Evidence-based pathway for leg ulcer treatment improves healing times but not quality of life scores

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Julie-Mullings-Wounds UK
Julie Mullings

Implementation of an evidence-based pathway for leg ulcer care in community nursing has resulted in a significant reduction in healing times, according to research conducted by the Manchester University NHS Foundation Trust, Manchester, UK. Although quality of life scores did not increase as expected, it was found that standardising care and embedding evidence-based practice into the everyday practice of nurses had a positive impact.

The findings, which were presented in a free paper session at the Wounds UK annual conference (4-6 November, Harrogate, UK) by Julie Mullings (Manchester, UK), also underlined the importance of patients’ psychological issues and that collecting quality of life data, with the use of a checklist, may not be enough to truly determine how wounds such as leg ulcers are affecting patients.

Mullings opened: “We are aware of the burden of chronic wound care from recent research conducted by Julian Guest, and that leg ulcers represent 34% of all wound types, making it the single largest category of wounds looked at. We also know that 50% of those wounds take 12 months or longer to heal, and treatment practices are not always evidence-based, which can have an effect on the quality of treatment we deliver to our patients.”

Furthermore, it has been established that treatment is negatively affected by delays in assessment and a lack of early intervention, which Mullings emphasised during her talk before highlighting that “all of these elements bundled together really do have an impact on patients’ quality of life.”

In order to combat these barriers to improved treatment, an evidence-based pathway for leg ulcer care that is patient-centred, structured and clearly guides the nurse to evidence-based practices that are the gold standard for care, has been introduced. Moreover, a quality of life wound care checklist first developed by Julie Green (Keele University, Staffordshire, UK)—as the Leg Ulcer Consultation Tool—was incorporated into the pathway, focusing on issues a patient may have when living with a wound.

As part of the quality of life examination, patients were asked to respond to 11 questions upon their initial assessment and every four weeks thereafter. These questions covered such areas as mobility, pain, hygiene and social impact, and the data collected provided an insight into patients’ quality of life during their period of leg ulceration.

On this topic, Mullings added: “At the time that we were launching the pathway and using this questionnaire, we held some focus groups that allowed us to speak to patients in a very informal environment. This included patients with existing leg ulcers, and those with wounds that had already healed. It was possible to talk with them, face-to-face, about what it is really like to live with a leg ulcer and this gave us some real insight as to how we can address quality of life in a much more effective way.”

During the focus groups patients responded that from their perspective, the most important aspects for nurses to consider, when thinking about the impact of wounds, are time to healing, whether there is an odour related to the leg ulcer, and pain reduction. “The least important, which we were quite surprised about,” said Mullings, “were improving sleep and the ability to wear preferred footwear”.

While the implementation of an evidence-based pathway did achieve a positive result, with research conducted by Mullings and her colleague Elizabeth Merlin-Manton (Manchester, UK) showing that 46% of patients healed quicker with a reduction in pain scores of 79%, the anticipated increase in quality of life scores was not demonstrated.

Explaining why this may have been the case, Mullings said: “We decided to look at other factors which could have influenced the results. From further interviews with patients, it became clear that some may have more than one condition, including conditions that we may not be able to influence. As I alluded to before, there was a patient who was awaiting a knee replacement and, as a result, they did not feel as though their quality of life had improved, because the problem with the knee had not been rectified.”

It was also found, Mullings revealed, that depending on how skilled the practitioner was at asking questions to patients, or explaining them, this could sometimes lead to misinterpretation. “This goes back to what we were saying before, about the depletion of expertise in community nursing, which can lead to inaccurate reporting of QoL outcomes,” Mullings commented. She added: “Also, we have seen that some patients do not always want to share their true feelings and experiences.”

Mullings concluded: “When we move to our next phase of looking at quality of life, we will do things a little bit differently. I think we underestimated the complexity of those psychological issues and how interrelated they are to each other, and also how collecting data from a checklist is not enough to determine what is really affecting quality of life for patients.”


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