clinical guidelines for the management of venous leg ... linee guida/arti inferiori/leg… ·...

Clinical guidelines for themanagement of venous leg ulcers

implementation

Clinical guidelines for themanagement of venous leg ulcers

Published by the Royal College of Nursing,20 Cavendish Square, London W1M OAB

March 2000

ISBN 1-873853-92-0

Publication code: 001 213

Price: RCN members £6.50Non-members £8.50

implementation

Clinical guidelines for the management of venous leg ulcers Implementation Guide

AuthorsLesley Duff, Senior Research and DevelopmentOfficer, Royal College of Nursing Institute (RCNI)

Alison Loftus-Hills, Postgraduate Research Student,RCNI

Clare Morrell, Senior Research and DevelopmentOfficer, RCNI

ContributorsJill Brooks, Primary Care Development Nurse,Oxfordshire Community NHS Trust

Duncan Courtney, Research Fellow,University of Hull

Carol Dealey, Research Fellow,University Hospital Birmingham NHS Trust

Chrissie Dunn, Senior Nurse, Practice Development,Battle Hospital, Reading

Jacqui Fletcher, Senior Lecturer,University of Hertfordshire

Gill Harvey, Head of Quality, RCNI

Hui Liao, Project Officer, RCNI

Claire Palmer, Clinical Effectiveness Manager,Royal College of Psychiatrists

Julia Schofield, Consultant Dermatologist,St Albans City Hospital, St Albans

The Clinical Guidelines Implementation ResourcePack Steering Group

© Royal College of Nursing, 2000

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Contents

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Introduction 5

Step 1: Decide who will lead and co-ordinate the work 6

Step 2: Determine where you are now 6

Step 3: Prepare the people and the environment for guidelineimplementation 8

Step 4: Decide which implementation techniques to useto promote use of the clinical guideline in practice 12

Step 5: Pulling it all together - devise an action plan for implementation 16

Step 6: Evaluating your progress 17

Summary 18

References 20

Appendix 1 Further reading 21

Appendix 2 Methods for reviewing the readiness of the environment 22

Appendix 3 Checklist: disseminating the clinical guideline 24

Appendix 4 Local strategies for the management of leg ulcers 25

Appendix 5 Patient information about leg ulcers 27

Appendix 6 Examples of leg ulcer assessment forms 29

Appendix 7 Methods of disseminating or implementing guidelines 36

Appendix 8 Dissemination/implementation strategies: summary 39

Appendix 9 PACE Project: West Berkshire 41

Appendix 10 Action plans 42

Clinical guidelines for the management of venous leg ulcers Implementation Guide4

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Introduction

The most recent strategy for nursing states: “It is forevery nurse, midwife and health visitor to strive forquality improvement in all aspects of practice”(Strategy for Nursing – Department of Health, 1999).This implementation guide forms part of a set, the focusof which is the development of care to people livingwith venous leg ulcers. The guide sets out in verypractical ways how to strive for quality improvementusing clinical practice guidelines.

Decisions about health care are complicated forprofessionals and for patients. The potentialbenefits and hazards of different interventions haveto be considered against a background of limitedresources and varying needs. Given thiscomplexity, there is increasing interest in clinicalguidelines as a way of assisting decision-making.

Clinical guidelines are developed using systematicreviews of research findings. Systematic reviewsclassify research studies by design and give anindication of the reliability and validity of theirfindings. A clinical guideline takes those findingsand turns them into an active document by makingrecommendations for practice. Increasinglypatients’ views are included in guidelines, whichensure that patients’ preferences are highlightedand thus included in clinical decision making.

This guide is designed to help you turn theguideline recommendations into reality. It aims to

set out practical ways in which you can improvecare locally by implementing the clinical guidelinefor the management of venous leg ulcers.

The clinical audit cycle can provide a usefulframework for implementing guidelines andevaluating improvement. This cycle contains thesame elements as the process involved inimplementing guidelines. The processes areessentially the same, having quality improvementas their goal. As you read textbooks and articlesyou will find slight differences in the order inwhich the elements are described. The clinical auditcycle is set out in figure 1. Both processes start withinvolving the entire team and finding the rightleadership. They end by feeding into a programmeof regular re-audit so that care is continuallyreviewed and improved. The steps in between varyslightly, but draw on the same sets of skills.

You may have been involved in clinical auditprojects before. Much time is spent in definingstandards or best practice. By using a clinicalguideline as a definition of best practice and anational audit tool to monitor, a great deal of timecan be saved. This enables the clinical team tofocus on the most important part of the audit cycle,taking action to implement the guidelinerecommendations to improve the service.

Translating guidelines into practice is a complexundertaking and the guide sets out a number oftechniques that have been tried and tested to makethis process easier. This process of developmentcan be divided into steps.

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Enlist the support of all staffinvolved Critically review the

available evidence

Collect valid andreliable data

Develop a standard,objective and criteria

Disseminate thestandard, develop a

monitoring tool

Implement the criteria

Identify sources of data andmethods for sampling

Compare results tothe objective

Feed back toparticipants

Generate a team action planand implement

Re-audit andevaluate

Describe currentpractice

Figure 1 – The Clinical Audit Cycle


The guide takes you through the steps in turn,outlining things that you can do as you plan toimplement the guideline recommendations locally.The steps are illustrated with examples frompractice, which you will find throughout the text.The steps are intended to provide a flexible model,recognising that organisations and teams will bestarting from different places. Wherever you arestarting from, we hope that you find the guideuseful as you seek to improve the services yourteam is able to offer locally.

Step 1: Decide who will leadand co-ordinate thework

The first step in implementing a clinical guidelineis to decide who will lead and co-ordinate thework. Successful behaviour change is usuallyachieved when people, who may not usually workin the same team, are brought together to achieve acommon goal. It is helpful, therefore, to set up aninter-professional group to lead and co-ordinatethe implementation of the guideline. The groupshould include representatives of everyone whowill be affected by the guideline. These people areoften referred to as the stakeholders.

Studies show that inter-professional work groupsachieve more when they have a facilitator (Harveyand Kitson, 1996). A facilitator is someone whoenables the group to work together to achieve itsgoals by attending to the group dynamics and theneeds of the participating individuals.

All members of the implementation group should beclear about their contribution to the group and tothe work involved in implementing the clinicalguideline. If roles and responsibilities are not agreed

at the outset, one or two people might take on allthe work thereby limiting the degree to whichothers can feel involved and able to participate inthe change. Sharing the work will also make thetasks quicker and less onerous. The implementationteam may then carry out each step in the process ofimplementing the guideline themselves or mayenlist the support of others, for example, to conductthe clinical audit or to review the environment.

It is also important for the group to agree what itwants the clinical guideline to accomplish.Members may otherwise disagree about prioritiesand feel confused and disillusioned if theirexpectations are not met.

Step 2: Determine whereyou are now

To effectively prepare to implement a clinicalguideline you first have to know what changes areneeded, whether the organisation is ready to makethem and what resources you have to supportthem. That is, you need to evaluate current clinicalpractice to find out the degree to which currentcare conforms with that recommended by theguideline. You also need to review the environmentto find out how ready health professionals andpatients are to implement the guideline and whatsystems and structures are already in place, or areneeded, to support any changes required.

Evaluation of clinical careThe degree to which current care conforms with theguideline recommendations and what changes areneeded can be determined by conducting a local audit.

Measurement is undertaken using the nationalsentinel audit protocol, which forms part of themanagement of venous leg ulcers set. There arethree stages:

� Collecting audit data

� Collating audit data

� Summarising audit data

During the audit you need to evaluate differentaspects of the care you provide including the

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Step1 Deciding who will lead the work

Step2 Determining where you are now

Step3 Preparing to implement the guideline

Step4 Identifying techniques to assist

Step5 Devising an action plan

Step6 Evaluating your progress

Six steps to improve the management of venous leg ulcers

Identify the stakeholdersSet up a group of stakeholder representatives tolead implementation of the guideline

Identify a facilitator

Measuring current clinical practice

Clarify and agree the roles and contributions of allgroup members

Agree the purpose of the clinical guideline


resources that are available (structure), the actionsand decisions you take in practice (process) and theoutcomes of care (outcomes). The audit protocolthat comes with the set focuses on the actions thattake place in clinical practice and some of theoutcomes that result from those actions. You mayalso want to ask questions to find out whether youhave all the resources, staffing and materials thatyou need to achieve the clinical guideline.

The audit protocol focuses on evaluating the clinicalcare of venous leg ulcers. It is also important to findout what patients think about the service offered.Additional guidance notes on involving patients andother service users in the evaluation of the service areavailable as part of the set. The audit protocol alsogives you suggestions about when to carry out theaudit, how to collect the data, the number of patientsand staff that you need to include in the audit (thesample) and who should carry out the audit.

Review the environmentReviewing the environment involves finding outmore about the people who will be affected by theproposed changes. For example, is everyonereceptive to the guideline and willing to use it inpractice? Does anyone need extra education ortraining to be able to provide care as recommended?

Review of the environment also involves findingout what systems and structures there are in placewithin the organisation to support implementationof the guideline. There is a section within thenational sentinel audit protocol, which you mayfind useful in addressing these issues.

Who will be influenced by the clinical guideline?As well as the stakeholders involved in the co-ordinating group, there may be other individualswho need to be included and accounted for in yourstrategy and plan. Many people within or externalto the organisation may influence theimplementation process including fundingorganisations, health care professionals with theirown ideas, community health councils and otherpatient representatives.

Little is known about how many people need toimplement a guideline before its effectiveness inimproving practice can be detected. The experienceof one area in implementing clinical guidelines forleg ulcers, however, suggests that for a populationof 40,000 one locality manager and 20 communitynurses were able to effectively change practice.

Receptivity to the guideline. Knowing who will beaffected by the clinical guideline and how they arelikely to respond to its introduction should helpyou tailor the way in which the clinical guideline isimplemented locally. It may also be helpful to thinkabout how changes to clinical practice have beenhandled in the past. As well as helping youunderstand people’s expectations, finding outabout previous attempts at managing change(successes and failures) will help you select themost suitable methods for implementing theclinical guideline.

It may be helpful to talk to clinical audit staff,information specialists, medical records staff,contract managers, local healthcommission/authority/board, quality managementstaff and so on when you evaluate clinical practiceand review the environment. It could also behelpful to talk to people who have experience ofworking in project groups, staff responsible for thearea of care training, development managers, andpatients and carers.

Systems and structuresConducting a review of the structures and systemsof the organisation into which the clinicalguideline will be introduced allows you to identifywhat aspects of that organisation will help youimplement it and what aspects are likely to hamperyou. Identifying these features enables you to takeactions to overcome difficulties and to capitalise onany strengths. You will then be able to plan how toprepare the organisation and the people who workwithin it to implement the clinical guideline. Forexample, does the organisation have an efficientmechanism for communication between itsemployees or will you need to set up somethingnew?

Reviewing the environment is a complex goal.However, there are a number of tools that can beused including the SWOT analysis and the Fishbonediagram – examples are included in Appendix 2.

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Decide who should be involved in theimplementation of the clinical guidelinesWhen should they get involved?How much should they get involved?

Find out what people think about the clinicalguidelineWhat do health professionals know about theguideline recommendations? Do patients have the same views asprofessionals? What are the implications of any differences inviews between professionals and patients?How do you think the introduction of the changewill be received?

Identify the systems and structures you need tosupport implementation of the guideline


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The success of the guideline implementation project in Walsall has been greatly facilitated by investingin assessment of the needs of the local population and those of clinical practitioners. A guidelinessteering group was set up with representatives from all clinical and management areas across thedistrict. This helped ensure the service has a truly multi-disciplinary focus and encouraged ownershipand commitment from all key players involved.

Guidelines have now been distributed to every clinical area in Walsall and are aimed at being acomprehensive educational resource on the prevention and management of leg ulceration. Educationalpathways are now in progress to ensure recommendations are implemented and standards are met.Educational strategies include theoretical sessions and clinical placements to assess knowledge andcompetencies. Clinical placements include community leg ulcer clinics and vascular and dermatologyclinics within the acute sector.

One of the aspects of the project that has been truly successful is the multi-disciplinary teamwork thathas resulted from developing district clinical guidelines. Clinical care and referral pathways have beenagreed and communication between nursing staff for complex patient referrals for relevantspecialist/consultant advice has improved significantly.

It is envisaged that full implementation of the guidelines will result in a much better partnershipbetween primary and secondary care and quality care provision for patients.

Donna Chaloner, Registered Specialist Practitioner (Tissue Viability)Walsall Community Health Trust

Example 1 – the importance of initial assessment

Step 3: Prepare the peopleand the environmentfor guidelineimplementation

Preparing the people

There are two purposes in preparing people toimplement a guideline. Firstly, to ensure that theyare receptive to the clinical guideline and knowhow to use it and secondly, that they have theclinical skills and knowledge to carry out care asrecommended in the guideline – this is absolutelycrucial to your success in implementing theguideline.

Improving people’s receptivity to the clinicalguideline. Some of the people who will be affectedby the clinical guideline will support itsimplementation and others may oppose it. Lots ofpeople will probably be indifferent. Health careprofessionals and patients may react differently tothe proposed changes. Some people may feel thatthe care provided is already the best possible,others may cling to outmoded practices, despiteknowing that other practices are more effective. Itis important to be aware of the views of all peoplewho can possibly influence the implementation of

the guideline in order to make plans to eithercapitalise on their support or to limit the amount towhich they can sabotage your efforts.

Block (1991) suggests that classifying people intoone of four groups can be a useful way of assessingwho is likely to be enthusiastic about introducing aclinical guideline and those who will be morereluctant. Block classifies people as bedfellows,allies, adversaries and opponents. The willingnessof each group to change is summarised in Figure 2and explained below.

Allies are people with influence who both supportyour implementation agenda, and in whom youhave high trust. On the positive side, you canmobilise them to support your aims, but on thenegative side they will not necessarily challengeyour view and help to create new perspectives.These people are similar to those described as

Identify your supporters and the possible saboteurs

High agreement Bedfellows Allies

with guidelines

Low agreement Adversaries Opponents

with guidelines

Low trust High trust

Figure 2


‘opinion leaders’ or ‘product champions’ and theycan be found at any level within the organisation.A defining characteristic is their influence andcredibility rather than their status or rank.

Opponents are those people with influence inwhom you have great trust, but who do notnecessarily share your aims. These individuals areuseful because they provide a sounding board foryour ideas and plans, and they can be counted onnot to block your aims unfairly or without notice.However, if you do not deal with opponents openly,the trust you share may be eroded and they maybecome adversaries.

Bedfellows are those people with influence whomyou are not able to trust fully. This is probablybecause you do not know them very well, orbecause in the past your dealings with them havebeen at arm’s length. They do, however, share someof your aims. These individuals are useful becausethey can be included in the implementation of theguideline by inviting their involvement, seekingtheir opinions, and by developing appropriateworking relationships in which they feel able totrust your aims.

Adversaries are those people with influence whomyou feel unable to trust and who do not share yourcommitment to guidelines.

Fence-sitters are those people with influence whoneither agree nor disagree with your aims and inwhom you consequently feel little trust. Block(1991) characterises these as the archetypalbureaucrat, the person who always plays safe andtakes refuge in the rules. On the positive side, theygenerally encourage review and debate but arereluctant to commit themselves. To counter this,Block suggests asking what they need for them tooffer their support.

Here are some suggestions about how negativeattitudes to clinical guidelines can be tackled:

� explain what clinical guidelines are AND whatthey are not

� explain the implications of the guideline, howthe organisation is contributing to its successfulimplementation, and what is expected of staff

� demonstrate why a clinical guideline is needed,what its benefits are and how it can improve care

� be honest about the advantages anddisadvantages of the clinical guideline

� find out the myths and legends surroundingclinical guidelines, and clarify the ways in whichthey threaten professionals and patients, thenoff-set these with their advantages

� agree to review the use of the clinical guidelineand its impact on care and working practicesafter a set period.

A key factor in improving people’s receptivity to aclinical guideline is to make sure that everyone isaware of its existence, what it involves and itsbenefits. It is helpful for people to be given thechance to think about and comment on plans forimplementing the guideline before any changestake place in practice.

It will also help share ideas about how difficultiesin implementation can be overcome and toencourage one another.

To make sure that everyone is aware of the clinicalguideline and what its recommendations mean forpractice it is important that it is widelydisseminated. A common reason why clinicalguidelines are not used is that the intendedaudience has never heard of them (Gupta et al.,1997; Tunis et al., 1994). Dissemination andconsultation will be promoted by an effectivecommunication strategy. Appendix 3 provides youwith an example of a check-list that you can use toidentify everyone who should receive a copy of theclinical guideline. In addition, there may be otherpeople who should know that the guideline is beingimplemented. It is useful to also list the members ofthis second group to ensure that no one isforgotten.

A communication strategy needs to take account ofthe following:

� People❍ all those who are influenced by the clinical

guideline❍ all those who will use it in practice ❍ the ‘gatekeepers’ through which information

is channelled (e.g. - to get information to staffnurses, do you need to go through wardmanagers?)

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Plan activities to overcome negative attitudes toclinical guidelines

Devise a communication strategy to supportimplementation of the clinical guideline

Change or add to systems and structures toenable effective organisation-widecommunication

Communicate plans to implement the clinicalguideline to everyone affected

This two way communication allows health careprofessionals to advise the co-ordinating groupof anything to do with the patients they workwith, in their environment or related to theirskills and knowledge which might influence theimplementation of the guideline.


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District Nurses and Registered General Nurses working in the Nottingham Community Trust, have theopportunity to undertake either the ENB N18 Management of Patients with Leg Ulcers, or the ENB N49Tissue Viability courses, as part of their professional development. Following completion of thesecourses, it is agreed and supported by management, that they will commence the role to Tissue ViabilityLink Nurse. All Link Nurses are expected to act as a resource for tissue viability advice within theirPrimary Care Group, to other District Nursing Teams. Their role also involves assisting with the currentin-service training programme, and co-ordinating a Community Leg Ulcer Clinic.

Monthly meetings are organised to support all Link Nurses in their role. Each meeting lastsapproximately two hours and a variety of speakers are invited each time, to update and increaseknowledge on all aspects of tissue viability. These meetings also allow time for discussion and reflection,enabling ideas and experiences to be exchanged. They are also an ideal opportunity for the TissueViability Nurses to disseminate information and obtain feedback about the tissue viability services.

All patients attending Community Leg Ulcer Clinics in Nottingham (there are currently 14) are nowassessed by a Link Nurse. We believe that this promotes quality of care, offering patients the opportunityto be assessed by a nurse who has undertaken further training and has specialist knowledge. This systemalso enables Link Nurses to consolidate their learning from either the ENB N18 or N49 courses. Settingup 12 Leg Ulcer Clinics in a year was a difficult task, however, each Link Nurse has been able to advise,support and teach other Link Nurses, how best to undertake this. Having peer support and sharing ideashas been extremely useful. The clinic setting has become a useful teaching area, for both trained staffand student nurses, to learn from Link Nurses about assessment techniques and the most appropriatemanagement strategies for patients with leg ulcers.

There are currently 28 Link Nurses and a waiting list for others to commence the ENB courses. TheTissue Viability Nurses see Link Nurses as an essential part of their team. The support and raisedawareness they bring to the service is invaluable. This ultimately improves patient outcomes.

Wendy Hodgkin, Tissue Viability NurseNottingham Community Health NHS Trust

Example 2 – Structures for two way communication; a tissue viability link nurse system

� What makes information about the guidelinemore accessible for different individuals orgroups?❍ vary the media of presentation rather than

only using paper formats e.g. use visualrepresentation of the guideline or audit results

❍ use different settings e.g. presentations,meetings, educational, administrative, hand-over meetings, ward rounds, social situations

❍ use information technology❍ use incentives that highlight and ‘sell’ the

guideline ❍ use different methods for different individuals

and groups❍ promote the credibility and rigour of the

clinical guideline

� Evaluation❍ how will you know that everyone who needs to

hear about the clinical guideline has done so?❍ how can you collate and feedback ideas about

implementing the guideline?

A wide range of methods has been used to disseminateinformation within health service settings. It may behelpful to think of the stakeholders you previouslyidentified as different ‘audiences’ for information.

Each audience may respond differently to thedissemination methods used. Your disseminationstrategy may, therefore, need to vary for each one (i.e.– making a presentation to one group and sending anewsletter to another). Strategies may also vary bywhether the target audience is a group of allies,adversaries, bedfellows or opponents.

Ensure professionals have the skills andknowledge to make changes to clinicalcare

The clinical management of venous leg ulcers isusually provided by district nurses, tissue viabilityspecialist nurses, leg ulcer clinical nurse specialists,some practice nurses with a special interest in legulcers and some provider unit outpatient nurseswith specialist skills. The assessment andmanagement of venous leg ulcers is specialisedwork, requiring in-depth knowledge about causesof leg ulcers, and assessment of patients with legulcers, including Doppler assessment andcompression bandaging techniques.


For the guideline to be successfully implementedthe nurses and general practitioners in the teamneed to have the knowledge and skills toimplement the guideline recommendations.

You may wish to liaise with a local educationprovider to obtain clinical training on theassessment and management of venous leg ulcersfor the district nurses and general practitioners inyour team. A number of areas have educationalinitiatives to improve the clinical care of patientswith venous leg ulcers. Examples of localinitiatives, including the Oxfordshire Leg UlcerStrategy, and work in Hertfordshire, Reading andBirmingham can be accessed through the contactnames provided in Appendix 4. Such examples cangive you good ideas about educating and

supporting nurses to assess and manage venous legulcers in line with the guideline recommendations.

Prepare patientsPatients must be involved in planning how theclinical guideline will be used to make sure thattheir preferences and views are to be included inthe decision-making process. Involving patientscan also ensure that they understand the reasonsfor the care they received and their contribution toits success. For example, a patient may be morewilling to wear a compression bandage forextended periods of time if he or she understandsthe reasons why that type of bandage is used.

The patient version of the clinical practiceguideline forms a part of the set QualityImprovement in the management of venous legulcers. You may choose to adopt this publication oradapt it to suit the needs of your community.

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Surrey Hampshire Borders NHS Trust currently includes seven Primary Care Groups, 66 District NursingTeams working out of 100 bases, five community hospitals and a Mental health team within a 700square mile geographical area. As the Tissue Viability Adviser, dissemination of new guidelines andeducation across the Trust is part of my responsibility. In order to achieve this, a leg ulcer forum hasbeen formed which includes representatives from Practice Nurses and District nurses from each of theseven Primary Care Groups and community hospitals. The forum meets monthly to consider newinitiatives. At each meeting a speaker from multidisciplinary teams or marketing companies is invited toupdate the forum members on current initiatives. The forum members are invited to attend a two dayin-house educational update yearly. It is expected that in the future each Primary Care Team will havean ENB N18 trained nurse, from the forum.

Education and follow up training for the management and prevention of leg ulceration has beenstructured across the trust. One day leg ulcer assessment and leg ulcer management sessions with afollow up Doppler and Bandage ‘pick and mix’ workshop, are offered to all trained staff, includingDistrict nursing, community hospital staff, back to nursing and twilight nursing services. Three one andhalf hour ‘In Surgery’ training sessions, for practice and district nurses, are also offered. These include,leg ulcer management, Doppler ultrasound, compression bandaging and dressings update.

In order that relevant members of the trust staff are kept up to date with Tissue Viability issues, anewsletter is sent three times a year, directly to every nursing base. Managers and relevantmultidisciplinary professionals allied to medicine are also sent a copy of the newsletter.

Mary Eagle, Tissue Viability AdviserSurrey Hampshire Borders NHS Trust

Example 3 – Skills and knowledge; a leg ulcer education programme

Do the nurses need to know more about how tocarry out the clinical care described in theguideline e.g.– Doppler measurement andcompression bandaging?How can you ensure they have the clinical skillsand knowledge that they need to implement theguideline?Provide an agreed education programme toensure professionals have the skills andknowledge they need to implement theguidelineSet up a system for clinical supervision toensure clinical practice is in accordance withguideline recommendations

How can patients be prepared to wearcompression bandages?Do nurses have the skills and knowledge toexplain compression therapy to the patients –how can they be developed?Prepare nurses to educate patients about thebenefits of compression therapyPrepare patient information leaflets about theclinical guideline


The preparation of written materials for use bypatients is a skilled task. It can be helpful to look atinformation leaflets that other groups haveprepared. In appendix 5 you will find:

� Sources of guidance about developing patientinformation

� Contact details of people who have successfullyproduced patient information on themanagement of leg ulcers.

Prepare the environmentTo implement many clinical guidelines, structuresand systems have to be changed. For example,pathology test order forms, outpatient clinicappointment letters or computer systems may haveto be altered. Systems may have to be created, forexample the inclusion of reminders in patients’notes or teaching sessions for clinical staff. Thestructures and systems you already reviewed andset up to support the implementation of the clinicalguideline will help identify what else is needed.

A number of resources may also be required toenable the clinical guideline to be implemented.Such resources include:� leg ulcer assessment forms (see Appendix 6)� Doppler ultrasound to screen for vascular

disease� compression bandaging� orthopaedic wool� specialist hosiery and other aids

The team will need to decide which type ofbandages and orthopaedic wool they wish to use.

Step 4: Decide whichimplementationtechniques to use topromote use of theclinical guideline inpractice

This section outlines a range of techniques, whichhave been used to implement changes in practice inhealth care settings. Research findings show that itis important to use a variety of implementationmethods and to integrate them with a strategy forchange (NHS Centre for Reviews and Dissemination[CRD], 1999; Dunning et al., 1997; Grimshaw &Russell, 1993; Thomas et al., 1998).

Traditionally, education and training have beenused to change the behaviour and practices ofhealth care professionals, to inform and convincepeople about the need to change and to ensure thatthere is consistency in care provided. However,knowledge and information by themselves are notenough to persuade people to change theirbehaviour (Freemantle et al., 1997). Instead othermethods and techniques also need to be usedincluding: education, social influence, facilitation,audit sanctions, marketing and reminders.

Appendix 7 provides a brief overview of studies,which examine the effectiveness of methods todisseminate and implement guidelines. You mayfind this information helpful in selecting themethods you will use in your implementationstrategy. Various factors such as the targetaudience, the educational influence and practicalconsiderations for each implementation techniqueare outlined in Appendix 8. In addition, projectssuch as that conducted by PACE and the SouthernBirmingham Community Health NHS Trust (Dealey

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Some patients find wearing compression bandage therapy and compression hosiery difficult to accept.One method I have found which aids compliance, is to draw up an agreed contract of care with thepatient. Documented in the care plan under interventions, statements regarding management of thepatient with an ulcer includes a section in which the patient agrees care. This is documented and thepatient reads this. I have found by documenting action required of the patient, the patient will agree andform an ownership of their own care management. This has led to improved compliance from a moreinformed patient.

Mary Eagle – Tissue Viability Adviser, Surrey Hampshire Borders NHS Trust

Example 4 – Agreeing contracts of care with patients

Do you need to create new systems andstructures to implement the guideline?Who do you need to involve in creating them?Do you have the resources you need, inparticular a leg ulcer assessment form?


et al., 1997) have specifically examined theimplementation of clinical guidelines for themanagement of venous leg ulcers. Details aboutthese projects are provided in Appendix 9.

Education and training. To implement the clinicalguideline it is important to provide education andtraining to everyone within an organisation so thatthey understand:� the benefits of clinical guidelines� how and why they are developed� what is needed to implement guidelines, in this

case the venous leg ulcer guideline� the content of the guideline and how it applies

to them� what they are being asked to do with the

guideline� how they can use the guideline� how they can monitor its use and ensure that

patient care improves.

Education may also be required in particularclinical skills relevant to the guidelines which staffmay need to develop. It is more likely to beeffective when it is tailored to the needs of theindividuals concerned and opportunities for smallgroup discussion are provided. Education is alsomore likely to be effective if it is combined withanother activity, for example, audit and feedback.

Education alone may be sufficient to achieve guidelineimplementation with those you have identified asbeing your keen supporters, but is unlikely to achieveguideline implementation with other groups. As we allknow, people react differently to change.

An alternative strategy is to use techniques thatwork by using social influence (Mittman et al.,1992). Social influence techniques include clinicalleadership, opinion leaders, product champions,peer support, clinical audit, and feedback andrewards.

Clinical leadership. Much of the literature onguideline implementation, as well as that onquality improvement, stresses the need for gainingthe support of influential and/or senior figures forany changes proposed. The need for senior supportis the case even where the development andimplementation activity is managed as a ‘bottom-up’ process. To enlist the support of key people youneed to identify the obvious leaders within yourorganisation including locality managers, clinicaldirectors, general practitioners, practice managersand chief executives. These people can then betargeted with information.

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Local guidelines have been developed across seven trusts which include the unification of documentationbetween the hospitals and communities in those trusts. Leg ulceration assessment and reassessment formshave been developed. The forms are suitable for both the hospital and community setting.

Also included in the guidelines is staff education, with a teaching element incorporated. Each member ofthe steering group has been provided with a computer floppy disc containing:� the format of the guidelines� layout for overhead projection sheets for teaching, enabling the member of implement workshops in

order to formalise the distribution of the guidelines throughout the trusts� aims of an in-service training programme� objectives of such a programme� suggested training content, ranging from anatomy and physiology through to creating a leg ulcer

service.

In this way, all seven trusts are delivering standardised information. The guidelines are non prescriptiveand can be adapted to meet specific local need. They also include local resource names and nationalspecialist courses which are currently available.

Mary Eagle – Tissue Viability Adviser, Surrey Hampshire Borders NHS Trust

Adapted from an article published in the Journal of Clinical Excellence, Eagle, M. and Knott, P. (1999) Venous Leg Ulceration:guidelines and audit. A health authority initiative, Journal of Clinical Excellence, vol 1, no. 2, pp65-69

Example 5 – Guidelines education

Devise and agree an education programme forthe health professionals you work withWhat would the aims of an educationalinitiative be? What type of education is likely to be mosteffective?How would the education be delivered? Bywhom? When?What other techniques can be used alongsideeducation?


Facilitation. To enable the multi-professional groupto work together it can be helpful to draw on theskills of a trained facilitator (Morrell and Harvey,1999). The term facilitation is used to describe aprocess of helping, guiding and enabling. In thecontext of implementing guidelines, the role of thefacilitator is to guide the project group through thesteps and to enable the group to work effectivelytogether to that end. The facilitator should bespecifically trained for the role with knowledge ofquality improvement, project management andgroup processes. The person chosen for the rolemay belong to the clinical team concerned with thetopic or come from elsewhere.

Opinion leaders. Opinion leaders are influential,respected individuals who are experts in theirchosen field (Lomas et al., 1988; Rogers, 1995).When compared to their peers, opinion leaders tendto have a higher social status, are more innovativeand tend to be the centre of an interpersonalnetwork. Opinion leaders encourage others to usenew information by using it themselves, thussetting an example and creating new implicit orexplicit social norms. Opinion leaders are highlyvisible and are accessible to others because of theirextensive interpersonal networks. This enables theirinfluence to travel beyond their immediate clinicalteam.

Product champions. Some individuals literally‘champion’ a product and ‘sell’ it to their colleagues(Stocking, 1985). The amount of time that theproduct champions put into supporting aninnovation is directly related to how well it isimplemented.

Once you have identified who the opinion leadersand product champions are in your team andorganisation, think about how to enlist their help inimplementing the clinical guideline. What is itabout the clinical guideline that will appeal tothem?

� might it save money?� might it reduce the chances of litigation?� does it relate to targets set by commissioners or

the health authority?� does it address a personal interest?� is it a guideline recommended by a royal college

or other professional organisation?� is it recommended by patients?

Peer support. People commonly learn and formulatenew opinions through discussion with their peersand are influenced by opinion leaders within theorganisation (Mittman et al., 1992). For example,nurses may want to talk to others in their groupabout the implications of the guideline to helpthem decide whether to use it. They will ask eachother questions such as:� is the guideline valid?� does it apply to the work we do and the patients

we see?� will it improve practice or may it have a harmful

effect?

These conversations often happen in socialsituations, for example, whilst in the car park or inthe staff canteen, and often have a great influenceon people’s decision-making. It has been arguedthat this social influence may be the biggest factorin whether a new initiative is implemented.Providing opportunities for discussion is, therefore,likely to have a beneficial effect on the adoption ofthe guideline. Discussion can be incorporated intoeducation sessions, team meetings andpresentations.

Feedback and reward. Management theorists andpsychologists describe how important it is for us toachieve and for others to recognise ourachievements. Achievement and recognitionmotivate us and give us the confidence to continueto perform well and to develop further, to try newthings and to perform even better. A key part of animplementation strategy is reward and celebration.

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Which senior or managerial people should agreethe implementation of the guideline?How can you enlist their support?How can you demonstrate to others in theorganisation that you have the support of thesenior and managerial people for the proposedchanges?

How can support for the clinical guideline beobtained from opinion leaders and productchampions?

What activities can they undertake for/with youto promote acceptance and use of the guideline?

Identify activities and events that you can use topromote the guidelineHow can you capitalise on social situations toget your messages to professionals and patients?How can you make formal situations moreenjoyable and memorable?

Who else has influence over the opinions of thehealth professionals and patients you work with?

Identify the opinion leaders and productchampions in your clinical team and/ororganisation


Positive results from clinical audit demonstrateachievements. There may be opportunities tocelebrate these at routine team meetings, to tellothers about the achievements through theorganisation’s internal communications systems, orat one-off events. Internal or external rewards oraccreditation schemes can also be used.Recognising and rewarding success not onlymotivates those already involved in implementinga guideline, but it also acts as a marketing devicefor those who remain sceptical. Benchmarking mayprovide a useful structure for this process (Ellis andMorris, 1997). This is described in step 6.

As well as social influence techniques, there arealso a number of other practical steps that you cantake to improve implementation of the clinicalguideline. These include the use of recordingsystems and care pathways.

Recording systems. Incorporating therecommendations of a clinical guideline into thesystems you use to record clinical information canbe a powerful way of reminding yourselves toadhere to the guideline. Recording systems can alsobe helpful in promoting a systematic approach toclinical care and the recording of information.

Integrated care pathways. Integrated care pathways(ICPs) present a plan for the clinical managementof patients with a particular condition that specifiesthe optimum course of events to happen within aset time-scale. They are developed by local multi-professional teams and may be based on or includerecommendations from clinical guidelines.Variations from the pathway are documented andthe reasons for the variations analysed. Avoidablevariations from the pathway can then be addressedand changes made to the pathway if necessary.

Having reviewed the range of techniques that youcan use to encourage people to use the clinicalguideline in practice, you now need to decidewhich ones will be most useful in your locality.

To help you decide which techniques to use, reviewthe answers to the questions asked in the previoussections. This information gives you insight intothe people who will be implementing the guidelineand the environment in which they are working. Aswell as helping you plan how best to prepareprofessionals, patients and the environment forguideline implementation, the information alsohelps you identify which techniques will be mosteffective. Using the information that you haveabout your locality think about:� which implementation techniques are most

attractive? � which are most feasible?� what are the resource implications of each idea?� are some ideas more suitable for some of the

groups of people you work with than others?� are some ideas more suitable for different stages

of the work?� how effective (based on the knowledge you have

gained whilst working through this guide) doyou think the different techniques will be?

You will probably want to use different techniquesat different stages in the process of implementingthe guideline. For example, in the early stages,techniques that promote people’s awareness of theguideline will be most useful. Later, you will needto use techniques that encourage and maintainguideline use. Whatever techniques you decide touse, success is more likely if you mix and matchthem according to the group, or groups, into whichyou are introducing the guidelines.

Jot down your ideas about implementation.

� have you identified everyone who will beaffected by the guideline?

� have you used a range of different techniquesfor each group?

� have you chosen techniques according to howready the group members are to implement theguideline?

� have you chosen techniques that suit thedifferent backgrounds and preferred learningstyles of all your target groups, e.g. – patients,nurses ?

� have you included a technique which addresseseducation and information provision?

� have you included a technique which makes useof social influences?

� have you considered the different techniquesyou will use over time?

� have you considered and addressed the practicalimplications of the techniques you haveidentified?

� have you considered the cost implications ofeach technique?

� are all the techniques realistic and achievable?

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How can your achievements be recognised andrewarded?

Can any of your assessment or patient recordforms be redesigned in line with guidelinerecommendations?

Decide which combination of techniques is mostsuitable for implementing the clinical guidelinewhere you work.


Step 5: Pulling it alltogether – devise anaction plan forimprovement

The answers to the questions posed during thisguide provide you with the information that youneed to devise a strategy for improving care locally.The final parts of developing the strategy areorganising the information into a set of sequentialactions, allocating each action to a namedindividual (or individuals) and setting targets anddeadlines for each activity – that is turning yourstrategy into manageable activities in the form ofan action plan.

An action plan needs careful consideration. Foreach issue identified you will need to consider:

� the appropriate course of action – havingidentified the priorities for action these need tobe clearly documented and broken down intosteps if necessary

� a named person responsible for the action – it isimportant that the group identifies a namedindividual/s to be responsible for leading or co-ordinating each of the actions specified. Most ofthe clinical audit group will have responsibilityfor some aspect of the plan depending on their

particular skills and the group that theyrepresent. Agree how that named person will besupported and by whom.

� the time-scale for action – the group need todetermine how long they need to implementeach of the actions identified. This depends onthe nature of the problem and the type of actionrequired. Short-term actions are those which canbe remedied almost immediately, in less than 6weeks. Medium-term actions require a longerperiod of up to six months to implement, whilelong-term actions are those which will take oversix months to achieve.

� contingency plans – what problems might youencounter? How will you deal with problemsshould they arise?

A comprehensive action plan is shown in appendix 10followed by a worked example. You may of coursehave your own approach to project planning whichyou would rather use. To ensure that your action planwill be effective check it against the following criteria:

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What are you trying to achieve?Is the timetable realistic?Have you communicated your plans to everyoneinvolved in implementing the guideline?Have you found someone to co-ordinate the work? Who will ensure that the work has been done?How will all those affected by the work be keptinformed?Who will monitor variance from the action plan?

The results of the initial audit highlighted a number of areas that Barnsley could improve upon. At thattime Barnsley did not have a standard assessment tool for leg ulcer management and this fact alone ledto a large variation in practice. The audit also highlighted other resource issues such as insufficientDoppler ultrasounds available for use within the community. There were no standard protocols in useand district nurses lacked the assessment skills which in itself identified a training need. Following the audit results a comprehensive report was produced that identified the areas for change inorder to produce improvement in the management of leg ulcers. A proposed action plan was preparedincluding resource costs, the need to develop an assessment tool and staff training needs.� It was agreed to adopt the national clinical practice guidelines for venous leg ulcer management as a

standard protocol for the whole district.� It was identified that some training needs could be met both internally and externally. A number of

district nurses have now completed the N18 leg ulcer management course and a research based in-house teaching package on leg ulcer management has been delivered and cascaded out to nurses ofall grades through the trust.

� A leg ulcer assessment tool was developed based around the national guidelines. It has been trialedand is now used district wide in Barnsley for all leg wounds of more than six weeks duration.

� Doppler ultrasounds have been purchased and are available to all district nursing teams.Involvement in the national audit project has enabled effective comparisons with other sites which inturn identified the urgency of the need to implement protocols, training and resources to enable us towork to the national guidelines.The whole process has proved to be a very useful tool in determining current need and practice standards.It has enabled appropriate use of resources and Barnsley is currently in the process of completing asecond audit which hopefully will provide information and demonstrate the benefits of the audit process.Margaret KitchenBarnsley Community and Priority Services NHS Trust

Example 6 – Action planning


Step 6: Evaluating yourprogress

The ongoing task is to re-audit and to see whethercare has improved in comparison with yourprevious results. Clinical audit is a continuousprocess and you will need to continue to measurepractice against the audit criteria at regularintervals. You may choose to monitor care morefrequently to track your progress as care isimproved.

As a part of your clinical audit programme you maywish to consider internal benchmarking (Ellis andMorris, 1997). Quality improvement occurs bycomparison between teams, and sharing how resultswere achieved. Internal benchmarking may providea useful first step to benchmarking between trusts.In this way, once district nursing teams and legulcer clinics have collected their data, results wouldbe shared internally, across the trust. A particularleg ulcer clinic may score highly on one criterion,for example physical assessment and clinical

history at first visit. The staff might then take on arole of sharing their practice and supporting otherswithin the trust. Those with high scores could thenshare their practice with district or regional groups.A network of those within similar settings, such asclinics and community, could be formed to sharebest practice and support development.

It is vital that you establish a programme of regularclinical audit in order to maintain the high standardsyou achieve. As staff change and other issuescompete for people’s attention, it is easy lose themomentum necessary to sustain clinical excellence.

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entationOur service was set up in 1994 under the guidance of Prof Christine Moffatt and the Charing CrossTeam. We are a community based service with strong links with the local hospital and the vascular con-sultant and we have a system of local Leg Ulcer Clinics using research based treatment for all types ofulcers, already complying with the majority of the clinical guidelines. As part of the contract for our ini-tial funding (for two years by LIZ (London Initiative Zone) money) we had to carry out detailed clinicalaudit, measuring healing rates for venous ulcers at 12 weeks of treatment, overall changes in costs(including dressings and bandages, nursing time, travelling time) and quality of life issues, comparingwith the situation before the introduction of the standardised regime. The initial audit was facilitated andanalysed by the Centre for Research and Implementation of Clinical Practice at Charing Cross and mea-sured quality of life by using the Nottingham Health Profile. The results of the audit were that weachieved over 70 per cent of venous ulcers healing within 12 weeks, that our overall costs were reducedfrom £27 per week to £19 per week per patient and the there were huge improvements in the quality oflife for patients, in terms of pain, anxiety and interference with daily life as well as social isolation.

Our funding is now part of the district nursing budget and periodically we carry out our own clinicalaudit, simplified to enable us to analyse the data for ourselves and we continue to monitor quality of lifeissues. At their first visit to a Leg Ulcer Clinic for assessment we ask patients to grade pain and anxietylevels with a simple 3 point scale, we also ask whether the ulcer interferes with a) their ability to take careof themselves or their homes, b) their work or hobbies c) their family or social life. At 12 weeks we repeatthese questions and also ask them to complete a patient satisfaction survey about their understanding ofand feelings about their treatment, clinic facilities and staff attitudes. We are still finding that the qualityof life of the majority of patients improves over the 12 week period, that pain and anxiety levels dropdramatically and that many patients are more able to carry on independent and social lives.

We also find that the social aspects of the Leg Ulcer Clinics can’t be over-emphasised – this isparticularly true for the less mobile patients. We provide ambulance transport for those who can’t get toclinics independently and for some patients this is their only outing of the week. The opportunity tomeet others who share their problems, in a friendly atmosphere is a real morale boost. Some enjoy thecompany and cups of tea so much that they are disappointed when their ulcers heal and they only comeback for three monthly check-ups.

Marian Jarvis, Administrator, Waltham Forest Leg Ulcer Service

Example 7 – A programme of regular re-audit; continuing the development of care to patients

Re-audit

Feed back the results to health professionals andpatients

Celebrate

Consider internal benchmarking

Identify further improvements to care

Devise a new action plan

Plan a programme of regular clinical audit


Summary

Step 1: Decide who will lead andco-ordinate the work

Step 2: Determine where you are now

Step 3: Prepare the people and theenvironment for guidelineimplementation

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�

�

�

�

Agree the purpose of the clinical guideline

Clarify and agree the roles and contributionsof all group members

Identify a facilitator

Set up a group of stakeholder representatives to leadimplementation of the guideline

Identify the stakeholders

�

�

�

�

Identify the systems and structures you need to supportimplementation of the guideline

Do patients have the same views as professionals?

What are the implications of any differences in views betweenprofessionals and patients?

Find out what people think about the clinical guideline

What do health professionals know about the guideline recommendations?

How do you think the introduction of the changewill be received?

Decide who should be involved in the implementationof the clinical guidelines

When should they get involved?

How much should they get involved?

Measure current clinical practice

�

�

�

�

�

Do you need to create new systems and structures toimplement the guideline?

Who do you need to involve in creating them?

Do you have the resources you need, e.g. – documentationsuch as leg ulcer assessment forms?

How can patients be prepared to wear compressionbandages?

Do nurses have the skills and knowledge to explaincompression therapy to the patients – how can they

be developed?

Prepare nurses to educate patients about the benefits ofcompression therapy

Prepare patient information leaflets about theclinical guideline

Do the nurses need to know more about how to carry out theclinical care described in the guideline e.g. – Doppler

measurement, compression bandaging?

How can you ensure they have the clinical skills andknowledge that they need to implement the guideline?

Agree standards of education

Agree methods for supervision of practice

Provide education to ensure professionals have the skills andknowledge they need to implement the guideline

Devise a communication strategy to support implementationof the clinical guideline

Change or add to systems and structures to enable effectiveorganisation-wide communication

Communicate plans to implement the clinical guideline toeveryone affected

Plan activities to overcome negative attitudes toclinical guidelines

Identify your supporters and possible saboteurs


Step 4: Decide which implementationtechniques to use to promoteuse of the clinical guideline inpractice

Step 5: Pulling it all together – devisean action plan forimprovement

Step 6: Evaluating your progress

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�

�

�

�

�

�

�

�

Decide which combination of implementation techniquesis most suitable for implementing the clinical guideline

where you work.

Try to devise a patient record form that can be used to remindprofessionals to implement the guideline recommendations

How can your achievements be recognised and rewarded?

Identify activities and events that you can use to promotethe guideline

How can you capitalise on social situations to get yourmessages to professionals and patients?

How can you make formal situations more enjoyableand memorable?

How can support for the clinical guideline be obtained fromopinion leaders and product champions?

What activities can they undertake for/with you to promoteacceptance and use of the guideline?

Identify the opinion leaders and product champions inyour clinical team and/or organisation

Who else has influence over the opinions of the healthprofessionals and patients you work with?

Which senior or managerial people should agree theimplementation of the guideline?

How can you enlist their support?

How can you demonstrate to others in the organisationthat you have the support of the senior and managerial

people for the proposed changes?

Agree an education programme for all involved professionals

What would the aims of an educational initiative be?

What type of education is likely to be most effective?

How would the education be delivered? By whom? When?

What other techniques can be used alongside education?

�

�

�

Consider internal benchmarking

Establish a programme of regular clinical audit

Identify next improvements

Devise new action plan

Feed back results to health professionals and patients

Celebrate

Re-audit

What are you trying to achieve?

Is the timetable realistic?

Have you communicated your plans to everyone involved inimplementing the guideline?

Have you found someone to co-ordinate the work?

Who will ensure that the work has been done?

How will all those affected by the work be kept informed?

Who will monitor variance from the action plan?


References

Block, P. (1991) The empowered manager: positivepolitical skills at work. San Francisco, Jossey Bass.

Clinical Guidelines Resource Pack Steering Group(in preparation). Implementing national clinicalguidelines – a resource pack. London, BailliereTindall.

Centre for Reviews and Dissemination (1999)Getting evidence into practice. Effective HealthCare Bulletin, 5 (1), 1-16. York, University of York.

Dealey, C., Blake, F., Lawrence, D and Keogh, A.(1997) Leg ulcer project 1995-1997. Final report.Birmingham: Southern Birmingham CommunityHealth NHS Trust.

Dopson S, Gabbay J, Locock L, Chambers D (1999)Evaluation of the PACE Programme: Final Report,Oxford Healthcare Management Institute,Templeton College, University of Oxford andWessex Institute for Health Research andDevelopment, University of Southampton.

Dunning, M., Abi-Aad, G., Gilbert, D., Gillam, S.and Livett, H. (1998) Turning evidence intoeveryday practice. London, King’s Fund.

Ellis J, Morris A (1997) Paediatric benchmarking: areview of its development, Nursing Standard, 12,2,43-46

Fenner, J. and Palmer, C. (1997) FOCUS ondissemination: draft report. London, Royal Collegeof Psychiatrists’ Research Unit.

Freemantle, N., Harvey, E.L., Wolf, F., Grimshaw,J.M., Grilli, R. and Bero, L.A. (1997) Printededucational materials: effects on professionalpractice and health care outcomes. The CochraneLibrary. Oxford: Update Software.

Gupta, L., Ward, J. and Hayward, R. (1997) Clinicalpractice guidelines in general practice: a nationalsurvey of recall, attitudes and impact. MedicalJournal of Australia, 166, 69-72.

Grimshaw, J.M. and Russell, I.T. (1993) Effect ofclinical guidelines on medical practice: asystematic review of rigorous evaluations. Lancet,342, 1317-1320.

Harvey, G. and Kitson, A. (1996) Achievingimprovement through quality: an evaluation of thekey factors in the implementation process. Journalof Advanced Nursing, 24, 185-195.

Kelson, M. (1999) A guide to involving older peoplein local clinical audit activity. London: College ofHealth.

Lomas, J. and Haynes, R.B. (1988) A taxonomy andcritical review of tested strategies for theapplication of clinical practice recommendations:from “official’’ to “individual” clinical policy.American Journal of Preventative Medicine, 4(Suppl.), 77-94.

Mittman, B.S., Tonesk, X. and Jacobson, P.D. (1992)Implementing clinical practice guidelines: socialinfluence strategies and practitioner behaviourchange. Quality Review Bulletin, 18 (12), 413-422.

Morrell C, Harvey G (1999) The Clinical AuditHandbook, London, Bailliere Tindall.

Rogers, E.M. (1995) Diffusion or innovation (4thEd.). New York: Free Press.

Stocking, B. (1985) Initiative and inertia: casestudies in the NHS. London, Nuffield ProvincialHospitals Trust.

Strategy for Nursing – Department of Health (1999)Making a difference. London: Department ofHealth.

Thomas, L., McColl, E., Cullum, N., Rousseau, N.,Soutter, J. and Steen, N. (1998) Effect of clinicalguidelines in nursing, midwifery, and the therapies:a systematic review of evaluations. Quality inHealth Care, 7, 183-91.

Tunis, S., et al. (1994) Internists’ attitudes aboutclinical practice guidelines. Annals of InternalMedicine, 120, 956-63.

Zaltman, G. and Duncan, R. (1977) Strategies forplanned change. New York, Wiley.

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Appendix 1

Further readingClinical Guidelines Resource Pack Steering Group(in press) Implementing national clinical guidelines– a resource pack, London, Bailliere Tindall.

Foundation of Nursing Studies (FONS) (1996)Reflection for Action: An exploration of nationaland local nursing research implementation cultures– barriers, expectations and achievements –identifying opportunities for the future. FONS,London.

Grimshaw J, Freemantle N, Wallace S, Russell I.(1995) Developing and Implementing ClinicalPractice Guidelines, Quality-In-Health-Care 4(1):55-64

Humphris D, Littlejohns P (1999) ImplementingClinical Guidelines, Oxford Radcliffe Medical Press.

Leg Ulcer Project Team. (1996) Leg ulcers. Aninformation booklet for community nurses.Birmingham: Southern Birmingham CommunityHealth NHS Trust (available from Carol Dealey).

Loftus-Hills, A. and Duff, L. (1997) Implementationof nutrition standards for older adults. NursingStandard, 11 (44), 33-37.

McKenna H (1997) A Practical approach tomonitoring quality in community nursing practice,in Mason C (ed) Achieving Quality in CommunityHealth Care Nursing, London, Macmillan.

Morrell C, Harvey G (1999) The Clinical AuditHandbook, London, Bailliere Tindall.

NHS Centre for Reviews and Dissemination (1994)Implementing clinical practice guidelines. EffectiveHealth Care Bulletin, 1 (8), 1-11.

NHS Centre for Reviews and Dissemination (1999)Getting Evidence into Practice. Effective HealthCare Bulletin, 5 (1), 1-16.

Royal College of Nursing (1999) Doing the rightthing: clinical effectiveness for nurses, RCN,London.

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Appendix 2Methods for Reviewing theReadiness of theEnvironment (HealthProfessionals, Patients,Systems and Structures) toImplement the ClinicalGuideline

Brainstorming is used to free up people’s thinkingand to help them to think in new ways. Afacilitator encourages people to explore an issue bysaying whatever comes into their heads. Each pointis recorded and no ‘for and against’ discussion orvalue judgements take place. When no more ideasare forthcoming, the facilitator helps the group tolook at all those recorded and to engage in a ‘forand against’ debate. Eventually, ideas considered tobe worth further exploration are prioritised, whileothers are deleted or saved for later consideration.Brainstorming is usually very lively and great fun.

Force field analysis is a technique to help people tolook at the features of their work situation whicheither drive or restrain change. Driving forces arefactors which cause instability and the need forchange including staff changes, finances, and theopenness to change. Restraining forces are thosewhich promote stability and the maintenance of thestatus quo, including resistance to change. Thefacilitator writes ‘Driving forces’ at the top of aflipchart sheet of paper, ‘Current Situation’ in themiddle and ‘Restraining Forces’ at the bottom. Groupmembers are invited to brainstorm the driving andrestraining forces which are put up on the flip chart.

The forces are then analysed by the group todetermine the needs and priorities to be addressedin planning for change.

SWOT analysis is a similar technique to the forcefield analysis in that it is also a method foridentifying promoters and opposers of change. Inthis case, four key dimensions are studied:

strengths, weaknesses, opportunities and threats –hence SWOT analysis. A facilitator divides theboard or flipchart paper into four squares andheads each square with one of the key headings, asillustrated below.

Group members then brainstorm under each of theheadings, either in a large group, or by breakinginto smaller sub-groups, depending on the numbersinvolved.

Nominal group technique helps a group to movetowards a consensus decision. A facilitator inviteseach member of the group to put forward theirviews on the topic under discussion. ‘Going roundthe group’ is an effective way of making sure thateveryone contributes. Each person’s statement iswritten on the flipchart and discussion is kept to aminimum at this point. When all views have beenrecorded, each statement is discussed in turn. Onlythose statements with which everyone agrees areretained and the others are scrapped.

Snowballing is another way of reaching consensusand ensuring that even the most reticent groupmembers contribute. A facilitator asks the group todivide into pairs and to discuss the topic for atimed period. The length of time for discussion willvary according to group size and how much time isavailable. The pair is asked to identify areas wherethey can reach agreement. The facilitator is thetime-keeper and tells the pair to join with another,when the time is up. In fours, each pair shares withthe other the consensus statements. All thestatements are discussed for a timed period andthose with which all four agree are retained. Theprocess is repeated with the four joining up withanother four, then eight with eight and so on, untilthe group has become one again. By this time,consensus statements will have been agreed by thewhole group.

Fishbone diagram. A fishbone is designed to focuson the cause of a problem instead of the problemitself. The name ‘fishbone’ comes from the way thediagram looks. It is made up of a horizontal line (thespine) with a box at one end (the head) with theproblem stated. Several angled lines come off thehorizontal line forming the ribs of the fish. Each ribwill have a probable cause of the problem listed atthe end of the rib. Contributors to the cause areusually put on the small branches of the rib.Fishbone diagrams are most useful when you knowthat a specific area needs to be analysed but you arenot sure which aspect of it is creating the problem.

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�

�

Restraining forces

Current situation

Driving forces

SWOT

Strengths Weaknesses

Opportunities Threats

Clinical guidelines for the management of venous leg ulcers Implementation Guide 23

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APPENDIX 3Checklist: Disseminating the

Clinical Guideline

Adapted from Palmer and Courtney, ClinicalGuidelines Resource Pack Steering Group (inpreparation). Implementing national clinicalguidelines – a resource pack. London, Bailliere Tindall.

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Do the following individuals or groups need to use Need to use Need to

or know about the guideline? guideline know aboutguideline

Tick Box (�)

District nurses

Practice nurses

General practitioners

Auxillary nurses

Trainee district nurses

Service manager(s)

Practice manager(s)

GP students

Pharmacists

Occupational therapists

Physiotherapists

Clinical staff from other specialities

Social workers

Housing support workers

Patients

Carers of service users

Local user advocacy / voluntary organisations

Chief executive

Training department staff

Clinical (nursing, medical etc.) tutors

Health and safety / occupational health staff

Administrative and support staff

Internal communications or public relations staff

Library staff

Clinical audit / quality improvement / risk management personnel

Information systems staff

Public health personnel

Health authority staff

Contracts department

OTHER, PLEASE LIST:


APPENDIX 4Local Strategies for theManagement of Leg Ulcers

A number of local groups have implemented clinicalguidelines for the management of venous leg ulcersin practice. The local groups have extensiveexperience of devising educational strategies,communication strategies and the audit of care.Contact details are provided for four of them:

HertfordshireLynne Rotchell, Clinical Nurse Specialist, Leg UlcersThe Health CentreStanmore RoadStevenage SG1 3QATelephone number: 01438 311531

OxfordshireJill Brooks, Primary Care Development NurseCommunity Services OfficeNuffield Health CentreWelch WayWitney Oxfordshire OX8 7HQ

Royal Berkshire and Battle NHS TrustChrissie DunnSenior Nurse, Practice DevelopmentBattle HospitalReadingBerkshire RG3 1AGTelephone: 0118-963-6508

Trish Powell, District Nurse 0118-959-6508

Southern Birmingham Community Health NHS TrustCarol DealeyResearch FellowNursing and Therapy Research Unit, Department ofNursing, Queen Elizabeth Hospital, QEMC,Birmingham B15 [email protected]

In Scotland and Northern Ireland work has beenunderway for some time in developing themanagement of venous leg ulcers:

Northern IrelandIn October 1998 the CREST group launched theWound Management Guidelines for Northern Ireland,which include guidelines on the management ofvenous leg ulcers. These have been widelydistributed through a programme of educationalevents to clinical staff across the province. Furtherinformation can be obtained from the Eastern Healthand Social Services Board on 01232 321313.

ScotlandThe Scottish Intercollegiate Guidelines Network haspublished A National Clinical Guideline on the Careof Patients with Chronic Leg Ulcer, publicationno.26. SIGN guidelines and reports are availablefree of charge within the NHS in Scotland.Elsewhere a charge of £7.50 applies. To ordercopies contact:The SIGN secretariat Royal College of Physicians 9 Queen Street Edinburgh EH2 1JQ Tel 0131 225 7324

SIGN guidelines can also be downloaded from theSIGN website: http://show.cee.hw.ac.uk/sign/home.htm

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Appendix 5Patient Information aboutLeg Ulcers

Patients need to have sufficient information abouttheir leg ulcer and the treatment that they willreceive to enable them to feel confident and able tocontribute to the management of their ulcer.Producing information for patients is a skilled task.Listed below are some suggestions for what shouldbe included in patient information from otherpeople who have already developed evidence-basedpatient information.

The Hertfordshire Patient Information ChecklistFrom Hertfordshire Consensus Guidelines (1998)The Management of Leg Ulcers. West HertfordshireHealth Authority.

The Hertfordshire consensus leg ulcer guidelineprovides a useful checklist for the information thatshould be provided to patients who have leg ulcers:

Initial informationInformation about service provision� Who provides the leg ulcer service e.g. District

Nurses, Community Clinics, Practice Nurses� How to obtain/access the service� What to expect when first seen with a leg ulcer

i.e. the initial assessment

Causes of leg ulcers� Venous, basic explanation of what this means� Other causes and the need for referral to other

health care professionals in certain situations

Treatment� Mention of a firm bandaging system

How the patient can help� Exercise. May need to be tailored for individual

patients. Suggested exercises:� Move toes up and down several times� Move ankles up and down and rotate (if

possible) several times� Keeping knees straight, pull toes towards

body several times� Bend and straighten knee and hold� Walk as much as possible and avoid

prolonged standing� Elevation (you may wish to include a picture)

Ankles at least higher than the bottom.This can be accomplished as follows:� Using stool and pillows� Sitting on the bed with feet on a pillow� Elevation of foot by elevation of one end of

bed or mattress

� Healthy diet, stopping smoking� Skin care/toenails

� Wash legs in warm water, soaking in abucket is preferable

� Emollient should be used in the water orapplied to the skin after washing

� Care for feet and toenails. Podiatry referralmay be necessary

� Avoid excessive heat and cold� It is helpful to include the statement

‘It is important to consult your doctor or nurserather than treating yourself’

What to do if bandages are uncomfortableFurther information� Telephone numbers� Quality information in respect of complaints and

compliments

Post healing informationThe following statements are suggested for inclusion� Nearly half a million people in the UK suffer with

leg ulcers, your ulcer has now healed and you willwant to do everything you can to keep it healed

� In this leaflet are a few guidelines to help youkeep your legs healthy and help prevent your legulcer from recurring

� Keep this leaflet handy and it will help youenjoy life after your leg ulcer

Advice should be included in respect of the following:� Wearing and renewal of compression hosiery, to

include:� When laundering stockings follow

instructions given by the manufacturer� Avoid drying on radiators or direct heat� Stockings should be renewed every 3-6 months� Application aids are available e.g. silk slipper,

applicator frames� Diet, health eating information. No smoking� Exercise, suggested exercises:

� Move toes up and down several times� Move ankles up and down and rotate (if

possible) several times� Keeping knees straight, pull toes towards

body several times� Bend and straighten knee and hold� Walk as much as possible and avoid

prolonged standing� Footwear� Skin care/toenails

� Wash legs in warm water, soaking in a bucketis preferable

� Emollient should be used in the water orapplied to the skin after washing

� Care for feet and toenails. Podiatry referralmay be necessary

� Avoid excessive heat and cold� Elevation (you may wish to include a picture).

27

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Ankles at least higher than bottom. This can beaccomplished as follows:� Using a stool and pillows� Sitting on a sofa with feet on one of the arms

or on pillows� Resting on the bed with feet on a pillow� Elevation of foot by elevation of one end of

bed or mattress� What to do if you are worried or the ulcer comes

back� Contact telephone numbers

Examples of documentation already in use can beobtained from Lynne Rotchell, Clinical NurseSpecialist: Leg Ulcers, North Herts NHS Trust, TheHealth Centre, Stanmore Road, Stevenage, SG1 3QA

Patient Information from the Oxfordshire LegUlcer StrategyFrom Brooks, J., et al. Primary Care Quality Forum(1997) The Oxfordshire Leg Ulcer Strategy.Oxfordshire Health Authority.

Patient information from the Berkshire Leg UlcerProjectRoyal Berks and Battle Hospitals and WestBerkshire Priority Care – Healthy Legs for Life:venous leg ulcers, information for patients(Contacts as page 35)

Additional information about producing patientinformation can be obtained from the following:Buckland, S. and Gann, B. (1997) Disseminatingtreatment outcomes information to consumers.London: King’s Fund.

Entwistle, V., Watt, I. and Herring, J. (1996)Information about health care effectiveness.London: King’s Fund.

The Centre for Health Information QualityHighcroftRomsey RoadWinchester Tel: 01962 872245www.hfht.org\chiq

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Appendix 6Examples of Leg UlcerAssessment Forms

Detailed assessment of the patient with a leg ulceris important to ensure that the ulcer is managedcorrectly and changes in the condition of the ulcernoted. The clinical guideline makesrecommendations about the assessment that shouldbe carried out but it is also important that theresults of the assessment are accurately recorded. Itis crucial to agree a detailed form of assessmentdocumentation. This may need to be developedlocally. Local groups have made recommendationsabout what information should be included on anassessment form. Those for Hertfordshire andOxfordshire are included below.

Hertfordshire

The Hertfordshire consensus guidelines recommendthe inclusion of the following in the assessmentform

Background information� Name, address, date of birth, sex� Next of kin� Community Nurse with overall responsibility for

the patient� General Practitioner� Source of referral

HistoryHistory of the present leg ulcer(s)� How and when the ulcer started, the duration of

the present ulcer� Current treatment i.e. who is treating the ulcer,

with what and how often� Past history of injury to the leg, varicose veins,

deep venous thrombosis or a family history ofleg ulcers

� History and duration of any previous leg ulcers� Pain

General medical condition � Diabetes mellitus, rheumatoid arthritis� Past history of stroke, angina or claudication� Anaemia, renal disease

Other important information� Smoking� History of reactions to dressings or bandages� Mobility� Medication� Nutritional status and diet

ExaminationGeneral condition� Looks well/looks ill� Pulse and blood pressure� Weight e.g. underweight/average/overweight

Examination of the legs� Condition of the legs:

� Presence of oedema� Temperature� Skin condition� Presence or absence of nails or hair� Foot pulses present or absent� Ankle and calf circumference

� Examination of the ulcer:� Site of ulcer, mark on a suitable diagram� Size of ulcer, a tracing of the ulcer MUST be

taken with measurements � Presence of absence of odour, slough, and/or

exudate

Measurement of Doppler ABPI � Ankle systolic pressure� Brachial systolic pressure� Ankle systolic/brachial systolic = Doppler ABPI

Other investigations� Urinalysis� FBC, ESR� Urea, electrolytes and creatinine� Blood glucose� Wound swab ONLY if appropriate

Reassessment� Needs to take place at 4-6 week intervals � Retrace the ulcer(s)� Document on-going management plan� Comment about patient compliance� Reassessment of Doppler ABPI at 12 weekly

intervals

Patient Assessment Forms from The OxfordshireLeg Ulcer Strategy

The next 8 pages are reproduced from theOxfordshire Leg Ulcer Strategy. These 8 pagesinclude forms for the assessment of patients’general health and their leg ulcers. Information andadvice about using these forms should be soughtfrom the Oxfordshire Primary Care Quality Forumvia Jill Brooks, Primary Care DevelopmentCommunity Nurse, C/O Community ServicesOfficer, Nuffield Health Centre, Welch Way, Witney,Oxfordshire, 0X8 7HQ

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PATIENT’S NAME & ADDRESS..............................................................................................................................

..................................................................................................................................... D o B ...............................................

PRESENT/PAST OCCUPATION OR HOBBIES ...................................................................................................

BLOOD TESTS (CONSIDER):

Blood Glucose ............................................................................................Hb .....................................................................

Urea/Electrolytes...........................................................................Other Blood Tests ........................................................

HEALTH STATUS:

Exercise/Mobility .............................................................................................................Osteo-Arthritis? Yes/No

Nutritional status .................................................................................................................................................................

Sleeping Position: Legs above heart level / at heart level / below heart level

Blood Pressure with Stethoscope .......................................................................................................................................

Weight: Under Weight / Normal / Over Weight

Smoking Past/Present..........................................................................................................................................................

MEDICATION...................................................................................................................................................................

................................................................................................................................................................................................

RELEVANT MEDICAL HISTORY

Left RightLeg Leg

Previous Leg Ulcer ❏ ❏

Staining ❏ ❏ Intermittent Claudication ❏

Induration (Hard fibrous tissue) ❏ ❏ Ischaemic Heart Disease ❏

Phlebitis ❏ ❏ Stroke or Transient Ischaemic Attack ❏

DVT ❏ ❏ Hypertension ❏

Varicose Veins ❏ ❏ Diabetes ❏

Poor Ankle Movement ❏ ❏ Rheumatoid Arthritis ❏

Fixed Ankle Joint ❏ ❏

Leg Injury or Leg Surgery ❏ ❏

Ankle Flare ❏ ❏

Other (Specify) ......................................................................................................................................................................

Assessor’s Name and Status........................................................................................Date................................................

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GENERAL HEALTH ASSESSMENT – FORM 1


Consider repeating three monthly, if compression used, if ABPI reduced or sooner if condition deteriorates

Systolic Brachial Pressure with Doppler Left Arm…… Systolic Brachial Pressure with Doppler Right Arm……

Highest Systolic Brachial Pressure……

LOCATION OF ULCERS (Indicate on diagram)

Left Left Right RightLeg Leg Leg LegFront Inner Front Inner

Aspect Aspect

Left RightSole Sole

Left Left Right RightLeg Leg Leg LegBack Outer Back Outer

Aspect Aspect

Referred for Patch Testing? Yes: Give Date..................................................No (please circle)

Results of Patch Test – known allergens ..........................................................................................................................

Assessor’s Name and Status........................................................................................Date................................................

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INITIAL LEG ULCER ASSESSMENT – FORM 2

Left Leg Yes No Doppler Pressure(any 2 from a,b & c)

Pulse a) Posterior Tibial ❏ ❏ ______________Palpated b) Dorsalis Pedis or ❏ ❏ ______________

Anterior Tibial ❏ ❏ ______________c) Peroneal ❏ ❏ ______________

Patient laying flat? Yes / No ABPI ............................

Left Ankle circumference (cms) prior to getting out ofbed/am ......................................

Right Leg Yes No Doppler Pressure(any 2 from a,b & c)

Pulse a) Posterior Tibial ❏ ❏ ______________Palpated b) Dorsalis Pedis or ❏ ❏ ______________

Anterior Tibial ❏ ❏ ______________c) Peroneal ❏ ❏ ______________

Patient laying flat? Yes / No ABPI ..........................

Right Ankle circumference (cms) prior to getting out ofbed/am........................................


TO BE CARRIED OUT AT EVALUATION DATE STATED ON CARE PLAN

Each leg should be assessed on a separate form, after cleansing. Where there are multiple ulcers of the same type,please assess the worst ulcer on each leg.

32

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WOUND ASSESSMENT FORM FOR LEG ULCERS – FORM 3

Leg: Left/Right DATE DATE DATE DATE DATE DATE DATE(please circle)

ABPI (Doppler Reading)

Wound Floor Condition(indicate % – total = 100%) % Epithelization (Pink)

% Healthy Granulation (Red)% Over Granulation% Thick Slough (Yellow)% Necrotic (Black/Grey)Other (Specify)

Dimensions Tracings (tick if carried out)Photographs (tick if carried out)Max length x max breadth (mm)Maximum depth (mm)

Exudate Amount (+,++,+++)

Odour (Tick) YesNo

Infection (Tick) Suspected & Swab Sent Results Received

Wound Edges (Tick) FlatRolledPunched OutHard/fibrousOther (Specify)

Condition of SurroundingSkin (Tick) Localised inflammation

DryIrritation/ EczemaHyperkeratosis (Thick Scales)CellulitisMoist/Macerated

Pain Score on a Scale 0 –10 (Patient’sPerception) Continuous

Intermittent (Comes and Goes)At Specific Times :

WalkingAt RestAt Dressing

ChangeOther (Specify)

Oedema (Tick) Foot only Toe to Knee Whole Leg Other (Specify)

Assessor’s Signature


DATE GOALS & COMMENTS PRESCRIBED TREATMENT SIGNATURE

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LEG ULCER TREATMENT FORM


VASCULAR (DOPPLER) ASSESSMENT

N.B. A DOPPLER ASSESSMENT SHOULD ALWAYS BE CARRIED OUT PRIOR TO THE APPLICATION OFCOMPRESSION THERAPY

The Doppler Ultrasound detects the flow of blood in the blood vessels.

It consists of a transducer (probe) which is attached to an audio unit. The probe should be used in conjunctionwith a coupling gel which aids the transmission of ultrasound.

The probes recommended are:-8 MHz for normal sized limbs5 MHz for obese/oedematous limbs

ArteriesHealthy arteries have a strong pulsating sound usually consisting of three phases (tri-phasic) but sometimesonly two phases can be heard (bi-phasic).

It is very important that practitioners recognise the normal pulsatile sound.

VeinsVeins do not pulsate and give a continuous ‘whooshing’ or ‘roaring ‘ sound.

Arteries of the Foot – (See Diagram)Two of the pulses and possibly three should be detected using the Doppler.

The two most frequently used arteries in Doppler assessment are:-

Posterior Tibial ArteryUsually found in the soft part mid-way on an imaginary line between the medial malleolus and the crest ofthe heel.

Dorsalis Pedis ArteryFound on the top of the foot in the soft spot between the hallus and the second toe.

12% of the population have a congenitally absent Doralis Pedis pulse (Barnhorst et al 1968).

Anterior Tibial ArteryUsually found on the crease line between the foot and the ankle. This is an extention of the Dorsalis Pedis.

Peroneal ArteryUsually found behind the lateral malleolus in the soft tissue or as indicated on diagram.

ANKLE BRACHIAL PRESSURE INDEX (ABPI)

The most consistent results are obtained by staff who use the technique regularly in ulcer and othervascular assessment (Douglas & Simpson 1995).

N.B. It is therefore strongly recommended that only staff who regularly use a Doppler and who havereceived initial training and regular updating should carry out this procedure.

� The patient should be resting for 15-20 minutes, lying flat (or as flat as possible, with the legs ashorizontal as possible) and relaxed. A patient history may be taken during this time.

� Record the position of the patient.� Place the sphygmomanometer cuff around the top of the arm. Palpate pulse and apply a blob of ultrasound

gel. KY jelly is not recommended.

34

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� Hold the Doppler probe between the fore finger and thumb at an angle of 45 degrees and place over thebrachial pulse.

� Inflate the cuff until the Doppler sound disappears, slowly deflate cuff until the sound returns. This is theBRACHIAL SYSTOLIC PRESSURE. Check the reading in each arm twice leaving a time delay between eachreading. Record the highest pressure reading.

� Palpate one of the arteries of the foot (usually the dorsalis pedis).

Place the sphygmomanometer cuff around the ankle above the malleoli. If an ulcer is present cover with a lowadherent dressing with a sheet of polythene over the top.� Inflate the cuff keeping the probe where a strong pulse can be heard. Once the pulse signal disappears

gradually deflate the cuff until the sound returns. This is the ANKLE SYSTOLIC PRESSURE. � Repeat the procedure using a different foot artery ( usually the post tibial artery).

Record the highest reading.

CALCULATION OF THE ANKLE BRACHIAL PRESSURE INDEX

Spuriously high Doppler readings are sometimes obtained in patients with diabetes and in patients withcalcified arteries. It is important, therefore, that practitioners do not rely exclusively on Doppler readingsbut use them to confirm their observations (Ertl 1993).

Method

Divide the ankle pressure reading by the brachial pressure reading.

ABPI = Highest ankle systolic pressure Highest brachial systolic pressure

e.g. Ankle = 100 divided by brachial 140 = ABPI of 0.71

INTERPRETATION OF ABPI� Patients with an ABPI of 0.8 or greater may have compression bandaging or hosiery.� Patients with an ABPI of 0.6 to 0.8 have moderate arterial disease. The General Assessment (Form 1), the

Initial Assessment ( Form 2) and the Wound Assessment (Form 3) should indicate whether the ulcer isclinically venous, in which case reduced compression may be used, or clinically non-venous, in which casethe underlying causes need to be considered. Referral is an option especially for patients with diabetes (seeflow chart).

� Patients with an ABPI of less than 0.6 have severe arterial disease. Immediate referral should be considered.Retention bandages only should be applied.

REPEATING THE DOPPLER ASSESSMENTIf compression is used it is recommended that the Doppler reading is repeated at three monthly intervals orsooner if clinical condition deteriorates. (Simon et al 94)

35

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are

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5. B

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ick

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989)

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an id

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alth

care

. New

Eng

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Jou

rnal

of M

edic

ine

320:

53-

56.

6. L

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994)

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n E

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l. Sa

gePu

blic

atio

ns: T

hous

and

Oak

s, C

alif

orni

a.7.

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ckin

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5) In

itia

tive

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iner

tia:

cas

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NH

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prov

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st: L

ondo

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B (1

986)

Way

s of

infl

uenc

ing

the

beha

viou

r of

gro

ups.

Jou

rnal

of t

he R

CGP

(Nov

embe

r): 5

17-5

219.

Rog

ers

E (1

983)

Diffu

sion

of i

nnov

atio

ns. T

he F

ree

Pres

s: N

ew Y

ork.

10. D

avis

D e

t al (

1992

) Evi

denc

e of

the

effe

ctiv

enes

s of

CM

E: a

rev

iew

of 5

0 RC

Ts. J

AM

A26

8: 1

111-

1117

11. L

enna

rson

Gre

er A

(198

8) T

he s

tate

of t

he a

rt v

ersu

s th

e st

ate

of th

e sc

ienc

e. In

tern

atio

nal J

ourn

al o

f Tec

hnol

ogy

Ass

essm

ent i

n H

ealth

Car

e12

. Han

dley

M, S

tuar

t M, K

irz

H (1

994)

an

evid

ence

-bas

ed a

ppro

ach

to e

valu

atin

g an

d im

prov

ing

clin

ical

pra

ctic

e: im

plem

entin

g cl

inic

al p

ract

ice

guid

elin

es. H

MO P

ract

ice

8: 7

5-83

13. L

ongm

an G

, Dun

can

R (1

977)

Str

ateg

ies

for

plan

ned

chan

ge. W

ylie

: New

Yor

k.14

. Fre

eman

tle e

t al (

1997

) The

eff

ectiv

enes

s of

pri

nted

mat

eria

ls in

impr

ovin

g th

e be

havi

our o

f hea

lth c

are

prof

essi

onal

s an

d pa

tient

out

com

es. T

he C

ochr

ane

Libr

ary.

Oxf

ord:

Upd

ate

Soft

war

e.15

. Kan

ouse

D, K

allic

h J,

Kah

an J

(199

5) D

isse

min

atio

n of

eff

ectiv

enes

s an

d ou

tcom

es r

esea

rch.

Hea

lth P

olic

y34

: 167

-192

16. G

rim

shaw

J (1

995)

Dev

elop

ing

and

impl

emen

ting

clin

ical

pra

ctic

e gu

idel

ines

. Qua

lity

in H

ealth

Car

e4:

55-6

4

38

impl

emen

tation

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hods

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d to

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sem

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d / or

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men

tsRe

fere

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(see

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impl

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t clin

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pra

ctic

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idel

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of A

ppen

dix

7 fo

r re

fere

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deta

ils)

15 16

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bine

d st

rate

gies

e.g

. edu

catio

n +

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bine

d st

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are

mor

e ef

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any

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dit f

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it fe

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entation

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mar

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epro

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issi

on fr

om P

alm

er C

and

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ner

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ettin

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cros

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ondo

n: G

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40

impl

emen

tation

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e A

ssum

ptio

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delin

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eing

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sem

inat

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plem

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ualit

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d fr

om a

cre

dibl

e bo

dy.

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audi

ence

for

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info

rmat

ion

is lo

cal c

linic

al te

ams.

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judg

emen

ts h

ave

been

mad

e by

the

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esea

rch

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t and

may

not

nece

ssar

ily b

e co

rrec

t.


Appendix 9PACE Project

Implementation of evidence based legulcer management in West BerkshirePACE (Promoting Action on Clinical Effectiveness)was a two year programme of change managementand organisational development across 16 UK sites.The aim of the programme was to support localprojects to demonstrate the effectiveimplementation of evidence-based practice.Within West Berkshire, one of these projects wasestablished to improve the effectiveness of leg ulcercare and in particular to reduce the duration,variation and cost of treating leg ulcers.

Organisation of the projectThe project used a multidisciplinary teamapproach. A project advisory group was convenedand a project nurse was appointed to raise theprofile of the project and initiate the work. Acommunication strategy was devised whichinvolved all interested parties. Existingcommunication channels were used which includedlocal newsletters, committees and groups.Information bulletins about the progress of theproject were also circulated.

The project plan included conducting:� Clinical audit� Developing an assessment tool and protocol

through a consensus process� Economic analysis� Education at 3 levels (specialist level,

practitioner level through workshops andgeneral awareness raising)

� Patient involvement and education

At the outset the project group saw that to besuccessful they would need:� A co-ordinated multidisciplinary approach

(across acute and community sectors)� Use of high compression bandaging� The talents and expertise of a tissue viability

group

Immediate problems� Resistance to change� Health service managers and GPs not investing

in the Doppler equipment and bandaging system� No standardised referral system to vascular

surgeons� Limited communication and co-operation

between hospital/community/provider units andcommissioning agencies

ResultsThe project ran for approximately two years. Theclinical audit demonstrated that graduatedcompression was a clinically effective treatment forleg ulcers: 81% leg ulcers had healed by more than50% . The economic analysis showed thatassessment and graduated compression could halvethe treatment costs of leg ulcer care. Gainingpatients’ views and providing patient educationwas also an intrinsic part of the project.

Lessons learnt� Keep on communicating. In this project they

used existing channels e.g. newsletters.� There is a need for evidence-based management

– budget holders were refusing to sanction thepurchase of supplies

� Lock into organisational priorities and developco-operative working practice with all healthcare staff involved in the care of leg ulcerpatients through networking

� Ensure that meetings are aimed at most likelytimes that health care providers can be available

� Education needs to use experiential learningwith ongoing input from a respected colleague.There is also a need for local champions ofevidence-based leg ulcer care.

� Keep reinforcing the change (for examplethrough setting up a specialist nurse network,and making a video of leg ulcer managementavailable).

Full reference: Dunn, C., Beegan, A., Morris, S.,and Powell, T. (1998) The Kings Fund PACE Projectin West Berkshire: Improving the care of patientswith leg ulcers, Royal Berkshire and BattleHospitals NHS Trust in conjunction with WestBerkshire Priority Care Services.

41

implem

entation


APPE

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46

impl

emen

tation


Notes

47

implem

entation


Notes

48

impl

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tation

© Copyright 2000: Royal College of Nursing. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, ortransmitted in any form or by any means electronic, mechanical, photocopying, recording or otherwise, without prior permission of the Publishers or alicence permitting restricted copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 9HE. This publication may notbe lent, resold, hired out or otherwise disposed of by way of trade in any form of binding or cover other than that in which it is published, without theprior consent of the Publishers.

RCN Members

£6.50Non RCN Members

£8.50March 2000

Publication Code: 001 213ISBN 1-873853-92-0

implementation

Working with the RCN todisseminate good practice

clinical guidelines for the management of venous leg ... linee guida/arti inferiori/leg… ·...

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