The management of patients with venous leg ulcers - Audit Protocol

 
The management of patients with venous leg ulcers - Audit Protocol
The management of
patients with venous leg ulcers

                   Audit Protocol
The management of patients
     with venous leg ulcers

             Audit Protocol
Acknowledgements

Produced by the Dynamic Quality Improvement
Programme, RCN Institute in conjunction with
the Clinical Governance Research and Development
Unit, Department of General Practice and Primary
Health Care, University of Leicester

We should like to thank the following who
undertook peer review of this protocol.
Steering group: Carol Dealey, Andrea Nelson,
Edward Dickinson, Karen Jones, Lesley Duff
Advisory Panel: Richard Baker, Ian Seccombe,
Mary Clay, Julia Schofield, Sir Norman Browse,
Sara Twaddle
Users group: Dawne Squires, Sarah Pankhurst,
Kath Robinson, and Kate Panico
Protocol developed by Xiao Hui Liao,
Francine Cheater

The National Sentinel Audit Project for the
Management of Venous Leg Ulcers, from which this
audit protocol was developed, was funded by the
NHS Executive, Department of Health

Published by the Royal College of Nursing,
20 Cavendish Square,
London W1M OAB

Management of patients with venous leg ulcers
Audit protocol
Publication code 001 269
ISBN 1-873853-89-0
July 2000
Price
RCN members: £3.50
RCN non-members: £4.50

The management of patients with venous leg ulcers
Contents

                                  1. Introduction                                                   2
                                       Why an audit of patients with leg ulcers                     2
                                       Background of national sentinel audit                        2
                                       What is included in the protocol                             2
                                       How to use this protocol                                     2
                                       Which patients are included                                  3
                                       Evidence grading                                             3
                                  2. Summary of criteria                                           4
                                       The criteria - assessment                                   5
                                       The criteria - management                                  13
                                       The criteria - cleansing, dressing, contact sensitivity    15
                                  3. Introducing change                                           19
                                  References                                                      20
                                  Sources of further information                                  23
                                  Appendix 1 -Documentation                                       24
                                  Appendix 2 -Audit Form                                          24

The management of patients with venous leg ulcers                                                Contents   1
1.         Introduction

    A. Why an audit of patients with leg ulcers?               audit tools, the RCN and its project partners will be
                                                               able to help local teams improve the quality of care
    Epidemiological data suggest that between 1.5-3.0
                                                               to patients. It is hoped that results will be collated
    per 1000 of the population have active leg ulcers
                                                               nationally in an anonymised form to enable
    (Fletcher et al 1997), and the prevalence increases
                                                               comparative data analysis to take place. This will
    to 20 per 1000 in people over 80 years-of-age.
                                                               allow individual teams to benchmark their
    The total cost to the NHS of treating leg ulcers is        performance against others, and by establishing
    estimated to be as high as £600 million a year             regional networks, to share good ideas and learn
    (Douglas et al 1995).                                      from the experiences of colleagues.
    A recent Effective Health Care Bulletin on                 The initial project in which this audit protocol was
    compression therapy for venous leg ulcers                  piloted was led by a collaborative partnership, co-
    concluded: “There is widespread variation in               ordinated by the RCN Dynamic Quality
    practice, and evidence of unnecessary suffering            Improvement Programme, a steering group of
    and costs due to inadequate management of                  representatives from other professional
    venous leg ulcers in the community.” (NHS Centre           organisations, and an advisory group of experts in
    for Reviews and Dissemination, 1997)                       the management of leg ulcers.
    Experience from initiatives set up to improve
                                                               C. This protocol was originally developed for the
    community-based nursing management of leg
                                                               national sentinel audit management of leg ulcers.
    ulcers (Moffat et al 1992; Thompson, 1993)
                                                               It contains:
    highlighted the potential for more clinical and
    cost-effective practice through more widespread            ◆   instructions to community nurses on how to
    adoption of evidence-based interventions.                      conduct the audit
                                                               ◆   detailed explanation and justification of the
    B. Background for national sentinel audit for leg ulcers       criteria from research evidence
                                                               ◆   criteria prioritised according to the strength of
    The National Sentinel Audit Project for the
                                                                   the research evidence and impact on the
    management of venous leg ulcers was funded by
                                                                   outcome (Baker et al 1995)
    the NHS Executive for an 18-month period. The aim
    was to pilot a methodology to improve the quality          ◆   data collection form
    of care for leg ulcer patients in terms of clinical and    ◆   brief advice about change.
    cost effectiveness. Evidence-based review criteria
    were developed, based on the national guideline:           D. How to use this protocol
    ‘Clinical practice guidelines for the management of
    patients with venous leg ulcers: recommendations           Planning the audit
    for assessment, compression therapy, cleansing,            A project leader must be identified who will take
    debridement, dressings, contact sensitivity, training/     responsibility for involving clinical staff.
    education and quality assurance’ (RCN et al 1998).         Involvement in a clinical audit project is about
    Methods of data collection have been developed             developing clinical practice, not just collecting
    drawing on the experience of practitioners,                data. It is vital that the project leader seeks to
    alongside the process of agreeing the evidence-            enable clinical staff to improve the service. Further
    based review criteria. Twenty pilot sites were             information on this can be found in the
    recruited to help the project team to test the             implementation guide. If you are using this audit
    development of the audit package and                       protocol as a part of a regional or national project,
    methodology.                                               comparing your results with others, you will need
                                                               to audit all the criteria. If you are using this
    The projrct team is grateful to the participating          protocol locally you may choose only to use the
    sites for their input and feedback in the                  ‘must do’ criteria. You may wish to add criteria
    development of the audit form.                             which refer to protocols for organising care locally.
    The purpose of clinical audit is to improve the            Ethical issues will also need to be considered at the
    quality of care to patients locally. It is intended that   planning stage. It is important to ensure that local
    by providing nationally-produced guidelines and            procedures for ethical approval are followed.

2   The management of patients with venous leg ulcers                                                       Introduction
Introduction

Data collection - one form per patient
You should use one data collection form for each
individual patient. It is recommended that the data
collection will last for a three month period. The
completed form should be sent back to the project
leader in your organisation.

E. Which patients are included in the audit?
The protocol has been designed for community
nurses working in leg ulcer clinics as well as home
care-based practice. Leg ulcers are defined as areas
of “loss of skin below the knee on the leg or foot
which take more than six weeks to heal” (Effective
Health Care Bulletin 1997). Patients diagnosed with
venous leg ulcers are included in the project. This
includes new patients, patients who are in the
process of treatment and patients who have a
recurrent ulcer. For more detailed criteria, please
read the Instruction for Audit Form in Appendix 2
before you complete the form.

F. The evidence, on which the guideline
recommendations from which the audit criteria
were developed, was graded as follows:
I Generally consistent findings in a majority of
    multiple acceptable studies.
II Either based on a single acceptable study, or a
    weak or inconsistent finding in multiple
    acceptable studies.
III Limited scientific evidence that does not meet all
    the criteria of acceptable studies, or absence of
    direct studies of good quality. This includes
    published or unpublished expert opinion
    (Waddell et al 1996).

The management of patients with venous leg ulcers        Introduction   3
2.         Summary of Criteria

    Assessment                                                12. The records show that products containing
                                                              lanolin or other potential allergens have not been
    1. The records show that at the first assessment*, a      used on the patient.
    clinical history (ulcer history, past medical history),
    physical examination (blood pressure                      13. The records show that topical antibiotics have
    measurement, weight, urinalysis) has been                 not been used on the patient.
    undertaken.
    2. The records show that on the first assessment,         * First assessment - a full assessment takes place
    the ankle/brachial pressure index (ABPI) has been           within two weeks of first contact with the patient
    measured.
    3. The records show that the ulcer size and wound
    status (edge, base, position, surrounding skin) is
    documented at the first assessment.
    4. The records show a referral via general
    practitioner to a specialist has been made in the
    following situations: the ABPI is
2.1        Assessment of Patients with Leg Ulcers

1. The records show that at the first assessment, a       Although methods and populations make
clinical history (ulcer history, past medical history),   comparison between studies difficult, there is
physical examination (blood pressure measurement,         general consensus on the aetiological factors and
weight, urinalysis) has been undertaken.                  the medical criteria used to define venous, non-
                                                          venous and mixed aetiology ulcers (Alexander
Justification                                             House Group 1992).

Lack of appropriate clinical assessment of patients       Arterial Ulcers - caused by an insufficient arterial
with limb ulceration in the community has often           blood supply to lower limb, resulting in ischaemia
led to long periods of ineffective and often              and necrosis (Belcarno et al 1983; Carter 1973).
inappropriate treatment (Cornwall et al 1986; Roe         Rheumatoid ulcers - are commonly described as
et al 1993; Stevens et al 1997; Elliott et al 1996). In   deep, well-demarcated and punched-out in
addition, inadequate diagnosis of ulcers of arterial      appearance. They are usually situated on the
origin (Callam et al 1987a) leading to inadequate         dorsum of the foot or calf (Lambert and McGuire
treatment can have serious adverse consequences           1989) and are often slow to heal.
for the patient (for example, ischaemia). It is
essential, therefore, that a patient presenting with      Diabetic ulcers - are usually found on the foot,
leg ulcers has a thorough clinical history and            often over a bony prominence such as the bunion
physical examination (Callam and Ruckley 1992).           area, or under the metatarsal heads, and usually
The clinical history and physical examination will        have a sloughy or necrotic appearance (Cullum and
assist the identification of both the underlying          Roe 1995). An ulcer in a diabetic patient may have
cause of leg ulcers and any associated diseases, and      neuropathic, arterial and/or venous components
will influence decisions about prognosis, referral,       (Browse et al 1988; Nelzen et al 1993). It is
investigation and management. If the practitioner         essential to identify the underlying aetiology.
is unable to conduct a physical examination, they          Malignant ulcers - are a rare cause of ulceration
must refer the patient to an appropriately trained        and exceptionally are a consequence of chronic
professional.                                             ulceration (Yang et al 1996; Baldursson et al 1995;
                                                          Ackroyd and Young 1983).
Ulcer history
Guideline recommendations indicate that                   Physical examination
information relating to ulcer history should include:     A good examination of the legs and the ulcers is
the year of occurrence of the first ulcer; the site of    important to recognise the signs of chronic venous
the ulcers and of any previous ulcers; the number of      insufficiency and arterial disease.
previous episodes of ulceration; the time taken to
heal in previous episodes; the time free of ulcers;
past treatment methods; previous and current use of
                                                          Venous disease
compression hosiery (RCN et al 1998).                     The ulcer is usually shallow (usually on the gaiter
                                                          area of leg) and may be associated with oedema,
The ulcer history will enable consideration of
                                                          eczema, ankle flare, lipodermatosclerosis, varicose
clinical factors that may impact on treatment and
                                                          veins, hyperpigmentation, atrophie blanche.
healing progress, as well as provide baseline
information on ulcer history.
                                                          Arterial disease
Medical history                                           The ulcer has a ‘punched out’ appearance, and the
                                                          base of wound is poorly perfused and pale. Other
Taking a medical history is an important part of the
                                                          symptoms may include: cold legs/feet; shiny, taut
assessment to identify the type of ulcer. The person
                                                          skin; dependent rubour; pale or blue feet;
conducting the assessment must be aware that ulcers
                                                          gangrenous toes.
may be arterial, diabetic, rheumatoid or malignant
and should record any unusual appearance.
This will assist the accurate identification of the
aetiology of the ulcer, which has major
implications for treatment choice (RCN et al 1998).

The management of patients with venous leg ulcers                                                      Assessment   5
2.1        Assessment of Patients with Leg Ulcers

    Mixed venous/arterial
    The ulcers have features of venous ulcer in
    combination with signs of arterial impairment.
    To assist in determining the type of ulcer the
    criterion used for examining the appearance of the
    ulcer is based on consensus statements, and
    literature reviews that concur on well-known
    features of the different types of ulcers (Browse
    et al 1988; Alexander House Group 1992).
    Other important elements of the assessment include
    taking the patient’s blood pressure, weight and a
    urinalysis. Blood pressure is taken to screen for
    hypertension, and urinalysis is taken to screen for
    undiagnosed diabetes mellitus.
    Although there is some empirical evidence of
    inadequate assessment in practice, there are no
    studies that examine patient outcomes that
    compare people who are given, or not given the
    benefit of a full clinical history and physical
    examination. The recommendations for what
    should comprise a clinical history and physical
    examinations are therefore based on consensus
    opinion (RCN et al 1998).

    Strength of evidence III

6   The management of patients with venous leg ulcers     Assessment
2. The records show that on the first assessment, the   3. The records show that the ulcer size and wound
ankle/brachial pressure index (ABPI) has been           status (edge, base, position, surrounding skin) is
measured.                                               documented at the first assessment.

Justification                                           Justification
Measurement of ABPI is to enable identification of      A detailed assessment and accurate written record
arterial disease for referral to specialist vascular    of ulcer characteristics should include the size, the
clinics and to assess the appropriateness for           edge, and the base, position of the ulcer and its
compression bandaging. All patients must be given       surrounding skin.
the benefit of Doppler ultrasound measurement of
                                                        Serial measurement of size (length and width) of
ABPI by an appropriately trained professional. This
                                                        the ulcer is a reliable index of healing. Appropriate
prevents misdiagnosis that could result in
                                                        techniques include tracing of the margins,
inappropriate therapy, with possibly serious
                                                        measuring the two maximum perpendicular axes,
adverse consequences for the patient.
                                                        or photography (Stacey 1991). The ulcer edge often
Research suggests that diagnosis should not be          gives a good indication of progress and should be
solely based on the absence/presence of pedal           carefully documented (for example, shallow,
pulses because there is generally poor agreement        epithelialising, punched out, rolling). The base of
between manual palpation and ABPI (Brearley et al       the ulcer should be described (for example,
1992; Callam et al 1987b: Moffatt et al ,1994). Two     granulating, sloughy, and necrotic). The position of
large studies have shown that 67% and 37% of            the ulcers should be clearly described (SIGN 1998).
limbs respectively with an ABPI of
2.1        Assessment of Patients with Leg Ulcers

    4. The records show a referral via general               Routine vascular referral
    practitioner to a specialist has been made in the
    following situations: the ABPI is
Assessment of Patients with Leg Ulcers

5. The records show that a bacterial swab has only       6. The records show that on the first assessment, the
been taken when there is evidence of clinical            patient’s pain level has been assessed and where
infection. For example, pyrexia, cellulitis, increased   indicated, appropriate management commenced.
pain and rapidly enlarging ulcer.
                                                         Justification
Justification                                            Leg ulcers are frequently painful. A significant
Routine bacteriological swabbing is unnecessary          proportion of patients with venous ulcers report
unless there is evidence of clinical infection such      moderate to severe pain (Dunn 1997; Hamer et al
as:                                                      1994; Walshe 1995; Steven et al 1997; Cullum and
◆ inflammation/ redness/ evidence of cellulitis          Roe 1995; Hofman et al 1997). However, one
◆ increased pain
                                                         survey found that 55% of district nurses did not
                                                         routinely assess pain in patients with leg ulcers
◆ purulent exudate
                                                         (Roe et al 1993). Increased pain on mobility may be
◆ rapid deterioration of the ulcer
                                                         associated with poorer healing rates (Johnson
◆ pyrexia.                                               1995), and may also be a sign of some underlying
The influence of bacteria on ulcer healing has been      pathology such as arterial disease or infection
examined in a number of studies (Trengove et al          (indicating that the patient may require referral for
1996; Skene et al 1992; Ericksson et al 1984), and       specialised assessment).
most have found that ulcer healing is not                Leg elevation is important since it can aid venous
influenced by the presence of bacteria.                  return and reduce pain and swelling in some
                                                         patients. However, leg elevation may make the pain
Strength of evidence I                                   worse in others (Hofman et al 1997). Compression
                                                         counteracts the harmful effects of venous
                                                         hypertension and compression may relieve pain
                                                         (Franks et al 1995).

                                                         Strength of the evidence II

The management of patients with venous leg ulcers                                                    Assessment   9
2.1        Assessment of Patients with Leg Ulcers

     7. The records show that the measurement of ABPI
     has been undertaken at least three-monthly or in
     any of the following situations: sudden increase in
     size of ulcer; ulcer became painful; change in
     colour/temperature of foot/leg.

     Justification
     Arterial disease may develop in patients with
     venous disease (Sindrup et al 1987; Callam et al
     1987c; Scriven et al 1997) and significant
     reductions in ABPI can occur over relatively short
     periods (Nelzen et al 1994; Simon et al 1994;
     Scriven et al 1997). ABPI will also fall with age.

     Strength of evidence II

10   The management of patients with venous leg ulcers     Assessment
2.2        Management of Patients with Venous Leg Ulcers

8. The records show that patients with venous leg       9. The records show that the patient with a healed
ulcer and an ABPI ≥ 0.8 have received high              ulcer has been educated about the need to wear and
compression (multi-layer – that is four-layer, three-   how to correctly apply compression stockings.
layer, or short stretch) bandaging.
                                                        Justification
Justification                                           Compression hosiery is an important element in the
Compression therapy is the most important element       prevention of recurrence of venous ulceration
of treatment of venous leg ulcers (Effective Health     (Effective Health Care Bulletin, 1997). One trial has
Care Bulletin, 1997). Research has shown that           shown that three to five year recurrence rates were
compression improved healing rates compared to          lower in patients using strong support from class
treatments using no compression (Rubin et al 1990;      three compression stockings (21%) than in those
Eriksson et al 1984), and is also more cost-effective   randomised to receive medium support from class
because the faster healing rate saved nursing time      two compression stockings (32%). Class two
(Taylor et al 1992 unpublished).                        stockings, however, were better tolerated by
                                                        patients (Harper et al 1995).
There is reliable evidence that high compression
(25-35 mmHg - Thomas 1990) achieves better
                                                        Strength of the evidence II
healing rates than low compression (Callam et al
1992). Research has shown the benefits of multi-
layer high compression system over single layer
(Nelson et al 1995b; Travers et al 1992).
It is important to apply compression bandages
correctly. Research has shown that incorrectly
applied compression bandages may be harmful or
ineffective and may predispose the patient to
cellulitis or skin breakdown. It has been shown that
more experienced or well-trained bandagers obtain
better and more consistent pressure results (Logan
et al 1992; Nelson et al 1995a).

Strength of the evidence I

The management of patients with venous leg ulcers                  Cleansing, Debridement,Dressings, Contact Sensitivety   11
2.3        Cleansing, Debridement, Dressings, Contact Sensitivity

     10. The records show that when wound cleansing is     11. The records show that the patient has received
     indicated, tap water or saline has been used for      simple, low cost, non - adherent wound dressings
     cleansing.                                            unless more costing dressing are indicated (for
                                                           example, odour, excessive exudate).
     Justification
     Wounds and skin are colonised with bacteria that
                                                           Justification
     do not appear to impede healing. The purpose of       There is strong evidence that the type of wound
     the dressing technique is not to remove bacteria      dressing has no effect on ulcer healing. A recent
     but rather to avoid cross-infection with sources of   systematic review (Nelson et al 1997) has
     contamination – for example, other sites of patient   concluded that hydrocolloid dressings confer no
     or other patients. A trial of clean versus aseptic    benefit over simple, low-adherent dressings. The
     technique in the cleansing of tracheotomy wounds      most important aspect of treatment is the
     failed to demonstrate any difference in infection     application of high compression bandaging. In the
     rates between the two methods (Sachine-Kardase et     absence of evidence, wound dressings should be
     al 1992). There are no trials comparing aseptic       low cost, simple to reduce risk of contact sensitivity
     technique with clean technique in cleaning chronic    and low, or non-adherent, to avoid any damage to
     wounds, including leg ulcers.                         the ulcer bed (RCN et al 1998).
     There is no evidence that the use of antiseptics
                                                           Strength of evidence I
     confers any benefit to preventing infection. In one
     study, cleansing traumatic wounds with tap water
     was associated with a lower rate of clinical
     infection when compared to sterile isotonic saline
     (Angeras et al 1992).

     Strength of the evidence III

12   The management of patients with venous leg ulcers                Cleansing, Debridement,Dressings, Contact Sensitivety
Cleansing, Debridement, Dressings, Contact Sensitivity

12. The records show that products containing
lanolin or other potential allergens have not been
used on the patient.

Justification
Patients with venous leg ulcers have variable rates
of sensitivity to products containing potential
allergens. Preparations commonly used as part of
the leg ulcer treatment reported to cause contact
sensitivity in certain individuals are listed below.
Frequency of contact sensitivity and the
commonest allergens in leg ulcer patients have
been examined in a number of studies (Blondeel et
al 1978; Kulozik et al 1988; Cameron 1990;
Cameron et al1991; Dooms-Goossens et al 1979;
Frake et al 1979; Malten and Kuiper 1985;
Paramsothy et al 1988).

Strength of evidence III

 List of common allergens
 Type                          Name of allergen                       Potential source
 Lanolin                       wool alcohol, amerchol 101             bath additives, creams, emollients, barriers
                                                                      and some baby products
 Rubber                        mercapto / carba/ thiuram mix          elastic bandages and supports, elastic stockings,
                                                                      latex gloves worn by carer
 Perfume                       fragrance mix, Balsam of Peru          bath oils, over the counter preparations such as
                                                                      moisturisers and baby products
 Preservatives                 parabens (hydroxybenzoates)            medicaments, creams and paste bandages
 Vehicle                       cetyl alcohol, stearyl alcohol,        most creams, including corticosteriod creams,
                               cetylstearyl alcohol, paste bandages   aqueous cream, emulsifying ointment and some
 Adhesive                      resin colophony, ester of rosin        adhesive backed bandages and dressings

The management of patients with venous leg ulcers                             Cleansing, Debridement,Dressings, Contact Sensitivety   13
2.3        Cleansing, Debridement, Dressings, Contact Sensitivity

     13. The records show that topical antibiotics have
     not been used on the patient.

     Justification
     Colonisation of venous leg ulcers is the norm
     (Skene et al 1992) and there is no firm evidence
     that it slows ulcer healing (Trengove et al 1996).
     The use of antibiotics therefore, should be kept to a
     minimum to discourage an increase in antibiotic
     resistant bacteria. Topical antibiotics should not be
     applied on patients with leg ulcers. The criterion is
     supported by consensus opinion (RCN et al 1998).

     Strength of evidence III

      List of topical antibodies
                                    Examples                           Source
      Topical antibiotics           neomycin, framycetin, bacitracin   medicaments, tulle dressings, antibiotic creams
                                                                       and ointments

14   The management of patients with venous leg ulcers                          Cleansing, Debridement,Dressings, Contact Sensitivety
3.         Introducing Change

The primary health care team will need to make
sure that all concerned have the opportunity to
study the findings. A multi-disciplinary seminar
or discussion meeting at a local level may be
appropriate to discuss the findings. Identify the
criteria and standards of which you did less well
and identify the possible reasons why. Your team
will then need an agreed action plan to improve leg
ulcer care. Consider the following suggestions:
◆ an educational and training programme for
   district nurses and practice nurses and general
   practitioners
◆ a revised policy for the assessment and
   management of patients with leg ulcers
◆ the introduction of a structured assessment form

◆ use of a computer record for patients with leg
   ulcers
◆ liaison with local tissue viability specialists,
   vascular surgeons, dermatologists,
   rheumatologists and diabetologists.
◆ keep any change as simple as possible to
   implement.
The organisation - community NHS trust
◆ discuss the findings at manager level

◆ compare the results with the national average of
  standards. Identify strengths and weaknesses
◆ consider the following suggestions for strategies
  for implementation of the clinical guideline
  recommendations:
◆ providing resources (personnel, facilities, time,
  equipment etc) for regular training and
  education
◆ introducing new technologies (health
  technology and information technology) into
  primary care
◆ developing a local structured assessment form
  for leg ulcers.
◆   support from other agencies such as the RCN or
    local clinical audit office.

For more information see the Implementation
Guide in this series.

The management of patients with venous leg ulcers     Intoducing Change   15
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                                                                    Sindrup JH, Groth S, Avnstorp C, Tonnesen KH,
     University of Liverpool
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                                                                    Skene AI, Smith JM, Dore CJ, Charlett A, Lewis JD
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                                                                    Stacey MC, Burnadnd KG, Layer GT, Pattison M,
     Surgery; 81:182-187.
                                                                    Browse NL 1991 Measurement of the healing of
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     Increased compression expedites venous ulcer
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     Paramsothy Y, Collins M, Smith AG 1988 Contact
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                                                                    Library, Swansea.
     RCN Institute, Centre for Evidence Based Nursing,
                                                                    Thomas S, Bandagers and Bandaging 1990 Nursing
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     Midwifery and Health Visiting, University of
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                                                                    new one-layer adhesive bandaging method in
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                                                                    maintaining prolonged limb compression and effects
     Roe BH, Luker KA, Cullum NA, Griffiths JM,                     on venous ulcer healing. Phlebology; 7:59-63.
     Kenrick M 1993 Assessment, prevention and
                                                                    Trengove NJ, Stacey MC, McGechie DF, Mata S
     monitoring of chronic leg ulcers in the community:
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     Rubin J, Alexander J, Plecha E et al 1990 Unna’s
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     Scriven JM, Hartshorne T, Bell PRF, Naylor AR,
     London NJM. Single-visit venous ulcer assessment
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18   The management of patients with venous leg ulcers                                                            References
Sources of Further Information

Useful contact addresses:                           Quality Improvement Programme
                                                    Information Service
Tissue Viability Society                            RCN
Glanville Centre                                    20 Cavendish Square
Salisbury district Hospital                         London W1M 0AB
Salisbury SP2 8BJ.                                  Tel: 020 7647 3831
Tel: 01722 336262                                   http://www.rcn.org.uk
http://www.tvs.org.uk/

The Audit Commission
1 Vincent Square
London SW1P 2PN
Tel: 020 7828 1212
http://www.audit-commission.gov.uk/

Scottish Intercollegiate Guidelines Network
The SIGN secretariat
Royal College of Physicians
9 Queen Street
Edinburgh EH2 1JQ
Tel: 0131 225 7324
http://www.show.scot.nhs.uk/sign/home.htm

The Cochrane Wounds Group
Department of Health Studies
University of York.
York Y01 5DD
Tel: 01904 43411
http://www.york.ac.uk/depts/hstd/centres/evidence
   /ev-intro.htm#cochrane-wounds-group

Clinical Governance Research and Development Unit
Department of General Practice and Primary Health
   Care
University of Leicester
Leicester General Hospital
Leicester LE5 4PW
Tel: 0116 258 4873
http://www.le.ac.uk/cgrdu/index.html

NICE (National Institute for Clinical Excellence)
90 Long Acre
London, WC2E 9RZ
Tel: 020 7849 3444
http://www.nice.org.uk

The management of patients with venous leg ulcers                                   Sources   19
Appendix 1. Documentation

     Development of review criteria
     Based on the national clinical guideline for leg
     ulcer management (RCN et al 1998), the review
     criteria were developed according to a method
     developed by researchers in the Clinical
     Governance Research and Development Unit (Baker
     et al 1995; Fraser et al 1997)
     The method involved:
     ◆ identification of the key elements of care
     ◆ focused systematic reviews based on the
       national clinical practice guideline (RCN et al
       1998) and justified by evidence
     ◆ taking into account consensus based
       recommendation considered to have an
       important impact on outcome
     ◆ presentation of the criteria in a protocol.

     The standards
     A standard in this audit protocol refers to the level
     of performance for each criterion, to which
     community nurses are aiming. The purpose of
     criteria and standards is to assist in the
     improvement of care. The ultimate aim for most of
     the criteria is the achievement of a standard of
     100%, although it is recognised that there may be
     perfectly acceptable reasons for falling short of this
     level on some occasions in relation to some criteria.

20   The management of patients with venous leg ulcers        Appendix 1: Audit Form
Appendix 2. Nursing Management of Venous Leg Ulcers in
the Community: Audit Form
Please read the Instructions for audit form before you complete the form.
Date completed:
Ref. No. _______________ DOB ____________ Sex: M ❑                     F❑
First assessment by district nurse ❑                practice nurse ❑   specialist nurse ❑   other ______ grade ______
Patient mostly seen at home ❑                       general clinic ❑   leg ulcer clinic ❑   other _________________
Patient mostly seen by district nurse ❑             practice nurse ❑   specialist nurse ❑   other ______ grade ______
Q 1. A clinical history and physical examination at assessment visit
       Has the medical history been documented?                               yes ❑ no ❑
       Has BP been recorded?                                                  yes ❑ no ❑
       Has urinalysis been undertaken?                                        yes ❑ no ❑
       Has weight been recorded?                                              yes ❑ no ❑
       Did record show that patient had a previous ulcer history ?            yes ❑ no ❑
       If yes, have the following items been documented?     duration of previous ulcer ❑                   site ❑
               number ❑ method of treatment ❑         time to heal ❑       type ❑
First assessment visit: a full assessment takes place within two weeks of first contact of leg ulcer patient

Q 2. Doppler ABPI at first assessment visit                      yes ❑ no ❑
       If not applicable, reason_____________________________________________________________
       Level of ABPI            L __________              R __________

Q 3. Has ulcer(s) size been measured at first assessment visit?        yes ❑ no ❑ date measured__________
       If yes, was this by: tape measure ❑ mapping ❑                   photograph ❑         length and width ❑
       other ______________________________
       Ulcer 1: length __cm width __cm duration of ulcer __mth                is this a recurrent ulcer?    yes ❑ no ❑
       Ulcer 2: length __cm width __cm duration of ulcer __mth                is this a recurrent ulcer?    yes ❑ no ❑
       Ulcer 3: length __cm width __cm duration of ulcer __mth                is this a recurrent ulcer?    yes ❑ no ❑

Q 4. Has pain assessment been undertaken?                              yes ❑ no ❑
       Is the ulcer painful?                                           yes ❑ no ❑
       If yes, did patient receive analgesia?                          yes ❑ no ❑
Please complete the following items at the end of the audit period or if patient is lost to follow-up/is
referred/ulcer healed/patient died. Date of completion: __________________________________________

Q 5. Referral
       Was referral made? yes ❑ no ❑ if yes, reasons: ____________________ date of referral_________
       Referred to: specialist nurse ❑ GP ❑ vascular surgeon ❑ dermatologist ❑                      diabetologist ❑
       other ______________________________

Q 6. Bacterial swab
Has a bacterial swab been taken? yes ❑ no ❑                      was ulcer infected? yes ❑ no ❑
                                                                                                   Please turn over page

The management of patients with venous leg ulcers                                                      Appendix 2: Audit Form   21
Appendix 2. Nursing Management of Venous Leg Ulcers in the
     Community: Audit Form
     Q 7. Leg ulcer re-assessment
            Has measurement of ulcer(s) size been repeated?          yes ❑ no ❑
            If yes, has ulcer size been repeated at every __________wk/wks

     Q 8. Graduated compression              yes ❑ no ❑ if not applicable, reasons ___________________________
            If yes, type of bandage used       Setopress ❑ Surepress ❑ Tensopress ❑ Comprilan ❑
            Robertson’s Ultra 4 ❑        Rosidal K ❑ 4 layer bandage ❑ Class 2/3 hosiery ❑
            other – list no more than five products __________________________________________________

     Q 9. Which cleansing agent was used?      tap water ❑ normal saline ❑   none r
            other – list no more than five products __________________________________________________

     Q10. Which dressings were used? Hydrocolloid ❑     Foam ❑     Alginate ❑ Tulle gras ❑ NA Tricotex r
           other – please state __________________________________________________

     Q11. Skin care
            Have you used any skin care preparation?           yes ❑ no ❑
            If yes, was it: emollient ❑ steroid cream or ointment ❑         if other, please state________________

     Q12. Outcome            healed ❑     improved ❑ no change ❑ referral ❑ leg ulcer related admission ❑
           died ❑            other __________________________________________________
            If ulcer(s) completely healed, please indicate the time to heal:
            Ulcer 1 __________wks        Ulcer 2 ________wks          Ulcer 3 ________wks

     Q13. Prevention of recurrence
            Did patient receive education on compression stockings?         yes ❑ no ❑
            If ulcer healed, did patient receive compression stockings?     yes ❑ no ❑ not applicable ❑
            If not applicable, please give reasons ____________________________________________________

     Q14. Work load
            On average, how many visits a week (leg ulcer care only)? _______________
            Total number of visits (leg ulcer care only) ______
            Average time for each visit 40 ❑
            (excluding travel time)

22   The management of patients with venous leg ulcers                                            Appendix 2: Audit Form
Appendix 2. Instructions for Audit Form

Which patients are included in this audit?
Patients diagnosed with venous leg ulcers are included in the project. This includes new patients, patients
who are in the process of treatment and patients who have a recurrent ulcer. This retrospective audit will
include patients with venous leg ulcers under your care at the present time. All patients who participate in the
audit project should have a sticker on their case records and an audit form attached.

Data collection - one form per patient
You should use one audit form for each individual patient. Questions 1 to 4 should be completed for patients
with venous leg ulcers at the start of the audit. Questions 5 to 14 should be completed at the end of the audit
or if the patient is lost to follow-up/ is referred/ has a healed ulcer/ has died. Please state the date of completion.

General information
The beginning of the form is general information about the patient. The reference number will be the patient’s
case record number or any code number for identifying the patient locally.

Q 1. A clinical history and physical examination has been undertaken at the first assessment.
Previous ulcer history - if the patient has a leg ulcer history, the yes box should be ticked, and the follow-up
questions answered according to available information in the case notes at the time of the assessment visit.
Medical history - the yes box should only be ticked when a full medical history is documented in the case
records. The no box ticked if there is no medical history documented (if a patient does not have a history of
relevant medical conditions for example, vascular disease, coronary heart disease etc, it must be documented
at the assessment visit). BP, urinalysis, weight - the yes box should only be ticked where those items were
undertaken and documented at the assessment visit.

Q 2. Doppler ABPI (ankle/brachial pressure index) has been measured at the first assessment visit.
Yes box is ticked when ABPI has been measured within two weeks of first contact. If yes, please state the
date of assessment and the level of ABPI. If a Doppler machine is not available in the team or practice or for
any other reason the ABPI could not be undertaken, please tick the not applicable box and state the reason.

Q 3. Ulcers recorded at first assessment
The yes box should only be ticked when the ulcer size is documented at the first assessment visit. Please
indicate how you measure ulcer size normally. If you use any other method of measurement, please tick other
and state the method you have used. If the patient has more than one ulcer on both legs, please describe ulcer
two or add ulcer three if necessary. If more than three ulcers, please document the largest three sites.

Q 4. Pain assessment
The yes box should only be ticked where pain assessment has been undertaken on the patient at the
assessment visit. For analgesia, the yes box should be ticked when the patient has received analgesia from any
professional.   Form
Q 5. Referral
If the patient needs to be referred to a specialist, please give the date of referral, the main reason for referral
and tick the type of specialist to which you have referred your patient. For most practices, the referral will go
to the GP first. In this situation, please tick GP and also tick any other specialist to which you consider the
patient should be referred.

Q 6. Bacterial swab
If the yes box is ticked, please state the reasons.

The management of patients with venous leg ulcers                                                  Appendix 2: Audit Form   23
Appendix 2. Instructions for Audit Form 2. Instructions for Audit

     Q 7. Leg ulcer re-assessment
     If yes box is ticked, please indicate how often the ulcer size has been re-measured.

     Q 8. Graduated compression
     Please indicate the products you have used on this patient (for the whole time of treatment) and tick more than
     one type of bandage if necessary. For other, please do not list more than five products. If the patient was not
     suitable for high compression (for example, acute heart failure, rheumatoid arthritis, grossly distended leg or
     any other reasons), please tick not applicable and state the reason.

     Q 9. Cleansing agent
     As you might use different agents for the patient during care, please tick the one you used most commonly -
     more than one if necessary. If you have used other cleansing agents, please list no more than five products.

     Q10. Dressings
     This applies to all dressings you have used for this patient during the whole treatment period. Please tick more
     than one if necessary. If you tick other, please list up no more than five products you have used.

     Q11. Skin care
     If yes, please tick the preparation you have used - you can tick more than one box if it is necessary. If you tick other,
     please state no more than five products.

     Q12. Outcome
     Please indicate the outcome for this patient. If the ulcer healed, please indicate the time to heal the ulcer(s). If
     the patient has more than one ulcer or ulcers on both legs, please describe the outcome of ulcer 2 or add ulcer
     3 if necessary.

     Q13. Prevention of recurrence
     For patients who have received education on compression stockings, the yes box should only be ticked if this
     has been documented. If the ulcer is not healed by the end of the audit, or is not suitable for compression
     stockings, please tick not applicable and state the reasons.

     Q14. Work load
     Number of visits a week - this will be the average number of visits per week in the period of care/or for most of
     the period of care. The average time for each visit will not include the first visit and will exclude travel time.

     Where should you send the completed forms?
     Once you have completed the form, please ensure all the items are filled in. The completed form should be sent
     back to the project leader in your organisation. Please make a photocopy of each form before sending it.

24   The management of patients with venous leg ulcers                                                    Appendix 2: Audit Form
The management of patients with venous leg ulcers   Notes   25
26   The management of patients with venous leg ulcers   Notes
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