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Treatment and prevention of recurrence of venous leg ulcers using

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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
	8 It is important to demonstrate         References                                     Iglesias C, Nelson EA, Cullum NA,
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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




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