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Leg Ulcer Best Practice Statement

This recent document provides the most up-to-date guidance on caring for the estimated 731,000 leg ulcer patients in the UK.

Written by an expert panel to:

  • meet the needs of UK clinicians and patients
  • promote consistent best practice via a clear treatment pathway
  • include assessment, diagnosis, management and prevention of recurrence
  • challenge the myths which underpin ritualistic practice

Download document

Leg ulcer treatment algorithm

The Best Practice Statement highlights that compression is an integral component of VLU management. The document presents an algorithm to underpin decision making which supports self-care solutions when appropriate. Our product solutions have been inserted to the algorithm below to show you how you can implement the generic algorithm in the document.

Download algorithm

Myths & truths

NHS reforms and the extent of the problem of venous leg ulcers, made the panel challenge the myths that underpin ritualistic practice.

Can you match the Myths with the Truths identified in the Best Practice Statement?

Show myths & truths

Myth

A wound must be present on the limb for at least 6 weeks to be classed as a leg ulcer and therefore treated with compression.

Truth

The definition adopted by the BPS panel indicates that if the wound has been present for over 2 weeks, the patient should be assessed for suitability of compression. Immediate treatment of a lower limb wound with compression where appropriate, particularly if venous signs are present, will prevent ulcer development and reduce burden to the patient and to healthcare delivery.

Myth

ABPI assessment confirms the presence of a VLU.

Truth

Whilst a fundamental component of assessment, ABPI assessment will not diagnosis venous disease — it will only exclude the presence of significant arterial disease — and is only a component of a full holistic assessment.

Myth

If a wound is healing, the surrounding skin does not require management.

Truth

Outcomes associated with compression will be improved if surrounding skin is managed effectively (including safe removal of hyperkeratosis).

Myth

Superabsorbent dressings cannot be used under compression and should be used over compression if required.

Truth

Superabsorbent dressings can be used under compression if the product effectively contains exudate to prevent maceration. They should not be used over compression, as sub—bandage materials and bandages soaked in exudate could result in further damage of surrounding tissues.

Myth

Compression should be stopped if the patient has cellulitis.

Truth

Compression treatment should be continued as long as the patient’s pain levels allow this. In the case of cellulitis, compression can help to prevent further lymphatic damage.

Myth

If a wound is small, then it will not benefit from compression during the healing process.

Truth

The decision to use compression is based upon clinical suitability for compression rather than the size of the wound. Regardless of size, venous leg ulcers require compression.

Myth

Reduced compression is therapeutic for VLUs.

Truth

While some compression is better than none, clinicians should always aim to use full compression systems when the vascular assessment deems it appropriate to do so, in order to prevent delays in healing through use of sub—therapeutic compression.

Myth

Inelastic bandages are not suitable for immobile patients.

Truth

Inelastic bandages can be used on both mobile and immobile patients, as fluctuations in pressure can be achieved even with small or passive movements to facilitate venous return.

Myth

Hosiery kits are only for self—caring patients.

Truth

Hosiery kits can be applied by the patient, carer or healthcare professional. In each of these scenarios use of a hosiery kit facilitates time efficient care delivery as well as potential quality of life improvements.

Myth

The compression system used determines the frequency of reapplication required.

Truth

The decision as to how frequently the limb needs to be reviewed should not depend on the compression system, rather the patient and the presentation. TMES principles should be considered in decision making, as factors such as tissue condition, presence of biofilm, potential for oedema reduction and surrounding skin condition should all be taken into account. Lifestyle factors should also be considered where possible, utilising selfcare solutions to enable frequency of change and improve quality of life.

Myth

Compression should not be applied to the foot.

Truth

Moderate to high compression must be applied to the foot to prevent foot oedema where there is little compression to the foot, the high compression to the gaiter region can create an oedematous foot and toes, thereby causing additional issues. The use of toe garments is recommended to aid oedema reduction.

Myth

Venous leg ulcers are not painful.

Truth

In a study examining pain in venous leg ulcers, a high proportion (64%) patients with ulcers of purely venous aetiology reported severe pain (Hofman et a1, 1997). The presence of severe pain does not necessarily indicate arterial disease or infection.

Wound and skin management

The TIME* acronym was developed as a quick and effective way to assess wounds and to promote the principles of wound bed preparation to stimulate wound healing.



The expert panel have added an ‘S’ to recognise the importance of the surrounding skin.



Debrisoft supports positive outcomes in each aspect of wound bed preparation, which is an integral part of every dressing change.

*EWMA 2004; Stephen Haynes 2007

The following table will help you apply the TIMES framework using our product solutions

Tissue, non-viable or deficient

The overall appearance of the wound bed indicates the ‘health’ of the tissue within the wound bed.

Devitalised tissue provides an ideal environment for microbial growth and, in most cases, should be removed to expedite healing.

Key actions:

  • Mechanical debridement (e.g. Debrisoft®) is recommended
  • Use a moisture-donating dressing (e.g. ActiFormCool®) to soften remaining devitalised tissue (if needed) between dressing changes

Infection, inflammation or biofilm

Wounds contain bacteria, which may proliferate and cause infection — delaying healing, and increasing pain, exudate and malodour.

Even where infection is not apparent, healing may also be impeded by the presence of biofilm.

Key actions:

  • Mechanically disrupt biofilm (e.g. by using Debrisoft) to break it up and allow antimicrobials to work
  • After disruption, use an antimicrobial dressing (e.g. Suprasorb® X+PHMB) for 2 weeks, then review

Moisture imbalance

Exudate is a normal part of wound healing, and drying out can impede the healing process.

High levels of moisture (often containing harmful proteases) can break down new wound tissue and macerate periwound skin.

Key actions:

  • Dry wound: Mechanically debride to remove loose dry skin; then hydrate with a moisture-donating dressing (e.g. ActiFormCool)
  • High exudate levels: Mechanically debride to reduce the body’s automatic response to produce moisture; then select an absorbent dressing that retains exudate effectively (e.g. Flivasorb®)

Edge of wound: non-advancing, undermining

Lack of new, healthy tissue at the wound edges, or the presence of rolled edges, indicate wound healing is not progressing normally.

Key actions:

  • Mechanically debride (e.g. Debrisoft) encrusted exudate at wound edges to remove local barriers to healing
  • Assess why the edge is not progressing — consider biofilm management (see I) or referral for biopsy
  • Protect delicate edge tissue(e.g. dressing with Lomatuell® Pro)

Surrounding skin

The wound management strategy may effect the surrounding skin — the condition of which can, in turn, affect the wound healing process.

Key actions:

  • Address the causes of skin issues » Manage hyperkeratosis/dry skin/ eczema/oedema/skin damage
  • Mechanically debride hyperkeratosis (e.g. using Debrisoft)
  • Protect the skin from further damage in line with best practice and local formulary guidelines
  • Encourage self-care

Download TIMES quick guide

Meet the panel

Best Practice Statement for the holistic management of venous leg ulcers panel
  • Expert working group
    • Chair: Jacqui Fletcher Independent Consultant
    • Leanne Atkin
      Lecturer practitioner/Vascular Nurse Specialist, School of Human and Health Sciences, University of Huddersfield and Mid Yorkshire NHS TrustCaroline Dowsett, Nurse Consultant, Tissue Viability, East London Foundation Trust, London
    • Alison Hopkins
      Chief Executive, Accelerate CIC, London
    • Joy Tickle
      Tissue Viability Nurse Specialist, Shropshire Community Health NHS Trust
    • Fran Worboys
      Clinical Director, Accelerate CIC, London
    • Anne Williams
      Lecturer in Nursing, Queen Margaret University, Edinburgh, and Lymphoedema Nurse, The Haven Centres, Lanarkshire
  • Review panel
    • Una Adderley
      Lecturer in Community Nursing, School of Healthcare, Faculty of Medicine and Health, University of Leeds
    • Emma Bond
      Vascular Clinical Nurse Specialist, Glan Clwyd Hospital, North Wales
    • Jackie Stephen-Haynes
      Professor in Tissue Viability, Birmingham City University, and Consultant Nurse, Worcestershire Health and Care NHS Trust
    • Chris Taylor
      Vascular Clinical Nurse Specialist, Lancashire Teaching Hospitals NHS Foundation Trust

Watch the launch videos of the UK Best Practice Statement for Holistic Management of Venous leg Ulceration

 
Jacqui Fletcher
 
Caroline Dowsett
 
Alison Hopkins
 
Leanne Atkin
Event

NEW FOR 2017 Leg Ulcers: Right Care, Right Time - Mercure Grand Bristol

Find out more and book
Event

Best Practice in the Management of Venous Leg Ulcers, Winchester

Find out more and book

Recommended e-learning modules

Leg ulcers

Causes and symptoms of leg ulcers, their treatment and management.

Two-layer hosiery kits

Two-layer hosiery kits: an effective alternative to compression bandaging for venous leg ulceration.

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