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Phillip A Morgan, PhD, RGN, is research fellow and director of the Lymphoedema Framework Project, Centre for Research and Implementation of Clinical Practice, Thames Valley University, London; Christine J Moffatt, PhD, MA, DN, RN, is professor of nursing and co-director, Centre for Research and Implementation of Clinical Practice, Thames Valley University, LondonAn international consensus document of best practice for the management of lymphoedema was launched at the annual conference of the British Lymphology Society (BLS) in October. The development of this document has been driven by the Lymphoedema Framework Project (LFP) and aims to raise the profile of the condition and improve the care that people with lymphoedema receive by defining and describing best practice in a practical and accessible way.
An international consensus document of best practice for the management of lymphoedema was launched at the annual conference of the British Lymphology Society (BLS) in October. The development of this document has been driven by the Lymphoedema Framework Project (LFP) and aims to raise the profile of the condition and improve the care that people with lymphoedema receive by defining and describing best practice in a practical and accessible way.
A strategy for change
The LFP is a national initiative that originated from an epidemiology study, undertaken in south-west London in 2002, which identified that lymphoedema is under-recognised, under-treated and under-resourced (Moffatt et al, 2003). In response to these findings, the mains aims of the project are to provide evidence that lymphoedema is a major health problem and to secure its place as a priority on the health-service agenda.
To achieve this aim, the project focuses on a shift of services from mainly hospital and hospice care to community care provision by supporting the development and evaluation of specialist-led, integrated primary care based lymphoedema services. The development of the integrated service is informed by a set of national standards and the best practice document which, together, provide guidance to ensure early recognition, appropriate treatment, ongoing care and access
to specialist services, regardless of the cause of
The best practice document is the product of a partnership approach and a rigorous process of consensus. The principle of active partnership is a key feature of the LFP and has been essential to enable the different stakeholder groups, both national and international, to be represented in achieving consensus about a range of key issues relating to the management of lymphoedema.
The partnership is led by the Centre for Research and Implementation of Clinical Practice at Thames Valley University, London and includes the Lymphoedema Support Network, the British Lymphology Society, participating PCTs and the wound care and compression industry. In addition, endorsement by key national lymphoedema organisations from around the world, as well as an advisory board comprising members from Australia, Canada, Europe, India, Japan, the USA and the UK, has provided an invaluable international perspective.
A consensus approach
Systematic reviews conducted by Badger et al (2004a; 2004b; 2003) demonstrated a lack of traditional empirical evidence, in the form of randomised controlled trials, to support much of what is done in key areas of lymphoedema management. In other areas of healthcare where this is also the case, it is generally recommended that alternative ways are found to develop guidance for practice that make use of alternative sources of evidence such as expert opinion and consensus (Kane et al, 2003; Rycroft-Malone, 2001).
The consensus approach used for the initial development of the best practice document was based on the health technology assessment (HTA) model (Murphy et al, 1998). This is a rigorous process that enables the use of a number of methods to gather opinion and promote discussion from as wide a range of contributors as possible. The aim was to achieve a balance between the research evidence that does exist
and the collective knowledge and expertise of those contributing.
The methodology adopted in the development of the best practice document included a number of stages culminating in an electronic appraisal in which all items for inclusion in the document were rated by a web-based system using a four-point Likert scale. By using this scale, a contributor could record that they strongly agreed, agreed, disagreed or strongly disagreed with each proposed item. To achieve inclusion in the document, each item had to score a level of agreement of at least 95%.
The final stage of the consensus process was the review of the document as a whole by an international advisory board of lymphoedema experts. This was a vitally important element because the international perspective has not only extended the document's scope and relevance but also enriched its content.
A practical document
The aim of the document is to support best practice in lymphoedema management. It is a practical document in which is embedded the essential requirements for the effective development of an integrated lymphoedema service (Box 1). Its content is relevant for all practitioners involved in the care and management of people with lymphoedema of all causes, both specialists and generalists. It is a document that is aspirational in philosophy rather than prescriptive. It sets a standard which all involved in lymphoedema care and management are striving to achieve, both in terms of individual professional practice as well as in service delivery.
The document covers key areas of management including the identification of the patient at risk, assessment and treatment decisions. Other areas include skin care and the management of cellulitis, lymphatic massage, lymphoedema bandaging, the use of compression garments, exercise and movement, psychosocial care, palliative care and surgery. There is also a section on other treatments such as drug treatments, breathing exercises, lymphoedema taping, hyperbaric oxygen and laser therapy. The text in each section is supported with photographs, simple diagrams, algorithms and flow charts. This document is designed to be useful on a day-to-day basis to all who are involved in the care of people with lymphoedema.
The document Best Practice for the Management of Lymphoedema: International Consensus is important for a number of reasons. It is the result of national and internationalconsensus which inevitably gives the content credibility. Endorsed by lymphology societies from around the world, it provides a sense of collaboration in the struggle to improve the care of people with lymphoedema, regardless of the cause and wherever they may be. Finally, the guidance provided is of real practical use to all those involved in lymphoedema and all those who strive to improve the care and, ultimately, the quality of life of people with this debilitating condition.
Box 1. Standards of practice for lymphoedema services
Standard 1: Identification of people at risk of or with lymphoedema
Standard 2: Empowerment of people at risk of or with lymphoedema
Standard 3: Provision of lymphoedema services that deliver high quality clinical care that is subject to continuous improvement and integrates community, hospital and hospice-based services
Standard 4: Provision of high-quality clinical care for people with cellulites/erysipelas (superficial bacterial skin infection that characteristically extends into the cutaneous lymphatics).
Standard 5: Provision of compression garments for people with lymphoedema
Standard 6: Provision of multi-agency health and social services
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Badger, C. et al (2004a)Antibiotics/Anti-inflammatories for Reducing Acute Inflammatory Episodes in Lymphoedema of the Limbs. (Cochrane Review.) Cochrane Database of Systematic Reviews; 2: CD003143.