Leg Ulceration The National Perspective

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Leg Ulceration The National Perspective

• Mark Collier B.A(Hons) RN, ONC, RCNT, RNT, V300
• Lead Nurse/Consultant Tissue Viability
• United Lincolnshire Hospitals NHS Trust (Acute)
• c/o Pilgrim Hospital, Sibsey Road, Boston, PE21
  9QS.

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Historical perspective

• 1500 BC The Ebers Papyrus refers to serpentine
  windings, possibly the first reference to
  varicose veins
• 479-300 BC Heang Ti Nei Ching Su Wen wrote about
  the treatment of ulcers in the Yellow Emperors
  Classic of Internal Medicine. The Chinese used
  bread mould, occlusive bandages and sometimes
  elephant skin
• 460-377 BC Hippocrates makes reference to the
  venous system and ulceration including perhaps
  the first description of compression which was
  used to drive out evil humours
• 200 BC An Indian textbook of surgery described
  both the debridement of ulcers with maggots and
  the use of inelastic bandages

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Historical perspective (2)

• 1452 Leonardo da Vinci produced detailed
  anatomical drawings of the venous system
• 1510-1590 Ambrose Pare described local
  compression bandaging extending form the foot to
  the knee
• 1585 Salomen Alberti published what is thought
  to be the first drawing of a venous valve
• 1669 Richard Lower made the first reference to
  venous tone and the calf muscle pump
• 1676 Richard Wiseman invented a lace up stocking
  which is thought to be the precursor to the
  modern elastic stocking
• 1733 The Reverend Stephen Hale measured both
  arterial and venous pressure in surgical texts

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Historical perspective (3)

• Mid-1770s Classification of Ulcers began to
  appear in surgical texts
• 1758 Sharp noted the association between the
  effect of gravity and the development of
  gravitational oedema leading to ulceration
• 1930 Dickson Wright introduced the concept of
  the gravitational ulcer and used adhesive
  bandages and local dressings to treat ulceration
• 1960 Satumura and Kameko introduce the Doppler
  shift velocity manometer
• 1990s Compression profiles identified and
  understood
• under both elastic and in-elastic materials
  (Partsch H)

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Main features of the last two decades

• 1986 Hand held Doppler ultrasound (Cornwall)
• 1985 Epidemiology studies painted a bleak
  picture for patient outcomes (Callam, Dale and
  Ruckley et al)
• 1986 Further epidemiological studies (Cornwall)
• 1988 Leg ulceration perceived as a hopeless
  condition affecting mainly the lower social
  classes (Browse et al)
• 1980s Care provision mainly in the community,
  hospital admissions viewed as expensive and
  protracted
• 1992 Studies highlighted variety of materials
  and combinations of the same being used by
  practitioners
• 1993 Leg ulceration often referred to a
  Cinderella problem (Bosanquet)

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How many of you now have access to a hand held
Doppler?
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Main features of the last two decades (2)

• 1992 Improved healing rates with the
  introduction of a multi-layer bandage system
  (Moffatt et al)
• 1993 Cost effectiveness of specialist management
  strategies identified (Bosanquet et al)
• 1993 Introduction of first recognised formal
  courses re management of patients with leg
  ulcers (ENB)
• 1993 Leg Ulcer Forum launched (London)
• 1995 Quality of life issues studied (Franks et
  al)
• 1996/7 Co-ordination of nurse led
  multi-disciplinary services for the care of
  patients with leg ulcers (Thomson et al)
  (Stevens)

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Missing elements?

• A recognition that leg ulceration was a
  significant health care problem
• Positive attitudes re potential outcomes from
  professionals caring for patients with leg ulcers
  (patients were often labelled)
• An appreciation of the actual needs of the
  patients
• Resources both financial and human
• Clinical research
• Evidence based health care / practice (not
  medicine)
• YOU and the LEG ULCER FORUM!

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On what evidence did you base your judgement?

• Evidence based healthcare (EBHC) takes place
• when decisions that affect the care of patients
• is taken with due weight accorded to all
• valid and relevant information available
• Hicks (1997)
• valid and relevant implies information has been
• appraised and is applicable to your client group

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Hierarchy of evidence

• I Evidence from meta-analysis of randomised
  controlled trials or at least one randomised
  controlled trial
• II Evidence form at least one controlled trial
  with randomisation or at least one other type of
  quasi- experimental study
• III Evidence from non-experimental descriptive
  studies, such as comparative studies,
  correlation studies and case control studies
• IV Evidence from expert committee reports of
  opinions and/or clinical experience of respected
  authorities
• Adapted from Eccles Mason (2001)

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Developments in Professional Practice

• It is possible to identify a number of factors
  that have contributed to advances in Leg ulcer
  care
• Epidemiology studies highlighted the size and the
  complexity of the problem
• A few large research studies were undertaken
• The Leg Ulcer Forum was launched
• National guidelines produced (RCN) (SIGN) (CREST)
• Systematic reviews published (Cullum et al 1999)

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The role of the Tissue Viability/Leg Ulcer Nurse
Specialist

• Role has become well established
• Proliferation of a variety of educational courses
  on offer ranging from single modules to
  Masters..
• Nurses have extended the boundaries of their
  practice
• Management of patients undergone significant
  changes (assessment techniques/technicians) hand
  held doppler ultrasound, photoplethysmography and
  pulse oximetry
• Importance recognised within the MDT
• Advent of nurse prescribing new
  responsibilities!

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The Development of Leg Ulcer Services

• The Riverside Community Leg Ulcer Project paved
  the way for the belief that leg ulceration was
  not only treatable but also a worthwhile
  investment of health care providers
• Reorganisation of services led to doubling of
  healing rates in most implementation projects
• Cost effectiveness studies identified that not
  only were there clinical improvements but that
  care was cost effective
• Enhanced knowledge of the chronic wound
• Integration and benefits of evidence based
  practice

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The Impact of Leg Ulceration

• Only started to appreciate the impact of leg
  ulceration within the last decade
• Medical texts perpetuated the myth that venous
  ulcers were not associated with pain
• Enhanced understanding of both nocioceptive and
  neuropathic pain experiences
• Symtomatology exudate /odour decreased mobility
  and social interaction
• Patients often report a sense of hopelessness
• Improved social support improved healing rates
• Development of Leg Clubs

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The Leg Ulcer Forum (LUF)

• Supporting professionals
• Provides a forum for the exchange of ideas
• Facilitates discussion, debate and reflection
• Disseminates new research findings
• Provides support to specialist nurses
• Encourages CPD

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LUF Membership includes

• At least eight mailings a year Leg Ulcer Forum
  Journal
• - NT Wound Care Supp (x6)
• - Annual Report/Wrap Up
• Educational information
• Reduced rates at the annual conference(s) and
  other LUF events
• Access to a national database
• Access to the WEB site
• Access to an expert panel

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The Leg Ulcer Forum

• P.O.Box 337
• Huntingdon, PE28 2WH
• legulcer.forum_at_btopenworld.com
• www.legulcerforum.org

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Challenges ahead?

• To ensure that all patients with a leg ulcer
  receive optimal care current estimate 50
• Ensuring opportunities are not missed the
  inclusion of tissue viability in the NSFs and
  other clinical governance frameworks / national
  risk strategies
• Reacting to both demographic and changes in the
  nature of leg ulcer aetiology
• Getting involved with research and the
  implementation of evidence based practice
• Widening the scope of the Leg Ulcer Forum
• Getting political!

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Thoughts for the day

• Human mind works like a parachute..
• ..best when open
• Anon
• We all must die. But that I can save him from
  days of torture, that is what I feel is my great
  and ever new privilege
• Dr Albert Schweitzer

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ANY QUESTIONS?