Best practice for chronic oedema in community settings: what can we learn?

The creation of the latest guidance ‘Chronic oedema: best practice in the community’, builds on work that has been done in the past and presented in the original guidelines ‘Best practice for the management of lymphoedema’ and the ‘Compression therapy: a position document on compression bandaging’ (International Lymphoedema Framework (ILF), 2006; 2012). Equally, it complements other guidelines that have been created, for example, ‘S.T.R.I.D.E. professional guide to compression garment selection for the lower extremity’ by Bjork et al (2019) and others shown within Table 1. The best practice and/or statements bring together the best available evidence at that time, alongside clinical opinion. These form part of the principles that are present in the application of evidence-based practice and how this can improve the care of patients (Black, 2015; Brownie, 2018). It has been estimated that some 4 per 1000 individuals in England may be affected by chronic oedema, and this figure increases with age to up to 29 per 1000 individuals (Moffatt et al, 2017). Individuals with chronic oedema who are older, for example those older than 65 years, may also present with multiple long-term conditions, and be already receiving care from several services, both primary and secondary (Rankin, 2016; National Lymphoedema Partnership (NLP), 2019). This adds complexity to the care that those diagnosed with chronic oedema or lymphoedema may receive from health professionals. It also adds emphasis to the need to have access to guidance and best practice in managing these patients.

Development of guidelines for community management

The guidance reflects the changing emphasis of the NHS and its provision on personalised care, and how that can be achieved (NHS England, 2019). There is also an increased emphasis on self-management, patient activation and empowerment for those with a long-term condition, such as chronic oedema or lymphoedema (Roberts et al, 2016). The availability of services that provide specialist care, such as lymphoedema services, is fragmented in certain areas; it is absent entirely in some places or is offered in only some services to those patients diagnosed specifically with cancer-related causes (NLP, 2019). Supporting patients with chronic oedema and optimising the use of available resources requires those working in the community to have increased awareness, knowledge and skills in the management of patients with chronic oedema (Wound Care People, 2019). The creation and application of mnemonics in these guidelines, such as the 6 S's, which will be explained in the article, aid the recall of key aspects of care. Other examples include S.T.R.I.D.E for the selection of compression therapy, which refers to Shape, Texture, Refill, Issues, Dosage and Etiology (Bjork et al, 2019). The current guidance offers insights into the condition, but has multiple parts that are applicable to the patient cases experienced by health professionals in the community, and be used alongside other guidance materials (Table 1).

Main features of the guidelines

The intention of the best practice is to offer a guide to those caring for people diagnosed with chronic oedema through interconnecting steps that are logical and with each part feeding seamlessly into the next. There are four main colour-coded sections that go into detail and sub-divide subjects into varying components, for example ‘chronic oedema assessment’ (Wound Care People, 2019). The first chapters aim to develop a mutual and shared understanding of the condition (Wound Care People, 2019). This is achieved through defining chronic oedema as a long-term condition, and it is stated that, according to estimates, this condition may affect up to 3.5 million people in the community older than 85 years by 2039 (Wound Care People, 2019). This is a rather sobering figure in light of recent policy changes and the ongoing coronavirus pandemic. The policy focus has been upon managing those with a long-term condition, through self-management supported by patient activation. However, the ability to deliver this at a time, with varied tiered lockdowns and restrictions on access to this vulnerable population. This presents challenges within the effective engagement of the condition by those diagnosed with the condition, but also by those supporting them. The chapter continues by including the causes of chronic oedema, with several reflection points that pose questions and encourage people to consider this within their own clinical areas.

The next section focuses on assessment and the application of six simple steps in that process (Figure 1). These include:

• Story-the person's history relating to their condition and their health
• Self-care-increasing a patient's ability to engage in their own care and increasing self-empowerment
• Site-the location of the oedema (leg or arm) and what this may indicate
• Skin-the benefit of skin care to reduce the risk of infections. This also includes what some consider a contentious issue surrounding the benefit and application of ankle brachial pressure index (ABPI), due to its recognised limited benefit in those diagnosed with chronic oedema (British Lymphology Society (BLS), 2018)
• Size-identifying the key areas when measuring the lower limb, which aids in creating a baseline, but also in evaluating improvements or deteriorations
• Shape-the appearance of the limb can influence a number of choices, including the type of treatment and management methods, for example, compression hosiery or adjustable wrap devices (AWDs).

Figure 1. Six steps in chronic oedema assessment

These steps are broken down into separate parts that are colour coded, to ensure quick and easy access to the relevant section.

The next two sections-‘Chronic oedema management’ and ‘Chronic oedema and wet legs pathway’-offer practical steps to support those engaging with selecting treatment or management strategies for chronic oedema (Wound Care People, 2019). The first section discusses and explains the different phases in managing patients. The intensive phase involves reducing and reshaping the limb, with compression bandaging, for example. This is followed by the maintenance phase, in which the aim is to maintain what has been achieved in the previous stage, for example, with appropriate hosiery style and compression class. This fits alongside other delivery of care modalities, such as skin care with emollients and identifying cellulitis, a well-known complication of chronic oedema (NLP, 2019).

The role and importance of exercise is also explained, which includes simple exercises related to foot and calf movement, that will stimulate the venous and lymphatic systems. To enhance the application of exercise, compression therapy and its multiple forms, such as bandages, hosiery and wrap-based systems, is also discussed. This leads to an explanation about how compression therapy works, due to it being recognised as the mainstay of treatment and long-term management of the condition (ILF, 2006).

The focus on self-management embraces the current political focus when it comes to long-term condition management. This extends to a discussion on the notion of adherence and concordance among patients with what is being prescribed and advised. It recognises previous and ongoing research in this area, citing past experiences of compression therapy as well as the presence of pain as factors that influence a patient's choice. Finally, there is a section that illustrates the wet leg pathway. Wet legs is another term used to describe lymphorrhoea, and this section incorporates the work undertaken by the Lymphoedema Network Wales (LNW) (2019). Lymphorrhoea can be linked to the potential presence of an infection, such as cellulitis, but also the level of fluid volume within the limb. This can lead to distress for the patient experiencing this condition, and also presents challenges in its management (LNW, 2019; Wound Care People, 2019).

What can be achieved through these guidelines?

The guidelines and the statements within it are intended to share best practice. This is formed from the evidence base at the time, but also on clinical opinion, set against the values of the patient. This document offers a means of improving patient outcomes, due to the application of evidence-based practice (Black et al, 2015). However, as highlighted in previous research, the ability to implement evidence-based practice requires an appropriate level of knowledge, as well as sufficient time to implement what is being proposed (Black et al, 2015). Equally, questions about the potential economic benefits and the impact of nursing when applying evidence-based practice have led to a variety of studies and reports (Brownie, 2017). The potential costs of not managing chronic oedema and for others to form part of the support for patients is illustrated in commissioning guidance (NLP, 2019):

• Hospital admissions related to lymphoedema and its complications, such as cellulitis, cost £178 million
• Bed stays-patient length of stay in hospital for lymphoedema can amount to over 400 000 bed stays each year
• Lower limb cellulitis accounts for 55 000 hospital admissions
• Cellulitis costs £172–254 million annually
• Compression garments cost £15 million annually in England and Wales.

Considering these figures, the strategy for the NHS focuses on personalised care tailored to the individual, locality and the health economy (NHS England, 2019). This is set against the delivery of services that are cost effective and quality driven with the ability to demonstrate outcome-based measures (NLP, 2019). In meeting the focus of the NHS and the underlying principles for the provision of services, the effective management of chronic oedema can offer an opportunity to meet both the political and patient view of care.

The best practice statement offers a quick, easy and succinct guide to the condition and its management. It addresses some of the barriers to evidence-based practice implementation, in terms of knowledge and time. However, what would be needed to accompany the information when used within the community would be the practical proficiencies in managing the condition. Despite this potential barrier, which can easily be overcome, the ability to identify the condition and then to confidently advocate treatment and management is an effective way to build a case for change.

Conclusion

Documents that promote best practice are useful tools that support those caring for chronic oedema patients, also leading to improvements in patient outcomes. The latest guidance created for chronic oedema management complements the existing provision of guidance materials in this area. With it focus on community settings, this document is particularly useful to community nurses and those from a general nursing background who are in contact or are delivering care to patients with chronic oedema. The commissioning of lymphoedema services in the UK can be variable, and this creates inequity and disparity in service provision. However, it may also offer an opportunity for others to develop knowledge and skills for the management of this patient group, although this will require the knowledge, time and proficiency to ensure effectiveness in improving patient outcomes and the efficient allocation of appropriate resources.

KEY POINTS

• Best practice document provide succinct and easy to access information, such as those affected by chronic oedema
• The document assists in the diagnosis of chronic oedema, and can lead to its effective management, such as appropriate skin care and compression therapy
• Chronic oedema represents a long-condition that can impact upon the person's biopsychosocial state, and may extend to significant others. This can be minimised by using this document and the evidence it is based on

CPD REFLECTIVE QUESTIONS

• In reading the ‘chronic oedema explained’ review your patient population and establish how many people are diagnosed with chronic oedema.
• Having identified the number of people diagnosed with chronic oedema, consider how many have yet to be diagnosed with the condition based upon the statistics presented.
• When managing patients, what tools are at your disposal in the workplace and what others are needed to manage the patient more effectively?