Journal of Community Nursing

8 JCN 2020,Vol 34, No 4 W hat a time community nursing is having. While the recent focus has rightly been on acute services and coping with the Covid-19 outbreak, community nursing continues to deliver care to the vulnerable. The coronavirus comes on the back of austerity, lack of investment and a high vacancy rate in community nursing. Add working in isolation and additional sickness and it is likely that you know of colleagues that are on their knees. Leg ulcer management continues to be a significant part of any caseload, often mentioned as between 40–80% of daily activity. As caseloads are being reviewed and risk rated, we need to be careful that a decision to reduce visits or instigate self-care does not backfire, either for clinicians or patients. If we do not manage people with leg ulcers successfully, these patients will simply deteriorate and create pressure on another part of the system when they present with complications such as cellulitis or septicaemia. There are actions we can take to reduce activity even in these stretched times. Many tissue viability nurses (TVNs) have been redeployed into the community and the conversation now focuses on a new ability to support consistent care by directly delivering more therapeutic levels of compression. Frequently, we find that although a compression bandage is applied, it does not always equate to therapeutic compression delivery, and as such, is simply an inefficient use of nursing time (Hopkins, 2020). Community matters Why optimising therapeutic compression is essential This is a common sense, practical approach to compression, which if adopted by community nurses has the potential to dramatically improve healing rates for lower limb wounds. It is an approach that I personally use as a vascular nurse practitioner. However, it often meets with resistance from community nurses.To have the recommendation made by the National Wound Care Strategy Programme, who has accepted the British Lymphology Society (BLS) stance, that, in the absence of ‘red flags’, it is appropriate to start mild compression without an ABPI makes me want to cheer on behalf of our patients. I have had patients, who have had mild compression discontinued upon discharge into the community because of the lack of an ABPI, never mind that the patient was assessed by a vascular nurse, finds compression comfortable, and the wound is healing. The large limbs we routinely see need strong, stiff compression for effectiveness. Mild compression is not fit for purpose for these legs. Add in the complication of bulky dressings around the lower gaiter to mop the high exudate volume, and the distorted shape caused by making the lower gaiter wider than the calf as a result, and it becomes clear why the mild compression being applied every other day is not doing the trick. The use of a zinc paste or icthammol bandage under compression is normal practice within our department.While not providing compression, the stiffness of the bandage as it is pleated up the leg from toe to knee helps to reduce oedema.The zinc paste is particularly good for debriding wounds and soothing skin, while the icthammol is beneficial for venous eczema when used with a topical steroid. Even if just used with wool and crepe on frailer patients, the paste bandage can reduce oedema and enhance healing. I do feel slightly apprehensive that there may be a tendency to allow patients to languish in sub-optimal levels of compression, and it needs to be clear that full compression is usually the preferred option following holistic assessment. In the UK, we are compression adverse compared to our European colleagues, with a detrimental effect on healing. However, I think that may be about to change. Jane Todhunter Vascular nurse practitioner, North Cumbria University Hospitals In each issue we investigate a hot topic currently affecting you and your community practice. Here, Alison Hopkins MBE, chief executive, Accelerate, explores...