Reality TV Managing patients in the real world. Wounds UK Harrogate 2009

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Stephen McBride
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1 Reality TV Managing patients in the real world Wounds UK Harrogate 2009

2 Reality TV Managing patients in the real world Brenda M King Nurse Consultant Tissue Viability Sheffield PCT Harrogate 2009

3 Familiar sight..?

4 Wet Oedematous legs.?

5 Complex wounds..?

6 Bandaging Technique?

7 Unravelling a problem?

8 Reality TV How do we manage patients like this in the real world..??

9 The Centre For Research and Implementation of Clinical Practice Understanding Chronic Oedema in Venous Disease Professor Christine Moffatt CBE Harrogate 2009

10 Chronic Oedema What is Oedema..? Oedema is an increase in interstitial fluid volume What is Chronic Oedema.? Oedema that has been present for more than 3 months and does not completely resolve on elevation

11 Lymphovenous (Chronic) Oedema 40 % of patients with chronic venous ulceration show signs of Lymphovenous Oedema

12 Chronic Venous Disease Why does venous disease result in Chronic Oedema? DVT and severe Chronic Venous Insufficiency cause damage to the deep sub- fascial lymphatics associated with damaged veins Areas of lipodermatosclerosis show damaged superficial prefascial lymphatics

13 Causes of chronic oedema Increased venous capillary pressure Heart failure Venous insufficiency (CVD) Dependency Oedema

PATHWAY TO VENOUS ULCERATION AND CHRONIC OEDEMA DVT Varicose Veins Immobility Reduced calf/ foot pump Increased Lymph flow Ischaemia Neutrophil activation Venous Hypertension Dermal Capillary

14 PATHWAY TO VENOUS ULCERATION AND CHRONIC OEDEMA DVT Varicose Veins Immobility Reduced calf/ foot pump Increased Lymph flow Ischaemia Neutrophil activation Venous Hypertension Dermal Capillary hypertension Increased Capillary permeability Vasodilatation Oedema occurs rapidly Oedema/Protein leakage Loss of veno/arteriolar reflex Tissue fibrin accumulation Decreased perfusion Ulceration/Chronic oedema

15 Development of Chronic Oedema

16 Progressive chronic oedema of the foot

17 Chronic Oedema in the Community

18 Uncontrolled Chronic Oedema Consequences of uncontrolled chronic oedema Impaired venous ulcer healing Increased risk of venous ulcer recurrence Cycles of cellulitis Decreased patient mobility Reduced quality of life for patients Professional management problems

19 Conclusion The Centre For Research and Implementation of Clinical Practice Compression will always remain the cornerstone for managing chronic oedema related to venous disease

20 Clinical Trial Recruitment Urgo are now seeking to recruit Investigating Centres for: European RCT Comparing two bandage compression systems Indication: Venous Leg Ulcers 8 patients per Recruitment Centre in a 1 year period Follow-up for 3 months If you would like to become an Investigator for this RCT: Please contact: Lesley Hobson Clinical Research Manager l.hobson@uk.urgo.com OR please visit the URGO stand

21 Compression bandaging for Lymphovenous Oedema 10 Case studies evaluating a new system Debra Doherty Clinical Nurse Specialist Lymphoedema Harrogate 2009

22 Background 10 Patients with Chronic Oedema Hospital & Community setting Written consent

23 Background Standardised protocol - interface pressure measurement Kukihime device B1 level measurement Same practitioner Assessment of arterial status

24 Case studies Wear time varied Patients asked about their subjective experience Ankle circumference measurements were re- evaluated

25 Case study 1 35 year old female Swelling of the right ankle and lower leg traumatic injury 6 months previously Subcutaneous tissue soft with pitting oedema ABPI on the right on the left - 1.0

26 Case study 1 After 1 week K Two bandage system applied to right leg, toe to knee Sub-bandage pressure 40mmHg on application of the system Reduction in ankle circumference cm (3.4 cm) after 1 week Minimised tightness and discomfort

27 Case study 2 66 year old female with bilateral lymphovenous swelling of the legs Full range of ankle movement Walks daily Usually wears compression garments

28 Case study 2 Tissue is soft with pitting oedema Positive Stemmer s sign She experiences heaviness and discomfort in the legs ABPI on the right on the left

29 Case study 2 (after 2 days) K Two bandage system applied to right leg toe to knee Sub-bandage pressure 32mmHg on application Very pleased as able to wear usual footwear Reduction of 1.5cm in ankle circumference after 2 days

30 Case study 3 59 year old female Gradual onset of swelling of ankles and feet aged 56 The tissue is soft and pitting She experiences discomfort, tingling and feeling of fullness in the legs ABPI on the right on the left

31 Case study 3 after 1 week K Two compression bandage system applied to left leg from toe to knee Sub-bandage pressure was 41mmHg on application Reduction in ankle circumference cm (2.1 cm in one week)

32 Patient experiences with K Two Supportive and comfortable when walking Eliminated tight feeling at end of the day Able to wear normal shoes Liked ability to wash & re-use outer layer Aided self management

33 Conclusion The use of K Two in the treatment of Chronic Oedema (Lymphovenous oedema) in the 10 case studies showed: Correct pressure range consistently applied Reduction in limb circumference Ease of use Bandage slippage was not an issue These case studies show that K Two has the potential to be an effective system for the compression of patients with Lymphovenous oedema. This study will lead the way for more robust clinical research in an area where there is currently little clinical evidence and will lead to huge potential benefits to both patients and clinicians

34 REALITY TV Ankle Sizes Addressing the BIGGER picture! Kate Bennett Tissue Viability Specialist Nurse East Sussex Downs and Weald NHS Harrogate 2009

35 Unreality TV?

37 Introduction Inelastic short-stretch compression predominant in PCT For large ankles > 25cm Requires 2 layers of compression bandages to achieve correct therapeutic graduated compression Effective - however in some cases, patients find it bulky and hot to wear, causing irritation especially when varicose eczema present The following cases demonstrate how changing to a new compression bandage system resolved the above problems and reduced the healing time of the venous leg ulcers

38 Case study 1 - Karen 46 year old with recurrent venous leg ulcers Predisposing factor DVT post caesarean 20 years ago Treated with inelastic compression therapy (PCT policy) Recurrence Feb 2009 March 2009 non-attendee to leg ulcer clinics Sept 2009 presented with large infected ulcer left leg Surrounding skin excoriated Pain level 10 at rest, at night and on exercise Crying and feeling very unwell

39 Initial Presentation 4 / 9 / 2009

40 Karen Reassessed and re-dopplered to confirm venous aetiology Ankle size > 25cm History of treatment with inelastic short stretch compression bandaging Needed padding and 2 layers of bandages to achieve adequate graduated compression Very active working long hours on her feet (barmaid) Wound : 6 cm x 5 cm Extending cellulitis Excoriation from exudate Plan : Try a new compression system K Two 25-32cm Daily dressings initially for 2 weeks with antimicrobial silver dressing Then weekly clinic visits with N/A dressing and K Two until wound healed

41 Full healing achieved in 7 weeks Initial presentation After 4½ wks with K Two Healed after 7 weeks

42 Case 2 - Peter 66 year old gentleman with a chronic venous leg ulcer following a train crash Occlusive dressing and compression hosiery had proved unsuccessful in the past due to irritant contact dermatitis Took weeks to persuade him to wear compression bandages Commenced inelastic short stretch compression system Happy initially but slow to heal Found it increasingly restrictive round his ankle and painful due to bulk of bandages necessary for larger ankle sizes After 6 months, wound not healed and refused to wear short-stretch Started on K Two 25-32cm 7 th September 2009

43 Peter from week 0 week 4 75% wound reduction in only 4 weeks with K Two

44 Mr W My first success using K Two 58 year old carpet fitter with recurrent skin breakdown Ankle size > 25cm Previous history of a venous leg ulcer 2004 Cellulitis October 2007 resulted in VLU right lateral gaiter Found layers of inelastic bandage too bulky and restrictive at work Bandages slipped while he worked so not effective therapy Hosiery with adhesive dressing also caused irritant dermatitis Knees became oedematous with below knee hosiery Wound healed for short period August 2008 broke down again after 2 weeks due to friction from stockings

and for a further 6 weeks after wound healing to reduce risk of skin breakdown Remains healed wearing

45 Commenced K Two 25-32cm 14 Oct 08 Wound healed in 6 weeks (end November 2008) Found it extremely comfortable Didn t slip whilst working No evidence of increased knee oedema K Two was applied weekly and for a further 6 weeks after wound healing to reduce risk of skin breakdown Remains healed wearing MTM thigh length compression hosiery Leg Ulcer during previous treatment Wound size at commencement of K Two

46 Summary K Two has proved to be successful and effective for active patients with venous leg ulcers Less bulk for ankles > 25cm Quotes from the patients wearing the system So comfortable to wear I forgot I even had a problem and got on with my job Just like wearing a sock Putting them into this system didn t appear to impact their daily lives and lifestyle Showed good healing rates Improved patient s Quality of Life

47 Thank you for your attention

48 Reality TV Managing patients in the real world Wounds UK Harrogate 2009

Improving customer care in compression hosiery

Improving customer care in compression hosiery Introduction Within the modern NHS, the Pharmacy Team provides the front line service that most patients have contact with. Compression hosiery has a key