Implementing evidence-based leg ulcer care in an Azorean healthcare centre

The Azores are a Portuguese territory and comprise nine volcanic islands situated in the North Atlantic Ocean. The largest and most populous island in this archipelago is São Miguel, which is famous for its beautiful lakes and green mountains. For decades, leg ulcer care in the Azores was not evidence-based; community nurses focused their attentions exclusively on the wound instead of the whole patient, ignoring the underlying cause. This situation led to inefficient, or even contradictory, practices and prolonged periods of ulceration. Since 2008, Ponta Delgada Health Care Centre – which delivers care to 85 000 people, representing 33% of the Azorean population – has invested in training clinicians in the treatment of leg ulceration, as well as acquiring the materials for evidencebased care (dressings, bandages, and portable Dopplers). However, despite this investment, it was decided a new, innovative approach was needed. In March 2012, a tissue viability team was formed, comprising two tissue viability nurses and a general practitioner. The team implemented a leg ulcer consultation in all 20 treatment rooms of the healthcare centre and 10 home care teams. The objectives of the leg ulcer consultation were to effectively triage patients with leg ulceration; properly evaluate the patient concerning ulceration aetiology and factors that influence healing and quality of life; adequately implement an evidence-based plan of care according to patient evaluation; prompt referral of the patient for specialist intervention when required; and frequently revaluate the patient and correct the plan of care when necessary. Regular visits were made by the tissue viability nurses to the community nurses at each setting to offer advice and training in clinical practice. One community nurse was chosen in each healthcare setting as a ‘reference nurse’ to coordinate the leg ulcer consultation. The integration of the general practitioner into the tissue viability team was essential to establish a referral protocol with the vascular surgery team of Ponta Delgada Hospital and to deliver medical care to patients with no access to GPs. The reference nurses developed knowledge and skills in triage according to protocol, clinical and wound history taking, physical examination, ankle–brachial pressure index (ABPI) measurement, wound bed preparation, dressing selection, skin care, compression therapy, delivering patient education, referral to other healthcare professionals, recurrence prevention, and leg ulcer consultation outcome statistics. Best practice protocol was based on the Riverside project in London[1] and the guidelines of the Royal College of Nursing,[2] Registered Nurses Association of Ontario, [3] Scottish Intercollegiate Guidelines Network,[4] Australian Wound Management Association,[5] and numerous scientific papers. Although the role of tissue viability nursing is established in England and Australia, this consultation was the first experience of clinical supervision of leg ulcer care on a large scale in Portugal. To evaluate the impact of the leg ulcer consultation supervised by the tissue viability team, a descriptive and retrospective study was performed, preand post-implementation. In this study, leg ulceration was defined as all ulcers occurring between the ankle and the knee, and present for 4 weeks or longer. The reference nurses completed a questionnaire for each patient identified. The annual treatment cost per patient was calculated by adding the nursing time and dressing cost from the previous treatment and multiplying it by dressing change frequency per week and then by 52 to find the annual total. Incidence and healing rate was calculated by consulting clinical records of the previous year. After 1 year, results of the previous treatment regimen and the new one were compared.