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.