The Ears of a Hippopotamus: Quality of Venous Leg Ulcer Care in Gauteng, South Africa

OBJECTIVE: To describe venous ulcer care and wound care practices in Gauteng, a province of South Africa, according to the Donabedian structure-process-outcome quality improvement model. METHODS: Forty-eight facilities were selected randomly from public and private wound care practices in Gauteng. Structured interviews were conducted with care providers via questionnaire to assess the structural aspects of the Donabedian model. Within these facilities, investigators randomly selected 160 patient files and extracted data using a checklist to assess processes implemented and outcomes reached for patients who had previously presented with lower-leg venous ulcers. RESULTS: Facilities lack the necessary equipment to perform vital assessments. Handheld Dopplers were available in 66% (n = 48) of the facilities. Sixty-one percent (n = 48) of the personnel at the facilities indicated that they had no formal wound care training. Although the majority of files (92%, n = 147) indicated that an assessment tool was used, many elements were not evaluated comprehensively according to the best available evidence. Aspects such as smoking, body mass index, and anemia were assessed in fewer than 30% of the patients. Distinguishing between superficial and deep infection and the accompanying overuse of antimicrobials and antibiotics were among the challenges identified. Further, 71% of patients received compression therapy, although the ankle-brachial pressure index of only 30% of patients was known. In 27 cases (17%), the outcome was amputation. CONCLUSIONS: From this survey, it is evident that not all clinicians providing wound care in Gauteng are adequately trained or fully implementing best practice guidelines, and the consequences are detrimental to patients, particularly in terms of amputation. This article highlights the need for improved legislation and regulation for practitioners who deliver wound care services.