Implementing evidence-based leg ulcer management

Leg ulceration is a chronic, recurring condition and it is estimated that 1% of adults will have a leg ulcer at some time. The majority of leg ulcers are due to venous disease, with arterial disease, diabetes, auto-immune diseases, and malignancy accounting for about 25%. In the UK, leg ulcers are usually managed by nurses.1 A systematic review of research on compression bandaging concluded that venous ulcers should be treated with multilayer high compression bandaging.2 No particular high compression bandaging regimen was found to be superior; Unna's boot, short stretch bandages, and multilayered elastomeric systems were all effective. Simple wound dressings are generally placed underneath the bandage and over the ulcer to allow healing to occur without drying of the wound and to prevent trauma on dressing removal and sensitisation to topical preparations.
In the Wirral, a mixed rural and urban area in north west England (population 332 000), we implemented 2 effective compression bandaging regimens. The use of appropriate primary wound dressings was also implemented as there is no evidence that semiocclusive or occlusive dressings such as foams, films, or hydrocolloids are more effective than simple, inexpensive dressings (eg, knitted viscose dressings or saline gauze) for venous leg ulcers.3 This paper describes the changes in practice and patient outcomes after the implementation of evidence-based guidelines for assessment, bandaging, and wound dressing.
Baseline audit: An initial audit of leg ulcer care and patient outcomes was commissioned using data collected by local practitioners. The local prevalence of ulceration (1.42 ulcers per 1000 people) was similar to national estimates for the UK. 21 different types of dressings were used. Of 319 ulcers, 83 (26%) were treated with dressings that contained iodine, 60 (19%) with hydrocolloid dressings, and 42 (13%) with knitted viscose dressings. 14 types of cream or ointments and 30 different types of bandages were used, of which only 21% were compression bandages. 25% of ulcers healed in 12 weeks.
In a baseline survey of knowledge and reported practice relating to leg ulcer care, nurses scored an average of 40%.4