Community venous leg ulcer clinic standard operating procedure for treatment of venous leg ulcers

The following standard operating procedure (SOP) is intended as an outline for Health Boards to develop their own standard operating procedure. The example below has been adapted from procedures used by the clinical team at NHS Tayside. It may need to be adjusted or expanded depending on availability of facilities (e.g. photography) and services locally and to ensure links are established with relevant local services (e.g. Primary Care, District Nursing, Vascular Surgery, Dermatology).

Purpose/background

Lack of appropriate clinical assessment of patients with limb ulceration in the community has often led to long periods of ineffective treatment (RCN, 2024). The mainstay treatment of a venous leg ulcer involves compression therapy to reduce venous hypertension. The aim of this SOP is to ensure safe and standardised care of venous leg ulcers in the Community Venous Leg Ulcer Clinic (VLUC).

Scope

This SOP applies to all registered nurses who are working within the VLUC.

Responsibility

All registered nurses are responsible for reading this SOP and signing to say they have understood this SOP and will comply with the instructions within.

Procedure

Full assessment of the patient, the leg and the ulcer including ankle brachial pressure index (ABPI) measurement should be carried out prior to any treatment. This is to establish the aetiology of the ulcer and ensure effective treatment. (See Venous leg ulcer clinic standard operating procedure for assessment of venous leg ulcers)

Patients with a reading of 0.8 to 1.3 (inclusive) with a clinical picture of venous ulceration, can safely have compression therapy applied
< 0.8 indicates arterial disease should be referred to the specialist leg ulcer clinic (see criteria for specialist referral)
< 0.5 contraindicates compression and requires an urgent vascular referral
Results > 1.3 may be found in some patients with diabetes or advanced renal disease who have heavily calcified vessels. These patients should be referred to the specialist leg ulcer clinic (see criteria for referral to secondary care below.)

Ulcerated legs should be washed in tap water. The leg should be immersed if possible in a floor sink or lined bucket/basin of warmed emollient solution (tap water with emulsifying ointment or diprobase cream) and dressings gently soaked off. This method cleanses the wound and moisturises the surrounding skin. The leg should then be carefully dried and an emollient applied
Topical corticosteroids may be required in the treatment of eczema or dermatitis (subject to local prescribing arrangements).
The ulcer margins should be coated with a barrier preparation to prevent maceration of the surrounding skin (e.g. zinc paste)
A simple non-adherent dressing should be used to cover the ulcerated areas. Alternative dressings should be selected using the relevant section of the local wound management formulary to meet the needs of the wound.
High compression multi-component bandaging should be used to treat venous leg ulcers. Patients should be offered the strongest compression that maintains patient concordance. Practitioners should take into account patient preference, lifestyle, likely concordance and the required frequency of application. Compression should only be applied by staff with appropriate training and in accordance with manufacturer’s instructions.
The Leg Ulcer Management form should be completed detailing the individual treatment plan.
Patients should be contacted within 24 hours by phone or seen if assessed as necessary to identify any complications following initial application of compression therapy.
Assessment should be carried out at each dressing change and amendments to treatment plan made as necessary. Full re-assessment including ABPI assessment should be carried out at 12 weeks. If there is no progress/improvement the patient should be referred to the specialist leg ulcer clinic (See criteria for specialist referral).

Criteria for referral to secondary care

Suspicion of malignancy
Peripheral arterial disease (ABPI <0.8 or >1.3)
Vasculitis
Atypical distribution of ulcers
Suspected contact dermatitis or dermatitis resistant to topical steroids
Non-healing ulcer despite appropriate treatment at 12 week review