What a time community nursing is having. While the recent focus has rightly been on acute services and coping with the COVID-19 outbreak, community nursing continues to deliver care to the vulnerable. The Coronavirus comes on the back of austerity, lack of investment and a high vacancy rate in community nursing. Add working in isolation and additional sickness and it is likely that you know of colleagues that are on their knees.

Leg ulcer management continues to be a significant part of any caseload, often mentioned as between 40-80% of daily activity. As caseloads are being reviewed and risk rated, we need to be careful that a decision to reduce visits or instigate self-care does not backfire, either for clinicians or patients. If we do not manage people with leg ulcers successfully, then these patients will simply deteriorate and create pressure on another part of the system when they present with complications such as cellulitis or septicaemia.

There are actions we can take to reduce activity even in these stretched times. Many tissue viability nurses have been redeployed into the community and the conversation now focuses on a new ability to support consistent care by directly delivering more therapeutic levels of compression. Frequently, we find that although a compression bandage is applied, it does not always equate to therapeutic compression delivery, and as such, is simply an inefficient use of nursing time¹.
 

Actions to improve compression therapy

There are a number of actions that can be taken to increase the dosage of compression to make it therapeutically effective, and even achieve a reduction in nursing activity.

Apply class 1 compression to all except those classified as purely ischaemic or that have significant neuropathy. The National Wound Care Strategy has produced a draft strategy of delivering light compression in the absence of an Ankle Brachial Pressure Index ². This is a game changer in lower limb wound management and the aim is to help to stop small lacerations becoming large ulcers. This guidance states that it is safe to apply mild graduated compression, up to 20 mmHg, to the limb. You can thus use:

• A Class 1 sock up to 20mmHg. British Standard hosiery is usually 14–17 mmHg. Please note that a liner sock may deliver compression as low as 10mmHg. a. Compression hosiery must be used on a ‘normal’ shaped lower limb, e.g. the limb should go in at the ankle and just below the knee, in order for graduated compression to be applied.
• A Type 3a compression bandage such as Profore 3 or K-Plus, using a figure of eight application technique. This is required on a limb where extra absorbency from dressings and bandages is needed, e.g. if exudate is not contained within a 10 x10cm dressing or if the patient has irregular limb shaping/moderate oedema and so is not suitable for British Standard class 1 hosiery.

Before application, please check that the patient has:

1. Good peripheral perfusion
2. Intact sensation
3. A normal shaped limb with no skin folds if choosing hosiery
4. A wound resulting from:
   • - Minor lower-limb swelling or early stage venous disease
   • - Acute lower-limb trauma, e.g. pre-tibial laceration
   • - Surgery, e.g. debrided haematoma or other procedure.

This reduced level of compression may even be enough for small traumatic wounds and create a swift healing environment. Alternatively, this amount of compression may be a good start to therapy, building confidence and having a positive impact on wound progress, allowing the compression to be increased once a full lower limb assessment and ABPI has been completed. Don’t forget that a recurrent ulcer requires swift assessment into high compression.

Top Tip. If the exudate volume remains large and requires more than 2 dressings per week to manage, then the faster you ensure they have high compression the better. Increasing compression will reduce the need for dressing changes.
 

What a time community nursing is having. While the recent focus has rightly been on acute services and coping with the COVID-19 outbreak, community nursing continues to deliver care to the vulnerable. The Coronavirus comes on the back of austerity, lack of investment and a high vacancy rate in community nursing. Add working in isolation and additional sickness and it is likely that you know of colleagues that are on their knees.

Leg ulcer management continues to be a significant part of any caseload, often mentioned as between 40-80% of daily activity. As caseloads are being reviewed and risk rated, we need to be careful that a decision to reduce visits or instigate self-care does not backfire, either for clinicians or patients. If we do not manage people with leg ulcers successfully, then these patients will simply deteriorate and create pressure on another part of the system when they present with complications such as cellulitis or septicaemia.

There are actions we can take to reduce activity even in these stretched times. Many tissue viability nurses have been redeployed into the community and the conversation now focuses on a new ability to support consistent care by directly delivering more therapeutic levels of compression. Frequently, we find that although a compression bandage is applied, it does not always equate to therapeutic compression delivery, and as such, is simply an inefficient use of nursing time¹.
 

Actions to improve compression therapy

There are a number of actions that can be taken to increase the dosage of compression to make it therapeutically effective, and even achieve a reduction in nursing activity.

Apply class 1 compression to all except those classified as purely ischaemic or that have significant neuropathy. The National Wound Care Strategy has produced a draft strategy of delivering light compression in the absence of an Ankle Brachial Pressure Index ². This is a game changer in lower limb wound management and the aim is to help to stop small lacerations becoming large ulcers. This guidance states that it is safe to apply mild graduated compression, up to 20 mmHg, to the limb. You can thus use:

• A Class 1 sock up to 20mmHg. British Standard hosiery is usually 14–17 mmHg. Please note that a liner sock may deliver compression as low as 10mmHg. a. Compression hosiery must be used on a ‘normal’ shaped lower limb, e.g. the limb should go in at the ankle and just below the knee, in order for graduated compression to be applied.
• A Type 3a compression bandage such as Profore 3 or K-Plus, using a figure of eight application technique. This is required on a limb where extra absorbency from dressings and bandages is needed, e.g. if exudate is not contained within a 10 x10cm dressing or if the patient has irregular limb shaping/moderate oedema and so is not suitable for British Standard class 1 hosiery.

Before application, please check that the patient has:

1. Good peripheral perfusion
2. Intact sensation
3. A normal shaped limb with no skin folds if choosing hosiery
4. A wound resulting from:
   • - Minor lower-limb swelling or early stage venous disease
   • - Acute lower-limb trauma, e.g. pre-tibial laceration
   • - Surgery, e.g. debrided haematoma or other procedure.

This reduced level of compression may even be enough for small traumatic wounds and create a swift healing environment. Alternatively, this amount of compression may be a good start to therapy, building confidence and having a positive impact on wound progress, allowing the compression to be increased once a full lower limb assessment and ABPI has been completed. Don’t forget that a recurrent ulcer requires swift assessment into high compression.

Top Tip. If the exudate volume remains large and requires more than 2 dressings per week to manage, then the faster you ensure they have high compression the better. Increasing compression will reduce the need for dressing changes.
 

2. Use paste bandages under compression. These seem to be classified as ‘old fashioned’ but they are effective at encasing the limb so that they assist in applying a stiffness to the compression regimen. Paste bandages or tubular bandages impregnated with zinc paste appear to create a positive wound and skin environment, especially for those with lymphorrhoea. If wet eczema is present, the use of a topical steroid before application can reduce the inflammation and heal superficial eczematous erosions. Absorbent dressing pads plus wadding are required but care should be taken not to create excessive width to the limb as this will only reduce the compression delivered. If there is concern about active heart failure then two layers of a retention bandage applied firmly can be used on top of this regimen. This approach could swiftly stop dripping legs in their tracks, again reducing the frequency of dressing change needed. To add the therapeutic compression required, use:

• Any compression regimen
• A tubular bandage plus hosiery where exudate is minimal.

Top Tip. If the exudate volume remains high, establish how the compression delivered and therapeutic dose can be increased; compression is THE treatment. Look out for signs of guttering as these longitudinal skin creases (think prune) are the evidence of dermal oedema reduction. If the patient is tall, they need more compression³. Getting the dosage of compression right will create swift healing and reduce the frequency of wound dressing.

3. Select the right dosage of compression. One size does not fit all. If the volume of exudate is not contained by the dressing, and more than twice weekly dressing changes are needed, it is likely that the wrong dosage of compression is being used. What you can do is:

- Make sure the choice of compression is being applied correctly and consistently. If not, then treatment is sub-optimal and clinician workload will be increased. Provide consistent care and well applied compression for two weeks and see the impact.
Determine how to increase the compression therapy. If the patient remains in mild compression, then do not be surprised if this is ineffective and hope is lost in the appoach.

- What you can do to increase the compression so it provides a therapeutic dose:

1. If using mild Type 3a bandage and it is tolerated, think about adding another layer. This will add another 15–20mmHg and the regimen will then provide a moderate level of compression. This type of increase is also well tolerated by patients.
2. If using a short-stretch regimen applied in a spiral formation, question if the patient needs another layer from the ankle to increase stiffness. Or would the use of an 8cm bandage to the foot provide a stiffer casing and conform to the shape to the foot and ankle?
3. Is the ulcer behind the ankle and static? If so, no regimen will help this area unless additional strapping or padding is applied. Get creative and work out where compression is lacking⁴
4. Use a compression wrap on top of mild or moderate compression bandages. This will increase compression therapy and is particularly needed in wide limbs.

If the chosen compression regimen is not working, do something different. Do not stop compressing but work out how you and your team can make sure this essential therapy is enhanced. You may be surprised at the impact this review has on your workload and the patient’s life.

For more information on application of compression therapy, go to product sites plus the resource page on the National Wound Care Strategy site www.ahsnnetwork.com/nwcsp-help-and-advice

For video tips on optimising compression therapy, please go to www.acceleratecic.com