Healing ambitions

1 November 2013

Helping prevent and heal faster debilitating and costly leg ulcers is the aim of the first trans-Tasman clinical guidelines for venous leg ulcers. Two years on from launching the Australasian guidelines, the push is on to get wider implementation. Some of Australasia’s experts in the field provide an update.

Concerns about some patients missing out on best practice care for their venous leg ulcers – and the high incidence of venous leg ulcers and recurrence on both sides of the Tasman – prompted the development of Australasia’s first clinical guidelines.

In New Zealand, most venous leg ulcers (VLUs) are managed in community settings by general practice and community-based nurses. The variablity in professional knowledge means some patients with VLUs will not receive compression therapy. They are therefore unlikely to heal and may end up requiring longterm wound management. In our experience, late referrals for assessment, diagnosis, and treatment of VLUs is an ongoing concern.

It is also difficult for patients to access varicose vein surgery to treat chronic venous insufficiency within the New Zealand public health system. And only 31.1 per cent of New Zealanders are covered by health insurance.

A collaborative response to these issues by the New Zealand Wound Care Society and the Australian Wound Management Association led to the Australian and New Zealand Clinical Practice Guideline for Prevention and Management of Venous Leg Ulcers being published in 2011. It replaced New Zealand’s first guidelines released back in 1999 that are now outdated.

The guideline seeks to help health professionals to identify patients at risk; accurately diagnose and assess VLUs; optimise management and promote self management; prevent or delay complications; optimise quality of life; and reduce the risk of recurrence.

Causes, prevalence and recurrence of venous ulceration

Venous leg ulcers result from venous occlusion, failure of calf muscle pump function, or venous valvular failure that give rise to venous hypertension. Venous ulceration is strongly related to risk factors, such as family history of, or previous surgery for, varicose veins; venous disease; phlebitis; deep vein thrombosis (DVT); congestive cardiac failure; obesity; immobility and previous leg injury.

In New Zealand and Australia, there is little data on prevalence and incidence of venous leg ulcers. However, a 1 per cent prevalence in the overall Australian population has been found. In New Zealand, the prevalence of all leg ulcers in 2002 was estimated as 2.48 per 1000 people. It is likely that 80 per cent of these ulcers were venous in origin.

Recurrence rates are also high, reported tobe between 22 per cent and 69 per cent. Venous leg ulcers are more likely to affect older populations. Within New Zealand, the number of over 65-year-olds is estimated to be 24 per cent by 2040, adding to the financial health burden associated with VLU management.

COST: The national purchase of compression therapy bandaging systems in New Zealand is considerable and varies between $80,000 and $185,000 per month according to the District Health Board Health Benefits Limited catalogue. Other associated direct costs include wound management, nursing time, and transport. Indirect costs such as days unavailable to work or to childmind, depression, and pain in those with VLUs are also substantial but hard to measure. It is anticipated that costs could be reduced by using evidence-based prevention strategies such as hosiery.

 

Implementation

Following any guideline development, there is an expectation that clinical practice and patient outcomes will improve. Clinicians can struggle to apply guidelines into the practice setting for a variety of reasons including lack of understanding, limited access to resources or inability to make the change. Successful implementation is reliant on clinicians, administrators, and patients embracing the guideline and applying it into everyday practice.

A systematic approach is being taken to implementing the Australasian guideline. A subgroup of the Australian and New Zealand Venous Leg Ulcer Advisory Panel has been formed to develop a robust implementation strategy and evaluation process. This group functions under the New Zealand Wound Care Society and will be widened to include nursing organisations, GPs, vascular surgeons, dermatologists, podiatrists, plastic surgeons, physiotherapists, ACC, Ministry of Health, Grey Power, and Māori and Pacific Island groups. The subgroup is in the process of identifying actual and potential barriers to implementation.

Funding to support the venture, including evaluation, is being explored in both Australia and New Zealand. The aim of the Australian and New Zealand Clinical Practice Guideline for Prevention and Management of Venous Leg Ulcers is to support clinicians in their decision-making and improve access to evidence-based care for patients with VLUs.

For further information regarding the guidelines or work being undertaken by the advisory panel please contact: Jeannette Henderson administrator@nzwcs.org.nz

Authors:

 

Julie Betts, nurse practitioner, Waikato District Health Board; Catherine Hammond, clinical nurse specialist, Nurse Maude, Christchurch; Pip Rutherford, nurse practitioner wound care, Hawkes Bay District Health Board; and Michael Woodward, associate professor/geriatrician, Melbourne.

 

References will be available with the online version of the article at www.nursingreview.co.nz or by emailing editor@nursingreview.co.nz

 

KEY RECOMMENDATIONS OF VLU CLINICAL GUIDELINES:

Preventing initial occurrence of VLUs

  • Provide DVT prophylaxis, detect, and manage DVT early, promote access to venous surgery and phlebology interventions, where there are no contra-indications apply compression therapy to prevent initial development of VLUs for those at risk (Consensus-based recommendation).

Assessment, diagnosis and referral

  • A health professional trained in the assessment and management of VLUs should conduct an initial comprehensive assessment (including history, examination and investigations to support diagnosis) of all patients presenting with a leg ulcer and then at regular intervals to guide ongoing management.
  • Refer patients with non-healing or atypical ulcers for biopsy.
  • Local guidelines should provide clear indications of appropriate criteria for referral to specialist health professionals.

Managing pain associated with VLUs

  • Provide adequate pain management to promote quality of life and VLU healing
  • When there are no contra-indications apply EMLA® cream to reduce pain associated with debridement of VLUs.

Management of VLUs

  • Provide patients with appropriate education on their condition and its management.
  • Elevate the patient’s leg to promote changes in microcirculation and decrease lower limb oedema. Progressive resistance exercises may improve calf muscle function.
  • Cadexomer iodine could be used to promote healing in VLUs when there in known increased microbial burden.
  • Topical antimicrobial agents should not be used in standard care of VLUs with no clinical signs of infection.
  • Systemic antibiotics should not be used in the standard care of VLUs that show no signs of clinical infection.
  • No specific dressing product is superior for reducing healing time in VLUs. Select dressings based on clinical assessment of the ulcer, cost, access, and patient/health professional preference.
  • Where there are no contraindications apply compression therapy to promote healing in VLUs.
  • Health professionals benefit from education on VLUs and their management. Patient outcomes may be superior when care is conducted by a trained health professional.
  • When there are no contraindications, pentoxifylline could be used to promote healing in VLUs.

Preventing recurrence of VLUs

  • Consider the continued use of compression therapy to reduce the risk of VLU recurrence.

NB: An electronic copy of the full guideline, an abridged version and a flow chart for assessment of VLUs can be downloaded for free from www.nzwcs.org.nz/publications/57-guidelines.html or http://www.nhmrc.gov.au/guidelines/publications/ext003.