Development and Implementation of a Clinical Pathway To Improve Venous Leg Ulcer Treatment
- 0 Comments
- 8482 reads
Blood flow is reversed and veins become damaged.4 Venous ulcers are a unique type of wound because the underlying condition usually has developed over several years and is often unknown to the patient.3 Venous leg ulcers are associated with considerable clinical problems, such as high levels of exudate and disproportionate limb sizes and shapes.3 It is generally recognized that sustained compression is required to promote leg ulcer closure.4–9 Graduated compression is used to counteract venous hypertension, which is the main component of managing venous leg ulceration.7–14
Effects of compression on microcirculatory levels may include: acceleration of blood flow in the capillaries, reduction of capillary filtration, and increased re-absorption due to enhanced tissue pressure and improved local lymphatic drainage.5
Compression has been demonstrated to reduce edema and improve superficial skin lymphatic function, as well as lymph transport within the sub-fascial system.4,15 Depending on the parameters measured, higher pressures are suggested to be more effective than lower pressures.4,15
There is a need for a standardized multidisciplinary approach with emphasis on training, research, prompt assessment of the patient, and quick access to specialists.3
Time to ulcer closure is the critical factor in cost-effectiveness analysis.4,5 A commonly used technique8,11 for applying short stretch bandages is to use bandages 8-cm and 10-cm wide, and to start wrapping at the foot using a modified Sigg technique. The bandages may be washed and reused.
Materials and Methods
A clinical pathway (CP) was developed, validated, and implemented, to improve cost efficacy of treatment for patients with venous leg ulcers. The CP and selected products were tested by using case evaluation, looking at clinical efficacy, time to ulcer closure, wound evolution, quality of life (QOL), and cost efficacy. For details on the QOL aspects questionnaire see Table 1. The QOL questionnaire was filled out on a weekly basis by the clinician according to the answers given by the patient. Cost efficacy was assessed through looking at time to ulcer closure, materials used during treatment, clinician’s time and QOL aspects. Clinical examination was performed, depending on the wound type, upon the start of the treatment and at 2-week intervals for a period of 12 weeks. The patients were then followed until ulcer closure. The study group (SG) received treatment with a short stretch compression system and a dressing, depending on wound condition, as defined in the clinical pathway (Figure 1).
The patients in the control group (CG) received conventional treatment (compression bandages and a wound dressing) before implementing the clinical pathway.
Twenty subjects were included in the study. Data was collected using a questionnaire. Data was entered and verified using a Statistical Package (SPSS). After the questionnaires were completed, each item was analyzed separately and item responses were summed to create a score for a group of items. Responses to a single item on the questionnaire were treated as ordinal data.
• The clinician completed the QOL questionnaire once per week according to the patients’ responses.
• A 5-point Likert16 scale was used for rating the various aspects of QOL. This type of psychometric response scale is often used in questionnaires in survey research. At the end of the study, the completed questionnaires were analyzed looking at separate items, as well as summed item responses to create a score for a group of items.
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.