Comparison of compression therapy use, lower limb wound prevalence and nursing activity in England: a multisite audit.

OBJECTIVE: This audit was designed to identify the need of the population and the clinical activity associated with wounds and the management of lower limb swelling. The exploration focused on lower leg wound management, access to diagnostics and compression therapy across each audit site. The variation across the sites was explored to gather insight into the real-world barriers to providing evidence-based management for leg ulceration. METHOD: We undertook wound prevalence audits across six diverse community provider sites in England. The audit was undertaken by the local providers, with the inclusion of tissue viability and podiatry leads and key local stakeholders, often local quality leads, primary care leads and nursing directors. Each audit was undertaken with full engagement of local clinicians. Data were collected centrally, and each audit site received their own local analysis and report, with additional analytical support from the local tissue viability lead to ensure the feedback was contextualised for their stakeholders. Analysis was provided by Accelerate CIC Lymphoedema & Leg Ulcer Clinic. RESULTS: A total of 2885 patients were reviewed via an online or a paper audit tool. In total, 2721 patients had one or more active wounds. However, 1350 patients had one or more lower leg wounds, with 164 patients being managed for lower limb swelling or prevention of leg ulceration; bilateral conditions ranged from 11-43% across audit sites. Of the six sites, two included both community and primary care providers, thus generating wound point prevalence data. The remaining four sites audited community nursing and podiatry services only, with two sites collecting data on lower limb wounds only rather than all wounds, generating point prevalence for their services only. Compression usage varied across care locations, with the greatest use being seen in community leg ulcer clinics, where it was >96% for 234 residents. Compression usage was lower in the home with a range of 14-62% among 692 residents. For 263 residents, where the cause of their lower leg wound was unknown, compression usage was very low at 12%. Compression usage decreased with age; for three audit sites this was noteworthy, with 65% of those aged >80 years not in receipt of compression. Compression usage had a direct impact on nursing activity; non-use of compression increased activity by 37%. CONCLUSION: Through the identification of wound location, this series of wound prevalence audits identified a greater number of patients with lower limb wounds than those recognised and classified as a leg ulcer. Substantial variation in access to diagnostics and compression therapy was observed between audit sites, and also between locations within their boroughs. The factors that reduced access to compression therapy included not classifying the lower leg wound as a leg ulcer, being cared for in the home and increasing age of the patient. Lack of compression usage increased nursing activity. Where there is lack of access to therapeutic intervention, the resultant patient harm is not systematically recognised or documented.

A pilot study investigating the effects of a manuka honey sinus rinse compared to a standard sinus rinse on sino-nasal outcome test scores in cystic fibrosis patients.

BACKGROUND: People with cystic fibrosis (CF) are prone to bacterial respiratory infections; these are often antibiotic resistant, are difficult to treat, and impact on the quality of life and lung function. The upper respiratory tract can act as a reservoir for these pathogens, and as part of clinical care, sinus rinses are used to alleviate symptoms in the upper airway. We have developed a sinus rinse containing manuka honey, to identify whether it can help improve symptoms or reduce the bacterial load. METHODS: We will undertake a randomised controlled trial where 30 adults with CF will be recruited and randomised to either the control or intervention group. Both groups will follow a sinus rinse protocol for 30 days (± 7 days); the control group will use the standard of care rinse, and the intervention group will use a manuka honey rinse. Both groups will provide samples at day 0 and day 30. The primary outcome measure will be a change in the 22-item Sino-Nasal Outcome Test (SNOT-22) score. Secondary outcomes will include changes to quality of life (questionnaire), bacterial load/community composition, and sputum viscosity. DISCUSSION: This trial will look at the use of a manuka honey-infused sinus rinse solution on patients diagnosed with cystic fibrosis (CF) suffering with sinusitis; it will allow us to determine the efficacy of the manuka honey sinus rinse compared to standard rinse and will allow us to determine if molecular bacterial diversity analysis will provide in-depth information beyond the usual conventional microbiological. It will allow us to determine the feasibility of recruiting participants to this type of trial, allow us to check participant compliance with the protocol, and inform future studies. TRIAL REGISTRATION: Approval was obtained from the Research Ethics Committee Wales REC7 reference 18/WA/0319. Results of this study will be published at international conferences and in peer-reviewed journals; they will also be presented to the relevant stakeholders and research networks. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov Identifier NCT04589897 (retrospectively registered).

Making Legs Matter: A Case for System Change and Transformation in Lower-Limb Management.

This consensus document is endorsed by The Queen's Nursing Institute (QNI) and The Queen's Nursing Institute Scotland (QNIS).

Use of compression therapy to treat lower limb wounds across Europe: a scoping review protocol.

INTRODUCTION: Poor lower wound care is an avoidable patient harm. Compression therapy is an effective way of treating non-ischaemic lower limbs wounds, but it is not always used appropriately. There are many guidelines which set out how compression therapy should be used, but there is dearth of evidence about how it is actually used at a population level across Europe. AIM: The aim of this scoping review is to map the evidence published in English relating to the use of compression therapy to treat lower limb wounds across Europe. METHODS: This scoping review will be conducted in line with the Joanna Briggs Institute and Preferred Reporting Items for Systematic Reviews and Meta-Analyses for Protocols and Scoping Reviews guidance. A search for relevant publications will be conducted on variety of databases and key websites in order to identify a comprehensive range of relevant literature. Peer reviewed empirical papers, theoretical papers and other publications in English relating to the use of compression therapy across Europe will be considered for inclusion. ETHICS AND DISSEMINATION: Ethical and research governance for this scoping review is not required because we will only gather secondary data. Our results will be disseminated to the widest possible audience through an open access paper in a peer reviewed international journal, conference presentations and a plain English summary. The results of this scoping review will be used by a panel of Key Opinion Leaders from across Europe to develop a driver diagram to underpin subsequent lower limb wound care improvement efforts.

Establishing community wound prevalence within an inner London borough: exploring the complexities.

The academic literature reveals a dearth of evidence regarding the wound prevalence across a community setting, despite the need for both clinicians and commissioners to understand local need. To support the commissioning process, a wound prevalence audit was undertaken across all community services in an inner London borough in 2012 as part of a local needs analysis and to identify where resources were required. Within a population of 254,000, 272 residents had a total of 325 wounds, giving a mean of 1.19 wounds and a community wound prevalence of 1.07 per 1000 residents. The majority were male (51%) and the age range was 9-96 years. Acute and traumatic wounds accounted for 44% followed by foot and leg ulcers at 41%, pressure ulcers at 13% and other wound types at 2.6%. Of the lower leg ulceration group, 34 patients had venous ulceration, giving a prevalence of 0.13 per 1000. The difficulties in establishing a comprehensive wound prevalence that includes acute services are discussed in addition to the significance of the findings in the context of a deprived ethnically diverse borough with a younger population. The number of residents with any wound type was lower than other reported studies with similar methodologies. This paper presents the view that, despite the deprivation of the borough, the combined factors of age, ethnicity and early access to specialist expertise appear to deliver a lower community wound prevalence.

EWMA Document: Home Care-Wound Care: Overview, Challenges and Perspectives.

This document provides an overview of the main approaches to the organisation of wound care within homecare settings across Europe with case exemplars from England, Germany and the Nordic Countries. By identifying possible barriers to best practice wound care in home care settings and uncovering the preconditions needed to provide safe and high quality care for wound patients and support for their families, the authors provide a list of minimum recommendations for the treatment of patients with wounds in their own homes.

Compression strapping: the development of a novel compression technique to enhance compression therapy and healing for 'hard-to-heal' leg ulcers.

Non healing wounds of the lower limb continue to be a significant issue for both practitioners and patients. Failure of gold-standard management demands a creative response. This article describes the development of a novel and intuitive strapping technique overlying the compression bandage that appears to have an influence in healing complex lower limb ulcers. A retrospective audit of 17 patients with 25 ulcers allows further analysis and discussion. The strapping technique uses cohesive inelastic compression bandaging; narrow strips of bandages are layered in a fan distribution over the ulcer and oedema. This approach seems to offer an intuitive response to these complex wounds, allowing management to be tailored to the site of the ulcer and oedema. Tolerance for this less bulky compression therapy regime is excellent, thereby aiding healing and reducing all costs associated with non healing leg ulcers.

The experience of living with a pressure ulcer.

This short paper presents a qualitative study, reported in detail elsewhere (Hopkins et al, 2006) that investigated the experience of older people with pressure ulcers. The researchers were surprised to find how significant pain associated with the pressure ulcer was to patients or the impact it had on their lives. All quotes from the participants are taken from Hopkins et al (2006).

Frequency and reliability of oestrogen receptor, progesterone receptor and HER2 in breast carcinoma determined by immunohistochemistry in Australasia: results of the RCPA Quality Assurance Program.

BACKGROUND AND AIMS: Immunohistochemistry (IHC) has replaced radioligand binding assay for the determination of oestrogen receptor (ER) status in breast carcinoma. IHC is also used for assessment of progesterone receptor (PR) and HER2. The Royal College of Pathologists of Australasia (RCPA) Quality Assurance Program (QAP) introduced a breast markers module in 2003 to evaluate the performance of laboratories with IHC for ER, PR and HER2. METHODS: An audit of laboratories reporting breast carcinomas was performed in 2005 and 2006 to evaluate in-house results. Laboratories were asked to submit the hormone receptor and HER2 status on each invasive breast carcinoma for the previous 6 month period up to a maximum of 100 cases. The time periods were 1 July 2004 to 31 December 2004, and 1 July 2005 to 31 December 2005. A total of 55 laboratories returned information for 2004 and 67 for 2005. RESULTS: Complete data on 8128 patients was returned for both surveys, 3353 cases for 2004 and 4775 for 2005. The results were similar for both surveys. Of the 8128 cases, 59.0% were ER+/PR+, 15.9% ER+/PR-, 2.4% ER-/PR+ and 22.7% ER-/PR-. HER2 data were submitted for a total of 6512 patients (excludes 52 patients with incomplete data sets); 17.1% were reported as 3+ positive on IHC, 12.5% as 2+ and 70.4% as negative. CONCLUSIONS: A laboratory audit was introduced into the RCPA QAP for breast markers due to concerns raised by participating laboratories about technical differences in supplied tissues for testing. This audit indicates that overall the results for ER, PR and HER2 fall inside established parameters. However, a number of individual laboratories do not meet the target values and variation in results would impact on patient treatment decisions.

Patient stories of living with a pressure ulcer.

AIM: This paper reports the findings of a pilot study exploring the experience of older people living with pressure ulcers. BACKGROUND: Pressure ulcers are known to be a significant health burden, but little is known of the impact on the quality of life of the sufferer. They mainly affect older people, and this is a neglected group in previous studies of this topic. METHODS: A Heideggerian phenomenological approach was used and patients were recruited if they were over 65 years of age and had a grade 3 or 4 pressure ulcer that had been present for more than a month. Patients were recruited from multiple centres but the data were analysed centrally. The study took place in 2003-2004. FINDINGS: Analysis of the transcripts revealed three main themes, all with associated subthemes: pressure ulcers produce endless pain; pressure ulcers produce a restricted life; coping with a pressure ulcer. The endless pain theme had four subthemes: constant presence, keeping still, equipment pain and treatment pain. Some patients found that keeping still reduced their pain. Several patients also reported that pain was exacerbated by their pressure relieving equipment and at dressing change. There were three subthemes for the restricted life theme: impact on self, impact on others and consequences. Patients found that the pressure ulcer restricted their activities and had an impact on their families. In addition, for some, the restrictions delayed their rehabilitation. To cope with their pressure ulcers, patients developed ways of accepting their situation or comparing themselves with others. CONCLUSIONS: Although a pilot, this study has produced a wealth of data that demonstrates the impact of pressure ulcers on people. While a larger study is required to obtain a European perspective, it is still reasonable to conclude that the issues of pain and restrictions should be considered in the development of pressure ulcer treatment and prevention guidelines.

The use of qualitative research methodologies to explore leg ulceration.

Qualitative research is used increasingly within tissue viability and this article specifically presents its use within the body of literature on leg ulceration. This article offers a discussion of the key features of qualitative methodology, such as subjectivity, bracketing, rigour and the analytic process. Furthermore it will be shown that understanding the underpinning philosophical approach is essential for clinicians undertaking qualitative research. The rich data obtained through this approach will be presented, revealing how a person living with leg ulceration can be heard.

Disrupted lives: investigating coping strategies for non-healing leg ulcers.

The aim of this study was to explore the lived experience of people who have non-healing venous ulcers using hermeneutic phenomenology. Unstructured interviews were carried out with five people who also completed a diary. Interpretative phenomenological analysis was utilized to identify themes and patterns. The core themes identified through analysis were biographical disruption, ways of coping, social implications and therapeutic relationships. The emergent themes reveal the impact of chronicity in participants' experience of chronic leg ulcers, their various emotional and problem-focused coping strategies and the positive role the district nurse plays in their lives. This study places leg ulceration within the body of literature on chronicity, linking nursing theory with the insights offered from health psychology.

Scintillation proximity assay (SPA) technology to study biomolecular interactions.

Scintillation proximity assay (SPA) is a versatile homogeneous technique for radioactive assays which eliminates the need for separation steps. In SPA, scintillant is incorporated into small fluomicrospheres. These microspheres or "beads" are constructed in such a way as to bind specific molecules. If a radioactive molecule is bound to the bead, it is brought into close enough proximity that it can stimulate the scintillant contained within to emit light. Otherwise, the unbound radioactivity is too distant, the energy released is dissipated before reaching the bead, and these disintegrations are not detected. In this unit, the application of SPA technology to measuring protein-protein interactions, Src Homology 2 (SH2) and 3 (SH3) domain binding to specific peptide sequences, and receptor-ligand interactions are described. Three other protocols discuss the application of SPA technology to cell-adhesion-molecule interactions, protein-DNA interactions, and radioimmunoassays. In addition, protocols are given for preparation of SK-N-MC cells and cell membranes.