Managing venous leg ulcers and oedema using compression hosiery

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1 Managing venous leg ulcers and oedema using compression hosiery Tickle J (2015) Managing venous leg ulcers and oedema using compression hosiery. Nursing Standard. 30, 8, Date of submission: July ; date of acceptance: August Abstract Increasing demand for services and rising costs in the NHS have resulted in reduced consultation times and resources for clinicians when treating patients with compression therapy. This article emphasises the importance of considering alternative treatment approaches, while encouraging patient choice, independence and self-care. One alternative treatment is the use of compression hosiery kits for the management of venous leg ulceration and oedema. Author Joy Tickle Tissue viability nurse specialist, Shropshire Community Health NHS Trust Tissue Viability Service, Shropshire, England. Correspondence to: joy.tickle@shropcom.nhs.uk Keywords compression therapy, hosiery kit, leg ulcer management, oedema, venous insufficiency, venous leg ulcers, wound care Review All articles are subject to external double-blind peer review and checked for plagiarism using automated software. Online For related articles visit the archive and search using the keywords above. Guidelines on writing for publication are available at: journals.rcni.com/r/author-guidelines. IT IS ESSENTIAL that clinicians and care providers aim to maximise resources and efficiency while ensuring optimum patient outcomes. Increased life expectancy has resulted in an increasing number of patients with multiple comorbidities and with more complex needs. Advances in health technology and surgery have led to the management of more complex wounds, resulting in greater challenges in terms of healthcare provision. One area of increasing expenditure in the NHS is the cost of treating venous leg ulcers, which is estimated to be at least 168 million to 198 million per year (Posnett and Franks 2008), with the cost of treating one leg ulcer estimated to be 1,298-1,526 per year (Scottish Intercollegiate Guidelines Network (SIGN) 2010). These costs add to the financial burden on the NHS and indicate the importance of clinical efficiency and optimum patient outcomes in the management of individuals with venous leg ulcers and oedema. Value of compression therapy Compression therapy is fundamental to the healing of venous leg ulcers, management of chronic venous insufficiency and associated symptoms such as varicose veins and lipodermatosclerosis, and management of chronic limb oedema (National Institute for Health and Care Excellence (NICE) 2012). Compression therapy supports the superficial veins in the limb and counteracts raised capillary pressure. The benefits of using compression therapy for the management of leg ulcers are established (World Union of Wound Healing Societies 2008, O Meara et al 2012, Harding et al 2015). However, new products and evidence provide alternative treatment options to the traditional approach of applying four-layer compression bandaging. Such options allow increased choice for clinicians and patients. Greater choice may improve patient comfort and quality of life, thereby aiding compliance with treatment regimens without compromising outcomes (Tickle 2015). It is essential that the clinician establishes the underlying aetiology of the wound to ensure that the most appropriate form of compression therapy is used (SIGN 2010). The clinician should have an understanding of the rationale for compression therapy, normal and abnormal venous return, characteristics of the bandage and/or hosiery material and properties such as elasticity and stiffness (Tickle 2014). It is essential to recognise and understand the interaction between pathophysiology, limb anatomy and compression materials to ensure safe and effective compression therapy (Vowden 2014). A holistic assessment of the patient, including limb, skin and vascular system, is essential if compression therapy is to be successful (Box 1). A vascular assessment should include a Doppler ultrasound recording, which is vital to ascertain if there is compromised arterial flow. The patient NURSING STANDARD october 21 :: vol 30 no 8 ::

2 will not be suitable for compression therapy if significant arterial insufficiency is evident (Wounds UK 2015). Compression hosiery or bandaging There are several options for compression therapy, the most common of which use bandaging or hosiery (Moffatt et al 2007). Traditionally, four-layer bandaging was used to manage venous leg ulcers. However, studies have emphasised the clinical, quality of life and cost benefits associated with using alternative forms of compression therapy to assist with venous leg ulcer healing (Ashby et al 2014, Guest et al 2015). These alternatives include BOX 1 Holistic patient assessment Patient-related factors: Medical history. Presence of comorbidities. Previous limb surgery and/or trauma. Family history. Medication history. Nutrition and hydration status. Presenting symptoms. Previous treatment and outcomes. Pain. Psychosocial-related factors: Lifestyle. Occupation. Quality of life. Social activity. Sleep pattern. Dexterity and mobility. Care and social support network. Expectations of treatment. Weight and/or body mass index. Limb-related factors: Ankle brachial pressure index (ABPI). Oedema: below and/or above the knee. Limb size and shape. Mobility and/or ankle movement. Presence of oedema. Vascular-related factors: ABPI to check for arterial insufficiency. Vascular history. Limb temperature. Erythema, pallor and/or cyanosis. Skin-related factors: Hydration. Skin changes such as haemosiderin staining, ankle flare and atrophie blanche. Lipodermatosclerosis. Skin folds. Skin allergies and/or sensitivities. Ulceration, including size, exudate levels, location, presence of infection. Scar tissue. (Tickle 2015) cohesive inelastic compression, two-layer bandaging kits and hosiery kits (Ashby et al 2014, Guest et al 2015). The application of four-layer bandaging should be performed by a skilled and appropriately trained member of the clinical team. However, the ability to apply bandages varies among clinicians (Chamanga 2014). Many patients find four-layer bandaging systems uncomfortable, or even painful, and the bulky nature of the bandages may lead to problems with footwear and reduced mobility. As a result, compliance with treatment regimens and healing rates may be reduced (O Meara et al 2012, Moffatt 2014). Nursing practice is often influenced by personal experience, a colleague s opinion, and tradition or ritual (Flanagan 2005). However, such practices may lead to poor and outdated practice (Flanagan 2005). For example, a clinician may continue to use a particular compression bandage out of habit, rather than selecting a product that meets the clinical needs of the individual. Patient access to effective compression therapy should not be restricted by the experience or knowledge of the practitioner (Moffatt 2014). There is consensus that options that allow for increased patient, family or carer involvement in leg ulcer care are likely to be the preferred management option. The benefits of ease of application and removal and ability to wash and reuse compression hosiery were also identified as important factors in selecting a product (Harding et al 2015). Hosiery kits Advances in the products available for the healing of venous leg ulcers and management of oedema have resulted in hosiery kits that can be used as a first-line treatment and can overcome some of the drawbacks associated with compression bandaging (Ashby et al 2014). Hosiery kits apply graduated compression, increasing venous return in the limb. Hosiery kits have a smooth, inner liner that applies 10mmHg of pressure to the limb. A second garment is then applied over the inner garment to increase the amount of pressure to the limb to 40mmHg (Figure 1). The advantage of using the smooth inner liner is that it allows the stronger outer layer garment to be applied more easily. This assists with ease of application, protects fragile skin and encourages self-care. Hosiery kits may be cosmetically favoured since they are available in a variety of styles, colours and designs. They may also allow the patient to wear their regular footwear, since they are less bulky compared to compression bandaging (Stephen-Haynes and Sykes 2013). Appropriate 58 october 21 :: vol 30 no 8 :: 2015 NURSING STANDARD

footwear and use of cosmetically acceptable hosiery can increase patient confidence and self-esteem when socialising, working or exercising (Tickle 2014).

4 footwear and use of cosmetically acceptable hosiery can increase patient confidence and self-esteem when socialising, working or exercising (Tickle 2014). If a wound is present, the hosiery kit should be worn during the day and night to deliver therapeutic compression therapy at all times. If a wound is not present, the hosiery may be removed at night when resting and reapplied in the morning when active (Activa Healthcare FIGURE 1 Hosiery kit worn on right lower leg BOX 2 The VenUS IV trial The VenUS IV trial was a randomised controlled trial including 453 patients with a venous leg ulcer at 34 centres (community nurse teams or services, GP practices, leg ulcer clinics, tissue viability clinics or services and wound clinics) in England and Northern Ireland, comparing four-layer compression bandaging to two-layer compression hosiery. It concluded that two-layer compression hosiery is a viable alternative to four-layer compression bandaging. There were reduced venous leg ulcer recurrence rates in the hosiery kit group and consistency of compression. When compared to four-layer bandages, two-layer compression hosiery was associated with: Healing in a similar proportion of patients. Healing in a similar time. Mean cost savings of approximately 300 per patient. Lower recurrence rates of venous leg ulcers once healed. (Ashby et al 2014) 2015). If the patient is not able to self-care, the ease of application of the hosiery kit enables a family member or carer to remove or reapply the kit. The use of hosiery kits can assist in promoting patient empowerment, enabling the individual to be involved in their own wound and skincare regimen, including bathing the skin and applying emollients. This may lead to fewer visits to or from clinicians (McNichol 2014, Ashby et al 2014). The VenUS IV randomised controlled trial (RCT) (Box 2) compared the clinical and cost-effectiveness of two-layer compression hosiery with four-layer compression bandaging for healing of venous leg ulcers (Ashby et al 2014). The trial identified reduced leg ulcer recurrence rates, increased cost-effectiveness and improved quality of life for patients (Ashby et al 2014). Findings also demonstrated that compression hosiery kits are a cost-effective and clinically effective alternative to four-layer compression bandaging for healing venous leg ulcers and preventing their recurrence. The trial demonstrated that hosiery kits cost approximately 300 less per patient per year than compression bandaging. This saving was largely attributable to less frequent nurse consultations for hosiery kits (Ashby et al 2014). The findings of the VenUS IV RCT emphasised the benefits of using hosiery kits for patients with open venous leg ulcers exhibiting a low to moderate volume of exudate. The hosiery kits can be used as a first-line treatment and can assist in overcoming some of the negative effects of four-layer compression bandaging, such as bulky bandaging and poor fitting footwear (Ashby et al 2014). Overall, the trial showed that hosiery had a 95% probability of being the most cost-effective treatment. It emphasised that two-layer hosiery kits are as effective as four-layer bandaging with regard to venous leg healing, can reduce recurrence and encourage patient self-care (Ashby et al 2014). Applying evidence to practice It is vital that an appropriate form of compression therapy is selected for each patient. Jones (2014) suggested that a four-step approach to assessment results in the successful selection of compression therapy for the management of venous leg ulcers. This involves assessing (Jones 2014): 1. The patient s health status, comorbidities and possible underlying conditions causing ulceration and/or oedema. 2. The presence of oedema (to identify the correct compression system). 3. The wound status, for example size of the wound and exudate volume. 60 october 21 :: vol 30 no 8 :: 2015 NURSING STANDARD

6 4. The patient s lifestyle factors, for example self-caring and mobility level. The four-step approach requires consistent and regular assessment of the patient s treatment. When appropriate, the patient can be stepped up or down with regard to compression bandage systems and hosiery kits to meet the needs of the individual, the limb and the wound. For example, if the patient s heavily exuding wound reduced to low or moderate levels of exudate, the use of compression bandage therapy could be stepped down to the use of compression hosiery kits (Tickle 2014). When selecting the hosiery kit it is important to choose the correct classification. There are two classifications for compression hosiery kits: British Standard and European class (Tickle 2014). European class hosiery kits have increased stiffness, which provides increased resistance to limb expansion and has a greater effect on the action of the calf muscle pump. These hosiery kits are effective for more oedematous limbs (Tickle 2014). British Standard hosiery kits are best suited to limbs where there is no or limited oedema or distortion (Anderson and Smith 2014). It is important that these factors are considered when selecting compression garments for the patient because it can mean the difference between effective treatment and compliance with the regimen, and ineffective treatment and non-compliance with the regimen resulting from patient discomfort, unresolved oedema and ineffective compression therapy. Following healing of a leg ulcer using the hosiery kit, the patient can be stepped down to hosiery for maintenance and prevention of recurrence. Evidence suggests that those patients whose leg ulcers healed as a result of treatment with a hosiery kit are less likely to experience ulcer recurrence within a 12-month period than those who were treated with four-layer compression bandaging (Ashby et al 2014). This may be because patients treated with hosiery kits were compliant with the long-term use of hosiery since they associated it with the healing of their ulcer and were accustomed to wearing such hosiery. Adopting the step-down approach to leg ulcer healing has benefits for the patient, as outlined in the VenUS IV trial (Ashby et al 2014). It also has benefits for the healthcare system, allowing more members of the healthcare team, including healthcare assistants, to be involved in care delivery. A study assessing the clinical outcomes in patients receiving compression bandaging, indicated that community nurse visits, followed by practice nurse appointments, were the main costs in the provision of leg ulcer care (Guest et al 2015). Involving a wider nursing skill mix in patient care and a reduction in the number of appointments for some patients should result in reduced costs. Application of hosiery kits in Shropshire The use of hosiery kits for the safe and effective delivery of compression therapy has been adopted in Shropshire. In February 2015, a clinical practice audit of a new tissue viability clinic was undertaken to identify clinical outcomes for patients receiving compression therapy. The following clinical outcomes were reported in 15 patients: Ten patients were already receiving compression bandaging from a practice nurse three times per week. Three patients were receiving compression bandaging from community nurses three times per week. Two patients were not receiving any form of compression therapy. From the 15 patients initially assessed, eight were considered suitable for the use of a compression hosiery kit. The patients and clinicians were supported in learning about the safe and effective use of the kit by the clinic nursing staff. All eight patients subsequently required application of the hosiery kit twice weekly for between eight and 20 weeks. The patients reported improved quality of life outcomes such as comfort, cosmetically acceptable appearance and increased independence. From the clinicians point of view, the overall benefits included ease and speed of application, and reduced clinical time and cost, since only two patient visits were scheduled weekly rather than three visits. The hosiery kits also assisted in preparing patients for self-management following ulcer healing. The hosiery kits provided several benefits to clinicians and patients in Shropshire. Patients were empowered to make decisions about the type of compression they wanted, enabling increased independence as well as the ability to self-care. One of the male patients who required compression therapy for a non-healing venous leg ulcer was in full-time employment and found it difficult to attend the GP surgery twice a week for compression bandaging. Following a consultation, it was decided to implement a simple wound and skincare regimen alongside the use of a two-layer compression hosiery kit. Initially, the patient attended the GP surgery once per week for treatment and was able to self-care between visits. This proved successful and after two weeks he chose to self-care exclusively and only attended the clinic for reassessment and follow up. Four weeks later, 62 october 21 :: vol 30 no 8 :: 2015 NURSING STANDARD

7 the patient s ulcer was completely healed and he continued to perform the skincare regimen and apply compression hosiery (Tickle 2015). Overall, patients reported increased control in their treatment because the hosiery kits could be easily applied and removed, and they welcomed the support and encouragement from the clinician. Conclusion The use of a compression hosiery kit and the stepped-down approach from four-layer compression bandaging to compression hosiery is an example of the type of practice change that improves patient outcomes and quality of life, as well as reducing healthcare costs. Compression hosiery kits are an effective therapy for the treatment of venous leg ulcers and an appropriate alternative to four-layer compression bandaging. In the author s area of practice, the use of hosiery kits provided an effective and economical treatment choice. Clinician s time was reduced as a result of the ease of application of the hosiery kits. The use of these kits also prepared patients for the use of maintenance hosiery following the healing of their wound, potentially reducing venous leg ulcer recurrence rates. The hosiery kits were cosmetically acceptable and less bulky than compression bandaging, allowing patients to wear normal clothes and footwear. Patients reported the advantage of being able to remove the garments easily for bathing and the application of emollients to the skin. Hosiery kits enable patient empowerment and involvement in their care, promote independence and increased self-esteem, and reduce the frequency of visits to clinics or the inconvenience of waiting for community nurses to visit. The long-term benefits of compression therapy are only achieved if compression therapy is worn consistently. It is important that the clinician is aware of available compression systems and their selection to meet all of the patient s needs. A compression hosiery kit is one such system NS Conflict of interest Funding for this article was provided by Activa Healthcare. The content of this article reflects the opinion of the author. References Activa Healthcare UK (2015) Compression Hosiery Kits for the Treatment of Venous Leg Ulceration. casestudies-files/compression_ hosiery.pdf (Last accessed: October ) Anderson I, Smith G (2014) Compression made easy. Wounds UK. 10, 3, 1-6. Ashby RL, Gabe R, Ali S et al (2014) Clinical and cost-effectiveness of compression hosiery versus compression bandages in treatment of venous leg ulcers (Venous leg Ulcer Study IV, VenUS IV): a randomised control trial. The Lancet. 383, 9920, Chamanga ET (2014) Community nurses experiences of treating patients with leg ulcers. Journal of Community Nursing. 28, 6, Flanagan M (2005) Barriers to the implementation of best practice in wound care. Wounds UK. 1, 1, Guest J, Gerrish A, Ayoub N, Vowden K, Vowden P (2015) Clinical outcomes and cost-effectiveness of three alternative compression systems used in the management of venous leg ulcers. Journal of Wound Care. 24, 7, Harding K, Dowsett C, Fias L et al (2015) Simplifying Venous Leg Ulcer Management: Consensus Recommendations. tinyurl. com/pckmnu5 (Last accessed: August ) Jones J (2014) In practice: implementing a treatment pathway for compression. Two Component Compression: Concordance, Evidence and Clinical Use. Wounds UK, London, McNichol E (2014) Involving patients with leg ulcers in developing innovations in treatment and management strategies. British Journal of Community Nursing. 19, Suppl 9, s27-s32. Moffatt C, Martin R, Smithdale R (2007) Leg Ulcer Management. Blackwell Publishing, Oxford. Moffatt CJ (2014) Compression therapy: a dramatic intervention in health care. Journal of Wound Care. 23, Suppl 4, s3. National Institute for Health and Care Excellence (2012) Compression Stockings. mpression-stockings#!topicsummary (Last accessed: August ) O Meara S, Cullum N, Nelson EA, Dumville JC (2012) Compression for venous leg ulcers. Cochrane Database of Systematic Reviews. Issue 11, CD Posnett J, Franks PJ (2008) The burden of chronic wounds in the UK. Nursing Times. 104, 3, Scottish Intercollegiate Guidelines Network (2010) Management of Chronic Venous Leg Ulcers. Clinical guideline No SIGN, Edinburgh. Stephen-Haynes J, Sykes R (2013) Audit of the use of compression hosiery in two NHS trusts. Wounds UK. 9, Tickle J (2014) Unravelling practice: compression therapy for venous leg ulcers. Journal of Community Nursing. 28, Suppl 6, Tickle J (2015) How can I improve leg ulcer care when faced with increasing service demands? Journal of Community Nursing. 29, 1, Vowden P (2014) Principles of compression and venous disease: a review. Wounds UK. 10, 4, Suppl 2, World Union of Wound Healing Societies (2008) Principles of Best Practice: Compression and Venous Leg Ulcers. MEP Ltd, London. Wounds UK (2015) Best Practice Statement: Compression Hosiery. Second edition. Wounds UK, London. NURSING STANDARD october 21 :: vol 30 no 8 ::

JoyTickle, Tissue Viability Nurse Specialist, Shropshire Community Health NHS Trust

JoyTickle, Tissue Viability Nurse Specialist, Shropshire Community Health NHS Trust Lower limb Ulceration Pathway: Leanne Atkin, Lecturer practitioner/vascular Nurse Specialist, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire NHS Trust, E mail: l.atkin@hud.ac.uk