Leg ulceration Resources

Wound care is a complex, under-addressed issue in the UK that places significant and unnecessary burden on patients and the healthcare system. Commonly perceived as a nursing issue, recent years have seen national programmes successfully support a shift in the recognition of wound care as a system issue. Partnership working between providers and national teams, such as the National Wound Care Strategy Programme (NWCSP) and Transforming Wound Care (TWC) programme, has generated the evidence and frameworks to support improvements in leg ulcer management (the largest percentage of all wounds in the UK) via dedicated services. Coupled with new evidence regarding the economic impact of leg ulcers, this makes a compelling case for change. Sustainable change in leg ulcer management will require providers, commissioners and policy makers to recognise the need for fundamental adjustments to the underlying service delivery models of care.

Suboptimal management of leg ulcers is a growing burden on NHS nursing and financial resources (Guest et al, 2015; 2017; 2020). Compression therapy plays a crucial role in leg ulcer management by improving outcomes and reducing the burden of disease, however it is not routinely applied in practice and knowledge and confidence between bandage types and application styles often varies greatly (Guest et al, 2017; Hopkins, 2023). This article focuses on the importance of compression therapy in the management of leg ulceration and how to select the appropriate compression therapy based on the patient’s presenting symptoms. It identifies possible barriers to application and offers potential strategies and suggestions to support the use of compression options in the community.

Increasing pressures on healthcare resources require constant evaluation of the efficiency and effectiveness of provision, particularly for the rising number of vulnerable, elderly and obese patients. Practices regarding compression are arguably often ingrained due to its historical usage, with evidence from managing chronic venous insufficiency (CVI) underpinning its effectiveness. This evaluation explores the clinical benefit, impact, outcomes and cost-efficiencies of using an adjustable compression wrap system instead of previous care. ‘Before-after design’ observation of 50 patients captured baseline resource use, costs and outcomes (clinical and patient) at the time of assessment and again at a maximum of six-month follow-up. Data after using the adjustable compression wrap showed significantly improved clinician-reported outcomes: presence of wounds/leg ulceration (from 56% to 21%), incidence of cellulitis (halved), and reduced complexity/severity of lymphoedema. Additionally, patient- reported outcomes, visual analogue scale (VAS) health score and LYMPROM© scores for pain, heaviness, shopping for shoes and clothes, and body image significantly improved. The mean number of community nurse visits per patient reduced from 11.6. to 9.1, but was not statistically significant (p-value 0.09). However, this evaluation found that over six months there was a mean cost reduction of over £383.70 per patient, which included the purchase price of the adjustable compression wrap system.

With an ageing population, it is likely that the numbers of leg ulcers requiring intervention will increase proportionately. Given that most leg ulcer care is conducted in the community, this will place an extra burden on primary care staff. Therefore, any cost-effective interventions which improve management are worth considering. The Complex Wound Clinic team (Central and North West London NHS Foundation Trust) undertook a 12-month evaluation of using octenidine-based antimicrobial wash mitts as an alternative to
bucket washing. The aim was to monitor both patient and staff reaction to the use of wash mitts instead of bucket washing, track reported incidents of staff musculoskeletal injuries, and monitor infection rates, including Pseudomonas and wound infections requiring antibiotics.

Chronic oedema is a major clinical problem worldwide (Moffatt et al, 2019a). The condition has many important secondary consequences for health, activity and participation (Moffatt et al, 2017). Its prevalence also has a significant association with the presence of a wound (Moffatt et al, 2019b). There are many challenges to managing patients in this group, which can lead to ineffective and inappropriate care and have a significant impact on patient quality of life (Green and Meskell, 2016). This article discusses some of these challenges and the impact which they may have on patients and healthcare professionals caring for them.

The fourth and final article in this four-part series about understanding compression therapy explores the options available to clinicians and patients when the need for compression bandaging therapy has been established through holistic assessment. This paper presents an overview of both inelastic and elastic bandage systems. In addition, the indications for appropriate use of each of these systems and their limitations are discussed. The cost of compression bandaging to the health service budget in terms of sustainability, equipment and clinician time is also explored. Gait is a fundamental area of leg ulcer care that needs assessment as part of lower limb management. Discussion regarding the implications of compression bandaging therapy itself, as well as the presence of leg ulcers and pain on gait are provided. Finally, a review of fundamental skin care principles to protect the skin is offered.