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

Login to Download
PDF version
Author(s): 
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
Netherlands
E-mail: anneke.a@tiscali.nl
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.

References: 

1. Fletcher A. The epidemiology of leg ulcers. In: Cullum NB, Roe BH, eds. Leg Ulcers, Nursing Management: A Research- based Guide. Middlesex, UK: Scutari Press; 1995.
2. Geerts WH, Pineo GF, Heit JA, et al. Consensus Conference dell'ACCP. Chest. 2004;126:338S–400S.
3. Andriessen A. The four-layer compression method. In: Gardon-Mollard C, Ramelet AA, eds. Compression Therapy. Masson: Paris, France; 1999:177–182.
4. Partsch H. Improvement of venous pumping function in chronic venous insufficiency by compression depending on pressure and material. Vasa. 1984;13:58–64.
5. Margolis DJ, Berlin JA, Strom BL. Which venous leg ulcers will heal with limb compression bandages? Am J Med. 2000;109(1):15–19.
6. Cullum N, Nelson EA, Fletcher AW, Sheldon TA. Compression for venous leg ulcer. Cochrane Review. Oxford: The Cochrane Library; 2003.
7. Marston WA, Carlin RE, Passman MA, Farber MA, Keagy BA. Healing rates and cost efficacy of outpatient treatment for leg ulcers associated with venous insufficiency. J Vasc Surg. 1999;30(3):491–498.
8. Partsch H, Menzinger G, Mostbeck A. Inelastic leg compression is more effective to reduce deep venous refluxes than elastic bandages. Dermatol Surg. 1999;25(9):695–700.
9. Clark M, Compression bandages: principles and definitions. EWMA Position document. Understanding compression therapy. MEP. 2003;5–7.
10. Duby T, Hoffman D, Cameron J, Doblhoff-Brown D, Cherry G, Ryan T. A randomized trial in the treatment of venous leg ulcers comparing short stretch bandages, four-layer bandage system and a long stretch-paste bandage system. WOUNDS. 1993;5:276–279.
11. Partsch H, Damstra RJ, Tazelaar DJ et al. Multicentre, randomized controlled trial of four-layer bandaging versus short-stretch bandaging in the treatment of venous leg ulcers. Vasa. 2001;30(2):108–113.
12. Ukat A, König M, Vanscheidt W, Münter KC. Short-stretch versus multilayer compression for venous leg ulcers: a comparison of healing rates. J Wound Care. 2003;12(4):139–143.
13. Partsch H, Menzinger G, Borst-Krafek B, Groiss E. Does thigh compression improve venous in chronic venous insufficiency? J Vasc Surg. 2002;36(5):948–952.
14. Moffatt CJ, McCullagh L, O’Connor T, et al. Randomized trial of four-layer and two-layer bandage systems in the management of chronic venous ulceration. Wound Repair Regen. 2003;11(3):166–171.
15. Partsch H. Effekte der Kompressionsthera-pie im Bereich der Beinvenen in Abhängigkeit von Andruck und Materialeigenschaften Eur J Vasc Endovasc Surg. 2005;30;415–421.
16. Latham GP. Work Motivation: History, Theory, Research, and Practice. SAGE Publications Ltd; 2006.
17. Moffatt CJ, Franks PJ, Oldroyd M, et al. Community clinics for leg ulcers and impact on healing. BMJ. 1992;305(6866):1389–1392.

















Post new comment

  • Lines and paragraphs break automatically.
  • Web page addresses and e-mail addresses turn into links automatically.
  • Use to create page breaks.

More information about formatting options

Image CAPTCHA
Enter the characters shown in the image.