AAWC Venous Ulcer Guideline

Content Validated, Evidence Based “Guideline of Venous Ulcer Guidelines”

Using the AAWC Venous Ulcer (VU) Guidelines to Manage Venous Ulcers

• 3 Steps to manage a VU patient:– Assess and document patient, skin & VU– Prevent VU with care plan focused on reducing risk– Treat patient and VU to heal and prevent recurrence

• For guideline details, references, implementation tools, patient brochure and evidence please see:http://aawconline.org/professional-resources/resources/

Fonts Used Here and in AAWC VU Guideline Checklist

• Recommendations in bold font are– Ready to Implement :

• A-level evidence support (Strong evidence)• + Content validity index (CVI)>0.75 (Strongly recommended)

• Recommendations in bold italics– Need more Education

• Content validity index (CVI) <0.75 (Raters say not relevant to VU care)• A-level evidence support

• Recommendations in normal font– Need 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.

AAWC VU Guideline Recommendation Strength of Evidence Ratings

A. Supported by at least 2 VU-related human:1. randomized controlled trials (RCTs) for efficacy or…2. 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.

B. One A-level study + at least one non-randomized controlled human VU study or at least 2 RCTs on animal model(s) validated for VU

C. One A-level study without B-level support (C1), case series (C2) or expert opinion (C3)

Overview 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 care Generate appropriate care plan to meet agreed on goals Perform care or order consults as needed to meet goals Document, communicate skin and ulcer progress to those

providing or consulting on care, patient and family• Patient / family : regularly as needed

Communicate goals, needs and capabilitiesParticipate in choosing appropriate, effective care plan Engage in care

AAWC VU GuidelineStep 1: Assess and Document

Physical/medical/surgical history to diagnose ulcer

causes & risk factors to guide care:

• Patient • Skin• Wound• Patient and family goals

Step 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) VU

– Etiology 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) veins• Optionally identify involved superficial or deep vein or perforator

– Pathophysiologic including no signs of vein disease (Pn) or:• Reflux (Pr), obstruction (Po) or reflux and obstruction (Pr,o)

Step 1. Trained Professional Assess Patient, Family Goals Capabilities

and Risk Factors for Slow Healing– Patient and family goals including: • pain • quality of life

– Risk factors for slow VU healing• VU > 5 cm2 • VU persists > 6 month• patient is obese and/or over 50 years of age• patient is male

Step 1. Assess: VU Differential Diagnosis

• Who: Trained professional or interdisciplinary wound team member • When: On admission and if VU closes < 40% in 3 weeks• What:

– ABI< 0.8 or local TcPO2 <30 mmHg: arterial consult – Vein refill time > 20 seconds: likely venous– Local heat >1.1○ C: suspect infection – Local hair growth suggests non-arterial ulcer

• Document progress regularly using reliable, valid measures– VU area or longest length x widest width to estimate area – Standardized edema measure

• Ensure formal assessments are accessible to those providing or consulting on VU care

AAWC 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 family• Aid venous return• Protect the skin• Address causes of tissue damage

Step 2: Venous Ulcer Prevention:Educate Patient and Family

• Educate patient and family on – Cause(s) of skin breakdown, – How and why to • Compress, • Exercise calf muscle and • Elevate lower legs

– Smoking cessation– Other behaviors that may damage veins

Step 2: Venous Ulcer Prevention: Aid Venous Return

• Apply safe, effective, cost effective VU compression• Multilayer sustained, elastic high-compression bandages,

stockings or tubular bandages afford similar VU outcomes• Match compression to patient needs & calf size

– Better outcomes with multilayer than 1-layer compression– 2-layer improves comfort and quality of life vs 4-layer– Elastic compression is generally better than inelastic– Unna’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 compression

Step 2: Venous Ulcer Prevention:Protect the Skin

• Moisturize dry skin• Protect affected skin from– Irritation – Sensitization– Chemical injury– Physical trauma

Step 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:– Nutrition– Circulation– Infection– Physical therapy– Other as appropriate

AAWC Venous Ulcer GuidelineStep 3 Overview:

Heal Venous Ulcer: Keep It Healed!

• Treat patient and VU to– Improve healing– Improve pain, quality of life & costs of care – Prevent hospitalization– Prevent recurrence

AAWC Venous Ulcer Guideline Step 3: Treat Patient and VU To Foster Healing

• Continue or implement measures to prevent VU• Manage venous return per institutional protocols and to

meet patient and family needs and goals Compress (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 fluid• Debride non-vital tissue using (debridement used):

Autolytic Enzymatic Surgical Other____

AAWC Venous Ulcer Guideline Step 3:Treat Patient and Venous Ulcer To Improve Pain,

Quality of Life (QoL), Costs of Care

• Moisture 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

AAWC Venous Ulcer Guideline Step 3: Treat Patient and VU To Prevent Hospitalization

• Evaluate VU at each dressing change for signs and symptoms of clinical infection– Use antimicrobial only if VU has clinical infection signs/

symptoms: increased pain, heat, odor, color, edema• Dress VU to maintain a moist environment, manage excess

exudate if needed, & protect ulcer and local skin• Manage VU-related pain to meet patient needs• If VU area <40% in 3 weeks: re-evaluate diagnosis and

care plan • If VU does not in area by 4 weeks: consider effective

vascular surgery or adjunct intervention + appropriate Step 3 interventions.

AAWC Venous Ulcer Guideline Step 3: Treat Patient and Healed VU To Prevent Recurrence

• Continue or implement measures to prevent VU after it has healed

• Perform weekly community nursing, coaching and peer support to encourage consistent… – Elevation of the lower leg above heart– Calf muscle exercise– Optimal, consistent compression use, e.g.

• Medium compression elastic stockings are used more consistently than high compression ones, with similar VU recurrence rates