Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part Two -- Venous Ulcerations

William J. Ennis, DO, MBA, FACOS, Patricio Meneses, PhD


Wounds. 2003;15(4) 

In This Article

Abstract and Introduction

As clinical practice guidelines and standard-of-care documents proliferate in the literature, the practicing clinician is often still uncertain as to the proper course of treatment for his or her patient. In this review, current information on venous leg ulcerations (VLUs) will be reviewed with an emphasis on identifying the evidence-based standard of care. Given that reported healing rates for VLUs only range from 50 to 70 percent, perhaps there are some patients who require more than standard of care. The focus of this report is to try and identify those clinical situations where advanced care technologies and approaches might be more appropriate. The report is supported by a large reference section and review of the literature.

Standard of care for venous ulcers has been addressed by several organizations, including the Wound Healing Society,[1] American Venous Forum,[2] investigators from the University of Pennsyvania,[3,4] British Association of Dermatology,[5] and the University of York/Manchester,[6] and numerous other individual authors and researchers.[7,8,9,10,11,12,13,14,15,16,17,18] These papers focus on accurate diagnosis, local wound care, infection control, and the application of compression therapy. The standard of care for venous disease implies following a "minimum" set of parameters and treatment regimens for all practitioners. Appropriate care as defined in this paper would address the specific needs of the patient and that which reasonably may be expected based on degree, skill, and experience of the profession or class to which the healthcare provider belongs. The following clinical examples are presented to clarify the point. An immunosuppressed patient may have an infection with a lower bioburden than the traditionally considered threshold. Some patients are physically unable to apply compression garments. Others may have mild to moderate arterial insufficiency, making compression contraindicated or necessitating the use of a modified compression technique. Some patients with venous ulcers suffer from hypercoagulable states and prior deep vein thrombosis. These patients require concomitant systemic anticoagulation therapy or medications, which improve the microcirculatory system. Variations in the specific form of compression therapy are needed for the nonambulatory patient versus the typical ambulatory outpatient-clinic patient. Some patients have recalcitrant wounds with clinical features (increased size, long duration) that transfer them into a very hard-to-heal category with long-time-to-healing courses. Is simple standard of care appropriate for these patients? When does standard of care become inappropriate care? At what point in time does referral to a wound specialist become a consideration and a necessity? Are there predictors of healing that can be used to help classify and differentiate these patients when additional care is needed? Numerous advanced care technologies for venous ulcers are available today. Growth factors, bioengineered tissues, surgical advances, thermal therapy, and systemic medications have all been evaluated for the treatment of venous ulcers. The most commonly used clinical guideline not yet mentioned is the personal guideline that each individual clinician has developed over time in his or her practice. These individual guidelines are experiential, anecdotal, and frequently not evidence based. Evidence-based guidelines, however, need to incorporate flexibility into their structure to allow for the introduction of new concepts and to improve clinician acceptance by simulating their current clinical reality.

This paper will attempt to review the pathogenesis of venous ulcers, describe diagnostic and classification schemes, and review treatment options keeping in mind the different concepts of standard care, appropriate care, and advanced care options.