Clinical innovations Wound management


implementation of the leg ulcer consultation. By contrast, the leg ulcer incidence increased by 28.2% from 1.27/1 000 (n=106) in 2011 to 1.77/1 000 in 2012 (n=147). Although the ABPI is pivotal in determining ulcer aetiology,[6]


it was performed only in 6.9% (n=6) of patients


prior to the implementation of the leg ulcer consultation. After implementation, the percentage of patients with ABPI evaluations performed rose to 66.7% (n=38). The percentage of undiagnosed leg ulceration dropped from 39.6% (n=34) to 12.3% (n=7). The largest increase in aetiology was found in arterial (2.3% to 14%) and mixed ulceration (5.8 to 10.5%). Venous ulceration diagnosis showed little difference (51.2% to 52.6%) between both studies. Prior to the implementation, only 52.5% (n=21) of venous


ulcers benefited from compression therapy. After 1 year, the percentage rose to 96.7% (n=29). Regarding referral, the percentage of arterial and mixed ulcers referred to the vascular team rose from 28.6% (n= 2) to 100% (n=13). The referral of patients with venous ulcers of at least 24 weeks’ duration rose from 75.0% (n=18) to 93.8% (n=15). Before the implementation of the project, dressing change


and wound cleansing were carried out using sterile tweezers and saline solution, with great implications on cost but no impact on healing. So, as part of the new project – and as supported by a Cochrane review[7] guidelines[4–5]


and other clinical – a clean, rather than sterile, technique was


adopted using tap water. Given the Royal College of Nursing advice that leg ulcer


dressings should be “low cost, simple to reduce risk of contact sensitivity and low, or non-adherent”,[2]


non-adherent gauze became the first choice of treatment as part of the new project. Likewise, highly absorbent and expensive dressings containing carboxymethylcellulose or polyurethane were used only in highly exuding wounds.


[A] the use of alginate and


Antimicrobials were used only when clinical signs of local infection were present. These measures reduced the frequency of dressing change


(average of 2.76 to 2.35 dressing changes per patients per week) resulted in the reduction of treatment cost per patient per year from €1143.93 to €777.50. Associated with the reduction of leg ulceration, the total cost of treatment of all patients reduced by nearly half (€86 787.18 to €43 402.99). Related to the efficacy of the treatment, healing rate at


12 weeks increased from 35.8% (38/106) in 2011 to 67.3% (99/147) in 2012, and at 24 weeks increased from 58.5% (62/106) in 2011 to 87.8% (137/147) in 2012 [Figure 1].


DISCUSSION The implementation of the leg ulcer consultation supervised by the tissue viability team proved to be an invaluable strategy in improving outcomes and reducing costs at the Ponta Delgada Health Care Centre. The positive results motivated the Azorean health secretary to authorise the dissemination of the leg ulcer consultation to all São Miguel healthcare centres, servicing some 137 830 people. It will be the first time a group of healthcare centres in Portugal will deliver a coordinated answer to the problem of leg ulcers. The increase in leg ulcer incidence can be explained by the improvement of quality of care delivered that might have motivated leg ulcer patients to choose being treated in the healthcare centre rather then self-care or a private institution. Nevertheless, now that treatment protocols have been standardised and improved, the focus needs to be on implementing optimum prevention strategies, particularly for those patients at risk of recurrence. n


AUTHOR DETAILS André Soares, Patricia Pimentel and Filipe Correia are Tissue Viability Nurses; Diogo Borges and José Duarte are GPs; Sandra Silva is Tissue Viability Coordinator and Community Nursing Specialist. All are based at Ponta Delgada Health Care Centre, Ponta Delgada, Portugal.


REFERENCES 1. Moffatt CJ, Martin R, Smithdale R (2007) Leg Ulcer Management – Essential Clinical Skills for Nurses. Blackwell, Oxford


2. Royal College of Nursing (2006) Clinical Practice Guidelines. The Management of Patients with Venous Leg Ulcers. RCN, London


[B]


3. Registered Nurses Association of Ontario (2004) Nurse Best Practice Guidelines. Assessment and Management of Venous Leg Ulcers. RNAO, Toronto, ON


4. Scottish Intercollegiate Guidelines Network (2011) Management of Chronic Venous Leg Ulcers. A National Clinical Guideline. SIGN, Edinburgh


5. Australian Wound Management Association & New Zealand Wound Care Society (2011) Clinical Practice Guideline for Prevention and Management of Venous Leg Ulcers. AWMA, Sydney, NSW


Figure 1. Leg ulcer healing rates at [A] 12 and [B] 24 weeks for 2011 and 2012.


6


6. Wounds International (2013) Principles of Compression in Venous Disease: A Practitioner’s Guide to Treatment and Prevention of Venous Leg Ulcers. WI, London


7. Fernandez R, Griffiths R (2008) Water for wound cleansing. Cochrane Database Syst Rev (1): CD003861


Wounds International Vol 5 | Issue 1 | ©Wounds International 2014 | www.woundsinternational.com


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