Presentation on theme: "AAWC Venous Ulcer Guideline"— Presentation transcript:
1AAWC Venous Ulcer Guideline Content Validated, Evidence Based “Guideline of Venous Ulcer Guidelines”
2Using the AAWC Venous Ulcer (VU) Guidelines to Manage Venous Ulcers 3 Steps to manage a VU patient:Assess and document patient, skin & VUPrevent VU with care plan focused on reducing riskTreat patient and VU to heal and prevent recurrenceFor guideline details, references, implementation tools, patient brochure and evidence please see:
3Fonts Used Here and in AAWC VU Guideline Checklist Recommendations in bold font areReady to Implement :A-level evidence support (Strong evidence)+ Content validity index (CVI)>0.75 (Strongly recommended)Recommendations in bold italicsNeed more EducationContent validity index (CVI) <0.75 (Raters say not relevant to VU care)A-level evidence supportRecommendations in normal fontNeed more research to be considered evidence-based , but have a CVI of at least 0.75,i.e. 75% of independent raters or more believed this recommendation was clinically relevant for VU practice.
4AAWC VU Guideline Recommendation Strength of Evidence Ratings Supported by at least 2 VU-related human:randomized controlled trials (RCTs) for efficacy or…For diagnostics or risk assessment screening: 2 prospective cohort studies and/or above RCTs reporting diagnostic (sensitivity or specificity) or screening (+ or - predictive validity) measures.One A-level study + at least one non-randomized controlled human VU study or at least 2 RCTs on animal model(s) validated for VUOne A-level study without B-level support (C1), case series (C2) or expert opinion (C3)
5Overview of AAWC VU Guideline: Who does What to Whom by When? Trained staff: regularly per protocol, as feasibleAssess patient, skin, VU condition, patient/family goalsCoach patient/family on safe, effective, appropriate careGenerate appropriate care plan to meet agreed on goalsPerform care or order consults as needed to meet goalsDocument, communicate skin and ulcer progress to those providing or consulting on care, patient and familyPatient / family : regularly as neededCommunicate goals, needs and capabilitiesParticipate in choosing appropriate, effective care planEngage in care
6AAWC VU Guideline Step 1: Assess and Document Physical/medical/surgical history to diagnose ulcer causes & risk factors to guide care:PatientSkinWoundPatient and family goals
7Step 1. Trained Professional Assess Patient, Skin, Wound Document CEAP signs of venous insufficiency developed and validated by the American Venous Forum:Clinical signs of venous disorders, including no signs (C0) or:Lower leg edema (C3), skin changes (C4), healed (C5) or active (C6) VUEtiology including no venous cause identified (En) or:Congenital (Ec), Primary reflux (Ep), secondary or post thrombotic (Es)Anatomic including no venous location identified (An) or:In superficial (As), perforator (Ap) or deep (Ad) veinsOptionally identify involved superficial or deep vein or perforatorPathophysiologic including no signs of vein disease (Pn) or:Reflux (Pr), obstruction (Po) or reflux and obstruction (Pr,o)
8Step 1. Trained Professional Assess Patient, Family Goals Capabilities and Risk Factors for Slow HealingPatient and family goals including:painquality of lifeRisk factors for slow VU healingVU > 5 cm2VU persists > 6 monthpatient is obese and/or over 50 years of agepatient is male
9Step 1. Assess: VU Differential Diagnosis Who: Trained professional or interdisciplinary wound team memberWhen: On admission and if VU closes < 40% in 3 weeksWhat:ABI< 0.8 or local TcPO2 <30 mmHg: arterial consultVein refill time > 20 seconds: likely venousLocal heat >1.1○ C: suspect infectionLocal hair growth suggests non-arterial ulcerDocument progress regularly using reliable, valid measuresVU area or longest length x widest width to estimate areaStandardized edema measureEnsure formal assessments are accessible to those providing or consulting on VU care
10AAWC Venous Ulcer Guideline: Step 2: Venous Ulcer Prevention Overview Trained staff address patient goals and risk factors to prevent VU or improve edema and venous return.Educate and coach patient and familyAid venous returnProtect the skinAddress causes of tissue damage
11Step 2: Venous Ulcer Prevention: Educate Patient and Family Educate patient and family onCause(s) of skin breakdown,How and why toCompress,Exercise calf muscle andElevate lower legsSmoking cessationOther behaviors that may damage veins
12Step 2: Venous Ulcer Prevention: Aid Venous Return Apply safe, effective, cost effective VU compressionMultilayer sustained, elastic high-compression bandages, stockings or tubular bandages afford similar VU outcomesMatch compression to patient needs & calf sizeBetter outcomes with multilayer than 1-layer compression2-layer improves comfort and quality of life vs 4-layerElastic compression is generally better than inelasticUnna’s Boot is better than no compression: improve results by adding an elastic layer (Duke Boot)Pneumatic compression, inelastic strapping device or standardized lymphatic massage are each more effective than no compressionIt’s worth the effort!
14Step 2: Venous Ulcer Prevention: Address Causes of Tissue Damage Perform consult(s) as needed and feasible to identify and reduce VU risk and control infection consistent with patient and family goals and professional consult advice on:NutritionCirculationInfectionPhysical therapyOther as appropriate
15AAWC Venous Ulcer Guideline Step 3 Overview: Heal Venous Ulcer: Keep It Healed! Treat patient and VU toImprove healingImprove pain, quality of life & costs of carePrevent hospitalizationPrevent recurrence
16AAWC Venous Ulcer Guideline Step 3: Treat Patient and VU To Foster Healing Continue or implement measures to prevent VUManage venous return per institutional protocols and to meet patient and family needs and goalsCompress (Consistent, multilayer, elastic wraps or socks)Elevate (above heart: e.g. books under foot of bed)Exercise calf (e.g. tip toes, walking, ankle flex) Other as appropriate (e.g. lymphatic massage, PT, IPC, SEPS)Cleanse VU (4-15 psi) with safe non-antimicrobial fluidDebride non-vital tissue using (debridement used): Autolytic Enzymatic Surgical Other____
17AAWC Venous Ulcer Guideline Step 3: Treat Patient and Venous Ulcer To Improve Pain, Quality of Life (QoL), Costs of CareMoisture sealing dressings plus elastic compression improve VU healing, pain, application time compared to short-stretch or Unna’s Boot compression.Add absorbent primary dressing if needed to prolong wear to allow weekly dressing changes.Frequent dressing changes cost and QoL
18AAWC Venous Ulcer Guideline Step 3: Heal VU Treat Patient and VU To Prevent Hospitalization Evaluate VU at each dressing change for signs and symptoms of clinical infectionUse antimicrobial only if VU has clinical infection signs/ symptoms: increased pain, heat, odor, color, edemaDress VU to maintain a moist environment, manage excess exudate if needed, & protect ulcer and local skinManage VU-related pain to meet patient needsIf VU area <40% in 3 weeks: re-evaluate diagnosis and care planIf VU does not in area by 4 weeks: consider effective vascular surgery or adjunct intervention + appropriate Step 3 interventions.
19AAWC Venous Ulcer Guideline Step 3: Treat Patient and Healed VU To Prevent Recurrence Continue or implement all measures to prevent VU after it has healedPerform weekly community nursing, coaching and peer support to encourage consistent…Elevation of the lower leg above heartCalf muscle exerciseOptimal, consistent compression use, e.g.Medium compression elastic stockings are used more consistently than high compression ones, with similar VU recurrence rates