Leg ulceration is a common condition, affecting 1.5–3 per 1000 population in the UK. It becomes more common with age and 20 per 1000 people over the age of 80 develop the condition.1
It is a cause of much misery for the nation's 100 000 sufferers. Mobility is compromised by pain and those affected often withdraw from society because they are embarrassed by the unpleasant smell associated with the ulcers.
Many suffer in silence for years, believing that little can be done to ease their misery, a belief reinforced by the poor results produced by traditional treatment methods.
Several studies have confirmed that the management of leg ulceration is haphazard and costly.1–3 Ineffective care was estimated to cost the NHS between £230 and £400 million a year in 1986.1
Nationally, community nurses spend up to half their time treating leg ulcers.4 Half the patients are seen more than twice weekly and more than a fifth are treated daily.
It is regarded as low status work5 and is commonly carried out by nurses who feel ill prepared for the task. They often become demoralised by their failure to produce good results despite the many hours they devote to the task.
Our semi-rural practice serves 9000 patients, approximately half of whom live in the small Herefordshire market town of Bromyard. Our three practice nurses work closely with their community nursing colleagues, who have an office in the same building.
Our management of venous leg ulcers used to be as ineffective as anyone else's. The same patients would regularly trundle down the corridor for their dressings, producing that familiar heartsink feeling.
We used a variety of applications and bandage methods in the hope that we might hit on the magic formula, and were pleased if we achieved the expected 25% healing rate.3
In 1997 one of the community nursing team was working on her conversion course from EN to RGN, and decided to review the management of leg ulcers as one of her assignments.
A review of the literature persuaded her that compression bandaging was the best method for treating venous leg ulcers, but in order to be effective the whole nursing team needed to be trained in its use and to apply it consistently.
She persuaded the entire practice team to support the initiative. At the time the necessary bandaging system was not available on prescription, and so money was used from fundholding savings to underwrite the treatment of eight patients.
The nursing team attended two training days, which were organised with the help and financial support of two pharmaceutical companies. Team members learned how to distinguish between arterial and venous ulcers with the aid of Doppler equipment.
Venous ulcers account for approximately 59% of all leg ulcers. It is important to make the distinction between them and arterial or mixed ulcers, in order to avoid applying compression to ischaemic limbs.
On the second day the nursing team learned how to apply the compression bandaging in a consistent, effective manner. They then devised a protocol to guide them in their clinical assessment. The objective was to select patients with venous ulcers that were suitable for treatment within the practice and to ensure that anyone with an arterial or mixed ulcer was referred to a local consultant vascular surgeon.
The protocol was developed and modified with use (Figure 1, below) and clinical details are now held on the EMIS computer system in template form.
|Figure 1: Protocol for leg ulcer management|
What happened next?
The first small group of patients was selected and persuaded to use the new treatment system. They were warned that the bandages would have to stay in place for a week at a time and might feel uncomfortable, but that the long-term gain from this short-term discomfort would, it was hoped, be the healing of their painful smelly ulcers.
After assessment (see Figure 2, below, for assessment forms), the ulcers were measured and photographed and the bandages applied. It quickly became apparent that ulcers that had defied all previous efforts to heal them were getting smaller.
Furthermore, less time was being spent on their treatment, freeing the nurses to undertake other tasks. Before the project it was not unusual for a patient to have daily dressings, and some were taking 2 hours of nursing time each week.
We estimated that each patient cost between £30 and £40 per week in nursing time and materials. With the introduction of compression bandaging, nursing time was reduced to approximately 30 minutes per week per patient.
Material costs were also lower, giving an overall cost of approximately £13 per patient per week – a significant saving, which of course increased once the ulcers healed and we were relieved of the recurring costs.6
The success of the pilot project persuaded us to extend the service to all patients with leg ulcers. A total of 53 ulcers were treated between 17 March 1998 and 24 November 2000. Of these:
- Six were recurrent ulcers after initial successful treatment
- 40 of the 53 ulcers (75%) healed: 23 within 12 weeks (43%) and 32 within 24 weeks (60%)
- Three patients were unable to continue with the treatment because they found it too painful.
These figures compare favourably with published community-based research,3 and led to the practice being awarded Beacon status.
How robust is the evidence underpinning the strategy?
Compression therapy is not new. It has long been known that leg ulcers can be healed if the superficial veins are emptied of blood, but it has proved difficult to devise a method that applied the appropriate amount of pressure. This has to be sufficient to empty the veins but not great enough to risk compromising the arterial supply.
Researchers at the Charing Cross Hospital devised a method to measure pressure under bandages.7 They then used a four-layer compression bandaging system to treat refractory venous leg ulcers.Their results were published in 1988.8 They treated 148 venous ulcers that had been present for a mean of 2.2 years, and found that 74% healed within 12 weeks.
The King's Fund then supported a larger study in the Riverside Health District.9 In this study, 550 ulcers were treated with multilayer compression bandaging over a 2-year period by specially trained community staff. Results showed that:
- 69% of ulcers healed within 12 weeks and 83% within 24 weeks
- Prevalence rates fell by 20% per year
- District costs fell from an estimated £433 600 to £169 000 a year.
Another community-based project in Stockport produced interesting results.3 Specialist community clinics were set up along similar lines to those in Riverside. In this project, ulcer-healing rates after 3 months treatment with multilayer compression bandaging improved from 66/252 (26%) in 1993 to 99/233 (42%) in 1994 (P<0.001). Trafford district was used as a control. There, healing rates were 47/203 (23%) in 1993 and 43/213 (20%) in 1994.
In Stockport the improved results were achieved with a reduction in annual expenditure from £409 991 to £253 371, whereas in Trafford the poorer second year results were associated with an increase in expenditure from £556 039 to £673 318. However, these impressive results did not persuade the NHS Centre for Reviews because the study was 'not properly randomised'.10
In 1994 the NHS Executive set up a multidisciplinary consensus conference on the management of venous ulceration. Draft guidelines were produced and a pilot project was set up in the Wirral.
This demonstrated that multilayer bandaging was effective, but dependent on the proper training of community nurses in its use. Its cost-effectiveness was proved again and the NHS was urged to make the system available through the NHS.11
For some reason the Treasury was not initially convinced by the compelling results, but there has since been a change of heart and multilayer bandaging is now available on prescription.
Impact on the practice
Patients have benefited greatly from our changed management strategy for leg ulcers. Some of them had lived with their ulcers for more than 20 years and now feel that they have been given a new lease of life. Word has spread that leg ulcers do not have to be tolerated and more people have come forward for treatment.
There have been tangible benefits for the practice as well. The nursing team is working more effectively and the relationship between the community nursing team and the practice nurses has been strengthened. A task that was once regarded as something of a drudge and demoralising is now regarded as a challenge, with the expectation that the patient's problem will be resolved.
We have developed a better relationship with our local consultant vascular surgeon, who feels that he is receiving more appropriate referrals.
And a substantial amount of nursing time has been saved, which has enabled us to develop other services such as a nurse-led asthma clinic. I wish we had been able to implement the programme sooner.
This is not an example of complex or sophisticated medical practice, but demonstrates how a simple change in the management of a common distressing condition can produce significant benefits in terms of patient care.
It also shows that improvements in patient care need not be costly – rather, they can be achieved with a net saving of time and resources. If this management programme were introduced throughout the UK, several hundred million pounds could be saved and used to provide much needed care elsewhere.2
- Cornwall J, Dore C, Lewis J. Leg ulcers: epidemiology and aetiology. Br J Surg 1986; 73: 693-6.
- Bosanquet N, Franks P, Moffat C et al. Community leg ulcer clinics: cost effectiveness. Health Trends 1993; 25: 146-8.
- Simon D, Freak L, Kinsella A et al. Community leg ulcer clinics: a comparative study in two health authorities. Br Med J 1996; 312: 1648-51.
- Callan MJ, Ruckley CV, Harper DR, Dale IJ. Chronic ulceration of the leg: extent of the problem and provision of care. Br Med J 1985; 290: 1855-6.
- Ryan TJ. The Management of Leg Ulcers (2nd edn). Oxford: Oxford University Press, 1987.
- Bandolier No. 79, September 2000: 7(9): 5-7.
- Wright DDI, Meek A, McCollum RM. Functional tests for venous insufficiency. J Cardiovasc Surg 1987; 28: 97.
- Blair S, Wright DDI, Backhouse CM, Riddle E, McCollum CN. Sustained compression and healing of chronic venous ulcers. Br Med J 1988; 297: 1159-61.
- Moffat CJ, Franks PJ, Oldroyd M et al. Community clinics for leg ulcers and impact on healing. Br Med J 1992; 305: 389-92.
- Fletcher A, Collum N, Sheldon TAA. Systematic review of compression treatment for venous leg ulcers. Br Med J 1997; 315: 576-80.
- Blair SD. Clinical Evidence Supplement: 'Profore' four-layer bandage. Smith and Nephew, 1997.
NHS Beacon Awards
Beacon status is awarded to practices, trusts and other healthcare organisations within the NHS that have demonstrated good practice. The NHS Beacon programme aims to spread best practice across the health service. For further information visit the website: www.nhs.uk/beacons