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PRACTICE TODAY
In Denmark non-disposable inelastic bandages have commonly
been used for the treatment of venous leg ulcers.
The benefit is that patient can keep the bandages on at
night – the bandages only need changing every third day
and not necessarily in the busy mornings. However, inelastic
bandages need to be washed every time they are
changed to ensure optimal effect. For immobile patients
elastic bandages have often been chosen due to their high
pressure when resting. Many patients in Denmark do not
have a Doppler or toe pressure index measured before
compression therapy is prescribed. Removing the bandages
at night has been widely recommended, to reduce the
theoretical risk of suppressing the arterial flow (4, 6). However,
elastic bandages need to be reapplied in the morning,
before the patient gets out of bed. When the ulcers are
healed compression therapy is continued with hosiery.
This practice had been common in Denmark until the
late 90s when modern multilayer bandages were introduced
to the Danish market and gained acceptance. As a
new initiative, hosiery treatment kits are being introduced
for patients with leg ulcers, and intermittent compression
therapy is gaining a foothold.
Often practice today in Denmark shows a large insecurity
and lack of knowledge of how to apply and maintain
different types of bandages. High staff turnover in the
primary healthcare sector (estimated to be 25% per year by
the Danish communities national association KL) results
in a high demand for education of all personnel treating
wounds to keep them updated on applying the correct type
of compression therapy and maintaining the bandages.
Compression therapy can be carried out with many different
products in Denmark today. We have based the
following overview (figure 1) on a questionnaire asking
which products were available in their areas completed
by 25 nurses responsible for wound care in their home
areas in West Zealand, Denmark. In line 6, for instance,
you can see that in four areas nurses have a choice of using
either inelastic bandages or multi-layer bandages for their
patients. Note that four nurses work for local GPs and two
are employed at the local hospitals.
26
Figure 1
To one question “Do you think that there is a need for
increasing the quality of prevention and treatment of venous
leg ulcers in your own area to ensure evidence-based
nursing and treatment?” 24 of the 25 nurses have answered
“Yes”.
The study can be seen on www.kvalicare.dk.
VALUE FOR MONEY
“How to obtain more value for money” is a highly relevant
question in healthcare systems in general. Concerning
“treatment of venous leg ulcers and mixed arterial and
venous ulcers” we need to consider which type of compression
therapy to choose, based on studies on efficiency and
socio-economics.
Demands to be met for compression therapy;
High level of safety
High patient compliance
Highest healing rate
Sustainable sub-bandage pressure
Socio-economical (Personnel time spent, bandages,
lost earnings)
EWMA, European Wound Management Association published
the Position Document “Understanding compression
therapy” in 2002. This document was developed by
a panel of international experts (7) and includes a recommended
management pathway. The above mentioned issues
are taken into account. See figure 2.
HIGH LEVEL OF SAFETY
Compression must be applied with the correct sub-bandage
pressure cf. ankle-brachial pressure index ABPI. If elastic,
inelastic or multi-layer bandages are used, the outcome
depends on the applying nurse’s estimate of how to apply
the bandage, resulting in possible ineffective treatment
if the bandages are applied too loosely and risking severe
injury if the bandages are applied too tightly. This risk
can be avoided by using bandages with pressure indicators
and/or by teaching staff how to apply the bandages with
a sub-bandage pressure measuring device, which can also
Combinations of Compression therapy available Number of communities (Two hospitals and four GPs included)
Hosiery 1
Elastic bandages 1
Inelastic bandages 3
Elastic and inelastic bandages 3
Elastic and multi-layer bandages 2
Inelastic and multi-layer bandages 4
Inelastic bandages + others 1
Elastic, inelastic and multi-layer bandages 7
Elastic multi-layer bandages and hosiery 2
Inelastic, elastic multi-layer bandages + others 1
EWMA Journal 2008 vol 8 no 3