West Gloucestershire Primary Care Trust Community Nursing Service Leg Ulcer Audit 2006 Gloucestershire Primary & Community Care Audit Group
Contents Page number Background 3 Audit Aims 4 Methodology 4 Criteria 4 Results 5-15 Discussion 16-17 Action Plan 18 2
Background Two major studies in the United Kingdom have provided similar figures for the prevalence of active ulceration at 0.15% to 0.18% that is 450 patients per health district of 250,000 population and 100,000 patients in the UK. (Cullum 1994). In July 2006 The Secretary of State for Health was asked what the cost to the NHS was for the treatment of leg ulcers. The reply was that Information on the number of people treated for leg ulcers, and the cost of providing this treatment, is not collected. The cost of treating leg ulcers was recently quoted as an estimate of 400 million per annum by Mr. K. Poskitt in his randomised controlled trial in July 2001. Leg ulcers have a typical cycle of healing followed by re-ulceration and re-healing. In surveys, two thirds of patients with leg ulcers were already experiencing a recurrence, and a third had experienced four or more episodes of ulceration. When ulcers are open, they tend to be present for some time. In cross-sectional surveys, half of all ulcers had been open for 9 12 months, 20% open for two years and 8% open for over five years. (Cullum 1994). It is vital that any patient with leg ulceration has a full assessment. Lack of assessment can lead to long periods of inappropriate and potentially dangerous treatment (Roe et al 1993, Stevens et al 1997). Clinical practice guidelines for the management of patients with venous leg ulcers issued by the Royal College of Nursing (1998) states that a doppler ultrasound to measure ABPI should be conducted 3 monthly. The Royal College of Nursing guidelines also state that graduated multi-layer high compression systems (including short stretch regimes), with adequate padding capable of sustaining compression for at least one week, should be the first line of treatment for uncomplicated venous leg ulcers. Accurate assessment and appropriate treatment are essential to heal a leg ulcer and healing rates are improved if there is consistency of approach to treatment. Improvement in the care available to leg ulcer patients will depend on the enthusiasm and skill of healthcare professionals in the clinical setting. R. Cooper (2004) leg ulcers: improving management. The New Generalist Vol.2 No2. 3
Audit Aims To identify current prevalence of patients with leg ulceration within West Gloucestershire Primary Care Trust. To identify by whom and where those patients are currently managed. To identify where those patients appropriately identified as having venous ulceration are being treated with the current Gold Standard research based care as recommended by NICE/RCN guidelines. Results to be used as a measure on the effectiveness of staff training may show a reduction in incidence and an increase in appropriateness of treatment. To identify how many patients are currently being referred to and treated within the Acute Hospital Services who could be treated solely within West Gloucestershire Primary Care Trust. Methodology Questionnaires were sent to 43 Care Homes, 32 District nurse teams and 32 Practice nurse teams within West Gloucestershire Primary Care Trust. The audit began on the 30.01.06 to continue for one week. One form to be completed for each patient with a leg ulcer currently treated on their caseload. The respondents were asked to provide information on the assessment, treatment and management of current leg ulcers. Prepaid envelopes were provided for anonymous returns. Criteria All patients with healed and non healing lower leg wounds of 6 weeks or more will be offered a baseline Doppler screen by a Doppler screen trained nurse. Patients in receipt of ongoing leg ulcer management healed and non healed will be offered a Doppler re screen every three months. 4
Results 173 completed forms returned. Forms were returned from Community Nurses and Practice nurses at 33 GP practices and 43 Care homes. Not all forms were fully completed. Some questionnaires did not contain the following information: Prescription code Patient age Patient location Had the patient been dopplered Date of last dopper assessment How long has the patient had the ulcer? If the patient is attending the vascular or dermatology department Which day routine treatment is given. Number of patients with leg ulcers 173. Total number of leg ulcers 307 Patient details Patient gender Gender Male 66 Female 10 6 Patient age Patient Age 30 yrs to 40 yrs 41 yrs to 50 yrs 0 2 51yrs to 60 yrs 11 61 yrs to 70 yrs 26 71 yrs to 80 yrs 44 81 yrs to 90 yrs 66 91+ years 17 5
The location given for all patients not resident in a care home. Patient location Gloucester 97 Forest of Dean 63 Notification from two Practice nurse bases recorded no leg ulcers at time of audit. The location given of Nursing Home residents Nursing home location 0 5 10 15 20 25 30 35 40 Gloucester 10 Forest of Dean 7 Out of 43 Care Homes 7 replied that they had no patients with leg ulcers at the time of the audit. Three were identified from the Forest area, four from Gloucester area. 6
Current Leg Ulcers Number of ulcers recorded on the patients right leg Numbers of ulcers on right leg One 73 Tw o 24 Three 10 Four 2 Five 1 More than five 1 35% had more than 1 ulcer on their right leg. 40 (23%) Patients had leg ulcers on both legs. The sites recorded for ulcers on the right leg. Site of ulcers on right leg Calf 28 Gaiter 49 Foot 26 Other 23 Ten of those sites named as other were as follows: ankle 4, shin 2, malleolus 2, below knee 1, stump 1. The remaining 13 were not identified. 7
The duration of the ulcers recorded on the right leg. Duration of ulcers on right leg 0 to 6 w eeks 14 7 to 12 w eeks 16 13 to 18 w eeks 11 19 to 24 w eeks 9 25+ w eeks 55 55 patients had leg ulcers on their right leg for more than 6 months. The length of ulceration ranged from 1 year to 50yrs. There were many comments recording that these were recurrent outbreaks. Number of ulcers recorded on the patients left leg Number of ulcers on left leg One 75 Tw o 17 Three 5 Four Five More than five 2 1 0 8
The sites recorded for ulcers on the left leg. Sites of ulcers on left leg Calf 21 Gaiter 60 Foot 26 Other 18 The sites names as other were as follows: Ankle 5, Thigh 1, Malleolus 2, Shin 3, Stump 1, Mid calf to below ankle 1, Pre tibial 1, Outer aspect of gaiter 1, Outer leg 1, front leg 1, below knee 1. The duration of the ulcers recorded on the left leg. Duration of ulcers on left leg 0 to 6 w eeks 10 7 to 12 w eeks 15 13 to 18 w eeks 10 19 to 24 w eeks 1 25+ w eeks 56 56 patients had leg ulcers on their left leg for more than 6 months. These varied from 7 months to 20 yrs. (98yrs old) 9
Assessment Has the patient been dopplered? Has a Doppler assessment been done? 140 Yes 125 No 36 The locations of the 36 above who were not dopplered are 24 from Gloucester and 10 from the Forest of Dean. Two locations are not known. Total number of patients not dopplered were 42. The 6 patients who refused or found it too painful are not included in the above graph. Aetiology Aetiology Venous 85 Mixed 28 Arterial 15 10
The date recorded of the last ABPI Date of last recorded ABPI 0 to 3 months 52 4 to 6 months 11 7 months to 9 months 10 10 months to 1 year 13 more than 1 year 21 49% of patients of patients received a doppler assessment 3 monthly Comments from this section 11 stated that ABPI assessment was done at leg ulcer clinic. These did not give dates. 4 patients were unable to tolerate assessment. 4 patients refused an assessment. 1 assessment had been requested. Identification of the aetiology? Who identified Aetiology? District nurse 52 Leg ulcer service 30 Vascular consultant Practice nurse 14 12 RGN care homes General practitioner Dermatologist 2 4 6 Combined diagnosis 17 3 recorded unknown, 1 recorded other and did not qualify who. 11
Treatment The treatment given at the last patient contact Treatment given at last contact Dressings only 87 Graduated compression 46 Which type of graduated compression is currently used? If graduated compression which type? Multi layered compression 33 Modified compression 48 2 layer 4 Short stretch 1 Compression 15 Makes given Profore Profore lite Profore kit 3 Progide One nurse stated 4 layer K provided by Kidderminster Trust, layers K soft, K lite, K plus Scholl ultima hosiery Class 1 Mepilex + Cavilon Spray 12
Management Who currently manages the patient on a weekly basis? Who manages the patient on a weekly basis? District nurse 96 Practice Nurse 30 RGN care homes 24 Leg ulcer service 1 Shared care nursing 14 Shared care nursing & Leg ulcer clinic 7 Comments given on shared care Care shared with Registered General Nurse & Health Care Assistant Care shared with Diabetic foot clinic Care shared with hospice Wife Patient passed from practice nurse to district nurse Patient care taken over from nursing home Attendance at Dermatology Department Seen at Dermatology Department? 140 Yes, but discharged 6 Still attending 7 No 122 2 replies recorded not known 13
Attendance at Vascular Department Seen at Vascular Department? 140 Yes, but discharged 23 Still attending 36 No 73 8 replies recorded not known Activity Which day do you routinely treat this patient? Many patients will be seen more than once a week. The total number of visits during the audit period 278 Which day do you routinely treat this patient? Monday 66 Tuesday 58 Wednesday Thursday 40 41 Friday 67 Saturday 2 Sunday 4 14
The number of visits to patients per week Number of visits per patient per week Once a w eek 78 Tw ice a w eek 65 Three times a w eek 18 Four times a w eek 4 Time spent with patient at each contact Time spent at each patient contact 10 to 20 mins 21 to 30 mins 60 63 31 to 40 mins 34 41 to 50 mins 10 51 to 60 mins More than 1 hour 2 2 Case management Is this patient case managed? Is this patient case managed? Yes 23 No 99 15
Discussion 50% of those invited to respond did so, recording 173 patients with a total of 307 leg ulcers. The wound formulary audit confirms that there are more than 173 patients with leg ulcers being treated. We can also show from the prescription codes that although the majority of forms returned were from District Nurses and Practice Nurses, the codes for 14 practices were missing from the returned forms. 24 Care Homes returned forms, 17 of which had patients with leg ulcers. It is not known if this is a low response rate or if this reflects the number of patients with ulcers in care homes. Not all forms were fully completed (see page 5) it is not known why some of the information was not recorded by respondents. The total number of leg ulcers recorded was 307 which may seriously underestimate the true prevalence. The number of ulcers on right and left legs was almost equal with 23% of patients having ulcers on both legs. The majority of ulcers (60%) were sited on the gaiter area this would be as expected. The total number of patient contacts during the audit week was 278 with the majority of patients treated Monday to Friday. The patient contact time (excluding travel) during the week of the audit accounted for 140½ hours (3.75 whole time equivalent) trained staff time. Due to the low response rate the total nursing time could amount to twice that figure. 13 extra contacts were made to patients with venous aetiology ulcers who were not treated with compression therapy during the week of the audit. RCN guidelines 1998 state that patients should be dopplered and re-assessed 3 monthly if in compression. 75% of patients with leg ulcers had received a Doppler assessment. 52 patients out of 107 (49%) were recorded as having had a re-doppler in 3 months or less. The remaining recorded ABPI (51%) ranged between 4 months and 1 year. 101 patients were recorded as currently being in some form of compression. These patients potentially should have received re-assessment re-doppler at 3 months. 43% of these patients had received a re-doppler in 3 months or less as per guidelines. The duration of ulcers can vary immensely due to patient variables and variations in treatment. 28% of ulcers recorded in this audit were still being treated at 12 weeks, with 52% still being treated at 25 weeks or longer. Venous aetiology was confirmed for 85 patients. The recommended treatment for these patients would be multilayer compression, which potentially reduces healing time. 24 of those patients with confirmed venous aetiology were not treated with compression therapy. The reason for this is not known. This could highlight a training need. With uncomplicated venous leg ulcers and patient compliance with recommended treatments a twelve week healing time would be expected. Lindsay states that belonging to a Leg Club enables patients to receive regular care and earlier intervention. This has shown an average healing time of 8.5 weeks. (Lindsay 2004) Some patients were treated with modified compression. Is the application of modified compression due to complex medical histories informing the nurse s decision on the bandage set applied or is it a lack of overall confidence / competence in applying compression therapy as only 6 patients are reported as refusing treatment and 87 patients were treated with topical dressings only. Hilary Field Tissue Viability Nurse Specialist undertook a research project that interviewed district nurses from South 16
Lincolnshire who regularly cared for patients with venous leg ulcers. One of the most evident points to arise from the discussions about compression therapy was fear of causing trauma to the leg through inappropriate compression. This fear led the district nurses to err on the side of caution when deciding treatment choices. All patients in the audit that were recorded as being in compression bandaging (other than 1 from another Trust) show compliance with Wound Formulary Guidelines for WGPCT The time needed to provide gold standard care for leg ulcer patients together with the evidence of local care suggests continual ongoing planning and management of active and healed leg ulcers provides improved healing time at less cost. Out of 173 patients included, 23 are case managed. It is recognised that leg ulcers are chronic recurring life long condition that are often coupled with other complex medical conditions e.g. diabetes, arthritis and would fit into the case management model. 17
Action Plan To recommend that the County Primary Care Trust adopts the Leg Ulcer Guidelines/Referral pathway. To recommend to the Director of Clinical Development that training in Leg ulcer Management and Doppler assessment should be available to all trained nursing staff within West Gloucestershire Primary Care Trust dependent on their personal development needs. Training should include practice competencies in the following: Holistic nursing assessment including the lower legs definition of aetiology using the Doppler tool. Interpretation of the results Application of the appropriate compression bandage system Written description of treatment in care plan Ongoing management of the lower leg ulcer until healed Measurement of the appropriate support hose where indicated Entry into program of follow up care Promotion of self care and knowledge of self referral to appropriate health care professional. To recommend that the County Primary Care Trust considers that leg ulcers are a long term condition and would fit into the case management model. 18