A leg ulcer is an open wound between the knee and ankle that remains unhealed for at least 4 weeks (Scottish Intercollegiate Guidelines Network (SIGN), 2010). Leg ulcers are painful, distressing and embarrassing for patients (Anderson et al, 2012). They can cause social isolation, immobility, uncontrolled wound exudate and an unpleasant odour (Vowden et al, 2000; Moffatt, 2004; Dumville et al, 2009). Around 1.5% of the UK population have a leg ulcer and prevalence increases with age (Green et al, 2017). Leg ulcers are very costly to treat and put a strain on healthcare providers (Guest et al, 2017; Gray et al, 2018).
Venous leg ulcers are the most common type (70%) of leg ulcers (Dealey, 1999; Guest et al, 2021). Compression therapy is the mainstay of treatment of venous leg ulceration and promotes healing by reducing oedema and improving venous return (SIGN, 2010; Guest at al, 2018). Compression therapy also helps to prevent ulcer recurrence, which can be as high as 70% (SIGN, 2010; White et al, 2011). While most leg ulcer patients are being cared for in community settings, patients can also be admitted to secondary care because of a complication of ulceration or for a comorbidity where the leg ulcer is not the primary concern.
A point prevalence audit conducted in December 2019 in a large NHS hospital (Lian et al, 2022a) found a significant proportion (8.5%) of hospital inpatients had an open leg ulceration. Of these 80 patients, 36 (45%) were assessed with ankle-brachial pressure index measurements and 25 of these 36 patients (69.4%) were eligible for full compression therapy. However, a recent literature review on compression for inpatients with leg ulcers (Lian et al, 2022b) demonstrated a lack of published evidence on the prevalence of hospital inpatients with leg ulcers and also highlighted the lack of leg ulcer service provision in secondary care settings.
Aim
This audit aims to explore current leg ulcer services including the provision of compression therapy for inpatients affected by leg ulcers in hospitals.
Methods
An online survey questionnaire exploring service provision for patients with leg ulceration in UK hospitals was carried out in November 2020. The survey was created using the SurveyMonkey platform and was sent to delegates at Wounds UK's national conference 2020. The delegates were largely tissue viability nurse specialists but there were other wound care specialists, such as vascular nurse specialists, podiatrists, district nurses and practice nurses. The online survey was also distributed via social media to wound care specialist groups via Facebook and Twitter.
The four survey questions were:
- Does your hospital have a designated service to care for inpatients with leg ulcerations? A. Yes B. No
- Which team delivers the leg ulcer service in your hospital? A. Vascular B. Tissue viability C. Both D. Other E. No service
- Does the leg ulcer service provide compression therapy for the management of venous leg ulcer patients in your hospital? A. Yes B. No
- Is your leg ulcer service an integrated service with the community team? A. Yes B. No
Results
Responses were obtained from 101 health professionals. Out of the 101 respondents, 68 (67.3%) reported there was no designated service to care for inpatients with leg ulceration. This suggests that fewer than one-third of practitioners work where there is such a service.
Of the 33 health professionals who have an inpatient leg ulcer service, 16 (48.5%) reported that the leg ulcer service was delivered by the tissue viability team, followed by 10 (30.3%) who said this was provided by vascular surgery. Only five responses stated that the leg ulcer service was provided by both the tissue viability team and vascular surgery (Figure 1).
Where an inpatient ulcer service was available, 32 of the 33 respondents (97.0%) reported that their services provided compression therapy as part of the leg ulcer care plan for inpatients with leg ulceration. In addition, 30/33 (90.9%) reported that the leg ulcer service was integrated with the community team.
Discussion
This is the first audit that highlights the significant paucity of leg ulcer service provision across NHS hospitals. This survey identified several areas in need of improvement: care inequality; care variation; and quality of service.
Inequality in care for inpatients with leg ulcers
This report highlighted a huge gap nationally in the provision of care for patients with leg ulcers across NHS organisations, with 67.3% of respondents reporting that there is no designated service to care for inpatients with leg ulcerations in their hospitals.
The National Wound Care Strategy's lower limb workstream (NWCSP, 2022) has been striving to improve care for patients with lower limb ulcerations nationally since 2018. However, while much in the way of resources and energy have been put into community settings, provision in secondary care has received little attention. In addition, while a plethora of publications have examined leg ulcer care in the community, little has been discussed regarding this issue in secondary care (Lian et al, 2022b).
Wide variations in the service providing leg ulcer care
Hospitals with an inpatient leg ulcer service should be congratulated for enabling this important part of care. However, clear variation exists regarding their set-up and the overseeing team. The majority of inpatient leg ulcer services were provided by tissue viability teams, followed by vascular surgery, with a small proportion of hospitals providing a combined approach.
These figures demonstrate the wide variations in leg ulcer service provision in hospitals. The reason for these variations are unclear, and may be due to a number of factors that warrant further investigation.
First, if there is no designated leg ulcer specialist service in a hospital, inpatients with leg ulcers are often referred to multiple specialities (Lian et al, 2020). This is because, although the majority of leg ulcers are venous, there are other complex aetiologies such as vasculitis and arterial, autoimmune and haematological disease, and dermatological conditions, which are potential causes (Chen and Rogers, 2007). Furthermore, multiple aetiologies can add levels of complexity when making an accurate diagnosis of leg ulcers (Lian et al, 2022a).
Occasionally, the diagnosis of leg ulceration requires involvement of multiple specialities at different stages, such as tissue viability nurses, vascular surgery and dermatology in the process of decision making. The involvement of multiple specialities may exacerbate variations in care.
Nevertheless, there is an urgent need for a unified approach in NHS organisations for patients with leg ulcers. This could be the role of National Wound Care Strategy's lower limb workstream, which could provide further instruction and directions to healthcare providers.
Quality of care
Although 33 of the 101 (32.7%) respondents reported having a designated service, there is still a question over how well they provide the service and what they actually offer.
Nonetheless, as the data show, the majority of the hospitals (32/33; 97%) providing leg ulcer services for inpatients provide compression therapy and are integrated with community services (30/33; 90.9%). This is encouraging in terms of setting out a future care model for patients with leg ulcers across organisations—an integrated leg ulcer service between community and secondary care.
Further research is needed to evaluate the details of leg ulcer service provision, including leg ulcer policy and guidelines, to benchmark services against national guidelines such as the NWCSP's (2020)Lower Limb—Recommendations For Clinical Care. There is also a need to critically explore the barriers and facilitators associated with the use of compression therapy and leg ulcer care plans for inpatients in secondary care.
Limitations
This audit has two major limitations. First, surveys are a quick and effective way of gathering information in a short period of time and are the most popular data collection method in healthcare settings (Ross, 2012). A drawback is that they can increase the risk of both representation and measurement errors. For example, this survey showed that 33 out of 101 NHS hospitals provided designated services to care for inpatients with leg ulceration. However, the author was unclear how many respondents actually worked in a hospital nor whether there were several respondents from the same institution.
The reliability of the online surveys can be weak—they will not necessarily obtain similar responses when repeated (Ross, 2012). Given that most delegates attending the national Wounds UK conference are wound care experts, the yearly representation could be quite similar. Therefore, repeating a similar survey could generate comparable results. However, if the survey were distributed at another conference, such as that of the Society of Vascular Nurses, the results could be very different.
Conclusion and recommendations
This audit showed there is an inequality in care for inpatients with leg ulceration in secondary care, with more than two-thirds of respondents reporting no designated leg ulcer service to care for these patients. The survey also highlighted the wide variations between leg ulcer service delivery in hospitals.
Further research is needed to evaluate the details of leg ulcer service provision to benchmark services against the national guidelines.
There is also a need to critically explore the barriers and enablers associated with the use of compression therapy and leg ulcer care plans for inpatients with leg ulcers in secondary care.
These proposed studies will close gaps in research and clinical practice with the aims of improving clinical outcomes, streamlining inpatient services, achieving equitable care, meeting patient expectations and achieving patient satisfaction, and enhancing the quality of life for those affected by leg ulcers across healthcare providers.
KEY POINTS
- Patients with leg ulceration in secondary care experience an inequality in care, with gaps in NHS provision and most attention paid to primary care
- Leg ulcer service delivery in hospitals varies widely
- A future care model for patients with leg ulcers could be an integrated leg ulcer service between community and secondary care
- The reasons for variations in leg ulcer service provision in secondary care are unknown and require research
CPD reflective questions
- How important do you think it is for inpatients with leg ulceration to have access to a dedicated leg ulcer service while in hospital?
- What kind of barriers and enablers do you think can influence the implementation of compression therapy for inpatients with venous leg ulceration in your local hospital?
- What factors need to be considered when implementing a leg ulcer clinical pathway in your hospital?