2019
WUK BPS
Factors of complexity
Assessment and management
Referral
Common patient-related complexities
Promoting continuity of care and self-care
Recurrence and prevention
Best Practice Statement
Addressing complexities in the
management of venous leg ulcers
BEST PRACTICE STATEMENT:
ADDRESSING COMPLEXITIES
IN THE MANAGEMENT OF
VENOUS LEG ULCERS
PUBLISHED BY:
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Web: www.wounds-uk.com
© Wounds UK, May 2019
is document has been developed
by Wounds UK and is supported by
an unrestricted educational grant
from L&R.
is publication was coordinated
by Wounds UK with the expert
working group and supported by
an unrestricted educational grant
from L&R. e views presented
in this document are the work of
the authors and do not necessarily
reflect the views of L&R.
is publication is endorsed by:
How to cite this document:
Wounds UK (2019) Best Practice
Statement:Addressing complexities
in the management of venous leg
ulcers. London: Wounds UK.
Available to download from:
www.wounds-uk.com
EXPERT WORKING GROUP:
Chair: Jacqui Fletcher, Independent
Consultant
Dr Leanne Atkin, Lecturer practitioner/
Vascular Nurse Consultant, University of
Huddersfield and Mid Yorkshire NHS Trust
Dr Caroline Dowsett, Independent Nurse
Consultant Tissue Viability, Clinical Nurse
Specialist Tissue Viability, East London
Foundation Trust
Sarah Gardner, Clinical Lead for Tissue
Viability, Oxford Health NHS Foundation Trust
Alison Schofield, Tissue Viability Team Lead
and Clinical Nurse, North Lincolnshire and
Goole NHS Foundation Trust
Karen Staines, Director of Wound Care and
Education, Accelerate CIC
Kath Vowden, Lecturer University of Bradford
and Nurse Consultant (Hon), Bradford
Teaching Hospitals NHS Foundation Trust
REVIEW PANEL:
Rebecca Elwell, Msc Lymphoedema,
Macmillan Lymphoedema ANP and Team
Dr Jemell Geraghty, Lead Nurse Tissue
Viability, Royal Free London NHS Foundation
Trust
Anita Kilroy-Findley, Clinical Lead Tissue
Viability, Leicestershire Partnership NHS Trust
Joy Tickle, Tissue Viability Nurse Specialist,
Shropshire Community Health NHS Trust
1
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
is document builds on the Best Practice
Statement: Holistic Management of Venous
Leg Ulcers (Wounds UK, 2016) to address
complexities in the management of venous
leg ulcers (VLUs). is guide is written
for healthcare professionals who have the
appropriate level of skills and knowledge to
assess and treat patients with (or at risk of
developing) VLUs.
e aim of this document is to help ensure
consistent clinical practices in relation to
the assessment and management of people
with VLUs who are outside the scope of
the leg ulcer treatment pathway (Atkin and
Tickle, 2016). It will provide guidance based
on relevant evidence and the experiences
and opinions of clinicians, with a focus
on practical, holistic and patient-centred
strategies.
e Best Practice Statement document
was derived from a one-day meeting of the
Expert Working Group, which convened
to discuss the complexities in VLU
management. Myths and truths of VLU
management were also developed. e
document was further developed by the
Expert Working Group during an extensive
review process involving a Review Panel.
INTRODUCTION
Developing best practice
GUIDE TO USING THIS DOCUMENT
Each section offers advice about best
clinical practice for patients with or
at risk of venous ulceration.
Tables, figures and boxes are included
to guide best practice. e best
practice statement is supported by
key references where possible.
ere is a glossary of terms used in
this document on pages 22–23.
2
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
Introduction and evidence update
INTRODUCTION &
EVIDENCE UPDATE
VLUs are believed to be the most common
chronic wound in the UK. In the Burden of
Wounds study, there were 278 000 patients
with VLUs in the study period, equating to
1 in 170 adults having a VLU. However, this
is thought to be an underestimation as there
were 420 000 patients with unspecified leg
ulcers, some of which will be venous in origin
(Guest et al, 2015).
VLUs pose a challenge as they are recurrent
and may persist for months or years (Harding
et al, 2015). NHS England (2017) has
highlighted that, for many, the management
of patients with lower leg ulceration is sub-
optimal, with unwanted variations increasing
cost and lengthening healing times. e mean
cost is currently estimated at £7600 per VLU
a year, with the cost of managing an unhealed
VLU 4.5 times higher than managing a healed
VLU (£3000 per healed VLU and £13 500 per
unhealed VLU) (Guest et al, 2017).
Findings from a recent retrospective
cohort analysis of 505 patients suggest that
compression therapy is not being initiated or
used correctly; only 53% of all VLUs healed
within 12 months, and the mean time to
healing was 3 months (Guest et al, 2018).
Possible reasons suggested by the group were
that patients were predominantly managed
in the community with minimal clinical
involvement of specialist clinicians; up to
30% of all the VLUs may have been clinically
infected at the time of presentation; and only
22% of patients had an ankle brachial pressure
index (ABPI) documented.
Patient-, wound-, healthcare professional-,
resource-/treatment-related factors contribute
to the sub-optimal use of compression.
Compression therapy may not be initiated
or maintained due to lack of clinician skill
and resource, time and confidence. e
inadequate use of compression therapy leads
to mistargeted use of human and financial
resources that may not aid healing of the
wound, and can lead to increased chronicity,
infection and other complications (Mullings,
2018). e use of therapeutic compression
should be improved and made more
consistent throughout the UK.
Since the Best Practice Statement: Holistic
Management of Venous Leg Ulcers (Wounds
UK, 2016), further evidence for VLU
management has been published. e Early
Venous Reflux Ablation (EVRA) randomised
controlled trial (RCT) investigated the
impact of early endovenous ablation in
patients with venous ulceration (Gohel,
2018). e study concluded that early venous
intervention resulted in faster healing of
VLUs, and more time free from ulceration
than deferred intervention.
Multidisciplinary team approach
A multidisciplinary team (MDT)
approach is an important feature for VLU
management to promote continuity of care
(Kjaer et al, 2005; Harding, 2006). However,
the findings from the Burden of Wounds
study suggest that the MDT approach is
not always available or implemented (Guest
et al, 2015), impacting on patient care and
outcomes.
A ‘seamless service’ through integration,
coordination and the sharing of
information between different specialists
and teams can promote continuity of care
(Gulliford et al, 2006). An MDT approach
improves healing, can protect at-risk
patients and prevent VLU recurrence.
Additionally, patients who are part of a
continuous care plan can benefit from
education that allows them to self-manage
(Wounds UK, 2015).
Leg ulcer treatment pathway
Following an established, evidence-based
pathway for the management of VLUs
provides consistency and continuity of
care. e leg ulcer treatment pathway
(Figure 1) was developed by Atkin and
Tickle (2016), and adopted in the
Best
Practice Statement: Holistic Management
of Venous Leg Ulcers
(Wounds UK, 2016).
It guides first-line clinicians on the most
appropriate VLU management with the aim
of earlier referral and access to specialist
services for patients where non-healing is
3
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
INTRODUCTION &
EVIDENCE UPDATE
apparent. It
highlights the requirement of
an MDT approach to VLU management
(including the requirement for venous
imaging). Additionally, it promotes the
use of compression hosiery kits to be used
first line, and, where possible, encourages
Figure 1. Leg ulcer treatment pathway (Atkin and Tickle, 2016; 2018; Wounds UK, 2016)
Patient with a wound on the lower limb
Holistic patient assessment including:
■ Past medical history
■ Limb assessment
■ Ulcer history
Consider other causes
and refer to appropriate
specialist:
■ Dermatology
■ Malignancy
■ Pressure
■ Autoimmune
■ Arterial
■ Diabetes
Unable to ABPI, refer to
vascular nurse or TVN
*Consider why exudate is not
controlled with topical dressings,
is there any evidence of infection
or increased bacterial load, is the
dressing size/choice appropriate
for exudate amount?
ABPI 0.8–1.3
No evidence of
signicant arterial
disease, safe to compress
(high compression)
Perform ABPI
Signs of venous
disease/oedema, e.g.
varicosities, skin
changes, skin staining,
oedema, eczema?
ABPI <0.5
Urgent referral to
vascular centre,
no compression
ABPI 0.5–0.8
Mixed disease, refer to
vascular centre/tissue
viability team, reduced
compression (max
20 mmHg) following
specialist advice
No*
Yes
Yes
No
No
Is the exudate
controlled within
topical dressing?
Is there a large
amount of
reducible oedema/
limb distortion?
Apply inelastic
compression
bandage system
When oedema and limb
distortion controlled,
change to European
classication hosiery
40 mmHg kit
After 4 weeks of treatment, if
there is no reduction in ulcer
size refer to vascular/tissue
viability service for review.
If the wound does not heal in
12 weeks, refer to vascular/
tissue viability service for
review.
Compression
hosiery kit
40 mmHg
Once leg ulceration is healed,
refer to recommendations in Best
Practice Statement: Compression
Hosiery (2nd edition) (Wounds
UK, 2015). Consider referral to
vascular services to assess need for
venous intervention to reduce the
risk of recurrence, as per NICE
guidelines CG168 (2013)
If oedema present,
apply inelastic
compression
bandage system
If no oedema
present, apply
elastic or inelastic
compression
bandage system
Re-assess
weekly
Yes
If suspected venous ulceration,
please refer to vascular centre
for consideration of venous
intervention
DO NOT WAIT FOR REVIEW
PRIOR TO COMMENCING
COMPRESSION.
ABPI >1.3
Consider calcication,
assess foot pulses,
Doppler waveow.
Consider referral to
vascular centre and/or
tissue viability
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
4
INTRODUCTION &
EVIDENCE UPDATE
patients to self-care and be monitored by
non-registered practitioners.
Complexity in VLU management
Complexity tends to refer to four key
factors in VLU management (European
Wound Management Association [EWMA],
2008):
■ Patient-related, e.g. comorbidities,
medication, pain, concordance
■ Wound-related, e.g. high exudate,
infection (Vowden, 2005), biofilm
(International Wound Infection Institute
[IWII], 2016)
■ Healthcare professional-related,
e.g. clinical skills and knowledge
■ Resource/treatment-related,
e.g. healthcare systems, availability, cost
(Figure 2).
e term complexity to describe a wound is
not the same as chronicity or a hard-to-heal
wound. A chronic or hard-to-heal wound is
defined as a wound that has not healed in 12
weeks, or if the wound has not improved/
not reduced in area by 40% in 4 weeks
of standard care following the leg ulcer
treatment pathway (Wounds UK, 2016).
Wound complexity increases the likelihood
of wound chronicity and can make a wound
hard-to-heal. When considering wound
complexity, it may be useful to determine the
factors contributing to wound complexity
and if the wound is:
■ Hard-to-assess
■ Hard-to-manage
■ Hard-to-heal.
Wound complexity
Patient-related
factors
Resource/
treatment-
related
factors
Wound-related
factors
Healthcare
professional-
related factors
Figure 2. Complexity in VLU
management
5
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
FACTORS OF
COMPLEXITY
Recognising, understanding and
addressing the factors that contribute
to wound complexity will help direct
treatment and management and impact on
healing progression (Figure 3).
Patient-related factors
Patient-related factors that impact on
wound complexity are varied. Physical
factors, such as older age (over 60) or
comorbidities, such as peripheral arterial
disease or diabetes impact on healing
(EWMA, 2008). Medications may also
impact on wound healing (Box 1).
Psychosocial factors, such as social
isolation, gender, economic status and
pain experience, have also been found
to influence healing (EWMA, 2008).
Concordance (or non-concordance)
is often used to describe a patient’s
engagement in care. Examining and
determining the root of a patient’s
non-concordance is vital, as it may
be manageable, i.e. patient's lack of
understanding of the importance of
treatment, or clinicians’ lack of knowledge
or experience leading to poor patient
education (Stanton et al, 2016).
Figure 3. Factors that may contribute to wound complexity (adapted from EWMA, 2008)
SECTION 1: FACTORS OF COMPLEXITY
Box 1. Medication that can affect wound healing
(Beitz, 2017).
Delay healing
Cytotoxic antineoplastics,
e.g. hydroxycarbamide;
immunosuppressive agents; antipyschotics;
corticosteroids; nonsteroidal anti-
inflammatory drugs (NSAIDs); and
anticoagulants.
Increase oedema
Calcium channel blockers,
e.g. amlodipine; NSAIDs.
Cause ulceration
Nicorandil (Rix and Bull, 2017);
hydroxycarbamide.
Affect surrounding skin
Systemic and topical steroids.
Positive effect
Penoxyifylline is an effective adjunct to
compression bandaging for treating VLUs
(off-label indication) and may be effective
in the absence of compression (Jull et al,
2012). High doses are required and major
gastrointestinal side effects are common.
Caution when prescribing penoxyifylline is
recommended as there are many possible
drug interactions.
Factors that may contribute to wound complexity
Patient-related factors
Wound-related factors
Healthcare professional-
related factors
Resource/
treatment-related factors
Healthcare system
Availability
Suitability
Effectiveness
Cost/reimbursement
Skill
Knowledge
Diagnostic
erapeutic
Interventional
Attitudes and
behaviour
Pathology
Duration/senescence
Allergy
Wound bed condition
Pain
Anatomical site
Comorbidity
Size (area and depth)
Psychosocial
Inflammation/
infection
Medication
Ischaemia
Concordance
Treatment response
Environment
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
6
FACTORS OF
COMPLEXITY
Wound-related factors
Increased wound duration and changes to
the wound size and wound bed condition
are all indicators of healing, and may
indicate a failure in care or sub-optimal
compression. If there has been no
improvement or reduction in wound size in
4 weeks of treatment, this is an indication
that the wound healing environment is not
optimal and the patient should be referred
to specialist services. e initial response to
treatment can be an indicator of subsequent
healing time (EWMA, 2008), healing
potential and wound complexity.
e main cause of venous leg ulceration
is venous insufficiency. Increased venous
pressure leads to a chronic inflammatory
response and local thrombosis (atrophie
blanche), which can result in the breakdown
of skin and ultimately ulceration (Chapman,
2017). However, it is important that the
presence of peripheral arterial disease is
assessed; reduced perfusion deprives tissue
of effective gas and metabolic exchange
required for wound healing.
Inflammation is part of the normal
wound healing response, but a prolonged
inflammatory response is detrimental
to wound healing. Wound complexity
may be influenced by infection, such as a
high bacterial load, and the presence of
more than one bacterial strain or biofilm
(EWMA, 2008).
e location of the wound will also affect
wound healing and management can be
more difficult, e.g. it may impact on the
ability to apply effective compression.
e selection of wound dressings and
compression therapy should preserve
dressing performance and limb function,
and avoid secondary problems, such
as bandage damage on the leg and
exacerbation of oedema on dorsum of foot.
Healthcare professional-related
factors
e skills, knowledge and attitudes of
healthcare professionals can have a
major impact on their ability to assess
wound complexity, to control a patient’s
symptoms and to manage associated
problems (EWMA, 2008). If treatment is
unsuccessful, a healthcare professional
may feel they have failed or may lead to
defensive behaviour or patient-blaming.
Education tools are available to help
clinicians provide consistent, accurate care
(e.g. Leg ulcer treatment pathway [Atkin
and Tickle, 2016] Figure 1). Box 2 provides
strategies that may help the clinician to
focus on the patient’s needs when a wound
is not healing (EWMA, 2008).
Resource/treatment-related factors
Healthcare resources should always be
used efficiently and effectively. e basic
equipment needed to assess a patient for
venous ulceration should be available to
ensure early diagnosis and timely treatment
interventions. If the basic equipment
needed to carry out a leg ulcer assessment is
not available, such as equipment to perform
ABPI
testing, this should be escalated to
clinical managers and a referral made in
line with local policy. Training should be
provided if there is a lack of competency to
perform leg ulcer assessments.
Box 2. Checklist for patient-centered
strategies for wound healing (EWMA,
2008).
■ Identify the patient’s needs and
concerns.
■ Identify and discuss potential barriers
to healing.
■ Provide support, calling on other
healthcare professionals or agencies
when necessary.
■ Manage the whole patient within their
care environment.
■ Develop a therapeutic relationship
between clinician and patient.
TRUTH
O
MYTH
P
A range of patient-, wound-,
healthcare professional- and
resource-related factors may
interact and impact on VLU
assessment, management and
healing. Understanding these
factors will help determine
an appropriate and
individualised management
plan for the patient.
Management for venous
ulceration is the same for all
patients.
7
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
ASSESSMENT AND
MANAGEMENT
Any potential signs and symptoms of
venous disease should be identified so
that an appropriate management plan can
be started as soon as possible (Atkin and
Tickle, 2016). e factors that impact on
complexity should also be considered.
For all VLUs, assessment should include
elements of the generic wound assessment
minimum data set (Coleman et al, 2017) and
:
■ General assessment.
■ Limb and vascular assessment.
■ Vascular assessment.
■ Venous assessment (including venous
duplex scan by vascular service [see
page 12]).
■ Wound and surrounding skin
assessment.
General assessment
e patient should be assessed holistically
with consideration for patient-related
factors, such as lifestyle, quality of life, and
overall health factors, i.e. underlying causes
or relevant medical history. Consider if any
current medication will have a detrimental
effect on wound healing (Box 1).
Limb and vascular assessment
Assessment of peripheral perfusion is a
fundamental requirement for leg ulcer
management. An ABPI provides an
assessment of the patient’s peripheral
arterial system and is often a first-line test
in limb assessment. Despite this, in the
Burden of Wounds Study, only 16% of all
patients with a leg or foot ulcer had an ABPI
in their records (Guest et al, 2015). e
omission of an ABPI assessment can lead
to an unconfirmed diagnosis, treatment
potentially sub-optimal, and delayed healing
resulting in increased patient and economic
costs.
ABPI testing can be completed with
a hand-held Doppler machine and
sphygmomanometer, or an automated ABPI
device. e results of an ABPI can help
determine whether arterial disease is present,
therefore, assessing the patient’s suitability
for compression therapy. ABPI values should
always be interpreted in the context of signs
and symptoms. For example, if the ABPI
is within the normal range but the patient
has symptoms of peripheral arterial disease,
e.g. intermittent claudication or rest pain,
a clinical review should be undertaken and
an onwards referral to a vascular service
considered (NICE, 2018a). Table 1 includes
common ABPI assessment challenges and
solutions.
It can be difficult to obtain an accurate ABPI
in some patients, such as those with severe
pain or chronic swelling, increased limb size,
high BMI or those physically unable to reach
a supine position. If the ABPI is elevated
(>1.3), arterial calcification may be present
and alternative assessment modalities
may be necessary. In these cases, further
assessment skills by specialist practitioners
are required to determine the patient’s
suitability for compression therapy, e.g.
pulse oximetry, pulse palpation, Toe Brachial
Pressure Index (British Lymphology Society
[BLS], 2018). See also Appendix 1 (Wounds
UK, 2016).
SECTION 2: ASSESSMENT AND MANAGEMENT
TRUTH
O
MYTH
P
While a fundamental component
of a full holistic assessment, ABPI
assessment will not diagnose
venous disease. It will only assess for
the presence of significant arterial
disease and, therefore, assess the
patient’s suitability for compression
therapy.
ABPI assessment confirms the
presence of venous disease and a
VLU.
TRUTH
O
MYTH
P
Patients with a confirmed VLU, no
symptoms of arterial disease and an
abnormal ABPI may benefit from
compression under supervision of a
competent healthcare professional
who is able to use other clinical
skills to assess patient suitability,
e.g. pulse oximetry, pulse palpation,
Toe Brachial Pressure Index.
Patients with a confirmed VLU
and an ABPI outside of the
0.8–1.3 range can not receive
compression therapy.
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
8
ASSESSMENT AND
MANAGEMENT
Table 1. Challenges, immediate actions and solutions of ankle-branchial pressure index (ABPI) assessment and readings.
Immediate action Solutions
Abnormal
ABPI result
■
Re-check with a hand-held Doppler machine, if an
automated ABPI machine has been previously used.
■
Repeat assessment.
■
Check clinical signs and symptoms as per BLS (2018) guidance.
■
Assess arterial supply with another tool, e.g. pulse palpation, waveforms,
toe pressure, and consider risks versus benefits of compression therapy.
■
Assess sensation.
■
Consider unusual pathologies, e.g. malignancy or pyoderma
gangrenosum.
■
If ABPI results remain abnormal or still unable to complete, refer to leg
ulcer service.
Unable to do
an ABPI
■
Receive advice from leg ulcer service, tissue viability
or local leg ulcer champions (as per local policy)
in-person, telephone or email.
ABPI <0.5
■
Arterial rest pain and/or ulceration could suggest
severe peripheral arterial disease or critical limb
ischaemia (CLI) (Harding et al, 2015).
■
If CLI present, arrange urgent referral to vascular
out-patient services – patient should be seen
within 2–14 days.
■
If there is concern regarding acute limb ischaemia,
arrange urgent (within 4 hours) consultation with
GP to establish a hospital admission.
■
If sudden deterioration of patient or limb, arrange
urgent discussion with GP for pain relief and
optimisation of perfusion. Consider referral to
vascular services.
■
Repeat assessment.
■
No compression unless advised by vascular clinic.
■
Continue to conservatively manage the patient and wound as per local
policy.
ABPI 0.5≤0.8
■
May suggest a degree of peripheral arterial disease
(Harding et al, 2015).
■
Receive advice from leg ulcer service, tissue viability
or local leg ulcer champions (as per local policy)
in-person, telephone or email.
■
Repeat assessment.
■
Establish predominate factor, i.e. venous or arterial insufficiency.
■
Consider modified compression: may be applied with frequent
reassessment and monitoring for signs and symptoms of peripheral
arterial disease and pressure damage (Harding et al, 2015).
■
Identify predominant factors:
■
Presence of oedema
■
Peripheral arterial disease (severity, progression or change)
■
Review presence or extent of venous disease.
■
Refer to specialist for further investigation and care.
ABPI >1.3
■
May suggest arterial calcification is present (Harding
et al, 2015).
■
Receive advice from leg ulcer service, tissue viability
or local leg ulcer champions (as per local policy)
in-person, telephone or email.
■
Check methodology for performing ABPI, e.g. cuff
size, cuff and patient position, appropriate Doppler
probe.
■
Repeat assessment.
■
See solutions for “Abnormal APBI result/Unable to do an ABPI”.
■
Identify predominant factors:
■
Presence of oedema
■
Presence of peripheral arterial disease (severity, progression or
change)
■
Review presence or extent of venous disease.
■
Increase frequency of arterial assessment.
■
Refer to specialist for further investigation and care.
■
In the absence of diabetes and/or renal failure, patients with no signs
of arterial disease and an ABPI of >1.3 may require high compression,
e.g. 40 mmHg.
When ABPI is abnormally high, future repeat ABPI testing would not
be useful.
9
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
ASSESSMENT AND
MANAGEMENT
Wound/surrounding skin assessment
Studies estimate that up to 79.7% of leg
ulcers have a vascular aetiology of either
venous, peripheral arterial disease or mixed,
while 20–23% of patients have wounds from
other aetiologies, i.e. vasculitis, pyoderma
gangrenosum and autoimmune diseases
(Körber et al, 2011). It is important to
determine wound cause and to be aware
of alternative causes of ulceration that may
affect wound healing and complexity.
e wound and surrounding skin should
be assessed using a structured assessment
method, such as the TIMES principle (Wounds
UK, 2017), which was expanded from the
TIME principle (EWMA, 2004). Box 3 is a
checklist of considerations for wound and
surrounding skin assessment for patients with
a VLU.
VLU classification
Following thorough holistic assessment,
the underlying diagnosis should be
established, e.g. venous, mixed or arterial,
and documented. If the wound is diagnosed
as a VLU, then it should be classified as either
‘simple’ or ‘complex’ in order to direct care
and onward referral (Box 4). ere is ongoing
academic debate whether the classification
of a ‘simple’ or ‘complex’ wound is suitable,
or if it focuses too heavily on the wound
and does not take into account other factors
(Vowden, 2005). e knowledge, skills and
competencies of the clinician will also impact
on what is defined as a ‘complex’ wound.
Box 3. Checklist of additional wound-
related considerations during wound and
surrounding skin assessment for patients
with venous ulceration.
T (Tissue viability, perfusion and
vascularisation):
■ If the wound is not progressing and
the patient is optimised for healing,
consider taking a biopsy to discount
malignancy.
■ Debride to ensure slough, necrotic
tissue and fibrous material is
removed.
■ Do not debride necrosis in patients
with arterial disease without
discussion with the vascular service.
■ Debridement by the podiatry team
may be required, particularly if the
patient has diabetes.
I (Infection or inflammation):
■ Assess and reduce the risk of cellulitis.
■ Assess and reduce the presence of
fungus.
■ Consider biofilm management wound
care.
M (Moisture imbalance):
■ Assess levels of fluid, e.g. oedematous
fluid, lymphorrhoea or exudate.
■ Assess the type and viscosity of
exudate, e.g. serous, purulent or
haemoserous.
E (Edge of the wound):
■ Assess for altered perfusion.
■ Assess the wound edge for abnormal
inflammation or abnormal
appearance.
S (Surrounding skin):
■ Assess skin health and hygiene.
■ Consider skin care management,
i.e. debridement and emollient use.
TRUTH
O
MYTH
P
‘Simple’ venous leg ulcers can become
complex if they do not receive appropriate
compression therapy.
If a VLU is defined as ‘simple’, compression
therapy is not required during the healing
process.
TRUTH
O
MYTH
P
Patients with a wound that
has been present for over
2 weeks should be assessed
for suitability of compression
therapy (NICE, 2013).
Immediate treatment of
a lower limb wound with
compression, particularly if
signs of venous disease are
present, will prevent ulcer
development and reduce the
burden to the patient and to
healthcare delivery.
A wound must be present
on the limb for at least
6 weeks to be classed as a
VLU before compression
therapy can commence.
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
10
ASSESSMENT AND
MANAGEMENT
Box 4. Checklist for a 'simple' and 'complex' VLU (Wounds UK, 2016).
Simple A ‘simple’ VLU is defined when the following patient or wound characteristics are present:
■ ABPI 0.8–1.3
■ Wound area <100 cm
2
■ Wound present for less than 6 months.
A simple VLU should be managed in a primary care or a community-based environment by clinicians
who are competent to administer compression therapy (Harding et al, 2015).
Complex A ‘complex’ VLU is defined when the following patient or wound characteristics are present:
■ ABPI outside of 0.8–1.3 range; unable to obtain ABPI
■ Wound area ≥100 cm
2
■ Wound present for more than 6 months
■ Controlled/uncontrolled cardiac failure
■ Current infection and/or history of recurrent infections
■ Patient has a history of non-concordance with treatment
■ Wound has failed to reduce in size by 20–30% at 4–6 weeks despite best practice
■ Fixed ankle or reduced range of motion
■ Foot deformity
■ Unmanaged pain
■ Severe lymphoedema.
A complex VLU should be managed by a specialist service designed to care for patients with complex
lower limb ulceration depending on local service provision. is may include a specialist leg ulcer
service, tissue viability service, local leg ulcer champions, community-based service (e.g. Leg Club®), or
dermatology/phlebology or vascular service. Further investigations, such as arterial or venous duplex
scans may be required (Harding et al, 2015).
Initiating compression therapy
Patients who present with venous
ulceration should be considered for
immediate compression therapy in order
to reduce the risk of chronicity (Wounds
UK, 2016). Compression therapy can be
perceived as painful, and, in practice,
healthcare professionals often avoid
using compression in patients with
painful ulceration (Wounds UK, 2016).
Compression can relieve pain associated
with venous disease, and delaying
treatment can cause patients more harm.
e risks of not actively treating with
compression include delayed healing,
increased pain and discomfort and
increased costs. e risk of harm from
compression therapy must be based
on individualised risk assessment of
the patient.
O
MYTH
Venous ulceration treatment including
compression therapy can cause more harm to
the patient than conservative treatment with
dressings.
TRUTH
e risk of not actively treating patients with
VLUs with compression therapy can be much
greater than the risk of causing them harm. To
prevent delays in treatment, in the absence of
a full vascular assessment and if no risk factors
or symptoms of peripheral arterial disease are
identified, patients can be prescribed low levels
of compression, e.g. class 1 British standard
hosiery (Wounds UK, 2016).
P
11
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
ASSESSMENT AND
MANAGEMENT
Common skin complexities
‘Wet leg’ syndrome
Unmanaged lymphorrhoea can cause
skin maceration and increase the risk of
infection and chronicity. e underlying
cause of lymphorrhoea should be
investigated and addressed, and treatment
may require referral to the MDT. High
compression therapy is often needed,
dressing change frequency should be
increased, and effective skin care and
hygiene promoted. It may be helpful to
consider referral and collaboration with
local tissue viability service for advice and
support on dressings.
Cellulitis
For the management of cellulitis, refer
to the BLS and Lymphoedema Support
Network (LSN) (2016) consensus. It is
essential that the patient’s response to
treatment is monitored. e patient should
seek further medical attention by the GP,
at a walk-in centre or out-of-hours service
if the symptoms or cellulitic margins are
not responding within 48 hours. If cellulitis
is present, compression can be continued
if tolerated by the patient. Compression
can be temporarily reduced to patient
tolerance to ease pain and then returned to
high compression, e.g. 40 mmHg, as soon
as possible (BLS and LSN, 2016).
'Red legs'
Symptoms of red legs include bilateral lower
limb redness, warmth and tenderness in
the absence of raised systemic temperature
or malaise, following from eczema or
other skin conditions. It is important
for clinicians to be aware of red legs, a
condition often misdiagnosed as cellulitis,
which can lead to patient distress and use
of unnecessary resources. Appropriate skin
care, which may include corticosteroid
creams, and long-term compression therapy
should be implemented. Patients most at
risk of developing red legs are usually those
who are unable to self-care (Elwell, 2014).
TRUTH
O
MYTH
P
Antibiotic therapy should be commenced
to treat cellulitis and compression therapy
can be continued to patient tolerance, as
compression can help to prevent further
lymphatic damage. In the acute setting,
compression method may need to be
modified, e.g. from bandages to wraps, to
allow daily skin inspection and monitoring of
antibiotic treatment.
Compression should be stopped if the patient
is diagnosed with cellulitis.
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
12
REFERRAL
SECTION 3: REFERRAL
VLUs should be reviewed and reassessed
at four-weekly intervals (Harding et al,
2015). At each dressing change, a less formal
intermediate review should be undertaken
to monitor current objectives, dressing and
bandage performance and determine if the
wound or patient has improved, deteriorated
or are unchanged (Wounds UK, 2018).
If after 4 weeks of treatment, there is little or
no reduction in ulcer size, or after 12 weeks
the wound has not healed, consider referral
to an appropriate service based on local
availability. Before referral, a full holistic
reassessment should be completed. Where
possible, seek advice and review from an
appropriate colleague, such as a team leader
or link nurse. Consider the reason(s) for
referral, i.e. hard-to-assess, hard-to-manage
or hard-to-heal.
Once referral to a specialist team is confirmed
to be the best next step and the reason(s)
confirmed, the following information should
be included in the referral request:
■ Up-to-date patient and wound history.
■ e reason(s) and main concern for
referral, i.e. hard-to-assess, hard-to-
manage, hard-to-heal.
■ e patient-, wound-, healthcare
professional- or resource/treatment-related
factors impacting on wound complexity.
While awaiting referral, continue to manage
the patient and wound symptoms. Box 5 is a
checklist for referral.
Early endovenous intervention
Early endovenous intervention has been
shown to not only reduce the rate of
recurrence, but also shorten the time to
heal (Gohel et al, 2018).
All patients with the clinical signs and
symptoms of venous disease require
an assessment of the venous system to
identify areas of venous insufficiency
that may be suitable for endovenous
intervention (Gohel et al, 2018). Referral to
vascular services that are able to complete
imaging of the venous system and offer
appropriate endovenous intervention is
vital, e.g. venous duplex scan and possible
endovenous ablation. A referral to vascular
services should not delay treatment.
Treatment can begin or continue while
referral is in progress or awaiting, e.g. high
compression therapy providing there are no
signs of peripheral arterial disease, such as
intermittent claudication or rest pain.
Vascular services must respond to the
findings of the EVRA trial (Gohel et al,
2018) with the provision of interventions.
Where available, all patients with a VLU
should be referred to vascular services for
intervention to prevent recurrence and
accelerate healing.
Conditions that require urgent care
or referral
Conditions that require urgent care or
referral to the appropriate specialist at
an early stage of management (Scorrish
Intercollegiate Guidelines Network [SIGN],
2010) as per local policy are in Table 2.
TRUTH
O
MYTH
P
Once a referral is made, the patient and
wound should continue to be actively
managed while awaiting referral.
Once a referral is made, further assessment
and decisions on treatment and management
are no longer required.
TRUTH
O
MYTH
P
Venous ulceration
management involves
appropriate dressings,
skin-care regimen and
compression therapy. All
patients with the clinical
signs and symptoms of
venous disease now require
an assessment of the venous
system to identify areas of
venous insufficiency that may
be suitable for endovenous
intervention to prevent VLU
recurrence and accelerate
healing (Gohel et al, 2018).
Venous ulceration can only
be treated with compression
therapy.
Box 5. Checklist for referral.
■ Complete full holistic reassessment.
■ Seek advice from an appropriate
colleague, e.g. a team leader/link nurse/
local leg ulcer champion, for advice.
■ Determine reason(s) for referral: is the
wound hard-to-assess, hard-to-manage
or hard-to-heal?
■ Continue management while referral is
in progress or awaiting.
13
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
REFERRAL
Table 2. Conditions that require urgent care or referral and examples of where to refer as per local policy.
Conditions that require urgent care Conditions that require referral to the appropriate
specialist at an early stage of management (SIGN, 2010).
■ Critical limb ischaemia (CLI) ➞ refer urgently to vascular
outpatient services. Patient should be seen within 2–14 days.
■ Peripheral arterial disease (ABPI <0.5) ➞ refer to
vascular service.
■ Acute limb ischaemia ➞ refer urgently within 4 hours of
consultation to the GP to establish a hospital admission.
■ Suspected diabetic ulcer (location: plantar aspect of
the foot, over metatarsal heads, or under the heel;
even wound margins; deep ulcers with red or pale
granular wound beds. Slough is common) ➞ refer
to GP or MDT.
■ Suspected acute cellulitis, osteomyelitis, cellulitis not
responding to oral treatment ➞ liaise with GP.
■ Rheumatoid arthritis or vasculitis ➞ refer to
rheumatology service.
■ Sepsis or necrotising fasciitis ➞ refer urgently to A&E as
patient will need admission for treatment (NICE, 2017).
■ Atypical distribution of ulcers ➞ refer to tissue
viability service.
■ Significant sudden deterioration in health, e.g. Modified Early
Warning Score (MEWS; Gardner-orpe et al, 2006) ➞ refer
urgently to A&E.
■ Suspected contact dermatitis or dermatitis resistant
to topical steroids ➞ refer to dermatology service.
■ Pyoderma gangrenosum ➞ refer urgently to dermatology
service or plastic surgery service depending on local policy.
■ Lymphoedema ➞ refer to lymphodema service.
■ Suspected malignancy (rapidly deteriorating ulcer, atypical
appearance or distribution of ulcers) ➞ refer urgently to
dermatology service for diagnosis and treatment.
■ Pressure ulcer ➞ refer to tissue viability service.
■ Calcinosis, e.g. calciphylaxis ➞ refer urgently to dermatology
or specialised leg ulcer clinic. Debridement may be necessary.
Non-concordance and non-adherence
e term concordance has become
synonymous with compliance and adherence;
however, this is incorrect. Concordance
relates to the patient’s relationship and
interaction with the clinician to work
towards treatment objectives (Horne et al,
2005). Developing an effective clinician–
patient relationship to maintain patient
concordance with treatment, especially
compression therapy, can result in effective
healing (Stanton et al, 2016).
A patient may not adhere to treatment for
a number of reasons, such as pain, impact
on lifestyle, or insufficient understanding of
their condition. If patients feel unsupported,
consider suggesting support groups, such as
Leg Club®. A change in compression system
may help improve concordance.
Before referring to a specialist service due
to ‘patient non-concordance’, consider the
questions in Box 6. If the answers are mostly
‘no’, this may indicate that concordance could
be improved. Box 7 includes tips to improve
concordance.
Box 7. Tips to improve concordance (Stanton et al, 2016).
■ Take a patient-centred approach during consultation and when
developing care plans.
■ Create a relaxed, non-judgemental clinic environment.
■ Assess the patient’s educational abilities, willingness to learn and
understanding of their condition.
■ Implement motivational interviewing strategies and techniques,
i.e. RULE: Resist the righting reflex; Understand the patient’s own
motivations; Listen with empathy; and Empower the patient (Hall et
al, 2012).
■ Reinforce knowledge with verbal information and leaflets aimed at
the patient’s educational level.
■ Is there a trusting, therapeutic patient–clinician relationship, where the
patient believes the clinician has a sustained interest in understanding
their problems?
■ Has treatment, including compression modalities, so far fitted into the
patient’s everyday life without much disruption to their lifestyle?
■ Is there a family member who has a shared interest in the patient’s
progress?
■ Does the patient perceive their condition as serious, but accepts that
treatment can control the symptoms?
■ If applicable, have steps been taken to manage pain?
Box 6. Questions to consider before referring for “patient non-concordance”
(Mandal, 2006; Stanton et al, 2016).
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
14
COMMON
PATIENTRELATED
COMPLEXITIES
SECTION 4: COMMON PATIENTRELATED
COMPLEXITIES
Once the signs and symptoms of venous
disease have been established, it is
important to identify the reasons for
wound complexity. In this section, common
patient-related complexities are discussed.
Patients with high BMI or large limbs
According to Guest et al (2018), the mean
BMI for people with a VLU is 34.9 kg/m
2
.
High BMI may be caused by:
■ Obesity
■ Oedema
■ Systemic organ disorders, e.g. cardiac,
renal or liver.
e main challenges when managing a
person with a obesity and/or oedema
are to overcome immobility and
venous hypertension in the lower limb
and abdomen. e solution is often
to commence and/or continue high
compression. For patients with systemic
organ disorders, such as congestive heart
failure or kidney failure, the main challenge
is peripheral oedema; here, compression
must be considered more cautiously. Note
these individuals may not have a high BMI,
but may have heavy, swollen limb(s).
Table 3 includes some of the challenges and
potential solutions to managing people with
high BMI. Some of the solutions may be
appropriate for people with VLUs who do
not have a high BMI.
Very tall people
Very tall people (defined as over
6 foot/182 cm) can pose a challenge for
venous ulceration management as they
often have higher hydrostatic pressure,
which can make achieving effective
compression difficult (Hopkins et al,
2017). For very tall patients, the aim is
to combat a higher hydrostatic pressure
with a higher sub-bandage pressure. is
can be achieved with high compression,
i.e. at least 40 mmHg. A compression
kit (which may need to be custom fit)
or longer bandage may be needed if the
length between ankle to knee is longer than
average. Advanced bandaging techniques,
including padding and shaping, may be
required to build up the calf muscle.
Patients with abnormal shaped limb
For patients with abnormal shaped limb
or very slim legs, advanced bandaging
techniques may be used to normalise limb
shape (Coull, 2002). Alternative forms of
compression, such as compression wraps,
may be useful. For very slim legs, the leg
shape may have to be reconstructed with
additional pads made from sub-bandage
padding and stockinette.
Patients with VLUs in challenging
anatomical locations
VLUs in unusual anatomical locations,
e.g. retromalleolar ulcers, ulcers in skin
folds, and dorsum of the foot or toes, can
be a challenge to provide appropriate
focussed compression (Hopkins et al,
2013). e protection of skin folds to avoid
fungal infections can be a management and
healing challenge. ese patients require
high compression on the foot and toes, for
which advanced compression techniques
may be required.
TRUTH
O
MYTH
P
Very tall patients with venous
ulceration require high compression
of at least 40 mmHg. For people
with lymphoedema, pressures of
≥60 mmHg can be considered.
40 mmHg is the optimum gold
standard compression pressure.
TRUTH
O
MYTH
P
Moderate to high compression
therapy must be applied to the foot
to prevent foot oedema, as long as
toes are protected. Where there is
little compression to the foot, the high
compression to the gaiter region can
create an oedematous foot and toes,
thereby causing additional issues. e
use of toe garments is recommended
where required to aid oedema
reduction.
Compression therapy should not be
applied to the foot.
15
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
COMMON
PATIENTRELATED
COMPLEXITIES
Table 3. Challenges and potential solutions to managing people with a high BMI.
Challenges Potential solutions
Lymphovenous disease
■
Specialist bandaging techniques using inelastic compression may be required, to accommodate
unusual limb shape or to treat toe swelling
.
■
Refer to lymphoedema service if available, and the skills/competencies are not availably locally.
■
Skin care should be a priority because of increased risk of infection.
Assessment challenges
Difficult to obtain an ABPI,
e.g. procedural challenges
■
See solutions for “Unable to obtain an ABPI” (Table 1, page 8).
■
Obtain appropriately sized equipment cuff and probe.
■
A non-formulary or non-catalogue item may be required.
■
For complex oedema, consider assessing thigh or toe pressures and refer to lymphoedema service.
Manual handling challenges
■
Risk assessment and consider necessary additional equipment, e.g. hoist.
Differentiating skin changes
■
Inspect skin and record changes and previous history.
■
Consider an individualised skin care plan as a preventative measure.
■
Refer to dermatology as appropriate.
Management challenges
Atypical VLU location, e.g. posterior
lower leg
■
Implement additional strapping, offload and redistribute pressure.
Increased risk of pressure ulcers
■
Appropriate risk assessment and pressure relief, it is vital to offload to prevent pressure ulcer on heel.
Reduced patient mobility
■
Provide appropriate activities, activity diaries, mobility equipment to facilitate increased activity, such
as exercise bands.
■
Gait analysis and referral.
■
Refer to services as per local policy, e.g. healthy lifestyle, weight management, occupational therapy,
physiotherapy.
Challenge achieving effective therapeutic
compression, e.g. in application, due to
abnormal shaped limbs
■
Consider adapted other compression systems:
■
Type.
■
Width based on ankle circumference.
■
Consider advanced bandaging techniques. e.g. use of padding, normalise limb shaping, tension layers.
■
If abnormal shape is due to lymphoedema, refer to lymphoedema service.
Skin folds of the leg
■
Consider inelastic compression bandaging with additional sub-bandage padding to address skin folds.
■
Once distortion lessens, step down to inelastic wrap systems or flat knit hosiery.
Venous obstruction due to large
panniculus (dense layer of fatty tissue)
■
Encourage mobilisation to accommodate panniculus, e.g. a riser recliner chair.
Healing challenges
Malnutrition
■
Refer to dietetics, provide guidance for resources and education as per local policy.
Skin hygiene/inability to self-care
■
Ensure appropriate skin hygiene protocols, provide guidance for resources and education as per
local policy.
Increased risk of fungal infection,
increased risk of cellulitis
■
Ensure appropriate skin hygiene protocols, provide guidance for resources and education as per local
policy.
■
Treat underlying/existing conditions e.g. tinea pedis.
■
Consider prophylactic antibiotics and refer to BLS and LSN recommendations (2016).
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
16
COMMON
PATIENTRELATED
COMPLEXITIES
16
Patients with a VLU who also have a
pressure ulcer on the heel
ABPI testing should be repeated in patients
with pressure ulceration on the heel. A
risk versus benefit assessment should be
undertaken to assess if it is suitable to
continue compression therapy, or if it has
contributed to the development of the
pressure ulcer.
e compression system and method
of application may need to be adapted
if compression can be continued. If the
patient is in a compression bandage, a
wrap compression system may be more
appropriate, particularly if the patient is in a
care setting and requires daily inspection of
the skin and/or pressure ulcer. For patients
in the community, compression therapy
can be continued as before as the limb and
pressure ulcer will be reviewed at each
appointment, e.g. 2 to 3 times a week.
People who use wheelchairs
long-term
People who use wheelchairs long-term
include those who have spina bifida or
paralysis. is group of patients are at
increased risk of pressure ulceration and
may experience muscle wastage, leading
to abnormal limb size and shape. Poor
lymphatic return and venous congestion may
be present, leading to discolouration of the
legs, toes and feet and oedema that needs to
be managed.
Compression can be useful to control
dependency oedema in immobile patients;
moderate to low forms of compression
may be sufficient to maintain skin integrity.
Elevation, passive exercise and frequent re-
positioning should be considered based on
individual patient ability.
Patients with insensate limbs
It is important to determine whether lack of
sensation is due to neuropathy, e.g. diabetes,
neurological disorders, multiple sclerosis,
or whether it is associated with a motor
disease, such as paralysis. Neurological
assessments should be part of the holistic
assessment to determine the extent of lack of
sensation. Sensation can be assessed by the
Ipswich Touch Test (Rayman et al, 2011), a
10 g monofilament, vibration (tuning fork),
neurosthesiometer or with a piece of cotton
wool.
For this patient group, advanced bandaging
techniques should be utilised and more
regular assessments conducted. Patients with
insensate limbs will be unable to feel changes
in pain, which indicate improvements or
deteriorations. is is an opportunity to
engage the patient and provide education on
how to conduct visual inspections of their
lower limb.
Patients with an active lifestyles
An active lifestyle should be promoted
among people with venous disease as it
promotes venous return. However, it is
important to remember that occupations
that involve standing for long periods of
time require high compression of at least
40 mmHg. Some patients in this group
may not be able to attend appointments
due to work commitments so self-care,
e.g. limb elevation, should be enabled and
encouraged.
Different compression modalities, which
may incorporate a varied compression
regimen, should be considered (Appendix 2;
Wounds UK, 2016).
is group may be particularly suitable
for early surgical intervention (Gohel et al,
2018).
TRUTH
O
MYTH
Compression is
contraindicated in patients
with a VLU who also have a
pressure ulcer of the heel.
P
Compression should be
continued following a
Doppler assessment to
rule out peripheral arterial
disease. e compression
system may need to be
changed to reduce pressure
over the heel area and allow
regular skin inspection.
Pressure-relieving
equipment should be
considered.
17
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
SECTION 5: COMPLEXITIES: CONSENT, CAPACITY
AND UNDERSTANDING
COMPLEXITIES:
CONSENT,
CAPACITY AND
UNDERSTANDING
Central to maintaining patient engagement
and concordance with VLU management is
the development of an effective therapeutic
relationship between clinician, patient,
carer(s) and their family (Stanton et al,
2016). Patient consent, capacity and
understanding are key to this and the
patient journey through care. If possible,
facilitate that the same clinician provides
VLU management for a patient who may
have difficulties in consent, capacity and
understanding.
Consent
For patient groups, such as those with a
learning disability, cognitive decline and
mental ill health, gaining informed consent
can be difficult. It is essential that any
material provided is in a format relevant to
the patient.
It is important to remember that people
have the right to make 'unwise decisions'
(Mental Capacity Act, 2005). Where
there is concern a patient with capacity is
choosing to self-neglect and there is a risk
of serious harm and/or death, all clinicians
have a responsibility to consider calling a
Vulnerable Adult Review Meeting under
local safeguarding procedures.
Clinicians should only make patient best-
interest decisions when all avenues to gain
informed consent have been explored.
An individualised management plan is key,
and actions and referrals may be subject to
local policy. To provide continuity of care,
the MDT and patients’ support network
should be engaged, e.g. learning disability
team, community psychiatric nurse, family/
carer(s), care or case worker.
In addition, longer appointments will be
required to support patients with illnesses
that affect information processing, such as
schizophrenia and dementia.
Capacity and understanding
Generic statements, such as ‘patient
lacks capacity’, are poor practice and not
supported by the principles of the Mental
Capacity Act (Department of Health,
2005). e assessment of mental capacity
is the remit of all healthcare professionals
(Department of Health, 2005).
It is important to remember that mental
capacity can change over time and should
be re-assessed regularly. Where capacity is
complex, members of the wider MDT, i.e.
registered mental health nurses and clinical
psychologists, may be able to assist if the
patient is receptive to them.
Patients with impaired capacity or
understanding may not understand the
need for compression therapy and try
to remove compression bandages. Box 8
includes tips to reduce the likelihood of
patients removing bandages.
17
Box 8. Tips to reduce likelihood of patients
removing compression bandages.
■ Finish bandage at the back of the leg.
■ Normalise clothing, e.g. use thigh
length/tights.
■ Encourage the patient to wear
trousers rather than skirts, and
wear loose socks over compression
bandaging.
■ Use distraction techniques while
applying compression.
■ Apply a tubular bandage on top of
bandage and tape in place.
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
18
COMPLEXITIES:
OTHER DISORDERS
SECTION 6: COMPLEXITIES AND OTHER CONDITIONS
Other underlying conditions that can
impact on wound complexity are described
below.
Heart failure
In the first instance to rule out heart failure,
an NT-Pro BNP (brain natriuretic peptide)
test can be requested (NICE, 2018a). e
results will help inform the practitioner
as to the likelihood of heart failure being
a cause of their oedema. If patients are
presenting asymptomatic of heart failure and
not in the acute stage, reduced or modified
compression can be applied with caution,
one leg at a time (NICE, 2018b). Where heart
failure is uncontrolled, extreme caution is
recommended.
Previous deep vein thrombosis
Blood clots in the deep venous system can
result in damage to the valves in the veins,
which will affect venous return and can lead
to long-term complications, i.e. post-phlebitis
limb/post-thrombotic syndrome. For patients
who have a VLU and a confirmed acute
deep vein thrombosis (DVT), there is often
confusion whether an ABPI assessment can
be performed or compression is suitable.
An ABPI assessment can be performed on a
patient who has confirmed DVT or who is
receiving DVT treatment, having had the first
dose of anticoagulation therapy (Vowden and
Vowden, 2002).
Patients with unexplained or multiple
DVT should be referred for investigations
for thrombotic disease, i.e. thrombophilia,
Factor V Leiden deficiency (Peus et al, 1997).
Autoimmune disorders
Autoimmune diseases and vasculitis play
a role in a fifth of patients with chronic
lower limb ulcers (Körber et al, 2011). It is
important to be aware that autoimmune
disorders may prolong the inflammation
phase of wound healing. In particular,
people with rheumatoid arthritis may have
multiple, small (0.5–2 cm) ulcers, which
suggests vasculitis. is group may also be
at increased risk of calciphylaxis. For these
patients, seek multidisciplinary working
with autoimmune specialists, such as
rheumatologists.
Haematological disorders
Leg ulcers are a common complication in
sickle cell disease, affecting 2.5% of patients
over 10 years of age with the condition
(Koshy et al, 1989). For this group, an
extended healing time of up to 6 times
longer should be expected. Patients with
sickle cell disease experience high levels of
pain; therefore, pain should be managed
appropriately so high compression can be
applied (Rivolo, 2018).
Some cancer and sickle cell disease
medications delay wound healing. In some
circumstances, the dose can be reduced
or stopped for a period to allow wound
healing; however, this should be under the
guidance of the oncology or haematology
team. Multidisciplinary working is
recommended.
For all patients with haematological and
bleeding disorders, caution is required
during debridement.
Patients at risk of self-harm or harm
to others
When managing patients who are at risk
of self-harm or harm to others who have
a VLU, it is important to be aware of the
potential ligature risk with compression
bandages, wraps and hosiery treatment kits.
Completing a risk assessment may suggest
compression therapy is not suitable.
For some patients who are at risk of
self-harm, the risk is not of ligaturing but
restricting blood supply to the foot by
pushing their bandages or hosiery kit down
the leg, a compression wrap system is a
good option to consider for these patients.
Chronic pain
Pain is, in general, inadequately controlled
in people with VLUs (Briggs et al, 2012).
e nature and intensity of pain should be
18
TRUTH
O
MYTH
Compression is
contraindicated in patients
with heart failure.
P
If patients are presenting
asymptomatic of heart
failure and not in the acute
stage, reduced or modified
compression can be applied
with caution, one leg at a
time (NICE, 2018b). Where
heart failure is uncontrolled,
extreme caution is
recommended.
TRUTH
O
MYTH
A patient with DVT
should not have an ABPI
assessment or high
compression therapy.
P
An ABPI assessment can
be performed on a patient
who has confirmed DVT
and has commenced
treatment, having had the
first dose of anticoagulation
therapy. Where appropriate,
compression may be applied
or continued.
19
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
monitored and documented regularly at
assessment and dressing change. VLUs are
very painful and compression can be hard
for some patients to tolerate. Pain needs
to be managed to allow compression to be
applied in the early stages to allow healing
progression. Compression, in time, may
help pain levels to decrease, as issues such as
oedema and inflammation are resolved and
venous return improves (Wounds UK, 2016).
For chronic pain, it is important to use a
full assessment to identify cause, nature and
severity, e.g. pain toolkit (www.paintoolkit.
org). Patients who find compression painful
require assessment of the compression type
and application technique. Analgesics should
be prescribed. For underlying disease- and
wound-related pain, analgesia support may
be appropriate. For chronic pain, consider
liaising with pain team.
People who inject drugs into the
lower limb
People who have a history of injecting
substances in the lower veins whether
illicit or not are at high risk of developing
complications in the legs. Repeated
injecting into the lower limb veins results
in chronic venous insufficiency (CVI). CVI
can present as varicose veins, leg swelling
or oedema, heaviness of the legs and/or
ulceration (Fiddes et al, 2010). CVI persists
in people who inject drugs (PWIDs)
even after injecting ceases and ulceration
may occur at any time, again, even after
prolonged periods free from injecting
(Pieper et al, 2009).
For this patient group, prevention of leg
ulceration is key. With consent, patients with
any history of injecting should have their legs
and feet regularly checked for the early signs
of oedema, venous hemosiderin staining,
venous eczema and ulceration. Unless there
are significant arterial risk factors that
reflect the ABPI reading, the majority of
patients in this group can tolerate and should
have high compression therapy, at least
40 mmHg. Harm reduction and working
closely with the MDT and key workers, i.e.
relevant mental health, substance misuse
and homeless teams, is vital. Box 9 includes
advice for working with people who inject
drugs.
COMPLEXITIES:
OTHER DISORDERS
19
TRUTH
O
MYTH
P
High compression can reduce pain for
patients with VLUs. Patients with chronic
pain may require additional support or
analgesia in the early stages to facilitate
concordance.
Patients with chronic pain will not be able to
tolerate high compression.
Box 9. Advice for working with people who
inject drugs .
■ It may be helpful to ring and remind
patients or their social worker of the
upcoming appointments either the
day before or morning of.
■ For some people, particularly
those who may be experiencing
homelessness, realistic options
of dressings and compression to
suit footwear and clothing may be
required.
■ Avoid negative discussions in terms of
“blame” in regard to non-attendances
at clinic, dressing removal and
potential deviant behaviour.
■ Maintain positivity, reassure the
patient and continue treatment as
planned.
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
20
PROMOTING
CONTINUITY
OF CARE AND
SELFCARE
20
SECTION 7: PROMOTING CONTINUITY OF CARE
AND SELFCARE
In the recently launched NHS Long Term
Plan (2019), prevention and proactive
working are priorities to keep patients well
for longer. Leading from the NHS Five Year
Forward View (NHS England, 2014), patient
empowerment and involvement are key
to this plan. Patients who feel empowered
with their care are more likely to adhere to
treatment (Moore, 2016). Some patients with
complex VLUs or complexities that make
assessment, management and healing difficult
are competent to self-care but require tools to
do so.
Many issues that increase complexity in
wound care are due to patient lifestyle
choices, and enabling self-care can be
difficult. Suitable patients should be
encouraged to take ownership of their
health. A good patient–clinician relationship
enables provision of consistent delivery of
care as the patient moves through services.
is may be achieved using digital or print
patient support, e.g. patient passport (Box
10) and patient contracts.
Telecommunication technology has the
potential to improve patient care and
reduce healthcare costs (Gray et al, 2010;
van Houwelingen et al, 2016). Digital
support, such as telephoning, emailing
and video calling, may be appropriate
for some patients who require advice
or for monitoring. Telecommunication
technology can be particularly useful
when the patient is in a remote location
or has difficulty travelling, perhaps due to
immobility or lack of transport (Santamaria
and Kapp, 2013).
Box 11 includes a checklist when
considering self-care solutions for patients
with venous ulceration.
Monitoring quality of life with a recognised
tool, e.g. Quality of Life Wound Checklist
(Green et al, 2018), can be helpful to gauge
how patients are coping with their wound
and how this may impact on self-care.
Continuity of care and treatment
Continuity of care with consistent
messaging is a key component to best
practice and may help to develop a strong
therapeutic patient–clinician relationship.
While the patient’s care plan should be
the responsibility of a named clinician,
the patient may move between services.
When the MDT is involved, it is helpful
for everyone’s roles and responsibilities to
be clearly communicated and the patients
treatment plan agreed according to
local policy.
Box 10. Patient passports.
Patient passports include the prescribed
treatments and can be used for transferring
information between services. ey may
be useful to engage self-care and encourage
patient ownership for suitable patients.
ey can also be used as a safety tool
during self-care, with a list of red flags.
Box 11. Checklist when considering self-
care solutions for patients with venous
ulceration (Wounds UK, 2015).
■ Self-care should be encouraged in
suitable patients, not forced.
■ Patients must be willing and able to
be involved, depending on skill level,
mobility and dexterity.
■ Patients should be prescribed a
compression system that fits both
their clinical and personal needs.
■ Family and carer involvement should
also be taken into account.
■ Flexible healthcare solutions may
be required, e.g. different levels of
compression.
■ Patients should be provided with
information and red flags for when to
seek medical help.
TRUTH
O
MYTH
P
Some patients are able to
engage in their own care and
help promote a continuity
of care between services.
Patients, carers or willing
family may require tools or
support to do so.
Venous ulceration
management should be
conducted by the clinical
team only.
21
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
Every effort should be made to prevent
ulceration and reulceration in patients with
complexities in assessment, management
and healing. For all VLUs, once healed, skin
maintenance and prevention of recurrence is
vital. e factors of complexity may remain,
even if the wound has healed, so closer
monitoring than usual may be required for
these patients.
When wound care no longer requires
specialist input, the patient can be referred
back to the leg ulcer treatment pathway
(Atkin and Tickle, 2016; Figure 1). ese
patients will require ongoing maintenance,
such as compression therapy. A step up/step
down approach of compression modalities
may be appropriate to facilitate concordance,
but it is important to maintain the therapeutic
level of compression to reduce reulceration
risk.
Utilise advanced compression techniques that
are simple and practical for patients to use on
an ongoing daily basis (Wounds UK, 2015),
such as flexible hosiery and compression
systems. Consideration should be given
to how the patient will apply and remove
compression systems independently.
Once healed, patients should be reviewed
at 3, 6 or 12 months depending on need
and risk of recurrence. It is important to
monitor how the patient is coping with the
maintenance phase of treatment and to re-
prescribe or re-supply compression therapy
when required. Education for patients, carers
or family is critical to maximise the life and
effectiveness of a garment until the next
prescription (Wounds UK, 2015). Patients
should also be educated on keeping vigilant
for any signs or red flags that require clinician
attention, e.g. trauma or changes to the lower
leg, and concerns about DVT or oedema
(Wounds UK, 2016).
Along with a focus on compression
maintenance, the importance of ongoing
holistic care should not be ignored. As such,
a simple skin-care regimen, along with
exercises, where suitable, will help to maintain
skin integrity and prevent recurrence.
Surgical correction
e ESCHAR study demonstrated that
varicose vein surgery reduced the risk of
recurrence from 28% to 12% (Barwell et al,
2004). Minimally invasive vein procedures
are undertaken as a day case under local
anesthetic. All patients with a VLU that has
healed in compression should be assessed
for suitability of corrective venous surgery to
reduce the risk of recurrence (NICE, 2013).
RECURRENCE &
PREVENTION
SECTION 8: RECURRENCE AND PREVENTION
TRUTH
O
MYTH
P
Once healed, patients with additional
complexities may require specific bespoke
devices to maintain intact skin as part of a
self-care regimen. Ongoing maintenance and
monitoring may be required depending on
need and risk of recurrence.
Once healed, patients with venous ulceration
no longer require specialist support.
TRUTH
O
MYTH
P
All patients should be assessed for
suitability for endovascular intervention,
such as venous duplex scanning. However,
venous hypertension may be as a result of
functional failure of the calf muscle pump,
rather than venous system incompetence;
therefore, surgery would not be appropriate
for these patients. Endovascular
intervention is highly appropriate for
structural superficial venous incompetence;
intervention for deep venous incompetence
technically requires consideration.
Venous hypertension is always repairable by
endovascular intervention.
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
22
GLOSSARY
GLOSSARY
Adherence
e degree to which patients follow the
instructions they are given for prescribed
treatments (Bissonnette, 2008). e term is
preferred compared to compliance.
Advanced compression techniques
Advanced compression techniques may
include chevron strapping or changing
from spiral to figure-of-eight method to
alter pressure (Coull, 2002). A figure-of-
eight method may be more appropriate
with additional strapping to enable focused
compression (Figure b). It may also include
use of additional padding to protect the
toes (Figures c&d), shape the leg and to
manage retromalleolar ulcers. Advanced
compression techniques should be completed
by
clinicians who are
competent in assessment
for appropriateness and application of these
techniques.
Biofilm
Classic definitions often describe
biofilms as bacteria attached to surfaces,
encapsulated in a self-produced
extracellular matrix and tolerant to
antimicrobial agents (this includes
antibiotics and antimicrobials) (World
Union of Wound Healing Societies, 2016).
ey are estimated to be present in up to
100% of wounds. Biofilms are not visible
to the naked eye and can only be decisively
diagnosed by biopsy.
Calciphylaxis
Build-up of calcium and phosphate
causing narrowing of small blood vessels.
It is diagnosed by tissue biopsy or X-ray.
Presents as mottled skin (retiform
purpura), purple blood blisters, nodules,
skin necrosis and ulcers with a violaceous
edge (Young, 2018). Calciphylaxis can
also result in hard, calcium deposits in the
wound bed.
Cellulitis (erysipelas or lymphangitis)
An acute, spreading inflammation
of the skin and subcutaneous tissues
characterised by pain, warmth, swelling and
erythema (BLS and LSN, 2017).
Advanced compression techniques:
(a): Retromalleolar ulcer position.
(b): Chevron strapping applying focused compression suitable for retromalleolar
ulcers.
(c): Toe bandaging
(d): Toe bandaging with padding. Extra padding may be required for protection to
reduce the risk of trauma for patients who have neuropathy.
Photos a,b & d, courtesy of Karen Staines. Photo c, courtesy of L&R.
Wound with calciphylaxis.
Courtesy of Sarah Gardner.
(a)
(b)
(c)
(d)
23
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
GLOSSARY
Chronic venous insufficiency (CVI)
Venous wall and valves in the leg are
ineffective, so blood pools in the legs. May
be caused by high blood pressure in the leg
veins, lack of exercise or smoking.
Compliance
e degree to which patient behaviour
matches a healthcare provider’s advice. e
term is no longer used as it is considered to
come from a punitive viewpoint (Horne et
al, 2005). e term adherence is preferred.
Concordance
e degree to which the relationship
and treatment regimen decision-making
between patient and provider results in the
desired treatment outcomes. e term is
preferred because it emphasises the factors
that affect patients’ choices (Horne et al,
2005).
Critical limb ischaemia (CLI)
Severe form of peripheral arterial disease,
which leads to tissue loss or arterial rest
pain due to markedly reduced blood flow.
CLI can lead to amputation if left untreated.
Hydrostatic pressure
e pressure produced by fluid in the
capillaries or tissues. For example,
increased capillary hydrostatic pressure
due to hypertension or venous stasis
will increase filtration of fluid out of the
capillary.
Osteomyelitis
Bacterial infection of the bone. Patients
are at increased risk of osteomyelitis if
ulcer located over bony prominence or if
bone exposed. Symptoms include fever,
disproportionate pain, local malodour, non-
healing sinus and oedema around wound,
especially in digits. Can be resolved with
early use of antibiotics.
Pyoderma gangrenosum (PG)
Rare skin condition that causes painful
ulcers. e cause is unknown, but is likely
a disorder of the immune system. PG is
not related to gangrene. e condition is
usually treatable but can take some time to
heal and may leave some scarring.
Sepsis
Serious complication of an infection.
Without rapid and aggressive treatment,
sepsis can lead to multiple organ failure and
death.
Sub-bandage interface pressure
Sub-bandage interface pressure is measured
between the compression therapy system
and the skin, and is used as a proxy for
the pressure within the leg (Harding et al,
2015).
Venous leg ulcer
An open skin lesion that usually occurs on
the medial side of the lower leg between
the ankle and the knee as a result of chronic
venous insufficiency (CVI) and ambulatory
venous hypertension, and that shows little
progress towards healing within 4–6 weeks
of initial occurrence (Harding et al, 2015).
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
24
APPENDIX 1
APPENDICES
Table A: Investigative tools for arterial assessment (Wounds UK, 2016)
Investigation Purpose
Ankle Brachial Pressure Index (ABPI) Bedside test to exclude the presence of significant peripheral arterial disease. ABPI
is the calculation of the ratio of blood pressure at the ankle compared with blood
pressure in the arms. ABPI <0.8 is suggestive of reduced blood supply to the legs,
indicating peripheral arterial disease.
Toe Brachial Pressure Index (TBPI) Similar procedure to ABPI but cuff is applied to great/first toe to obtain hallux
pressure. is may be useful/reliable in patients where the limbs are too large to
compress or where there is presence of arterial calcification (ABPI >1.3). TBPI <0.7
indicates arterial disease.
Pulse oximetry Pulse oximetry alone is a secondary diagnostic tool to measure levels of
oxygenated blood, which is unreliable in excluding peripheral arterial disease.
Pulse oximetry can be used to calculate ABPI measurement; however, this should
not be routine practice.
Transcutaneous oxygen tension (TcPO
2
) Local non-invasive measurement to assess the amount of oxygen that has diffused
from the capillaries into the epidermis. Provides useful information used to assess
level of potential for healing in ischaemic wounds.
Arterial duplex scan Non-invasive ultrasound scan of the arteries. Duplex scans capture two elements of
information: used to assess the visual structure of the arteries and also to assess blood
flow within the arteries. Useful investigation if peripheral arterial disease is suspected.
Computer Tomography Angiogram (CTA) Technique for imaging larger sections of arteries. In the lower limb, CTA can be
used to see the whole arterial system from below the level of the aorta. Requires the
injection of contrast dye into the arteries. Useful if looking for larger inflow arterial
disease or small vessel disease below the knee.
Magnetic Resonance Angiogram (MRA) As per CTA but uses magnetic fields/radio waves to evaluate blood vessels and
identify areas of abnormality or arterial disease; may be a preferable option for
patients with poor renal function. Radiation doses are lower compared with CTA.
Angiography Angiography is an invasive investigation, therefore should only be used where
intervention is required and should not be used for first-line investigations. Contrast
dye is injected into the arteries, then a series of X-rays is taken to examine for the
presence of arterial disease or other abnormalities.
Table B. Investigative tools for venous assessment (Wounds UK, 2016)
Investigation Purpose
Venous Duplex Non-invasive ultrasound scan of the veins. Duplex scans capture two elements of
information: used to assess the visual structure of the veins and also to assess blood
flow within the veins Useful investigation to assess condition and functioning of
veins, will assess for incompetence (failing/backflow) of both deep and superficial
venous system.
Photoplethysmography Used to assess venous refill time and investigate deficiencies of the calf muscle
pump. Venous reflux time >20 indicates venous insufficiency.
Computer Tomography Venogram (CTV) A venogram involves injecting contrast material into the veins, which then allows
the veins to be imaged with a CT scanner. This allows for the assessment of
obstructions, congenital issues, and provides detailed accurate assessment of the
venous system.
Venogram As CTV but images are taken using a series of X-rays. is requires continual
injections into the veins, and as such is classed as an invasive investigation.
erefore, this is primarily only used for vein bypass planning or where very detailed
information is required.
25
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
APPENDICES
Table C: Details of the different compression systems available (Wounds UK, 2016)
Compression
system
Evidence Advantages Disadvantages Patient perspective
Compression
hosiery kits
(first-line
treatment where
possible)
■
Multi-centre randomised
controlled trial included 457
patients.
■
Proven to be as effective as
multi-component bandaging
in healing venous ulceration.
■
Additional advantage as less
expensive and reduced risk
of recurrence of ulceration
(Ashby et al, 2014).
■
Does not require a high level of
skill to apply.
■
Delivers known and consistent
compression levels.
■
Allows for patient self-care.
■
Cost-effective.
■
Delivers compression to the foot.
■
Some kits have zips to ease
compression and some can be
custom fit.
■
Not suitable for unusual limb
profiles.
■
Not suitable for rapidly
decreasing limb sizes.
■
Exudate needs to be
maintained within dressings.
■
Low profile – no
limits to footwear/
clothing.
■
Allows self-care/
family care.
Compression
wraps
■
Over 65 articles published,
no randomised controlled
trial relating to venous ulcer
healing.
■
Small (28 patient)
comparative study showed
faster healing compared to
Unna Boot (DePalma et al,
1999).
■
Compression value adjustable –
value dependent on application
technique. Allows for easy
adjustment as limb volume
decreases.
■
Facilitates self care.
■
Delivers compression to the foot
only if foot piece supplied.
■
Not practical if ulcer is
highly exuding.
■
Low profile –
minimal impact on
footwear/ clothing.
■
Allows self-care/
family care.
■
Can be adjusted
to adapt to limb
circumference
changes and
improve comfort.
Compression
bandages
■
Meta-analysis of many
trials including randomised
controlled trials, proving that
multi-component bandages
are effective in the treatment
of venous leg ulceration
(O’Meara et al, 2012).
■
Adaptable so permits good
anatomical fit in unusual-shaped
limbs.
■
Suitable for most limb shapes/
sizes. Inelastic compression
bandages can facilitate volume
reduction/reshaping.
■
High-stiffness systems (e.g.
inelastic bandages) produce the
greatest improvements in venous
blood flow (Harding et al, 2015).
■
Good for high levels of exudate/
lymphorrhoea.
■
Compression value
dependent on application
technique – high level of
skill required to apply.
■
Some bandage systems do
not involve compression
from the foot upwards to
prevent pooling of oedema
in the foot and toes,
impacting on mobility and
potentially delaying healing
of wounds around the
malleolous.
■
Can be bulky –
may limit footwear
and clothing.
■
Does not facilitate
self-care.
APPENDIX 2
BEST PRACTICE STATEMENT: ADDRESSING COMPLEXITIES IN THE MANAGEMENT OF VENOUS LEG ULCERS
26
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