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SECOND EDITION
Full holistic assessment
Hosiery classification
and product selection
Hosiery application
and removal, self-care
and hosiery care
Disease and service
management
BEST PRACTICE STATEMENT: EXPERT WORKING GROUP:
COMPRESSION HOSIERY Jackie Stephen-Haynes (Chair), Professor and
(2ND EDITION) 2015 Consultant Nurse in Tissue Viability,
Birmingham City University and
PUBLISHED BY: Worcestershire Health & Care Trust
Wounds UK
Leanne Atkin, Vascular Nurse Specialist,
A division of Schofield Healthcare
Mid Yorks NHS Trust
Media Limited, Enterprise House
12 Hatfields, London SE1 9PG, UK Alan Elstone, Vascular Nurse Specialist,
Tel: +44 (0)20 7627 1510 Derriford Hospital
Web: www.wounds-uk.com
Lesley Johnson, Faculty Development Lead,
Royal Pharmaceutical Society
appropriate specialist
Skin folds for further assessment
Papillomatosis
and/or treatment.
Lymphangiomata
Lymphorrhoea (wet legs)
the necessary competencies, and has access to and circulation statuses to help diagnose the
the knowledge, skills and resources required to underlying disease process (Table 1) (Lymphoe-
make decisions and referrals for the patients dema Framework, 2006).
care (Appendix 1, p18). The practitioner must
undertake and document a holistic assessment Wellbeing, quality of life and lifestyle factors
of the patient and limb with the goals of com- such as occupation, mobility, obesity status,
pleting a full assessment, reaching an accurate history of previous ulceration, interests and
diagnosis regarding the condition and stage of limitations to daily activities should also be
disease (Figure 1, p2), providing an appropriate assessed and, if possible, addressed, to manage
service and treatment in primary care settings, patient expectations of treatment outcomes
and referring appropriately to secondary care or (Keeley, 2008; Upton, 2013). Age should also be
other specialist services. a consideration, as incidence of venous disease
increases with older age, and intervention at an
Patients should receive a comprehensive assess- early stage is important.
ment within 10 working days of presentation
with symptoms to establish the underlying aeti- Other patient-specific factors include sleep
ology of venous or oedema-related skin changes status, nutrition status, psychological and social
(Wounds UK Guidelines for Practice, 2013). impact, weight and wound history. Patients
When deemed urgent, assessment should be should be assessed for their understanding of
done within 3 working days. Triage by phone or the role of hosiery in disease treatment, the
remote video can be done to aid prioritisation. need to wear hosiery long-term and how they
will apply/remove hosiery, because concordance
Components of holistic assessment with hosiery is critical to good outcomes.
On presentation, a comprehensive assessment
should be taken, beginning with a detailed Vascular assessment
history, including past medical and surgical his- Doppler ultrasound for ankle-brachial pressure
tory, history of limb trauma and skin infection, index (ABPI) is considered the standard tool for
medications (e.g. steroids), concurrent illnesses, vascular assessment to rule out arterial involve-
a family history of venous disease or limb swell- ment (RCN, 2006; SIGN, 2010). Compression is
ing, and ankle mobility (Partsch, 2003). The contraindicated where there is significant arterial
practitioner should assess the skin, lower limb disease (e.g. ABPI<0.5, critical ischaemia) (SIGN,
2010) or where arterial disease is suspected. These distribution of oedema or presence of advanced
patients should be therefore be referred for assessment disease. In such cases, all other aspects of a full
and further diagnostic testing by a vascular specialist vascular assessment should be carried out by a
to determine adequacy of blood flow in the limb: practitioner who has achieved competence in this
If ABPI is carried out by the initial assessing prac- area and can confidently determine suitability for
titioner, the patient should be referred if <0.9 or compression. Consultation with a vascular special-
>1.31.5, depending on the results of the holistic ist is recommended.
assessment (SIGN, 2010; NICE, 2014). Younger patients (e.g. 20 to 30 years old) may
Where the results of the assessment lead the have high ABPI readings that are not indicative
practitioner to suspect arterial disease, e.g. painful of vascular insufficiency; these patients should be
cramping in leg muscles during activity, leg numb- referred for vascular assessment only if other risk
ness or weakness, change in colour of legs, shiny factors are present, not based on ABPI alone (Al-
skin on legs, hair loss or slower hair growth on feet Qaisi et al, 2009).
and legs, slower growth of toenails. For patients who are deemed low risk for arterial
All patients presenting with a venous leg ulcer insufficiency, hosiery 17mmHG can be issued
should be referred to either a specialist leg ulcer without a full vascular assessment (see page 6,
clinic or a vascular team (NICE, 2014; Wounds UK column 1, for more information). Such patients
Guidelines for Practice, 2013). will still require monitoring. This may not be a
Patients at risk of (e.g. due to diabetes, immobility) long-term option, as venous, lymphatic and arterial
or presenting with lower-limb signs or symptoms, status could deteriorate over time. The patient may
who require compression at a level of higher than in future require a full vascular assessment, special-
18mmHg, should undergo a full vascular assess- ist review and change of treatment.
ment with a specialist before hosiery is prescribed.
Where very oedematous limbs make ABPI difficult It is important to consider local guidelines when
to carry out, and access to a non-vascular practitio- determining whether to refer a patient to a specialist.
ner skilled in carrying out and interpreting an ABPI Patients who have had a vascular assessment should
reading may be limited. These patients should be be sent for regular, subsequent assessments incorpo-
referred to a vascular specialist for further evalu- rating Doppler, usually at 3-, 6- or 12-month intervals,
ation (e.g. duplex ultrasonography) to determine depending on initial and ongoing assessment out-
treatment in line with the underlying disease. comes, patient needs, or according to local guidelines
If under the care of a lymphoedema specialist, (NICE, 2014). Those at high risk of arterial disease
ABPI may be deemed inappropriate due to the should be monitored and reassessed more frequently.
The initial assessment should be carried out To ensure patients receive appropri- The practitioner should be trained and competent in assessment,
by an appropriately qualified practitioner with ate, multidisciplinary care on an diagnosis and appropriate care planning, referring to specialist
access to the knowledge, skills and resources ongoing basis services where necessary
required to make decisions about care and
referrals if required
Based on the results of the initial and To determine when further diagnostic Document the results of risk-stratification assessment in the patient
vascular assessment, patients should be testing, such as Doppler or duplex, is record, making particular note of the rationale for the decision and
risk-stratified needed outlining the care plan to be followed
Based on the holistic assessment, patients To ensure the patient receives appro- Document the diagnosis resulting from holistic assessment in
should be provided a diagnosis that will priate compression hosiery or is seen the patient record, making particular note of the rationale for the
lead to the prescription and application of by the appropriate specialists decision and outlining the care plan to be followed
compression hosiery, or referred on to the
appropriate specialist for further assessment
and/or treatment
(BNF, 2015) | *Quality and test specifications carried out according to national norms
If the patient has a history of peripheral arte- dages difficult to tolerate or who have low-
rial disease but is otherwise asymptomatic, exuding ulcers, recent research indicates
Class I may be implemented, along with that hosiery kits may provide an equally ef-
onward referral for specialist assessment. fective alternative for treating active ulcers.
Depending on the severity of symptoms, a
Doppler/duplex scan may be advised after In the multicentre, randomised, controlled
prescription of Class I hosiery to confirm the VenUS IV trial, 453 participants randomly
outcomes of the clinical examination. Lack allocated into hosiery kits (230) and bandag-
of dexterity or a carer who can apply hosiery ing (223) groups finished the trial. Median
may contraindicate prescription of compres- time to ulcer healing was 99 days in the
sion that can be applied at home. hosiery group (70.9% healed ulcers) and 98
days in the bandaging group (70.4% healed),
Ongoing maintenance indicating that both compression hosiery
Compression hosiery is most commonly and the gold standard of VLU treatment
used post-ulcer healing to control oedema may be equally effective during the intensive
and reduce venous hypertension, both management phase (Ashby et al, 2014).
of which help prevent ulcer recurrence
(secondary prevention) (Anderson and Furthermore, the researchers economic
Smith, 2014). Patients are also commonly analysis found that the average mean costs
post-thrombotic. In patients with chronic were about 300 lower per participant
oedema and lymphoedema, all use of per year in the hosiery group than in the
compression hosiery is considered to be bandage group (Ashby et al, 2014), mak-
ongoing maintenance, to control oedema, ing compression hosiery a potentially more
with some reduction if possible. cost-effective option.
Any patient who will be prescribed pressures Although participants had more complaints
18mmHg (e.g. Class II British standard, about discomfort with hosiery, Ashby et al
European class I or higher) for ongoing (2014) did note a significant reduction in
maintenance or intensive management (see recurrence in people allocated to hosiery,
next section) should undergo vascular as- which might support the idea that patients
sessment and may require further diagnostic who became used to wearing hosiery as an
testing before prescription or compression ulcer treatment would be more likely to
application. wear it as a maintenance treatment after
healing and therefore reduce their risk of ul-
Intensive management cer recurrence. The authors concluded that
Compression bandaging historically has increased use of hosiery as a treatment is
been considered the gold-standard treat- likely to result in substantial savings for the
ment for venous ulceration (Ashby et al, NHS and improved quality of life for people
2014). However, for patients who find ban- with venous ulcers (Ashby et al, 2014).
Compression hosiery kits have an inner for standard sizes, customised (made-to- Box 2. Patient-specific
layer (liner) that delivers approximately 10 measure) hosiery should be prescribed. This considerations
20mmHg to the limb (depending on manu- may require referral to a practitioner with
facturer specifications). A higher-pressure knowledge of how to correctly measure for Mobility
hosiery garment is then applied to increase made-to-measure garments. Current suppli- Dexterity
pressure to the limb, usually up to 40mmHg in ers are outlined in the drug tariffs for England Skin status (friable skin
total. The inner layer helps the stronger outer and Wales, Scotland and Northern Ireland should not be a contra-
layer to be applied more easily, as it provides (BNF, 2014). indication, but should be
a smoother surface than skin. However, these approached with caution)
kits may be difficult to apply over some dress- Patient considerations Limb shape
ings, especially if they are bulky or there is a Patient-specific factors should be taken into Site of oedema
high level of exudate present. When there is consideration but, more than that, a patient- Weight status/build
severe oedema present, compression bandag- partnership approach should be taken (Box Sex
ing may be worn to improve the management 2). The practitioner should speak in clear Age
of oedema and exudate levels before applica- language patients can easily understand, to Comorbidities
tion of compression hosiery. encourage shared decision-making. Other regular/ongoing
treatments (e.g. podiatry
Measurement and sizing Identify the focus of the consultation. The care for diabetic foot)
Compression hosiery works only if measure- patient needs to know what to expect at Preference for open- versus
ments are correct and hosiery is subsequently each stage. Encourage patients to return to closed-toe hosiery
applied correctly. Legs should therefore be the same pharmacy, nurse or GP for repeat Ability with/preference for a
measured and hosiery prescribed according assessment; explain that hosiery should be particular application aid
to each manufacturers own measuring guide, removed at bedtime, but may be worn up to Ability to self-care/-manage
as sizes vary according to manufacturer. Every 7 days before bedtime removal and morning Availability of help/
effort should be made to reduce oedema reapplication if necessary, based on appropri- assistance
before hosiery is measured. In most cases, ate assessment and advice. Patients also need Ability of carer
bandaging should be used short-term dur- to be aware that patient choice cannot always Psychosocial factors
ing the intensive management phase to help be 100% accommodated, that there may have Colour preference
reshape the limb and/or treat the ulcer. Once to be some balance between clinical need and Whether the patient will
the ulcer has healed and oedema has reduced, patient preference. This can enhance concor- need/can afford to buy extra
patients can be measured for hosiery (Box 1, dance, because patients will understand what pairs
p7) and prescribed a garment that will deliver the trade-offs are for effective care.
sufficient pressure to control oedema on an
ongoing basis. Discuss modification of treatment to use a
lower class if high compression is not tol-
If a patient does not fit into the measure- erated, but also explain that, over time, as
ments on the manufacturers sizing chart tolerance builds, compression levels may also
be increased. Practitioner and patient alike some compression is better than no compres-
should understand that compression is an sion, and patient concordance is crucial to
ongoing treatment that needs to be worn long- positive clinical outcomes. It is important that
term, just as long-term medication regimens the practitioner understand the psychosocial
should be adhered to. issues that may result in non-concordance,
and that he or she try to identify these factors
A patient may require open-toe hosiery (Box 3, p8).
because:
The patient has arthritic or clawed toes Who selects and prescribes hosiery
The patient has a fungal infection To support patients in choosing, practitioners
The patient prefers to wear a sock over the must know what hosiery choices are available
compression hosiery and be able to instruct the patient on the vari-
The patient has a long foot size compared ous ways to don and doff hosiery. The practi-
with calf size (hosiery with longer foot-size tioner should have an understanding of venous
options available, if necessary) and lymphatic disease processes, and be able
The patient requires regular podiatry/chi- to advise according to the patients condition
ropody appointments and limb shape (British Lymphology Society
There is no oedema present in the toes, and Tariff Costings Document, 2013).
the patient prefers open-toe hosiery (NICE,
2012). Finally, the practitioner should prescribe two
pairs every 6 months (one to wash, one to
Ultimately, the hosiery selected should be wear) to ensure effectiveness of compression,
the patients choice. The practitioners job is regardless of the type of compression or class.
to explain the options and direct the patient Prescriptions should be clearly and thoroughly
towards the clinically optimal choice, but specified to ensure accurate dispensing.
Best practice statement (BPS) Reason for BPS How to demonstrate best practice
Once venous disease or chronic oedema is To ensure that the patient receives the most Document the care plan to be followed, in line with
confirmed, hosiery must be selected based on appropriate, optimised care for his or her the diagnosis
the outcomes of the holistic assessment, and condition
according to the goals of treatment
Product selection should also take into Because hosiery may be inelastic or elastic, The practitioner should be competent in knowledge
account limb size and shape, the strength may be circular- or flat-knit, and may be regarding hosiery construction: the different classes,
and stiffness of the garment, and patient available off the shelf or made to measure, standards and strengths of hosiery; the indications
considerations and the manufacturers of medical and associated with these different types of hosiery; and
support hosiery follow different standards how to accommodate patient considerations while
for construction optimising hosiery choice
Patient-specific factors should be taken into To encourage patients to be part of the The practitioner should speak in clear language patients
consideration as part of a patient/practitioner- conversation about their care; to promote can easily understand, and engage patients by discussing
partnership approach ownership and self-management of the the range of treatment options, the trade-off with lower
condition compression, and compromise
Practitioners must know what hosiery choices To support patients in making a choice The practitioner should be competent in knowledge
are available, be able to advise according to the regarding hosiery choices, how they affect the
patients condition and limb shape, and be aware patients condition, and the practical factors that may
of the wear times for hosiery (typically two pairs affect hosiery choice in relation to patient condition
every 6 months)
have issues with hand-grip strength to wear reduced sensation, such as under skin folds Box 1. Indicators of good
washing-up gloves when applying and and between the toes. compression hosiery fit
removing hosiery, to improve their grips
and protect fingernails from damaging the Care of hosiery Hosiery not loose, with no
hosiery material or skin. Patients and carers will largely have the slippage
responsibility for keeping compression Hosiery not twisted/rolled
Note any skin changes, as these may indi- hosiery in good condition, so it is critical No compression ridges/
cate progression of venous or lymphatic dis- that they receive good education in order creases on the skin
eases. Educate patients on what healthy skin to maximise the life and effectiveness of a Hosiery not too high on
looks like, and what a healthy-skin regimen garment until the next prescription. Use back of knee or thigh
should include (Box 2, p12). It is impor- the tips for hosiery care in Box 3 (p13) as Hosiery does not pinch skin
tant that patients or carers remove hosiery a handout for patient education, or as a or cause pain
daily (or as often as possible) to inspect the checklist of education to be communicated Hosiery does not result in
skin for any breaks, signs of infection (e.g. to the patient. Note that many of these dos numbness, discomfort or
increased temperature or tenderness) and and donts also help encourage good skin discolouration
rashes or fungal infections (e.g. tinea pedis), care and donning practices. Providing writ- Hosiery does not cause
or the early signs of pressure damage. Pay ten information that patients can refer to on shortness of breath
particular attention to areas where there is an ongoing basis is essential.
6
application and removal of hosiery application and removal of hosiery
Roll-on adhesive Roll-on substance that helps hosiery stick to the limb while Roll adhesive on to skin using the applicator bottle, 6
(various) remaining pliable, and that can be washed off with water apply hosiery and press to secure
Apply skin care products (e.g. emollients, topical corticosteroids) in the evening, after removing hosiery for bed
Check skin daily (or as often as possible) for changes, including on the legs, toes/nails and interdigital spaces
Gently elevate legs when resting to reduce pooling of oedema that can result in skin damage (high elevation is not necessary)
Keep physically active to the fullest extent possible, depending on each patients specific situation
Don hosiery first thing in the morning, when oedema is at its lowest levels, to help avoid skin damage and limb expansion
BPS application to practice: Hosiery application and removal, self-care and hosiery care
Best practice statement (BPS) Reason for BPS How to demonstrate best practice
The practitioner who measured, selected To ensure continuity of care The practitioner should be able to demonstrate competence in
and prescribed the hosiery should guide and that the practitioner has knowledge regarding hosiery application, skin care under compression
the patient through first application, the requisite specialist skills to and care of compression hosiery
and educate on application at home, guide the patient in beginning
skin care under compression and care of compression hosiery therapy
compression hosiery
Hosiery or bandaging should not be To ensure continuity of care, Schedule a fitting appointment with the patient as soon after dispensing
discontinued until the new hosiery and that the new prescription is as possible. Inspect the limb for signs of improper fit. Help the patient
prescription is available, and a good fit appropriate practise application and removal, to get used to the new garment. Document
has been ensured the results of the inspection and the patient education provided
Even if the patient is experienced with To ensure the hosiery Schedule a fitting appointment with the patient as soon after dispensing as
compression hosiery, he or she should prescription fits the limb possible. Inspect the limb for signs of improper fit. Help the patient practise
not independently apply compression properly application and removal, to get used to the new garment. Document the
hosiery for the first time or if the results of the inspection and the patient education provided
prescription has changed
Skin care should be considered part of To prevent skin breakdown Provide patients pragmatic advice about skin care and skin changes to look for,
hosiery management and the overall under compression and take steps to prevent skin-related issues. Document the education in the
treatment plan, rather than a discrete patients notes
condition to be managed on its own
Instruct patients to remove hosiery daily Skin changes should be noted, as Educate patients on what healthy skin looks like, and what a healthy-skin
(or as often as possible) to inspect the these may indicate progression regimen should include. Document the education provided in the patients
skin for changes (e.g. breaks, signs of of venous or lymphatic diseases notes
infection and rashes)
Instruct patients in the care To extend the hosierys effective Document the education provided in the patients notes. Provide literature that
requirements of their hosiery life until re-prescription is due patients can refer to if needed when self-applying and removing hosiery
ment and be re-measured and re-fitted for factors can help to find solutions (Moffatt,
a new hosiery prescription every 6 months. 2004). Written information should be
Old hosiery should be checked for lack of provided, to support patients at home.
expected wear or over-use. Patients should be
given the option of regular contact to monitor This might result in balancing evidence-based
treatment, such as face-to-face appointments, care with what patients will accept and use,
telephone or text message check-ins or via to improve concordance. For example, if an
online methods. elderly patient cannot tolerate the indicated
level of compression or is unwilling based on
Pharmacists undertake Medicines Use Reviews a previous experience of pain, the practitioner
(MURs; known as Chronic Medication Service might need to be pragmatic and apply re-
in Scotland and Managing Your Medicines duced compression to re-introduce compres-
in Northern Ireland) on long-term, repeat sion to gain the patients trust (Vowden and
prescriptions. In these structured reviews, Vowden, 2012; Beldon, 2013). It is acceptable
pharmacists identify and discuss prescrip- to discuss compromise, as it keeps the patient
tions and over-the-counter medications with engaged and can help ease patients into the
patients, sending the results of the review to idea of committing to a long-term treatment
patients GPs. such as compression hosiery.
The MUR process may seem more infor- Box 1. The changing role of pharmacists
mal to patients, but it should be part of the
formal ongoing review process, with trig- Differently placed from other practitioners, pharmacists can work both as a direct
gers for intervention and referral. Trigger contact with the patient and a care link with the members of the multidisciplinary team.
Because pharmacists may be the first point of contact for patients (and potential
questions for prescribing or re-prescribing patients), and may see some patients more often than GPs do, they are ideally posi-
may include: tioned to engage people at risk of venous or lymphatic disease on a daily basis, and
Are you experiencing swelling in your legs? discuss intervention at an early stage (OHanlon, 2013). Patients may be at risk due to:
If yes: Have you been prescribed appropri- Hereditary factors (e.g. a parent had venous disease)
ate compression hosiery? Pregnancy (including after birth, in addition to during gestation)
Occupation (e.g. standing for long periods of time)
Do you have any problems with the skin on Injury to the legs
your legs? Being overweight
Do you have any issues with your compres- Age (vein elasticity is gradually lost with age)
sion hosiery? Travel, particularly long-haul air travel.
Have you had an ABPI in the last year?
Pharmacists are in a prime position to make interventions on a regular basis with
patients, based on their medication histories, by observing them or by asking relevant
Any problems reported by patients should trig- questions while face-to-face with patients. They are therefore ideally positioned to help:
ger a re-assessment. In addition, the pharma- People with untreated swelling of the limbs, or changes in the appearance of the skin
cist could intervene when a patient presents on their lower limbs
at the pharmacy for the dispensing of other People who dont re-order hosiery
People with ill-fitting hosiery and related problems
prescriptions or healthcare needs, and share People with mobility problems that may make hosiery difficult to self-apply
information with the GP. In this way, the phar- Changes to the persons original condition. For example, a deterioration in the
macist can act as the safety net of the MDT. varices or the other leg becoming affected.
Patient involvement and concordance In addition, pharmacists can intervene when a patient presents at the pharmacy with a
prescription. For example, where GPs prescribe only one pair instead of two, or one leg
Although patients do need to take some instead of both, or patients decline to fill repeat prescriptions. Where this is seen, the
responsibility for their care, this should be pharmacist can speak to the patient or contact the GP or practice to advise.
supported by practitioners taking a caring and
motivational approach. When patients are Medicines Use Reviews (MURs; known as Chronic Medication Service in Scotland
involved in decision-making (Hopkins, 2004; and Managing Your Medicines in Northern Ireland) are opportunities to see whether a
patient has been re-prescribed hosiery at the appropriate intervals. The pharmacy team,
International Consensus, 2012) practitioners including pharmacy technicians, can also use patient medication records to identify
can improve patient concordance with medi- when reassessment and re-prescription of hosiery is needed, to help improve compli-
cal advice by tailoring treatment to individual ance. Further, the pharmacist and technicians can opportunistically enquire about
patients needs and desires. However, ensur- hosiery during pharmacy visits, asking how they are wearing it and whether they are
ing concordance with compression therapy having any issues with it. If patients are not complying with treatment, the pharmacist
can explain why hosiery should be worn, initiate a discussion about referral back to the
remains a challenge (Box 4, p17). Listening GP for follow-up, and offer possible solutions (e.g. different style or colour).
to a patient to understand important lifestyle
Orthotics
Palliative care Nursing/care Box 3. Risk stratification for
home re-assessment*
Leg ulcer
Rheumatologist service Plastic
surgeon Annual
Lymphoedema No cellulitis
Nursing team specialist Limited or well-controlled
Microbiology service
comorbidities
Patient Dermatologist Healed ulcer (no recurrence
Vascular in 12 months)
specialist
Social services
GP Stable oedema
service
Fully concordant, no report-
ed problems with hosiery
Tissue viability Healthcare Commissioners ABPI >0.9
nurse assistants
Dietician
6-monthly
Colour key Community Lower-leg infection, even if it
Podiatrist based leg care has been resolved
Care focus Clinical
Core team psychologist
Diagnosed with new disease/
Extended team comorbidity
Care link History of recurrent lower-
Pharmacist limb problems
Multiple morbidities on an
Figure 1. Patient-focused care in the context of a multidisciplinary team established regimen
3-monthly
Give patients practical advice. Have them will have to pay only the excess above the History of non-concordance
bring hosiery with them to appointments, and tariff price. Repeated poor fit
spend time reiterating good practice in don- Increasing oedema
Skin breakdown/ulceration
ning and doffing. Be realistic about the chal- Explore other avenues that will aid treat- Rapidly changing medical
lenges of everyday life for some patients when ment and make compression more tolerable, condition (e.g. palliative)
advising on hosiery removal and application, e.g. skin care, elevation, activity and weight
hosiery wear times, and how to care for the loss (bringing a dietitian into the MDT if *Expedite new assessment if
garment. Let patients know they are able to necessary). Discuss the advantages and there is increased oedema,
lower-leg pain or new ulceration
choose colours that arent on drug tariff, and disadvantages of application aids that may
nicating about and coordinating services and ROLES AND DEFINED LEVELS OF
care between the hospital and the community. COMPETENCYAND SKILL
Role: Assess and diagnose patients; measure, A competent person is someone with enough
prescribe, fit and explain the use and care of training and experience or knowledge and
compression hosiery; communicate informa- other qualities to be able to implement these
tion about care to other members of the MDT. measures properly. Keep in mind that this
diagram provides only general guidance, and
Vascular surgeon that actual competency levels and roles will
A specialist physician focusing on medical vary by specialty, area and practice (Figure 1).
and surgical interventions for the treatment of
diseases affecting the vascular system, includ-
ing diseases of arteries, veins and lymphatic
vessels. Role: Treat the underlying disease Specialist
via surgical intervention. Direct patients to
relevant practitioner if oedema increases or Advanced
skin changes in the limb.
Generalist
Compression hosiery Requires training in District nurse, GP, lymphoedema specialist, pharmacist, tissue
measurement measurement and fitting viability nurse, vascular nurse, pharmacy technician
Compression hosiery product Requires understanding of GP, lymphoedema specialist, pharmacist (typically 1417mmHg),
selection and prescription different types of compression practice nurse (typically 1417mmHg), tissue viability nurse,
and levels of pressure applied vascular nurse
First application of new hosiery Requires training in applica- GP, lymphoedema specialist, pharmacist, practice nurse, tissue
and instruction in use of aids tion of compression viability nurse, vascular nurse
Referral for assessment and Requires understanding of Dietitian, district nurse, GP, lymphoedema specialist, pharma-
triggers for referral and ability
diagnosis cist, physiotherapist, podiatrist, practice nurse, rheumatologist
to make referrals
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Hopkins A (2004) Disrupted lives: investigating
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International Consensus (2012) Optimising (EWMA) Position Statement: Understanding
compression bandages in treatment of venous
wellbeing in patients living with a wound. compression therapy. Medical Education
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