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Venous Leg Ulcers – a Life Changing Affliction

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On my recent return to practice placement I became aware that there has been a significant change to the way that leg ulcers are treated and so I decided to further investigate this health problem and its implications to nursing, the patient and the NHS in general. The assignment will seek to examine the changes in the understanding and the treatment of venous leg ulcers and how the condition effects the quality of life of those suffering with the condition.

Following a time of being a full time mother, I joined a busy General Practice (GP) surgery as a Health Care Assistant (HCA). My previous health service employment was as a hospital based staff nurse. I have enjoyed working as a Health Care Assistant but at times feel frustrated that I am unable to use previous skills and knowledge. When I started working for the practice my duties were centred around phlebotomy. However during the five years that I have been at, the surgery many personnel roles and responsibilities have undergone considerable change. A recent analysis of the changes in General Practise (Kings Fund, May 2016) begin with the alarming words ‘General practice is in crisis’ and goes on to examine the many changes of a General Practices ‘new’ roles and responsibilities. A personal example being the phlebotomy service, in which I worked, has been outsourced and my job now includes many different functions, from assisting in minor surgery to stock control.

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My recent placement within a local community based nursing team has reinforced my commitment to GP or community based nursing. During the placement visits, I was surprised by the number of Venous leg ulcer care visits we routinely made, I estimated that over half of our patient contact time was spent helping people manage this life changing condition. Venous leg ulcers are described as open wounds which typically occur in the gaiter region i.e. ankle to mid-calf and are often shallow and irregular in shape with ill-defined edges they are often large (Primary Care Dermatology Society (PCDS), updated October 2017). The National Institute for Health and Care Excellence (NICE) define the Venus leg ulcer (para-phrased) as a wound on the leg below the knee, generally and to fit this category, it is caused by a shortage of blood to the lower leg, the blood pools in the veins which in turn can damage the skin and tissue leaving an open wound that unaided will not heal. The reduction in blood flow also makes healing almost impossible without on-going help (NICE, November 2015).

According to the Primary Care Dermatology Society (PCDS), an organisation developed to support General Practioners (GP’s) “Leg ulcers are of huge socio-economic importance costing the NHS over £1,000,000 per year. There are in excess of 100,000 active venous ulcers in the UK at any one time, 80% of these are receiving treatment that is community based. A leg ulcer is not a ‘diagnosis’ ; it is a manifestation of an underlying disease process and so the concept should be of the patient with the leg ulcer”. (PCDS, October 2016)

The standard recommended treatment for venous leg ulcers, according to NICE is the use of compression bandages. NICE’s description goes on to describe a potential 5 year treatment regime, an indication of how difficult it is to achieve a successful outcome within a short time frame (NICE, 2015). Harding K, et al. (2015) in the same year that NICE published their guidelines, critically suggested that we are being slow to adopt compression as the single most effective way to manage venous leg ulcers. Harding’s research reported in “Simplifying Venous Leg Ulcer Management” repeatedly makes the point that compression therapy is ‘known’ to significantly increase Venous leg ulcer healing rates and reduce recurrence. Harding believes that despite detailing evidence of the success of compression there are still a significant number of practitioners using the past ‘advanced wound dressings’ and other therapies Harding clearly believing that compression therapy, as the proven treatment is being “ignored and that this is completely detrimental to the best interest of the patient”. Upon reflection I have never heard it suggested that the patient should be given a choice in this condition, nor heard anyone suggesting possible alternate treatment.

Not everyone in the medical institutions of the UK appears to concur with Harding’s statement that “the cornerstone of treatment for venous leg ulcers is compression therapy”. The British Medical Journal (The BMJ, Tate S et al, 2nd May 2018) make the point that they agreed that compression dressings provides an important, valuable and vital resource and that Harding’s article does offers valuable sensible advice. However, Tate et al also adds that ‘heavy reliance on this single approach alone doesn’t address the underlying cause of the ulcer’, believing that treating the cause should ‘overshadow a narrow focus on dressings’. Barwell (2004) has previous stated that he had ‘proved that the surgical correction of superficial venous reflux reduced the likelihood of relapse from venous ulceration’. This was also supported this year (2018), by Gohel MS, who believes that there is “high-quality evidence” that if done promptly venous reflux surgical correction encourages faster healing and achieves longer ulcer free time than just using compression therapy.

The BMJ article (2nd May, 2018) came to the conclusion that “failing to recognise the importance of vascular referral, and focusing solely on local wound care, is an important reason that venous ulcers remain such a prevalent public health issue”. We will wait and see if this warning is heeded.

Whilst the venous leg wounds are unpleasant and clearly extremely painful for the patient it was also apparent that in most of the patients, with leg ulcers, that I came across, also appeared to be very withdrawn, down and despondent. A study “Lived experiences of life with a leg ulcer – a life in hell”. European Wound Management Association (EWMA, Journal 2017 vol. 17 no 1) surveyed a group of patients to determine how their quality of life had been affected since developing the ulcer. Responses included that they were “living a life of hell” and “would rather die than live … with a leg ulcer”.

The Royal College of Nursing (RCNi) published a paper on ‘How venous leg ulcers affects quality of life’ There was an agreement in the literature studied that Quality of Life is affected by every patient’s physical, psychological and social state (World Health Organization 1998, McKevitt et al 2003, Centres for Disease Control and Prevention 2011). Evidence presented by RCNi suggests that all these aspects can, individually or collectively, affect patients with Venus leg ulcers. Protocols have been formulated based on this evidence for community based nurses to guide wound management. However, it is admitted that guidance for practice in the psychological and social implications of supporting this group of patients is ‘limited’.

Amy Isaac and Christine Watson (March 2016) published a research project on How Venous Leg Ulcers Affect Quality of Life with the headlines:

  • “The lives of people with Venous Leg Ulcers are usually dominated by pain, in some cases so severe that the patients concerned have considered suicide”.
  • “Social isolation, altered body image, lack of sleep, fear, pain, frustration, exudate and malodour can all be associated with VLU, and all affect psychological wellbeing.”
  • “Patients often recognise those nurses who have advanced skills and knowledge, which inspires confidence in their treatment. Patients also find regular feedback and positive reinforcement to be supportive”.

Other literature searches confirmed my observations that low mood and depression are common in people with Venous leg ulcers (Byrne and Kelly 2010, Green et al 2013, Edwards et al 2014). The studies suggests a tangible link between patients who are not following their treatment plan of their self care and with the incidence of depression. It is no surprise mental awareness and mood improved with improvements to their health. Ironically improvement depends on compliance with health care instructions which is often only achieved with improvement. Mood improvement often goes hand in hand with healing, which in turn depends on compliance with treatment. (Finlayson et al 2010, Green et al 2013) Similar ‘catch 22’ situations occur regarding body image and unsightly bandages. Body image and clothing choices are particularly important to female patients with Venous Leg Ulcers, creating social isolating if the female is uncomfortable going out wearing clothing she believes necessary to disguise bandages. This also applies to wearing appropriate footwear.

Obviously perhaps but leaking bandages can also affect body image, especially if malodour exists. The unpredictable nature of exudate and malodour can cause distress, embarrassment, lack of self worth and anxiety. All these factors can lead to depression and social isolation. Worry or anxiety about damage or harm to affected areas is also common. Some individuals keep their legs padded to prevent trauma and tend to avoid events and environments, such as children’s parties and shopping in crowded places, where they may damage them. (Finlayson K, Edwards H, Courtney M (2011)).

The Health Awareness website attempted to raise awareness of the leg ulcer issue as the headline item on their webpage (December, 2016). The article “The growing burden of leg ulcers in the UK” reported that over four hundred thousand of the nearly three quarters of a million leg ulcers that the NHS treat every year were classified as unspecified. Is it just possible that patients aren’t being assessed thoroughly? Professor Peter Vowden, Honorary Professor of Wound Healing Research at the University of Bradford of is quoted as saying that “Assessments are technically challenging and take longer than the 10-minute appointment slot, so we either need to make more time, or find faster assessment methods.”

An article published on-line by the Queen’s Nursing Institute and written by Alison Hopkins, CEO of Accelerate CIC , wrote “are the changes in leg ulcer management affecting you?” (26th Jan, 2018). The question being asked with an almost certain response of “what changes?”. The author goes on to contrast the advances in most other areas of ill health, for example the progress made in treatment over the last twenty years in stroke, heart disease, diabetes, etc., where considerable advances have been made, contrasting to the progress in venous leg ulcer care which has seen little change in progress. The author felt this was “strange when we consider the average time spent on these patients by District/Community Nurses equals over forty percent of their entire working week”! This article was published on-line by the Queen’s Nursing Institute and primarily aimed at the general public, consequently there are no ‘peer citations’ but I believe that it makes a valid comment made by a respected medical body.

Cost-effective management and encouraging healing of Venus leg ulcers remains a challenging problem for the NHS. A recent study in the International Wound Journal reported that the annual cost of treatment and support for a patient with an ‘unhealed Venus leg ulcers was £13,500 compared to £3,000 for a healed Venus leg ulcers based on 2015/2016 prices’. The number of new Venus leg ulcers in the UK has been estimated to rise to 170,000 in 2017/18 and is predicted to cost the NHS an estimated £1⋅3 billion in the first 12 months from onset. This is additional cost over and above the costs published for 2015/16. (Guest et Al (2016))

I include for interest and comparison details of a study made in another West European country, so we may get insight as to whether a similar demographic population has found any way of improving the sufferers experience of the condition. A cross sectional study of patients with chronic leg ulcers was undertaken in Portugal by Cunha, Campos, and Cabete (2017) using an anonymised questionnaire. Portugal has a similar demographic to England. The study was aimed at examining the effect of quality of life for the victims suffering with venous leg ulcers. The study highlighted some results that are interesting but difficult in this instance to compare with the UK experience . Almost eighty percent of the Portuguese responders said they had to give up work, although without an age profile this is difficult to cross reference with the UK figures, fifty percent said that family relationships changed and fifteen percent reported that they hid their condition from others. Just under 20 percent said that their quality of life has been either ‘very‘ or ‘extremely’ affected. These results echoed a previous major study by Gonzalez-Consuegra R.V and Verdu J (2011) which collated the results of twenty two previous studies of the subject by using a cross section of questioning methods. They concluded that a venous ulcer has a negative impact on overall quality of life. Patients they saw, at home, were virtually house bound, many of them not entirely because of the physical nature of their condition but nearly all were ‘world weary’ with low self-esteem and apparent poor motivation.

The preceding pages illustrate that the progress in leg ulcer treatments has developed significantly and it appears that it is continuing to do so. Improvement can only increase sufferers quality of life. Helping nurses to treat leg ulcers more effectively will have also have a positive benefits to the NHS by reducing the amount of money spent on leg ulcers. As an illustration that we are living in a time of rapid medical technology advances, I refer to a news item originating from ‘Science Daily’ announcing the design of a colour-changing compression bandage that changes colour as the bandage is stretched. Using a colour chart the nurse/carer can stretch the bandage until it matches the colour of the desired pressure before wrapping it round the patients leg. (ScienceDaily. 29th May 2018)

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