparisons 2009/10. venous leg ulcers improving from
36% at 12 weeks to 72%, and from
It should be noted that some More importantly, the feedback 40% at 24 weeks to 100% for 2010.
centres refer to ‘European’ class from the patients has been positive. Patient reported satisfaction has
hosiery, but this does not exist as a Patients report a better fit, ease of also improved, with patients feeling
recognised classification. application and they are more likely that they are now receiving greater
to be concordant with treatment. In continuity in their care.
Patient outcomes and efficiency gains terms of outcomes, the recurrence
Recurrence rates in the nurse-led clinics rates have been reduced from 18–20% Conclusion
before the changes were between down to 5.8% for the period April– In the current healthcare climate, it
18–20%. Some of this was in part due September 2010. is important to demonstrate how
to patients not wearing their hosiery services are driving up quality, increasing
because of poor fitting, discomfort productivity and increasing patient
and a general lack of concordance.
Regular monitoring of satisfaction (Dowsett and White, 2010).
Many patients failed to attend follow- healing and recurrence The three domains of quality are safety,
up prevention appointments. The rates through audit and effectiveness and patient experience
effectiveness of compression hosiery is patient satisfaction surveys and this service redesign has addressed
due to correct fit, pressure generated is important for advancing the quality agenda and demonstrated
beneath the stocking and, of course, practice, and also for that taking a different approach to the
relies on the patient wearing their delivery of leg ulcer care can significantly
stockings. The following benefits of
identifying those patients improve patient outcomes and their
using RAL hosiery have been seen by who are not healing in a experience. However, as clinicians,
the leg ulcer clinics: timely fashion. we need to be constantly looking at
8 Patients get a higher level of innovative ways of achieving clinically and
compression and are therefore cost-effective patient-centred care. While
more likely to remain healed The leg ulcer coordinators report many patients have benefited from this
8 They have more choice of size that they have had to request less service development, there are still those
with extra wide calf and shoe size made-to-measure hosiery, as the patients who do not heal in compression
available increased availability of sizes means and need to be managed outside of
8 They are reviewed every six that many patients who have had the nurse-led community leg ulcer clinic
months instead of three months, as made-to-measure in the past now fit model in more specialist areas.
the hosiery lasts for six months in sizes available on FP10. To ensure
8 This has lead to increased that patients receive their compression Regular monitoring of healing
productivity in that more patients hosiery in a timely manner, the clinics and recurrence rates through audit
can be seen in the clinic as less carry a stock of RAL hosiery. Patients and patient satisfaction surveys is
frequent visits free up time for are measured, fitted and have their important for advancing practice, and
new patients hosiery applied and they replace the also for identifying those patients who
8 The cost has decreased as each stock on the first review visit. are not healing in a timely fashion.
patient requires less nursing time These patients can be referred to
and the hosiery lasts for six months As well as improving recurrence specialist clinics where they can be
instead of the previous three months rates for venous leg ulcers, the service considered for further investigations,
8 Patients now attend routine follow- redesign has also impacted on the surgery, advanced products such as
up appointments. management of those patients with skin substitutes, or other biological
118 Wounds uk, 2011, Vol 7, No 1
Clinical PRACTICE DEVELOPMENT
based on a symposia presentation at ulcers. Symposia Presentation. Wounds
the Wounds UK Conference in UK. November 2010.
November 2010. Dowsett C, White R (2010) Delivering
Key points quality and the High Impact Actions. Br J
Healthcare Management 16(2): 609–10
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Acknowledgements 12(12): 861–3
audit in demonstrating quality in tissue
This paper has been sponsored by an Dowsett C (2010) RAL Hosiery: Treatment viability services. Wounds UK 6(1): 100–
educational grant from medi UK and is and prevention of recurrence of venous leg 105
To order your copy, please go online to: www.wounds-uk.com
Wounds uk, 2011, Vol 7, No 1 119
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