M easuring, O rdering, F itting and A fter-Care for compression hosiery in the lower limb M-O-F-A
Learning objectives 1. To have a clear understanding of how to measure for compression garments correctly 2. To understand what is required to fill in a prescription form correctly when ordering garments 3. To be able to teach your patients/carers the correct application of the garment 4. To know what after-care is recommended for patients and garments alike
Understanding how to choose which type of compression to use (1) • Patient history • Differential diagnosis — venous, arterial, mixed aetiology? • Doppler signals / ABPI • Clinic protocols • British Lymphology Society (BLS) guidelines
Understanding how to choose which type of compression to use (2) • What are the individual patient/healthcare professional goals? • What pressures are likely to be needed to achieve these? • What stiffness is likely to be needed to achieve these? • What are the patient’s/carer’s circumstances and ability to apply what is required? • Remember your personal competences
Understanding compression — considerations • How are garments made to get the pressures and tensions they apply? • How do manufacturers test their garments to a recognised standard?
Circular-knit and Elastic flat-knit garments 1. Elastic circular knit / • Components to mesh consider are the 2. Elastic type and mix of circular knit / yarns, and the mesh with manufacturer’s inlay yarn weave of the garment/fabric 3. Flat-knit weave fabric and inlay yarn Inelastic
Pressures and tensions Circular- and flat-knit garments • The body yarn (A) of these together make up the ‘thickness’ and ‘stiffness’ of the product • The inlay yarn (B) is responsible for the compression pressure • Together, they give the total BODY YARN A prescription/overall ‘dose’ of what is INLAY YARN B required, e.g. compression and soft/stiff garment S.T.R.I.D.E. Supplement. JWC. 2019.
Compression level chart
Compression level chart
Compression level chart
Compression level chart
Manufacturer pressure testing • When a garment says it is between 20–30mmHg it is tested using apparatus known as a Dynamometer (generic name) • There are a number of these, common ones used are HATRA and HOSY machines • These are then translated into RAL/European/British/AFNOR, which we commonly hear referred to as test norms / standards • No one is better than the other, as it is a manufacturing test, not a ‘highest/best’ pressure test
M easuring O.F.A Know what you are measuring for…. Off-the-shelf or standard • Made-to-measure (M2M) — circular- or flat-knit • Consider the SHAPE of the limb • Remember: when choosing the style, e.g. below-knee or thigh-high, where possible always take the garment above the oedema/swelling Consider patient choice: open / closed toe / grip top etc
Measuring for standard size Circumference measurement positions: cG - Thigh (2cm below gluteal fold) cD - Narrowest point approx. 2– 3cm below the knee cC - Widest part of the calf cB - Ankle (narrowest point above ankle bone)
Measuring for made-to-measure Circumference measurements positions: cG - Thigh (2–5cm below gluteal fold) cF - Mid-thigh for circumference cD - Narrowest point approx. 2–3cm below the knee cC - Widest part of the calf cB - Ankle 2cm above malleolus for circumference cY – Around heel with foot dorsi-flexed
Decisions when measuring • What to do if someone fits into two or even three different sizes? • Which size do we choose?
Size decisions • 20–30mmHg compression garment • Ankle (cB) = 21cm • Size range is 21–26cm • Therefore, 20mmHg will be approximately exerted at the ankle However… • Ankle (cB) = 26cm • Therefore, 30mmHg will be approximately exerted at the ankle
Size decisions Below-knee garment example: • Patient has normal ankle (B) • Far end of calf spectrum (C) • Out of range on top measurement (D) • Consider wide calf option • Alternative is to measure for a circular-knit made-to-measure garment and don’t forget about length: • Length of limb (short/standard/long)
What next? • Once we have M easured and know what size, compression class and type of compression, i.e. circular- or flat-knit • We need to O rder them
M. O rdering .F.A This can be done in two ways: • Order direct from manufacturer/wholesaler — (DT price + VAT) o Individual orders o Stock holding of garments • Prescription FP10/GP10 — (VAT exempt = DT Price and no delivery charges)
Generating the prescription —what is needed?
Example stock item — circular-knit • Brand – ABC British Standard • Class – Class 2 (18-24) • Colour - Black • Style – Below knee, open toe • Size - Large • Quantity – 2 x pairs
Example stock item — prescription charges British Standard Hosiery charge by items in box 1 box = 2 x garments 2 charges (£18) 4 x Prescription charges (£36)
Example stock item — flat-knit • Brand – ABC M2M • Class – Class 3 (34-46) • Colour - Sand • Style – Below knee • Optional extras – 2 x closed toe, 2 x T- heel • Quantity – 2 x pairs
Example stock item — flat-knit Lymphoedema garments category • The garments ordered must be the same (stock and MTM) • Optional extras are part of the garment • Any charges (i.e. order two colours) would incur additional prescription charges • No limits on quantity = 1 x prescription charge for 2 lymphoedema MTM garments
Don’t forget the back • Ensure the back of the prescription is clearly completed and marked if the patient needs to pay for their prescription, or if they are exempt • If your patient is not exempt, the NHS Prescription Prepayment Certificate can save them money
Challenges in getting the garment • 57% of clinicians who experienced problems caused by garments (hosiery) had been supplied incorrectly 1 1. Survey results from 630 responses to a JCN/GPN in Sept 2018/Jan 2019
Challenges in getting the garment • 76% of clinicians estimated that they have issues with waiting time and delays 1 1. Survey results from 630 responses to a JCN/GPN in Sept 2018/Jan 2019
Dispensing option 1 Local pharmacy: • General dispenser for all FP10/GP10 prescription items • Normally link to GP surgeries • Patient can collect once the item(s) have arrived • Offer advice in different areas
Dispensing option 2 Specialist dispenser, i.e. dispensing appliance contractor (DAC): • Home delivery direct to any UK address or clinic • Knowledge/expert advice • Communication and a direct link to manufacturers • Understanding of compression and double checking of measurements • A wide choice of manufacturers • Knowledge of charges in this area
M.O. F itting. A • So, let’s imagine by now we have measured, ordered and received exactly what we asked for • We need to ensure that the patient can fit the compression garment and then apply it
Application aids
M.O.F. A fter-care • How to wash • How long to wear • When to re-order
Washing instructions Always follow the manufacturer’s guidelines which should be in the box or on the label
How long to wear • Patient and clinician goals • Throughout the day • 24 hours • Night-time compression
When to reorder How often should the hosiery be replaced? • Most manufacturers’ garments will last for a 100 washes • Two pairs should be prescribed at once — one to wear, one to wash • Both should be replaced after six months When should the hosiery be reordered? • Order before six months as they are OUT OF WARRANTY at six months • In this time, the manufacturer will replace the garment if defects appear. The manufacturer may ask for the garment to be returned before a replacement is issued
Summary —M.O.F.A Full vascular and differential • diagnosis Accurate M easuring • O rdering — writing of prescription • Reliable quick supply and service • F itting — patient/carer application, • i.e. do they need an aid A ftercare to self-care • Reminder — when do they need • their next assessment or garment?
Useful resources #TVN 2 gether
Daylong is your KEY to fast and accurate dispensing for ALL compression hosiery Daylong Call us on: 0800 195 0160 Email: prescriptions@daylong.co.uk or Visit: www.daylong.co.uk
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