Implementing evidence-based leg ulcer management
- Angela Tinkler, BSc(HONS), PG DIP1,
- Julie Hotchkiss, SRN, MPH, HON MFPHM1,
- E Andrea Nelson, RGN, BSc(HONS)2,
- Liz Edwards, RGN, DN, BSc(HONS)3
- 1Wirral Health Authority, St Catherine's Hospital, Merseyside, UK
- 2University of York, York, UK (Department of Nursing, University of Liverpool at time of project)
- 3Wirral and West Cheshire Community NHS Trust, Merseyside, UK
Leg ulceration is a chronic, recurring condition and it is estimated that 1% of adults will have a leg ulcer at some time. The majority of leg ulcers are due to venous disease, with arterial disease, diabetes, auto-immune diseases, and malignancy accounting for about 25%. In the UK, leg ulcers are usually managed by nurses.1 A systematic review of research on compression bandaging concluded that venous ulcers should be treated with multilayer high compression bandaging.2 No particular high compression bandaging regimen was found to be superior; Unna's boot, short stretch bandages, and multilayered elastomeric systems were all effective. Simple wound dressings are generally placed underneath the bandage and over the ulcer to allow healing to occur without drying of the wound and to prevent trauma on dressing removal and sensitisation to topical preparations.
In the Wirral, a mixed rural and urban area in north west England (population 332 000), we implemented 2 effective compression bandaging regimens. The use of appropriate primary wound dressings was also implemented as there is no evidence that semiocclusive or occlusive dressings such as foams, films, or hydrocolloids are more effective than simple, inexpensive dressings (eg, knitted viscose dressings or saline gauze) for venous leg ulcers.3 This paper describes the changes in practice and patient outcomes after the implementation of evidence-based guidelines for assessment, bandaging, and wound dressing.
An initial audit of leg ulcer care and patient outcomes was commissioned using data collected by local practitioners. The local prevalence of ulceration (1.42 ulcers per 1000 people) was similar to national estimates for the UK. 21 different types of dressings were used. Of 319 ulcers, 83 (26%) were treated with dressings that contained iodine, 60 (19%) with hydrocolloid dressings, and 42 (13%) with knitted viscose dressings. 14 types of cream or ointments and 30 different types of bandages were used, of which only 21% were compression bandages. 25% of ulcers healed in 12 weeks.
In a baseline survey of knowledge and reported practice relating to leg ulcer care, nurses scored an average of 40%.4
Implementing the Wirral Leg Ulcer Pilot Project
The following were key elements required to narrow the gap between current practice and best possible practice:
All staff in the Wirral to adopt a consistent approach to leg ulcer assessment and treatment
Use of handheld Doppler ultrasound should be part of the assessment
Patients should be assessed to determine suitability for compression bandages or need for referral for specialist medical opinion
Handheld Dopplers and compression bandages should be readily available
Nurses should be trained in the application of compression bandages
Nurses should apply a simple low adherent dressing to venous leg ulcers.
Although it was clear that multilayer compression was beneficial, the best method of application was unclear. It was decided to advocate the use of 3 and 4 layer systems (table). This minimised costs while enabling nurses and patients to exercise choice.
The estimated cost of using each of the two bandaging regimens for 12 weeks was £103.08 for the 4 layer, and between £49.22 and £100.32 for the 3 layer regimen (1996 costs), depending on the ability and propensity of patients to wash and reuse their bandages.
SECURING FUNDING FOR THE PROJECT
First year costs (setup, bandages, and evaluation) were £135 000 and recurrent annual costs are £55 000 (to purchase the elements not available on prescription). The local health authority, which purchases health care for local residents, agreed to provide £70 000 for the first year to buy treatments not available on prescription (such as orthopaedic wool, shaped tubular bandages, and cohesive bandages) and to fund a nurse specialist. The development, implementation, and evaluation of the nurse training package cost an additional £39 000.
The nurse training programme comprised:
2 study days with lectures on leg ulcer aetiology, assessment, treatment, prevention of recurrence, referral, and skin care
Practical workshops on using handheld Dopplers and applying compression bandages
A video showing application of the 4 layer and 3 layer bandaging regimens
Visits to leg ulcer clinics to observe and practise patient assessment and bandage application
A training package containing reference information and self assessment exercises.
DEVELOPMENT OF A DATABASE
The introduction of the guideline was identified as an opportunity to set up a system to monitor the process and patient outcomes in leg ulcer management. The local community care providers developed a comprehensive database, which enabled ongoing audit of patients with venous leg ulcers. Nurses sent 3 monthly updates on all patients with venous leg ulcers to the clinical nurse specialist and these data were used to generate reports on patient outcomes.
USE OF COMPRESSION BANDAGING
Between July 1995 and April 1997, 138 patients (36%) were treated with 3 layer bandaging and 194 (51%) with 4 layer bandaging (ie, a total of 87% received compression compared with 21% at baseline). 45 (12%) did not tolerate high compression as per the guideline and were treated using reduced compression, 2 received no bandaging, and 1 person wore a compression sock.
USE OF PRIMARY DRESSINGS
At baseline, the most commonly used primary dressings were hydrocolloid sheets (19%), simple dressings (14%), and iodine impregnated petroleum gauze (14%). After introduction of the guideline, fewer than 5% of patients were treated with a hydrocolloid, and 94% were treated with a simple non-adherent dressing. The range of dressing types decreased from 21 before implementation to 5 after implementation. There is no evidence that dressings that contain iodine or hydrocolloid dressings are more effective than simple dressings,3 and hence the cost difference (approximately £2.00 compared with £0.30 per dressing) may result in considerable savings.
There were significant changes in knowledge about leg ulcer assessment, treatment, and reported practice after nurses completed the training programme.4 Bandaging skill also improved: before training, most nurses applied compression bandages in such a way as to produce a tourniquet effect. After training this fell to 40% of nurses for the 4 layer and 64% of nurses for the first 2 layers of the 3 layer regimen.4
ULCER HEALING RATES
Patient and ulcer healing rates were assessed quarterly using the audit data. Some patients had >1 ulcer; presenting the healing rates by patient gives a lower figure because patient healing requires that all of a patient's ulcers heal. Although this study did not evaluate the bandages per se, and patients were not randomised to the alternatives, we compared the proportion of patients whose ulcers completely healed using the different systems; these were not significantly different (34% v 32% at 12 wk and 60% v 54% at 24 wk, in the 3 and 4 layer systems, respectively). The healing rate for patients treated with reduced compression therapy was 19% at 24 weeks. One of the barriers to documenting the results was that nurses failed to report when healing occurred.
Barriers to implementation
ORGANISATION AND FUNDING OF SERVICES
Thorne conducted a systematic review of community leg ulcer clinics and found that although they appear to improve patient outcomes, poor research design meant that it was not possible to tell whether improvements in outcome were independent of other changes in the service, such as provision of training or bandaging.5 Given that Cullum and Last found that 78% of patients receiving district nurse visits for leg ulcer treatment were fully mobile, it seemed sensible to establish clinics so that nurse travel time could be minimised.6 Initially, plans were drawn up for weekly community leg ulcer clinics in each of the 6 areas of the Wirral. Some general practitioners (GPs), however, especially those who employed nurses directly to work with their caseloads, refused to allow “their” staff to treat other patients. A compromise was reached whereby patients received care in one of 3 settings—community clinics in health centres where patients of many GPs were seen, clinics in GP premises where patients from that practice were seen, and at home.
Although most leg ulcers can be treated in the community, recalcitrant leg ulcers require referral to hospital for further investigation and treatment. A few patients with uncomplicated leg ulcers may be treated in hospital if they are admitted with co-existing medical problems. Unfortunately, few hospital nurses were able to attend the training. This threatened the continuity of care between hospital and community. The community leg ulcer specialist was frequently called into the hospital to treat patients because no nurses were available who had undergone training in the application of compression bandages.
Within the local secondary care setting, only the 4 layer bandage system was used because of the consultant's preferences and because a component of the 3 layer regimen (class 3c bandage) was not readily available through the hospital stores. This posed a problem for patients who had already started the 3 layer regimen in the community and had to change to the 4 layer if they were referred to secondary care.
LACK OF AVAILABILITY OF BANDAGE COMPONENTS
Some components of the effective bandaging systems (eg, orthopaedic wool padding, shaped tubular bandages, and cohesive bandages) were not available on prescription. This project was possible because the health authority provided £55 000 each year for the purchase of non-prescription items. Thus the cost of setting up a similar service in other districts may be prohibitive until the issue of provision of items not available on prescription is addressed.
The provision of research funds to develop, implement, and evaluate a comprehensive training package was crucial to the implementation and success of the project
Involvement of the independent sector (ie, nursing homes) was essential to ensure continuity of care
Involvement of the hospital tissue viability nurse and senior nursing or clinic managers might have increased the uptake of the training by hospital nurses and reduced the need for the project nurse to treat patients in the hospital
Multilayer compression bandaging was effective in settings other than leg ulcer clinics
Even after training not every nurse could apply compression therapy to the same standard
3 layer compression therapy can be more difficult to apply than 4 layer, but the comparability in terms of cost effectiveness is unclear.
We reported the improvements in practice and patient outcomes after the implementation of an evidence-based guideline. The approach to implementation was multifaceted, incorporating interactive study days, audit and feedback, paper-based teaching materials and guidelines, video, educational outreach, and organisational change. In the evaluation, we could neither determine the relative contribution of the different implementation strategies nor of the individual changes to leg ulcer care such as change in bandage use, nurse training, and reorganisation of service. Implementation of the guideline, however, was clearly associated with improved practice and patient outcomes.
We are grateful to North West Region NHS Executive for funding the project.