Study Setting
The Saolta Hospital Group comprises seven hospitals in the West of
Ireland, caring for a total population of approximately 800 000 people.
University Hospital Galway (UHG) is the tertiary referral centre for the
group, where vascular surgical services for the entire group are based.
Four of the hospitals provide elective and acute general surgical care,
while the remaining two provide only elective and day case surgical
services.
In July 2016, a one-stop venous ulcer clinic was introduced, operating
once weekly for a full day from Roscommon University Hospital. Patients
are seen and assessed by a vascular clinical nurse specialist and
vascular surgeon, with ultrasound assessment of venous disease and
suitability for endovenous intervention. Where necessary, further
imaging or investigation can be arranged but for the majority, the aim
is same day treatment of superficial venous reflux, and/or commencement
of compression therapy as appropriate. Suitable patients are offered
axial ablation (mechanochemical ablation using
ClariveinTM (Vascular Insights LLC, Quincy, MA, USA)),
or foam sclerotherapy (using FibroveinTM (STD
Pharmaceutical Products Ltd., Hereford, UK)) into the sub-ulcer plexus
of veins, as appropriate. Axial ablation is offered to patients with
great or small saphenous vein reflux. Foam is offered along with axial
ablation if prominent varicose veins between the ulcer and the ablated
segment are an issue, in an effort to treat to the lowest possible point
of reflux. Treatment with foam alone is offered for perforator reflux,
or reflux without discernible superficial venous disease. All of this is
done in consultation with the patient, and some, particularly more
elderly patients, elect for foam alone as the, perceived, least invasive
procedure, while many elect to continue with compression alone.
Compression bandaging is offered to all patients with a VLU and
superficial or deep venous reflux with no contraindications.
The clinic runs in parallel with a day case operating list for varicose
vein interventions. This allows clinic patients undergoing intervention
to be added onto the daycase list and undergo same-day intervention.
Another advantage of this is that is allows the clinic to be run with
only one additional staff member: the clinical nurse specialist. Theatre
nurses, secretaries and other personnel do so in addition to their
normal duties, reducing costs.
Patients are referred to the VLU clinic from general practice, community
wound care services, and from general surgical teams in any of the
hospitals within the Saolta group where such services are provided.
Patients with venous reflux of any type, without ulceration, were not
diverted to the rapid access clinic. Following their initial assessment,
and intervention if performed, patients are reviewed every four weeks
until their VLU has healed. Where this is not practical for other
reasons, most commonly if patients have travelled long distances for
assessment and treatment, some patients were followed up locally. If
issues arose during follow up, Public Health Nurses (PHNs) were able to
contact the clinic nurse directly to arrange rapid reassessment, and
indeed patients themselves could make contact directly if necessary.