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Making better use of nurses' time: leg ulcers

Implementing effective treatment for leg ulcers at Nunwell Surgery, Bromyard, Herefordshire
Why was the initiative launched?
What was done?
Did it work?
Impact on nurses
Impact on patients
Impact on GPs
Tips for success
For more information contact a member of the team

Why was the initiative launched?

In 1997 one of the District Nursing team working with the Nunwell Surgery was working on her conversion course from EN to RGN. She chose to investigate the management of leg ulcers as one of the assignments for her course. Apart from looking at the current arrangements for managing patients locally she assembled evidence about effective treatments. Her conclusion was that although the use of compression bandaging was a proven technique the management locally of venous leg ulcers was haphazard and ineffective. Ways needed to be found to improve quality of care.

What was done?

Discussing the results persuaded the practice team that something had to be done to improve the situation. The four district nurses from the community Trust who worked with the practice agreed to take part in an initiative. Work was put in hand to tackle four tasks.

First, to develop a local protocol to guide the nurses in the assessment of leg ulcers. Based on the available evidence this was designed to ensure that nurses could distinguish between venous and arterial ulcers. The objective was to treat venous ulcers within the practice and ensure that arterial ulcers were referred swiftly to the local Consultant Vascular Surgeon.

Second, to select a small pilot group of patients. The challenge was not only to identify the patients who it appeared would benefit from the use of compression bandaging but also to persuade them to take part. Care had to be taken to balance the long term benefits, increasing mobility and getting rid of the smell, against the short term discomfort and possible additional pain from the compression treatment. Not all patients were keen to take part: many had got used to their ulcers. Eight patients agreed to take part.

Third, arrangements for suitable training for the four district nurses. This was difficult because training funds were scarce. The practice agreed the practical way froward was to accept offers from two pharmaceutical representatives to cover the costs of two types of study days. One was concerned with ensuring that the nurses had the skills to undertake proper assessments using Doppler equipment. The other was to ensure that nurses had the skills to apply compression bandaging. These sessions were effective in developing the skills of the district nurses.

Fourth, ways had to be found to cover the short term costs of additional multi-layer compression bandaging which at the time could not be prescribed but was available on the FP10. The practice agreed to fund the initial costs from savings on the fundholding budget. Subsequent changes allow compression bandaging to be prescribed.

Did it work?

After their training the four district nurses started to apply their new skills in April 1998. A thorough assessment of the patients was undertaken which in addition to the necessary Doppler investigation included photographing and tracing the ulcer to determine its size. Very soon the success of their work became apparent: ulcers were healing and the nurses' precious time was being saved. With hindsight the practice recognised that they could have done more to lay plans to measure the benefits of the work. Nevertheless the impact of the work was visible to patients, nurses, and general practitioners. This success was acknowledged when the practice was awarded Beacon status in 1999.

Impact on nurses

Before the initiative was launched individual nurses would be spending time changing dressings daily, perhaps up to two hours per patient per week. This old fashioned treatment was costing between £30 and £40 per patient, depending on the materials used (Table 1). The initiative reduced this to seeing patients weekly for about half an hour. The costs of the evidence-based approach are about £13 per patient per week (time and materials). The time saving has allowed the development of new services including an asthma clinic. The success persuaded the practice nurses to get involved and additional study days were laid on to help them build up their skills. The initiative had a positive effect on the morale of nurses working in the practice.

Table 1: Nunwell Surgery: broad comparative costs (£) for treatment of leg ulcers

  Old Method 1 Old Method 2 New Method
  Iodine plus dressings Ointment plus dressings Evidence-based compression
Dressings and materials 11.00 19.90 8.25
Labour costs 20.00 20.00 5.00
Total costs 31.00 39.90 13.25

Impact on patients

Patients are increasingly pleased with their progress. Between January 1998 and May 2000, about 50 patients have been treated. Many of these had suffered with ulcers for many years or had more that one ulcer. Three quarters of these have been healed and on-going care is currently being provided for 13 patients with most of these progressing towards healing. Some of the ulcers took well over a year to heal, but many others were healed within six weeks (Figure 1). One patient, a man in his '50s had suffered with ulcers for over 20 years applying his own dressings. He had been reluctant to seek treatment for an 'old ladies' complaint. Following the intervention of a friend, an assessment confirmed the presence of venous ulcers and treatment was started. The ulcers quickly became less painful and one ulcer has healed and the other virtually healed.

Figure 1: Healing times for patients with venous leg ulcers


Impact on GPs

Nurses have undertaken the bulk of the work involved in the initiative but the work has had a significant impact on GPs. Compared with attitudes before the work started, there is now a real sense that something can be done for these patients. The initiative also had a noticeable effect on relations with the local hospital. The Consultant Vascular Surgeon has complemented the practice because he is now getting the right patients, those who needed his attention.

Two problems remain. A few patients cannot handle compression therapy. Two patients refused to carry on, one because it was too painful, the other because it was taking too long. It requires stamina and can take many months to heal a large ulcer and patience is required. It is proving difficult to maintain continuity of treatment for the ulcer when patents are admitted to hospital for other conditions. Nursing staff in hospital may not have the skills and support to allow them to apply the same treatment regime. Discussions are in hand to seek ways to tackle this situation

Tips for success

√ Good teamwork is essential for effective care with clear recognition about relative roles. Don't try to increase nursing responsibilities unless they and GPs have confidence in the proposed approach.
√ Take time and patience to explain the benefits to patients but don't gloss over the inevitable pain they will have to endure as compression takes effect.
√ Basic skills in assessment and the application of compression bandaging are essential. Find practical ways to enable nurses to build up their skills.
√ Improving the quality of primary care can improve also relationships between primary and secondary care.
√ Make plans before you launch initiatives to decide how you will measure success

For more information contact a member of the team

Olive Hadley, Co-ordinator
Mandy Taylor, Practice Nurse
Dr Kevin Ilsley, General Practitioner
Nunwell Surgery, 10 Pump Street
Bromyard HR7 4BZ

Telephone 01885 483412 Fax 01885 488739

The following material is available

Training notes: management of leg ulcers in primary care using compression therapy

ImpAct bottom line

Significant timesavings for hard pressed nursing staff can be an important spin off from the implementation of effective treatments


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