My role as a chronic oedema liaison nurse (COLN) developed as part of a service development project, jointly funded by the South Eastern Health and Social Care Trust and the local commissioning group. My work in a multidisciplinary team alongside Pippa McCabe (lymphoedema clinical lead) and Susan Patterson (pharmacy adviser to the Health and Social Care Board) has proved that early identification and management of simple oedema and early venous disease is cost-effective and has quality-of-life benefits to individuals suffering from the symptoms.
The project aimed to explore new ways to improve the ongoing management and review of patients with simple leg oedema, developing a model of care that has been rolled out to GP practices within the South Eastern Trust in Northern Ireland since 2018. This exciting and innovative project has fundamental benefits, ultimately reducing the pressure on specialist tissue viability nurses (TVNs), lymphoedema services, and treatment room nurses. In doing so, this will prevent the development of complications secondary to chronic leg oedema, such as cellulitis and onward vascular referrals.
The project has been widely recognised. As well as achieving runner up in the BJN Awards 2019, it was selected for an oral presentation at the International Lymphoedema Framework conference in Chicago in June 2019.
Lower limb oedema
It is thought that around one in 200 patients aged over 65 have lower limb oedema, a prevalence that increases with age (Charles, 2013). As Northern Ireland has an increasing number of people aged 85 and over, this will be an increasing problem, with huge financial implications if not managed well (Northern Ireland Statistics and Research Agency, 2019). There is potential for cost savings and improved patient satisfaction if diagnosis and early management is instigated (NHS England, 2017)
These patients do not meet referral criteria for tissue viability nurse (TVN) and lymphoedema services and GPs need to action appropriate care early.
The GAIN audit (Guidelines and Audit Implementation Network, 2013) reported that only 55% of patients across five Trust areas in Northern Ireland received a Doppler test on their first assessment visit, resulting in inadequate assessment and diagnosis. This is also a recognised problem UK-wide, with adherence to the best practice guidance varying (Guest et al, 2017). It is widely recognised that, in order to reverse this trend, there is a need to maximise the skills and knowledge of primary care professionals who care for patients with chronic oedema of the lower limb (Murdoch, 2019). Therefore, the Healthy Leg Project was borne out of a recognised gap in management, where the patient with simple oedema was often being overlooked until a more complex issue arose.
As chronic oedema increases the risk of venous ulcers, using compression hosiery for prevention has the potential to save the costs of prescribing dressings and compression bandaging, and of daily district nurse visits or treatment room attendances, which have been estimated at £1500 per patient per year using 2001 data. However, a more recent investigation into the burden of chronic wound management by Guest et al (2017) states that this could actually be as high as £5976 per unhealed leg ulcer. Our project has found that the cost of prevention of leg ulceration as a result of venous hypertension can be as low as £100 per person per year.
The aim of practice-based Healthy Leg Clinics is to identify patients with early uncomplicated lower limb oedema and to provide early assessment and management, using class 1 compression hosiery, to prevent the development of chronic oedema and complex skin issues. Through assessment and review the project aim is to:
The project
Using quality improvement methodology, a pilot site was selected—a small GP practice (4721 patients). In order to begin the first clinics, the GP clinical system was searched to identify patients who had been prescribed compression hosiery in the previous 12 months and who required review. Patient information leaflets regarding compression hosiery and donning aids were provided to the practice as well as a list of READ codes to record reasons for referral to the clinic (eg swollen legs N2470). The GP referred patients to the clinic for a review of previous venous-related disease and/or previous compression hosiery prescription.
Data were collected using a bespoke Excel spreadsheet and the clinical system template for lower limb assessment.
GPs and practice nurse education sessions were delivered at each practice. The benefits of this education have been evident in the reduction of unnecessary prescribing of both loop diuretics for dependent oedema and antibiotics for red legs (a chronic inflammatory condition often misdiagnosed as cellulitis) (Salmon, 2015).
Following successful implementation in the pilot site, and following a local enhanced service (LES) agreement, continued interest in the project has grown, with 25 out of 50 practices within the Trust now participating. Data collection from each area shows a 30% reduction in diuretic therapy prescribing following attendance and compression hosiery use. GPs report that they are more aware of identifying features of cellulitis versus red legs, and the management of both.
In order to assist GPs with a pathway for management of patients presenting with lower limb oedema, a flowchart was developed (Figure 1). This simple algorithm provides clear guidance to GPs on which service and management line the patient may follow, reducing unnecessary referrals to a specialist team and directing the patient to prompt preventive compression hosiery prescription and a Healthy Leg Clinic appointment, if required.
The multidisciplinary approach to the project has been its success. Each discipline has much to offer and the collaboration between nursing, physiotherapy, community and practice-based pharmacists, and GPs has ensured that the patient remains central to the goal of prevention in healthcare management.
Education sessions were held for pharmacy colleagues, to enable them to increase knowledge and skills when service users approached them for advice on compression hosiery or donning aids. All of the pharmacists who attended increased their knowledge of all aspects of compression hosiery prescribing, including ranges available, donning aids, contraindications and made-to-measure hosiery. Pharmacists scored an average of 40% in a test of their knowledge before oedema management training and around 80% after the training.
Results
The initial results of the project were very promising, but slow recruitment of practices was initially frustrating. This was due to staffing issues within the practices and room availability. However, despite this, significant cost savings were identified in our pilot site. Of those attending for a review of their hosiery (n=22), eight patients were identified as requesting hosiery too frequently (monthly or 3-monthly), and two patients required an increase in prescribing. Prescribing savings for 22 patients equated to £597 per year. Only a small number of patients (n=7) had been previously prescribed antibiotics for bilateral red legs/suspected cellulitis, indicating sound knowledge of true cellulitis and appropriate usage in this area. The potential reduction in the incidence of cellulitis will require long-term data collection, but in the short term, improved patient outcomes were clearly demonstrated.
The quality improvement methodology PDSA cycles—plan, do, study, act—was used to review data from the pilot site, review and adapt to improve systems and data collection. Upscaling to further practices Trust-wide has continued as practices express interest in involvement in the project.
More than 180 patients have now been assessed and educated in 12 practices participating in the first 15 months of the project, and this number continues to grow, with practices delivering on average 1-2 clinics per month past the initial training clinics. Approximately 90% of the diuretics prescribed to the patients attending the Healthy Legs Clinics were identified for the management of dependent oedema. This information was referred back to the GPs for removal of unnecessary drugs from prescriptions, reducing cost and potential harm (eg adverse renal effects).
Patient quality-of-life data were obtained in the pilot site and continued evaluation using the Lymphoedema Life Impact Scale (Weiss and Daniel, 2015) continues and is being collated. Initial reports show patient satisfaction as 100%, with highest improvement in areas of pain, tightness and heaviness of the limb. Individual patient stories have also been collected and their impression of this new service has been extremely positive (Box 1).
There were many aspects to practice improvement throughout the implementation of the model of care in each practice. As a support service, I worked with the GPs and practice managers to reduce the number of codes used for lower limb oedema, to facilitate easier database searches and audits in the future. Posters and aide-memoires were offered to assist this. Delivering bespoke education for all members of the team, including the community pharmacists though evening sessions for continuing professional development, helped develop their knowledge to assist with appropriate and up-to-date advice they may need to offer.
Group information sessions were offered to inform GPs at each practice to ensure awareness of simple lower limb oedema management and the referral pathway to the Healthy Leg Clinics.
This multidisciplinary approach has ensured each profession is aware of their role in the seamless and effective implementation of the Healthy Leg Clinics.
Patient information leaflets were compiled to ensure that the information given verbally could be supported, increasing patient knowledge and concordance with hosiery use. Alongside this a pre-clinic attendance leaflet informed the patient of what to expect once at the clinic, which improved attendance and reduced patient anxiety.
The project is now in its second year, delivering support and directing the multidisciplinary teams to better manage the person who presents with simple lower leg oedema. This clearly demonstrates appropriate and timely interventions being prioritised in practices where education and support has been delivered. This model of care should therefore be easily replicated in practices Trust-wide and beyond.