AAWC Venous Ulcer Guideline

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

2. 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/

3. 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.

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

5. Overview of AAWC VU Guideline:Who does What to Whom by When? • Trained staff: regularly per protocol, as feasible • Assess patient, skin, VU condition,patient/family goals • Coach 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 capabilities • Participate in choosing appropriate, effective care plan • Engage in care

6. AAWC VU GuidelineStep 1: Assess and DocumentPhysical/medical/surgical history to diagnose ulcer causes & risk factors to guide care: • Patient • Skin • Wound • Patient and family goals

7. 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)

8. 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

9. 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

10. AAWC Venous Ulcer Guideline:Step 2: Venous Ulcer Prevention OverviewTrained 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

11. 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

12. 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

13. Step 2: Venous Ulcer Prevention:Protect the Skin • Moisturize dry skin • Protect affected skin from • Irritation • Sensitization • Chemical injury • Physical trauma

14. 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

15. 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

16. 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____

17. 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

18. 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 oradjunct intervention + appropriate Step 3 interventions.

19. 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