Lower limb oedema is defined as

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1 CHRONIC OEDEMA Chronic oedema: identifying areas for service improvement Rachel Sweeney This paper looks at an audit which compared the clinical outcomes of patients with lower limb oedema, who were either treated in a designated leg ulcer clinic or in their own homes. From exploring the and documentation of leg assessments. The piece of work forms part KEYWORDS: Chronic oedema Assessment Lower limb oedema is defined as a persistent, abnormal swelling of the lower limb (Bianchi et al, 2012), which is considered chronic after being present for over three months (Moffatt et al, 2003). If unrecognised and mismanaged, chronic oedema will eventually lead to lymphovenous oedema. However, this disease progression can be prevented if diagnosed and treated early in the disease continuum nuum (Atkin, 2014). The author works within a multidisciplinary skin integrity team (SIT), which has a common interest t in the management of lower limb issues due to the many overlapping problems. The team comprises a tissue viability nurse, specialist dermatology and lymphoedema nurses, and covers a clinical commissioning group (CCG) area including both urban and rural populations. With the relatively recent formation of the SIT, focus has been on patients on the community nurse caseload with leg ulceration Rachel Sweeney, tissue viability specialist nurse; Norfolk Community Health and Care NHS Trust and how the SIT can support practice and outcomes within the leg ulcer clinics and for housebound patients who are cared for by the community nursing ng team. Care Peo As a result of attending an MSc module on the management of chronic oedema, the author recognised that within practice, community nurse visits were often made on a daily basis to see patients with wet, weepy legs, indicating that oedema was being neither recognised nor appropriately treated. Leg ulcer management (venous, mixed and unspecified in aetiology) has been found to have a 33% prevalence (732,000 patients) among the UK adult population, contributing to an estimated annual cost to the NHS of 5.3 billion for wound care and associated management of comorbidities (Guest et al, 2015). Lymphoedema and chronic oedema have been estimated to affect over 100,000 people in the UK (Moffatt, 2003). A subsequent study also identified that leg ulceration was present in 50% of community and inpatients who also had a diagnosis of chronic oedema, with this prevalence increasing ng with age (Moffatt and Pinnington, 2012). With such statistics and following owing the annual trust leg ulcer audit conducted in 2015, the author decided to review local practice more closely with a chronic c oedema audit. The aim of this audit was to reflect on local practice to gain an insight into clinical outcomes for this patient population by comparing practice between two clinical settings, namely a leg ulcer clinic and a community nursing team. This included looking at: Assessment Care planning Treatment. P ople Ltd Both the clinic and community team serve the same geographical area. Patients who are ambulatory are invited to attend the leg ulcer clinic, while housebound patients are seen in their own homes by community nurses. The audit was undertaken by the author reviewing 10 patients care plans on each respective caseload (leg ulcer clinic and community). The author set the audit questions and recorded findings on an excel spreadsheet for analysis (Tables 1 and 2). All patients were active to the community nursing service and care plans documented on SystmOne (electronic patient record). Practice point Leaking fluid from lower limbs occurs when the lymphatic system is no longer able to cope with the fluid volume, which, in turn, has a detrimental effect on skin integrity and manifests as weeping legs, skin breakdown and infection (Mahoney, 2015). 24 JCN 2017, Vol 31, No 6

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3 CHRONIC OEDEMA The audit focused on one team, i.e. the community nursing time which covered the leg ulcer clinic and home visits, to allow for easier comparison between clinical settings and to reduce the number of variables, e.g. same leadership, training opportunities, team culture. Limiting the audit to one team also facilitated the identification of practice learning points and enabled targeted, focused training and implementation of an improvement plan. FINDINGS As a result of scoping the community nursing service, and gaining an understanding of the dynamics and skill sets of the community nursing team, the author observed that historical and ritualistic practice was commonplace for the treatment of patients with lower limb oedema. This chronic oedema audit highlighted the need to revise the existing venous leg ulcer policy (which had been reviewed following the trust-wide audit in 2015), as it identified variations in practice between healthcare professionals and clinic settings, which had an impact on healing outcomes. The author also identified that there was a perception among some community staff that they were achieving good clinical outcomes, despite audit data illustrating the contrary compared to national healing rates. RESPONSE TO AUDIT FINDINGS Thus, the trust s s lower limb policy was revised and published following principles from a recent Best Practice Statement ent (Wounds UK, 2016). The new policy introduced different compression systems and gave staff the opportunity to attend a robust training programme to attain clinical competencies. Interestingly, Billingham (2008) identified that staff often report feeling out of their depth and unsafe with new practice techniques and so need to be aware of their own limitations. This may in part account for the mismanagement of chronic oedema, in conjunction with healthcare professionals lack of recognition of the disease process, which the audit identified. 017 The findings also demonstrated that, at the time of the audit, the average length of time on the clinic caseload for the patient sample was days (7.65 months), with healing still not being achieved. (These patients remained on the caseload, leading to congested clinics, and community nurses continuing to see housebound patients.) A consensus document has estimated that healing rates for venous leg ulceration is approximately 5.9 months and 7.4 months for mixed aetiology leg ulcers (Harding et al, 2015), highlighting how the new lower limb policy and training programme in the author s trust has not yet realised the desired impact on clinical outcomes. Each of the three community nursing teams within the author s locality has a different clinical lead, with different knowledge and skill sets, which, as said, led to variations ions in practice. Thus, it has been decided that practice and training opportunities are to be standardised across the locality utilising a coordinated approach. The training programme has been developed with support from tissue viability colleagues from other localities and the SIT, and includes clinical competencies, as well as: One-day update for nurses who have completed both a one-day accredited course in leg ulcer and chronic oedema management Two-day training for registered nurses in leg ulcer management (this does not currently include chronic oedema management) Two-day training for assistant practitioners (band 4) in leg ulcer management One-day training for band 3 healthcare assistants in lower limb issues. The author keeps a spreadsheet of all staff, recording who has undertaken which training and when competencies have been achieved. If staff are not being released for training, this is escalated to senior management. A training needs analysis was conducted across the locality in 2016 in response to the audit s findings, which identified that 12.5% of the substantive registered nursing establishment hold an accredited leg ulcer management qualification. Within this group, two of the nurses were also on maternity leave for the period 2015/16 (local trust data), thus reducing available staff. Due to the lack of qualified leg ulcer nurses during the audit period, the leg ulcer clinic had to be staffed with temporary (bank) registered nurses, not all of whom held a recognised leg ulcer management qualification. The author also identified that the community munity nursing service had been through a period of extensive change in recent years, with the implementation of an electronic patient record system (SystmOne) and high levels of activity, i.e. more visits than planned due to high demand, which has negatively impacted on time allocated to patient visits, leading to non-completion of holistic assessments and low staff morale. As said, Guest et al (2015) acknowledged that there is a financial burden to the NHS of treating chronic wounds, of which leg ulceration forms a significant proportion. This cost is made up of wound care products, healthcare professionals time, as well as the costs incurred in holding and delivering a clinic environment. nd Care People Ltd Furthermore, CCGs are being encouraged to seek value for money in the services they commission. Indeed, in 2014, the Department of Health (DH) published guidance for CCGs to improve access and choice for patients by utilising an Any Qualified Provider (AQP) initiative, and this included treatment for venous leg ulceration (NHS England, 2014). Thus, trusts and community service providers need to be able to demonstrate clinical efficacy and cost-effective outcomes to remain competitive within this changing healthcare climate. Practice point Cellulitis, an acute bacterial skin infection, is often localised. However, it can be extensive and lead to septicaemia (Schofield, 2013). 26 JCN 2017, Vol 31, No 6

4 Automatic Ankle Brachial Index System Guest et al highlighted only 16% of patients with leg or foot ulcers had an ABPI recorded* YOUR ABPI SOLUTION - AUTOMATIC, EASY AND FAST Now with the Dopplex Ability ABPI system, Ankle Brachial Pressure Index has never been simpler or quicker. Simple to use, only one operator with minimal training ing required Measures ABPI in under 3 minutes No need to rest the patient (clinically proven) No need to locate the vessels Automatically detects systolic pressures, calculates ABPIs, and classifi es severity Measures all 4 limbs complies with all National/International guidelines Integral printer for recording results with time and date Optional PC based software package for reviewing and archiving results (DR4) 2017WW opl For more information contact: or visit: Huntleigh Healthcare, Diagnostic Products Division, 35 Portmanmoor Road, Cardiff CF24 5HN * Guest JF, et al. Health economic burden that wounds impose on the National Health Service in the UK BMJ Open 2015

5 Pe CHRONIC OEDEMA Recent Hospital Episode Statistics (HES) data (2015/16) revealed that the author s audited CCG had a spend of 123,709 on non-elective admission costs for leg ulceration, and 257,083 for admissions due to cellulitis. This ranked the CCG 38 out of 209 national CCGs for leg ulcer admissions, and 138/209 for cellulitis, which was higher than spends from neighbouring CCGs within the same county. With these local statistics, the need to audit clinical caseloads and understand current practice in more detail is evident. Also, with an ageing workforce, it is imperative that the skill and knowledge base for community nurses is strengthened and, in the author s clinical opinion, there is a need to plan for the future to sustain and improve the service and care delivered to patients, rather than relying on ad hoc educational funding from alternative sources, such as industry. Without appropriate and holistic assessment and effective management, patients with lower limb oedema are susceptible to complications such as infection (Stalbow, 2004). Furthermore, a study conducted by Dupuy et al (1999) found that breaks in skin integrity, lymphoedema, leg ulceration, oedema, tinea pedis and chronic venous insufficiency (CVI) are common risk factors associated with cellulitis. The patients audited within the author s review of practice had many of these risk factors, as they were found to have breaks in the skin/active ulceration with or without oedema if oedema is present and limbs are weeping, there is a higher her risk of fungal infections, especially ecially between the toes (Keast, 2013). The HES data indicated that the author s team works within an area a of significant admission rates for cellulitis, with patients requiring inpatient care and treatment. As well as physical risk factors and complications identified with chronic oedema, patients mental wellbeing can be compromised. For example, restrictions to clothing and foot wear can lead to depression, (Billingham, 2007), and altered body image, restricted mobility, and skin changes associated with the later stages of lymphovenous disease can all impact negatively on patients quality of life (Atkin, 2014). Training staff within the scope of their responsibility aims to allow early recognition of risk factors associated with CVI, leading to timely assessment (Newton, 2011), diagnosis and starting treatment. A UK consensus document (Wounds UK, 2013) suggested that patients should receive comprehensive assessment within 10 working days of referral to establish underlying aetiology. Bianchi (2013) described how the signs and symptoms of venous and lymphatic disease are not sudden, but gradually worsen if left unchecked. Thus, once recognised, a management plan should be put in place to prevent further deterioration. As historically there had been little training in lower limb management provided by the trust, an in-house training programme ramme was implemented in December 2016, for bands 3, 4, registered nurses, as well as updates for staff who had an accredited leg ulcer qualification. This is a rolling educational programme so that all clinical cal staff receive training, supported by formal higher educational courses if funding allows. Comments made by community nurses in the audit also mirrored the findings of Evans (2017), that wound care is everyone s job, but no one s responsibility. This highlighted the need to define individual roles and responsibilities, so that healthcare professionals are accountable for the care they are giving. As numbers of clinical specialists vary across organisations (Todd, 2013), specialists are unable to solely manage this complex patient group, and so a collaborative approach which offers support is required to provide the most appropriate treatment (Todd, 2013). Thus, the aim is for the SIT to support leg ulcer nurses (i.e. those holding an accredited leg ulcer qualification) within the locality to take ownership and to case manage this patient group and to coordinate care from referral for assessment/doppler to post-healing management, utilising their enhanced skills and knowledge Wound Care Pe Treatment pathways provide a framework for healthcare professionals to work from; guiding them through Key findings from the audit Delays in initiating treatment Although patients were seen on time within the community setting, there was a delay in recognising long-term risks and subsequent assessment Lack of holistic leg ulcer assessmentss Lack of assessment of oedema Not all patients ts had a Doppler assessment, despite being treated ed with compression Incorrect rect care plans being set Inappropriate treatment plans Length of visit not being amended from pre-set care plan, thus unable to gain true picture of time spent managing this patient group Length of time on caseloads higher then suggested figure Care for patients in the community better than the designated leg ulcer clinic. People Ltd the anticipated patient journey and signposting referral to specialists at appropriate intervals based on assessment, if the expected outcome is not achieved. Through the audit, the author observed that patients had not been referred onto specialist services for input or advice. Variation in practice in terms of assessment was also noted. For example, few patients received comprehensive holistic leg ulcer assessment. This may in part have been due to the low numbers of appropriately trained staff. The audit, worryingly identified that some patients had been treated with compression therapy without assessment or a Doppler reading to measure ankle brachial pressure index (ABPI), while many of the patients appeared to have treatment decisions based on Doppler assessment alone. Todd (2015) advocated that Doppler should be performed as part of holistic assessment, and that it should be performed by experienced nurses. During periods of high activity within the community nursing 28 JCN 2017, Vol 31, No 6

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7 CHRONIC OEDEMA Table 1: Audit results from the dedicated leg ulcer clinic setting* Audit results Leg ulcer clinic setting Time between referral and initial 0% within one week of initial referral contact/review 50% between two to four weeks of initial referral 50% over one month after initial referral Time between referral for leg ulcer Eight patients received no initial leg ulcer assessment/ treatment and initial nursing leg template completed assessment/leg template completion One patient received partial template completion within 58 days One patient received assessment within 43 days Who undertook the leg ulcer assessment/ One patient assessment partially completed by advanced completed the template nurse practitioner One patient assessed by leg ulcer nurse (only two patients out of the 10 audited were assessed) Has the patient been identified as having 50% not assessed chronic oedema 50% assessed as having oedema Date of vascular assessment (Doppler) 20% historical Doppler before referral to clinic 50% on initial assessment 10% within one month of initial referral 0% over two months of initial referral 20% no Doppler recorded Doppler undertaken by whom 12.5% leg ulcer nurse 37.5% registered nurse 50% assistant practitioner Which care plan has been set following 80% venous ulcer care plan leg and Doppler assessments 10% mixed aetiology care plan 10% amended care plan, e.g. chronic oedema/ lymphoedema Who set the care plan 10% leg ulcer nurse 80% registered nurse 10% assistant practitioner Was appropriate treatment/ 30% yes plan prescribed 60% no 10% treatment plan not clear on patient record Length of time on caseload Average length of time on caseload was days * Results were calculated from responses to audit questions, which were collected by the author and recorded on a spreadsheet service, holistic assessments sments were seen by some senior staff within the organisation n as a task that was an added bonus, rather than a necessity (author s interpretation of the situation from talking with colleagues). As previously discussed, assessment is the first opportunity to diagnose a patient and initiate appropriate treatment, and so the earlier this takes place, the better the outcome for the patient, as well as the potential for avoiding unnecessary healthcare costs. In the author s clinical experience, undertaking comprehensive assessment and involving patients in the decision-making process, as well as providing patient education and health promotion, can improve patient adherence to treatment. ADDITIONAL CHANGES AS A RESULT OF AUDIT S FINDINGS As a result of the audit s findings, equipment has now been purchased to ensure that staff have access to Doppler machines, once training and competencies have been achieved. The more staff who are available to measure ABPI, the quicker this test will be performed to avoid patients sitting on waiting lists for long periods of time, as has historically been the case. Referrals into the trust are managed by a central hub, with triage nurses and administration staff accepting referrals and allocating visits. However, this audit identified that visits are being allocated to community nurses inappropriately e Palloca due to limited information being included on patient care plans, as a result of incomplete patient assessment and incorrect care plans being set by the community nurses. For example, due to the infancy of training within the organisation around chronic oedema management and associated compression therapy, not all staff are confident and competent with application and yet have been allocated visits to see patients requiring this type of care, which could lead to suboptimal treatment being applied and potential harm to patients. However, it is thought that subsequent uent review ew of existing care plans and refining the wording to assist the administration team, which is currently being done by the author and staff within practice development, will help to ensure that appropriately trained healthcare professionals are allocated to each patient. Futhermore, compression systems within the local wound care formulary were reviewed last year. Three systems were on the formulary, but as a result of evidence that they were not being used appropriately, one of the systems was removed. This allowed for focused training on the indications and use of the two remaining systems to aid formulary compliance and application skills. However, during the chronic oedema audit, it was identified that old regimens were still in use without clinical rationale, again identifying the need for better support and education of new systems and trust guidelines. The author acknowledges that lack of documentation may stem from the complex system in which patient assessments are recorded. Nurses initially complete care plans for the tasks undertaken, more detailed assessments are generally completed on a template which is linked to the care plan. This way of working is timeconsuming to navigate and so is being evaluated by the author Wo Wound Care People Ltd CONCLUSION Although work had already begun in improving leg ulcer care provision within the locality, this audit highlighted new issues, e.g. lack of chronic oedema awareness and management strategies. 30 JCN 2017, Vol 31, No 6

8 CHRONIC OEDEMA Table 2: Audit results from the community setting* Audit results Time between referral and initial contact/review Time between referral for leg ulcer treatment and initial nursing leg assessment/leg template completion Who undertook the leg ulcer assessment/ completed the template Has the patient been identified as having chronic oedema Date of vascular assessment (Doppler) Doppler undertaken by whom Community setting 100% within one week of initial referral 0% between two to four weeks of initial referral 0% over one month after initial referral 50% of patients received no initial leg ulcer assessment/ template completed 50% of patients received partial template completion within 143 days 100% of patients assessed by leg ulcer nurse 10% not assessed 60% assessed as having oedema 30% assessed as not having chronic oedema 10% historical Doppler before referral to clinic 10% on initial assessment 10% within one month of initial referral 50% over two months of initial referral 20% no Doppler recorded 62.5% leg ulcer nurse 0% registered nurse 37.5% assistant practitioner Which care plan has been set following 80% venous ulcer care plan leg and Doppler assessments 20% mixed aetiology care plan 0% amended care plan, e.g. chronic oedema/ ema/ lymphoedema Who set the care plan 60% leg ulcer nurse 40% registered nurse 0% assistant practitionerioner Was appropriate treatment/ 70% yes plan prescribed 30% no 0% treatment plan not clear on patient record Length of time on caseload Average length of time on caseload was days * Results were calculated from responses to audit questions, which were collected by the author and recorded on a spreadsheet The audit also demonstrated that chronic oedema was underrecognised and therefore the service is not meeting the needs of these patients, which h has a knock-on effect for the patient, both physically and mentally, ly, and the service is wasting resources and time by mismanaging patients care. JCN REFERENCES Atkin L (2014) Lower-Limb oedema: assessment, treatment and challenges. Br J Community Nurs 19(suppl 10): S22 S28 Bianchi J, Vowden K, Whitaker J (2012) Chronic oedema made easy. Wounds UK 8(2). Available online: com/pdf/content_10473.pdf Bianchi J (2013) The CHROSS checker: a tool kit to detect early skin changes associated with venous and lymphovenous disease. J Community Nurs 27(4): 43 9 Billington R (2008) Chronic oedema, recognising your skills. Br J Community Nurs Supplement April: S3 5 Billingham R (2007) Chronic oedema. Wounds UK 3(2): Dupuy A, Benchikhi H, Roujeay J, et al (1999) Risk factors for erysipelas of the leg (cellulitis): a case control study. BMJ 318(7198): Evans K (2017) Improving wound care through reducing variation in practice. J Community Nurs 31(2): 20 1 Guest J, Ayoub N, Mcllwraith T, et al (2015) Health economic burden that wounds impose on the National Health Service in the UK. BMJ Open; 5:e Available online: content/5/12/e Wound Wound Care Peop Harding K (2015) Simplifying venous leg ulcer management. Consensus recommendations. Wounds International Hospital Episode Statistics data (2015/2016) obtained via personal correspondence with industry representative. Date of communication 30 March, 2017 Keast D (2013) Lymphoedema. In: Flanagan M, ed. Wound Healing and Skin Integrity: Principles and Practice. 1st edn. John Wiley & Sons Mahoney K (2015) Identifying and managing wet or leaky legs. Skin Care Today 1(1): Moffatt C (2003) 03) The hidden epidemic. Br J Nurs 2(4): S53 4 Moffatt C, Franks F, Doherty D, et al (2003) Lymphoedema: an underestimated health problem. QJM 96(10): Moffatt C, Pinnington L (2012) Project Evaluation Report. Facilitating development of community based lymphoedema services through clinical education: A report prepared ple Ltd for the East Midlands Health, Innovation and Education Cluster. University of Nottingham and Derby Hospitals NHS Foundation Trust Newton H (2011) Chronic oedema of the lower limb: pathophysiology and management. Br J Community Nurs 16(4): S4 S12 NHS England (2014) Five year forward view. Available online: wp-content/uploads/2014/10/5yfv-web.pdf (accessed 20 May, 2017) Norfolk County Council (2012) Demography and information in Norfolk. Available online: (accessed 20 May, 2017 Schofield J (2013) Skin integrity and dermatology. In: Flanagan M, ed. Wound Healing and Skin Integrity: Principles and Practice. 1st edn. John Wiley & Sons Stalbow J (2004) Preventing cellulitis in older people with persistent lower limb oedema. Br J Nurs 13(12): Todd M (2013) Chronic oedema: impact and management. Br J Nurs 22(11): Todd M (2015) Best Practice: treating chronic oedema and venous disease. Nurs Residential Care 17(2): 82 6 Wounds UK (2013) Optimising venous leg ulcer services in a changing NHS: A UK consensus. Wounds UK, London Wounds UK (2016) Best Practice statement: Holistic management of venous leg ulceration. Wounds UK, London JCN 2017, Vol 31, No 6 31