What promotes or prevents greater use of appropriate compression in people with venous leg ulcers? A qualitative interview study with nurses in the north of England using the Theoretical Domains Framework.

OBJECTIVES: To investigate factors that promote and prevent the use of compression therapy in people with venous leg ulcers. DESIGN: Qualitative interview study with nurses using the Theoretical Domains Framework (TDF). SETTING: Three National Health Service Trusts in England. PARTICIPANTS: Purposive sample of 15 nurses delivering wound care. RESULTS: Nurses described factors which made provision of compression therapy challenging. Organisational barriers (TDF domains environmental context and resources/knowledge, skills/behavioural regulation) included heavy/increasing caseloads; lack of knowledge/skills and the provision of training; and prescribing issues (variations in bandaging systems/whether nurses could prescribe). Absence of specialist leg ulcer services to refer patients into was perceived as a barrier to providing optimal care by some community-based nurses. Compression use was perceived to be facilitated by clinics for timely initial assessment; continuity of staff and good liaison between vascular/leg ulcer clinics and community teams; clear local policies and care pathways; and opportunities for training such as 'shadowing' in vascular/leg ulcer clinics. Patient engagement barriers (TDF domains goals/beliefs about consequences) focused on getting patients 'on board' with compression, and supporting them in using it. Clear explanations were seen as key in promoting compression use. CONCLUSIONS: Rising workload pressures present significant challenges to enhancing leg ulcer services. There may be opportunities to develop facilitated approaches to enable community nursing teams to make changes to practice, enhancing quality of patient care. The majority of venous leg ulcers could be managed in the community without referral to specialist community services if issues relating to workloads/skills/training are addressed. Barriers to promoting compression use could also be targeted, for example, through the development of clear patient information leaflets. While the patient engagement barriers may be easier/quicker to address than organisational barriers, unless organisational barriers are addressed it seems unlikely that all people who would benefit from compression therapy will receive it.

Embedding National Institute for Health and Care Excellence guidance into a leg ulcer pathway.

Research has shown that leg ulcers represent the largest category of wound type treated within the UK. Venous leg ulcers are often classified as chronic wounds with increased protease levels causing the wound to become suspended in the inflammatory stage, which leads to delayed healing. If treatment choices are not evidence-based and appropriate regimens are not instigated early on in the wound care journey, the cost to both the patient and the healthcare service is substantial. Recent guidance from the National Institute of Health and Care Excellence (NICE) recommends UrgoStart (Urgo Medical) for treating venous leg ulcers as an adjunct therapy to the gold standard of compression therapy. Correct treatment choices must be made by clinicians using up-to-date relevant wound care knowledge. Evidence-based treatment algorithms and pathways can assist with correct product and therapy placement, assisting decision-making to improve patient outcomes. The present article describes a patient-centred leg ulcer pathway that embeds NICE guidance.

Improving patient outcomes through the implementation of a person-centred leg ulcer pathway.

OBJECTIVE: To develop a holistic pathway for leg ulcer assessment and management, implemented within a local community organisation. The primary aim for this pathway was to reduce time-to-healing. METHOD: A leg ulcer pathway was designed to be used in all care settings to support continuity, and contains quality of life (QoL) assessment tools, a treatment algorithm, guidance for use, a leg ulcer assessment form, and a wound treatment chart. RESULTS: Data analysis, carried out 12 months after implementation, compared pre- and post-averages for ulcer time-to-healing: 123.7 days (median: 84 days), n=46 pre-implementation, versus 69.1 days (median: 46 days), n=30 post-implementation, respectively, which demonstrated a minimum 44% reduction in time. Cost saving analysis demonstrated a minimum cost reduction of 45% in nursing time. CONCLUSION: The implementation of a structured, person-centred leg ulcer pathway has provided many benefits to patients, clinicians and the hospital and community trust. Enhancing correct dressing product placement by ensuring the right dressing is used at the right time, in tandem with the correct compression regime, improved healing outcomes. The patient journey has become more streamlined providing the best chance to achieve full healing quickly.

Using a modified Delphi methodology to gain consensus on the use of dressings in chronic wounds management.

OBJECTIVE: Managing chronic wounds is associated with a burden to patients, caregivers, health services and society and there is a lack of clarity regarding the role of dressings in improving outcomes. This study aimed to provide understanding on a range of topics, including: the definition of chronicity in wounds, the burden of illness, clinical outcomes of reducing healing time and the impact of early interventions on clinical and economic outcomes and the role of matrix metalloproteinases (MMPs) in wound healing. METHOD: A systematic review of the literature was carried out on the role of dressings in diabetic foot ulcer (DFU), and venous leg ulcer (VLU) management strategies, their effectiveness, associated resource use/cost, and quality of life (QoL) impact on patients. From this evidence-base statements were written regarding chronicity in wounds, burden of illness, healing time, and the role of MMPs, early interventions and dressings. A modified Delphi methodology involving two iterations of email questionnaires followed by a face-to-face meeting was used to validate the statements, in order to arrive at a consensus for each. Clinical experts were selected, representing nurses, surgeons, podiatrists, academics, and policy experts. RESULTS: In the first round, 38/47 statements reached or exceeded the consensus threshold of 80% and none were rejected. According to the protocol, any statement not confirmed or rejected had to be modified using the comments from participants and resubmitted. In the second round, 5/9 remaining statements were confirmed and none rejected, leaving 4 to discuss at the meeting. All final statements were confirmed with at least 80% consensus. CONCLUSION: This modified Delphi panel sought to gain clarity from clinical experts surrounding the use of dressings in the management of chronic wounds. A full consensus statement was developed to help clinicians and policy makers improve the management of patients with these conditions.