Clinical. Management of Chronic Leg Ulcers Policy

Transcription

1 NHS TAYSIDE Clinical Management of Chronic Leg Ulcers Policy Author: Mrs Eleanor Stewart, Specialist Nurse/Dr S M Morley, Consultant Dermatologist Review Group: Tissue Viability Network Review Date: January 2011 Last Update: January 2009 Document No: Issue No: UNCONTROLLED WHEN PRINTED Signed: Executive Lead (Authorised Signatory)

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3 Contents Page number 1. Purpose and Scope 3 2. Statement of Policy 3 3. Responsibilities and Organisational Arrangements Assessment of Leg Ulcer Patients Competencies Management Plan Referral for Specialist Assessment Patient Education Antibiotics Re-assessment Secondary Prevention Religions and Cultures 6 4. References 6 5. Key Contacts 7 6. Members of the Tissue Viability Newtwork 7 7. Policy Approval Checklist 9 8. Rapid Impact Checklist 10 APPENDIX 1: Leg Ulcer Management Follow Up Sheet 12 Final:

4 1. Purpose and Scope The purpose of this policy is to ensure that all NHS Tayside practitioners who care for Patients with leg ulcers provide effective evidence based assessment and treatment of patients with leg ulcers. Leg ulcers are defined in the current SIGN Guidelines, as an open lesion between the knee and ankle joint that remains unhealed for at least four weeks. 2. Statement of Policy Nurses who care for patients with leg ulcers must be competent in leg ulcer management and bandage application. It is recommended that this can be achieved by completing the NHS Tayside Leg Ulcer Clinical Skills Pack. Staff who have previously gained knowledge and experience elsewhere must complete theoretical and practical assessment. This policy applies to all nurses employed by NHS Tayside and its adoption is recommended for practice-employed nurses. 3. Responsibilities and Organisational Arrangements The majority of patients with leg ulcers will be cared for in the community setting, by either or both Practice and District Nurses, under the responsibility of the Primary Care Physicians. Support from Specialists in Secondary Care is available and must be utilised promptly to maximise the rate of healing of these wounds. Close co-ordination and co-operation is essential if good care is to be delivered. It is anticipated that only nurses with a special interest in this condition will be identified and specifically trained, since it has been shown that training all nurses to have these competencies is not effective (Scottish Leg Ulcer Project Report, 2002). The following points are considered to be core to the correct management of this clinical condition. 3.1 Assessment of Leg Ulcer Patients All NHS Tayside patients with a wound on the lower leg, which has remained unhealed for at least four weeks, must have a holistic assessment (SIGN 1998). The assessment must include non-invasive vascular assessment using either Doppler Ultrasound or Pulse Oximetry, carried out by an appropriately trained individual. The aim of assessment is to determine: the immediate cause and history of the ulcer; the underlying pathology in the lower limb; local problems at the wound site which may delay healing; general medical conditions which may delay healing; patients social circumstances; the optimum setting for care. Rationale: Final:

5 Accurate diagnosis and documentation supports early and correct patient focused intervention, which will improve healing rates. It reduces the risk of inappropriate or inadequate use of compression bandaging. (Callam MJ. Ruckley CV. Harper DR. Dale JJ. (1985) Callam MJ. Ruckley CV,(1999) Gibson B (1995) SIGN Guidelines 26,(1998), Tayside Clinical Skills Pack, 2005) 3.2 Competencies Leg Ulcer assessment and management must be undertaken by practitioners who can demonstrate the required competencies outlined in the Tayside Clinical Skills Pack.. Appropriate use of correctly applied bandages is especially important. Rationale: Assessment of leg ulcers is complex and practitioners are required to maintain levels of competencies to provide safe effective practice, eliminating significant risks such as inaccurate diagnosis and inappropriate treatment. In particular, modern bandaging techniques require regular usage to maintain standards and confidence. The report from Kaiser et al (1999) illustrates this principle with regard to Ankle Brachial Pressure Index (ABPI) assessment: experienced recorders of ABPI carry out the procedure more than 10 times a week, and the less experienced 5 to 15 times a month. Pulse oximeters require no previous experience (Joyce et al 1990) but interpreting the results and then applying the correct bandage requires training. Further papers discussing this subject Ray et al (1994) Vowden and Vowden (2001) Fowkes et al (1998) Ruckley CV (2001) Lucke et al, 1999; Bianchi et al, 2000; Zamiri et al In Tayside, wherever possible, ABPIs are performed by the staff from the Vascular laboratory and can be arranged in Dundee, Perth and Stracathro, at the request of Secondary Care staff. 3.3 Management Plan Following assessment and diagnosis, an evidence based treatment plan must be commenced. The wound must be dressed and treated with suitable dressings and/or topical therapies depending upon the ulcer s characteristics and the condition of the surrounding skin. This must be completed in accordance with guidance found in Tayside Clinical Skills Pack and local wound care formularies. Assessment and treatment plans will be recorded on standard forms, used by all staff across NHS Tayside, to facilitate transfer of care and accurate audit. (Appendix 1.) Rationale: Agreed, written documents are the means by which the accountable practitioner can rationalise any prescribed treatment, ensure continuity of patient care and reduce risk. (Hon and Jones, 1996 NMC, 1998). Most litigation cases relate to poor documentation. 3.4 Referral for specialist assessment Patients with the following features must be referred promptly by the professional performing the initial assessment Diabetes Mellitus Peripheral Vascular Disease (ABPI or Toe Finger Pulse Oximetry less than 0.8) Suspicion of malignancy Rheumatoid arthritis / vasculitis Atypical distribution of ulcers. Final:

6 Patients with the following features must be referred within 8 weeks, following consultation with the patient s GP. Contact dermatitis or dermatitis resistant to topical steroids Patients who may benefit from venous surgery Failure to progress despite following SIGN Guidelines If there is any uncertainty regarding referrals for specialist assessment, referrals will be sent to Dermatology, where triage will be carried out. The Dermatology consultants will assess all referrals, and refer on in accordance with patient need. All referrals must include summary sheet of medication, patient s medical history, wound history and treatments. Rationale: All of the above features if left untreated will contribute to delay in healing of the ulcer. All data show that healing rates are best in ulcers of short duration. Specialist assessment is particularly important for patients with diabetes mellitus, where the consequences of mismanagement can be extremely dangerous, and for patients with suspected arterial disease, where a thorough vascular assessment is required to determine the extent of ischemia and suitability for vascular surgery. (SIGN 1998) 3.5 Patient education Patient education leaflets on Leg Ulcers and Compression stockings are to be given out (these can be accessed via NHS Tayside Staffnet homepage Clinical Information Patient Information Leaflets). Patients attending their local community pharmacy to purchase leg ulcer treatments must be advised to seek nursing advice, rather than continuing with self treatment. 3.6 Antibiotics In the absence of clinical signs of infection there is no indication for routine bacteriological swabbing or the use of systemic antibiotic therapy. Excess or inappropriate use of antibiotics leads to development of bacterial resistance. MRSA contamination/infection is common in chronic leg ulcers. Rationale: All ulcers will be contaminated, colonised or critically colonised by micro-organisms at some point; this in itself is not necessarily associated with delayed healing. (SIGN 26) 3.7 Re-assessment It is important to reassess progress 12 weeks after treatment has commenced. This assessment will follow the recommendations for the initial assessment. Likewise, when an ulcer recurs, a full assessment must be carried out, and thereafter at 12 weekly intervals. The following will be considered: Is the ulcer healing? If yes, continue current treatment. If not: Is the aetiology of the ulcer confirmed? Final:

7 Are there new co-morbidities? Does the ulcer require a biopsy? Is management consistent and appropriate? Is the patient complying with treatment? 3.8 Secondary prevention Care must be maintained following leg ulcer healing to avoid ulcer recurrence. For venous ulcers, this presently takes the form of graduated compression hosiery, surgery if appropriate and regular patient review and education from trained nursing staff. Correctly fitted compression hosiery and appliance aids if required must be prescribed for at least five years for all patients who have successfully healed venous ulcers, or indefinitely if the underlying haemodynamic abnormality has not been corrected. All patients with compression hosiery are to be given the NHS Tayside Patient Information Leaflet Compression Hosiery (this can be accessed via NHS Tayside Staffnet homepage Clinical Information Patient Information Leaflets). Rationale Chronic leg ulcers almost always recur unless secondary prevention is maintained. Appropriate surgical review should be carried out at an early stage in the clinical course for arterial and venous disease. The use of low dose aspirin and or statins should be considered. Surgery and graduated compression hosiery are associated with good outcomes for venous ulcers. Maximum interval of patient review, 6 months (ABPI reassessed if new symptoms evident). Regular review ensures hosiery is renewed appropriately, skin integrity and concordance is maintained. Patient information leaflets encourage patients to comply with treatment. 3.9 Religions and Cultures Acknowledge any cultural or spiritual needs that the patient and/or carers may have in relation to leg ulcer treatment. Refer to Religions and Cultures-Guide to Beliefs and Customs for Health Staff and Social Care Services- Revised Edition Advice and guidance can be obtained at Royal Dundee Liff Hospital, Dundee on , or in an emergency situation contact the Communication Centre at Ninewells Hospital, Dundee on and ask for the On-Call Chaplain. 4. References Callam M J, Ruckley CV, Harper DR, Dale JJ, (1985) Chronic ulceration of the leg; extent of the problem and provision of care. British Medical Journal. 240; Fowkes FGR, Housley E, MacIntyre CCA, Prescott RJ, Ruckley CV, (1998) Variability of ankle brachial systolic pressures in the measurement of atherosclerotic peripheral arteries. Journal of Epidemiology and Community Health. 42; 2: Gibson B, (1995) The Nursing Assessment of Patients with Leg Ulcers. Sited in; Leg Ulcers, Nursing Management, A research-based Guide. Cullum N, Roe B. Balliere Tindal, London. Kaiser V, Kester ADM, Stoffers HE, (1999) The influence of experience on the reproducibility of the ankle-brachial systolic pressure ratio in peripheral occlusive disease. European Journal of Vascular and Endovascular Surgery. 18; Final:

8 Joyce WFP, Walsh K, Gough DB, Gorey TF, Fitzpatrick JM, (1990) Pulse oximetry; a new non-invasive assessment of peripheral arterial occlusive disease. British Journal of Surgery 10; 6: Lucke TW, Bianchi J, Zamiri M, (2005) LOI; an alternative to Doppler in leg ulcer patients Wounds UK, 1, 1, National Guidelines SIGN 26 (1998) Scottish Leg Ulcer Trial: Phlebology (202) 17: Ray SA, Srodon PD, Taylor RS, Dormandy JA. (1994) Reliability of ankle brachial pressure index measurements by junior doctors. British Journal of Surgery 81; Ruckley CV, (2001) The Scottish Leg Ulcer Trial: evaluation of the impacts of national (SIGN) guidelines and an intensive training programme on leg ulcer healing in the community. Proceedings of the 11 th Conference of European Wound Management Association. Tayside Clinical Skills Pack (2005) Vowden K & Vowden P. (2001) Doppler and the ABPI how good is our understanding. Journal of Wound Care 10; 6: Key Contacts (past and present) Ms Debbie Baldie Ms Allison Carnegie Mr Tejinder Chima Mrs A Coulson Ms Kate Danskin Mrs Rhona Guild Ms Joan Wilson Dr A Russell Ms Eleanor Stewart Dr Susan Morley 6. Members of the Tissue Viability Network Andrew Wilmhurst Anne Ritchie Dawn Weir Diane Campbell Eileen McKenna Fiona McGrehan Fiona Petrie Gail Robertson Gail Smith Gail Young Iain Rennie Final:

9 Jenny Bowes Kevin Cameron Lana Syme Lorna Cameron Lorraine Findlay Marion Gaffney Paul Smith Sue Morley Susan Lundie Vicky Green Final:

10 NHS TAYSIDE - POLICY/STRATEGY APPROVAL CHECKLIST This checklist must be completed and forwarded with policy to the appropriate forum/committee for approval. POLICY/STRATEGY AREA: Clinical POLICY/STRATEGY TITLE: Management of Chronic Leg Ulcers LEAD OFFICER: Dr S Morley Why has this policy/strategy been developed? Has the policy/strategy been developed in accordance with or related to legislation? Please give details of applicable legislation. Has a risk control plan been developed? Who is the owner of the risk? Who has been involved/consulted in the development of the policy/strategy? Has the policy/strategy been assessed for Equality and Diversity in relation to:- Race/Ethnicity Gender Age Religion/Faith Disability Sexual Orientation Please indicate Yes/No for the following: Yes Yes Yes Yes Yes Yes Does the policy/strategy contain evidence of the Equality & Diversity Impact Assessment Process? Is there an implementation plan? Which officers are responsible for implementation? When will the policy/strategy take effect? Who must comply with the policy/strategy? How will they be informed of their responsibilities? Is any training required? If yes, has any been arranged? Are there any cost implications? If yes, please detail costs and note source of funding Who is responsible for auditing the implementation of the policy/strategy? What is the audit interval? Who will receive the audit reports? When will the policy/strategy be reviewed and by whom? (please give designation) To improve the delivery of leg ulcer care in Tayside No No Nursing and Medical staff (primary and secondary care), Pharmacists, Patients Has the policy/strategy been assessed For Equality and Diversity not to disadvantage the following groups:- Please indicate Yes/No for the following: Minority Ethnic Communities Yes (includes Gypsy/Travellers, Refugees & Asylum Seekers) Women and Men Religious & Faith Groups Disabled People Children and Young People Lesbian, Gay, Bisexual & Transgender Community Yes Yes Local Managers All NHS Tayside staff caring for leg ulcer patients Through implementation plan Yes (as per Implementation Plan) Clinical Skills Pack available (as per Implementation Plan) No Dr S Morley Annual Clinical Governance Report 2010 Final:

11 Name: Dr S Morley Date: 22 January 2009 Final:

12 1. Rapid Impact Checklist (RIC) Each policy must include a completed and signed template of assessment Page 1 of 2 Which groups of the population do you think will be affected by this proposal? minority ethnic people (incl. gypsy/travellers, refugees & asylum seekers) women and men people in religious/faith groups disabled people older people, children and young people lesbian, gay, bisexual and transgender people N.B. The word proposal is used below as shorthand for any policy, procedure, strategy or proposal that might be assessed. What impact will the proposal have on lifestyles? For example, will the changes affect: Diet and nutrition? Exercise and physical activity? Substance use: tobacco, alcohol or drugs? Risk taking behaviour? Education and learning, or skills? Will the proposal have any impact on the social environment? Things that might be affected include Social status Employment (paid or unpaid) Social/family support Stress Income Will the proposal have any impact on Discrimination? Equality of opportunity? Relations between groups? Will the proposal have an impact on the physical environment? For example, will there be impacts on: Living conditions? Working conditions? Accidental injuries or public safety? Transmission of infectious disease? Will the proposal affect access to and experience of services? For example, Health care Transport Social services Housing services Education people of low income Other Groups: people with mental health problems homeless people people involved in criminal justice system staff What positive and negative impacts do you think there may be? Which groups will be affected by these impacts? Positive impact of a healed ulcer No No No No This policy is directed to any patient with a chronic leg ulcer regardless of social situation: all these groups would be treated the same way. Final:

13 2 Rapid Impact Checklist (RIC): Summary Sheet Each policy must include a completed and signed template of assessment 1. POSITIVE IMPACTS (NOTE THE GROUPS AFFECTED) 2. NEGATIVE IMPACTS (NOTE THE GROUPS AFFECTED) Better, evidence based care of all patients with chronic leg ulcers regardless of any sub grouping. No 3. ADDITIONAL INFORMATION AND EVIDENCE REQUIRED This policy relates to the delivery of correct treatment for chronic leg ulcers only. It involves the adoption of SIGN (Scottish Intercollegiate Guidelines Network) guideline number 26, which provides the evidence base for the treatment. 4. RECOMMENDATIONS I would recommend this policy be introduced by the Tayside Health Board 5. FROM THE OUTCOME OF THE RIC, HAVE NEGATIVE IMPACTS BEEN IDENTIFIED FOR RACE OR OTHER EQUALITY GROUPS? HAS A FULL EQIA PROCESS BEEN RECOMMENDED? IF NOT, WHY NOT? No negative impacts have been identified. Full EQIA not required: national guidelines are fully researched and based on available evidence for good clinical care. Manager s Signature: Susan M Morley Date:

14 LEG ULCER MANAGEMENT FOLLOW-UP SHEET Patient name Address GP name/address DOB Hospital no Consultant Occupation Parity Date ULCER HISTORY RIGHT LEFT Duration of present ulcer Onset of first ulcer Number of episodes Months/years Months/years Pain ulcer calf joints Sleep disturbance Current Treatment Bandages Dressings/applications OTHER HISTORY R L Diabetes Claudication/arterial disease Rheumatoid arthritis Previous DVT Osteoarthritis Previous fracture Cardiovascular Previous surgery: venous disease Cerebrovascular arterial disease Other: DRUG HISTORY Final:

15 ALLERGIES SOCIAL CIRCUMSTANCES Lives alone Support Practice nurse With District nurse family/partner Sleeps In bed Health visitor In chair Social worker Washes Bath Shower Nursing home EXAMINATION Height: cm Weight: kg BP: SMOKING STATUS non-smoker/never smoked current smoker former smoker MOBILITY out and about walks with stick fully mobile at home chair bound walks with stick LEG ASSESSMENT RIGHT LEFT Ankle circumference (cm) Calf circumference (cm) Restriction in ankle movement Oedema Pigmentation/lipodermatosclerosis Varicosity Dermatitis Cellulitis PULSES Posterior tibial Dorsalis pedis DOPPLERS Brachial (mmhg) Dorsalis pedis (mmhg) Posterior tibial (mmhg) APPI Final:

16 EXAMINATION Height: cm Weight: kg BP: ULCER ASSESSMENT Size (indicate size on diagram) No1 X = mm 2 No2 X = mm 2 No3 X = mm 2 No4 X = mm 2 No5 X = mm 2 No6 X = mm 2 3 Margin Sloping Necrotic Hyperplasic Base Slough Granulation Rolled Punched Depth Pain Exudate Odour Wash Lower Leg Warm water emuls K Perm Other specify Massage Leg 50:50 WSP/LP Aqueous cream Diprobase Other specify Treatment surrounding Eczema Trimovate cream Eumovate cream Elecon cream Other specify (STRENGTH OF TOPICAL STEROID USED WILL BE ASSESSED ON EACH VISIT, ADJUSTED AS NECESSARY AND RECORDED). Final:

17 Primary dressing to ulcer NA dressing Mepilex Aquacel Other specify Type of compression Multi-layer high bandages Multi-layer low compression Modified high compression short stretch Other Information to Patients care of bandages elevation exercise diet/lifestyle other specify INVESTIGATIONS Hb = Glucose = (random/fasting) Biopsy required Patch testing booked Oximetry booked? Vascular opinion arranged DIAGNOSIS yes yes yes yes no no no no Main cause(s): venous arterial vasculitis neoplasm Contributing factors: obesity Diabetes Arterial Cardiac Rheumatoid Poor mobility armchair legs other REASSESMENT AT 12 WEEKS Ulcer Healed Class II compression stockings Class I compression Other specify Ulcer Healing Final:

18 Continue present treatment Other specify Ulcer Deteriorating Full assessment and new treatment plan Other: specify Final:

19 LEG ULCER MANAGEMENT FOLLOW-UP SHEET Date Problems/Changes in Treatment Signature GR/JL May 08