Leg ulcers continue to be a common cause of suffering for patients and their management places a significant burden on the NHS and nursing workforce.
It is estimated that approximately 2% of the adult population in the UK is affected by lower limb ulceration (over 1 million patients) and yet less than a quarter receive appropriate assessment and treatment (Guest et al, 2020). This unwarranted variation of care and the under use of evidence-based best practice results in sub-optimal healing rates and increased NHS spend. The cost of managing patients with lower limb ulceration is over £3bn each year, this is more than double the spend of any other wound type (Guest et al, 2020).
Much of this burden is predominantly managed in the community with a 399% increase in the number of district and community nurse visits in the last five years, reflective of the 81% of the total annual NHS wound care cost (Guest et al, 2020) currently absorbed by community services.
Despite the evidence available on best practice in lower limb ulceration treatment, there are significant variations in clinical practice. Such variations have been highlighted by NHS England’s “Betty’s Story” under the Leading Change, Adding Value framework (NHS Rightcare, 2017), which provided detailed evidence on unnecessary spend, multiple visits to healthcare providers, elongated healing times, and impact on patients’ quality of life.
In 2019, The Commissioning for Quality and Innovation (CQUIN) for Lower Leg Wounds was introduced as a framework to enhance patient outcomes through excellence and continuous improvement, providing much-needed guidance to drive quality improvement within community services.
Supporting existing evidence-based best practice the National Wound Care Strategy Programme (NWCSP) has influenced and supported the Commissioning for Quality and Innovation (CQUIN) developments including the assessment, diagnosis and treatment of leg wounds (CCG14), which will focus on:
- Timely and holistic assessment;
- Differential diagnosis;
- Correct treatment and vascular referral.
The CQUIN notes that a minimum target of 25% of the local population of patients with lower limb ulcers should receive an accurate assessment, diagnosis and treatment by community nursing services within four weeks.
Criteria 1: Lower Limb Assessment Essential Criteria
The first step to guaranteeing effective high-quality care is to ensure accurate and timely diagnosis (Atkin and Ticklet, 2016). To support holistic assessment The Lower Limb Assessment Essential Criteria has been compiled using detail from the NHS England Leading Change, Adding Value framework minimum data set (Coleman et al, 2017) (Table 4 p 235) and the assessment criteria from the Scottish Intercollegiate Guidelines Network’s guideline for venous leg ulcers (SIGN, 2010).
Criteria 2: A leg wound with adequate arterial supply
Patients with a leg wound above the malleolus (ankle bone) with an adequate arterial supply (ABPI > 0.8-1.3), and where no other condition that contra-indicates compression therapy is suspected, should be treated with a minimum of 40mmHg compression therapy. The NWCSP recommend the use of full therapeutic compression (40mmHg) in the form of two-layer compression hosiery kits as first line treatment (NWCSP, 2020).
In line with this, the Atkin and Tickle (2016) Best Practice Leg Ulcer Treatment Pathway promotes the use of two-layer compression hosiery kits as first-line treatment based on the strength of the evidence base for venous leg ulcer management. This pathway utilises clinical evidence, such as the VenUS IV trial (Ashby et al, 2014) and the EVRA study (Gohel et al, 2018) , ensuring patients receive timely intervention and have the choice for supported self-care.
Criteria 3: Referral to the vascular department
Patients diagnosed with a venous leg ulcer should be referred to the vascular department for consideration of surgical/endovenous intervention.
All patients with non-healing lower leg wounds (>28 days) should be referred onwards to vascular services, unless deemed inappropriate, regardless of whether the differential diagnosis is arterial or venous (NHS England and NHS Improvement, 2022).
These evidence-based recommendations support excellence in assessing, diagnosing and treating of leg wounds to optimise healing and minimise the burden of wounds for patients, the community nursing workforce and the NHS.
To support the assessment, diagnosis and treatment of lower limb wounds, L&R Medical have launched the ‘Lower Leg Wound CQUIN’ learning module on their e-learning platform, LeaRn on Demand.
To access the CQUIN support module sign up to the LeaRn on Demand platform for free here.
To find out how L&R Medical can support you to achieve the lower leg wound CQUIN in your organisation visit here.
Ashby RL et al (2014) Clinical and cost-effectiveness of compression hosiery versus compression bandages in treatment of venous leg ulcers (Venous Leg Ulcer Study lV, VenUS lV): a randomised controlled trial. The Lancet; 383: 9920, 871-879.
Atkin L, Tickle J (2016) A New Pathway for Lower Limb Ulceration. Wounds UK.
Coleman S et al (2017) Development of a generic wound care assessment minimum data set. Journal Of Tissue Viability; 26(4) 226-40.
Gohel MS et al (2018) A randomized trial of early endovenous ablation in venous ulceration. New England Journal of Medicine; 378: 22, 2105-2114.
Guest JF et al (2020) Cohort study evaluating the burden of wounds to the UK’s National Health Service in 2017/2018: update from 2012/2013. BMJ Open 2020; 10(12).
National Wound Care Strategy Programme (2020) Recommendations for Lower Limb Ulcers. NWCSP.
NHS England and NHS Improvement (2022) Commissioning for Quality and Innovation (CQUIN) scheme for 2022/23. Annex: Indicator Specifications. NHSE and NHSI.
NHS RightCare (2017) NHS RightCare scenario: The variation between sub-optimal and optimal pathways. NHS Rightcare.
Scottish Intercollegiate Guidelines Network (2010) Management of Chronic Venous Leg Ulcers: A National Clinical Guideline. SIGN.