Measuring, Ordering, Fitting and After-Care for compression hosiery in the lower limb

M-O-F-A

Learning objectives1. 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 flat-knit garments

2. Elastic circular knit / mesh with inlay yarn

1. Elastic circular knit / mesh

3. Flat-knit weave fabric and inlay yarn

• Components to consider are the type and mix of yarns, and the manufacturer’s weave of the garment/fabric

Elastic

Inelastic

Pressures and tensionsCircular- 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 prescription/overall ‘dose’ of what is required, e.g. compression and soft/stiff garment

S.T.R.I.D.E. Supplement. JWC. 2019.

BODY YARN AINLAY YARN B

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

Measuring 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 measurementpositions:cG - Thigh (2cm below gluteal fold)cD - Narrowest point approx. 2–3cm below the kneecC - Widest part of the calfcB - Ankle (narrowest point above ankle bone)

Measuring formade-to-measure

Circumference measurementspositions:cG - Thigh (2–5cm below gluteal fold)cF - Mid-thigh for circumferencecD - Narrowest point approx. 2–3cm below the kneecC - Widest part of the calfcB - 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 decisionsBelow-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 Measured and know what size, compression

class and type of compression, i.e. circular- or flat-knit• We need to Order them

M.Ordering.F.A

This can be done in two ways:• Order direct from manufacturer/wholesaler — (DT price + VAT)

o Individual orderso 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 chargesBritish 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-knitLymphoedema 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 for2 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 incorrectly1

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 delays1

1. Survey results from 630 responses to a JCN/GPN in Sept 2018/Jan 2019

Dispensing option 1Local 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 2Specialist 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.Fitting.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.After-care• How to wash• How long to wear• When to re-order

Washing instructionsAlways 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 reorderHow 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 Measuring• Ordering — writing of prescription• Reliable quick supply and service• Fitting — patient/carer application,

i.e. do they need an aid• Aftercare to self-care• Reminder — when do they need

their next assessment or garment?

Useful resources

#TVN2gether

DaylongDaylong is your KEY to fast and accurate

dispensing for ALL compression hosiery

Call us on: 0800 195 0160Email: prescriptions@daylong.co.ukor Visit: www.daylong.co.uk

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