Avenous leg ulcer (VLU) can

Transcription

1 Compression therapy in the community Dr Giovanni Mosti This article examines current guidelines and best practice statements for the treatment and management of chronic venous leg ulcers (VLUs). There is a need for continuous professional development KEYWORDS: Venous leg ulcers Assessment Compression therapy Avenous leg ulcer (VLU) can be described as loss of skin below the knee that takes more than two weeks to heal due to chronic venous insufficiency (CVI) (Templeton and Telford, 2010). If still unhealed after four weeks, it is said to be chronic, and recurrent, if further ulceration occurs after healing (Scottish Intercollegiate Guidelines Network [SIGN], 2010; Franks et al, 2016; National al Institute tute for Health and Excellence (NICE), 2016a; Watkins, 2016; s UK 2016). Patients with VLUs often present with repeated cycles of ulceration, healing, and recurrence. ren Such ulcers can take weeks eks or months to heal, and 12 month recurrence rates are estimated to be between 18 and 28%, so ongoing management and prevention of recurrence should be treated as a priority, not only to improve patient outcomes and quality of life, but also to reduce costs (Ashby et al, 2014; s UK, 2016). Dr Giovanni Mosti, director, Department of Angiology, Clinica MD Barbantini, Lucca, Italy; president, International Compression Club (ICC), PREVALENCE Prevalence studies have shown that at least one in every 170 adults has a VLU (Guest et al, 2015a). Breakdown of figures shows a prevalence of 0.3/1000 in males and 0.5/1000 in females (Moffatt et al, 2004). Each year, nurses working in ncommunity settings care for 1.45 million people with wounds (Guest et al, 2015a). Around 51% receiving wound care in the community have acute wounds and 49% have chronic wounds (Vowden and Vowden, 2009; Todd, ). Community nurses spend around 25 50% of their time caring for people with leg ulcers (Chamanga et al, 2015; Nazarko, 2016), who are often frail and have multiple comorbidities, and it has been found that around 39% of chronic wounds have not healed within a year (Guest et al, 2015a). COSTS S The NHS spends around 5 billion pounds a year managing an estimated 2.2 million wounds (Guest et al, 2015b). As around two out of three people are cared for in the community, this means that the NHS is spending 3.33 billion on wound care in this setting (Nazarko, 2016), and around 110 million a year on advanced wound and antimicrobial dressings. However, evidence to guide choices is not well known and is of poorer quality than in other areas of prescribing (NICE, 2016b), with NICE suggesting that there is little evidence to support one particular dressing over another. re ple TRAINING/GUIDELINES All qualified nurses have an obligation to keep up to date with current treatments based on the best evidence and practice available (Nursing and Midwifery Council [NMC], 2015). Providing such care in any field requires continuous training and evaluation of the THE SCIENCE The venous system is made up of long deep veins, superficial and perforator veins, which have non-return valves. When a person walks or stands, venous blood in the lower legs needs to be pumped back into the venous system to the heart against gravity. Blood is squeezed upwards as muscles in the calf, thighs and feet contract and the negative pressure produced in the thorax when the person inhales, also aids venous return to the heart. To stop the blood flowing back as a result of gravity, the nonreturn valves close as the calf muscle relaxes (s International, 2013; Brown, 2016). 36 JCN, Vol 31, No 5

2 The new way to put on and remove compression stockings Steve+ All over the world millions of people, both young and old, wear therapeutic elastic stockings. Until now, putting on and removing these stockings was no easy task. Steve+ solves this problem. With Steve+ you can easily put on and remove all types of stockings - with or without assistance. This can be done while sitting or lying down. Steve+ is the perfect aid, wherever you are. Using Steve+ without assistance Bending over is no longer required, so even rheumatism or arthritis sufferers can easily use Steve+. Steve+ is completely ely demountable, making it easy to take with you. Using Steve+ with assistance Steve+ is a convenient nt solution for medical professionals and caregivers. Any stocking can be put on or removed from the care receiver - with hardly any effort. A wide range of sizes to avoid wear Steve+ is available aila in various sizes to fit all requirements. remen As a result, the stocking provides more support with minimal wear. Ca td For more information visit UK Distributor Gardamed Limited The Pixmore Centre, Pixmore Avenue, Letchworth Garden City. Herts. SG6 1JG Tel info@gardamed.com Manufactured by West, Postbus EP Amsterdam, The Netherlands Available in four sizes: Steve+ Extra Small for calf circumference cm / inches Steve+ Small for calf circumference cm / inches Steve+ Medium for calf circumference cm / inches Steve+ Large for calf circumference cm / inches

3 Table 1: CEAP classification of venous disorders (Eklof, 2004; Nazarko, 2013) C0 C1 C2 C3 C4 C4a C4b C5 C6 Spider veins (telangiectasis) visible Varicose veins Ankle oedema associated with chronic venous insufficiency Haemosiderin staining Varicose eczema 20 2 Atrophie blanche 201 Healed venous ulcer, note epithelisation Shallow, wet, sloughy ulcer with undefined margins, classic presentation of a chronic venous ulcer No visible or palpable signs of venous disease Telangiectasis or reticular veins Varicose veins; distinguished from reticular veins by a diameter of 3mm or more Oedema Photographs reproduced by kind permission of Elaine Gibson Changes in skin and subcutaneous tissue secondary to CVD, now divided into two subclasses s to better define the differing severity of venous disease Pigmentation or eczema Lipodermatosclerosis or atrophie blanche Wou ound Healed venous ulcer Active venous ulcer current literature and questioning unsuccessful treatment outcomes. Therefore, ongoing education and training is crucial for nurses who are dealing with the complexities associated with chronic VLUs. Guest et al (2015a) suggest that only 38% of people who present with leg ulcers receive a diagnosis of venous ulceration, and that there are flaws in current assessment and documentation. While there has been a plethora of guidelines and best practice statements in recent literature, it can be confusing when they span different countries and care environments. nments. Most guidelines have been developed using experts in the field of wound care, vascular disease, dermatology and general medicine. For the purpose of this paper, NICE, (2016a and b); s UK (2016) and SIGN (2010) have been used. ASSESSMENT AND CLASSIFICATION An ideal management plan for patients with chronic leg ulcers should involve a strategic and coordinated approach in delivering appropriate treatment for each individual patient, following a full holistic assessment by a trained clinician. Taking a patient s ankle brachial pressure index (ABPI) with Doppler ultrasound should always be undertaken as part of assessment to exclude the presence of arterial disease and thus determine if compression therapy is safe. Compression therapy can be safely used in patients who have an ABPI greater than 0.8. who have an ABPI of less than 0.8 should be referred for vascular assessment, and those with an ABPI less than 0.5 should be referred urgently to vascular services (Royal College of Nurses [RCN], 2006). ABPI assessment should be completed at 3, 6 or 12 month intervals, depending on initial and ongoing assessment outcomes, or according to local guidelines (s UK, 2016). The wound and surrounding tissue should be documented using a 38 JCN, Vol 31, No 5

4 Table 2: Classification of venous leg ulcers (adapted from Harding et al, 2015) Classification Symptoms Management Simple VLU Complex VLU ABPI Area <100cm 2 Present for <six months ABPI outside of Area >100cm 2 Present for >six months Cardiac failure History of non-concordance has failed to reduce in size despite best practice Fixed ankle, foot deformity, reduced range of movement Unmanaged pain structured assessment process, such as the TIME(S) checklist (s, 2016): Tissue Infection or inflammation Moisture imbalance Edge of wound Surrounding skin. Once an accurate diagnosis of venous leg ulceration is reached, it can be classified using the CEAP classification of venous disorders, or the simple or complex grading suggested by Harding et al (2015) (Tables 1 and 2). The choice of classification will depend on local trust policy and guidelines. HEALTH-RELATED QUALITY OF LIFE (HRQOL) Leg ulcers are debilitating and greatly reduce patients quality of life, with associated personal, social and psychological effects; they also have a considerable financial impact on healthcare providers, as well l as a wider social and economic impact (Franks et al, 2016; Hellström et al 2016). size, duration, heavy exudate volume and leaking dressings are recognised as issues that cause embarrassment and social isolation (Franks and Moffatt, 2006; Hopman et al, 2013). One of the most consistently cited factors associated with reduced health-related quality of life (HRQOL) in this patient population is the presence of pain. This has been found to range between 61 and 80%, and may be as high as 87% (Edwards et al, 2009; Hopman et al, 2016). Should be managed by competent community nurses (including care home nurses) Should be managed by VLU specialist service Limiting lifestyle factors are key elements to consider when caring for patients with VLUs, such as smoking or weight-related issues. It is also important to bear in mind a patient s ability to self-care and comorbidities, such as arthritis, which may restrict dexterity and mobility, particularly when applying hosiery or multilayer component systems. Empowering patients to take an active role in their care and providing them with knowledge of the disease and therapy options available may influence their choice of treatment when diagnosis has been en established (Edwards et al, 2009; 09; s UK, 2016). COMPRESSION THERAPY Compression is gold standard treatment for VLUs (SIGN, 2010). It should be applied as early as possible by competent clinicians (Harding et al, 2015). There are various bandaging, hosiery and wrap-around systems available, which aim to reduce oedema by relieving CVI and supporting the movement of fluid from the tissues back into the deep veins. Four-layer bandaging is advocated by some guidelines (SIGN, 2010; Hampton 2016; NICE, 2016). However, research has shown that two-layer bandaging systems and hosiery kits can be just as effective (Adderley, 2015). Adjustable, wrap-around compression systems (i.e. Velcro wrap devices) are also useful in the management of VLUs, and have the benefits of being: Easy to apply Less time-consuming Less restrictive for patients to wear, i.e. offering greater freedom. However, similar to hosiery kits, they may not be suitable for patients with heavily exudating wounds (Freeman and Norris, 2016; s UK, 2016). To provide patients with the best care possible, it is important that healthcare professionals s are aware of the different ent compression systems available so that, in discussion with the patient and following comprehensive, holistic assessment, they choose the most appropriate option (s UK, 2016). Indeed, incorrect treatment choice can lead to non-concordance and subsequent deterioration of symptoms (Mahoney, ). With the current focus on self-care, hosiery kits, which enable patients to manage their leg ulcers independently, are another viable option. Indeed, Ashby et al (2014) highlighted how healing rates of VLUs in patients treated with hosiery kits were comparable to those of four-layer bandaging and also resulted in substantial Figure 1. Gloria UlcerKit PRO. JCN, Vol 31, No 5 39

5 Figure 2. Gloria UlcerKit PRO contents. cost-savings. This study also found a marked improvement in patient quality of life and that the participants who wore hosiery when they had ulcers were more likely to continue wearing their garments after their ulcer had healed, thus reducing the risk of recurrence. GLORIA ULCERKIT PRO MULTILAYER STOCKING SYSTEM A recent introduction to the UK market is Gloria Ulcerkit PRO multilayer stocking system (Gardamed) (Figure 1). This system comprises one thin underlayer stocking, one compression stocking with either 18mmHg or 24mmHg and a class 2 stocking, which is available in either Cotton or Strong. The system delivers either 35 40mmHg (Gloria UlcerKit PRO 35) or 40 45mmHg (Gloria UlcerKit PRO 40) respectively. Gloria Ulcerkit PRO 35 is indicated both for the treatment of venous leg ulcers without,,or with, mild-tomoderate venous insufficiency, while Gloria Ulcerkit PRO 40 is suitable for treating venous leg ulcers with CVI. Gloria UlcerKit PRO is contraindicated in the presence of arterial disease and patients with diabetic neuropathy. The effectiveness of Gloria UlcerKit PRO was evaluated in patients with venous disease (Mosti, 2014). From a total of 500 patients being treated with compression stockings during (318 women and 182 men, aged between 18 and 90 years): 125 presented with symptoms of CVI and were given scores for each symptom (i.e. feeling of tension and heaviness in the legs, leg pain in the evening, and night cramps), on a scale where 1=light symptoms and 10=unbearable pain 104 had lower limb oedema 35 had evidence of skin changes, including fibrosis 70 had active leg ulceration 60 had healed ulcers and were being treated to prevent recurrence 106 had undergone varicose vein surgery or sclerotherapy. Table 3 outlines the treatment regimens for the patients in the study. Results Patients were followed up for six months, and it was found that there was a net reduction of approximately 60% in patients with symptomatic varicose veins. Furthermore, oedema disappeared in all patients, and those with fibrosis reported a reduction in their symptoms of pain, redness, swelling and feelings of tension. The 70 patients with venous ulcers all improved: 40 recovered and 30 venous leg ulcers reduced in size from 15±5cm 5cm 2 to 3±1cm 2. None of the patients with healed venous leg ulcers had any recurrence during the study period. Apart from a few patients with minor bruising following surgery, all patients ts responded positively to the compression hosiery, with pain scores remaining under 5 (on a scale where 1=no pain and 10=unbearable pain). Table 3: Treatment rationale (Mosti, 2014) No. of Patient type Treatment chosen Kit description Pressure applied patients 70 Patients with venous ulcers and those with small, recent ulcers who did not exhibit oedematous limbs Gloria UlcerKit PRO 35 and Gloria UlcerKit PRO 40 Consists of one underlayer (Gloriamed Fix ) and two compression stockings Underlayer keeps the dressing in place and does not contain pressure. The second stocking provides either 18 or 24mmHg and the third stocking provides pressure between 23 32mmHg. UlcerKit PRO provides a total pressure of 35 40mmHg, or 40 45mmHg 60 Patients with healed venous ulcers Gloria UlcerKit PRO 35 Consists of one underlayer (Gloriamed Fix ) and two compression stockings Since the ulcer had healed, it was not necessary to use Gloriamed Fix to keep the dressing in place and only the two compression layers were used, the first exerted 18mmHg and the second 23 32mmHg, giving a final pressure of 35 40mmHg d 35 Dermatofibrosis Gloriamed Strong class Patients with oedema in their lower limbs caused by superficial or deep vein insufficiency 125 Symptoms of varicose veins 106 Patients who had undergone surgical or endovascular procedures (high ligation, stripping, varicectomy or sclerotherapy) re Gloriamed Comfort class 2 and Gloriamed Soft class 2 Gloriamed Micro class 1 Gloriamed PostOp Kit Latex-free rubber RAL standard class 3 stocking RAL standard class 2 stocking RAL standard class 1 stocking Gloriamed PostOp Kit consists of Gloriamed Fix thigh-high and Gloriamed Strong class 2 thigh-high stocking 34 46mmHg 23 32mmHg 18 21mmHg Gloriamed Fix exerts no pressure, while the RAL class 2 provides a graduated compression of 23 32mmHg 40 JCN, Vol 31, No 5

6 Introducing Gardamed... Gardamed Limited is the UK sole distributor of the Gloriamed brand of compression hosiery. Gloria Med SpA is a family-run company with a long European history of producing compression therapy. Its centurylong involvement in this area has resulted in developing compression garments that are in line with modern developments in treatment. Gloria Med SpA started to manufacture compression products in Lugano, Switzerland in 1926, and in 1936 introduced the first, totally automated loom to produce two-way stretch, seamless compression stockings. In the 1950s, the company moved to Menaggio, on Lake Como, and became well-known throughout Europe for its Gloria range of compression products, which are available in a wide range of fabrics, styles, sizes and colours. In 1990, Gloria joined the Quality Association of medical stockings in Germany and today is a world-wide market leader. This autumn sees Gloria s introduction to the UK Drug Tariff and NHS supply chain. For further information, please contact Gardamed Limited on: , or visit their website at: The author concluded that the treatment regimen with Gloriamed compression stockings resulted in marked improvement in patient quality of life, as it both promoted healing and prevented recurrence of VLUs. Furthermore, the patients who had previously undergone surgery had less incidence of postoperative symptoms. CONCLUSION The plethora of guidelines and best practice statements can be confusing for community staff, who are constantly under pressure to maintain evidencebased practice when dealing with the complex, clinical challenging environment associated with chronic venous leg ulcers. With an ever-growing elderly population, nurses need to be highly skilled and motivated. Keeping up to date with the literature and guidelines on management strategies is a helpful way of providing the best possible care. Compression hosiery systems, such as Gloria UlcerKit PRO, provide an innovative addition to the community nurse s armamentarium and a new treatment choice for patients to consider. JCN e Revalidation Alert Having read this article, What is involved in wound assessment The impact that venous leg ulcers can have on healthrelated quality of life Your knowledge of classifying venous disorders. Then, upload the article to the free JCN revalidation e-portfolio as evidence of your continued learning: JCN, Vol 31, No 5 41

7 REFERENCES Adderley U (2015) Prescribing for the management of venous leg ulceration. Nurse Prescribing Alavi A, Sibbald RG, Phillips TJ, et al (2016) What s new: management of venous leg ulcers. J Am Acad Dermatol Ashby RL, Gabe R, Ali S, Adderley U (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 controlled trial. Lancet Australian Management Association Inc, New Zealand Society Inc (2011) Australian and New Zealand Clinical Practice Guideline for Prevention and Management of Venous Leg Ulcers. Brown A (2016) Venous leg ulcers: treating a chronic condition. Nurs Residential Chamanga E, Christie J, McKeown E (2014) Community nurses experiences of treating patients with leg ulcers. J Community Nurs Dowsett C, Newton H, (2008) bed preparation: TIME in practice. s UK Available online: www. wounds-uk.com/journal-articles/woundbed-preparation-time-in-practice-1 (accessed 20 September, ) Edwards H, Courtney M, Finlayson K, Shuter P, Lindsay E (2009) A randomised controlled trial of a community nursing intervention: improved quality of life and healing for clients with chronic leg ulcers. J Clin Nurs Eklöf B, Rutherford RB, Bergan JJ, et al (2004) Revision of the CEAP classification for chronic venous disorders: consensus statement. J Vasc Surg European Management Association (2004) 04) Position ion Document: Bed Preparation ration in Practice. MEP, London Franks PJ, Barker J, Collier M, et al (2016) Management of Patients With Venous Leg Ulcers: Challenges and Current Best Practice. J S1 S67. Franks PJ, Moffatt CJ (2006) Do clinical and social factors predict quality of life in leg ulceration? Int J Lower Extremity s Freeman N, Norris R (2016) Using an adjustable compression system to treat community leg ulcers. J Community Nurs 4752 Guest JF, Ayoub N, McIlwraith T, et al (2015a) Health economic burden that wounds impose on the National Health Service in the UK. BMJ Open 5: e doi: /bmjopen Available online: com/content/5/12/e Guest JF, Gerrish A, Ayoub N, Vowden K, Vowden P (2015b) Clinical outcomes and cost-effectiveness of three alternative compression systems used in the management of venous leg ulcers. J Hampton S (2016) The difficulty and the solution of compression therapy in a healed venous leg ulcer. Br J Community Nurs S34 S38 Harding K, Dowsett C, Fias L, et al (2015) Simplifying venous leg ulcer management. Consensus Recommendations. s International, London. Available online: (accessed 23 September, ) Hellström A, Nilsson C, Nilsson A, et al (2016) Leg ulcers in older people: a national study addressing variation in diagnosis, pain and sleep disturbance. BMC Geriatr 25 Hopman WM, Buchanan M, VanDenKerkhof EG, Harrison rison MB (2013) Pain and healthrelated ed quality of life in people with chronic leg ulcers. Chronic Dis Inj Can Hopman WM, Vandenkerkhof EG, Carley ME, Harrison MB (2016) Health-related quality of life at healing in individuals with chronic venous or mixed-venous leg ulceration: a longitudinal assessment. J Adv Nurs O Donnell TF, Passman MA, Marston WA et al (2014) Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery and the American Venous Forum. J Vasc Surg 3S 59S Mahoney K () Unravelling compression therapy for venous leg ulcers in general practice. J General Practice Nurs Moffatt CJ, Franks PJ, Doherty DC, et al (2004) Prevalence of leg ulceration in a London population. QCM Mosti G (2014) Unpublished data. Reported at the Italian College of Phlebology (CIF) national meeting in Florence Nazarko L (2016) Venous leg ulcers: appropriate diagnosis and evidencebased treatment. Br J Community Nurs S8 S14 National Institute for Health and Excellence (2016a). Leg ulcer venous. Clinical Knowledge Summary. NICE, London. Availale online: org.uk/leg-ulcer-venous#!topicsummary (accessed 24 September, ) National Institute for Health and Excellence (2016b) Medicines prescribing briefings. Chronic wounds: advanced wound dressings and antimicrobial dressings. Evidence summary [ESMPB2]. NICE, London. Available online: ww.n org.uk/advice/esmpb2/chapter/ chapter/ keypoints-from-the-evidencewww.nice. evidencewww.n ewww.n org.uk/guidance/esmpb2 (accessed 21 September, ) Posnett J, Gottrup F, Lundgren H, Saal G (2009) 09) The resource impact of wounds on health-care providers in Europe. J Nursing and Midwifery Council (2015) The Code: Professional Standards of Practice and Behaviour for Nurses and Midwives. NMC, London. Available online: ly/2cjmeil (accessed 20 September, ) Royal College of Nurses (2006) Management of patients with venous leg ulcers. Available online: www2.rcn.org.uk/_data/assets/ pdf_file/0004/107941/ pdf Scottish Intercollegiate Guidelines Network (2010) Management of chronic venous leg ulcers. SIGN. Edinburgh. Available online: index. html (accessed 21 September, ) Templeton S, Telford K (2010) Diagnosis and management of venous leg ulcers: a nurse s role? Practice Res 72 9 Todd M () Management of venous leg ulcers in the care home. Nurs Residential 84 9 Vowden KR, Vowden P (2009) A survey of wound care provision within one English health care district. J Tissue Viability 2 6 Watkins J (2016) Managing venous leg ulcers in a residential setting. Nurs Residential s International (2013) Principles of compression in venous disease: a practitioner s guide to treatment and prevention of venous leg ulcers. s International. Available online: (accessed 20 September, ) s UK (2016) Best Practice Statement: Holistic management of venous leg ulceration. s UK, London. Available online: (accessed 23 September, )?? 42 JCN 2015,, Vol 29, 31, No 5