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Introduction

In Australia, the incidence of venous leg ulcers (VLUs) is higher in older adults, with a mean age over 70 years.^1,2 Due to an increase in the ageing population—in 2007, 13% of Australians were over the age of 65 years compared to 16% in 2023³—the present and future financial, psychosocial and health impact of people with VLUs in this age group is considerable.

General practice (GP) clinics are the primary service providers for adults with leg ulcers, and frequent visits are common. Chronic VLUs are the most frequently seen wound in general practice.⁴ In Australia, 91% of people with a VLU attended their GP clinic within the 12 months preceding referral to a specialist wound clinic. They visit their GP one to two times/week for an average of 16 weeks,⁵ indicating the substantial time commitment required for VLU management. Despite the significant role of GP clinics in managing VLUs, GP clinics have been identified as the group in greatest need for education on evidence-based leg ulcer care.⁶

Several guidelines exist for the treatment of VLUs that cover areas such as cleansing, debridement, dressings and compression therapy.^7-9 However, a study conducted in 2012 by Weller and Evans⁴ showed that health professionals working in GP clinics demonstrated a number of deficits in the treatment of VLUs. These deficits were particularly evident in the management of leg ulceration, use of ankle brachial index (ABI) measurements, over confidence in the actions of the wound dressings, poor knowledge of compression therapy and the reluctance of General Practitioners to refer people on to other specialist services.⁴ A further study by Weller et al in 2020¹⁰ showed that these deficits persist.¹⁰ The deficits identified may be partly explained by studies indicating a lack of awareness of clinical guidelines¹¹ and that accessing them can be challenging.¹² In 2016 Norman et al¹³ identified that these deficits were further complicated by a lack of confidence and a lack of proficiency in evidenced-based practice for ulcer management. Norman et al also indicated an urgent need for education and training of primary health care professionals focusing on the implementation of evidence-based practice, optimal wound surveillance and greater understanding and use of appropriate wound dressings.¹³

To address these challenges, a pathway of care was developed for health care professionals. A pathway of care as a structured intervention aims to address identified deficits by providing a framework to guide decision making care processes for specific patient groups over a defined period.¹⁴ The goal of such a pathway is to enhance quality of care across the continuum by improving individual health outcomes, safety, satisfaction and the use of resources.¹⁴ Pathways of care are successfully used in health, and specifically in wound care, as a step-by-step approach that is evidence-based and practical.^15,16

The pathway of care developed by the research team incorporates a VLU risk assessment (VLURA) tool. The VLURA tool provides staff with a practical approach for early identification and management of people at risk of delayed healing.¹⁷ The VLURA tool has been prospectively validated in community and hospital settings.¹ The integration of the prospectively validated VLURA tool within this care pathway has the potential to lead to several key benefits. These include earlier implementation of wound management interventions, timelier referral to specialist wound service providers, improved healing rates, and positive impacts on both financial outcomes and patient quality of life. Embedding the VLURA tool within a structured pathway of care is intended to ensure its ease of use for clinicians in their daily practice. This integrated approach also aims to benefit individuals with VLUs by facilitating prompt referral to specialist wound care services when indicated by the risk assessment. Furthermore, care pathways, including those in wound care, have been successfully employed as evidence-based and practical step-by-step approaches to enhance patient care^15,16 The education component of this project could also benefit health professionals in GP practices and/or people with VLUs, specifically in the area of improved VLU assessment. To evaluate the benefits of this approach, this study aimed to assess the impact of the developed VLU pathway of care, incorporating the VLURA risk assessment tool as an intervention, within general practice settings.

Methods

A pilot observational study of health professionals examined the practicality and use of the VLURA tool incorporated in a pathway of care using a quasi-experimental design with pre and post-intervention measures to test the pathway of care. Pilot studies are used broadly to determine whether an intervention is appropriate for further testing and this study seeks to focus on the areas of acceptability and implementation. While the GP sites were randomised, randomisation within GP sites was not possible as the intervention could not have been controlled to only randomised participants at each site. Hence, a quasi-experimental design that involves nonequivalent groups was a feasible option that is often used in real world settings.¹⁸

Research settings

Two general practice clinics in the outskirts of Brisbane were recruited following an expression-of-interest process. These clinics had catchment populations of 15,273 and 145,806 with comparable median ages (33–36 years) and both serving culturally diverse communities.¹⁹

Participants

Health professionals were invited to participate in the intervention study of the pathway of care if their GP practice met the inclusion criteria. One of the participating general practice clinics was assigned to the intervention group, while the other served as the control site. People with VLUs attending these GP clinics were invited by the health professionals on site to participate in the collection of their VLU information.

Measures

The VLU Risk Assessment Tool (VLURA) was designed to provide early detection of people at risk of delayed healing of VLUs. It was developed in both a hard copy and an IT application. The development of the tool was  outlined by Parker et al in 2017,¹⁷ in a paper that included results from a literature review of risk factors for delayed healing, results of analyses of significant predictors for delayed healing from retrospective and prospective studies, and content validation by consensus of an expert interdisciplinary wound advisory group.¹⁷ The tool consists of eight questions about the person and their VLU which produces a baseline risk assessment score. The items include: age (in years), ulcer duration (in weeks), history of previous deep vein thrombosis (DVT) in the leg with the ulcer, whether the person lives alone, whether the person uses an assistive device to ambulate, whether the wound bed has >50% coverage of slough and/or necrotic tissue, ulcer area (in square cms) and whether treatment currently involves compression <30mmHg.¹⁷ An additional two items measured at two weeks from baseline include changes in ulcer area and calf circumference¹⁷ producing a total risk score. Scores range from ‘low risk of not healing’ to ‘high risk of not healing’. This tool has been prospectively validated in hard copy in community and hospital settings with an area under the curve (AUC) of 0.8.¹ Previous validation results have indicated good discrimination and goodness-of-fit with an AUC of 0.78 (95% CI, 0.71–0.85, p < 0.001)¹ and reliability results of ICC 0.84, 95% confidence interval (CI) 0.70–0.92, p<0.001.¹⁷

Baseline pre-intervention health professional survey

A paper-based survey asked for baseline information about the health professionals with demographic questions including their discipline, years of experience in their discipline and how many years’ experiences they had in providing clinical care/preventative management to those with VLUs or at risk of getting a VLU. The survey also included questions based on a validated tool, the Self-Efficacy in EBP scale,²⁰ about their level of confidence in identifying, assessing, managing, and implementing evidence-based VLU prevention strategies, possible restrictions for the choice of treatment, change management (such as finding evidence, setting goals to implement change and implementing change in the workplace) and use of clinical pathways for assessment of VLUs. A post-intervention health professional survey repeated the pre-study survey, omitting the demographic questions.

Pre and post lower limb surveys of people attending the participating clinics with a VLU

A paper-based survey was used to collect data about participants’ VLUs. This survey included questions about demographics, details of present VLU/s, history of VLU/s, assessment and management interventions used, and documentation of the VLU in the preceding seven days.

Venous leg ulcer clinical pathway of care

An evidence-based pathway of care for people with VLUs which covered assessment, management and referrals was developed by the research team based on evidence-based guidelines and principles.^{9, 21, 22} See Figure 1.

 

Figure 1: Venous Leg Ulcer Clinical Pathway of Care ^{9, 21, 22}

 

Procedure

Health professional participants signed a consent form, completed a pre-intervention survey and undertook a three-month pre-intervention phase. This involved research staff providing on site education and resources on VLU assessment and change management, in sessions that took about 15 minutes and included how and where to refer people to a specialised wound clinic. This pre-intervention phase also included data collection on current wound assessment, treatment procedures and management of VLUs within the two nominated GP clinics. Health professionals completed a VLU survey about their consenting patients with VLUs. People who met the inclusion criteria (leg ulcers of primarily venous aetiology, ankle ABPI ≥0.8, VLU below the knee as diagnosed by clinician in charge of care, ≥18 years, understood English, not diagnosed with cognitive impairment) were identified by their clinicians and invited to voluntarily participate.

At the completion of the three-month pre-intervention phase, one of the GP clinics was randomly selected to receive the intervention for three months, while the control site continued with routine procedures during this time. An online randomisation program (Research Randomizer©)¹⁴ was used to randomise the two GP sites to either the intervention or control site. The intervention consisted of the implementation of a pathway of care for people with VLUs incorporating the use of the VLURA IT tool. The research team provided in-person on-site training for practice staff on using both the app and hard copy versions of the risk assessment tool and the pathway of care. These sessions were videoed for those unable to attend the session. The practice was provided with an iPad for the duration of the study to enable staff to use the VLURA IT tool. Both participating GP clinics were contacted by phone biweekly to support practice staff and address enquiries.

Following the intervention phase, surveys about the assessment and management processes were delivered to staff at the participating practices (with self-addressed envelopes for return of the surveys, and a request that they be returned by email, fax or mail). Participants were instructed to use the same four-character personal code they used for the pre-intervention survey. During this three-month post intervention phase both GP clinics completed VLU skin integrity surveys for people with VLUs in the same way they did in the pre-intervention phase.

At the conclusion of the post-intervention phase, the control site was provided with the same education as the intervention site, with GP clinic staff receiving education on the risk assessment tool and pathway of care.

Ethics

After receiving University ethics approval (Ethics number 1600000695) and letters of approval from GP practices, the participating health professionals in all sites were provided with an information sheet outlining the aims of the study and advising that their participation was entirely voluntary and non-participation or withdrawal from the study would have no impact on future relationships with the research team or their workplace.

Participating patients were provided with an information sheet and consented to participate by ticking and dating the consent box. They were advised that their participation was entirely voluntary, and that participation or non-participation would in no way impact their care or any relationship with the GP clinic, the university and/or the researchers. Flyers about the study (specific to each site) were also available for people in the waiting rooms of both practices.

Data analysis

The data were analysed with the Statistical Package for the Social Science (SPSS 23.0) (Version 23, Chicago, Illinois) software. Descriptive analyses were undertaken using descriptive statistics of frequencies and percentages.

Results

Staff survey

In all 22 practice health professionals completed the pre-intervention survey across the two sites and 11 health professionals completed the post survey. Health professionals’ completion of the post-intervention survey was not contingent on pre-intervention survey completion. Some staff completed the pre-intervention survey but not the post-intervention survey. There was also some inconsistency in respondents coding their surveys which meant pre and post intervention surveys could not always be matched. As a result, there were limited cases (n=2 at control site and n=6 at intervention site) where both pre and post surveys could be matched to the same person.

Pre-intervention staff survey results

Respondents who completed the pre survey were predominately general practitioners (63.6%), had over 20 years of experience (50.0%), provided clinical care to people at risk or with current VLUs (95.5%), and had over 10 years of experience in caring for people with chronic venous insufficiency (54.5%). See full breakdown of respondents in Table 2.

 

Table 2. Demographics of health professionals who completed the pre-study survey (n=22)

 

VLURA tool and pathway of care

Baseline data across the staff who completed the pre-intervention survey in the participating GP practices showed that overall, the most frequent response across all the ten questions was ‘somewhat confident’. The areas with the most respondents giving a ‘very confident’ rating were confidence in applying evidence to clinical practice (40.9%) and confidence in finding evidence to identify, manage and prevent VLUs (27.3%). The main areas where respondents indicated they were ‘not confident’ were in measuring effects of change in the workplace (22.7%) and developing networks with other health professionals (14.3%). Across all measures between 0% and 4.8% of respondents indicated that they were ‘unsure’ of their level of confidence. See Figure 2.

 

Figure 2. Confidence of health professionals in wound care and associated activities (n=22; *n=21)

 

Most health professionals (54.5%) said they could choose the most appropriate wound care (including dressing and compression) ‘some of the time’, while 36.4% said they could do this ‘always’ and 9.1% said they could ‘never’ do this.

The majority of respondents (57.1%) reported that their practice does not have existing protocols and policies for the management of VLUs and no one indicated that they use a wound assessment tool in their documentation. Some, 41%, had referred a person with a VLU elsewhere with reason for referral being failure to heal. The most common place to refer was a hospital-based wound care clinic.

The most frequently identified restrictions to wound care were availability and financial restriction on the type of dressings that could be used (with 63.6% of surveyed staff indicating both of these were restrictions). All restrictions are shown in the Figure 3, ordered from the most restrictive to least.

 

Figure 3. Restrictions to treatment choices (n=22)

 

The most frequently used methods to assess VLUs as reported by the participants were talking generally to a person (regularly occurring 40.9% and always occurring 59.1%), using previous experience (regularly occurring 42.9% and always occurring 47.6%) and assessing surrounding skin (regularly occurring 68.2% and always occurring 13.6%). The least used methods were using a pain assessment tool (regularly occurring 9.5% and always occurring 14.3%), using digital photography (regularly occurring 4.7%), and tracing the wound (regularly occurring 18.2% and always occurring 18.2%).

Post-intervention staff survey results

Due to the small number of matched pre- and post- intervention surveys no inferences could be drawn regarding improvements in staff confidence levels following the intervention, particularly when comparing intervention and control sites. However, as shown in Table 3, the trend is that at both the intervention and control sites, staff reported increases in confidence. At neither site did staff confidence levels reduce during the study.

 

Table 3. Pre and post levels of confidence for HCPs at control and intervention sites (with 0 being unsure, 1 not confident, 2 somewhat confident, 3 very confident)

 

The pathway of care also appeared to assist in referrals. Prior to the intervention n=9 (41%) of participants indicated that they would refer people with VLUs elsewhere with the majority (n=7, 78%) indicating that that this would be based on the VLU failing to improve. Post intervention, 64% of participants indicated that they would refer with 30% of those indicating that this would be based on assessment/risk assessment.

Patient VLU survey

The patient VLU survey was administered to eight consenting people with VLUs across the two sites, both before and after the intervention. The timing of survey delivery and demographics of the individuals is shown in Table 4 and the details of ulcers and treatments are shown in Table 5. Of the 16 participants, eight (50%) indicated that they had accessed some form of support services at home. These were predominantly domestic assistance and personal care.

Mostly participants at both sites had one VLU. Documentation improved at both sites although individual education, peri-wound care and pain management showed little improvement, if any, from a low baseline.  For further details see Table 5.

 

Table 4. Skin integrity survey patient details (n=16)

 

Table 5. Details of ulcers and treatments

 

Discussion

Wound management is a large and important part of the daily activities for most primary health care nurses with wound management reported to be the most frequent clinical procedure in general practice.²³ Consequently, the importance of this research is substantial. Depite the small numbers of people with VLUs involved in the study, results suggest that a general practice pathway of care incorporating a risk assessment tool for early identification of people at risk of delayed healing may improve outcomes for health facilities, professionals, and the individuals. The introduction of a structured process/pathway of wound management addressed the gap between evidence-based practice and actual VLU care and referrals reported in other studies.^5,10 The time the practice had cared for ulcers increased in the intervention group, potentially indicating that this practice felt more confident in addressing these wounds. Post-intervention changes were also seen in increasing referrals and importantly referrals based on assessment. The significance of prolonged VLU duration as a risk factor for delayed healing is well-established.²⁴ Therefore, basing referrals on a comprehensive assessment and standardised assessment characteristics, including a risk assessment tool that identifies people at risk of delayed healing,¹ is crucial for implementing timely interventions. The simple and easy variables within the risk assessment tool ensures the ease of including people with VLUs in discussion about the scoring of the tool and the importance of the variables within the clinical pathway of care. This person-centred approach was  acknowledged by Weller et al in 2021²⁵ as being able to better address people’s physical, psychological and social needs.

Documentation improved at both sites. However, education, peri-wound care, pain management and current assessment and management in relation to ABPIs and high compression showed little improvement from a low baseline, indicating these were never previously completed. This was not surprising as these are areas of wound management have previously been found to be lacking. Bechert and Abraham (2009) described pain as frequently experienced and yet often overlooked in wound care²⁶ and vascular assessment in the form of ABPIs have been noted to be challenging in relation to the availability of the hand-held Dopplers in primary care, knowledge, skills, confidence, organisational culture and referrals.²⁷ While education of people with wounds has been noted to be of importance,²⁸ this type of education has been noted to be missing when wound care education courses were reviewed.²⁹  A recommendation was made to educate people with wounds to empower them, encourage independence and improve care and quality of life.²⁹ Although Wounds Australia’s 2023 guidelines³⁰  promote the assessment and management of the peri-wound area and there is further support for the importance of the care of the peri-wound skin,³¹ this area is often given lower priority than caring for the wound itself.³² These activities take increased time to complete, in addition to addressing the wound itself. When time taken for wound care has already been acknowledged as a barrier to evidence-based wound management,¹² it is not surprising that these wound care strategies showed little improvement when structural and facility changes would need to occur to allow the time to assist in these processes.

Staff survey results indicated that staff were somewhat confident in their level of ‘confidence in assessing, managing and preventing wounds’, along with ‘finding evidence’ and ‘change management’. This may be due to over 50% of particiants having worked in general pratice for over 10 years. However, this does not always translate into evidence-based pratice with challenges in implementing theory into practice acknowledged, including insufficient time, lack of awareness of evidence-based guidelines, lack of education and access to services and high costs of products and services.³³ Due to the small sample size, only descriptive statistics could be used to assess changes following the intervention. Nevertheless, the intervention site demonstrated greater improvement compared to the control site in terms of setting goals for change implementation, communicating workplace change, and implementing workplace change. It was of interest in this cohort of predominantly general practitioners that these results are consistent with a previous study in general practices which aimed to transfer knowledge into practice and found significant improvements after a ‘Champions for Skin Integrity’ model of evidence-based practice was implemented, mostly with registered nurses.²⁰ Restrictions to treatment choices (due to product availability, cost, and lack of knowledge) and the challenges of changing current practice and policies are consistent with the key barriers to evidence-based wound care highlighted in 2018 by Pacella et al.³³ Pacella and colleagues reported these as being lack of awareness of the significance of chronic wounds, poor access to wound services, poor education and the high costs of services and products.³³

Wound Australia’s recent five-point plan for improving wound care access and affordability highlighted the exisiting disparities and financial burdens with a need for a more holistic, equitable approach to wound care. The Chronic Wound Consumables Scheme came into effect in May 2025, and will cover the cost of wound consumable products for older people aged 65 and over, or First Nations people aged 50 and over, who have diabetes and a chronic wound. While this is a step in the right direction,³⁴ continued barriers exist for others.

The health staff in this study indicated that they are ‘somewhat’ confident across many aspects of wound care. This is consistent with literature that highlights the lack of wound care education for our health professionals prior to registration. While health curricula are guided by the standards of practice for nurses and allied health practitioners,^35,36 current evidence indicates a significant gap between the wound care competencies of new graduates and the expectations of clinical settings, where the care of people with wounds is complex. This disparity highlights an urgent need for curricular reforms that can adequately prepare students for the realities of contemporary clinical environments, including those found in primary care.

The small sample size was a limitation in this study, as was the inability to determine the fidelity of the risk assessment tool and pathway of care. A previous study has highlighted the challenges in relation to ensuring that health professionals followed referral pathways,³⁷ hence further research with larger numbers and consideration to assessing the effectiveness of the utilisation of the risk assessment tool and the clinical pathway of care would be of benefit.

In conclusion, the results from this pilot study concluded that a risk assessment tool for early detection of those at risk of delayed healing was well accepted, and that a pathway of care, incorporating the risk assessment tool, could provide benefits to the health organisation, health care professional staff and the patients.

Author contributions

CP and KF contributed to conceptualisation and methodology. All authors contributed to screening, critical appraisal, data extraction and data synthesis, and all authors were responsible for manuscript preparation including providing feedback and critical comments on the manuscript. All authors have read and approved the final paper manuscript.

Acknowledgements

Participation of the clinics involved is acknowledged.

Conflict of interest

The authors declare no conflicts of interest.

Funding

This study was funded by a university Early Career Researcher grant.

Author(s)

Christina N Parker*^1,2, Katy Wyles¹, Kathleen J Finlayson^1,2
1Faculty of Health, Queensland University of Technology, Victoria Park Road, Kelvin Grove, 4059, Queensland, Australia
²Centre for Healthcare Transformation, Queensland University of Technology, Queensland, Australia

*Corresponding author email christina.parker@qut.edu.au

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