Management Of Venous Leg Ulcers

Leg ulcers are distinct as a “trouncing of skin under the knee on the leg or foot which takes further than six weeks to cure” (Dale et al., 1983). They stand for a frequently happening (as well as chronic) constant predicament, causing substantial suffering plus uneasiness to those who endure as of them. It is predictable that amid 1.5 -3.0 per 1,000 inhabitants have lively leg ulcers, this number growing to about 20 per 1,000 in persons in excess of 80 years of time. By means of the mounting figures of adult populace in civilization, these numbers are put to increase supplementary, rising the requirement for leg ulcer handling in the prospect.

Variation in practice

Broad differences in medical perform plus the medical administration of leg ulcers are obvious as of preceding investigate studies plus assessments assumed on this subject. This is chiefly in relation to the correctness of appraisal as well as the variety of involvements used to pleasure leg ulcers. A learn concluded in the Mersey area by Roe et al (1993). Designated substantial differences in the treatment appraisal of leg ulcers – for instance in relation to the captivating of foot pulses, the utilizing of Doppler ultrasound, and the appraisal of soreness plus the early capacity of leg ulcers.

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There is extensive disparity in perform, as well as facts of needless pain as well as expenses suitable to insufficient supervision of venous leg ulcers in the society. Rulings such as these exemplify a important require to recover the supervision of leg ulcers, not slightest to advance the superiority of existence for those who experience as of them.

Understanding as of proposals arrangement to get improved the society based treatment supervision of leg ulcers – for instance the latent for additional medical as well as price efficient perform during extensive espousal of confirmation based interferences. By means of additional efficient organization of leg ulcers, it has been optional that it would be practical to anticipate 70 per cent of venous leg ulcers to cure in a twelve week time, even though hardly any studies have attain this curative pace.

Recognition of the key elements of concern

This phase concerned recognizing the entire core subject pertinent to the appraisal as well as supervision of patients through venous leg ulcers. The chief constituents of concern are recognized as of pre-existing methodically urbanized instructions plus methodical appraisals. Intended for the cause of the expansion the medical do lessons as well as the organization of patients by means of venous leg ulcers as well as the effectual Health Care statement, firmness treatment for venous leg ulcers were used to recognize the core subjects pertinent to effectual mind. The medical perform principle was shaped by means of a healthy loom -proposals were relying on methodical evaluations of the writing as well as the conclusion of a multidisciplinary agreement cluster.

Exercise of bacterial wash

The proposal in the medical perform teaching is that practice bacteriological washing is needless if not there is confirmation of medical disease. Where washes had been in use, the grounds agreed on the statistics compilation pieces were scrutinized.

These incorporated odour, exudates, escalating soreness, ruddiness, and cellulites plus worsening of the ulcer. The outstanding not appropriate answer in the initial inspection comprised two suitable motives eczema needing twice a day steroid ointment, plus heaviness painful on the heel; 11 unsuitable motives counting leg oedema, exudate as well as preceding DVT; as well as in six cases no grounds were given. Considerably better statistics of patients established compression bandaging on the second review compared to the first (Chi-square=22.56, DF=1, p=0.000).

So as to determine whether compression bandaging was being applied properly, its use was then cross-tabulated with ankle brachial stress indices over and below the disconnect value of 0.8. An indicator of more than or up to 0.8 signifies that there is no verification of major arterial disease. Consequently, if the patient has a venous leg ulcer (as strong-minded by clinical assessment) then the patient is appropriate for treatment with compression bandaging. Compression bandaging was applied to patients who had ABPI of <0.8 in 25 cases in the first audit (5.2%) and 30 cases in the second audit (5.3%). This is a total of 55 people whose venous leg ulcers were not treated according to the instruction. The amount did not progress among the first and second audit.

Of those patients with ankle brachial pressure index of less than 0.8, who would not be measured appropriate for compression, a large proportion had received compression bandaging

Compression stockings

The guideline suggests the use of compression stockings for patients with healed ulcers, to decrease venous ulcer recurrence rates. The work shows whether compression stockings were given to patients, whether patients received education about compression stockings.

In support of both these criteria, about half the forms were returned with these data missing. It would consequently be unsuitable to draw conclusions from these results, but the results are comparable in both audits. Missing data for whether compression stockings were given were 417 (49.8%) omissions in the first audit and 320 (42.2%) in the second and for whether education was given, 423 (50.5%) in the first review and 308 (40.6%) in the second.

The moment taken for the major leg ulcer to cure decreased considerably among the two audit periods. In the second audit 69.4% of venous leg ulcers had healed in twelve weeks or under, as opposed to 54.7% in the first audit. There is a marked transfer, with far fewer ulcers taking 25 weeks or longer to heal. The missing data for this variable were 13.1% in the first audit and 5.2% in the second.

Nursing time spent in the treatment of venous leg ulcers

The median time spent treating leg ulcers was eight hours in the first review and six hours in the second audit. This represents a 25% decline in median time spent treating ulcers. The range of times spent decreased dramatically between the two audits.

This may have been because the long-standing venous leg ulcers healed during or after the first data collection period, with fewer long-standing ulcers represented during the second audit.

Test of significance for difference in median times between first and second audits. Mann-Whitney test showed the decrease in time spent treating ulcers between audits one and two to be significant (Z=-3.64, p=0.00).

Further analysis of audit data

Further analysis of the data was performed using the categorical variable, healed or improved versus other. The proportion of missing data was very low, 0.4% in the first audit and 1.1% in the second audit. The proportion of ulcers healed or improved increased from 82.6% to 90.0%. Chi squared testing shows this result to be significant (Chisquare= 22.33, DF=1, p=0.000).

In order to ascertain the reasons associated with sites that did not show improvement across the two audits, a binary variable was created reflecting sites that did not improve versus those that did. A logistic regression analysis was performed with the binary variable, sites not improving versus those improving as the dependent variable. The independent variables were entered in three blocks. The first block contained the possible confounding patient variables of age and gender. The second block contained the possible confounding ulcer variables of ulcer size, ulcer duration and average ABPI. The third block contained the care variables of interest: whether the nurse at assessment was F grade or above

_ whether or not the patient was seen at a leg ulcer clinic

_ whether or not compression bandaging was applied

_ all possible interactions of the above three variables.

This third block of variables was entered using a stepwise forward likelihood ratio method. Table

3.19 shows the significant variables from block 3 of the analysis that explain sites failing to improve versus those that did between the first and second audits, having controlled for differences in patient and ulcer attributes:

This analysis demonstrates that sites improving between the first and second audits were significantly more likely to be applying compression bandaging, and significantly more likely to be treating patients in leg ulcer clinics. In addition, compression bandaging was significantly more likely to be applied if a nurse of F grade or above performed the initial assessment, as

indicated by the significant interaction term.

The total cost of venous leg ulcers has been estimated to lie in the range £294 to £650 million

each year in the UK. However such estimates give little indication of the degree to which costs can be affected by different management strategies. It is important to carry out an analysis of the economic implications of different management strategies to ensure that quality gains are made while contributing to the goal of efficient use of scarce NHS resources.

The RCN and partners in 1998 developed clinical guidelines for the management of patients with venous leg ulcers. It was recognised that the guidelines should be subject to economic evaluation to provide information on the comparative costs and outcomes of leg ulcer management during their introduction. This evaluation was carried out as part of the National Sentinel Audit of the Management of Venous Leg Ulcers. The audit used criteria based on the guideline and was conducted at two time periods, giving comparative information on the impact of the guidelines. It should be noted that the guidelines were not disseminated in isolation from other initiatives in this area – for example the Effective Health Care Bulletin on compression therapy for venous leg ulcers had been widely circulated in 1997. Thus, although the economic evaluation seeks to address the cost effectiveness of the introduction of the guideline, there may be other influences on practice which cannot be accounted for and which may limit the generalisability of the findings.

Economic evaluation allows the issue of cost effectiveness to be addressed. For a change in practice to be cost effective, either resource use is lower and the benefits are the same or greater than before, or resource use is the same but outcomes are improved. If resource use is greater and outcomes are improved, further research is required.

The results suggest that the introduction of clinical guidelines for the nursing management of venous leg ulcers in the community is cost effective. The results show statistically significantly lower mean total costs and improved outcomes after the introduction of the guidelines. These results were robust to variations in the assumptions used to calculate the costs.

A possible concern about the conclusions drawn is that they are based on a subset of patients. Bias may be introduced if these patients are different to the larger group. However it is suggested this is not the case. It details resource use for all patients managed for up to and including 26 weeks and shows statistically significant differences in resource use before and after the introduction of the guidelines. These differences are reflected in the differences in costs shown in table 4.3. However a lot of data were missing on level of input and there is no way of knowing if the group with full data recorded had more or less input than the larger group. This is a concern as the amount of contact with patients is the key factor influencing total costs.

Furthermore, there are other elements of resource use that may be affected by a change in practice, which were not picked up by the information collected in the audit. These include recurrence rates and the costs of specialist referral beyond the primary referral. Even given these concerns, however, the data collected and presented above suggest that the leg ulcer management guideline has led to a cost-effective change in practice.

4.5 Conclusions

The results of the economic evaluation show lower costs and improved outcomes after the introduction of clinical guidelines for the management of venous leg ulcers in the community. This is a cost effective change in practice, giving more benefit for less cost.