Vascular Surgery Blog
Guest blog by Muhammad Kabeer
The accompanying presentation can be found in the Vascular Surgery Document Repository.
Over the years the practice of Vascular Surgery has changed hugely. This has been brought about partly due to the rapid development of new techniques in minimally invasive diagnostic and interventional procedures and partly by the demands of the ageing population, ever increasing co-morbidities, increasing demands on inpatient beds, shortage of trained specialist staff and the recommendations of the Vascular Society of GB & I.
The changes in practice brought about in D&G Vascular Services focussed on three key aspects of service provision. These are discussed below and can also be accessed in a power point presentation on the vascular surgery document repository.
- Development of Vascular Laboratory with a trained Vascular Scientist (band 7) performing Duplex scans for primary infra inguinal disease, surveillance for interventions, fistulas and aneurysms (and some supra inguinal and visceral cases).
- These are often performed as a one-stop procedure on the same day of the initial clinic review.
- Surgeon-led Endovascular Service:
- Both surgeons are endovascular trained; hence able to perform interventions without the dependence on interventional radiology service.
- Vascular Nurse Specialist:
- Development of Vascular Nurse Specialist who is able to share some of the primary outpatient workload.
- Able to conduct independent clinics and help with angioplasty lists.
Change of primary modality of imaging to Duplex scans for below the groin disease assessment, treatment and surveillance post treatment has reduced the dependence of the service on radiologists for reporting, freeing up their time for other assessments, is safe as there is no radiation involved, can be performed buy a band7 nurse. This has reduced the CT requests from the Vascular Services by about 50%.
The Surgeon-led Endovascular Service has had a big impact on major operative procedures. Most patients are treated under local anaesthetic as day cases or 23 hour admissions. This has also reduced the dependence on interventional radiologists and gives the surgeons to perform hybrid procedures independently. Overall, it has reduced the risks of interventions in the vascular patient group, reduced bed occupancy both in the wards as well as in the HDU/ ICU setting and freeing up anaesthetists for other major specialties. It has also given us the opportunity to train more surgeons with a similar mindset to develop services elsewhere.
The ability to develop the Vascular Nurse Specialist (VNS) service has been fundamental to the provision of this service. Our nurse is highly trained and is able to assess patients and arrange investigations after primary care and inpatient referrals (e.g. for claudication, varicose veins and chronic ulcers). In the current environment of shortage of middle grade doctors and increasing workload on consultants; this is an invaluable recourse. The VNS also maintains databases for AAA surveillance and surveillance of post procedure cases (bypasses and angioplasties/stents). She is also a trained nurse with prescription rights so is able to prescribe and is also trained to assist with angioplasty sessions. She is able to give advice on specialist dressings for inpatients and community nurses and is actively involved in training other nursing staff in specialist wound management and works closely with the dermatology team and tissue viability nurse specialist.
Explanation of graphs in power point presentation: These slides clearly show that over the period from 2015- 17, due to the changes in D&G Vascular Service provision, the number of endovascular interventions for limb salvage has increased (graph 1). The number of major arterial reconstructions has reduced (graph 2). The number of major amputations has reduced and the number of minor amputations has increased pointing towards good outcomes in terms of limb salvage (graph 3). This is comparable to other boards who are working towards a similar model.
In January 2019, the Digital Health and Care Institute (DHI) began work with the NHS Scotland Vascular Surgery Specialty on improving pathways for patients and staff. Under the umbrella project The Scottish Access Collaborative, the specialty group and the DHI team will work together to unpick current vascular surgery services and make recommendations for service innovations based on the findings and insights gathered over the coming months.
The aim of the Scottish Access Collaborative is to sustainably improve waiting times for patients waiting for non-emergency procedures. The program is guided by its six founding principles which foreground patient experience, clinical benefit, and transparent services. The six principles can be seen here.
The DHI was established as a collaboration between the University of Strathclyde and the Glasgow School of Art and is part of the Scottish Funding Council’s Innovation Centre Programme. It is part funded by Scottish Government. DHI support innovation between academia, the public and third sectors and businesses in the area of health and care.
The DHI was commissioned by Scottish Government to design workshops for the Scottish Access Collaborative clinical specialty-led programme. These workshops involve a range of clinical staff from primary and secondary care, health managers, patients and third sector organizations undertaking a cycle of design-led workshops.
In this first workshop, the aim was to map out the common symptoms and conditions vascular surgery deal with currently as part of their non-acute out-patient service, and prioritize what issues the group want to focus on in the next two workshops.
Common Symptoms: Why focus in this?
Through a discussion around common symptoms and opportunities for improvements, the group focused in on a number of areas for focus for the next two workshops.
To help prioritize the aims for the next two workshops, it was useful to reflect on each common symptom and ask ‘why’ this would be a good area to focus on, highlighting the key issues and opportunities for innovation and improvement.
- THROMBOPHLEBITIS (Inflammation of the superficial veins): This is the most common vascular issue seen within primary care and numbers are increasing due to an ageing population. While there are a high number of patients with this symptom seen in primary care, only around 5% are referred into secondary care. New guidance advises referral for all cases of thrombophlebitis for scanning. This will be a major change in practice in primary care and will greatly impact on the provision in secondary care of the facilities and expertise for scanning. Preempting this increase demand will be essential to managing waiting times for vascular surgery specialty centres. This symptom can be linked to lifestyle issues such as obesity. Generally, patients with this symptom should be referred into secondary care, this is not done often enough at the moment. There is a risk that it can develop into a deep vein issue which is more dangerous. An ultrasound is a common test for patients presenting with this symptom. Some GPs however do not have access to the necessary ultrasound machines, or a practice nurse with enough time to carry out the test, requiring that the test be performed in secondary care. In some cases, patients once referred are vetted to an ANP led, consultant supervised clinic for tests and treatment, but this is not a national service. After treatment, a small number of patients return to the GP if there are complications.
- CLAUDICATION (pain when walking): Within primary care, this makes up around 10% of referrals. Most patients are referred to secondary care, and are usually anxious. This makes up 60% of secondary care outpatient appointments and is mostly seen by consultants. There is a variety of reasons why people present with this symptom, some are urgent some are routine. There can be co morbidities issue with this symptom for example heart disease, strokes, kidney disease, diabetes (generally vascular related disorders). Claudication is usually not urgent however, this depends on the severity in combination with other symptoms. In some cases, it is important to assess and treat early due to a higher chance of complications and losing parts of the body. Claudication is often linked to lifestyle issues. It is important to take control of these lifestyle issues before seeing a specialist for tailored treatment. Most often, imaging or assessment is needed and this takes up time and resource within radiology departments.
- VARICOSE VEINS: It is a significant resource to treat these patients, even when managed with injections and minimally invasive treatments rather than surgery, but mostly it is a cosmetic issue and has little clinical value. There are very strict guidelines for referral into secondary care, only patients with complications can be referred as this is not life or limb threatening (example complications include: recurrent thrombophlebitis, pain, bleeding, ulcers and eczema). Varicose veins are often an issue post pregnancy and can cause significant discomfort, it can be difficult to decide what to do when veins are causing discomfort, are large but asymptomatic. Suggesting private sector treatment can create inequalities. There is a need to balance potential gains against treating conditions that are more serious and need this time and resource.
- ULCERS: GPs see a lot of leg ulcers and it can be difficult to know where to refer therefore primary care are dealing with a lot of this issue. They can occur as part of vein issues or artery issues or they can be just a skin issue which tends to be a dermatology issue, most of the time the GP will refer to vascular for diagnostic and treatment, Currently, patients often only get referred if the symptom is long-standing. This means, a lot of time and resource will have already been spent in primary care involving tissue viability nurses and district nurses doing dressings. Community and primary based care is costing a lot of time and money. Keeping on top of dressings cost a lot of money and is very materially wasteful for example. The threshold for referral is probably too high. Secondary want to see these patients earlier to asses and diagnose and deal with any underlying issues quickly, yet this is not well known. Foot clinics and podiatry are helpful for foot ulcers, however there are long waiting times and very strict referral criteria or availability of house visits where people can walk little, as this is a very stretched resource.
- ANEURYSM: Aneurysms are sometimes identified during screening, but are more often incidental findings in ultrasounds done by GPs. This is a small percentage of referrals to secondary care. Patients are vetted and generally sent for a test, some are seen in clinic, some are discharged via a letter. In some cases, the patient may return to the GP for reassurance after receiving a letter. If the aneurysm changes patients must return to their GP to be re-referred to secondary care. This raised the question: do patients need to go back to the GP for re-referral?
- GENERAL: a general point raised by the group was that there are not enough exercise programmes to refer to. Rehabilitation programmes are good because there is a lot of psychology input in how to deal with illness, and how to self-manage going forward.
The next steps for vascular surgery will be to dig deeper into the issues and opportunities for the identified prioritised areas and highlight any recommendations for service improvements in line with the Access Collaborative principles. This will take place over two further design workshops facilitated by the DHI team. While the Access Collaborative aims to develop new ways of working for NHS services, there is also recognition that there are national work programs already underway as well as existing innovations in individual boards and hospitals. Over the coming months the DHI team will also work with the vascular surgery group to promote relevant national initiatives and share examples of best practice through this blog.
If you would like to know more about this work or would like to attend the next workshops, please contact the DHI project team via email
Guest blog by Dr. Rita Rigg, General Practitioner
Superficial Venous Thrombosis is now the recommended more accurate description of the condition previously widely known as Superficial Venous Thrombophlebitis. Recent evidence (BMJ MAY 2018) (DTB 2017;6:66; SIGN 2014 CG 122) shows that our previous management of Superficial Venous Thrombosis in which up to 77% have resulted in missed DVT needs to change. The guidelines eg REFHELP have not been kept up to date with the changes recommended by this evidence.
Superficial Venous Thrombosis occurs in varicose veins in 80-90% of the time. Immobility and high BMI are amongst several risk factors. Dupleix ultrasonography is considered the optimal venous imaging modality and is recommended to confirm the diagnosis, to exclude DVT and define disease extent. Clinical examination alone will underestimate the extent of Superficial Venous Thrombosis in up to 77% of cases. Additionally an associated DVT is reported in 6-53% of cases. As such the recommendation is that all patients with suspected Superficial Venous Thrombosis should be considered for referral, duplex imaging and ongoing management especially if patient is at high risk ie.-
- If the Superficial Venous Thrombosis is close to the sapheno- femoral or sapheno-popliteal junctions
- If More extensive eg>5 cms or progressive Superficial Venous Thrombosis especially if above knee
Patients with thrombus near the junction may be considered for anticoagulants or surgical intervention. Once acute phase has passed then referral is useful to guide intervention to reduce risk of recurrence.
Due to this major change in recommendations for management of Superficial Venous Thrombosis there will be an appropriate evidence based increase in demand from primary care for scanning for diagnosis at DVT clinics. How this is provided will need to be ascertained by secondary care eg could scanning be done by trained HCSW, technical scanners. Treatment is available and effective following accurate diagnosis.
Preventing Superficial Venous Thrombosis by reducing immobility and obesity is essential. Dieticians and phsyiotherapists are needed to provide this service in the community.
Guest blog by Dr. Rita Rigg, General Practitioner
The estimated prevalence of leg ulcers in the population is 0.1 to 0.3% in UK with a risk of developing a leg ulcer in ones lifetime estimated to be 1%.
60-80 % of leg ulcers have a venous component. Venous leg ulcers are the most severe manifestation of venous disease caused by venous hypertension. Mixed arterial - venous causes affect up to 26% of patients. 9% occur in cases of rheumatoid arthritis. 5% have diabetes.
The cost of treating an ulcer is over £1600 / year. The total annual cost in Lothian for dressings is £3.72 million (ISD).
The mainstay of treatment is compression bandaging where ABPI is more than 0.6.
Management advised is to offer early referral to vascular specialists for ulcers that have not healed within two weeks of treatment or that recur. (ÉVRA trial Semin vascular surg 2015:28:54-60)
Duplex USS can confirm diagnosis.
Early endovenous ablation of superficial venous reflux promotes healing of venous leg ulcers. Surgery can be performed for arterial revascularisation as indicated.
Best medical therapy for arterial cause should be given. Refer early to vascular surgeons. If not either venous or arterial cause found refer dermatology (optimal skin care, patch testing, malignancy), plastic surgery (grafting), rheumatologist (Vasculitis), diabetologist (association), haematogist (anaemia, polycythemia)
Amongst the risk factors are high BMI and sedentary lifestyle. Providing dietary and phsyiotherapy services in the community will reduce risk factors.
Service requirements to provide optimum, cost-effective, evidence based timely care:-
- Facilities and resources to provide timely vascular specialist investigation and intervention
- Resources in primary care to provide weight management programmes and physiotherapy services
Guest blog by Professor Roy Scott, Consultant Vascular Surgeon
& Professor Eamonn Brankin, Clinical Director of Primary Care, NHS Lanarkshire
More than 7,000 patients have now used the Community Claudication Clinic service which has been extended across 10 localities in NHSL over the last 12 years. We presented our 10-year experience at the 2016 ESVS meeting in Copenhagen, below is a copy of our abstract for information. Hopefully this gives a sense of how things have developed.
Introduction: In 2004 the waiting time for the Vascular Out Patient Clinic (VOPC) at one of the hospitals in Lanarkshire reached 511 days. Many patients referred to VOPC did not have peripheral arterial disease (PAD). The few patients who did have PAD rarely needed any hospital investigations or treatment. In 2005, as a result of collaboration between a local vascular surgeon and general practitioner, we introduced nurse-led Community Claudication Clinics (CCCs) with the aim of reducing waiting times for assessment and diagnosis, and introducing a more cost effective approach designed to ensure earlier appropriate risk factor modification and lifestyle advice, with more rapid referral to VOPC when necessary.
Methods: Retrospective analysis of 5570 patients identified from a prospectively collated database through a combination of electronic case note review, radiology archive software (PACS) review and theatre database analysis.
Results: The CCC service has grown from a clinic in a single health centre to a regional service managed by NHS Lanarkshire in ten localities around the county. Between June 2006 and December 2015, 5570 patients were assessed at CCCs. The average waiting time was 81 days (+/− S.D. 42). The cost for one attendance is estimated at £51 for CCCs, compared with £156 for VOPC. 3400 (61%) had Intermittent Claudication (IC) excluded as the cause of their leg pain by one visit to our CCCs in primary care. 2170 (39%) of patients had the diagnosis of IC confirmed. 1002 (18%) met agreed criteria for referral to VOPC for specialist surgical assessment. Of this subgroup, 650 (65%) did not require any vascular imaging and were treated conservatively; 198 (20%) underwent arterial imaging but did not require open surgery or endovascular intervention; and 164 (16%) had imaging and intervention.
Conclusion: 82% of patients referred to the CCCs with suspected PAD were managed by that service in primary care. CCCs are safe and offer quicker and more cost-effective access to appropriate risk factor modification, supported by a multidisciplinary team. In the important subgroup who required referral from CCCs (in primary care) to VOPC (in hospital), about one third needed vascular imaging or intervention. There was no evidence of any delay to necessary treatment.
For more information, please contact Professor Roy Scott: email@example.com
In February 2019, the Scottish Access Collaborative Vascular Surgery specialty reconvened for their second design led workshop. The ultimate aim of the collaborative is to collectively enhance clinical pathways for staff and patients so patients who need primary and secondary care are identified, diagnosed, and treated appropriately and efficiently. This will involve mapping current service designs, identifying current issues, responding with ideas for new innovations, and also identifying and replicating best practice where possible. In the first Vascular Surgery workshop, some common symptoms were proposed and some common issues identified resulting in a number of specific symptom profiles. This second workshop reviewed the proposed symptoms, enhancing the existing symptom profiles by adding more issues, developing some focussed challenges in the form of ‘how might we’ statements, and proposing some initial ideas for improvements. The reason for developing how might we statements is to combine and prioritise some of the main issues for Vascular Surgery into individual manageable tasks that form the basis of new ideas and innovations that the group will propose and detail in the next phase.
What follows are short summaries of the enhanced key symptom profiles for Vascular Surgery as well as a summary of a general discussion, the how might we statements that developed as part of the group discussion and, in some cases, some initial ideas of how to improve current services.
Summary: patients suffering Claudication can be complex, often with multiple conditions. It can be difficult to diagnose exactly what the issue is and therefore it is difficult to treat. Many referrals to secondary are for diagnosis of the cause of pain rather than for treatment. It can be significantly limiting to a patient’s quality of life, enhancing their desire for surgical intervention. Variation across boards in available resources limits the extent to which intervention can be offered equitably. Conservative management can offer an improvement in quality of life for patients, however, appropriate and timely intervention can prevent deterioration, which if left unchecked, can result in more serious amputation. The amputation of a limb has a significant impact on a patient, a direct economic cost, plus a societal cost. The treatments for Claudication can be very expensive and poor general health and fitness will affect how effective it is, so there is an issue around health messaging and this symptom. There are examples of community based vascular clinics with MDT input from community nurses, GPs, and secondary care vascular services that present a potential model of best practice. These community claudication clinics offer support to tackle risk factors that make the condition worse (including smoking, exercise, and diet). In terms of procedures, there is an issue with the capacity within vascular surgery to perform angioplasty and to train others to perform angioplasty. Another issue regards the benefit versus the investment of procedure for some patients.
How Might We….
- Anticipate improvements in treatments and the impact on staffing levels?
- Better train in treatments and new technologies (i.e. angioplasty)
- Improve national access to angioplasty?
- Assess the total cost of complex cases of claudication across the health and social services?
- Recruit more radiologists?
- Scale up claudication clinics nationally?
- Improve public health messaging, for example about smoking effect on circulatory system.
Roll out community claudication clinics
Summary: These patients are not generally referred to for vascular input and are often managed in primary care with prescribed anti-inflammatories. A recent change in clinical guidelines suggests that all patients suspected of having thrombophlebitis should be referred for an ultrasound scan to confirm or exclude diagnosis. There is an issue with capacity to withstand this change in current services. This raised the questions: What are the options for ‘clustering’ for ultrasound scans in primary? Can we improve the access to ultrasound in primary?
How Might We….
- Increase access to ultrasound?
Regional clusters for ultrasound scans
Summary: Accessibility to diagnostic testing to establish the cause of leg ulcers is felt to be insufficient, despite the fact that definitive diagnosis would be of significant clinical value. Failure to establish the cause can result in life-long management in the community (at significant cost) and increase the risk of complications such as septicemia. There is variation national in regards to who deals with ulcers, dermatology of vascular surgery, and the guidelines vary across boards also. A big issue is that the true cost of ulcers from a holistic end to end system view is not known.
How Might We….
- Better support correct referral from primary care and community services into vascular?
- Increase availability of ultrasound scanning for veins and arteries?
- Catch varicose veins in order to prevent development of leg ulcers?
- How do we know which conditions could be helped by treatment?
- Develop better community support for patients with neuropathy?
- Increase and improve ultrasound training?
- Catalogue the variation of use of ultrasound nationally?
- Better co-ordinate the use of staff involved in the treatment of leg ulcers?
Vascular scientists could be a solution to a lot of the issues. They are trained to do most of all the necessary ultrasound scans for vascular and this takes away from radiology resource, it is non-invasive (don’t need to inject dye to the patient), it doesn’t expose patient to radiation. The scientists only do the vascular scanning work so they have much more experience. Ultrasound is becoming a specialist area in itself.
Summary: Although the risk of limb or life loss due to varicose veins is almost negligible the condition increases the patient’s risk of developing leg ulcers which can severely limit the patient’s quality of life and carries a significant economic burden. Regional variation was identified in terms of which specialty has clinical ownership of these patients. Poor co-ordination of care delivery between the multiple specialties involved (e.g. dermatology, diabetes, community nursing, vascular specialist nurses / consultants) was identified as a significant weakness in current service models.
Summary: it was felt that current pathway/ model of care was sufficiently robust and no action points were identified.
Referrals to secondary care from other specialties (secondary care)
Summary: The number of different specialties involved in the care of patients with various vascular conditions was discussed and the need for improving the co-ordination and integration of cross-specialty treatment was identified as a point for further investigation / discussion. Dealing with foot problems occurring in diabetics is a fairly significant issue for vascular.
Summary: Two key things are happening in vascular: there is a big debate about minimally invasive procedure verses open surgery, there is no evidence yet to show the minimally invasive angioplasty is successful and so the community cannot not endorse a change to endovascular angioplasty. There is no evidence, but the evidence will take a while to come. We need a national platform to find the consensus on this from the clinical community. Raising the questions: What are the criteria for intervention currently in Scotland? What is the variation in practice?
There is variation between boards in terms of service provision. Some boards are more inclined toward nurse led service for example reducing the time spent in hospital for patients, some are more inclined to consultant led service with more time for the patient spent in hospital. Raising the question: Should there be a national approach?
General How Might We….
- Prevent other comorbidities in patients developing?
- Provide consistent information to a patient who has been identified as being at vascular risk?
The next step will be to return to the how might we statements, develop more detailed ideas to address the challenges, and develop some associated action plans. All the agreed actions will be documented as recommendation in the Vascular Surgery report to be published via this site.
In Workshop Two for Vascular Surgery key issues were discussed and some focussed challenges developed regarding ‘how might we’ statements. The statements translate identified issues into opportunities for change. After the last workshop, the aim for workshop three was to return to the how might we statements, develop more detailed ideas to address the challenges, and develop some associated action plans to take forward as recommendations for national reforms in vascular surgery. The intention is to develop ideas that are in line with the access collaborative principles which emphasise patient-centred care, efficient use of resources and high quality at all times. All the agreed actions will be documented as recommendations in the Vascular Surgery report to be published via this site.
What follows are the ‘how might we’ statements tackled collectively in the workshop, the ideas in response to the challenges, summaries of the potential impact of change, and associated actions that can move the ideas toward implementation.
Each idea was developed by a multi discipline group including consultant, GP, patient and managerial representation, with support from the DHI design team.
- Idea 1
How might we: Help people to have a realistic understanding of claudication in order to make changes which matter to help manage their condition and improve overall health?
Idea Name: Community Claudication Management
A community claudication clinic with links to other services like smoking cessation, and easy access to Vascular Services. On offer through the clinic would be services like tailored walking support. It would produce multi-media educational messages, for example positive patient stories. The clinic would run annual nurse training courses. It would be based in primary care and the community. The clinic nurse’s role would include taking ABPI measurement and completing a vascular risk factor assessment, with protocol guidance for referral back to GP for non-claudication cases, and for referral urgently to Vascular Surgery if indicated (e.g. suspected critical limb ischaemia).
If implemented the impact of such a clinic would benefit patients who would have access to positive community management of vascular disease. Vascular services would see a reduction in referrals. Early detection of peripheral arterial disease (PAD), and exclusion of diagnosis would also be a positive outcome. Reduced vascular risk, i.e. cardiovascular and stroke, and appropriate PAD referrals to secondary care including urgent high risk referrals are additional positive effects. A reduction in waiting times for secondary care could also result from this change. Consideration would need to be given to the fact that there would be a transfer of workload to primary and community care, and to supporting patients with life limiting disease to live positively. Success would be measured in vascular referral rates, reduced vascular mortality, reduced lower limb amputation rate, an improvement in a person’s quality of life and the distances they can walk.
To implement national community claudication clinics there should be a review of an existing Community Claudication Clinic in Lanarkshire, as this could form the basis of a template for all other clinics. Virtual solutions, for example video channels and virtual buddies, should be developed to support patients in the clinics. Existing assets that can help with implementation are exercise programs, walking groups, weight management programs and smoking cessation programs, and peripheral artery disease support groups. This first phase should involve primary care, secondary care, the public, the government and the DHI innovation centre. Barriers to this change will be resources (funding, skills, etc.), getting buy in, and being able to apply successful early education. Once established the next steps will be a wider, multi media advertising strategy in primary and secondary care.
The result of all of this will be claudication services in primary care and an improved quality of life for patients.
- Idea 2
How might we: Design an effective leg ulcer service available throughout Scotland?
Idea name: Community Leg Ulcer Clinic
A locality based specialty clinic with available transport for patients. The clinic would deal with comprehensive assessment of ulcers both venous and arterial, and co-morbidities. Easy access to secondary care with direct referral and support from both dermatology and vascular services. The clinics would re-establish community tissue viability services and leg ulcer services. The clinics would develop and promote patient education and information and practical advice, as well as promote positive messaging about prevention. They would provide regular standardised staff training. To develop this will take the input from podiatry, primary care, nursing staff, GPs, ANPs, the public, and health board decision makers.
The value of such a change would be faster healing leg ulcers, better informed patients and families, and evidence based treatments. The success of this change would reflect in a clear referral pathway for primary care, reduced costs for the NHS, a more effective expanded role for nurses, and GPs seeing fewer appointments. This could be measured by the time ulcers take to heal, looking at the cost of dressings, the waiting time to assessment and overall patient satisfaction. Presently there is a lack of nursing resource across Scotland to implement this, and it will need initial funding. Another issue to consider is the potential to increase the workload in the community.
The first steps to implementing change will be to engage primary and secondary care across dermatology and vascular (currently referrals are sent to both) to implement SIGN guideline 120. This will address the lack of clarity on the correct referral pathways. The immediate challenges to implementing change are that current assets including district nurses and tissue viability nurses are too busy, and there is a lack of funding and resources. The next step will be to embed and implement nurse led leg ulcer clinics nationally. This will involve looking at the current approach in Lothian to influence the national approach. Key will be taking an MDT approach to support and advise the clinics, using phone and email to enable the close relationship between clinics and the wider team that the clinics will need. The service should look at the potential to involve Podiatry services. It will be important to implement adequate training and support for clinic staff. This will involve input from dermatology, vascular surgery, and GPs. Also, important will be education and awareness for the public.
Implementing this change has the potential to create the perfect leg ulcer service. Characterised by improved access, quality of service, and reduced repeat investigations i.e. dopplers.
Outwith the very focused discussions summarised above, there were also some general but important points raised that should not be overlooked.
Transport for claudication patients can be a big issue. They need help to get to appointments but currently help is only available for hospital visits. Even though community care is often most appropriate, patients with mobility issues who need help with travel would be unable to get there with the current system. On idea that would combat this was for community clinics to do home visits where appropriate.
Varicose Veins present an opportunity for a national approach and currently there is a variation in referral guidelines and practice nationally. Currently there is a conflict of opinion in terms of when and how they are dealt with. On one hand, there is a school of thought that subscribes to early intervention with symptomatic patients to prevent further issues. On the other hand, the opinion is to wait until there are more significant complications. There is a NICE guideline that could be implemented, the consensus of the group was that following the guideline would be a positive step to dealing with varicose veins before they develop into something more serious like leg ulcers. This would have the dual effect of saving money for the NHS in the long run, and improving a patient’s quality of life, leg ulcers cause significant discomfort and can be life limiting leading to other issues.
While difficult to enact, behavioural change for patients at risk of vascular issues should be a key aim for the health service. Focus needs to change from the symptom, i.e. claudication, to the broader vascular health risks resulting from lifestyle choices. The service needs to motivate change in people with the simple message; making changes that count. The message will not be enough, and thought should be given to specific supports that people need and can use. For example, looking at tailored exercise programs for claudication, including support to understand the pain felt by patients, what that means, and how exercise is actually helping. As well as practical advice and education about products that can help them, like walking sticks.
The next steps will be for the DHI design team to collate the ideas and recommendations into the Vascular Surgery report. The report will be circulated around the Vascular Surgery Community for comment before it is published via the SAC Turas website. Once the published, the ideas and recommendations will be presented to the SAC board with the aim of identifying which can be taken forward for further development and implementation.
Chronic venous insufficiency (CVI) affects between 20% and 40% of the adult population. Venous leg ulcers (VLU) are chronic wounds, caused by venous insufficiency and are the most common type of leg ulcer, affecting around 1% of the population and 3% of people over 80 years. The main risk factors for VLUs include family history, deep venous thrombosis, age and obesity. Specific groups affected by VLU include:
- People with reduced mobility
- Multiple co-morbidities e.g. obesity, diabetes
- People who inject drugs (PWID)
- Homeless/Chaotic lifestyles
VLU most often occur in the gaiter region of the lower leg, from mid-calf to just below the ankle. A VLU is defined as an open lesion between the knee and the ankle joint that occurs in the presence of venous disease and takes more than two weeks to heal or occurs in someone with a previous history of venous leg ulceration.
It is estimated that 93% of VLUs will heal in 12 months and that 7% remain unhealed after five years. Repeated cycles of ulceration, healing and recurrence are common and recurrence rate within three months of healing can be as high as 70%.
In a recent study from the UK which included over 500 patients with VLU, it was noted that:
- Patients with a VLU were predominantly managed in the community by nurses with minimal clinical involvement of specialist clinicians
- Up to 30% of all the VLUs may have been clinically infected at the time of presentation
- Only 22% of patients had an ankle brachial pressure index recorded in their records
- 53% of all VLUs healed within 12 months
- Mean time to healing was 3months
- 13% of patients were never prescribed any recognised compression system and 78% of their wounds healed
- In comparison 87% of patients were prescribed arecognised compression system and 52% of their wounds healed.
- The VLU healing rate was lower in patients with a putative infection, and the mean time to healing was longer. Furthermore, the cost of wound management of an uninfected VLU was at least 69% less than that of a wound with a putative infection
Assessment and Treatment
NICE and International guidelines agree that all patients with a wound on the lower leg should have a holistic assessment, including Doppler APBI, to assess arterial supply. Once the assessment is complete the decision will be made dependent of findings:
- If the limb has poor arterial supply, e.g. ABPI below 0.8 or above 1; the patient will be referred to vascular surgeons for full assessment for suitability for surgery.
- If there is sufficient arterial supply, e.g. ABPI between 0.8 and 1.3; then ‘Gold Standard’ treatment of full compression therapy can be prescribed.
- Ulcers with ‘mixed’ aetiology, e.g. ABPI between 0.6 and 0.8 and increased pain; will require referral to vascular for assessment but may be suitable for modified compression.
Compression therapy aims to support venous return and prevent the build-up of fluid and toxins in the tissues to support wound healing. Compression therapy can be provided by multi-layer bandage kits, hosiery kits or stockings or compression wraps. Most systems cover the foot but provide a graduated compression from ankle to below the knee.
As well as assessment for the appropriate compression therapy system there needs to be:
- Assessment and maintenance of skin condition of the leg
- Assessment of oedema
- Wound (ulcer) assessment
- Wound bed preparation. Wound bed preparation may involve removing devitalised tissue and reducing bacterial biofilms to support healing.
- Appropriate dressing to protect the wound bed and manage the level of exudate is required. Exudate levels should reduce once compression therapy starts and the venous return is improved.
- Once healed then long term prevention in the form of compression hosiery is required to prevent the risk of recurrence.
If a patient is not suitable for compression therapy or is non-concordant with treatment then long term management may be the aim of treatment rather than healing.
Experience of patients with Leg ulcers
Patient’s experience a range of concerns related to VLU these include painful, wet, malodorous wounds. They are often distressing and have a considerable impact on quality of life. What matters most to people with ulcers is complete wound healing.
The challenges of patients not having access to correct assessment and management leads to sub optimal care. This can be due to a long wait for assessment with a risk of deterioration of the ulcer leading to a longer time to healing and increased risk of cellulitis and/or sepsis.
VLUs have been found to have a significant impact on patients’ quality of life, with associated personal, social and psychological effects; this also has a considerable financial impact on healthcare providers, as well as a wider social and economic impact.
Resources and costs including Community Nursing
Across the UK it is estimated that total costs to the NHS for VLU is up to £600 million per year. One study showed that the mean NHS cost of wound care over 12months was an estimated £7600 per VLU, with the cost of managing an unhealed VLU being 4⋅5 times more than that of managing a healed VLU (£3000 per healed VLU and £13 500 per unhealed VLU, 2015-16 prices)
Patients with CVI account for between 35-65% of District Nursing caseloads, those who require management of VLU, account for 61-64% of costs of community nursing visits. These include the wound (ulcer) dressings required as well as the compression therapy systems.
Patients with long term leg ulceration are more likely to develop cellulitis and require hospital admissions for IV antibiotics adding to the hidden costs of care related to VLU.
The burden of CVI is likely to increase with changing demographics, with a growing number of people with VLU. The main challenges are around:
- Lack of awareness by general public about prevention e.g. Legs Matter campaign www.legsmatter.org
- Lack of skilled community staff to undertake first line Doppler ABPI assessment and start compression therapy
- Long waiting times for referral to Vascular for full assessment for surgery or other treatments
- Long waiting times for referral to Dermatology for leg ulcer patch testing for allergies/sensitivities
- Variation in care provided from one area to another.
- Non-healing wounds due to underlying co-morbidities
- Non-concordance of patients with compression bandages or therapies
- Lack of follow up to prevent recurrence of VLU
Gold Standard Service for VLU
A ‘Gold Standard’ service for prevention and management of VLU would include:
1stline- General nurses (hospital/community) trained to assess VLU and start treatment of those which fit the criteria for full compression, normal limb shape and no challenges. Also referral to Vascular to assess for surgical intervention to improve healing rates.
2ndLine- Centralised Leg Ulcer or Lower limb Service for each Health Board - run by Clinical Nurse Specialist plus registered nurse(s) to assess and manage more complex VLU or those not suitable for compression and/or redirect to other services dependent on needs. For example linking directly to Lymphoedema services, Vascular surgery, Dermatology and Diabetic clinics.
3rdline- Leg Clubs in each locality/area to support prevention of VLU and maintenance of healed ulcer.
There is a clear need for evidence-based strategies and services to prevent and treat VLUs. Educating health care workers and developing their skills and competencies is essential with centralised services and local support groups to maintain and prevent long term problems.
Author: Ruth Ropper, Lead Nurse Tissue Viability, NHS Lothian, Oct 2019
- Dr. Alison Coull, Nursing Dept. Napier University
- Janice Bianchi, Medical Education Specialist/Honorary Lecturer, Glasgow University.