Development and Implementation of a Clinical Pathway To Improve Venous Leg Ulcer Treatment

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Prof. Anneke E. Andriessen, RN, CNS, MA, PhD; Roberto Polignano, MD; Martin Abel, PharmD

Abstract: A clinical pathway (CP) was developed and implemented to improve treatment outcomes for patients with venous leg ulcers. The CP and products (Rosidal® sys, Suprasorb® A, Suprasorb® P, and Suprasorb® C, Lohmann & Rauscher GmbH, Rengsdorf, Germany) were tested by case evaluation. Patients from the center were examined to determine his or her general condition, associated factors, wound type and stage, wound evolution, quality of life (QOL), treatment efficacy, and costs. Patients with venous leg ulceration (N = 20) were recruited to the clinical evaluation. Examination was performed upon presentation, and then at 2-week intervals for 12 weeks. The patients were then followed until ulcer closure. The outcome of the study group (SG) was compared to the results of a randomly selected patient control group (CG) at the center before implementing the clinical pathway. Statistic evaluation was performed using StatXact 5.0, double sided (α = 0.05) for paired and Wilcoxon test, and unpaired with Mann-Whitney (N = 20, [10/10]). After implementation, a statistically significant (P < 0.005) shorter period for ulcer closure was demonstrated for the SG when compared to previous treatment given to the CG. In the SG, 5/10 ulcers closed within 12 weeks versus 3/10 in the CG. An improvement in QOL was noted for the SG (P < 0.05 for the combined parameters, and P < 0.005 for pain), as well as cost savings (P < 0.05). The CP applied throughout the complete care chain improved quality of treatment outcomes and made effective use of resources and materials.

Address correspondence to:
Anneke E. Andriessen, RN, CNS, MA, PhD
Andriessen Consultants
Zwenkgras 25
Malden 6581 RK
Phone: 31 24 3587086

     Leg ulcers are an underestimated problem in primary health care, particularly among elderly patients. One to 2% of the population will suffer from a poorly healing ulcer of the lower extremity in their lifetime.1 Prevalence increases with age (> 80 years) to almost 20 per 1000.2 Ambulatory venous hypertension is the final common pathway, which in most cases leads to venous ulcer (VU) formation.3 Subsequently, the superficial venous network may be exposed to much higher pressures than normal, up to 90 mmHg instead of the normal 30 mmHg.4 Increased pressure causes the veins to over dilate.4 The valves become incompetent leading to reflux, which can lead to venous stasis. Slower flow rates in areas of stasis result in deposits of red blood cells and increased blood viscosity.4

     When valves in the perforator veins become incompetent, reflux also affects the superficial venous system.


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