Venous Ulcers
Venous ulcers are becoming a large national problem as baby boomers come of age. More than a million people in the United States are affected by lower extremity ulcers. According to articles by several authors it is estimated that 80 percent 90 percent are caused by venous insufficiency with approximately 500,000 venous ulcers seen in the U.S. alone on a yearly basis. These represent $1.5 to $3.5 billion in health care costs and 2 million workdays lost.. In addition, those affected have significant pain and suffering with loss of mobility, potential limb loss and possible fatality. Interestingly, there is a 62 percent female predominance. These are just a few of the startling statistics. With the majority of health seeking behaviors and buying decisions being made by women, this is an area of potential growth for the durable medical equipment (DME) and home health provider.
Demographics
According to Sibbald, approximately twenty-two percent of the population have developed their first ulcer by the age of 40 percent and 72 percent by the age of 60. He further notes that ulcers usually take over a year to heal and recur at a rate of 72 percent. This is very discouraging for patients coming into wound clinics to be treated for the first time. Practitioners not only deliver a diagnosis that will interfere with the patient's work, they tell them it will take up to a year to heal, it could cost up to more than $40,000 over their lifetime to treat, cause them pain, change their life style and that the wound will most probably recur. This is a grim, depressing prognosis. These patients are looking for more than just products, they need education, expertise and hope.
Understanding the Problem
A brief review of anatomy and physiology may be of assistance in guiding patients to a better understanding of their disease process and increasing compliance. Blood is pumped into the lower extremities by the heart and travels through the arteries, arterioles, and capillaries to feed the cells. It then moves through the superficial veins (the greater and lesser saphenous) through the perforator system into the deep veins (the posterior and anterior tibial and peroneal) back up to the heart to be oxygenated.
The calf muscle pump propels the blood toward the heart with each step, an ambulatory process. The bicuspid valves of the heart are designed to prevent refluxing and pooling of blood in the lower extremities. When this pump becomes ineffective, related to valvular insuffiency, the blood flows backwards. All this can result in venous hypertension, which is a constant, high-pressure in the veins during activity. This is why we also see these individuals with pitting edema (extreme swelling) leading to ulcers. There is no clear reason why venous hypertension leads to ulceration, but the hypothesis is two-fold: 1. oxygen restricted to the tissues is trapped and leads to ischemia and 2. ischemia predisposes the tissue to injury and also impairs healing once it is
damaged.
Characteristics
Most often these ulcers occur over the medial malleolus (inner ankle) where the long saphenous vein is the most superficial and has the greatest curvature, making it fragile and more susceptible to injury. They tend to occur in the gaiter area (where people wore the old time button-up gaiter type shoes that went over and slightly above the ankles). They can also be seen in other areas on the lower extremities below the knee and above the foot.
Venous ulcers have very distinguishing details which separate them from arterial ulcers. It is imperative that these wounds be assessed by a skilled practitioner: a Wound, Ostomy and Continence Nurse (WOCN), a Certified Wound Specialist (CWS) or a vascular surgeon. Hemosiderin staining is the breakdown of erythrocytes and fibrinogen and the brownish discoloration to the skin is caused by the iron permeating the
skin. It can be most upsetting to the patients, presenting a loss of body image. These ulcers have irregular edges as opposed to the smooth cookie-cutter edges of the arterial ulcers. The legs also have distinct characteristics. Most have dermatitis associated with the ulcers. As these ulcers become chronic, they may have a thick, scaly skin about the ankle and extending all the way from the knees to the feet, giving the appearance of fish scales. This skin condition is known as lipodermatosclerosis. The lower leg often has the appearance of and upside down champagne bottle or bowling pin and most always the lower extremities are edematous for the reasons discussed earlier. With these chronically open wounds, the recurrence of cellulitis (infection) is a high probability. These patients are often working and not caring for their wounds as they should. Their wounds are not cleansed properly; dressings are not changed as frequently as they should be. The longer a wound is present, the greater the chances are for it to become infected.
These patients also complain of pain that is relieved by elevation of the lower extremities. It was long thought that they did not have discomfort unless their wound was desiccated (dried out) or it was infected. Hofman, et al (1997) showed that 37.5 to 78 percent of patients with venous ulcers had pain. Even more startling is that 64 percent of the participants in this study reported their pain to be severe and generally uncontrolled. Clinicians need to be advocates for patients and be sure they are prescribed pain medication to make them comfortable enough to carry out the activities of daily living. Providers can offer special contact layer dressings with cellulose and soft silicone dressing that offer pain relief.
Krasner did a study on the pain that these patients experience and found that it profoundly impacted four areas of their lives. First, these patients experienced feelings of frustration. They have a disorder that causes an ulcer on their leg, it may take a year to heal and the chances of recurrence are 72 percent-a bleak outlook. Secondly this is interfering with their occupation. The physician has told them to have frequent rest periods with their lower extremities above heart level, they should not stand for long periods of time. Thirdly, they have to make significant changes in their lives. This may mean a career or job change if they currently spend a great amount of time on their feet. Lastly, they must find satisfaction in this new activity they are undertaking. If someone elects to change places of employment it is quite different than having to change because of health reasons. These are tough issues to deal with on top off dealing with a brutal diagnosis. As providers, we need to offer ways to assist these patients.
Treatment, a Multifaceted Plan
Management of venous ulcers is critical. As with anything, the underlying medical and nutritional disorders it must be managed and kept under control. These are generally the patients with multiple underlying co-morbidities such as congestive heart failure (CHF), diabetes, chronic obstructive pulmonary disease (COPD). Control of these disorders must be maintained to keep venous ulcers in check. This is an excellent opportunity for a managed care approach by the home health provider, a one-stop shop.
Nutritional consults are often necessary. These patients are not as active and therefore not as hungry. They may also eat foods that are low in nutritional value. Dietitians can be most helpful in guiding individuals toward more fresh fruits and vegetables in place of the foods higher in sodium. Vitamins A, C, and zinc have been shown to be very helpful in wound healing, but can be consumed in the normal diet or in a multiple vitamin (100 percent R.D.A.). It is far more effective to consume these as a part of the diet than in supplement form since the body absorbs natural substances easier than supplements. That patient that will drink nothing else but their coffee can add a simple protein supplement that is indistinguishable from regular coffee, yet offers nutritional value. Make sure that your stock includes more than just the run-of-the-mill nutritional shakes in cans.
If these patients are also obese, providers can arrange consults for weight reduction. Encouraging activities that the patient enjoys and can handle, like walking is an important adjunct to treatment. Walking provides a great exercise and keeps the calf muscle pump functioning. A workshop lead by a local dietician or exercise physiologist may be a good way to introduce these patients and their families to your products and services.
Since we know that pain is a factor with these ulcers, we need to address this from a multidisciplinary approach. Can occupational therapy or physical therapy fit the patient with orthotics to make them more comfortable when walking? Can the primary care physician give them analgesics to allow them to walk without discomfort? The DME supplier can work together with the team to get the patient up and moving, by offering the value added services of an on-staff therapist or WOC Nurse.
Preparing the Wound Bed
Local wound care includes supporting moist wound healing just as we would with any other wound. If there is necrotic tissue, it should to be debrided. In the home care environment, chemical and autolytic debridement offers ease and lessens complications. If the wound is clean with a pink or beefy red bed application of a wound gel or another dressing that supports granulation can be used. Cleansing with normal saline should be performed with every dressing change. Normal saline is the safest and most cost-effective wound cleanser.
More important to remember is what to avoid placing in a wound bed. Cleansers like povidone iodine (Betadine®) or H2O2, hydrogen peroxide, can damage the fibroblasts and delay wound healing. Povidone iodine has never been approved by the Food and Drug Administration (FDA) for anything other than a surgical scrub. It has never been approved for application into a wound. Antibiotic ointments such as Neosporin® can actually add to the cross-resistant problems that already exist. Topical antimicrobials should be used for no longer than a few days. A better alternative is the newer slow release dressing impregnated with silver or cadexomer iodine is a useful, non-resistant alternative. Consider having these available on your shelf.
The cornerstone of care for venous ulcers is compression. There are several modes available, multi-layer wraps, short and long stretch bandages and compression hose. All need to be used in combination with elevation of the lower extremities. Compression reduces edema and thereby helps to bring the wound edges closer together. It is, however, contraindicated in patients who have arterial disease. Clinicians should always make sure pedal pulses can be palpated and are documented. Measuring an ankle-brachial index (A.B.I.) is a crucial first step before applying any compression. The wound specialist can perform this simple test to ascertain the cause of the ulcer. The purpose of compression is to apply counterpressure on the dilated superficial veins by delivering a controlled graded pressure. This improves flow from the toes to the knees.
Compression can be achieved with ace wraps if they are re-wrapped three times in a 24 hour period. This is not practical since it is difficult to measure the correct amount of stretch and also an extremely labor intensive and time consuming activity. More dependable compression comes in the form of the multilayer compression dressings. These are designed to be worn up to seven days and deliver a sustained pressure over that time period. If the patient has high output exudates from their venous ulcers, these dressings can be changed more often, or a more appropriate, highly absorbent dressing can be used.
Another big concern with this patient population is education. Smoking cessation is another key area where the DME supplier can offer classes for the patient and family. One clever supplier offers such a class called, You can have your cigarettes or you can have your legs, not both. Another dealer offers specialty pamphlets on quitting smoking and other healthy behaviors like nutrition and blood sugar control with their company name and logo on it describing their products and services. Having a prescribing referral source such as a local WOC Nurse or vascular surgeon is a great way to make your products and services known throughout the community.
Skin care is another important issue for the venous ulcer patient. Frequent moisturizing helps prevent cracking and drying of the skin that can lead to future ulceration. Having a full line of skin care products along with topical wound care and compression is essential in their care. Consider offering the services of a WOC or E.T. Nurse to plan protocols and teaching regimens along with value added assessment and treatment within your company.
Complying with medical therapy is often difficult. Patients may not have the funds or transportation necessary to get these supplies. Another challenge is that Medicare B does not reimburse for bandages, stockings or compression therapy. Consider offering frequent buyer programs and other value added things that bring these customers back.
Wrapping it Together
As the U.S. population ages, venous ulcers are becoming a more burdensome and expensive problem. By the year 2010 there will be 60 million people over 65 and 17 million over 80. DME providers can offer hope in addition to the products necessary to care for patients with venous disease and venous ulcers. Manufacturers and distributors may partner to offer educational courses, literature and support to assist your customers. Providing workshops, on-site specialist consults, educational booklets and reasons to come back can ease the stress these individuals and families face as well as set your business apart.
This article originally appeared in the May 2003 issue of HME Business.