SIGN Guideline 120: Management of chronic venous leg ulcers

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6 Provision of care

6.1 BACKGROUND

A survey of a population of around one million individuals found that in 83% of cases of leg ulcer the care was carried out entirely in the community, in 12% it was a joint effort between hospital and the community, and in 5% of cases patients were hospital inpatients.3 Scottish data from 2002 showed that the average case load for a community based nurse is 2-4 leg ulcer patients annually.16

6.2 TRAINING

A review of studies addressing the effectiveness of training found that a large number of community nurses perform bandaging inadequately. In two of the studies, technique improved following appropriate training. This improvement was sustained at 2-4 weeks following training, but diminished to near baseline levels at 6-10 weeks.79 Evidence level 1+

A large RCT of training (Scottish Leg Ulcer Trial) randomised community nurses to cascade training and release of (SIGN) guidelines or release of guidelines alone. There was no measurable impact in either group with the three month healing rate of leg ulcers being 30% both at baseline and after the interventions.16 Evidence level 1+

6.3 SPECIALIST LEG ULCER CLINICS

A specialist leg ulcer clinic involves nurses who are specially trained in the assessment and management of patients with leg ulcers.

A Cochrane review identified four RCTs which compared compression bandaging (4LB in three trials, SSB in one) within a specialised leg ulcer care setting with usual management by the general practitioner and district nurse. Overall, healing rates were significantly increased in the patients receiving compression within a specialist leg ulcer care setting, a contributing factor of which was likely to be the higher level of staff expertise which resulted in better management of leg ulceration overall.51 Evidence level 1++

Cost data was outlined for the three trials which used 4LB. In the first there were significantly lower costs in the specialist leg ulcer group when compared on the basis of consumables, district nurse time and mileage both per week and for the three month trial duration. The second found no difference in the mean NHS costs per patient. The third trial found costs per leg healed were significantly lower for the compression group within the specialist leg ulcer clinic setting. Evidence level 1++

A locality based observational study used the setting up of a specialist clinic as the intervention. The ulcer healing rate improved in the area of intervention (six and 12 week healing increasing to 8% and 22% respectively versus 4% and 12 % for the control area). However, only 40% of the ulcers diagnosed in the intervention locality were referred to the new clinic and for these patients the 6 and 12 week healing rates were 24% and 48% respectively. There was also a significant reduction in the recurrence rates in the intervention group.80 Another comparison study demonstrated similarly improved healing rates associated with attendance at a specialist clinic. A greater proportion of the clinic group received compression bandaging, (81% compared with 42% in the control group).81 Evidence level 3

The improvement in care and outcomes observed in specialist clinics may in part be due to the more stringent delivery of evidence-based recommendations. One study involving specially trained nurses following an evidence based protocol found no significant difference in outcomes for patients receiving treatment at home when compared to clinic treatment and concluded that organisation of care, and not the setting where care is delivered, is the factor which most influences healing rates. This study has limited applicability to current practice.82 Evidence level 1+

No studies were identified on the role of case load in acquisition and maintenance of healthcare practitioner skills in leg ulcer management. It is likely that skill development around measurement of ABPI and application of compression is likely to be better facilitated where practitioners operate in a specialist leg ulcer setting due to the larger case loads to which they are exposed.

B Specialist leg ulcer clinics are recommended as the optimal service for community treatment of venous leg ulcer.

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6.4 LEG CLUBS

Regular (eg weekly) meetings of clients and healthcare workers (leg clubs) offer support to patients and, in a small number studies, have demonstrated improved concordance with treatment.58 Definitions and assessments of concordance vary widely and are often dependent on self reporting or nurse-administered questionnaires.

In a small Australian RCT pilot, n=67, patients were randomised to either the Lindsay Leg Club® model of care (n=34), or the traditional community nursing model (n=33) consisting of individual home visits by a registered nurse. Participants who received care under the leg club model had better ulcer healing outcome as well as benefits in terms of pain, quality of life, self esteem and functional ability.83

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