Leg Ulcer Management Policy

Transcription

1 Leg Ulcer Management Policy Page1

2 Policy Title: Executive Summary: Leg Ulcer Management Policy This policy for the Management of Leg Ulcers is for East Cheshire Trust. The aim is that that all leg ulcers will be managed appropriately. This policy covers details on leg ulcer assessment, use of compression in management, when to refer on, and prevention of reoccurrence. Supersedes: Wound management guidelines Description of Leg ulcer Management was included in the previous Wound Management Amendment(s): Guidelines these have now been taken out and are a stand-alone policy. This policy will impact on: All Trust Staff Financial Implications: Policy Area: Clinical Document ECT Reference: Version Number: 9 Effective Date: December 2017 Issued By: Sally Walsh Review Date: End January 2019 Author: Tissue Viability Nurse Lead Impact Assessment Date: July 2017 APPROVAL RECORD Consultation: Approved and Ratified: Committees / Group Tissue Viability. Lead Nurse (hospital and Community) to both community and hospital staff. Infection Control, Risk management sub-committee Medicines management committee Medicines management committee Date November 2017 November 2017 November 2017 December 2017 November 2017 Page2

3 Table of Contents 1. Introduction 4 2. Objectives of Policy 4 3. Roles and Responsibilities 5 4. Definitions 6 5. Assessment 6 6. Referral to Other Specialists Leg Ulcer Management Reassessment and Review Patient Information and Education Compliance and Monitoring/Audit 18 References Appendices Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Appendix 7 Procedure for undertaking an Ankle Brachial Pressure Index Guidance for management of Leg Ulcers in the community Venous Eczema Assessment Pathway Measurement for steroid ointment Table of layer kits available Table of wraps available Risk assessment for timing of reviews Equality Analysis Page3

4 1. Introduction This policy is for the management and treatment of leg ulcers within East Cheshire Trust. Where the policy is specific to either Community or Hospital this will be stated. The aim is that all leg ulcers will be managed appropriately following National guidance where available. Venous ulceration is the most common type of leg ulceration. 60% to 80% of leg ulcers have a venous component. The Lothian and Forth Valley Study examined 600 patients with leg ulceration and found that 76% of ulcerated legs had evidence of venous disease and 22% had evidence of arterial disease. 10% to 20% of cases had both arterial and venous insufficiency. 9% per cent of ulcerated legs were in patients with rheumatoid arthritis. 5% of the patient group had diabetes Callum and Dale et al (1987). Therefore it is important that leg ulcers are correctly assessed to determine underlying aetiology and appropriate management. This policy has been produced for use by any member of the Healthcare team. They are not intended as a substitute for professional judgement but are in support of the practitioner making an informed decision relating to the management of the patient, in accordance with individual professional competence. It is the policy of the Trust that employees will not be discriminated against on grounds of age, disability, gender, gender re-assignment, marital status, race (including colour, nationality and ethnic or national origins), religion or belief or sexual orientation. The Trust will provide interpretation services or documentation in other mediums as requested and necessary to ensure natural justice and equality of access.. 2. Objectives of Policy The purpose of this policy is to ensure best practice and minimise the potential for inconsistency of care through standardising approaches to leg ulcer assessment, management and care by; Promoting a systematic approach to leg ulcer management consistent assessment process, pathway for management following assessment. Providing a standardised approach to leg ulcer care within the framework of holistic care. Standardising the assessment of leg ulcers using agreed documentation / templates. Implementing individualised treatment plans to effectively manage leg ulcers Ensuring the most appropriate product is utilised for optimum wound healing, patient comfort and cost effectiveness (following the agreed standardised formulary list for dressings) Ensuring appropriate management that meets the set aims of treatment. To provide a standardised approach to bandaging within the framework of holistic care. Supporting families, carers and healthcare professionals with a framework for the management of leg ulcers. Ensuring referral onto Tissue Viability / vascular/ dermatology services are appropriate and timely Page4

5 Prevention of re-occurrence of venous ulceration once healed through appropriate compression systems and follow up. 3.0 Role and Responsibilities 3.1 The Director of Nursing, Performance and Quality: On behalf of the Chief Executive, will ensure that comprehensive guidance for leg ulcer management within the Trusts are developed, agreed and reviewed. Will ensure that resources are made available for the provision of appropriate dressings/ equipment. Will ensure that there is a rolling programme to train staff to ensure that care is provided by a competent workforce. Will ensure that there is a robust monitoring system in place for the measurement of patients being admitted with cellulitis when the leg ulcer identified as the source. 3.2 Lead Nurses/Professional Leads/Business Unit Service Managers: Will ensure that this policy is implemented within their area of responsibility. 3.3 Tissue Viability Nurse The Tissue Viability Nurse will be responsible for; Monitoring and liaising with other members of the Trust to ensure clinical practice is developed in line with evidence and best practice. Identifying to the line manager when the practice is not compliant with best practice/guidance. Review leg ulcers referred (that meet criteria) within allocated timescales. To deliver training on the assessment and management leg ulcers as identified through personal development plans. Reviewing the leg ulcer management policy within review timescales set 3.4 Risk Management: Are responsible for alerting Tissue Viability to any incidents relating to use of compression. If compression bandaging has caused tissue damage as a result of its application then an incident will be reported on Datix. Risk management will support in the investigation of these incidents if a stage 3 or stage 4 pressure injury has resulted. 3.5 Ward/Department/ Managers/ District Nurse Leads/ Matrons Will ensure that all staff are aware of the policy and adhere to it. Will identify training needs and ensure staff are appropriately trained in leg ulcer management (where appropriate) and will record all training. Will incorporate leg ulcer management training monitoring within staff appraisal. Will ensure that the Matron/Professional leads responsible for the clinical area are aware of all incidents/ failures to comply with the policy. 3.6 All Clinical Staff involved in Leg ulcer management Will adhere to the policy. Will identify their training needs and make their managers aware of any training deficit. It is an individual s responsibility to maintain personal records of all training. Community staff will refer all patients to Tissue Viability following the assessment/ referral pathway. Page5

6 Hospital staff will refer all patients with leg ulcers to tissue viability. Have the ability to recognise non-healing leg ulcers and when to refer on to the Tissue Viability Nurse (following leg ulcer pathway). 4.0 Definitions Chronic venous leg ulcer is defined as an open lesion between the knee and the ankle joint that remains unhealed for at least four weeks and occurs in the presence of venous disease (Sign 2010). A leg ulcer is a wound on the lower gaiter area of the leg which has been present for over 6 weeks making it a chronic leg ulcer (NHS choices 2016). For the purpose of this policy, all wounds on the leg between the knee and the ankle joint, must have a full leg ulcer assessment to determine any venous or arterial aetiology if unhealed after 6 weeks. 5.0 Assessment All wounds are assessed following the wound management policy on first assessment. Within MDGH, all patients with leg ulcers over 2 weeks who are not responding to treatment will need to be referred to Tissue Viability for assessment. This is to ensure correct assessment, diagnosis and management. Within the community all patients with leg ulcers (over 6 weeks old) to have a full leg ulcer assessment by the nursing team responsible for that patients care. The assessment undertaken is detailed below in the table. Full holistic assessment to be undertaken following RCN clinical practice guidelines (2006). ASSESSMENT Complete a leg ulcer assessment form for patients as above. This should be completed before the patient has had the leg ulcer for eight weeks. RATIONALE To ensure standardisation of care and the use of evidence based practice. This time frame would start from the commencement of the wound developing. This assessment will identify any venous or arterial aetiology and guide management or referral on to other specialists. PAST MEDICAL HISTORY The assessment, either first or recurrent leg ulcer, should include a detailed history of the onset of the problem. Assessment of past medical history will contribute to the Page6

7 ASSESSMENT The past medical history should include those factors which impact on persons with any chronic condition. RATIONALE assessment in order to determine the underlying cause of the ulcer. A Medical History suggestive of venous disease includes any of the following: Varicose Veins (record whether or not these have been treated) Proven Deep Vein Thrombosis in the affected leg Phlebitis in the affected leg Suspected Deep Vein Thrombosis e.g. swollen leg following surgery, pregnancy or trauma Surgery to the leg Fractures to the leg Known history of pulmonary embolus Pregnancy (problems with legs in pregnancy) A medical history suggestive of arterial disease includes; Congestive cardiac failure (MI) Cerebro vascular accident Diabetes Mellitis Rheumatoid arthritis Chest pain / angina Claudication Hypertension EXAMINATION OF THE LEGS AND SKIN Both legs should be examined, whether or not both are ulcerated. Past ulcer history and all previous methods of treatment both successful and unsuccessful should be recorded. Oedema should be assessed and non-venous causes of unilateral and bilateral oedema ruled out (SIGN 2010). Physical signs of Venous Disease may be identified by clinical examination and include: Varicose Veins (best seen when the patient is standing). Lipodermatosclerosis (hardening of the dermis and underlying subcutaneous fat). Eczema Ankle Flare (the appearance of many dilated intradermal venules over the medical aspect of the ankle). To complete a thorough assessment. To ensure management of oedema is appropriate. Observational assessment of the leg can aid in determining the presence of underlying chronic venous insufficiency (CVI). Signs of Arterial Disease may also be identified and include: Cold legs/feet identified by touch or palpation (in a warm environment) Dependant Rubor Changes within the leg indicate the progression of underlying arterial disease. Pale or Blue feet Page7

8 ASSESSMENT Gangrenous toes Absent foot Pulses (determined by palpation and use of Doppler) RATIONALE Oedema may be present in either venous or arterial disease. However, its presence should be noted and possible other causes should be investigated e.g. other co-morbidities such as heart failure or renal disease. CLINICAL INVESTIGATIONS Clinical investigations will include Blood pressure, as part of the assessment. Weight as part of the assessment, with reference to a Body Mass Index chart for being overweight or obese (with appropriate health education or signposting to other support services). Routine urinalysis (to screen for diabetes mellitus and note presence of protein and blood) as part of the assessment. Routine clinical investigations can aid in eliminating other health related problems. VASCULAR ASSESSMENT The use of Doppler ultrasound by trained health care professional to measure the Ankle Brachial Pressure Index (ABPI) is mandatory. Doppler assessment is part of the on-going assessment must be repeated every three months Recorded in leg ulcer assessment documentation This should be repeated whilst compression therapy remains part of the treatment. Procedure for undertaking Hand held Doppler Ultrasound assessment in appendix 1 (Vowden 2001). All patients with a non-healing wound on the leg of greater than 4 6 weeks should have a vascular assessment by means of Doppler Ultrasound to eliminate any underlying ischaemic disease (RCN Clinical practice Guidelines 2006). EXAMINATION OF THE ULCER The assessment will include careful observation of the ulcer itself to facilitate both diagnosis and subsequent treatment choice, including the following: SITE: Most venous ulcers occur in the gaiter area of the leg, This is defined as extending from just above the ankle to below the knee and tends to occur on both the inside of the calf (medial) and outside the calf (lateral). RATIONALE The clinical appearance of an ulcer, the tissue types involved can help determine the underlying cause of the ulcer. Page8

9 Sites elsewhere should be investigated for other causes. APPEARANCE AND DEPTH Venous ulcers are often shallow i.e. including epidermis and dermis, whereas deep ulcers are more likely to be arterial. Malignant ulcers, though rare, do occur and can be confused with venous ulcers, in this respect, beware of ulcers with atypical appearance such as rolled edges, or non-healing ulcers with a raised ulcer bed. SIZE: Dimensions of the ulcer should be taken at first presentation and weekly thereafter and recorded in the service users notes. Measurements should be recorded as highlighted on the training and document in leg ulcer notes. Photography is an important adjunct to assessment and can aid concordance of the patient. PAIN: The level of pain associated with the ulcer must be assessed on presentation and at each visit thereafter using an analogue pain scale included in the Leg Ulcer Assessment form which is available to all healthcare professionals. Pain may suggest infection or arterial disease so careful assessment is required. SURROUNDING SKIN AREA: The type of tissue presented and observation of these tissue types help in determining the underlying cause of the ulcer. Baseline assessment is necessary in order to help future evaluations to identify progression or deterioration of the ulcer, will aid in subsequent referrals as necessary. Pain is a significant problem for patients suffering with leg ulcers. Baseline assessment and subsequent evaluation is necessary in order to ensure pain is appropriately managed. This is also a key quality of life indicator. Inappropriate pain management will also have a significant effect on the healing rate of leg ulcers (Johnson 1995). Observe for the presence of eczema, hyperkeratotic skin Skin changes such as (hypertrophy of the stratum corneum or the horny layer of skin), eczema and hyperkeratosis maceration, cellulitis, signs of irritation and scratching which are are an indication of underlying signs and symptoms associated with underlying Venous Venous Disease. Disease. Inappropriate management can cause significant problems such as irritant dermatitis, contact dermatitis, and allergic dermatitis. Following completion of the above assessment (which includes Ankle brachial pressure index (Al-Qaisi et al 2009) follow the flow chart Appendix 2 to determine the patients management plan this may be compression to be carried out by the community nursing staff or referral on to dermatology, tissue Viability or Vascular. If there is any uncertainty as to which avenue the patient should go down please send a referral to Tissue viability with the completed leg ulcer assessment. This assessment is to be documented following standard documentation. 6. Referral to Other Specialists Page9

10 6. Referral to Other Specialists The vast majority of patients with leg ulcers will not need to be referred for further assessment of the ulcer. As detailed in the pathway for guidance for the management of leg ulcers referral on to vascular or dermatology may be required. This should be done through the GP. In addition, the patient may need to be referred to the GP if there are any concerns highlighted in the leg ulcer assessment e.g. Ulcers suspected of non-venous aetiology e.g. diabetic ulcers, malignant ulcers. Treatment of underlying medical problems e.g. hypertension, irregular heartbeat. Any differences in brachial pressures of over 10mmhg. Signs and symptoms of infection. Excessive pain needs to be investigated further if analgesia is unsuccessful. Healed venous ulcers with a view to venous surgery and any venous ulcer where varicose veins appear to be associated, where correction of the venous problem can help in the healing phase (NICE 2013). Recurring venous ulceration where surgery may be appropriate. 7. Leg Ulcer Management 7.1 Cleansing of the Ulcer Cleansing should be kept simple. Dressing technique should be clean and aimed at preventing cross infection. Ulcerated legs should be washed normally with tap water. Process for Cleansing Soak the affected leg in a clean bucket that has been lined with a yellow plastic bag and filled with warmed tap water. or Irrigate the ulcer with warmed saline. Gently pat the leg dry with a clean paper towel. or A sterile paper dressing towel. Alternative If for any reason washing in a bucket with tap water is not appropriate the leg can be washed with Octenisan wash mits (following instructions for use on the packet). These are a cost effective alternative to using UCS wipes where only the washing of legs is required. These mits are available in packs of 10 and are single patient use. Following cleansing Remove scabs with forceps, if they can easily be removed to allow epithelialisation of the wound. There should be no bleeding after the removal of the scab. Page10

11 Removal of necrotic and devitalised tissue can be achieved through mechanical or autolytic means. For hyperkerototic skin Debrisoft can be used to aid mechanical debridement (ensure manufacturer s instructions followed). 7.2 Dressings NOTE - At present there is insufficient evidence from clinical trials to recommend one dressing type over another (SIGN 2010). Primary dressing should be chosen using the following criteria: Must be simple, low adherent. Cost Effective. Be comfortable and acceptable for the patient. The following primary dressing is suggested because it s least likely to damage the healing tissue or cause sensitivity and allergic reaction. Product Atrauman Supplier Paul Hartmann Products that commonly cause skin sensitivity such as those containing lanolin and topical antibiotics should not be used on any patient (Cameron 1990). 7.3 Dermatitis / Eczema Health professionals should be aware that patients could become sensitised to elements of their treatment at any time (Cameron 1998). Patients with sensitivity reactions to unknown sensitizers should be referred to a dermatologist for patch testing. Following patch testing, identified allergens must be avoided. In cases of contact sensitivity: Remove the known or potential allergens. Elevate and rest the limb. Avoid using cream which may contain sensitizers (eg E45 cream, sudocrem), always use ointments. Apply prescribed steroid ointment (potency appropriate to the degree of eczema) to the skin, reducing the potency down the ladder once eczema is under control. Replace the steroid with white soft paraffin emollient when the bottom of the ladder has been reached. The potency of the steroid should be determined by the degree of eczema e.g.. POTENCY STEROID Mild Hydrocortisone 1% Moderate Eumovate Potent Betnovate; locoid Very Potent Dermovate Some patients react to Hydrocortisone, in this case use half the number of fingertip units of Eumovate recommended for the area covered rather than stepping down to Page11

12 hydrocortisone. Steroids are measured in finger-tip units Appendix 4. If there is a poor response to treatment the patient should be further investigated including the possibility of sensitivity to their current steroid therapy. Venous ulcers are commonly associated with varicose eczema which is characterised by erythema, weeping, scaling and pigmentation, and may be misdiagnosed as infection. Community nursing to follow the steroid pathway for venous eczema Appendix 3. If the patients surrounding skin is dry only use a simple emollient to soothe and hydrate the skin e.g. white/yellow soft paraffin (50/50 emollient). 7.4 Compression Therapy Compression therapy aims to improve venous return and reduce venous hypertension. Compression therapy is the most important element of the treatment of venous leg ulcers. Compression should not be applied to legs with an ABPI of less than 0.8 (unless supervised by vascular consultant or tissue viability). It should also be used with caution in patients with diabetes or rheumatoid disease, who may have unreliable ABPIs due to arterial calcification compression in these patients should be instigated by Tissue Viability or Vascular team. Patients with underlying sensory neuropathy may not feel if the bandages are too tight so therefore must be used with extreme caution in this category of patient. High compression multicomponent bandaging should be routinely used for the treatment of venous leg ulcers. Patients should be offered the strongest compression that maintains patient concordance (up to 40mmhg at the ankle). At initiation of compression, patients should be assessed for skin complications within hours (SIGN 2010). When considering the type of compression to use, practitioners should take into account: patient preference lifestyle and likely concordance required frequency of application practitioner level of expertise size and shape of leg. Compression should only be applied by staff with appropriate training and in accordance with the manufacturer s instructions following completion of a holistic patient assessment. Multi-layer compression systems will normally maintain compression for 1 week. However, the frequency of change should be determined in conjunction with the patient. Reasons for renewing the bandages more often include: Strike through of exudate Patient discomfort Page12

13 Slippage of bandage European Wound Management Association (EWMA) (2003) clearly states that clinicians must know their bandages, their properties, the effect they have on the limb and the opportunities and challenges they provide for the patients. Multilayer bandaging used within ECT The 4 layer bandage system applies 40mmhg of pressure at the ankle, and so the combination will need to be adjusted depending on the ankle circumference. Less than 18cm 18cm 25cm 26cm - 30cm Over 30cm 2 K soft padding 1 K lite (spiral) 1 K Plus (fig8) 1 Ko flex 1 K soft padding 1 K lite (spiral) 1 K Plus (fig8) 1 Ko flex (spiral) 1 K soft 1 K3C (Spiral) 1 Ko flex long (Spiral) 1 K soft long 1 K Plus long (fig 8) 1 K3C (Spiral) 1 Ko flex long (Spiral) Although multilayer bandaging should be the first choice, some patients either cannot tolerate it, or it is not compatible with the lifestyle they lead. For this reason other methods of applying compression should be offered to the patient. This can be an option for patients who are mobile and prefer a system with less bandaging. Short Stretch Bandaging There is evidence to support the use of short stretch bandages. The clinical practice guidelines for the management of patients with venous leg ulcers (RCN 2006) state that no real difference in healing rates between the two systems has been found, following a recent literature review. They have the advantage of applying very high pressure when the patient is active. The pressure falls when the patient is resting. Benefits Exert low pressure at rest. Easier to tolerate at night. Short stretch remains rigid when calf muscle contracts improving efficiency of calf muscle pump during exercise. Page13

14 Cost effective. Disadvantages They may need reapplying more frequently as more likely to slip as they reduce the oedema quickly. Size The width of the bandage used should be equal to the diameter of the calf at its widest point. The bandages offer a width of 8, or 15cms. Short Stretch bandaging used within ECT The short stretch bandage used is Actico (this is not washable). This is consistent with the formulary. Hosiery Kits Hosiery systems designed for treatment purposes can be used if the exudate can be maintained with a primary dressing. This system may be useful for patients who want to be in control of their treatment. These systems consist of a liner that usually gives 10mmhg with a support stocking over the top to provide a total of 40mmhg at the ankle. NB: Check each make of hosiery kit and pressures provided as some liners provide 20mmhg with the top stocking also providing 20mmg. There are others where the liner provides 17mmhg and the top stocking gives 23mmhg. A list of kits available and sizes are listed in Appendix 5. Compression wrap systems The wrap systems give an alternative to the above by allow the patient to wrap the compression around the leg in the form of a stiff fabric that wraps around the leg and fastens by Velcro at the front. The advantage of these are that apply a set amount of compression when applied correctly and the patient can do it themselves (with training). Different wrap systems require a varying level of training and adjustment in order to achieve the required compression level. The different systems have been evaluated by the Tissue Viability team to aid the clinician in their choice. The information on the wraps considered is in the table in Appendix 6. The wrap system chosen as first choice is the ReadyWrap. This is one of the easiest to apply with its colour coded velcro straps, you can anchor each strap making it easier to pull the straps together, looks the neatest and is cost comparable. It is available both on FP10 and NHS supply chain. It is a compression garment designed by Activa as an alternative to 4 layer bandage and hosiery kits. It is designed to be easy to apply giving patients the opportunity to self-manage their care. The ReadyWrap aims to improve quality of life, reduce the risk of reoccurrence and prevent swelling in the limbs which will improve mobility. Below is a table with the key details of the Ready Wrap. Page14

15 Warranty Price Size options Application/ Training needs Options FP10/NHS Supplies Amount Of compression Colour Liners 6months Calf- 85 Foot S, M, L,XL, XXL Colour coded velcro straps Thigh, Knee Calf Foot FP10 and NHS supplies (drug tariff price + 20% VAT) 40mmhg at ankle Black and beige 1 closed toe A tubular bandage can be used as an open toe liner. Measuring for the ReadyWrap is quick and easy and details can be found on their website along with ordering codes there is a form to fill in with the measurements and once the form has been received, delivery will be within 7 days. 8. Reassessment and Review Once a venous ulcer is healed, compression will need to be continued to ensure venous return this is normally provided using compression hosiery. Further information can be found within the Best Practice statement Compression Hosiery Ideally this will be at the same level that was required for treatment e.g. 40mmhg. If this is not achievable, some compression is better than no compression and a reduced class can be used. Arterial status must be re-assessed 3-12 monthly, using the ABPI, to ensure compression is still suitable. Re-measurement of legs will be needed 3-12 monthly to ensure the new hosiery ordered fits the patient.. A risk assessment should be carried out to determine how often the re-doppler is required. Appendix 7 It is important that the continuing care of healed leg ulcer patients is maintained, as there is a risk of recurrence of venous leg ulceration. Patients should be informed that it is likely that compression will be required indefinitely. Strategies to prevent recurrence of ulceration should involve: Discourage patients from self-treatment with over the counter preparations. Encouragement of patients early referral at the first signs of possible skin breakdown. Educating patients to avoid accidents or trauma to their legs. Encouragement of mobility and exercise. Correct elevation of the limb when immobile. Lifetime compression therapy. Education about skin care. Page15

16 Referral to GP if diabetic for modification of therapy. Follow up appointment 3-12 monthly by trained member of staff to: o Monitor condition of skin. o Compliance with compression hosiery. o Measure for new compression hosiery. o Re-Doppler and record reading in notes. If patient would consider surgery and if feasible a referral to a vascular surgeon should be made with a view to venous investigation and surgery. This option should be emphasized in active patients who appear to have straightforward varicose veins. Measuring for hosiery Compression hosiery options vary in degrees of compression, fabric, stiffness, size, length, and whether they are closed or open-toe; these variances can lead to inconsistency in the way compression hosiery is selected and prescribed (NICE, 2012). For venous disease below knee stockings are appropriate for most patients. The exceptions to this are: If the patient has varicose veins behind the knee or up the thigh. If patient has arthritis or oedema of the knee. Tips for hosiery measurement Take measurements as early in the morning as possible, when oedema is at a minimum Take measurements directly against the skin to ensure accuracy (use a skin marker to ensure reproducibility and accuracy) Take measurements for each leg as they may differ in size Take measurements when the patient is sitting down, with feet flat on the floor Use the correct measuring guide for the brand of hosiery to be prescribed, as each manufacturer will vary If the patient has skin folds due to oedema, or the limb is particularly misshapen, a specialist flat-knit garment and, therefore, referral for specialist assessment may be required If a patient feels uncomfortable or embarrassed when having their legs measured, try to make them feel more at ease by: Taking the measurements in a private area. Explaining how you are going to measure their legs before you start, including how far up the leg you will need to measure for thigh-length hosiery. Explaining why it is important to get the right size hosiery so that it works properly. Explaining what you are doing at each stage. How to measure for hosiery Measure both legs. Record the circumference of the ankle at the narrowest point. Record the circumference of the calf at the widest point. Record the circumference of the thigh at the widest point. Record the length of the foot from the tip of the big toe to the heel. Record the length of the leg from the heel to below the knee or groin for thigh length. Page16

17 Construction of hosiery Construction of compression hosiery materials may be inelastic (also known as shortstretch) or elastic. Inelastic compression hosiery is favoured for those with chronic oedema, as the fabric does not yield to expansion related to the oedema. Hosiery can be constructed in two ways: circular-knit or flat-knit. Both types are used in the UK; in some parts of Europe and for the management of lymphoedema, flat-knit is predominantly used (Anderson and Smith, 2014). a) Circular-knit The fabric is knitted on a cylinder with circular needles and has no seam. The fabric tends to be finer, which patients often find more cosmetically acceptable. Circular-knit is generally used to create ready-to-wear hosiery (although it can be used for made to-measure hosiery) and is most suitable where there is no or minimal limb distortion due to oedema (Anderson and Smith, 2014). b) Flat-knit The edges of a flat fabric are sewn together, creating a seam. The fabric tends to be relatively thick and stiff, which lets it lie across skin folds without cutting into the skin. Flatknit is usually used for made-to measure garments because it can be more readily adapted to limb shape distortion (Lymphoedema Framework, 2006). Hosiery available in standard sizes, which may not be appropriate for all patients or limb sizes/shapes, is known as ready to wear. Where the patient does not fit into standard sizing, made-to-measure hosiery can be ordered and customised according to the measurements and shape of the limb being treated. Classes of compression hosiery terminology It is important to remember that hosiery pressure can be measured using either class system (British or European). Therefore it is important to remember when requesting hosiery that the class and which system is being used must be stated. Class British Class European class Class mmHg 18 21mmHg Class mmHg 23 32mmHg Class mmHg 34 46mmHg Open toe / closed toe This is often down to patient preference although check on the make as some do not offer both options on all classes. What needs to be on a prescription? 1. Make of hosiery. 2. Size. 3. Open toe or closed toe. 4. Class and which system. Page17

18 5. Colour. 6. Numbers required. N.B. If made to measure a made to measure form with all the measurements will be required alongside the prescription. Risk assessment for hosiery refitting The patient should be reassessed in relation to arterial status and re-measuring of hosiery. The timing of this will depend on the patients risk level of developing complications. The Risk assessment and timing is detailed in Appendix Patient Information and Education All patients are entitled to and should be offered accessible and appropriate information on their leg ulcer disease. An information leaflet should be provided for every patient. The rational for their treatment should be clearly and simply explained. Patients should: Be aware of the leg ulcer services available to them within East Cheshire Understand the basic principles of leg ulcer treatment Encouraged to ask questions regarding their treatment Understand the importance of continuation of care following a leg ulcer 10. Compliance and Monitoring/Audit Compliance to the clinical standards within this policy will be monitored by the Tissue Viability lead nurse annually by auditing 20 patients randomly selected from EMIS. All staff who undertakes full leg ulcer assessments and compression bandaging will be appropriately trained having undertaken the Trusts 3 day (in-house), leg ulcer course. This is recorded through the training department and monitored by community nurse manager. All staff undertaking compression bandaging will have the bandage pressures checked every 2 years. These will be undertaken by Tissue Viability and evidence provided for the individuals portfolio and monitored through appraisal. The undertaking of wound assessment within 4 weeks will be monitored through the CQUIN for wound assessment and reported through Quality forum. All leg ulcer assessments will be documented on EMIS by the clinician undertaking the full assessment. Other policies related available on the Infonet Wound management policy 2016, SOP Topical negative pressure 2015, SOP Larvae therapy 2015 ANTT Page18

19 References Activa healthcare Readywrap activa healthcare. [ONLINE] Available at: [Accessed 10 May 2017] Anderson I, Smith G (2014) Compression made easy. Wounds Uk. Available at: Al-Qaisi M, Nott DM, King DH, Kaddoura S (2009) Ankle brachial pressure index (ABPI): an update for practitioners. Vasc Health Risk Manage 5: Callam MJ, Harper DR, Dale JJ, Ruckley CV. Chronic ulcer of the leg: clinical history. Br Med J (Clin Res Ed) 1987;294(6584): Cameron J, Wilson C, Powell S et al (1991) An update on contact dermatitis in leg ulcer patients, Symposium on Advanced Wound care: San Francisco. Cameron (1998). Contact sensitivity in relation to allergen exposure in leg ulcer patients. Unpublished M. Phil. Liverpool: The University of Liverpool EUMA ( 2003) Marston W, Vowden K. Compression therapy: a guide to safe practice. In: Understanding compression therapy: EWMA Position document. London: MEP Ltd, 2003; Johnson M (1995) The influence of patient characteristics and environmental factors in leg ulcer healing. Journal of Wound Care, 4(6) pp Lymphoedema framework (2006) Template for Practice: Compression hosiery in lymphoedema. London: MEP Ltd. Available at: (accessed ) National Health Service. (2016). Venous leg ulcers. Retrieved from: NHS Choices National Institute for Health and Care Excellence (2013) Varicose veins in the legs. The diagnosis and management of varicose veins. NICE clinical Guideline 168. RCN Guidelines Clinical practice guidelines. The Nursing management of patients with venous leg ulcers. Recommendations. RCN. London. Scottish Intercollegiate Guidelines Network (2010) SIGN Guidelines 120. Management of chronic venous leg ulcers. SIGN Edinburgh. Vowden.K (2001), Doppler assessment and ABPI: interpretation in the management of leg ulceration. World Wide Wounds Vowden K (2001) Doppler and the ABPI: how good is our understanding? Journal of Wound Care. June Vol 10. No 6 Page19

20 Appendix 1 PROCEDURE FOR UNDERTAKING AN ABPI How to Calculate the ABPI Explain the procedure and reassure the patient. Ensure the patient is lying flat and is comfortable, relaxed and adequately rested, with no pressure on the proximal vessels. 1. Measure the brachial systolic blood pressure - Place an appropriately sized cuff around the upper arm - Ensure the equipment and arm are at heart level, with the patient rested and supine - Locate the brachial pulse and apply ultrasound contact gel - Angle the Doppler probe at 45 o and move it to obtain the best signal - Inflate the cuff until the signal is abolished. Then deflate the cuff slowly and record the pressure at which the signal returns, being careful not to move the probe from the line of the artery - Repeat the procedure on the other arm - Use the highest of the two values as the best non-invasive estimate of central systolic pressure. Use this figure to calculate the ABP1 2. Measure the ankle systolic pressure - Place an appropriately sized cuff around the ankle immediately above the malleoli, having first protected any ulcer of fragile skin that may be present - Examine the foot, locating the dorsalis pedis pulse and apply contact gel - Continue as for the brachial pressure, recording this pressure in the same way with the equipment at heart level - Repeat on the posterior tibial artery and, if required, peroneal and anterior tibial arteries - Use the highest reading obtained to calculate the ABP1 for that leg - Repeat on the other leg - Calculate the ABP1 for each leg using the formula below or look up the ABP1 using a reference chart ABP1 = Highest pressure recorded at the ankle for that leg Highest brachial pressure obtained for both arms K Vowden, BSc (Hons).RN.DPSN (TV) Page20

21 Appendix 2 GUIDANCE FOR THE MANAGEMENT OF LEG ULCERS IN THE COMMUNITY AIM -To facilitate wound healing by ensuring an accurate assessment AIM To refer non-venous ulcers to the appropriate professional for further assessment Undertake full holistic assessment including ABPI on all leg ulcers (6 weeks or over) Undertake wound assessment including tracings or photographs. Reassess weekly Diagnosis of rheumatoid arthritis or diabetes Venous ulcer Evidence of venous disease plus ABPI Mixed Ulcer Evidence of venous disease plus arterial disease ABPI Arterial Ulcer Evidence of arterial disease ABPI under 0.6 Calcification of vessels ABPI over 1.3 Contact Dermatitis - Treat with steroid ladder Refer to Dermatology for patch testing Refer to Tissue Viability. Patients will be offered an appointment within 7 working days If ulcer responds to compression - continue Treat with compression If ulcer fails to respond within 4 weeks of compression refer to Tissue Viability Patients will be offered an appointment within 7 working days Refer to Tissue Viability. Patients will be offered an appointment within 7 working days Urgent referral to vascular Refer to Tissue Viability. Patients will be offered an appointment within 7 working days Any patient, with or without a wound, who exhibits symptomatic vascular impairment to be referred to vascular nurse or consultant Cautionary Patients with reduced sensation may not feel pain as a symptom if there Page21 are any problems with compression. Leg Ulcer Close Management monitoring Policy. will be Author required. Sally Walsh. Date of Publication 18 th December

22 Appendix 3 Venous Eczema Assessment Pathway This pathway does not cover steroid use for any other indications. ASSESSMENT 1. Indicate on picture below area covered with eczema: Left Right Right Left Guidance 1Finger tip Unit 2FTU = 1 gram of ointment Max length of affected area (cm) Right Left. Max breadth of affected area (cm) Right Left. 2. Define severity of eczema Mild / Moderate / Severe Rt Leg Lt leg 3 FTU ankle to knee 2 FTU 1 foot S T A R T Severe Moderate Mild level 4 level 3 Level 2 Dermovate ointment ( ) 7 applications Betnovate ointment ( ) 7 applications Eumovate ointment ( ) 7 applications Eumovate (1/2 number FTU used previously and replace other number of FTU with 50/50 ointment) Replace with 50/50 ointment Report effect in nursing records 3. Previous 12 mth steroid history (for venous eczema) Episode Date ladder commenced Date ladder discontinued (If known) Stop steroid 1 2

23 Appendix 4 If more than 2 episodes of venous eczema in a 12mth period consider cause, need for compression or patch testing Page23

24 Appendix 5 Name Price Level of compression Colour Type of knit What is included Extra information Sizes available Medi (Mediven ulcer kit) Activa (Leg ulcer hosiery kit) Jobst (Ulcer care) 6months guarantee Urgo Medical (Altipress 40 leg ulcer kit) Kit Liner kit Kit Liner kit Kit Liner pack Custom fit kit Custom fit liner kit Kit Liner pack Custom fit kit Custom fit liner pack mmHg liner 20mmHg over stocking giving a total of 40mmHg Liner 10mmHg Over stocking 25-35mmHg Giving a total of 40mmHg Liner 17mmHg Outer 23mmHg Liner 10mmHg Stocking 30mmHg Grey liners and beige outer stocking Sand stockings with white liners or black stockings with sand liners Black or beige Soft beige or white Circular knit Custom fit- flat knitted 2 liners, 1 over stocking, 1 easy on slipper and information leaflet 2 liners and 1 over stocking 2 liners and 1 compression stocking 2 white liners and 1 beige stocking Inspection opening at sole of foot. Yarn coated with silver at the ankle to eliminate odour Easy to put on due to the liners material and the outer layer sliding over with ease. Can be with or without a zip which can be on the inside or outside of the stocking Doesn t tell you on the box how much compression is in each layer Difficult to put on due to similar materials don t glide over each other 7 sizes available Each measurement overlaps Once measured there is a table which indicates what colour you need to order Largest ankle calf and below knee Small, medium, large, X large and XX large all overlap with measurements Largest- calf , above malleolus heel to toe sizes available overlap with measurements Largest size ankle and calf Lengths short (34/38), regular (38-42)and long (42-46) Small, medium, large, X large and XX large Largest size calf and ankle Sizes overlap

25 Appendix 6 Name and warranty Price Size options Application/ Training needs Options e.g. lite FP10/NHS supplies Amount of compression Colour Liners Evaluation Medi/Juxta 6 months Juzo-wrap 6 months Juxta cure 150 Ankle/foot wrap (open/closed heel) ACS wrap, calf piece- 85 Foot wrap 35 Short, Standard, long (width is cut to size) XS, S, M, L, XL Simple to use, rep will support staff/patients in training. Velcro fasten Easy to apply rep will assist in training. Velcro straps Needs to be remeasured when oedema has reduced Has anti odour properties. Foot wrap Calf wrap Knee wrap Thigh wrap FP10 NHS supplies Can set up system for us to order direct and bill procurement 20,30,40 or 50 built in pressure guide and adjustable(needs to be adjusted up to 3 times a day) Beige But can get a cover up which sticks to front and back FP10 Up to 40 Black and beige Open/closed toes Doesn t come with one, has an integrated one. Bulky in appearance Hardest to apply correctly Difficult to see level of compression as lines between very small. Most expensive. Didn t evaluate as not available on NHS supplies Jobst/farrow wrap 6 months Activa/ready wrap 6 months Calf Foot Toe cap Calf- 85 Foot XS,S,M,L,X L And custom fit. S,M,L,XL, XXL Easy to apply rep will assist in training. Velcro straps Easy to apply rep will assist in training Colour coded velcro straps Lite Classic Strong (is the one we would use) Thigh Knee Calf Foot FP10, NHS supplies (similar price) Hospital price for calf, 2 liners and foot piece ( 166) FP10 and NHS supplies (drug tariff price +20% VAT) however no way of accessing how much 40 but no way of measuring Beige The liner goes over the wrap and looks like a sock Black and beige Closed toes 1 closed toe For open toe then a tubular bandage needs to be used. Hard to apply as can t anchor first pull. Colour coded straps and way to anchor makes it easy to apply however no way of measuring compression and we got levels of 68. No lite available Cost comparable Correct prices and sizes June 2017 None of the wraps were particularly easy to apply. Elderly patients or patients with arthritis may find it difficult to apply, meaning in order for a patient to benefit from a wrap they either need to be able to apply it themselves or have someone there each day to put it on. Page25

26 Appendix 7 Patients with healed venous ulcers who are wearing compression hosiery will need to be re-dopplered to detect the presence of arterial disease. The frequency of this will depend on the level of risk of the patient. This is in accordance with European Wound Management Association (EWMA) Best Practice statement for compression hosiery (2010) LOW RISK Must fit all criteria AT RISK Previous Doppler between 0.8 & 1.3 Healed Venous Ulcer Wearing compression hosiery on a daily basis Does not have any of the at risk factors associated with the at Risk patient No complaints of pains in the legs Patient able to report any problems Reassess Yearly Initial Assessment by Registered Nurses then every alternate reassessment can be completed by an Assistant Practitioner Patients with: Cardiovascular disease e.g. coronary heart disease, previous MI, angina, TIA, Stroke Peripheral arterial disease e.g. intermittent Claudication Diabetes Rheumatoid Previous Arterial Surgery ABPI below 0.8 or above 1.3 Signs and Symptoms of: Absent foot pulses Pain in Legs Pale/bluish foot White colourless leg Reassess 3 monthly Must be performed by a Registered Nurse Page26

27 Equality Analysis Equality Analysis (Impact assessment) Please START this assessment BEFORE writing your policy, procedure, proposal, strategy or service so that you can identify any adverse impacts and include action to mitigate these in your finished policy, procedure, proposal, strategy or service. Use it to help you develop fair and equal services. Eg. If there is an impact on Deaf people, then include in the policy how Deaf people will have equal access. 1. What is being assessed? Leg Ulcer Management Policy Details of person responsible for completing the assessment: Name: Sally Walsh Position: Tissue Viability Lead Nurse Team/service: Tissue Viability State main purpose or aim of the policy, procedure, proposal, strategy or service: (usually the first paragraph of what you are writing. Also include details of legislation, guidance, regulations etc which have shaped or informed the document) This policy is for the Management of Leg ulcers for East Cheshire Trust. The aim is that all leg ulcers will be managed appropriately following National guidance where available. National guidance was initially provided in 1998 by the RCN and has been progressively added to by NICE and European wound management association. 2. Consideration of Data and Research To carry out the equality analysis you will need to consider information about the people who use the service and the staff that provide it. Think about the information below how does this apply to your policy, procedure, proposal, strategy or service 2.1 Give details of RELEVANT information available that gives you an understanding of who will be affected by this document Cheshire East (CE) covers Eastern Cheshire CCG and South Cheshire CCG. Cheshire West & Chester (CWAC) covers Vale Royal CCG and Cheshire West CCG. In 2011, 370,100 people resided in CE and 329,608 people resided in CWAC. Page27

28 Age: East Cheshire and South Cheshire CCG s serve a predominantly older population than the national average, with 19.3% aged over 65 (71,400 people) and 2.6% aged over 85 (9,700 people). Vale Royal CCGs registered population in general has a younger age profile compared to the CWAC average, with 14% aged over 65 (14,561 people) and 2% aged over 85 (2,111 people). Since the 2001 census the number of over 65s has increased by 26% compared with 20% nationally. The number of over 85s has increased by 35% compared with 24% nationally. Race: In 2011, 93.6% of CE residents, and 94.7% of CWAC residents were White British 5.1% of CE residents, and 4.9% of CWAC residents were born outside the UK Poland and India being the most common 3% of CE households have members for whom English is not the main language (11,103 people) and 1.2% of CWAC households have no people for whom English is their main language. Gypsies & travellers estimated 18,600 in England in Gender: In 2011, c. 49% of the population in both CE and CWAC were male and 51% female. For CE, the assumption from national figures is that 20 per 100,000 are likely to be transgender and for CWAC 1,500 transgender people will be living in the CWAC area. Disability: In 2011, 7.9% of the population in CE and 8.7% in CWAC had a long term health problem or disability In CE, there are c.4500 people aged 65+ with dementia, and c.1430 aged 65+ with dementia in CWAC. 1 in 20 people over 65 has a form of dementia Over 10 million (c. 1 in 6) people in the UK have a degree of hearing impairment or deafness. C. 2 million people in the UK have visual impairment, of these around 365,000 are registered as blind or partially sighted. In CE, it is estimated that around 7000 people have learning disabilities and 6500 people in CWAC. Mental health 1 in 4 will have mental health problems at some time in their lives. Sexual Orientation: CE - In 2011, the lesbian, gay, bisexual and transgender (LGBT) population in CE was estimated at18,700, based on assumptions that 5-7% of the population are likely to be lesbian, gay or bisexual and 20 per 100,000 are likely to be transgender (The Lesbian & Gay Foundation). CWAC - In 2011, the LGBT population in CWAC is unknown, but in 2010 there were c. 20,000 LGB people in the area and as many as 1,500 transgender people residing in CWAC. Religion/Belief: The proportion of CE people classing themselves as Christian has fallen from 80.3% in 2001 to 68.9% In 2011 and in CWAC a similar picture from 80.7% to 70.1%, the proportion saying they had no religion doubled in both areas from around 11%-22%. Christian: 68.9% of Cheshire East and 70.1% of Cheshire West & Chester Page28