West Gloucestershire Primary Care Trust. Gloucestershire Primary & Community Care Audit Group. Lower Leg Ulcer Audit

Transcription

1 West Gloucestershire Primary Care Trust Gloucestershire Primary & Community Care Audit Group Lower Leg Ulcer Audit Date October 4

2 Contents Page Number Background 3 Doppler assessments 4 Audit of Lower leg ulcer management 4 Results 5 - Discussion Appendices List of courses attended 23 Audit tool

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 3 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 (4) 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 6 9% 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, (3) Health related quality of life tools for venous-ulcerated patients. British Journal of Nursing Vol. 12, No.1. 3 Management of venous leg ulcers has advanced considerably over the last 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 4) 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 (4) Leg ulcers: improving management. The New Generalist Vol.2 No2. 3

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 3. The standard outlines how to determine the aetiology of leg ulcers. The standard promotes a three monthly rescreen 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 3 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 4 with a return date for the questionnaires of 14 th May 4. 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. 4

5 Results Questionnaires were distributed to 128 Community nurses and approximately 7 Practice nurses. 91 questionnaires were completed, giving a return rate of 4% 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 Professionals completing audit questionnaire (56%) 51 (44%) 4 Practice Nurse Community Nurse Nursing grade of professional completing the audit questionnaire n=8 Grade of professional completing questionnaire (42%) 23(29%) 12(15%) 5(6%) 5(6%) 1(1%) H G F E D N/A 5

6 Workplace location There was a poor response to this question with only thirty seven of the ninety one responding. n=37 Location of professional South Forest 6 North Forest 12 South Glos 8 North Glos Section 2 Training Have you completed any training in lower leg ulcer management? n=82 Have you completed any training in lower leg ulcer management? 12 7 Yes No n=7 Role of those who have completed training in lower leg ulcer management? Practice nurse Community nurse 65% (n=4) Practice nurses and 86% (n=51) Community nurses recorded that they had received training. 6

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 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 7

8 Did your training include assessment and confirmation of the aetiology of lower leg ulcers? Combined results for all staff n=8 Did your training include assessment & confirmation of the aetiology of lower leg ulcers? Assessment included Assessment not included Assessment included but further training required Training required Results by uni-professional role n=8 Did your training include assessment & confirmation of the aetiology of lower leg ulcers? Assessment included Assessment not included Practice nurse Assessment included but Further training required Community nurse Training required The grades of those nurses who responded yes to training which included assessment & confirmation of the aetiology of lower leg ulcers. n=68 Did your training include assessment & confirmation of the aetiology of lower leg ulcers? (41%) 22 (32%) 5 (7%) 9 (13%) 3 (4%) 1 (1.%) H G F E D N/A One nurse responded no, nine nurses did not respond. Yes 8

9 Did your training include interpretation of Doppler machine readings? Combined results for all staff n=8 Did your training include interpretation of Doppler machine readings? Doppler interpretation included 1 Doppler interpretation included but training required No Doppler interpretation included 2 5 No Doppler interpretation & training required Training required Results by uni-professional role n=8 Did your training include interpretation of Doppler machine readings? Doppler interpretation included 1 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 Did your training include interpretation of Doppler machine readings? (39%) 18 (31%) 9 (15%) 5 (8%) 3 (5%) 1 (2%) H G F E D N/A Yes Eleven nurses responded no, and eleven nurses did not respond 9

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? 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? 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 Did your training include planning & discussion of a treatment plan? (43%) 21 (31%) 5 (7%) 9 (13%) 3 (4%) 1 (1%) H G F E D N/A Yes Three nurses responded no, twelve nurses did not respond.

11 Comments were made on the subject of training as follows: Section 3 Caseload * So long ago & infrequently used. * I could do with more training. * Updating required. * Assessment mentioned briefly. The following questions in this section refers to the six month period prior to the audit October 3 to March 4 How many patients with a non healing wound on their lower legs of greater than 6 weeks have you treated? n=8 How many patients with non healing lower leg wounds of greater than 6 w eeks have you treated? Nil 1 to 5 6 to 11 to to 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 19 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? nil 1 to 5 6 to 11 to to + 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. 11

12 How many patients have you treated with 4 layer bandaging? n=75 How many patients have you treated with 4 layer bandaging? nil 1 to 5 6 to 11 to to Numerous How many patients have you treated with compression hose? n=77 How many patients have you treated with compression hose? nil 1to 5 6 to 11to to to 3 Numerous Comments were made concerning this section as follows: * We Doppler all patients who have ulcers slow to heal * Still training * With colleague who has trained * Sent to foot clinic or diabetic clinic where they were dopplered * All needed modified 3 layer. I have not used this treatment to heal wounds referred to D/N * Unable to Doppler 1 pt due to chromic Oedema * Modified Use * None as not assessed as competent yet. Undergoing supervised practice at leg ulcer clinic * Either domiciliary visit surgery clinic or Cheltenham or Gloucester leg ulcer clinic/ or modified compression. 1 following healing * Not trained to do them but understand theory. X1 modified bandaging 3 layer only * The others dopplered at clinics 12

13 Section 4 Skills How confident are you that you always interpret Doppler readings correctly? Combined results for all staff N= 78 How confident are you that you always interpret Doppler readings correctly? (6%) 15 (19%) 16 (21%) Very confident Quite confident Not confident Results by professional role n=78 How confident are you that you alw ays interpret Doppler readings correctly? Very confident Quite confident Not confident Practice nurses Community nurses How confident are you that you always correctly identify aetiology of lower leg ulcers? Combined results for all staff n=8 How confident are you that you always identify aetiology of lower leg ulcers? (63%) 17 (21%) 13 (16%) Very confident Quite confident Not confident 13

14 Results by professional role N=8 How confident are you that you alw ays correctly identify aetiology of lowere leg ulcers? Very confident Quite confident Not confident Practice nurses Community nurses How confident do you feel in planning & discussing a treatment plan? Combined results for all staff N=81 How confident do you feel in planning & discussing a treatment plan? (4%) 38 (48%) 11 (14%) Very confident Quite confident Not confident Results by professional role N=81 How confident do you feel in planning & discussion a treatment plan? Very confident Quite confident Not confident Practice nurses Community nurses 14

15 Section 5 Treatment Plan It was expected that only one answer would be given for this question, however some nurses made more than one response. A few nurses recorded that they may vary the length of time between Doppler re-screen. When do you routinely Doppler re-screen patients to confirm aetiology? n= 71 When do you routinely Doppler re-screen patients to confirm aetiology? No Doppler rescreen 1 Doppler rescreen monthly Doppler rescreen 3 monthly Doppler rescreen 6 monthly 17 Practice nurses and 7 Community nurses, did not respond to this question the grades were equally split. If you do not use a Doppler machine please give reasons. n=26 If you do not use a Doppler machine please give reasons No access to equipment Shared equipment Lack of training Staff resources Comments given were as follows: * Was told on training course that as E grade not eligible to do this - only higher grades should do them. * Policy to refer to specialist nurse at leg ulcer clinic. * Lack of treatment room space has to be done at home. * Shared equipment with practice nurses is not satisfactory. Doppler for each DN would be useful. * Already have staff with required skills & good liaison with same. No wish to further dilute my own skills. * No time to do properly. 15

16 Is it routine practice for Practice nurses and Community nurses to jointly assess patients with lower leg ulcers? This question was responded to by 81 nurses, thirty (37%) of whom recorded that they jointly assess patients with leg ulcers. Comments were given * Have done so initially before D/Ns were confident/experienced. * Occasionally. * We do work together on leg ulcer principles of care. * Depends on patient if housebound no. * Some. * But improving. * Not routine but occasionally. Does joint assessment included the use of a Doppler machine? Thirty seven nurses replied yes. Comments were given * Lack of time for Doppler. Occasional patient assessed * District nurses use Dopplers I think * Sometimes shared care * Don't know Section 6 Follow up care Please indicate follow up care after confirmation of the healing of a lower leg ulcer. n=88 Follow up care at confirmation of the healing of a low er leg ulcer Discharge Reassess 3 monthly Routinely remeasure for compression hose 3 monthly 11 Other 16

17 How many patients with healed venous leg ulcers are on your re-screen programme? n=51 How many patients with healed venous lower leg ulcers are on your re-screen programme numerous Nil How often are patients with healed venous lower leg ulcers recalled? n=3 How often are patients with healed venous lower leg ulcers recalled? Not recalled 5 Variable Depends on individual Monthly 3-4 Monthly Monthly Monthly 2 Nil

18 The following comments were made regarding follow up care. * Only if high compression i.e. ii or iii. * Only ever healed patients on 3 layer bandaging. * Patients are reviewed to ensure no breakdown. * Review three monthly. Ask patient to ring if problems arise. For those tolerating hosiery tell them to get new ones every 3/12. * 6 monthly aim. Monthly check & leg wash by team NA. * Put on to N/A Cambridge leg and foot care list. * Discharge pt 1/12-6/52 after healed and measure for compression hosiery. * More like annually. * Unfortunately insufficient staff to reassess routinely. * Review as required. Final comments: Many nurses took the time to comment at the end of the questionnaire. These have been themed into the following headings. Training * Would be good to have a refresher to ensure standardisation of procedures. Initial training was some time ago so a refresher study day would be good revision and networking problems and ideas. * One in four practice nurses can do this but all D/N are able to assess & apply this care. * Updating would be appreciated. * Would like an update session especially re Doppler to discuss sounds as well as the readings. * Regular updating of treatments would be very beneficial for all staff locally or within the trust. * I would like regular updates of latest techniques. * Have only recently joined West Glos. PCT 4 have attended leg ulcer clinic. PCDM would like me to undertake leg ulcer & Doppler training. * Would like a refresher course. * Waiting for in-house training. * The course I did at GRH was not designed to teach Doppler assessment more like an overview. 18

19 Referral * Most patients are referred to Ulcer Clinics. * I hand over to my colleagues once 4 layer/compression is required. * Any patients with non-healing leg ulcers we refer to our District Nurse team to assess. They do all our patients who need 4 layer bandages. * If I am unsure about aetiology or treatment I consult or send patients to the leg ulcer clinic at Gloucester Hospital. * Our patients with lower leg ulcers are referred to GRH leg clinic for Doppler assessment. * Fortunate in Blakeney to have good liaison with District Nurse team, able to refer or confer as need arises. * Refer to District Nurse * My practice nurse colleague and I refer patients on to our District nurse team(after we have made the initial assessment) the District nurse Doppler and decide if patients suitable for compression if housebound. District nurse continues care. Patient Care * Patients are advised to return at the first sign of any problem for re-assessment. * There is no hard and fast rule each patient is assessed individually and their views taken into account. * Patients usually contact us for support hosiery and we review them. * Never discharge healed leg ulcer patients weekly foot toilet surveillance from HCA. 3 6 monthly re Doppler. Work closely with leg ulcer clinic GRH. Practice nurse does not undertake assessment District nurse does this in surgery. * I am aware that our healed patients are followed up in the leg ulcer clinic 3 monthly for a year and yearly after that. * Recalled when hosiery script needs updating re-measure then. * Currently review and change dressing 3 weekly if no change is identified. Patient Choice * Sometimes patients decline re Doppler assessment and we do not force care. We try to obtain informed consent. * Out of four, one won t comply. Two had surgery of which one will not elevate legs or go to bed. The other one is struggling with skin grafts that are not healing. 19

20 Resources * Due to lack of resources re-screen not done. * Very grey area tends to get missed due to workload. Area that needs to be addressed & implemented * Patients do not have appropriate screening due to lack of Doppler machine. Most/all are screened at leg ulcer clinic. * Do not have a re-screen programme. Most patients access leg ulcer clinic GRH & Doppler undertaken there. Do not have the time or resources to do regular screening once patient has healed. * We don t really have time to do re-screen. * I would visit staff shortages as a reason for not re-screening, we are limited at present to reacting to problems, giving care but not prevention. * We used to aim to re-screen 3/12 but time and staffing do not always permit. However patients are re Dopplered when not healing or if changes are noted. * Unable to re-screen with a District nurse team due to staff shortages. * Difficulties in follow up screening due to high numbers on case load. * Patients are seen in Churchdown leg ulcer clinic. We would have liked to have re Dopplered more of our patients but due to 2 unfilled staff posts, staff sickness/maternity leave and nurses untrained unable to achieve aims. * In an ideal world we would do all of the above but we have no time to adequately assess and re-screen so we rely on the leg ulcer service. * We would very much like a Doppler machine new and up to date for Distric nurse use. Future Plans * We are just re-planning our aftercare to include re measuring and re Doppler testing. * We hope to develop an integrated leg ulcer service with District nurse and practice nurse team for leg ulcer management. * Planning joint clinic with P/N in September 4

21 Discussion The management of leg ulcers is a major and costly problem to the National Health Service, with a conservative estimate of 4 million being spent each year by the NHS on treatment. A high proportion of these costs are taken up in the provision of the community nursing service (Morrison & Moffatt 1994). It has been estimated that between 8, and, people in the UK suffer with a leg ulcer at any one time and that many ulcers remain unhealed for more than years (Moffatt et al, 1992). Leg ulcer strategies involving staff training and compression therapy have produced healing rates of up to 69% at 12 weeks (Moffatt et al 1992). In this audit one aim was to discover the extent of the problem in West Gloucestershire. The questionnaire asked nurses how many patients with a leg ulcer they have on their caseload. The results showed that 37% of nurses have between 1 and 5 patients with a leg ulcer on their caseload. The figures suggested that 37% of nurses have between 5 and patients in compression hose to be re-screened, some of whom are re-screened by district nurses, practice nurses with the remainder referred to specialist clinic. The reasons for referral are indicated as a lack of time, ability, competency or equipment availability. The results show that 7 (85%) of nurses who responded have undergone training in lower leg management. This number was higher than expected. However, it is important to note that 47(69%) had received their training at least three years previously. The comments from the survey show that nurses recognise the need for updating and are actively requesting update sessions. The course titles given by the respondents were varied. The audit demonstrated that the three main elements of care for lower leg ulcers were covered in the training sessions that were attended. It is not known how fully these three elements were covered in the training. One comment made about assessment of the aetiology we touched on this briefly, would suggest that a consistent approach may not have been offered. Of the 4 practice nurses that completed questionnaires 26 had attended leg ulcer management training, 24 (6%) had attended training which included assessment & confirmation of the aetiology. Interpretation of Doppler readings had been included in the training for 17 (43%) and planning & discussing for 25 (63%). Training for Community seemed more comprehensive with of them recalling an element on assessment and confirmation of the aetiology, for interpretation of Doppler readings 86% and 94% for planning & discussing a treatment plan. This distinction in the lack of training for practice nurses was noted by one nurse who commented One in four practice nurses can do this but all community nurses are able to assess and apply this care. One of the hopes for the future is that Practice nurses and community nurses will undertake joint leg ulcer clinics. Therefore it is important that a consistency of training is offered to all. 21

22 The questionnaire asked nurses to say how confident they felt in leg ulcers management. The number of nurses who said they felt very confident to plan and discuss a treatment plan was double the number who were very confident in identifying the aetiology or interpreting Doppler readings. This indicates an urgent need for practical Doppler skills training and aetiology definition. One in five nurses said they did not feel confident to interpret Doppler readings. Three out of four of these were Practice nurses, however it should be noted that a much lower number of practice nurses than community nurses had been able to access training. This does demonstrate an overall need for a complete training package for both disciplines. The standard for Doppler screen assessment states: Patients in receipt of ongoing leg ulcer management (healed/non healed) will be offered a Doppler re screen every three month within the practice area/community nurse caseload. Responses to this audit illustrated that 24(27%) nurses achieve three monthly assessment and (22%) routinely re measure for compression hose three monthly. Thirty three nurses (37%) stated that they discharge the patient at point of healing. It is not known if any of the discharged patients have a follow up appointment at a Gloucester Royal Hospital based led leg ulcer clinic. Wherever treatment is given, at home, clinic or hospital it is labour intensive and time consuming. Practices may not see follow up leg ulcer care as a high priority in chronic disease management due to other commitments. It is clear from the results that many patients are not re screened as per standard. Some patients are referred to a leg ulcer clinic, for which we have no knowledge of the regime for follow up care. Some patients are seen later than the standard requires, while some patients are discharged and advised to return at any sign of any further problem. Many comments were made concerning resources for follow up care. The lack of equipment and staffing levels were named together with the need for training. It is evident that nurses are aware of the standards instruction to reassess leg ulcers three monthly, and stated the difficulty in attempting to achieve this in practice due to lack of resources. Vision The audit comments showed that good working relationships exist between practice nurses and community nurses. Many refer or confer on the care of patients being treated for leg ulcers. Some are beginning to work jointly at leg ulcer clinics. This is a way of working that should be promoted in order to maintain or gain the necessary skills. The NSF made explicit reference to the importance of nursing leadership in developing and improving the care of older people, it provides a foundation upon which to build services to meet future needs. Sturdy, D. (4) Department of Health Championing change for older people, Leading the leaders to lead. Our challenge and duty as practitioners, driven by the changing needs of patients, new research and technologies is to raise the standard of venous leg ulcer care, particularly as the number of old people are expected to keep rising. The management of venous leg ulceration should be seen as an integral part of chronic disease management and as nurses we should be proactive in the development of strategies to raise awareness and meet the educational needs of those providing services. 22

23 Appendix 1 List of Courses attended Leg ulcer course Management of leg ulcers Management & treatment of leg ulcers 3 day course on leg ulcer management 4 layer bandaging 4 layer assessment & bandaging Leg ulcer assessment Assessment & treatment of leg ulcers Wound care module at diploma level Tissue viability modules Tissue viability / wound management Leg ulcer module Focus on leg ulcers 8 week course on leg ulcer assessment & management Charing cross leg ulcer college 3 days Wound care 94 symposia 23

24 PRIMARY AND COMMUNITY CARE AUDIT GROUP West Gloucestershire Primary Care Trust Lower Leg Ulcers Audit In early January the distribution of the Standard for Doppler testing and re-screening to prevent ulcer reoccurrence took place. The following questionnaire is to help assess your knowledge, skills and competencies in the treatment of lower leg ulcers. The aim is to inform the Primary Care Trust regarding future training needs. If you have any questions please contact:: Sarah Balinger/ Anna Gibbins Tel , or Rebecca Caton or Denise Frost Section 1 About you & where you work Practice nurse Community Nurse Please enter your grade North Glos. South Glos North Forest South Forest Section 2 Training Have you completed any training in lower leg ulcer management? Yes No If no please go to section 3 If yes, can you give details? Date Course Title Provider Yes No Training Required? Did your training include assessment and confirmation of the aetiology of lower leg ulcers? Did your training include interpretation of Doppler machine readings? Did your training include the planning and discussion of a treatment plan (eg. 4 layer bandaging) Section 3 Caseload In Thinking of the past 6 months (Oct. 3 to March 4) How many patients with non healing wounds on their lower legs of greater than 6 weeks duration have you treated? For how many patients did you make a Doppler assessment for to inform your treatment plan. How many patients have you treated with 4 layer bandaging? How many patients have you treated with compression hose? 24

25 Very Quite Not Section 4 Skills Confident Confident confident How confident are you that you always interpret Doppler readings correctly? How confident are you that you always correctly identify aetiology of lower leg ulcers? How confident do you feel in planning & discussing a treatment plan? (e.g. 4 layer Bandaging/compression hose) Section 5 Treatment Plan Following implementation of a treatment regime of 4 layer bandaging/compression hose, when do you routinely Doppler re-screen patients to confirm aetiology? Please tick one box No Doppler re-screening Doppler re-screen 1 monthly Doppler re-screen 3 monthly Doppler re-screen 6 monthly If you do not use a Doppler machine please give reason(s) (Tick as many as apply) No access to equipment Shared equipment Lack of training Staff resources Other please specify. Is it routine practice for District nurses and practice nurses to jointly assess patients with lower leg ulcers? Yes No If yes, does this involve using a Doppler machine? Yes No Section 6 Follow up care When you have confirmed the healing of a lower leg ulcer do you Please tick all boxes that apply Yes No Discharge patient at point of healing Reassess Doppler every three months Do you routinely re-measure for compression hosiery every three months Other If, other please specify How many patients with healed venous lower leg ulcers are on you re-screen programme? How often are these patients recalled? Comments.. Thank you for completing this questionnaire Please return in envelop provided to: The primary & Community Care Audit Group Agriculture House, Sandhurst Lane, Gloucester, GL2 9AS. 25