Promoting best practices in lower limb wound care

Rachael Lee, Acting Programme Manager of the National Wound Care Strategy Programme (NWCSP), discusses the challenges in wound care provision and the efforts to enhance dedicated lower limb services. She also emphasises the importance of fostering collaboration across health and social care sectors

The National Wound Care Strategy Programme (NWCSP), commissioned by NHS England, builds on several previous initiatives addressing the issue of sub-optimal wound care. (1-4) Together, these drew attention to the significant impact of current wound care practices on patients, carers and the NHS, highlighting the urgent need for quality improvement. The programme is driven by several foundational principles:

• Wound care must be integrated into the broader care of underlying co-morbidities that cause or contribute to wounds and hinder healing, rather than treated as a standalone issue.
• The NWCSP is a long-term commitment to improving wound care.
• Success relies on collaboration across health and social care sectors, professional groups and services.
• The key priority is to improve patient care, leading to reduced NHS resource use.

The prevalence of lower limb wounds

One of the NWCSP’s main clinical priorities is improving care for people with lower limb wounds. In the UK, leg and foot ulcers account for at least 42% of all wounds, with leg ulceration alone comprising 34% of this total. (3) Leg ulcers most commonly occur because of problems with blood flow, either through venous insufficiency (venous ulceration) or peripheral arterial disease (arterial ulceration). Some, however, arise from a combination of both (‘mixed’ ulcers). Diabetes and related complications increase the risk of foot/lower limb ulceration and often stall healing. (5) Peripheral arterial disease is the most common cause of foot ulcers in people without diabetes, and over half of all major lower limb amputations are now in this group. (6)

Challenges in wound care provision

Care for chronic lower limb wounds varies according to the underlying cause(s) and is outlined in the NWCSP Recommendations for Lower Limb Wounds. (13, 14) These build on clinical guidelines, which have existed for over 20 years but have never been systematically implemented. Most wound care takes place in the community setting, (4) with patients commonly receiving care from practice nurses, depending on community nursing services. However, attempting to deliver quality lower limb care against other demands of a generalist service often leads to unnecessary delays in assessment and treatment. This contributes to prolonged healing times and higher recurrence rates, further adding to the burden of wound care for both patients and providers.

Improving lower limb care

To realise the opportunity to improve patient outcomes, the NWCSP recommends taking a transformative approach by establishing dedicated lower limb services. (15) Evidence from the UK (16) and Canada (17) demonstrates that successful implementation of clinical guidelines relies on dedicated, well-structured services with clear escalation routes, adequate staff, specialist training, quality data capture systems, and expert clinical leadership. In testing this model, there have been notable improvements in patient outcomes and several recommentations, (18) setting a new national benchmark for best practices in lower limb wound care.(19)

The Leg Ulcer Best Practice Bundle (20) provides a framework to support healthcare providers and commissioners with the system-level changes required to successfully implement best practice service models. By investing in dedicated services and fostering collaboration across the health and social care landscape, we can improve outcomes for patients and create a more sustainable model for wound care in the NHS.

References

1. NHS Improvement Stop the Pressure https://www.england.nhs.uk/national-stop-the-pressure-programme-one-year-on/
2. NHS England (2016) Leading Change Adding Value https://www.england.nhs. uk/wp-content/uploads/2016/05/nursing-framework.pdf
3. Guest JF, Ayoub N, McIlwraith T, et al. Health economic burden that wounds impose on the National Health Service in the UK BMJ Open 2015;5: e009283. doi: 10.1136/bmjopen-2015-009283.
4. Guest, J.F., G.W. Fuller, and P. Vowden, Cohort study evaluating the burden of wounds to the UK’s National Health Service in 2017/2018: update from 2012/2013. BMJ Open, 2020. 10(12): p. e045253.
5. Wounds UK. 2012. Best Practice Statement Care of the person with diabetes and lower limb ulcers. https://wounds-uk.com/wp-content/uploads/2023/02/627f50978c2ed6f892ba1480f837fdba.pdf
6. Ahmad, N., Thomas, G. N., Gill, P. & Torella, F. 2016. The prevalence of major lower limb amputation in the diabetic and non-diabetic population of England 2003-2013. Diab Vasc Dis Res, 13, 348-53. 9
7. Darwin, E., Liu, G., Kirsner, R. S., & Lev-Tov, H. (2019). Examining risk factors and preventive treatments for first venous leg ulceration: A cohort study. Journal of the American Academy of Dermatology. https://doi.org/10.1016/j.jaad.2019.12.046
8. O’Meara, S., Al-Kurdi, D., Ologun, Y., Ovington, L. G., James, M. M.-S., & Richardson, R. 2014. Antibiotics and antiseptics for venous leg ulcers. Cochrane Database of Systematic Reviews, 1. https://doi.org/10.1002/14651858.CD003557.pub5
9. Petherick, E., 2010. Leg ulceration: An exploration of the role of socioeconomic factors in the epidemiology, access to health care and outcomes: The University of York, Department of Health Sciences. https://core.ac.uk/download/pdf/40026636.pdf
10. Nanjo, A. et al., 2020. Prevalence, incidence, and outcomes across cardiovascular diseases in homeless individuals using national linked electronic health records. European Heart Journal, 41(41), p. 4011–4020. https://academic.oup.com/eurheartj/article/41/41/4011/5986607
11. Malik, J. & Geraghty, J. 2021. Misunderstood and Overlooked: Piloting tissue viability wound care and nurse outreach with people experiencing homelessness and multiple disadvantage. London: Fulfilling Lives in Islington and Camden. Available from: https://www.shp.org.uk/wp-content/uploads/2024/10/Misunderstood-and-Overlooked-report.pdf
12. Scottish Intercollegiate Guidelines Network. (2010). Management of chronic venous leg ulcers: A national clinical guideline. Scottish Intercollegiate Guidelines Network. https://www.sign.ac.uk/our-guidelines/management-of-chronic-venous-leg-ulcers/
13. NWCSP. 2024. Leg Ulcer Recommendations. https://www.nationalwoundcarestrategy.net/wp-content/uploads/2024/07/NWCSP-Leg-Ulcer-Recommendations-final-version-15.07.2024.pdf
14. NWCSP. 2024. Foot Ulcer Recommendations. https://www.nationalwoundcarestrategy.net/wp-content/uploads/2024/07/NWCSP-Foot-Ulcer-Recommendations-final-15.07.2024.pdf
15. National Wound Care Strategy Programme (NWCSP). 2021. Preventing and Improving Care of Chronic Lower Limb Wounds: Implementation Case. https://www.nationalwoundcarestrategy.net/wp-content/uploads/2021/04/NWCSP-Implementing-the-Lower-Limb-Recommendations-15.12.20-1.pdf
16. Moffatt CJ, Franks P. Implementation of a leg ulcer strategy. Br J Dermatol 2004;151:857-67.
17. Harrison MB, Graham ID, Lorimer K, Friedberg E, Pierscianowski T, Brandys T. Leg-ulcer care in the community, before and after implementation of an evidence-based service. CMAJ: Canadian Medical Association Journal. 2005;172(11):1447-52.
18. NWCSP. 2024. Implementing the Lower Limb Recommendations and Learnings from the First Tranche Implementation Sites: Final Evaluation Report. https://www.nationalwoundcarestrategy.net/wp-content/uploads/2024/07/NWCSP-Final-Evaluation-Report-Full-Version_final.pdf
19. NHS England. Priorities and operational planning guidance 2024/25. https://www.england.nhs.uk/publication/priorities-and-operational-planning-guidance-2024-25/
20. NWCSP. 2024. Leg Ulcer Best Practice Bundle. https://www.nationalwoundcarestrategy.net/wp-content/uploads/2024/04/NWCSP-Best-Practice-Leg-Ulcer-Bundle-v1.0-04.04.24.pdf