Lower leg ulcer Audit Report October 2004

Description

West Gloucestershire Primary Care Trust Gloucestershire Primary & Community Care Audit Group Lower Leg Ulcer Audit Date October 2004 Contents Page Number Background 3 Doppler assessments 4 Audit of Lower leg ulcer management 4 Results 5 -20 Discusion 21 - 22 Appendices List of courses attended 23 Audit tool 24 - 25 2 Background Despite a prolific amount of research, education and improved treatment, leg ulcers remain a debilitating and painful condition. They affect about 1% of the British population and annually cost the NHS at least £300 million. Leg ulceration can be defined as: “Loss of skin below the knee, on the leg or foot, which has not healed within six weeks.” There is wide variation in practice, and evidence of unnecessary suffering and cost as a result of inadequate management. R. Cooper (2004) Leg ulcers: improving management The New Generalist Vol.2 No2 Leg ulcer disease is typically cyclical and chronic, with periods of complete healing followed by recurrence. Two thirds of patients with leg ulcers experience two or more recurrences. It is a major cause of morbidity and suffering and has a significant impact on health service costs. Although delivery of care varies, between 60 – 90% of patients are seen ...

Informations

• Publié par: Siom
• Nombre de lectures: 23
• Langue: English

Extrait

West Gloucestershire Primary Care Trust

Gloucestershire

Primary & Community Care Audit Group

Date October 2004

Lower Leg Ulcer Audit

2

Contents

Page Number

Background

3

Doppler assessments

4

Audit of Lower leg ulcer management

4

R

e

s

u

l

t

s

5

-

2

0

D

i

s

c

u

s

s

i

o

n

2

1

-

2

2

Appendices

List of courses attended

23

Audit tool

24 - 25

3

Background

Despite a prolific amount of research, education and improved treatment, leg ulcers remain a

debilitating and painful condition.

They affect about 1% of the British population and

annually cost the NHS at least £300 million.

Leg ulceration can be defined as: “Loss of skin below the knee, on the leg or foot, which has

not healed within six weeks.” There is wide variation in practice, and evidence of

unnecessary suffering and cost as a result of inadequate management. R. Cooper (2004)

Leg ulcers: improving management

The New Generalist

Vol.2 No2

Leg ulcer disease is typically cyclical and chronic, with periods of complete healing followed

by recurrence.

Two thirds of patients with leg ulcers experience two or more recurrences.

It

is a major cause of morbidity and suffering and has a significant impact on health service

costs.

Although delivery of care varies, between 60 – 90% of patients are seen in the

community by District Nurses, it is estimated that leg ulcer patients comprise between 8% -

22% of District Nurse caseloads. Bandolier (Dec. 1994) Leg ulcers, A review of research in

nursing management in the community.

Leg ulceration considerably affects quality of life, with patients experiencing, pain,

depression, anxiety, fear, social isolation and disruption to their daily and social activities.

Anand, S.C, Dean, C, Nettleton, R, Praburaj, D.V, (2003) Health related quality of life tools

for venous-ulcerated patients.

British Journal of Nursing

Vol. 12, No.1. 2003

Management of venous leg ulcers has advanced considerably over the last 10 years for

various reasons but mainly from greater knowledge and the publication of national

guidelines, e.g. The Royal College of Nursing Guidelines (1998) the management of venous

Leg Ulcers.

Localities should be progressing towards full implementation of the National Service

Framework for older people, with older people benefiting from reforms in chronic diseases

management. (Department of Health, (June 2004) National

Director of Older People’s

Services, Championing change for older people, Making progress.

Accurate assessment and appropriate treatment are essential to heal a leg ulcer and healing

rates are improved if there is consistency of approach to treatment.

Improvement in the care

available to leg ulcer patients will depend on the enthusiasm and skill of healthcare

professionals in the clinical setting.

R. Cooper (2004) Leg ulcers: improving management.

The New Generalist

Vol.2 No2.

4

Doppler Assessment

An ankle brachial pressure index (ABPI) is a non-invasive method of identifying arterial

insufficiency within a limb.

Information gained from Doppler assessment in calculating the

ankle brachial pressure index is used to determine the aetiology of the ulcer to identify those

patients with arterial disease.

A West Gloucestershire standard for Doppler screen assessment was written by the Practice

Development Network.

This standard was verified in spring 2003.

The standard outlines

how to determine the aetiology of leg ulcers. The standard promotes a three monthly re-

screen by Doppler machine for ongoing management and planning of chronic leg ulcers and

for sustaining the appropriate use of compression hose in healed venous leg ulcers.

The Standard was issued in autumn 2003 to all district nursing staff and practice nurses

within the West Gloucestershire PCT.

Audit of Lower leg ulcer management

The audit was undertaken three months after circulation of the standard.

Aims

™

To give a snapshot of current caseload.

™

To confirm compliance with standard.

™

To highlight training needs.

™

To reduce reoccurrence rates.

™

To reduce nursing aid prescription costs.

Methodology

A small working group of a community nurse, a practice nurse and two students developed a

questionnaire to gather the required information.

This is attached as appendix 2

Each practice nurse and community nurse in West Gloucestershire was asked to participate.

The students hand delivered a large percentage of questionnaires to surgeries and

community nurse bases

The survey began on the 26

th

April 2004

with a return date for the questionnaires of 14

th

May

2004.

Response

The response rate for this audit was lower than expected despite the extra planning and

personally addressed questionnaires.

The question asking for the location of the

professional completing the questionnaire also gained a low response.

Therefore it is not

possible to show a breakdown of the responses into PCT locality.

5

Results

Questionnaires were distributed to 128 Community nurses and approximately 70 Practice

nurses.

91 questionnaires were completed, giving a return rate of 40% from community nurses and

57% from practice nurses.

Section 1 About you and where you work

A breakdown of the professionals completing the audit questionnaire.

n=91

Nursing grade of professional completing the audit questionnaire

n=80

Professionals completing audit questionnaire

(44%)

40

(56%)

51

Practice Nurse

Community Nurse

Grade of professional completing questionnaire

1(1%)

5(6%)

5(6%)

34(42%)

12(15%)

23

(29%)

0

10

20

30

40

50

60

70

80

H

G

F

E

D

N/A

6

Workplace location

There was a poor response to this question with only thirty seven of the ninety one

responding.

n=37

Section 2 Training

Have you completed any training in lower leg ulcer management?

n=82

n=70

65% (n=40) Practice nurses and 86% (n=51) Community nurses recorded that they had

received training.

Have you completed any training in lower leg ulcer

management?

12

70

Yes

No

Role of those who have completed training in lower leg ulcer

management?

26

44

Practice nurse

Community nurse

Location of professional

11

8

12

6

0

1

0

2

0

3

0

40

50

North Glos

South Glos

North Forest

South Forest

7

Dates when training took place

69% of those who had received training had had their training at least three years ago.

n= 68

Dates when training took place

21

19

24

4

0

10

20

30

40

50

60

70

2002 - 2004

1999 - 2001

1996 - 1998

1993 - 1994

Respondents were asked to name the title of the course they attended.

Various courses were named in this section.

Those most frequently named were:

*

Assessment and management of leg ulcers.

*

Leg ulcer management

*

Assessment and treatment of leg ulcers

*

Leg ulcer course

A full list can be seen in appendix 1.

Respondents were asked to name provider of the course they attended.

There were a total of sixteen replies.

*

6

Chris Palmer

*

2

Leg Ulcer Clinic

*

5

Company representative

*

1

Collingwood House

*

1

Specialist nurse representative from a 4 layer producer

*

1

West Glos PCT Maxine Taylor & Leg Ulcer Staff

8

Did your training include assessment and confirmation of the aetiology of lower leg ulcers?

Combined results for all staff

n=80

Results by uni-professional role

n=80

The grades of those nurses who responded “yes” to training which included assessment &

confirmation of the aetiology of lower leg ulcers.

n=68

One nurse responded “no”, nine nurses did not respond.

Did your training include assessment & confirmation of the

aetiology of lower leg ulcers?

5 (7%)

28 (41%)

9 (13%)

22 (32%)

3 (4%)

1 (1.%)

0

10

20

30

40

50

60

H

G

F

E

D

N/A

Yes

Did your training include assessment & confirmation of

the aetiology of lower leg ulcers?

24

1

2

3

49

0

0

1

0

10

20

30

40

50

60

70

80

Assessment

included

Assessment not

included

Assessment

included but

Further training

required

Training required

Practice nurse

Community nurse

Did your training include assessment & confirmation of

the aetiology of lower leg ulcers?

73

1

2

4

0

10

20

30

40

50

60

70

80

Assessment

included

Assessment not

included

Assessment

included but

further training

required

Training required

9

Did your training include interpretation of Doppler machine readings?

Combined results for all staff

n=80

Results by uni-professional role

n=80

Did your training include interpretation of Doppler

machine readings?

17

1

7

1

4

44

0

3

1

1

0

20

40

60

80

Doppler

interpretation

included

Doppler

interpretation

included but

training

required

No doppler

interpretation

included

No doppler

interpretation

& training

required

Training

required

Practice nurse

Community nurse

One nurse recorded that Doppler interpretation had been included but did not record a

professional role.

The grades of those nurses who responded “yes” to training which included interpretation of

Doppler machine readings.

n= 59

Eleven nurses responded “no”, and eleven nurses did not respond

Did your training include interpretation of Doppler

machine readings?

1

10

2

5

62

0

10

20

30

40

50

60

70

80

Doppler

interpretation

included

Doppler

interpretation

included but

training

required

No Doppler

interpretation

included

No Doppler

interpretation

& training

required

Training

required

Did your training include interpretation of Doppler machine

readings?

5

(8%)

23 (39%)

9 (15%)

18 (31%)

3 (5%)

1 (2%)

0

10

20

30

40

50

H

G

F

E

D

N/A

Yes

10

Did your training include planning & discussion of a treatment plan?

Combined results for all staff

n=79

Did your training include planning & discussion of a

treatment plan?

73

2

1

3

0

10

20

30

40

50

60

70

80

Planning &

discussion

included

Planning &

discussion not

included

Planning &

discussion not

included &

required

Training required

Results by uni-professional role

n=79

Did your training include the planning & discussion of a

treatment plan?

25

1

1

2

48

1

0

1

0

10

20

30

40

50

60

70

80

Planning &

discussion

included

No planning &

discussion not

included

Not included &

required

Training required

Practice nurses

Community nurses

The grades of those nurses who responded “yes” to training which included planning &

discussion of a treatment plan.

n=68

Three nurses responded “no”, twelve nurses did not respond.

Did your training include planning & discussion of a

treatment plan?

5 (7%)

29 (43%)

9 (13%)

21 (31%)

3 (4%)

1 (1%)

0

10

20

30

40

50

60

H

G

F

E

D

N/A

Yes

11

Comments were made on the subject of training as follows:

*

So long ago & infrequently used.

*

I could do with more training.

*

Updating required.

*

Assessment mentioned briefly.

Section 3 Caseload

The following questions in this section refers to the six month period prior to the audit

October 2003 to March 2004

How many patients with a non healing wound on their lower legs of greater than 6 weeks

have you treated?

n=80

How many patients with non healing lower leg wounds of

greater than 6 weeks have you treated?

2

16

13

2

1

1

0

14

17

12

2

0

0

10

20

30

40

50

60

70

80

Nil

1 to 5

6 to 10

11 to 15

16 to 20

Numerous

Practice

Nurse

Comm nurse

The total number of patients with non healing wounds recorded were 572, not including one

nurse caseload who recorded numerous.

Community nurses recorded 381 wounds, a mean of 7.5

Practice nurses recorded 190 wounds, a mean of 4.8

For how many patients did you make a Doppler assessment to inform your treatment plan?

RCN guidelines recommend all patients with a non healing lower leg wound of greater than 6

weeks should receive a baseline Doppler assessment.

Sixty two replies reported that they

use Doppler assessment to inform their treatment plan.

The audit does not inform us if all

the remaining patients are referred for Doppler assessment.

n=74

For how many patients did you make a doppler

assessment for to inform your treatment plan?

12

37

18

1

2

2

2

0

10

20

30

40

50

60

70

nil

1 to 5

6 to 10

11 to 15

16 to 20

20+

All

A total of 349 patients were recorded as having received a Doppler assessment, this is 61%

of the total caseload of lower leg wounds.