Issue 12 Winter 1999 CLINIC - Leg Ulcer Forum · 2000. 7. 27. · Tissue Viability Nurse...

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LEGULCERCLINIC

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ImplementationAssessment of local leg ulcer needsAn International Perspective of Larval Therapy

Issue 12 Winter 1999

ImplementationAssessment of local leg ulcer needsAn International Perspective of Larval Therapy

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The Leg Ulcer Forum – Winter 1999

Contents LEG ULCER FORUM

Executive committeemembers

Christine MoffattMA, RGN, DN

Professor of Nursing, Co-Directorfor The Centre for Research and

Implementation of Clinical PracticePRESIDENT

Lilian BradleySRN, ONC

Tissue Viability NurseCHAIRPERSON FOR THE NORTHERN

IRELAND BRANCH

Mark CollierBA (Hons), RGN, ONC, RCNT, RNT

Nurse Consultant/Senior LecturerCHAIRMAN

Merry CollinsonRGN, NDN, Cert Ed.

District NurseEDUCATIONAL FACILITATOR

Pauline DiamondSRN RM Diploma in Nursing

Wound Care Specialist

Lynfa EdwardsRGN, NDN, Cert Ed.

Senior Lecturer/Nurse PractitionerEDITOR

Gill HennRGN, NDN, OND

District Tissue Viability Nurse SpecialistSECRETARY

Penny MussonRGN

Vascular Leg Ulcer SpecialistEDUCATIONAL FACILITATOR

Maria PooleBsc (Hons), RGN, NDN, CPT

Clinical Nurse Specialist Wound CareTREASURER

Julie StevensBsc (Hons) RGN, NDN, FETC

Clinical Nurse Specialist Tissue ViabilityPUBLICITY CO-ORDINATOR

Nicky StubbingRGN, RNT

Clinical Nurse Specialist Vascular Technologist

Co-opted members

Andrew MoretonRGN, NDN

Clinical Nurse Specialist

Katherine VowdenRGN, FETC, DPSN

Vascular Nurse Specialist Tissue Viability

This journal is kindlysponsored by

Leadership in Worldwide Healthcare

The front cover is an illustration of the winning entryof ‘Design an educational leaflet cover’ by Jane Cave

Editorial 3

Call for nominations (form)to the executive committee 3

A message from your Chairman and 4Summer Conference report

A message from your President 6

Larval Therapy – an international perspective 8

District leg ulcer services –assessment of local need 10

The Leg Ulcer Forum – Ireland Branch 14

Developing Leg Ulcer Services in Northern Ireland 15

Society of Vascular Nurses – update 16

Results of the ‘Design an educationalleaflet cover’ competition 17

Courses 18

Conferences 19

We are also grateful to the following companies for their kind sponsorship towardsthe leg ulcer forum:

Mölnlycke Maersk Medical Smith and Nephew SSL INternational plc

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Editorial

Dear Readers

May I welcome you to the last Leg Ulcer Forum Journal of the 20th century.

As the new millennium rapidly approaches it is becoming more apparent that the Leg UlcerForum is spreading its wings into pastures new. Our affiliation with the British LymphologySociety and the Society of Vascular Nurses is gaining strength.

Our international connection is being sought by our President, Professor Chris Moffatt. Wewere honoured to have Margaret Harrison and Ian Graham from Ottawa Canada presenting atour recent Cambridge conference.

Congratulations to Mark for organizing the summer conference in Cambridge and to LilianBradley and Pauline Diamond for organizing the Irish conference in Galway, Southern Ireland.

As editor of the journal I would personally like to invite you to contribute to your Leg UlcerForum Journal. I welcome articles or care studies which you think would be of interest to ourreaders. Perhaps you would like to voice your opinion on a particular issue or simply write aletter. I welcome your input.

Can I remind you to send nominations for the executive comittee and complete and return theleg ulcer service data base form.

May I take this opportunity of wishing you all a very Merry Christmas and an exciting newcentury. Hope to see you on December 3rd at the conference.

Best Wishes

Lynfa M Edwards, Editor

NOMINATIONS FOR THE LEG ULCER FORUM EXECUTIVE COMMITTEE

I wish to nominate .................................................................................................................

of ..................................................................................................................

Please return all completed forms to:Gill Henn, Secretary to The Leg Ulcer Forum, Wordsley Hospital, Wordsley, Stourbridge, West Midlands DY8 5QX

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Chairman’s message and

Cambridgeconference report

CONFERENCE REPORTSPRING/SUMMER 1999HUNTINGDON, CAMBRIDGESHIRE

The Leg Ulcer Forum/Wound Care Event was held at theSwallow Hotel, Huntingdon on Monday and Tuesday14/15 June.

The two day meeting, generically entitled ‘Current concepts –Latest thinking’, was supported by Mölnlycke Health Care onDay 1 and the current sponsors of the Leg Ulcer Forum (seebrochure listing) on Day 2.

As Chairperson for the two days, I had the pleasure ofwelcoming delegates to the meeting before presenting the firstsession, Principles of Trauma and the Management of Patientswith Traumatic Wounds. This session highlighted, in particular,the rationale for the choice of wound cleansing solutions andwound management materials that may be seen in the Accidentand Emergency department. Unfortunately this presentation wasa substitute for the planned session, Surgical Management of thePatient with Burns, as with regret the Consultant PlasticSurgeon who was all set to attend found himself operating on afive year-old child on the same Monday morning. Just goes toshow that the patients always come first with the members andsupporters of the Leg Ulcer Forum!

Madeleine Flanagan (Principal Lecturer, University ofHertfordshire) then followed coffee with a stimulating lectureon the History of Wound Management – a Nursing Perspective,before Ann Fowler (Clinical Nurse Specialist – Burns Unit,Mount Vernon Hospital) stolethe morning glory with herpresentation on the First AidManagement of the Patientwith Burns. To complete themorning session AmandaWoodcock, (Clinical ResearchManager, Mölnlycke HealthCare) discussed the latestresearch relating to modernwound management materialssuch as Mepitel – currentlyavailable on FP10.

After a three-course sit-down lunch, delegates returned to hearthree further presentations from Professor Christine Moffatt

Professor Nick London discusses theconcept of ‘One-Stop Shops’

A MESSAGE FROM THE CHAIRMAN

As the next Annual General Meeting (AGM) ofthe Leg Ulcer Forum (LUF) fast approaches, Iwould like to take this opportunity of thanking –

through this brochure – all the members of the executivecommittee for their hard work throughout the year onyour behalf.

This year has been particularly interesting. It is the firstsince you approved the new constitution. The Irish branchof the LUF has run independently for the first time, andour affiliations with the British Lymphology Society(BLS) and Society of Vascular Nurses (SVN) have beenmore fully explored.

Nevertheless in some ways it has been a difficult year, asyou the practitioners find it more difficult to get time offwork to attend forum events and commercial companieshave less money to sponsor both societies and theirrelated events across the country.

With this in mind and as in the New Year you will beasked for the first time to renew your membership of theforum (it remains free!), the executive committee havefelt it appropriate to ask you at the same time to indicatewhether or not you wish to continue to receive the LegUlcer Forum Brochure. This is because although Smithand Nephew sponsor the printing of the brochure, thepostal costs have to be covered from general Forumfunds. Please ensure therefore to answer all questions onyour renewal form when it comes, as of course we wantto continue to send you the brochure, but we also want toensure that it is of use to you.

Remember the Leg Ulcer Forum is your Forum!However, in order to reflect your views we need to knowwhat they are. Do feel free to write to me at C.R.I.C.P orcontact any other members of the executive committee atyour convenience (send articles for the brochure to LynfaEdwards at C.R.I.C.P), or speak to us at the next meetingof the Leg Ulcer Forum scheduled for Friday 3rdDecember1999 in London.

See you there.

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(Self-Inflicted Wounding), Dr Peter Franks (Quality of Life – asan Outcome Indicator) – both of the Centre for Research andImplementation of Clinical Practice, Thames Valley University– and Mr John Church (Larval Therapy – An InternationalPerspective) a retired Orthopaedic Consultant Surgeon nowlinked with the Surgical Materials Testing Laboratory (SMTL),Bridgend General Hospital, all of which were highly evaluatedby the delegates. Professor Moffatt’s session was an updatedand expanded version of a presentation given at the EuropeanWound Management Association Conference – Harrogate 1998,Dr Frank’s thoughts are now in print (Journal of Wound Care,EMAP Publications) whilst a transcript of Mr. Church’s sessioncan be found on page 8.

On the Monday evening private dining was arranged for thosestaying over and attending both days of the conference. Thechosen menu and ambience created proved a big hit with thoseattending, judging by the free flow of conversation and wine, orshould that be wine and conversation?

Day Two – the 13th Meeting of the Leg Ulcer Forum (LUF) –commenced with feedback from the recently circulatedquestionnaire to all LUF members being incorporated intoProfessor Moffatt’s session entitled Implementation – ANational Perspective.

This was then followed byanother first for the forum, asour International guests wereintroduced – Margaret Harrisonand Ian Graham from Ottawa,Canada – who spoke on thesubject of Implementation – AnInternational Perspective.Although they left no transcriptof their joint presentation, theydid leave a couple of articleson their subject with me,written by themselves, which Iwould be more than happy to

photocopy and circulate on request.

During the remainder of the morning Dr Peter Franksintroduced A Model for Implementation, Professor Nick London– Consultant Vascular Surgeon, Leicester Royal Infirmary –discussed the concept of Vascular One Stop Shops and two ofthe executive committee (Kath Vowden and Merry Collinson)gave their own personal accounts of how they had beeninvolved with the implementation of ‘local’ leg ulcer initiatives.

After lunch in the hotel restaurant, delegates again returned tothe conference suite, this time to be involved in a series ofinteractive workshop sessions, encompassing a number ofrelevant topics such as Clinical Governance and Primary CareGroups (PCG’s); Quality, Audit and Standards, and the processfor the Development of a Model for Implementation.

To conclude both a very packed day, meeting and conference,Professor Christine Moffatt – President of the Leg Ulcer Forum– returned in order to challenge delegates to keep up the goodwork, continue to facilitate change and ensure the futureimplementation of new leg ulcer services throughout thecountry, however they could.

Feedback (encompassing comments related to both days) fromthose attending:

• As usual very interesting subjects chosen – very worthwhilemeeting

• Lots of valuable information; handouts would have beenuseful because of time constraints; most speakers spoke toofast for me to take notes

• Excellent, informative and thought-provoking

• Topics on implementationpresented to the converted.These presentations need tobe made to new strugglingclinics who wantencouragement and supportfrom those that had beenthere and succeeded

• Workshops discussed anumber of important issueshowever needed more time

• Very good organisation andvenue. Interesting speakers,especially contribution fromcolleagues from overseas.Lots of good ideas and goodpractice evident.

• Excellent organisation and venue. Relaxed and informal –good setting for learning. Food wonderful – just too manydoughnuts!

• A well organised event. Always putting the practitioner first.

In summaryOverall the event was considered a great success, enjoyed by allthat attended. A new design for the front cover of all futureeducational leaflets was chosen (see entries in this brochure).The only disappointing aspect was that more delegates did notattend. Still I look forward to welcoming you to the 14thmeeting of the Leg Ulcer Forum on Friday 3rd December 1999in London.

Cheers!

Mark CollierSenior Lecturer/Nurse Consultant – Tissue Viability

Centre for Research and Implementation of Clinical PracticeThames Valley University, Ealing, London

Merry Collinson talks about theimplementation of leg ulcer initiativesin her local area

Margaret Harrison and Ian Grahamspeak about the Ottawa experience ofImplementation – an InternationalPerspective

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The June conference of the Leg Ulcer Forum focused on the last decade ofdevelopments in leg ulcer management. No-one can doubt that the last 10 years haveseen a proliferation in new services for leg ulcer patients and a changing profile of the

condition. However, there is no reason for complacency. Effective services for patients are notuniform throughout the country and despite the recent systematic review on leg ulcermanagement and the RCN guidelines on leg ulcer management, no national strategy exists toensure these will be implemented.

At the conference in June we presented data from the forum membership who had completedthe questionnaire sent out last year. Our thanks to the 317 people who returned thequestionnaire and gave us a valuable insight into the difficulties experienced in implementingleg ulcer services.

A common theme emerging from the questionnaire was the difficulty experienced inmanaging a major organisational change. For many it was an isolating, lonely experiencewhich involved being asked to undertake tasks such as business planning for which no helpand support were available. All of this activity was set against the backdrop of continuinghealth service reforms that set a turbulent scene. Concepts such as bridging the gap betweenprimary and secondary care became complicated by trusts vying to provide services and GPfund holding. The health service is set for major change again with the development ofprimary care groups and ultimately, primary care trusts. Those of us involved in leg ulcerservices must reflect on how these developments will affect leg ulcer care. However, theadvances in terms of quality care and health outcome for leg ulcer patients that have beenachieved in the last decade are excellent examples of what the clinical governance agendashould be about.

It was clear from the questionnaires that development of services was occurring throughoutthe country as well as in Scotland, Wales and Northern and Southern Ireland. Nearly 70% ofrespondents were actively involved in running an entire leg ulcer service: 25% of services hadbeen running for 5-10 years with 44% being developed in the last 2-5 years.

The commonest problem experienced in implementation was the resistance from staff at grassroots level and management level. These issues highlight the importance of understanding thecontext and culture of the organisations we work in. The political agendas of varyingprofessional groups, coupled with the anxiety generated from attempting to make a radicalchange in practice are challenging and frequently bewildering. Many of you faced practicalproblems such as lack of transport and accommodation that made developing the service

A message from

the President

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difficult. Education was cited as an important factor in changing people’s attitudes and buildingownership to the change process. Frequently management failed to understand the importanceof releasing staff for training. This was set against the continuing struggle of inadequatestaffing and a lack of cover when staff were being trained.

We asked you to tell us what you would do differently if you could start the project again. Themost frequently cited comment was to gain adequate management support and to prepare anadequate business plan. Many of you also would invest greater time in providing education.The value of networking was seen as a most important issue. There was an awareness thatmeeting others at the Leg Ulcer Forum conferences was extremely valuable. Many of youreferred to not wanting to re-invent the wheel and learning from each other’s experience. Thisis at the heart of the leg ulcer forum’s ethos and will remain so.

Where should we go next? And what role should the leg ulcer forum play in shaping leg ulcerservices for patients?

Clearly steps have already been taken in the forum’s development with affiliations to theBritish Lymphology Society and the Society of Vascular Nurses. This not only broadens ourbasis but allows us to benefit and share experience with like minded though distinct, groups.

However, I believe if we are to gain momentum that we must develop frameworks to undertakeresearch within the forum membership. So many questions remain concerning leg ulcertreatments. Despite advances in managing venous ulcers, little has been done to identify thebest methods of treatment for mixed aetiology ulceration, an increasingly dominant populationof patients within our services. Any of you who have been involved in undertaking researchwill know how daunting it is to have to recruit large numbers of patients to a study. CRICP arehelping to facilitate the Wound Healing Nursing Research Network, should this be extendedmore widely into the forum membership? Only by combining forces can we undertake studiesof adequate size and methodological rigour to answer the questions we are all looking for.Nurses have proven their ability to lead research in this area and we must strive to continue thiswork.

How might the forum help shape the rolling out of the RCN guidelines and the standardisationof practice nationally? Representatives from the forum are already in discussion with the RCNto see what possible avenues exist. Members of the forum continue to have a high profile onother wound care councils within the UK and in Europe. With the establishment of NICE andthe recommendations to examine issues such as pressure ulceration and bandaging, the forummust stay alert to the need to have a strong political voice in the arguments and debates whichwill doubtless ensue.

Chris Moffatt

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Larval Therapy –

an international perspective

Introduction

Larval Therapy (LT) is also known as Maggot Therapy(MT) or Maggot Debridement Therapy (MDT). Thelatter two terms have been used primarily in America,

by Dr Ronald Sherman and his co-workers. We try to avoidusing the term ‘maggot’ because of its negative associationswith dirt, disease and death.

To set the scene we need to define Larval Therapy. The latter-day definition is the use of the larvae of the blowfly LucilicaSericata as agents of debridement in open wounds. Aprerequisite of such treatment is that the larvae should becultured under strictly controlled laboratory conditions, and sentout in bacteria-free containers. This pertains in the majorcountries now using this therapy.

We can however broaden the definition to include any situationwhere larvae are active in human wounds, with some element ofhuman control, and the assumption that they will do at leastsome good while there. This allows us to look at the use oflarvae in traditional health care systems, especially in non-western countries. Historically, larvae from a number of flyspecies have been used, or have been reported as effective, incausing wound debridement.

We can also broaden our perspective to look at the global needs,in wound care, particularly of the lower limb, and where we cango in terms of the development of larval therapy worldwide.

LT in traditional health care systemsChinaI have a personal communication from Mrs J Matthews. In theearly 1900s, her grandfather, who was a farrier, went to China totake care of the horses at the Shanghai Horse BazaarRacecourse. Her father, then ten years old, had a bad fall from ahorse, injuring his knee. “The knee was so damaged, theEnglish doctor thought the leg would have to be amputated, butwhen a Chinese surgeon was consulted, he said that he couldsave the leg with maggots and sun rays. This was carried out...with the knee uncovered, but covered with maggots. Althoughhis leg was saved, it remained rigid. All the same, my father wasalways agile, and had very little trouble or scars on the ‘stiff’leg... he lived to 93!”

When I went to China in September 1996, to attend the FirstJoint Meeting of the Chinese Tissue Repair Society and the

ETRS, I spoke to a number of Chinese doctors. Several vouchedfor the fact that maggots were still being used traditionally inopen wounds, but I could obtain no details.

JamaicaProfessor Mary Dyson (The Tissue Repair Research Unit, Guy’sHospital) has a technician from Jamaica, who told us of “nativepractitioners who use maggots in wounds, and cover them witha leaf”.

LabradorDr David Rogers, of the Entomology Department in Oxford,supplied me with a story from Mr and Mrs H D Felsberg, ofLabrador. A fisherman suffered a laceration of the hand withsevere infection, becoming ‘an angry mass of tissue, a bloatedlimb, a useless appendage, a very threat to life itself’. An 80year old widow was allowed to try the “old way my mothershows me” – applying maggots to the wound, with success.

BurmaIn a personal communication from Mr J H Harris, he refers to abook entitled ‘Elephant Bill’. This gives the experiences of anEnglishman who lived with a Malay tribe in the jungle, herdingelephants. He injured his leg, and the wound refused to heal. Atribesman covered the wound with a ‘poultice of elephant dungin which there were maggots. In a short time the maggotscleaned all the gangrene from the wound, which healedsuccessfully.’

These anecdotes, few and far between though they are, serve togive us a glimpse into the traditional use of maggots. I have nodoubt that this picture could be filled in far more widely, ifsomeone were to go out and search for further such material.

Major countries now using Larval Therapy.North AmericaThough historically European surgeons, particularly militarysurgeons, first used larvae therapeutically, it is to North Americain th 1930s that we can turn for the major development of thistreatment, with the setting up of properly establishedlaboratories, culturing flies and larvae under controlledconditions. There is an extensive literature of the period. Thencame a decline in the use of larvae, sufficient to this ‘wheelhaving to be re-invented’, as it were, in the 1980s.

I first met Dr Ron Sherman in 1988 at the School of TropicalMedicine in London. He wrote some prophetic words at that

John CT Church, MD FRCSESurgical Materials Testing Laboratory (SMTL)Bridgend General Hospital

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time: “I am particularly interested in the beneficial uses ofinsects in medicine”. Six years later, in September 1994, I hadthe opportunity to visit him in Long Beach, California. By thistime his Maggot Debridement Therapy (MDT) service was wellestablished, and he had personally delivered over 1000treatments. He must be regarded as the latter-day ‘re-initiator’of Larval Therapy.

UKDr Sherman reported on his work at the European Tissue RepairSociety Consensus meeting on wound debridement, held inOxford in January 1995. At that time Professor Terence Ryaninvited me to join him and his colleagues in the Wound HealingUnit in Oxford, and we started tentative clinical trials usinglarvae provided for us by Dr David Rogers in the Universitydepartment of Zoology. There was also considerable mediainterest over that period, which served to help us initiate thiswork in the UK. Then Dr Stephen Thomas and I met, and the‘Biosurgery’ laboratory was set up in Bridgend, within theSurgical Materials testing Laboratory (SMTL).

Our first conference, held in Porthcawl, was entitled a‘Biosurgery’ conference, focussing on the use of leeches insurgery and the re-emerging use of larvae in wounddebridement. We were honoured to have Dr Sherman at thatconference. We have since held two further very successfulannual IBS conferences.

IsraelDr Kosta Mumcuoglu, in Israel, started using larvae in 1995,mainly in the treatment of diabetic feet. His work is now wellestablished in hospitals in and around Jerusalem, where hehosted the third IBS conference. He is now the President ofthe IBS.

EuropeDuring this time there has been a steady development of LT,with increasing interest in Europe. There has been spectacularprogress in Germany, headed by Dr Wim Fleischmann and histeam, but also in Sweden, with Professor Carita Hansson andher colleagues, in the Ukraine, with Dr Yuri Markyvevich, andlatterly in Switzerland with Professor Lasse Braathen. TheBiosurgery Laboratory is now housed in excellent new premisesin Bridgend. Details of this work (on biosurgery/biotherapy) areavailable on the following web sites:

Dr Shermanhttp://www.com.uci.edu/~path/sherman/home_pg.htm

Dr Mumcuogluhttp://www,md.huji.ac.il/depts/parasitology/p-3-7.html

Dr Thomashttp://www.smtl.co.uk/

Global development of LTIt can be seen from this summary of the present position that LT,though proving to be efficacious in wound debridement andbacterial control, is by no means universally accepted yet. Itsdevelopment across the globe is patchy and unbalanced. In thecurrent league table, if such there is, Germany would seem to beleading the field, with Israel, the UK and other Europeancountries following.

The global need in terms of wound care, be it acute woundsfollowing conflict or natural disaster, or chronic wounds withinfection, would lead us to concentrate on the tropics, or thoseparts of the world where the medical services are under-provided. I worked in East Africa from 1959-1973, initially inan isolated ‘bush’ mission hospital in North-East Rwanda. Thiswas during the first period of civil war in Rwanda, and I had todeal with countless machete (panga) and spear wounds, and alot of tropical infections.

But the problem in setting up a Larval Therapy service in suchcountries is a complex one. Politically it is perceived as ‘downmarket’ or even derisory to suggest that maggots might beuseful in open wounds when their real needs are for CTscanners and keyhole surgery. Even the simplest of fly culturelaboratories needs a budget, and personnel to maintain it.Professor Terence Ryan, as President of the InternationalDermatological Association, has been the mainspring in theestablishment of a training school, in Northern Tanzania, forpara-medical dermatologists. A small fly culture laboratory inassociation with that training school would be ideal indeed, buthas yet to be started.

Though clinical outcomes are good in the majority of ourpatients, I would add a word of caution. There are a number ofquestions that we do not yet know the answers to. For instance,could some patients become allergic to larvae? Such patientscould, for instance, be diabetics who have had successfultreatment some months or years before, and who return withfurther trouble. Would some of these patients be hypersensitiveto larval excretions? Can larvae harbour organisms (bacteria orviruses) that could become pathogenic to man? Is the intense‘monoculture’ of the flies in our latter-day laboratories breedinga less robust stock than the natural equivalent? Should we belooking at the use of other fly species, with a known trackrecord (albeit largely anecdotal and untested) which wouldprove to be more efficacious in certain clinical conditions?

ConclusionIn conclusion I predict that, despite possible setbacks, there willbe steady development of Larval Therapy across the world,primarily in affluent states but ultimately in poorer countries.The International Biotherapy Society (IBS) provides an idealvehicle for the study of, and expansion of, this therapeuticventure.

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District Leg Ulcer Services

Assessment of local need

Introduction

Chronic venous leg ulceration places a significant drainon health resources and is estimated to consume 2% ofthe total health care budget of the European community

(Laing 1992). It is estimated that 1-3 % of the population willsuffer from a leg ulcer at least once during their lifetime(Callum et al 1985) this not only represents large numbers ofunhealed wounds but also impacts directly on the quality ofpatients lives, often causing poor mobility, pain andembarrassment due to exudate leakage and malodour. Theassessment and treatment of leg ulceration has improveddramatically over the past decade and many Health Authoritiesare now seeking to develop district wide community leg ulcerservices to specifically meet the needs of local populations.

Walsall Community Health Trust launched its community legulcer service in 1993 following a baseline audit on the prevalenceof leg ulceration on district nurses caseloads and a baseline auditof community nurses knowledge and skills. The overall aim wasto provide a quality service for patients with leg ulceration,comprehensive assessment, evidence based care and optimumwound healing, resulting in an efficient use of resources, greaterindependence and improved quality of life for patients.

This has been achieved through:

• Setting up leg ulcer clinics in centralised areas where patientscan be treated in a relaxed and friendly atmosphere.

• Provision of education and training for community nurses.

• Use of multi-layered high compression therapy for patientswith venous ulceration.

• Use of reduced compression for patients with mixed aetiology.

• Prompt referral of patients requiring vascular or dermatologyassessment.

• Provision of an after care service to prevent ulcer recurrence.

• Continued provision of domiciliary services for patientsunable to access clinics.

Healing rates for the community leg ulcer clinics in Walsallhave been shown to be 76% of patients achieving full healing inan average time of 11 weeks.

Community leg ulcer clinics have been set up in all localities inWalsall. However, when assessing local needs in one it becameapparent that there was a fundamental difference in the needs ofthe local population. The area, is populated by minority ethnicgroups mainly of Asian origin, and there is a very lowprevalence of patients presenting with leg ulceration in thisarea. This has influenced the Service to investigate the needs ofthe Minority Ethnic Groups further in relation to leg ulcer care.

Development of a District Wide StrategyDespite these encouraging healing rates in Walsall, there was alack of information on the extent of leg ulceration across theDistrict of Walsall and especially limited information on theprevalence of leg ulceration among the ethnic minority groups.In January 1998 Walsall Health Authority invested in thedevelopment of a district wide strategy for the assessment andtreatment of leg ulceration.

The aims of the strategy were:

• To assess the size of the problem of leg ulcers in Walsall

• To evaluate current service provision for leg ulcer care

• To develop effective care programmes

• To set up a district-wide standard assessment and referralprotocols

• To implement changes, if necessary, to ensure that localservices are evidence-based and comply with nationalrecommendations.

As this project was to be a collaborative project betweenWalsall Health Authority, Walsall Community Health Trust,Walsall Hospitals NHS Trust and the Independent Sector asteering group was initially set up including members from eacharea. This helped to ensure the service had a truly multi-disciplinary focus and would encourage ownership and

D M Chaloner BSc (hons) RGN NDN CPTRegistered Specialist Practitioner in Tissue ViabilityWalsall Community Health Trust

P J Franks PHDDirector, Centre for Research andImplementation of Clinical PracticeThames Valley University

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commitment from all key players involved.

To assess the prevalence and current treatment of leg ulcerationacross the district a baseline prevalence audit and nurse’sknowledge and skills analysis was undertaken. This article willillustrate the findings of the borough wide prevalence study.

Audit MethodologyPrior to commencing this study, approval was sought from theLocal Research and Ethics Committee. Each care providerwithin the district was then sent an explanatory letter detailingthe strategy aims and prevalence questionnaires. Thisquestionnaire was completed for each patient requiring activetreatment for leg ulceration during the period of weekcommencing March 9th 1998. Questionnaires were distributedto all clinical areas across the District.

Data AnalysisThe information was entered into a standard databaseprogramme and analysed using SPSS-pc.

Initially, the age specific ascertainment of patients sufferingfrom leg ulceration was compared with the catchmentpopulation of the trust. Comparisons between sexes, and ethnicgroups was performed, using the mantel Haenszel procedurewith results expressed as odds ratios and 95% confidenceintervals. In addition, the number of pateints expected to presentwith leg ulceration from the Asian subcontinent was estimatedbased on the reported ascertainment from the white population.

ResultsResponse RatesThe response rates were encouraging ranging from 100% withinthe leg ulcer clinics, 95% within the District Nursing Services,91% from the independent sector, acute wards 68% and PracticeNurses 57%.

Patient DetailsIn all, there were 304 patients identified in this audit who werebeing treated within Walsall for a leg ulcer, giving a crudeascertainment of 1.17 patients per 1,000 population. Thebreakdown of ascertainment by sex and age is given in Table 1.Overall there were 116 men and 187 women suffering from legulceration, giving crude population prevalence of 0.91/1,000and 1.42/1,000 respectively.

As expected the leg ulcer rate was highly age specific, withmost patients presenting after the age of 65 years. The rate ofulceration was low in those under the age of 55 years being just0.19/1,000 in men and 0.12/1,000 in women. However in theoldest age group (>85 years) this increased to 30.77/1,000 inmen and 18.77/1,000 in women. This implies that 3% of menand 1.9% of women over the age of 85 suffer from a current legulcer. Despite these differences, adjustment for age using theMantel Haenszel test indicated that the leg ulcer rates weresimilar between the sexes (Odds ratio = 1.00, p = 0.96).

Table I. Comparison of leg ulcer rates between men and women inWalsallMEN

cases population rate/1000

0-54 19 97709 0.19

55-64 19 14412 1.32

65-74 24 10140 2.37

75-84 34 4380 7.76

85+ 20 650 30.77

TOTAL 116 127291 0.91

WOMEN


0-54 11 95352 0.12

55-64 13 14464 0.90

65-74 41 12450 3.29

75-84 81 7747 10.46

85+ 41 2184 18.77

TOTAL 187 132197 1.42

TOTAL POPULATION

304 259488 1.17

Patient Details by Health Care ProviderThe majority of patients with leg ulceration in Walsall (76%)are currently being treated by district nurses (DN) within theirown homes. These figures reflect the findings of Cornwall et al(1986) where 80% of patients with leg ulceration were found tobe treated entirely by the primary health care team. The legulcer clinics (LUC) within Walsall catered for a small number(32), however all patients who attended a clinic had a Dopplermeasurement of Ankle Brachial Pressure (ABPI) performed,and 83% of those treated by the district nursing service hadDoppler measurements. In some cases, justification was givenfor not performing Doppler ultrasound such as grosslyoedematous legs or patient refusal. Other sources of patientascertainment indicated that Dopplers were not routinelyperformed in patients, the lowest rate in patients being treatedby practice nurses (PN), and those patients being seen on a ward(25%). In these patients respectively, A.B.P.I. measurements hadbeen performed by the Community Tissue Viability Nurse andthe Acute Trust Tissue Viability Nurse. The Dopplermeasurement also allowed for more certainty about the cause ofthe ulceration. All patients being seen in the leg ulcer clinicshad a diagnosis of their ulceration whilst in patients beingtreated by district nurses 22/257 (9%) limbs did not have acause for the ulceration. As expected the most frequentdiagnosis was venous ulceration (52%), although there was aproportion of patients who were suffering from either arterial(17%) or mixed venous/arterial (7%) ulceration.

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Recurrent ulceration was a problem for all providers of care,except district nurses, where almost 50% of their patients withulceration were first time ulceration.

Use of Health Care Resources:use of topical agents and dressingsThe audit also provided us with information on the frequency oftopical agents and dressings used on the ulcerated limbs. Therewas a high use of Iodine based products and hydrocolloids inpatients being treated by district nurses. However, in the legulcer clinic a low adherent dressing was the most frequentlyused primary dressing. In all there were 39 different topicalagents/dressings used by district nurses compared with 10 inpatients attending the leg ulcer clinics. The majority of topicalproducts in use were newer generation treatments with evidenceto support their use. These treatments promote a warm moistenvironment at the wound interface to provide optimumhealing. (Winter 1962).

Comparison of ascertainment rates inWhite and Asian PopulationsIn addition to the evaluation of clinical practice, informationwas also provided on the ethnic group of each patient. Aprevious study in Ealing, West London had shown that patientsfrom the Indian subcontinent (South Asians) appeared to presentfor treatment of leg ulceration less frequently than the whitepopulation in the same area (Franks et al 1997). The expectednumbers of South Asian patients based on the white populationpresentation rates, indicated that there should have been 23South Asians presenting for treatment of whom 13 should havebeen women. In the study just five South Asian patientspresented for treatment of their leg ulceration, all of whom weremale. Since Walsall has a high proportion of ethnic minorities inits population it was decided to examine whether this effect wasnoted in this population. Using the leg ulcer rates in the whitepopulation it was anticipated that we would have expectedseven South Asian patients. In fact, four patients presented fortreatment. There were fewer men than expected (one versusfour), giving odds ratio of 4.49. However, due to these smallnumbers the confidence intervals were wide, and did notapproach statistical significance (p=0.18). Table II. In womenwe expected to have three women presenting for treatment, andthis was the number found. Table III. Combining the sexes wehad fewer South Asians presenting than expected, although theascertainment rates indicating that 1.84 times more whites thanSouth Asians were presenting for treatment. However, theconfidence intervals were wide and again did not achievestatistical significance (p=0.32).

Table II. Comparison between rates in white and Asian menWHITE


0-54 17 86420 0.20

55-64 19 13542 1.40

65-74 24 9808 2.45

75-84 34 4313 7.88

85+ 20 625 32.00

ASIAN

cases population rate/1000 expected

0-54 1 9084 0.11 1.82

55-64 0 656 0.0 0.92

65-74 0 238 0.0 0.58

75-84 0 44 0.0 0.35

85+ 0 22 0.0 0.70

TOTAL 1 4.37

Table III. Comparison of ulcer rates in white and Asian womenWHITE


0-54 9 84179 0.11

55-64 13 13773 0.94

65-74 39 12181 3.20

75-84 81 7683 10.54

85+ 41 2164 18.95

ASIAN

cases population rate/1000 expected

0-54 2 8890 0.22 0.98

55-64 0 517 0.0 0.49

65-74 1 196 5.10 0.63

75-84 0 47 0.0 0.50

85+ 0 17 0.0 0.32

TOTAL 3 2.92

Odds ratio=0.98, 95% confidence Intervals (0.90 to 1.08)Chi squared=0.11 (4df), p=0.75

OVERALL (women and men combined)expected numbers=7.29 seen=4Odds ratio=1.84, 95% confidence Intervals (0.56 to 6.04)Chi squared=1.01 (9df), p=0.32

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DiscussionThis study provided us with specific information on leg ulceraetiology, patients age, sex, ethnic origin, place of treatment,duration of ulcer, ulcer recurrence, assessment criteria andcurrent practice. It has shown that the majority of patients arebeing seen by district nurses in their own homes. The results ofthis study suggest that patients receiving treatment within thecommunity leg ulcer clinics receive the most comprehensiveassessment with 100% having Doppler measurements.

The results of this study confirmed that there are differentapproaches to leg ulcer assessment and treatments across thedistrict and that certain clinical areas may benefit from trainingprogrammes in the assessment and management of patientssuffering from leg ulceration.

Whilst there was some evidence of a lower presentation rate inSouth Asians in Walsall, this effect was much less dramatic thanthe evidence from Ealing. Further assessment needs to beundertaken within the ethnic minority groups to establishwhether patients do have a ‘true’ low prevalence of legulceration, are reluctant to present for treatment or whetherservices are not sensitive to minority ethnic groups needs?

This initial study has provided invaluable information in orderto base the development of a District wide strategy and it isenvisaged that the development of District Clinical Guidelinesand effective referral pathways for leg ulceration will result in atrue partnership between primary and secondary care andquality care provision for patients.

ReferencesCallum M J, Ruckley C V, Harper D R, Dale J J (1985)Chronic ulceration of the leg, extent of the problem and provisionof careBritish Medical Journal 290, 1855

Cornwall JV, Dore CJ, Lewis JD, (1986)Leg ulcers: epidemiology and aetiologyBritish Journal of Surgery 73: 693-6

Franks P J, Morton N, Cambell A, Moffatt C, (1997)Leg ulceration and ethnicity: a study in West LondonPublic Health 111, 327-29

Laing W (1992)Chronic Venous Ulcers of the LegOffice of Health Economics, London

Winter GD (1962)Formation of the scab and the rate of epithelialisation ofsuperficial wounds in the skin of the domestic pigNature 193, 293

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The Leg Ulcer Forum

(Ireland Branch)

A Multi-faceted Approach toLeg Ulcer Management

The Corrib Great Southern Hotel in the picturesque cityof Galway was the setting for the 2nd AnnualConference held by the Ireland Branch of the Leg Ulcer

Forum. On Friday 11th June 1999, more than 80 delegatesgathered from all over the South as well as the North of Irelandto participate in this one day event. As the title suggests theconference did offer a multifarious insight into the managementof leg ulceration.

Speakers included Mr Mark Collier from the Centre forResearch and Implementation of Clinical Practice whodelivered a very comprehensible overview of the WoundHealing Process and in doing so managed to incorporatehumour into it. As anyone who has ever presented on thissubject will know this is no mean feat!

Dr James Kelly (Consultant Geriatrician, Erne Hospital, Co.Fermanagh) took on the daunting task of presenting WhichDressing/Which Wound? This session, which was illustratedwith case studies, provided practical non-biased information onan aspect of wound care which is being added to at such a ratethat we all struggle to keep up.

Professor Christine Moffatt, also from the Centre for Researchand Implementation of Clinical Practice, took the podium ontwo occasions in the conference. The reason for which becameabundantly clear as she spoke. In her first session ProfessorMoffatt gave a pragmatic presentation on Vascular Assessment,incorporating issues such as the use of Doppler Ultrasound andCompression therapy. In her second session, Professor Moffatthighlighted the Social and Psychological problems of clientswhich can be encountered in Leg Ulcer Management. This wasfollowed by the presentation of case studies involving clientswith Fictitious Wounds and an insight into their management.

Mr Martin Feeley (Vascular Consultant, Dublin) created manylight moments with his witty but informative presentation onLeg Ulcers of other Aetiologies.

Mrs Mary Waddell (Director of Nursing, Eastern Health &Social Services Board and Chairperson of the C.R.E.S.T.Wound management Group) discussed the newly launchedGuidelines for Wound Management in Northern Ireland. MrsWaddell emphasised the need for a structured approach to theassessment and management of patients with wounds. This

inspiring presentation created a great deal of interest fromdelegates, who like all of us are looking for recommendationsfor best practice that are, as far as possible, research based.

Bernadette Corrigan (Ward Sister, St. Vincent's Hospital,Dublin) presented The Legal Issues. A few hair-raising legalcases were discussed, indirectly reinforcing Mrs Waddell'spresentation Why Guidelines?

This Conference provided a comprehensive insight into theholistic management of clients with Leg Ulceration. Thefeedback from the conference was very positive; indeed manydelegates appeared as though they did not want to leave, staying45 minutes or more afterwards chatting to speakers. Thisenthusiasm on a Friday afternoon was quite extraordinary andoverwhelming.

The success of this conference was a combination of manyfactors, namely:

• the professional and efficient manner in which theconference was run, the credit of which is due to theorganisers of the event, Mrs Pauline Diamond and MrsLillian Bradley,

• the high calibre of guest speakers and the remarkable way inwhich they delivered their presentations,

• the courteous and professional manner in which the CorribGreat Southern Hotel catered for all guests and delegates ofthe conference,

• and last but by no means least, the ardent participation of alldelegates which made the conference seem very worthwhile.

The management of leg ulceration as we know can be a verycomplex and demanding task for many Health Careprofessionals. Therefore it is important for us to have theopportunity to gain education and support from an organisationlike the Leg Ulcer Forum; the fact that it is now on our doorstephas limitless benefits.

The Leg Ulcer Forum (Ireland Branch) Annual conference isone that I will not miss in the future!

Fionnuala LynchTissue Viability NurseDown Lisburn Trust, Northern Ireland

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Lilian Bradley (Mrs)Member of the Leg Ulcer Forum Executive

Prior to 1996 most Leg Ulcer Clinics were based in theAcute Sector. These, by their very nature, could see onlya small proportion of leg ulcer sufferers and not on a

regular basis. Patients were discharged into the care of thePrimary Health Care Team who often did not have the necessaryskill or expertise.

Certainly this was the finding of an Audit conducted in UlsterCommunity and Hospitals HSS Trust in 1995. This Trustsubsequently funded two nurses to attend the then CharingCross short course on Leg Ulcer Management. Enter ProfessorChristine Moffatt, who encouraged those nurses to pursue thedevelopment of nurse-led leg ulcer Clinics in Community.

Two nurses then successfully completed the ENB N18 inProfessional Development in Leg Ulcer Management andshared their knowledge with colleagues.

A Pilot Clinic within the Trust demonstrating improved healingrates encouraged Trust management to appoint a Leg UlcerAdvisor with a remit to educate staff and develop clinics in allmajor towns within the Trust.

In October 1996 Christine Moffatt, accompanied by LynfaEdwards, conducted the first 3-day Short Course in NorthernIreland. This was repeated in February 1997, drawing nursesfrom across the province. A similar 3-day course was developedlocally, and has now been accredited by The Queen's Universityof Belfast at Level II, and negotiations are under way to developa course at Level III.

Other Community Trusts have appointed Leg Ulcer Advisors orTissue Viability Nurses, and other In-Service EducationConsortia have also developed, or are developing courses.Throughout all of this, Vascular Consultants, Dermatologistsand Podiatrists have offered the support so necessary for aneffective nuclear service.

The Inaugural meeting of the Leg Ulcer Forum – IrelandBranch was held in Belfast’s prestigious Waterfront Hall in May1998, and in June of this year the Forum met in Galway – theoyster capital of Ireland.

At next year’s Conference the Management of Complex LegUlcers will be addressed, including the Rheumatoid patient,Diabetic foot ulcers and Dermatological issues. This will beheld on 19th May 2000 in the historic City of Londonderry.

The publication of the CREST Wound Management Guidelines,incorporating Leg Ulcer Guidelines, is promoting evidence-based practice in the Province. Recently two RegionalFacilitators were appointed to encourage implementation of theGuidelines.

There is no doubt that leg ulcer management in particular, andwound management in general, is high on the agenda within theProvince, and this can only be good news for users of the service.

The development of Leg Ulcer Services in the Republic ofIreland will feature in the next edition of the Journal.

Developing Leg Ulcer Services

in Northern Ireland

16


The Society of

Vascular Nurses (UK)

The Sociey of Vascular Nurses, founded in 1993, isdelighted to become an affiliated group to the Leg UlcerForum, and recognise that we both share areas of

nursing focus.

The SVN is run by nurses for nurses and other health careprofessionals working in this speciality. This year our individualmembership has reached nearly 2000 with representation frommost areas of the UK. Ward membership is also available. Ouraims are:

• to promote a national network of vascular nurses throughnewsletters, conferences and the facilitation of regionalgroups,

• to collaborate with other national and internationalprofessional associations who share concern and interest forpeople with vascular disease,

• to provide a forum to advance the education of nursesinvolved in the care of patients with vascular disease,

• to encourage members to be pro-active in the development ofvascular nursing,

• to support developments in vascular nursing research,

• to encourage members to be active within the fields ofHealth Education and Health Promotion for people withvascular disease.

The Society creates a forum for education and debate on vascularnursing issues and creates an opportunity for the members to shareexperiences beyond their own locality and to provide support.A quarterly newsletter is produced which includes book andliterature reviews, educational updates and study day information,in addition to providing a communication tool for members.

The SVN has developed regional groups which provide forumsfor members to meet locally. Group activity for 1998/99 hasbeen somewhat reduced due to the increasing pressures in theworkplace that most nurses have experienced, especially duringwinter crisis months.

Most groups run full or half study days where members set theirown nursing-focussed agendas and invite guest speakers.Discussion and debate forms a key part of these meetings sothat all members can become fully involved. These meetingsprovide a more frequent educational forum in addition to ourannual national conference.

A group of Vascular Nurse Specialists was established in May1997 in response to the growing number of nurses in theseposts. This group provides a very informal opportunity for thesespecialist nurses to share developments and practices of care.The group now has forty-eight members and meets quarterly.Vascular Nurses can often work in isolation and their role canvary hugely. The greatest value of this group is the mutualsupport members are able to provide each other as they developtheir roles to enhance nursing practice.

The SVN provides a bursary of up to £200 for membersundertaking any educational pursuit specifically related to theadvancement of vascular care. Successful applicants arerequired to share their new knowledge with members throughconference presentations and newsletter articles. Recentbursaries have been awarded to enable members to reviewintegrated care pathways in specialist centres and to attendnational and international conferences.

This year the society aims to:

• recruit members from Northern Ireland

• review its affiliation to the RCN

• develop links with the Society for Vascular Nursing in America.We have been invited to become an “international chapter”

• develop association with the British Vascular Foundation(charity) supported by the Department of Health.

The SVN hopes that members of the Leg Ulcer Forum can jointhem at their conference (Autumn 2000), and look forward todeveloping a productive working relationship with you.

• • • • •

If anyone is interested in joining one of our regional or nursespecialist groups, please contact Carolyn for further details on01793 426974.

If you wish to become a committee member (you must be amember of the SVN), please contact Carolyn for a nominationform.

Carolyn NoctonChairperson, SVN

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Design an educational leaflet

Competition ResultsWe had a great response to this competition and as you can seethe entries were of a high standard. This made the the judges jobvery difficult to pick an outright winner.

1 2 3

4 5 6

7 8 9

10 11 12

The winner, designed by Jane Cave

1 Sharon Minnis

2 Teresa O’Connor

3 Joan Lynch

4-8 Janette Pilditch

9-12 Steve Hawkin

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Education Courses in Wound Care

The Centre for Research and Implementation ofClinical Practice (CRICP) of which ProfessorChristine Moffatt is Director, is experienced inrunning educational programmes designed for arange of health care professionals from differentsettings. Details of the courses currently offeredby the Centre in partnership with the WolfsonInstitute of Health Sciences, Thames Valley Uni-versity, are as follows:

Leg Ulcer Management

ENB N18 – Professional Development in theManagement of Leg Ulcers

Course dates: January 2000at the Royal Berkshire Hospital, Reading

March and June 2000at Wolfson Institute of Health Sciences, Ealing

Master Class - Leg Ulceration – Complex CaseScenarios

Dates: 18 November 1999, 11 May 2000, 27 July 2000at Wolfson Institute of Health Sciences, Ealing

24 February, 2000at the Royal Berkshire Hospital, Reading

Pressure Sores

ENB N36 – Professional Development in thePrevention and Management of Pressure Sores

Course dates: February 2000

Master Class – Pressure Sores – Professional andEthical Dilemmas

Dates: 14 March 2000

Study days

Dates: 19 January 2000

Tissue Viability and Wound Management

ENB N49

Course dates: January and June 2000at Wolfson Institute of Health Sciences, Ealing

March 2000at Royal Berkshire Hospital, Reading

Master Class – Wound Healing – The State of the Art

Dates: 18 January 2000, 13 June 2000at Wolfson Institute of Health Sciences, Ealing

27 March 2000at Royal Berkshire Hospital, Reading

Study Days

Dates: 16 February 2000

Tissue Viability Modules by Flexibleand Distance Learning

Three packages by leading clinical experts – Access to ClinicalEducation – have been produced and published by ChurchillLivingstone. These are:

Leg Ulcers

Pressure Sores

Wound Management

Further details

Further details of the above courses can be obtained from:

The Centre for Research and Implementationof Clinical Practice

Wolfson Institute of Health Sciences

32-38 Uxbridge Road

London W5 2BS

Tel: 0181 280 5020

Courses • Courses • Courses • Courses

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Conferences • Conferences • Conferences

Leg Ulcer Forum14th Meeting

Complex Issues – Practical Solutions

3rd December 1999Hammersmith and Fulham Irish Centre

Black Road, Hammersmith, London W6 9DT

Topics to include

• Pyoderma Gangrenosum • Vasculitis• Mixed Aetiology Leg Ulcers • Practical Workshops

Cost £45 (includes lunch and coffee)

For further details, contact Rene White at CRICP on 0181 280 5020

Articles for LUF journal

Would you like to share professional information or news with your colleagues about events, meetings or functions? Thensend details to Lynfa Edwards, CRICP, (address below). If you would like to include any articles, service news or items ofinterest for future publication in the LUF journal, please send a hard copy and disc copy (saved as text only) by 1 March forthe summer edition or 31 August for the winter edition.

The Centre for Research and Implementation of Clinical Practice

Wolfson Institute Of Health Sciences

32-38 Uxbridge Road

London W5 2BS

Supporting the professionals

Providing a forum for nurses working within the field ofleg ulcer management and wound care

•Facilitating discussion, debate and reflective practice in

which all members are encouraged to participate

•Disseminating new research and identifying and

supporting areas of good practice

•Providing support to specialist nurses involved in

establishing leg ulcer services

•Encouraging continuous professional development

THE LEG ULCER FORUMCentre for Research and Implementation of Clinical Practice

Thames Valley University, Westell House, Uxbridge Road, Ealing W5

Issue 12 Winter 1999 CLINIC - Leg Ulcer Forum · 2000. 7. 27. · Tissue Viability Nurse...

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