EWMA Journal January 2010

Volume 10 Number 1 January 2010 Published by European Wound Management Association

ATIONS NIS GA

ON TH S U C E O F

MENT O AGE R AN

OUND W S S I M W S

The EWMA Journal ISSN number: 1609-2759 Volume 10, No 1, January, 2010

EWMA Council

Electronic Supplement January 2010: www.ewma.org

Zena Moore

Marco Romanelli

President

Immediate Past President

The Journal of the European Wound Management Association Published three times a year Editorial Board Carol Dealey, Editor Deborah Hofman, Editor Electronic Supplement Finn Gottrup Zena Moore Marco Romanelli Zbigniew Rybak José Verdú Soriano Rita Gaspar Videira Peter Vowden

EWMA web site www.ewma.org

Editorial Office please contact: EWMA Secretariat Martensens Allé 8 1828 Frederiksberg C, Denmark.

Tel: (+45) 7020 0305 Fax: (+45) 7020 0315 ewma@ewma.org

Paulo Alves

Sue Bale

Luc Gryson

Patricia Price

Recorder

Treasurer

Honorary Secretary

Carol Dealey

Corrado M. Durante

Marcus Gürgen

Severin Läuchli

Maarten J. Lubbers

Jan Apelqvist

EWMA Journal Editor

Eskild Winther Henneberg

Gerrolt Jukema

Martin Koschnick

Layout: Birgitte Clematide Printed by: Kailow Graphic A/S, Denmark Copies printed: 13,000 Prices: Distributed free of charge to members of the European Wound Management Association and members of co-operating associations.

Individual subscription per issue: 7.50€ Libraries and institutions per issue: 25€ The next issue will be published in May 2010. Prospective material for publication must be with the editors as soon as possible and no later than 15 February 2010 The contents of articles and letters in EWMA Journal do not necessarily reflect the opinions of the Editors or the European WoundManagement Association.

Copyright of all published material and illustrations is the property of the European Wound Management Association. However, provided prior written consent for their reproduction obtained from both the Author and EWMA via the Editorial Board of the Journal, and proper acknowledgement and printed, such permission will normally be readily granted.

Requests to reproduce material should state where material is to be published, and, if it is abstracted, summarised, or abbreviated, then the proposed new text should be sent to the EWMA Journal Editor for final approval.

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Sylvie Meaume

Rytis Rimdeika

José Verdú Soriano

Rita Videira

CO-OPERATING ORGANISATIONS’ BOARD Jasmina Begić-Rahić, URuBiH Andrea Bellingeri, AISLeC Barbara Esther den Boogert-Ruimschotel, V&VN Saša Borović, SWHS Rosine van den Bulck, AFISCeP.be Michael Clark, TVS Mark Collier, LUF Rodica Crutescu, ROWMA Louk van Doorn, NOVW Bülent Erdogan, WMAT Milada Francu, CSLR Kiro Georgievski, MWMA Georgina Gethin, WMAOI Finn Gottrup, DSFS

Editorial Board Members Carol Dealey, UK (Editor) Finn Gottrup, Denmark Deborah Hofman, UK Zena Moore, Ireland Marco Romanelli, Italy Zbigniew Rybak, Poland José Verdú Soriano, Spain Rita Gaspar Videira, Portugal Peter Vowden, UK

João Gouveia, GAIF Luc Gryson, BFW Marcus Gürgen, NIFS Mária Hok, SEBINKO Gabriela Hösl, AWA Dubravko Huljev, CWA Hunyadi János, MST Arkadiusz Jawień, PWMA Els Jonckheere, CNC Aníbal Justiniano, APTFeridas Susan Knight, LUF Martin Koschnick, DGfW Jozefa Koskova, SSOOR Aleksandra Kuspelo, LBAA

EWMA Journal Scientific Review Panel Paulo Jorge Pereira Alves, Portugal Caroline Amery, UK Sue Bale, UK Michelle Briggs, UK Mark Collier, UK Bulent Erdogan, Turkey Madeleine Flanagan, UK Milada Franců, Czech Republic Peter Franks, UK Francisco P. García-Fernández, Spain Luc Gryson, Belgium Alison Hopkins, UK

For contact information, see www.ewma.org

Goran D. Lazovic, SAWMA Christina Lindholm, SSIS Magnus Löndahl, SWHS Sandi Luft, WMAS Kestutis Maslauskas, LWMA Sylvie Meaume, SFFPC Karl-Christian Münter, ICW Guðbjörg Pálsdóttir, SUMS Alessandro Scalise, AIUC Salla Seppänen, FWCS José Verdú Soriano, GNEAUPP Corinne Ward, MADWN Anne Wilson, NATVNS Carolyn Wyndham-White, SAfW Skender Zatriqi, WMAK

Gabriela Hösl, Austria Zoltán Kökény, Hungary Zena Moore, Ireland Karl-Christian Münter, Germany Andrea Nelson, UK Pedro L. Pancorbo-Hidalgo, Spain Hugo Partsch, Austria Patricia Price, UK Rytis Rimdeika, Lithuania Salla Seppänen, Finland Carolyn Wyndham-White, Switzerland Gerald Zöch, Austria

Guest Editorial by Professor Finn Gottrup

Dear Readers Science, Practice and Education 5 Systematic review of Repositioning for the Treatment of Pressure Ulcers Zena Moore, Seamus Cowman

14 Analysis of wound care in nursing care homes as part of a district-wide wound care audit Peter Vowden, Kathryn Vowden

19 Chronic leg ulcers among the Icelandic population Guðbjörg Pálsdóttir, Ásta Thoroddsen

24 Cross-sectional Survey of the Occurrence of Chronic Wounds within Capital Region in Finland Anita Mäkelä

EBWM 28 Abstracts of recent Cochrane Reviews Sally Bell-Syer

EWMA 30 EWMA Journal Previous Issues and International Journals 32 20th Conference of the European Wound Management Association, 26-28 May 2010 Geneva, Switzerland – Get The Timing Right 36 Introducing the Swiss Association for Wound Care Severin Läuchli, Hubert Vuagnat

38 The EWMA Teach the Teacher Project Zena Moore

40 EWMA Activities Update 44 Corporate Sponsor Contact Data

Conferences 48 Conference Calendar 51 12th European Pressure Ulcer Advisory Panel Meeting Jacqui Fletcher

53 Recap from the EWMA-Eucomed AWCS Wound in Brussels 6 October 2009 Zena Moore

Organisations 54 DEBRA International – an International Partner Organisation of EWMA 55 SUMS 5 Years Anniversary, 25 September 2009 Finn Gottrup

56 Report from the third PWMA Congress, Bydgoszcz, Poland Arkadiusz Jawien, Maria T. Szewczyk

58 WAWLC John M Macdonald

60 GIWLC – Uganda Site Visit 61 SCALE – Final Consensus Statement on Skin Changes At Life’s End 62 Cooperating Organisations 63 Associated Organisations 63 International Partner Organisations

Classification and Terms for Non-healing Wounds To initiate an optimal wound treatment it is normally claimed that it is necessary to know the patient’s type of wound. This could typically be termed as chronic wound, diabetic wound, leg ulcer, pressure ulcer etc.

Most people working in the field of wounds know these terms, but do they really know how they are defined?

The majority would say yes, because the classification of wound types seems simple. The truth is, however, that there has never been a national or international consensus about wound classification. The important question then is: Do we really need to know the exact type of wound of the patient? The answer is yes, because optimal recommendations, guidelines and clinical trials cannot be established if we do not know what the single terms of each wound type stand for. It is not possible to produce the best treatment guidelines or comparable groups in an RCT, if the target wound is not clearly described or defined.

Thus, from the author’s point of view, the problem can be divided into two elements: 1. Is it possible to find a single term to cover all types for a non-healing wound? and 2. How can the different types of non-healing wounds be subdivided into well defined groups usable in clinical practice?

Single term for all types of non-healing wounds: Several words have been suggested: Chronic, difficult, complicated, complex, problem etc.

No general agreement has been achieved, but recently the focus has been on the following terms: Complex wound, which has been suggested by some Spanish-speaking countries1 and Problem wounds, which has been suggested by the author2.

Subdividing of wound types: It has been suggested that subgroups be established related to aspects of the wounds: Time or period of having a wound (acute – chronic), Background disease of the patient (Diabetes Mellitus, cancer, AIDS etc.), Morphology of the wound (black, yellow, red), Surgical procedures related to the wound (primary, secondary or delayed closing etc.) and finally to Aetiological background (related to vessels, trauma, pressure, infectious, etc.). None of these subdivisions are ideal, because they are not totally exact in relation to definition and treatment. From the author’s point of view the subdivision based on aetiological background is the most practical to use clinically3: The definition of wounds types can be related to: Vascular Reasons (Arterial, Venous, Lymphatic), Trauma, Surgery (Clean, Contaminated, Infected), Pressure/Friction, Diseases (Diabetes, Cancer, Immune/Metabol., Others), Infectious (Specific types: AIDS, Leprosy, Syphilis, TB etc), Self Mutilation, and Other Reasons.

This editorial has focused on the problem not having a single term for non-healing wounds and an accepted wound classification. In order to get an international consensus in these areas the author suggests establishing a working group focussing on these important wound topics. EWMA could be an ideal organisation to initiate such a working group.

Finn Gottrup, MD, DMSci., Professor of Surgery References: 1. Ferreira MC, et al. Complex wounds. Clinics 2006; 61: 571-8.

2. Gottrup F et al. A new concept of a multidisciplinary wound healing center and national export function of wound healing. Arch Surg 2001; 136: 765-72

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3. Gottrup F, Karlsmark T. Wounds – Background, Diagnosis and Treatment.

2nd. Edition. 2008, Munksgaard, Copenhagen

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Question: After treating the same wound for 7.5 years, what eventually healed it?

Answer: PROMOGRAN* in just 6 weeks.

MMPs, Elastase, and wound surface area, in a 7.5 year old wound(1) 100

MMPs Activity Elastase Activity Wound Area

80

After 7.5 YEARS of treatment WITHOUT Promogran*

After 6 WEEKS of treatment WITH Promogran*

If you think PROMOGRAN might bring the same quality of life back to your patients, heal more wounds faster(2,3,4,5), and cost-effectively(3,5,6), we are just an e-mail away:

% Reduction

60 40 20 0

0

1

2

3

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Time from initial treatment (weeks)

SYS/GBI/008/1209

Send it to: i-want-a-rep@systagenix.com Quote on subject: PROMOGRAN References: 1. Cullen, B., Boyle, C., Webb, Y. Modulation of the chronic wound environment; an in vitro evaluation of advanced wound therapies. SAWC, Tampa FL, 2007. 2. Nisi G et al.

Use of protease-modulating matrix in the treatment of pressure sores. Chir Ital 2005;57:465-8 4. Vin F et all. The healing properties of PROMOGRAN* in venous leg ulcers, J Wound Care 2002;11:335-41 5. 3. Veves A et al. A randomized , controlled trial of PROMOGRAN* (a collagen/oxidised regenerated cellulose dressing) vs standard treatments in the management of diabetic foot ulcers. Arch Surg 2002;137:822-827 4. Lazaro-Martinez et all. Estudio aleatorizado y comparativo de un apósito de colágeno y celulosa oxidada regenerada en el tratamiento de úlceras neuropáticas de pie diabético. Cir Esp. 2007;82(1):27-31 5. Ghatenekar O. Willis. M. Persson U. Health Economics. ‘Cost effectiveness of treating deep diabetic foot ulcers with PROMOGRAN* in four European countries’. J Wound Care, Vol 11, No2. Feb 2002. 6. Snyder. Sequential therapies and advanced wound care products as a standard practice in the home care setting. Home health abstract for SAWC, San Diego, April 2008 (presentation at the J&J satellite symposium)

www.systagenix.com

Science, Practice and Education

Systematic review of Repositioning for the Treatment of Pressure Ulcers ABSTRACT

Background: Pressure, from lying or sitting on a particular part of the body, results in oxygen deprivation to the affected area. If a patient with an existing pressure ulcer continues to lie or bear weight on the affected area, the tissues become depleted of blood flow and there is no oxygen or nutrient supply to the wound, and no removal of waste products from the wound, all of which are necessary for healing. Patients who cannot reposition themselves require assistance. International best practice advocates the use of repositioning as an integral component of a pressure ulcer management strategy. This review has been conducted to clarify the role of repositioning in the management of patients with pressure ulcers.

Objectives: The objective was to assess the effects of repositioning patients on the healing rates of pressure ulcers.

Search strategy: We searched the following databases: the Cochrane Wounds Group Specialised Register (5 December 2008); the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 4); Ovid MEDLINE (1950 to November Week 3 2008); Ovid EMBASE (1980 to 2008 Week 49); and EBSCO CINAHL (1982 to November Week 4 2008).

Selection criteria: We considered randomised controlled trials (RCTs) comparing repositioning with no repositioning, or RCTs comparing different repositioning techniques, or RCTs comparing different repositioning frequencies for the review.

Controlled clinical trials (CCTs) were only to be considered in the absence of RCTs. Data collection and analysis: Two authors independently assessed titles and, where available, abstracts of the studies identified by the search strategy for their eligibility. We obtained full versions of potentially relevant studies and two authors independently screened these against the inclusion criteria.

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Main results: We identified no studies that met the inclusion criteria.

Conclusion: Despite the widespread use of repositioning as a component of the management plan for individuals with existing pressure ulcers, no randomised trials exist that assess the effects of repositioning patients on the healing rates of pressure ulcers. Therefore, we cannot conclude whether repositioning patients improves the healing rates of pressure ulcers. Thus, the effect of repositioning on pressure ulcer healing needs to be evaluated.

INTRODUCTION Description of the condition Pressure ulcers (also known as bed sores, pressure sores and decubitus ulcers) are localised areas of tissue damage, caused by excess pressure, shearing or friction forces (Nixon, Smye et al. 1999), that occur in people who do not have the ability to reposition themselves in order to relieve pressure (Cullum, Deeks et al. 1995). Those most at risk are the very old, the malnourished and those with acute illness (Lindgren, Unosson et al. 2004). Approximately 18% of hospitalised patients have a pressure ulcer (EPUAP 2002) and although some of these may be present on admission, most occur during hospitalisation for acute illness (Baumgarten, Margolis et al. 2003).The proportion of people that develop an ulcer ranges from 2.2% to 66% in the UK, and from 0% to 65.6% in the USA and Canada (Kaltenthaler, Whitfield et al.

2001). These figures are influenced by the location and condition of the patient group (hospital versus community setting, general hospital patients versus those with fractured neck of femur), with the highest incidence noted among elderly orthopaedic patients (Richardson and Meyer 1981; Versluysen 1986; Hanson, Langemo et al.

1993; Bridel, Banks et al. 1996). Interestingly, a

Dr. Zena Moore PhD, MSc, FFNMRCSI, PG Dip, Dip Management, RGN Lecturer in Wound Healing & Tissue Repair and Research Methodology, Faculty of Nursing & Midwifery, RCSI, 123 St Stephen’s Green, Dublin 2, Ireland zmoore@rcsi.ie Professor Seamus Cowman PhD, MSc, FFNMRCSI, PG Cert Ed (Adults), Dip N (London), RNT, RGN, RPN Head of Department Royal College of Surgeons in Ireland St Stephens Green, Dublin 2 scowman@rcsi.ie www.rcsi.ie Conflict of interest: none.

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review of data from a six-year national incidence study in the USA found that the annual incidences in 1999 and 2004 were 8% and 7% respectively; demonstrating little change in overall figures (Whittington and Briones 2004).

Pressure ulcers have a negative impact on quality of life; it is known that individuals with pressure ulcers frequently experience pain combined with fear, isolation and anxiety regarding wound healing (Fox 2002; Hopkins, Dealey et al. 2006). Importantly, it has also been argued that pressure ulcers contribute to increased mortality (Allman 1997).

One study identified that the risk of dying was three times greater for elderly patients with a pressure ulcer, than for those without a pressure ulcer, although this increase in mortality is probably due to co-morbidities that contribute to the development of the pressure ulcer, rather than the ulcer itself (Berlowitz and Wilking 1990).

Pressure ulcers are a significant financial burden to healthcare systems. Bennett et al suggested that the total annual cost for pressure ulcer management in the UK is £1.4 to £2.1 billion, which at that time was equivalent to 4% of the total UK healthcare expenditure (Bennett, Dealey et al. 2004). Similar findings have been noted in the Netherlands, where pressure ulcers have been found to be the third most expensive health problem (Haalboom 2000). It has been suggested that hospital stays are two to three times greater for those with a pressure ulcer, than for similar cases without one (30.4 days compared to 12.8 days) (Allman 1997). Globally, the exact economic impact of pressure ulcers has yet to be established, however it is known that pressure ulcers are common (EPUAP 2002) and affect patients in both community (Margolis, Bilker et al. 2002) and hospital settings (Clark 1994).

Although individuals of any age can develop pressure ulcers, they are more common in patient groups such as the elderly (Whittington and Briones 2004) and those in orthopaedic settings (Versluysen 1986), though other medical conditions can predispose individuals to their development (Schoonhoven, Defloor et al. 2002). Changing demographics, and the rise in the number of elderly in the future, mean that the number of pressure ulcers is likely to increase in the years ahead. Therefore, it is reasonable to expect that treatment strategies that reduce the impact of pressure ulcers will have a positive impact on patients and the health service as a whole (Thompson and Brooks 1999).

Description of the intervention Wound healing is a normal response to injury. It is initiated after the skin’s integrity has been interrupted, for example, by the development of a pressure ulcer (Martin

1997). The purpose of the healing process is to replace the tissue that has been damaged, with living tissue, and to restore the continuity of the skin (Tarnuzzer and Schultz 1996). Open wounds, including pressure heal through formation of granulation tissue and epithelialisation (Slavin 1996). Granulation tissue is characterised by a high density of blood vessels, capillaries and many different cells, so the metabolic need of the wounded area is great (Krishnamoorthy, Morris et al. 2001). Normal cellular metabolism requires an adequate supply of oxygen and nutrients, and also an effective elimination of waste metabolites (Kosiak 1966). Sustained unrelieved pressure causes vascular obstruction that eliminates capillary blood flow to an area (Kosiak 1959), causing oxygen and nutrient deprivation there (Husain 1953). Since the cells necessary for wound healing cannot proliferate in such an environment, wound healing is impaired (Kosiak 1966). Certain positioning techniques, for example, 90-degree lateral rotation, which is used during bed rest, may exacerbate this situation and cause complete anoxia (lack of oxygen) to the weightbearing area (Seiler, Allen et al. 1986; Colin, Abraham et al. 1996; Sachse, Fink et al. 1998). Since it is possible that a patient may be positioned directly onto a pressure ulcer, especially when multiple ulcers are present, the impact that this may have on wound healing is an important consideration.

The management of patients with pressure ulcers involves numerous different interventions including nutritional care (European Pressure Ulcer Advisory Panel 2003; Langer, Schloemer et al. 2003), pressure reducing/relieving surfaces (Clark and Cullum 1992; McInnes 2004; McInnes, Bell-Syer et al. 2008), and skin and wound care(Bergstrom, Allman et al. 1994; Flanagan 1998; Moore and Cowman 2005). Repositioning patients is also an important component in the management of pressure ulcers (NICE 2005).

Pressure, from lying or sitting on a particular part of the body, results in oxygen deprivation to the affected area (Defloor, De Bacquer et al. 2005). This normally results in pain and discomfort which stimulates the individual to move. Failure to reposition will result in ongoing oxygen deprivation; poor wound healing and further tissue damage (Defloor, De Bacquer et al. 2005).

Patients who cannot reposition themselves require assistance. International best practice advocates the use of repositioning as an integral component of a pressure ulcer management strategy. Although repositioning is advocated, confusion exists about the frequency and exact method of repositioning required: the Agency for Health Care Policy and Research, USA advocates two-hourly repositioning (AHCPR 1992), whereas the European Pressure Ulcer Advisory Panel and the National Institute for 䊳

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Poster Presentation. Clinical Symposium on Advances in Skin & Wound Care October 2008. Las Vegas, NV, USA 2. Stenius M. Fast Healing of Pressure Ulcers in Spinal Cord Injured (SCI) People Through the Use of PolyMem® Dressings. Poster Presentation. EWMA May 2008. Lisbon, Portugal.

3. Tamir J, Haik J. Polymeric Membrane Dressings for Skin Graft Donor Sites: 4 Years Experience on 800 Cases.

Poster Presentation. Clinical Symposium on Advances in Skin & Wound Care October 2008. Las Vegas, NV, USA

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Clinical Excellence, UK advocate repositioning as required by the individual patient (EPUAP 1999; NICE 2005).

This lack of unity necessitated a systematic review of the literature to summarise the current evidence. The review may provide a contribution to relevant clinical guidelines.

In addition, the review informs research in this important area of patient care.

Secondary outcomes The secondary outcomes of interest were: procedural pain; assessment of quality of life (using validated scales, where reported); ease of use of the method of repositioning; adverse events such as falls, length of hospital stay or death.

We planned to report secondary outcomes only from studies that also reported the primary outcomes.

OBJECTIVES The objective of this review was to assess the effects of repositioning patients on the healing rates of pressure ulcers.

Search methods for identification of studies A full outline of the search strategy is available from the Cochrane library (http://www.mrw.interscience.wiley. com/cochrane/clsysrev/articles/CD006898/frame.html)

METHODS Criteria for considering studies for this review Types of studies We considered randomised controlled trials (RCTs) comparing repositioning with no repositioning, or RCTs comparing different repositioning techniques, or RCTs comparing different repositioning frequencies for the review. Controlled clinical trials (CCTs) were only to be considered in the absence of RCTs. Types of participants We considered studies involving people of any age, in any healthcare setting, with existing pressure ulcers (defined as a break in the continuity of the skin caused by pressure, shearing or friction forces (Nixon, Smye et al. 1999).

Types of interventions Studies describing the following comparisons were eligible for the review.

1. Repositioning compared with no repositioning.

2. Comparisons between different frequencies of repositioning.

3. Comparisons between different positions for repositioning (e.g. 90-degree lateral rotation, 30-degree tilt).

Types of outcome measures Primary outcomes We considered trials if they reported at least one of the primary outcomes. The primary outcomes were objective measures of pressure ulcer healing and included: time to complete healing; absolute or percentage change in pressure ulcer area or volume over time; proportion of pressure ulcers healed at the completion of the trial period; or healing rate.

Data collection and analysis Selection of studies Two authors independently assessed titles and, where available, abstracts of the studies identified by the search strategy for their eligibility for inclusion in the review.

We obtained full versions of potentially relevant studies and two authors independently screened these against the inclusion criteria. We resolved any differences in opinion by discussion.

Data extraction and management We planned to extract and summarise details of eligible studies using a data extraction sheet. For a full outline of this planned process see the Cochrane Library. Two authors were to extract data independently; any differences in opinion was to be resolved by discussion and, where necessary, reference to the Wounds Group editorial base. If data were missing from reports, we intended to make attempts to contact authors to obtain the missing information.

Assessment of risk of bias in included studies The quality of studies was to be assessed independently by two authors, without blinding to journal or authorship, using the Cochrane Collaboration tool for assessing risk of bias (Higgins and Altman 2008). We planned to present assessment of risk of bias using a ‘Risk of bias’ summary figure, which presents all of the judgments in a cross-tabulation of study by entry. This display of internal validity indicates the weight the reader may give the results of each study.

Assessment of heterogeneity We planned to explore clinical heterogeneity by examining potentially influential factors, e.g. care setting or patient characteristics. Statistical heterogeneity was to be assessed using the I² statistic (Higgins and Altman 2008). This examines the percentage of total variation across studies due to heterogeneity rather than chance. Values of I² over 75% indicate a high level of heterogeneity. If there were 䊳

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sufficiently similar studies to consider pooling, we planned to use a fixed-effect model for low to moderate levels of heterogeneity (I2 0% to 50%). If there was evidence of heterogeneity (values of I² over 50%) we planned to use a random-effects model. If pooling was not appropriate, we planned to present the studies in a narrative summary only. Results were to be presented by care setting and patient group.

Data synthesis We planned to conduct a structured narrative summary of the studies reviewed initially. For dichotomous outcomes, we were to calculate relative risk (RR) plus 95% confidence interval (CI). For continuous outcomes, we were to calculate weighted mean difference (WMD) plus 95% CI. Sensitivity analysis We planned to include all eligible trials in the initial analysis and to carry out sensitivity analyses to evaluate the effect of trial quality. This was to be done by excluding trials most susceptible to bias based on the quality assessment: those with inadequate allocation concealment, high levels of post randomisation losses or exclusions, and uncertain or unblinded outcome assessment.

RESULTS Description of studies The initial search identified 91 titles. Following independent review of the titles and abstracts of the citations by two review authors, no papers met the inclusion criteria. Nor did any papers appear to potentially meet the inclusion criteria and therefore there were no studies added to the Table of Excluded studies. We wrote 55 letters to wound care experts; 12 replies were received, yielding a response rate of 21%. We identified no further trials through this process. No studies, RCTs or CCTs, met the inclusion criteria.

References Agency for Health Care Policy and Research (1992). Clinical practice guideline number 3. P. H. Service. Rockville MD, Department of Health and Human Services USA. Allman, R. M. (1997). “Pressure ulcer prevalence, incidence, risk factors and impact.” Clinical Geriatric Medicine 13: 421-6.

Baumgarten, M., D. Margolis, et al. (2003). “Risk factors for pressure ulcers among elderly hip fracture patients.”

Wound Repair and Regeneration 11: 96-103.

Bennett, G., C. Dealey, et al. (2004). “The cost of pressure ulcers in the UK.” Age and Ageing 33(3): 230-5.

Bergstrom, N., R. Allman, et al. (1994). Ulcer Care Treatment of pressure ulcers Clinical Practice Guideline 15.

P. H. Service. Rockville MD, Department of Health and Human Services USA: 45-57.

Berlowitz, D. R. and S. V. Wilking (1990). “The short-term outcome of pressure sores.” Journal of the American Geriatric Society 37(7): 748-52.

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Risk of bias in included studies We identified no eligible studies (RCTs or CCTs).

Effects of interventions We identified no eligible studies (RCTs or CCTs).

DISCUSSION We identified no eligible studies despite our having made every attempt to identify all relevant studies, including contacting experts in this field and searching conference proceedings to identify studies as yet unpublished. It is theoretically possible, though unlikely, that we did not manage to locate some potentially eligible studies. In line with Cochrane policy, future updates of this review will be undertaken and any studies identified at that stage which meet the inclusion criteria will be included. In order to maintain health, tissues require an adequate supply of oxygen and nutrients (Gottrup 2004). Pressure from lying or sitting on a particular part of the body results in oxygen deprivation to the affected area (Defloor, De Bacquer et al. 2005). There are normally a number of stimulators, during sleep and whilst awake, that motivate the individual to move (Krapfl and Gray 2008). Failure to reposition will result in ongoing oxygen deprivation and inevitable tissue damage (Defloor, De Bacquer et al. 2005), because of ongoing occlusion of blood supply to the affected area (Husain 1953).

Repositioning is advocated as one of the interventions needed for the management of pressure ulcers and involves moving the individual into a different position in order to remove or redistribute pressure from a particular part of the body (Krapfl and Gray 2008). The two concerns are firstly, the individual’s ability to feel pain, and secondly, the individual’s actual physical ability to move or to reposition themselves (Defloor, De Bacquer et al. 2005). In the absence of the patient having the ability to reposition, they require assistance.

Bridel, J., S. Banks, et al. (1996). The admission prevalence and hospital-acquired incidence of pressure sores within a large teaching hospital during April 1994 to March 1995. 5th European Conference on Advances in Wound Management., Macmillan.

Clark, M. (1994). The financial cost of pressure ulcers to the UK National Health Service. 4th European Conference on Advances in Wound Management, Copenhagen, Macmillan Magazines.

Clark, M. and N. Cullum (1992). “Matching patient need for pressure sore prevention with the supply of pressure redistributing mattresses.” Journal of Advanced Nursing 17(3): 310-316.

Colin, D., P. Abraham, et al. (1996). “Comparison of 90 degree and 30 degree laterally inclined positions in the prevention of pressure ulcers using transcutaneous oxygen and carbon dioxide pressures.” Advances in Wound Care 9(3): 35-8.

Cullum, N., J. Deeks, et al. (1995). “The prevention and treatment of pressure sores.” Effective Health Care Bulletin 2(1): 1-16.

Defloor, T., D. De Bacquer, et al. (2005). “The effect of various combinations of turning and pressure reducing devices on the incidence of pressure ulcers.” International Journal of Nursing Studies 42(1): 37-46.

Donner, A. and N. Klar (2004). “Pitfalls of and controversies in cluster randomisation trials.” American Journal of Public Health 94(3): 416-22.

European Pressure Advisory Panel (1999). “Guidelines on treatment of pressure ulcers.” EPUAP Review 2: 31-3.

European Pressure Ulcer Advisory Panel (2002). “Summary report on the prevalence of pressure ulcers.” EPUAP Review 4(2): 49-57.

European Pressure Ulcer Advisory Panel (2003). “EPUAP guidelines on the role of nutrition in pressure ulcer prevention and management.” EPUAP Review 5(2): 50-63.

Flanagan, M. (1998). Managing wounds. Access to Clinical Education; Wound Management. London, Churchill Livingstone: 51-66.

Fox, C. (2002). “Living with a pressure ulcer: a descriptive study of patients’ experiences.” British Journal of Community Nursing – Wound Care Supplement 10: 12-14.

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Certain positioning techniques, for example 90-degree lateral rotation, which is used during bed rest, may exacerbate this situation and cause complete anoxia (lack of oxygen) to the weight-bearing area (Seiler, Allen et al. 1986; Colin, Abraham et al. 1996; Sachse, Fink et al. 1998). It is possible that a patient may be positioned directly onto a pressure ulcer - especially when multiple ulcers are present.

If a patient with an existing pressure ulcer continues to lie or bear weight on the affected area, the tissues will be depleted of blood flow and will therefore remain without oxygen supply (Kosiak 1959). Depleted blood flow also means that the nutrients required for wound healing will not be made available to the wound and the removal of waste products from the wound will be impaired (Kosiak 1959). The overall result of this is that the wound will not heal and that, furthermore, the patient will be at risk of developing further tissue damage (Krapfl and Gray 2008).

A fundamental way in which nurses and care staff may contribute to maximising the healing potential of existing pressure ulcers is by repositioning those patients who are unable to reposition themselves. International best practice advocates the use of repositioning as an integral component of a pressure ulcer prevention and management strategy. Although repositioning is advocated, there remains little scientific evidence upon which to base clinical decisions. Confusion exists regarding the frequency of turning required, with the AHCPR (1992) USA. advocating twohourly turns, while the EPUAP (1999) and the National Institute for Clinical Evidence, UK (National Institute for Health and Clinical Excellence 2005) advocate turning as required by the individual patient. Indeed, the AHCPR (1992) acknowledges that whereas repositioning is a practice with good face validity, no well-designed controlled trials have examined its effect. Overall, there is a lack of randomised controlled trial (RCT) evidence available.

Gottrup, F. (2004). “Oxygen in Wound Healing and Infection.” World Journal of Surgery 28: 312-15.

Haalboom, J. R. E. (2000). “Some remarks about overlays in the prevention and treatment of pressure ulcers.”

EPUAP Review 2(2): 67-70.

Hanson, D., D. Langemo, et al. (1993). “The prevalence and incidence of pressure ulcers in home care: are patients at risk?” Journal of Home Health Care Practice 5(3): 25-32.

Higgins, J. P. T. and D. Altman (2008). Assessing risk of bias in included studies. Cochrane Handbook for Systematic Reviews of Interventions. J. Higgins, S. Green and Cochrane Collaboration. London, John Wiley and Sons: 187-243.

Hopkins, A., C. Dealey, et al. (2006). “Patient stories of living with a pressure ulcer.” Journal of Advanced Nursing 56(4): 345-353.

Husain, T. (1953). “An experimental study of some pressure effects on tissues with reference to the bed-sore problem.” Journal of Pathology Bacteriology 66(347-56).

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Repositioning continues to play a central role in the management of those individuals with existing pressure ulcers.

Repositioning is not a novel concept, indeed it has been discussed in the literature for many decades and as far back as 1848, Robert Graves first described how pressure ulcers could be prevented and managed more effectively, through the use of repositioning (Sebastian 2000). It is interesting that even today the question of whether repositioning makes any difference to pressure ulcer healing has yet to be researched in a methodologically sound manner.

Repositioning continues to be advocated as part of pressure ulcer prevention and management strategies.

It is a challenge to conduct clinical research, especially in today’s health care climate where there are many calls on staff time, in addition to resource limitations and recruitment embargos. The strive to design and implement the perfect clinical trial is also a difficulty as it requires large investment in time and consistency in adherence to the trial protocol. In reality the need for a pragmatic approach to research in pressure ulcer prevention may mean that owing to the potential for the impact of confounding variables it becomes very complex. Pressure ulcers have been around since time began, and thus there may be a misconception that research in this area has already been done. Further, the interest in pressure ulcers may be undermined by the more “exciting” areas of clinical research. This highlights the value of the Cochrane process, in that it identifies what we already know and don’t know regarding a particular aspect of care. This in turn will form the impetus for the development of clinical trials that will, in time, address 䊳 clinically relevant problems.

Kaltenthaler, E., M. D. Whitfield, et al. (2001). “UK, USA and Canada: how do their pressure ulcer prevalence and incidence data compare?” Journal of Wound Care 10(1): 530-535.

Kosiak, M. (1959). “Etiology and pathology of ischaemic ulcers.” Archives of Physical Medicine and Rehabilitation 40: 62-9.

Kosiak, M. (1966). “An effective method of preventing decubital ulcers.” Archives of Physical Medicine and Rehabilitation 14(7): 724-9.

Krapfl, L. and M. Gray (2008). “Does regular repositioning prevent pressure ulcers?” Journal of Wound, Ostomy, and Continence Nursing 36(6): 571-7.

Krishnamoorthy, L., H. L. Morris, et al. (2001). “A dynamic regulator: the role of growth factors in tissue repair.” Journal of Wound Care 10(4): 99-101.

Langer, G., G. Schloemer, et al. (2003). Nutritional interventions for preventing and treating pressure ulcers.

The Cochrane Database of Systematic Reviews, Wiley.

Issue 4. Art. No.: CD003216.DOI: 10.1002/14651858.

CD003216.

LaVan, F. B. and T. K. Hunt (1990). “Oxygen and wound healing.” Clinical Plastic Surgery 17(3): 463-72.

Lindgren, M., M. Unosson, et al. (2004). “Immobility - a major risk factor for the development of pressure ulcers among hospitalised patients: a prospective study.” Scand J Caring Sci 18: 57-64.

Margolis, D. J., W. Bilker, et al. (2002). “The incidence and prevalence of pressure ulcers among elderly patients in general medical practice.” Annals of Epidemiology 12: 321-325.

Martin, P. (1997). “Wound healing - aiming for perfect skin regeneration.” Science 276: 75-81.

McInnes, E. (2004). “The use of pressure relieving devices (beds, mattresses and overlays) for the prevention of pressure ulcers in primary and secondary care.” Journal of Tissue Viability 14(1): 4-6, 8, 10.

McInnes, E., S. E. M. Bell-Syer, et al. (2008). “Support surfaces for pressure ulcer prevention.” Cochrane Database of Systematic Reviews (4. Art. No: CD001735. DOI: 10.1002/14651858.CD001735.pub3.).

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Science, Practice and Education

CONCLUSION Implications for practice We found no randomised controlled trial (RCT) evidence that addresses the question of whether repositioning patients improves the healing rates of pressure ulcers.

Although repositioning is a practice with good face value, we found no RCT evidence to provide specific guidance for practice. Weight bearing directly onto an existing pressure ulcer will cause vascular obstruction which will eliminate capillary blood flow to the pressure ulcer. Therefore, it is reasonable to suggest that individuals with pressure ulcers are repositioned to avoid depriving the wounded area of oxygen and nutrients which are needed for tissue repair. It is not clear whether any of the particular repositioning schedules (e.g. 2 hourly / as required) or techniques (e.g. 30 degree tilt versus standard repositioning) is better than each other.

Implications for research Repositioning is an integral component of pressure ulcer management strategies and is widely utilised in clinical practice. To date, there is no clear RCT evidence available to identify whether repositioning makes any difference to the healing rates of pressure ulcers. There is a need for a large cluster-randomised study, correctly powered, with treatment groups comparable at baseline, allocation to groups concealed, blinded outcome assessment and intention-to-treat analysis, to confirm the role of repositioning in the healing of pressure ulcers. Cluster randomisation involves the randomisation of units rather than individuals to the different arms of a study, for example units within a hospital, rather than individual patients (Medical Research Council 2002).Cluster randomised trials are used for a number of reasons; increased efficiency, increased compliance with the study protocol and avoidance of contamination (Donner and Klar 2004). Contamination is said to occur when an intervention is given to an individual but may affect others within the trial (Puffer, Torgerson et al.

Medical Research Council (2002) Cluster randomised trials: methodological and ethical issues. Volume, DOI: Moore, Z. E. H. and S. Cowman (2005). Wound cleansing for pressure ulcers. Cochrane Database of Systematic Reviews, Wiley and Sons. 4.

National Institute for Health and Clinical Excellence (2005). The management of pressure ulcers in primary and secondary care, National Institute for Health and Clinical Excellence: 1-245.

Nixon, J., S. Smye, et al. (1999). “The diagnosis of early pressure sores: report of the pilot study.” Journal of Tissue Viability 9: 62-66.

Puffer, S., D. J. Torgerson, et al. (2005). “Cluster randomized controlled trials.” Journal of Evaluation in Clinical Practice 11(5): 479-83.

Richardson, R. R. and P. R. Meyer (1981). “Prevalence and incidence of pressure sores in acute spinal cord injuries.” Paraplegia 19(4): 235-247.

12

2005). For example, in a repositioning trial, care staff using a specific repositioning regime (e.g. the 30 degree tilt) may find it more practical to administer the intervention to all those who meet the inclusion criteria in a specific unit, rather than administer different repositioning regimes to different patients within the same unit. Repositioning trials need to consider the effects of the following on the healing rates of pressure ulcers: 䡲 The effects of different repositioning regimes, for example, the 30 degree tilt versus the 90 degree lateral rotation. 䡲 The effects of different frequencies of repositioning, for example, 2 hourly turning, 3 hourly turning, 4 hourly turning etc. 䡲 The effects of different repositioning regimes, in combination with a pressure redistribution mattress. 䡲 The effects of different frequencies of repositioning, in combination with pressure redistribution mattress.

Acknowledgements The authors would like to acknowledge the peer referees (Anne-Marie Bagnall, Sheila Benton-Jones, Carol Dealey, Liz McGinnis) and the Wounds Group Editors (Mieke Flour, Liz McInnes, Gill Worthy) for their feedback on the protocol and review. In addition, thanks to Jenny Bellorini, Cochrane Copy Editor, Ruth Foxlee, Trial Search Coordinator, for her advice and input on the search strategy and to Sally Bell-Syer, Review Group Coordinator, for her support, advice and guidance at all stages of the 䡵 development of this review.

Copyright Cochrane Collaboration. Reprinted with kind permission of John Wiley & Sons Limited.

Moore ZEH, Cowman S. Repositioning for treating pressure ulcers. Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD006898. DOI: 10.1002/14651858.

CD006898.pub2.

Sachse, R., S. A. Fink, et al. (1998). “Comparison of supine and lateral positioning on various clinically used surfaces.” Annals of Plastic Surgery 41: 513-8.

Thompson, J. S. and R. G. Brooks (1999). “The economics of preventing and treating pressure ulcers: a pilot study.” Journal of Wound Care 8(6): 312-316.

Schoonhoven, L., T. Defloor, et al. (2002). “Incidence of pressure ulcers due to surgery.” Journal of Clinical Nursing 11: 479-487.

Versluysen, M. (1986). “How elderly patients with femoral fracture develop pressure sores in hospital.” British Medical Journal 292(6531): 1311-1313.

Sebastian, A. (2000). Robert Graves (1796-1853).

A Dictionary of the History of Medicine. New York, Partenon Publishing group.

Whittington, K. T. and R. Briones (2004). “National Prevalence and Incidence Study: 6-year sequential acute care data.” Advances in Skin & Wound Care 17(9): 490-4.

Seiler, W. O., S. Allen, et al. (1986). “Influence of the 30 degree laterally inclined position and the ‘super-soft’ 3-pience mattress on skin oxygen tension on areas of maximum pressure - implications for pressure sore prevention.” Gerontology 32: 158-66.

Slavin, J. (1996). “The role of cytokines in wound healing.” Journal of Pathology Bacteriology 178: 5-10.

Tarnuzzer, R. W. and G. S. Schultz (1996). “Biochemical analysis of acute and chronic wound environments.”

Wound Repair & Regeneration 4(3): 321-5.

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Analysis of wound care in nursing care homes as part of a district-wide wound care audit AIM To evaluate wound care activity and quality standards in nursing care homes.

Peter Vowden Consultant Vascular Surgeon and Professor of Wound Healing at Bradford University Kathryn Vowden Nurse Consultant Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom peter.vowden@mac.com Conflict of interest: none

INTRODUCTION It is well recognised that a progressively aging population will place increasing demands on health care providers and will be associated with a rising demand for wound care. The majority of wound care services, particularly those for the management of chronic wounds, in the United Kingdom are community-based with care divided between the patient’s home or local surgery and residential care in either residential or nursing home.

The basic difference being that in the latter care is provided by the nursing home’s own staff in the former care is provide by community nursing services. The basic unit of care provision in the UK is defined as a Primary Care Trust (PCT) and this organisation is responsible for delivering all local healthcare services and commissions secondary care provision. Following a recent health care services review our local PCT boundaries were redefined and four smaller Trusts combined to create a larger PCT serving a population approach 500,000. The wound care provision in the original four Trusts and their associated hospital providers differed and it was therefore felt appropriate that a major audit be undertaken to gain a better understanding of wound care service provision.

This report details part of that audit and focuses on the results from nursing home.

METHOD As part of a district-wide audit of wound care undertaken in March 2007 data was captured from 69 nursing homes within the boundary defined by a PCT covering a then population of 488,000. Approval for the audit was obtained from all care organisations across the district. Each nursing home was approached and all agreed to participate. Members of the Wound Healing Unit visited all nursing homes during the audit week supporting data capture. Detailed description of

14

the methodology and analysis of the overall patient population has been published elsewhere.1-4 For the purpose of the audit a nursing home was classified as a care home staffed by trained nurses who perform wound care. All nursing homes in the defined area have access to community tissue viability services and work to common districtwide local wound care and pressure ulcer prevention and management policies.

RESULTS 2874 nursing home beds were available and occupied at the time of the audit. The prevalence of wounds was 109.9 per 1000 residents. The 201 patients with wounds had a total of 338 wounds reported, 124 patients having a single wound while 3 patents had 6 wounds. Patients with multiple wounds were more likely to have a pressure ulcer as their most serious wound. Nursing home bed density was observed to have a marked influence on wound prevalence across the population as a whole. Figure 1a and 1b show the variation in wound prevalence across the district and the impact of nursing homes on wound prevalence, particularly for the over 75-year group of patients.

In nursing homes 132 (66%) of the wounds reported were pressure ulcers (EPUAP Grade 1:22, 2:64, 3:28, 4:18), 22 leg ulcers (11%) and 32 (16%) acute wounds. This compared with the overall audit population of 1735 patients with 2620 wounds where there were 826 (47%) acute wounds, 482 (28%) leg ulcers and 363 (21%) pressure ulcers (Figure 2). Most wounds were located on the lower limb (89) or sacrum (59).

The majority of the pressure ulcers developed in the patient’s current care setting, 97 of 132 (73.5%) pressure ulcers developing in the nursing home, the majority of these (65) were Grade 1 or 2 pressure ulcers. 32 of 46 (69.6%) Grade 3 and 4 pressure ulcers developed in the nursing home.

Overall there were 59 Grade 2-4 sacral pressure ulcers. Only 6 patients were reported to not have/

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Science, Practice and Education

Figure 1a: Wound prevalence for each postcode in the Bradford and Airedale PCT

Figure 1b: Distribution of nursing home beds and prevalence of wounds in the over 75-age group

*Refers to overall and not just to nursing home population within each Postcode District

Figure 2: Distribution of wound types in the general population and in the nursing homes

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use any special pressure relieving equipment, the majority (98-74%) of patients with a pressure ulcer having a powered bed. 100 patients (75.8%) had a documented repositioning schedule.

76% of the acute wounds were traumatic in origin. 80% of these were on the lower limb. Many of these “acute” wounds (12 of 25 wounds) were of long duration (> 6 weeks) but had not been classified as a leg ulcer. Local policy states that patients with long duration wounds should have been referred for wound care specialist assessment; 72

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wounds (35.8%) were present for 3 months or longer. Of 114 wounds present for 6 or more weeks, 61 (53.5%) had been seen be a Community Tissue Viability Nurse (TVN).

68.2% of patients had their wound dressed 2-3 times per week or more frequently with 10% of patients receiving daily dressings. 18 patients receiving frequent dressing changes were requiring more than 20 minutes for each dressing. Analysis of dressing choice showed that 6 dressing types predominated out of those chosen from the local wound care formulary. The most common dressing used 䊳

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15

was a foam, the second most common an antimicrobial. Nursing time for wound care was estimated to be 9600 hours per annum (£403k) with dressing costs at approximately £240k. Further details relating to the cost of wound care in relation to the overall audit has been published elsewhere5. Despite these costs only 34% of patients were reported to have been seen by the community TVN.

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DISCUSSION Analysis of wound population by postcode across the Bradford and Airedale PCT catchment population demonstrated the marked effect that nursing home bed density had on wound numbers in each locality. In addition the wound type reported in nursing homes differed from that reported in the general population. This factor should be taken into consideration in future research, particularly when looking at the prevalence and aetiology of pressure ulceration. Data would suggest that nonhealing and hard-to-heal wounds were not recognised early enough and as a result there was a delay in involving Community and Secondary care teams in patient wound care. This is a potentially important cost driver for care in this group of patients.

CONCLUSION Nursing homes, which in the UK are classified as part of the Independent sector were responsible for approximately 12% of wound care provision (11.6% of patients with wounds and 12.9% of all wounds), this being mainly pressure ulcer management, 36.4% of pressure ulcers being cared for in nursing home. Innovative changes in service delivery, such as easier access to specialist services without an increased requirement for patient transportation, could improve outcome and reduce costs.

Health and social care provision differs widely throughout Europe. Care provision for elderly patients can influence the distribution of wounds within a community and in future prevalence audits, particularly those focusing on pressure ulceration, must include take this into account and ensure that patients in such care settings are included if they are to fully account for wound care workload. 䡵 References: 1. Vowden KR, Vowden P. A survey of wound care provision within one English health care district. Journal of Tissue Viability. 2009;18:2-6.

2. Vowden KR, Vowden P. The prevalence, management and outcome for acute wounds identified in a wound care survey within one English health care district.

Journal of Tissue Viability. 2009;18:7-12.

3. Vowden KR, Vowden P. The prevalence, management and outcome for patients with lower limb ulceration identified in a wound care survey within one English health care district. Journal of Tissue Viability. 2009;18:13-9.

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4. Vowden KR, Vowden P. The prevalence, management, equipment provision and outcome for patients with pressure ulceration identified in a wound care survey within one English health care district. Journal of Tissue Viability. 2009;18:20-6.

5. Vowden KR, Vowden P, Posnett J. The resource Costs of Wound Care in Bradford and Airedale primary care trust in the UK. Journal of Wound Care. 2009;18(3):93102.

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Science, Practice and Education

Chronic leg ulcers among the Icelandic population ABSTRACT

Background: Chronic leg and foot ulcers are a major health care concern, especially among the elderly population. To date little is known about the extent of the problem of chronic leg ulcers in Iceland.

Aim: To identify the number of chronic leg ulcer patients in Iceland and determine their aetiology in order to create an empirical background for further research, health care policy making and evaluation of service.

Methods: Descriptive, retrospective study. Chronic leg ulcers were defined as all ulcers below knee, open * 6 weeks. Patients were identified by health care professionals. Data were collected in every health care institution in Iceland, 166 units altogether. Twenty cases were selected for further validation.

Results: Leg ulcer prevalence was 0.072% (n=226), rising up to 0.61% among population * 70 years. Male/female ratio was 1.2/1. Estimated aetiology was venous in 34% cases, other or unknown in 25% cases. Diagnosis based on clinical observation alone was in 57% cases.

Conclusion: Prevalence is low compared to other studies. Male/female ratio differs from most studies. Diagnostic methods need to improve.

Evidence based leg ulcer practice needs to be implemented. Empirical background on chronic leg ulcers in Iceland has been established.

INTRODUCTION Chronic leg and foot ulcers are a major health care concern, especially among the elderly population.

Prevalence rates of open leg ulcers range from 0.045% to 1.69% depending on the population studied1-2. The condition can persist for months and even years and recurrence rate is high. Underlying aetiology in most leg ulcers is related to defects in the vascular system of the legs, such as venous or arterial insufficiency, but many contributing factors can influence healing and development of the ulcer. These factors can be physical factors, psychological and social factors as well

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as environmental and economic factors. Major developments have been seen in the management of chronic leg ulcers in the world in the last decade or two3. In Canada as well as in Europe, clinical practice guidelines on management of chronic leg ulcers have been developed4-6 and evidence-based practice has been implemented in various forms.

The Icelandic healthcare system is based on public health insurance where all citizens have equal access to healthcare. The management of chronic wounds, including leg ulcers, has been poorly defined within the Icelandic health care system and procedure policy for the management of chronic leg ulcers is rare. Little is known about the extent of the problem of chronic leg ulcers in Iceland and, to date, the prevalence has been unknown.

The aim of this study was to determine the prevalence of leg ulcers and their estimated aetiology among the Icelandic population. Another purpose was to create an empirical background for health care policy making and evaluation of leg ulcer service.

Guðbjörg Pálsdóttir, RN, MS. Specialist practice in wound management in Landspitali University Hospital in Reykjavik, Iceland. Ásta Thoroddsen, RN, PhD cand.

Associate Professor at University of Iceland, Faculty of Nursing Landspitali University Hospital, Reykjavik, Iceland Correspondence to: Gudbjorg Palsdottir Grettisgata 48 101 Reykjavik Iceland gpsara@landspitali.is

METHODS A descriptive, retrospective study with a cross-sectional design was done, where leg ulcer patients were studied over a period of two weeks in May 2008. Chronic leg ulcers were defined as all ulcers below knee, open * 6 weeks. The population in this study consisted of all individuals registered in Iceland during the study period. The sample consisted of all leg ulcer cases identified by health care providers in all health care institutions likely to treat leg ulcer patients in Iceland. There were 53, one to 17 units each, adding up to 166 units all together and included all primary health care clinics and related services in Iceland, all centres of home nursing, all nursing homes and geriatric/ long term hospital wards as well as all hospital outpatient clinics in Iceland. Excluded from the study were acute hospital wards as it was expected that individuals incidentally hospitalised during the study period would be identified elsewhere,

Conflict of interest: none

䊳

19

Figure 1. Icelandic population, age and gender

Figure 2. Chronic leg ulcers in Iceland, distribution by age and gender provided they had been treated for leg ulceration within the health care system prior to hospitalisation. One private detoxification clinic and two rehabilitation centres were not included in the study.

A questionnaire used for data collection was developed by the first author with reference to two existing questionnaires with permission from their authors, Christina Lindholm and Peter Franks and his team. The questionnaire was divided into background questions, ulcer history, diagnosis and management. A letter to introduce the study was sent to the 166 units. Each unit was then contacted by telephone to ask them to participate and establish contact. Health care providers were asked to fill out one questionnaire for every Significance level was set at p < 0.05. Study procedure was leg ulcer patient they had treated or knew of during the approved by the National Bioethics Committee (#08-076) study period. Personal identification numbers were used in Iceland. to prevent double counting and then eliminated from the data before analysis.

RESULTS Validation of cases was done in 20 patients randomly The registered population of Iceland in January 2008 selected from the whole sample. The purpose of this was was 313,376 individuals. Men were 159,488 (50.9%) to evaluate the reliability of the data on the underlying and women 153,888 (49.1%) (fig. 1)7. All 166 health aetiology of the leg ulceration of patients identified. Pacare units contacted for data collection were willing to tients selected were identified through the list of numbers participate in the study, giving a 100% response rate. Of connected to the personal identification numbers, and those, 67 units had seen no leg ulcer patients during the contacted through the health care institutions where they study period. The remaining 99 units reported from one were being treated. With patients’ consent they were seen to 30 cases each. All in all, 233 questionnaires were coleither in connection with their planned ulcer treatment lected, each presenting one leg ulcer patient. One case or, if the patient preferred, at a separate appointment. did not meet the inclusion criteria as a chronic leg ulcer Assessment was non-invasive and included ulcer history, and six cases were double counted, leaving a total number clinical observation and measurement of ankle brachial of 226 cases identified. This represents a prevalence of pressure index (ABPI) with the use of Doppler.

0.072% (0.72/1000 population) during the two weeks Descriptive statistics were used to describe frequenstudy period. Mean age was 75.2 years (SD=1.93, range cies and proportions. Most variables were measured by 25-99). Age was reported in 224 cases and gender in 221 nominal measurements. Chi-square non parametric procases. Both age and gender were reported in 219 cases. As cedure was used for testing differences between groups. expected the prevalence rates were highly age dependent, SPSS, version 15.0 and Excel were used for data analysis.

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Figure 3. Chronic leg ulcers in Iceland, aetiology and gender

*Gender missing in one case ** Gender missing in two cases

rising from 0.072% to 0.61% in the population 70 years and older. Eighty-six percent of cases were 60 years or older (fig. 2).

Unexpectedly the total count of men was higher than total count of women (n=121/100). The difference was most obvious in population under 70 years of age where the number of men with leg ulcers were more than twice as many as women (r2 = 8.86, df=1, p<0.01) (table 1). In the population 70 years and older, the difference was very small, with total count of 77 men and 80 women. Among patients with diabetic ulcers men were five times as many as women (n=19/5) (fig. 3).

Ulcers were divided equally between left and right leg, 131 patients had ulcers on each leg and 36 had bilateral ulcers. All in all, 367 ulcers were reported on the 226 patients identified. Of all ulcers 52.5% were located on the legs and 47.5% on the feet, 11% on the heels and 14% on the toes. Twenty-two percent of patients had had their ulcers longer than one year and 11% longer than two years.

Patients had recurrent ulcers in 47.8% of cases.

Aetiology of ulcers was given in 212 cases. Venous leg ulcers were reported in 34% of cases, 7% were arterial ulcers, 6% mixed venous/arterial, 10% diabetic foot ulcers and 18% pressure ulcers (fig.3). Only in 6% cases (n=14) was there either unknown aetiology or missing data. In 19% cases (n=43) the aetiology was scored as “other”. In most of those cases further explanations were reported in

free text. Those were explanations such as trauma, which was the most prominent issue, immunological ulcers and infections. Some of the explanations written in free text were descriptions of symptoms rather than aetiological factors.

When asked about how ulcer aetiology was determined, four possible scores were available on the questionnaire.

After the data collection, the scores were ranked by accuracy of the diagnostic method by the researcher. If two possibilities were scored, such as clinical observation and ABPI as well, ABPI was considered the answer as it is more accurate than clinical observation alone. Examination by vascular surgeons, dermatologists, plastic surgeons and other specialist consultants was ranked as the most accurate diagnostic method. In 57% of cases ulcer aetiology was determined by clinical observation alone and ABPI was reported in only 8% for that purpose (table 2).

Nineteen of the 20 patients (one could not be traced) selected for further validation of the underlying aetiology participated. In 12 of the 19 cases (63%) complete consistency was found in aetiology estimated by the researcher and by the practitioners answering the questionnaires.

Three of the seven patients with mismatching aetiology had insufficient arterial blood supply not previously diagnosed. Cases with mismatching aetiology had all been assessed with clinical observation alone according to the 䊳 questionnaires.

Table 1. Age and gender among the Icelandic leg ulcer population

Table 2. Diagnostic methods reported in leg ulcer management N (%) Clinical observation 129 (57,1) ABPI (ankle brachial pressure index) 19 (8,4) Referral to a physician with special function 76 (33,6) Not known 2 (0,9) Total 226 (100)

Age

Men

0-69 years 70 years and over Total

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(%)

44 77 121

(71) (49) (55.3)

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Women n (%) 18 80 98

(29) (51) (44.7)

n

Total (%)

62 157 219

(100) (100) (100)

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DISCUSSION The purpose of this study was to establish knowledge on the extent of chronic leg ulcers in Iceland and the provision of care of patients with leg ulcers within the Icelandic health care system. Until now, the scope of the health care problem of chronic leg ulcers in Iceland has not been addressed and estimates of the situation in this society have been based mainly on speculation. The population under focus in this study was the population of the whole country, 313,000, which is unique, but in size it is comparable to many similar studies focusing on defined districts. Data collection for this study is considered thorough as all institutions in Iceland, likely to treat patients with leg ulcers, were included. Achieving a 100% response rate is more than was expected but can be explained by the fact that the researcher made a personal contact with a key person in every health care unit before data collection and up to three times following the study period to remind and encourage health care providers to respond. In terms of the thoroughness of the data collection and the excellent response rate, the results should give a fair picture of the situation in Iceland.

Total prevalence of 0.072% and 0.61% in the elderly population (* 70 years) is among the lowest prevalence rates known. Due to methodological differences, however, it can be difficult to compare prevalence rates in various studies. In a review of 22 studies on leg ulcer prevalence, rates from 0.1% to 0.3% were found in studies with methods similar to present study8-14. Lower prevalence (0.045%) rates were found in only one study, conducted

by Moffatt and colleagues in a defined London popula-

References 1. Margolis DJ, Bilker W, Santanna J, Baumgarten M. Venous leg ulcers: Incidence and prevalence in the elderly. Journal of the American Academy of Dermatology. 2002; 46: 381-386.

2. Moffatt CJ, Franks PJ, Doherty DC, Martin R, Blewett R, Ross F. Prevalence of leg ulceration in a London population. QMJ: monthly journal of the Association of Physicians. 2004; 97: 431-437.

3. Moffatt C, Morison MJ, Pina E. Wound bed preparation for venous leg ulcers.

European Wound Management Association (EWMA). Position Document: wound bed preparation in practice. London: MEP Ltd; 2004.

4. Clinical practice guidelines: The nursing management of patients with venous leg ulcers. Recommendations. In: Royal College of Nursing (RCN). 2006; http://www. rcn.org.uk/development/practice/clinicalguidelines/venous_leg_ulcers (5 August, 2008)

tion3 but her team, for example, excluded all patients with isolated foot ulcers from their study. It has been suggested that up to 40% of the leg ulcer population in Sweden is unknown to the health care system15. Presuming that it is the same in Iceland, this raises the total prevalence up to 0.1% and 1% among the elderly population but this needs to be studied further.

Generally it is accepted that chronic leg ulcers are more prominent among women than men but in this study it was found to be the other way around with the male/ female ratio 1.2/1. Only one recent study was found with ratio similar to this16. The difference, though, is only seen among the age group under 70 years, where men with leg ulcers are more than twice as many as women. This would be of interest in further studies. Women with leg ulcers in Iceland are older than the men as is seen in other studies and is proportional to Icelandic demography.

Aetiological distribution is comparable to other studies, with venous leg ulcers being the dominant ulcer type2,8,10,11,14,15,17,20-22. It has to be pointed out that as many as 25% of cases had aetiology reported as other or unknown and in 57% of cases, aetiology is determined by clinical observation alone. Therefore, the accuracy of the aetiological determination among this population can be questioned. The validation of cases confirms inaccuracy of diagnostic methods in some cases, although in 63% of the validated cases consistency was found between aetiology estimated by practitioners and researcher. In all the mismatching cases, aetiology had been determined by clinical observation alone on behalf of the practitioners collecting the data.

12. Marklund B, Sülau T, Lindholm C. Prevalence of non-healed and healed chronic leg ulcers in an elderly rural population. Scandinavian Journal of Primary Health Care.

2000; 18: 58-60.

13. Nelzén O, Bergqvist D, Lindhagen A, Hallböök T. Chronic leg ulcers: an underestimated problem in primary health care among elderly patients. Journal of Epidemiology and Community Health. 1991; 45: 184-187.

14. O’Brien JF, Grace PA, Perry IJ, Burke PE. Prevalence and aetiology of leg ulcers in Ireland. Irish Journal of Medical Science. 2000; 169: 110-112.

15. Nelzén O, Bergqvist D, Lindhagen A. The prevalence of chronic lower-limb ulceration has been underestimated: results of a validated population questionnaire.

British Journal of Surgery. 1996; 83: 255-258.

16. Forssgren A, Fransson I, Nelzén O. Leg ulcer point prevalence can be decreased by broad-scale intervention: A follow-up cross-sectional study of a defined geographical population. Acta Dermato-Venereologica. 2008; 88: 252-256.

5. Nursing best practice guideline: Assessment and management of venous leg ulcers.

In: Registered Nurses Association of Ontario (RNAO). 2004; http://www.rnao.org/ Page.asp?PageID=924&ContentID=722 (5 August, 2008)

17. Andersson E, Hansson C, Swanbeck G. Leg and foot ulcer prevalence and investigation of the peripheral arterial and venous circulation in a randomised elderly population. Acta Dermato Venereology. 1993; 73: 57-61.

6. Nursing best practice guideline: Assessment and management of foot ulcers for people with diabetes. In: Registered Nurses Association of Ontario (RNAO).

2005;http://www.rnao.org/Page.asp?PageID=924&ContentID=719 (23 Oct. 2008)

18. Baker SR, Stacey MC, Singh G, Hoskin SE, Thompson PJ. Aetiology of chronic leg ulcers. European Journal of Vascular Surgery. 1992; 6: 245-251.

7. Hagtölur. In: Hagstofa Íslands. 2008; http://hagstofa.is/Hagtolur/Mannfjoldi (20 August, 2008) 8. Ebbeskog B, Lindholm C, Öhman S. Leg and foot ulcer patients. Scandinavian Journal of Primary Health Care. 1996; 14: 238-243.

9. Franks PJ, Morton N, Campbell A, Moffatt CJ. Leg ulceration and ethnicity: a study in west London. Public Health. 1997; 111: 327-239.

10. Lindholm C, Bjellerup M, Christensen OB, Zederfeldt B. A demographic survey of leg and foot ulcer patients in a defined population. Acta Dermato-Venereologica. 1992; 72: 227-230.

11. Lindholm C, Bergsten A, Berglund E. Chronic wounds and nursing care. Journal of Wound Care. 1999; 8: 5-10.

22

19. Clarke-Moloney M, Keane N, Kavanagh E. Changes in leg ulcer management practice following training in an Irish community setting. Journal of Wound Care.

2008; 17: 116-121.

20. Lorimer KR, Harrison MB, Graham ID, Friedberg E, Davies B. Assessing venous ulcer population characteristics and practices in a home care community. Ostomy/Wound Management. 2003; 49: 32-43.

21. Soldevilla J, Torra JE, Verdu J, Rueda J, Martinez F, Roche E. Epidemiology of chronic wounds in Spain: results of the first national studies on pressure and leg ulcer prevalence. Wounds. 2006; 18(8): 213-226.

22. Öien RF, Håkansson A, Ovhed I, Hansen BU. Wound management for 287 patients with chronic leg ulcers demand 12 full-time nurses. Scandinavian Journal of Primary Health Care. 2000; 18: 220-225.

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Identifying an underlying cause is a fundamental factor in the management of chronic leg ulcers. This requires a thorough and holistic assessment, including ABPI measurement, to rule out arterial insufficiency. Clinical observation and palpable pulses alone cannot be relied on for that purpose4-6. It is a matter of concern that in majority of cases, the diagnostic methods used in practice relied on clinical observation alone and ABPI was rarely used as such. The clinical importance of this, considering the fact that almost 50% of patients had recurrent ulcers and over 20% had ulcer duration of more than one year, is of more concern than that of getting the exact demographic picture. 䡵

Implications for practice 䡲 Empirical background on chronic leg ulcers in Iceland has been established 䡲 Results will serve as foundation for – Health care policy making – Evaluation of service – Further research 䡲 Diagnostic methods need to be improved 䡲 Evidence-based practices with continuous education and training programs for practitioners need to be implemented – where interdisciplinary focuses, within and between care settings, are emphasised.

Further research 䡲 It is important to involve a bigger sample in clinical validation in order to give more detailed information on management and aetiological factors. 䡲 Leg ulcer population practicing self treatment is still unknown in Iceland. 䡲 Evaluation following implementation of clinical practice guidelines.

ELECTRONIC SUPPLEMENT JANUARY 2010 The January edition of the EWMA Journal Electronic Supplement includes articles with news from EWMA Cooperating Organisations.

All organisations have been invited to contribute with information about their organisation, its recent activities, research projects and meetings, as well as their political and scientific involvement in wound care on a national level.

Contents 1. Francophone Nurses Association in Stoma Therapy, Healing and Wounds (AFISCeP) 2. Italian Nurses Cutaneous Wounds Association (AISLeC) 3. Italian Asspciation for the study of Cutaneous Ulcers (AIUC) 4. Portuguese Association for the Treatment of Wounds (APTFeridas) 5. Croation Wound Association (CWA) 6. Associated Group of Research in Wounds (GAIF) 7. National Advisory Group for the Study of Pressure Ulcers and Chronic Wounds (GNEAUPP) 8. Norwegian Wound Healing Association (NIFS)

Acknowledgement The study was a part of a thesis for a Master of Science Degree in Nursing at the University of Iceland. Acknowledgements to members of the masters committee; Dr. Arun Sigurdardottir and Dr. Baldur T. Baldursson.

The study was supported by the Icelandic Nurses Association and the Icelandic Wound Healing Society.

9. Swiss Association for Wound Care (SAfW) 10. Tissue Viability Society (TVS) 11. Wound Management Association of Turkey (WMAT)

www.ewma.org/english/ewma-journal/ electronic-supplement.html

WWW.EWMA.ORG EWMA JOURNAL

2010 VOL 10 NO 1

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Cross-sectional Survey of the Occurrence of Chronic Wounds within Capital Region in Finland ABSTRACT

Anita Mäkelä Annanmäki L, Koivunen E, Jyvälahti A, Mattsson K, Iso-Aho M, Nurkkala H, Hietanen H, Juutilainen V, Kaira A-M, Iivanainen A, Tukiainen E, Lepäntalo M, and the Working Group for Treatment of Chronic Wounds within the Capital Region in Finland Correspondence: Anita Mäkelä, Department of Vascular Surgery, Helsinki University Central Hospital, Meilahti Hospital, Finland anita.makela@hus.fi Conflict of interest: none

Aim and methods: The aim was to find out the number of patients with chronic wounds in Helsinki, Espoo and Vantaa (the Capital region in Finland). The survey was made cross-sectionally during one day in December 2008. It included all patients in primary health care wards, health centres and home care as well as in hospital wards and out-patient clinics. Questionnaires were sent to 765 units.

Results: A total of 466 questionnaires (61%) were returned. A total of 1029 patients with chronic wounds were encountered. 524 (51%) of them were institutionalized. Chronic wound prevalence encoutered was 0.10% in the Capital region. 23 percent were pressure ulcers, 13% venous, 11% diabetic, 11% unhealed operative, 7% ischemic, 21% multifactorial and 14% wounds with unsettled aetiology. 36% were situated in the feet or at the ankle level, 27% in the legs and 19% in the back, hips or buttocks.

Conclusions: When compared to previous data 29% increase in chronic wounds was observed in Helsinki in 10 years. The number of pressure ulcers seemed to be decreasing, whereas the number of venous, diabetic and ischemic, often included in the multifactorial group, was increasing.

INTRODUCTION The prevalence of chronic lower extremity wounds has been reported to range 0.04-1,1% in Western Europe(1-4) and 0.09-0.8% in Finland(5). Chronic leg wound will appear within 1,3-3,6% of population in selected populations(1-4). The underlying aetiology of the ulceration is caused mostly by vascular disease, venous insufficiency in 37-76% of cases(6-8) and peripheral arterial occlusive disease in 9-22% of cases(6). Pressure ulcers are also frequent(9). The incidence of diabetic ulcers is also increasing(10).

A previous one-day cross sectional survey in Helsinki was made in 1998. The survey counted the number of patients with chronic wound treat-

24

ed in eleven hospitals and five outpatient districts in one city in southern Finland (population 546 317). There were 582 chronic wounds among 348 patients which represent the prevalence of 6,4% among institutionalized patients(9). There is no other data available on prevalence of chronic wounds within the capital region in Finland.

The important goal is to create an integrated treatment path for ulcer prevention and to improve the effectiveness of care. To make this possible the full extent of the problem needs to be evaluated.

AIM Aim of this study was to assess the number of patients suffering from a current chronic wounds within the capital region of Finland including the cities of Helsinki, Espoo and Vantaa. The survey was made cross-sectionally during one day (Dec 3, 2008, while the population was 1 013 594).

METHODS This survey aimed to include all patients in primary health care wards, health centres and home care as well as in hospital wards and out-patient clinics. Questionnaires were mailed to the health service institutions with a covering letter asking them to complete a form for each unit. The data were collected by electronic questionnaires sent to be filled by responsible nurses of given units. All the data were collected on the same day to avoid patients being included in the material more than once. The institutions were instructed to complete questionnaire even if the unit had no chronic wound patients. Questionnaires were sent to 765 institutions of which 310 to primary care units and 285 to units within secondary care. The rest 170 were miscellaneous units within private sector.

The chronic wound was defined as an open wound which had not healed within the last four weeks. Prevalence in this case is defined as the number of people with chronic wound at a certain

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Science, Practice and Education Table 1.

Comparison of the prevalence of different chronic wound aetiologies Cause

Helsinki 1998 Helsinki 2008 n % n % Pressure ulcer 228* 45 180 22 Venous ulcer 61 12 105 13 Ischemic ulcer 7 1 65 8 Diabetic ulcer 52 10 90 11 Unhealed postsurgical wound 9 2 93 11 Other cause 153 30 285 35 Total 510 100 818 100

p < 0.05 0.64 < 0.05 0.64 < 0.05 0.07

*grade II-IV included

time. The main aetiology and the location of the wound was also to be assessed. Comparisons were made using x2 test as appropriate.

RESULTS A total of 466 units (61%) responded. Units in primary care gave a response rate 79-100% (health centre, in patient units both acute and chronic care 100%, out-patient units 92-100%, home care 80-100%, public sheltered homes, old-age homes, private nursing homes as outsourcing service 79-100%). 1029 patients with chronic wounds were encountered. 524 (51%) of them were institutionalized. Primary health care reported 819 (80%) patients and private health care units reported 71 (7%) patients. There were 139 (13%) patients with chronic wounds within secondary care units seen during one day. A prevalence of 0.10% was observed in the Capital region (Helsinki 533, Espoo 114 and Vantaa 172).

As to the main aetiology 23% were pressure ulcers, 13% venous, 11% diabetic, 11% unhealed post-surgical wound, 7% ischemic, 21% multifactorial and 14% wound with unsettled aetiology. 36% of chronic wounds were situated in the feet or at the ankle level, 27% in the legs and 19% in the back, hips or buttocks.

In order to find out the development trends of characteristic of chronic wounds, the results of the subgroup from Helsinki were compared to the results of a previous

study performed some 10 years ago covering the same geographic area(9) (Table 1).

There were significantly more patients treated as in-patients (80%) ten years ago than now (43%) (p< 0.05). This decrease is due to diminished need for acute in-patient care which to-day is substituted by increased out-patient activity, whereas there is no major change in the need for chronic care. With those treated as in-patient 49% were treated in chronic care in 1998, 56% in 2008, respectively.

DISCUSSION Treatment of chronic wounds in Finland is fragmented and steering is insufficient. To-day treatment paths do not work or they are inadequate. Wards in secondary care are encumbered with patients with chronic wounds because the treatment path is blocked by the unability of the primary care to continue the treatment of patients not ready to be discharged straight home. On the other hand discharging patient too early may lead to poor result, deterioration of wound healing or even recurrence of ulceration. Problem wounds are often treated in wrong institutions and this kind of fragmented activity leads to overlap among institutions.

Patients are treated often without a proper diagnosis or treatment plan and wound prevention is largely neglected. There is a lack of vacancies for expert nurses or podiatrists in primary care. Most undergoing training end up to private sector.

Omissions are always a problem in large-scale population studies, even more so when the entity studied and population sample are poorly definable and response rate is low. In studies on the prevalence of chronic wounds previous authors have reported a response rate 84-98%(3-4,11-19).

Yet, most of these studies have predefined the study population to cover only health services with long-term-care facilities or individuals more than 65 years old. Our study 䊳

Table 2. Prevalence rates of chronic ulcers Authors

Study year Study population

Andersson et al11 Callam et al12 Cornwall et al13 Nelzen et al14 Baker et al15 Lindholm et al16 Lees & Lambert17 Ebbeskog et al18 O’Brien et al19 Moffatt et al3 Pina et al4 Mäkelä et al

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1980 1982 1982 1988 1989 1990 1991 1994 1998 2004 2005 2008

city; Sweden 2 health districts; Scotland health district; United Kingdom county; Sweden health district; Australia city; Sweden health district; United Kingdom city; Sweden health district; Ireland city; United Kingdom one area of city; Portugal health district; Finland

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Methods Hospitals/clinics medical records Postal survey Questionnaire to health professionals Postal survey Questionnaire to health professionals Postal survey Questionnaire to District Nurses Postal survey Questionnaire to health professionals Postal survey Postal survey Questionnaire to health professionals

Size

% total population prevalence 434 699 0.32 1 000 000 0.15 198 900 0.18 270 800 0.3 238 000 0.11 232 908 0.12 240 000 0.19 241 804 1.12 317 069 0.12 252 000 0.05 186 000 0.14 1 013 594 0.1

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Science, Practice and Education

had a response rate of 61% but it covered all units, many of those such as pediatry, obstetrics, psychiatry, head and neck diseases unlikely to have chronic wounds. This incompleteness of the data caused less bias than the percentual share of omissions may indicate as primary health care reported adequately as did those within secondary care working with wounds. As major parties has reported adequately, these results can be accepted to cover the problem on a given day. Yet, there may be a number of patients escaping recording in one day survey as all wounds are not treated actively every day.

The prevalence of chronic wounds vary in different studies (Table 2). Therefore it is difficult to make direct comparisons because the study designs, methods and classifications used and criteria applied are differently. Yet, the studies made using questionnaires to health professionals give rather uniform results with prevalence ranging 0,1-0,19(13,15,17,19). Some ulcer prevalence studies include only leg ulcers, the others any break in skin, some include only open wounds and the others both open and healed wounds.

When compared to previous data a 29% increase in chronic wounds can be observed in Helsinki in 10 years.

The number of pressure ulcers seemed to be decreasing, which can be explained by increased education and proper information and usage of offloading as a part of wound prevention and treatment. On the other hand the number of venous, diabetic and ischemic ulcers was slightly increasing, especially when neuroischemic ulcers were predominantly reported as multifactorial. Indeed, there are data to show that half of the diabetic ulcers are neuroischemic(20).

The main reason probably is the aging of the population.

There was also a significant increase in the number of unhealed post-surgical wounds during the last ten years.

This may be due to shortened hospital stays, partly due to overloaded wards both in hospitals and health care. Also during the past ten years many multiresistant bacterial strains (e.g. Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococcus (VRE), tobramycin-resistant Pseudomonas aeruginosa (TRPA)) have become a bane of health care.

This data are used to further develop to treatment path of problem wounds. Regarding ulcer prevention and treatment of uncomplicated wounds, first line wound treatment, health centres and home care are in a key position.

Problem wound treatment and consultation will be carried out by teamwork of primary and secondary care(21).

Integrated wound clinics with in- and out-patient facilities should be based between primary and secondary care.

These wound clinic functions could be responsible for creating uniform guidelines, training, consulting and quality control. 䡵

26

Implications for Clinical Practice 䡲 It is important to assess the magnitude of the chronic wound problem to understand the need for resources 䡲 Cross-sectional studies need to be supported with prospective data

Further Research 䡲 Chronic wound registries should be made available to gather prospective data 䡲 Registry data should steer the development of treatment path of chronic wounds

Acknowledgements: The authors would like to thank all the members of The Working Group for Treatment of Chronic Wounds within the Capital Region in Finland.

References 1. Nelzen O, Bergqvist D, Lindhagen A. The prevalence of chronic lower-limb ulceration has been underestimated: results of a validated population questionnaire.

Br J Surg 1996;83(2):255-8.

2. Graham ID, Harrison MB, Nelson EA, Lorimer K, Fisher A. Prevalence of lower-limb ulceration: a systematic review of prevalence studies. Adv Skin Wound Care 2003;16:305-16.

3. Moffatt CJ, Franks PJ, Doherty DC, Martin R, Blewett R, Ross F. Prevalence of leg ulceration in a London population. Q J Med (Quarterly journal of medicine) 2004;97:431-7.

4. Pina E, Furtado K, Franks PJ, Moffatt CJ. Leg ulceration in Portugal: prevalence and clinical history. Eur J Vasc Endovasc Surg 2005;29(5):549-53.

5. Chronic leg ulcers. The Finnish Current Care guidelines. Duodecim 2007;123(17):2138-52.

6. Briggs M, Closs SJ. The prevalence of leg ulceration: a review of the literature.

EWMA Journal 2003;3(2):14-20.

7. Khan NA, Rahim SA, Anand SS, Simel DL, Panju A. Does the clinical examination predict lower extremity peripheral arterial disease? JAMA 2006;295(5):536-46.

8. Körber A, Schadendorf D, Dissemond J. Causes of leg ulcers : Analysis of the data from a dermatologic wound care center. Der Hautarzt 2009; Epub Mar 22.

9. Eriksson E, Asko-Seljavaara S, Hietanen H, Seppälä A. [Prevalence of chronic wounds]. Suomen Lääkärilehti (Finnish Medical Journal) 1999;54(8):921-5.

10. Vuorisalo S, Venermo M, Lepäntalo M, and The Finnish Guideline Working Group on Current Care of Diabetic Foot Problems. Treatment of diabetic foot ulcers. J Cardiovasc Surg 2009;50:275-91.

11. Andersson E, Hansson C, Swanbeck G. Leg and foot ulcers. An epidemiological survey. Acta Derm Venereol 1984;64(3):227–32.

12. Callam MJ, Ruckley CV, Harper DR, Dale JJ. Chronic ulceration of the leg: extent of the problem and provision of care. Br Med J 1985;290(6485):1855–6.

13. Cornwall JV, Doré CJ, Lewis JD. Leg ulcers: epidemiology and aetiology. Br J Surg 1986;73(9):693–6.

14. Nelzén O, Bergqvist D, Lindhagen A, Hallböök T. Chronic leg ulcers: an underestimated problem in primary health care among elderly patients. J Epidemiol Community Health 1991;45(3):184–7.

15. Baker SR, Stacey MC. Epidemiology of chronic leg ulcers in Australia. Aust N Z J Surg 1994;64(4):258–61.

16. Lindholm C, Bjellerup M, Christensen OB, Zederfeldt B. A demographic survey of leg and foot ulcer patients in a defined population. Acta Derm Venereol 1992;72(3):227–30.

17. Lees TA, Lambert D. Prevalence of lower limb ulceration in an urban health district.

Br J Surg 1992;79(10):1032–4.

18. Ebbeskog B, Lindholm C, Ohman S. Leg and foot ulcer patients. Epidemiology and nursing care in an urban population in south Stockholm, Sweden. Scand J Prim Health Care 1996;14(4):238–43.

19. O’Brien JF, Grace PA, Perry IJ, Burke PE. Prevalence and aetology of leg ulcers in Ireland. Ir J Med Sci 2000;169(2):110–2.

20. Oyibo SO, Jude EB, Voyatzoglou D, Boulton AJM. Clinical characteristics of patients with diabetic foot problems: changing patterns of foot ulcer presentation. Pract Diabetes Int 2002;19:10-2.

21. Lepäntalo M, Ahokas T, Heinänen T, Heiskanen-Kuisma K, Hietanen H, Juutilainen V, Iivanainen A, Iso-Aho M, Tukiainen E, Sane T, Valtonen V. Treatment path of wound patient in the HUC medical care district. Duodecim 2009;125(4):457-65.

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2010 VOL 10 NO 1

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ABSTRACTS OF RECENT COCHRANE REVIEWS Publication in The Cochrane Library Issue 1, 2010

Complex interventions for preventing diabetic foot ulceration

Sally Bell-Syer, MSc Review Group Co-ordinator Cochrane Wounds Group Department of Health Sciences Area 2 Seebohm Rowntree Building University of York York, United Kingdom sembs1@york.ac.uk

Johannes A N Dorresteijn, Didi M W Kriegsman, Gerlof D Valk This record should be cited as: Dorresteijn JA N, Kriegsman DM W, Valk GD. Complex interventions for preventing diabetic foot ulceration. Cochrane Database of Systematic Reviews 2010, Issue 1.

ABSTRACT Background:Ulceration of the feet, which can lead to the amputation of feet and legs, is a major problem for people with diabetes mellitus, and can cause substantial economic burden. Single preventive strategies have not been shown to reduce the incidence of foot ulceration to a significant extent. Therefore, in clinical practice, preventive interventions directed at patients, health care providers and/or the structure of health care are often combined (complex interventions).

EWMA values your opinion and would like to invite all readers to participate in shaping the organisation.

Please submit possible topics for future conference sessions.

EWMA is also interested in receiving book reviews, articles etc.

Please contact the EWMA Secretariat at ewma@ewma.org

28

Objectives: To assess the effectiveness of complex interventions on the prevention of foot ulcers in people with diabetes mellitus compared with single interventions, usual care or alternative complex interventions.

A complex intervention is defined as an integrated care approach, combining two or more prevention strategies on at least two different levels of care: the patient, the healthcare provider and/or the structure of healthcare.

Search strategy: Eligible studies were identified by searching the Cochrane Wounds Group Specialised Register (28/05/09), the Cochrane Central Register of Controlled Trials (CENTRAL, 28 May 2009), Ovid MEDLINE (1950 to May Week 3 2009), Ovid EMBASE (1980 to 2009 Week 21) and EBSCO CINAHL (1982 to May Week 4 2009).

Selection criteria: Prospective randomised controlled trials (RCTs) which compared the effectiveness of combinations of preventive strategies, not solely patient education, for the prevention of foot ulcers in people with diabetes mellitus, with single interventions, usual care or alternative complex interventions.

Data collection and analysis: Two review authors were assigned to independently select studies, to extract study data and to assess risk of bias of included studies, using predefined criteria.

Main results: Only five RCTs met the criteria for inclusion. The study characteristics differed substantially in terms of health care settings, the nature of the interventions studied and outcome measures reported. In three studies that compared the effect of an education centred complex intervention with usual care or written instructions only, little evidence of benefit was found.

Two studies compared the effect of more intensive and comprehensive complex interventions with usual care.

One of these reported improvement of patients’ self care behaviour. In the other study a significant and cost-effective reduction of lower extremity amputations (RR 0.30 (95% CI 0.13 to 0.71)) was achieved. All five included RCTs were at high risk of bias; with hardly any of the predefined quality assessment criteria met.

Authors’ conclusions: There is no high quality research evidence evaluating complex interventions for preventing diabetic foot ulceration and insufficient evidence of benefit. 䡵

EWMA JOURNAL

2010 VOL 10 NO 1

A less painful dressing change is something to smile about

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With Safetac, there’s no reason a dressing change should be more painful for anyone. Give your patients more reason to smile. Reduce the pain at dressing changes with Safetac technology.

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The Mölnlycke Health Care name and logo, Safetac®, Mepilex® wound dressings, Mepitel®, Mepitac® and Mepiform® are registered trademarks of Mölnlycke Health Care AB. Mölnlycke Health Care AB, Box 13080, SE-402 52 Göteborg, Sweden. Phone + 46 31 722 30 00. www.molnlycke.com © Copyright 2009 Mölnlycke Health Care. All rights reserved.

1. White R., Wounds UK 2008; Vol 4, No 1 2. Dykes PJ et al. Journal of Wound Care 2001: 10: 7-10 3. White R. Evidence for atraumatic soft silicone wound dressing use. Wounds UK 2005; 1 (3): 104-109. 3. White R. Evidence for atraumatic soft silicone wound dressing use. Wounds UK 2005; 1 (3): 104-109.

EWMA Journal Previous Issues Volume 9, no 3, October 2009 Alcohol-based hand-rub versus traditional surgical scrub and the risk of surgical site infection Mohammed Y. Al-Naami Woundswest: Identifying the prevalence of wounds within western Australia’s public health system Nick Santamaria, Keryln Carville, Jenny Prentice An exploration of current practice in nursing documentation of pressure ulcer prevention and management Julie Jordan O Brien Dressings and Topical Agents for Treating Donor Sites of Split-Skin Grafts Sanne Schreuder, et al.

The resource impact of wounds on health-care providers in Europe J. Posnett Pressure ulcer audit highlights important gaps in the delivery of preventative care in England and Wales 2005-2008 Jill Buttery, Lyn Phillips

International Journals The section on International Journals is part of EWMA’s attempt to exchange information on wound healing in a broad perspective.

English

Advances in Skin & Wound Care, vol. 23, no 1, 2010 www.aswcjournal.com Molecular Mechanism of Pulsed-Dye Laser in Treatment of Keloids: An In Vitro Study Xiao Zhibo, Zhang Miaobo Randomized Comparison of OASIS Wound Matrix versus Moist Wound Dressing in the Treatment of Difficult-to-Heal Wounds of Mixed Arterial/Venous Etiology Marco Romanelli, Valentina Dini, Maria Stefania Bertone Older Adults and Ulcers: Chronic Wounds in the Geriatric Population Catherine Cheung

Volume 9, no 2, May 2009 A simple guide to randomised control trials in wound care Carolina D Weller New HydroBalance concept tested in the primary health care sector – an impartial study of the HydroBalance concept in the community of Sorø in Denmark Rie Nygaard, Susan F. Jørgensen Synthesizing data from qualitative research Michelle Briggs A methodology for evaluating wound care technologies in the context of treatment and care Patricia R Grocott, Natasha C Campling RUT – a winning concept for both patients and the health care sector Rut F Öien Opinion Paper: Does wound care require an alternative to the randomised trial to evaluate product effectiveness?

Peter Vowden

Dutch Journal of Woundcare NTVW, vol 4. no 12, 2009 You only need two fools to start a footclinic Interview Bela Parach on the start of a specialized footclinic for diabetics Nursing Specialist contributes to higher qualit Interview Nurse Practitioner Annemieke Mooi, Slotervaart Ziekenhuis Amsterdam

Finnish

TRAM.breast Helena Puonti Wound problems after Breast Surgery Tiina Jahkola The Left Breast and Other Medical Problems Tiina With Treatment of Mediastinitis after the Sternotomy Eeva Härkönen, Antero Sahlman, Janne J. Jokinen Method LUND – V.A.C. –therapy in treatment in infection of sternum Therese Wilhelmsen Wound Management after Kidney Transplantation Pirjo Ojala, Hanna Parviainen Open abdomen – review of treatments Tiina Pukki Nurse Assess and Recognises the Changes in Surgical Wound Jonna Heiskanen, Susanna Rojo

Volume 9, no 1, January 2009 Wound related pain: evaluating the impact of education on nursing practice Helen Hollinworth Safety and efficacy of a dermal substitute in the coverage of cancellous bone after surgical debridement for severe diabetic foot ulceration Carlo Caravaggi, Adriana Barbara, Sganzaroli, Ileana Pogliaghi, Paola Cavaiani, Matteo Fabbi, Ferraresi Roberto Does surgery heal venous ulcers?

Giorgio Guarnera The CEAP classification and its evolution Pier Luigi Antignani, Claudio Allegra The role of incompetent perforators Olle Nelzén Hemodynamic patterns of venous reflux in patients with leg ulcers Hugo Partsch Combined superficial and deep vein reflux in venous ulcers: operative strategy Giorgio Guarnera, Zena Moore Volume 8, no 3, October 2008 Eucomed – Advanced Wound Care Sector (AWCS).

Positioning of advanced wound care Hans Lundgren A Laboratory Survey of the Antimicrobial Properties of Honey-Containing Dressings Rowena Jenkins Topical negative pressure versus conventional treatment of deep sternal wound infection in cardiac surgery Martin Šimek Quality of Life in the Patients with Chronic Leg Ulcers – A Preliminary Report Veronika Slonkova Compression therapy for venous leg ulcers – how to get more value for money Susan F. Jørgensen

The EWMA Journals can be downloaded free of charge from www.ewma.org

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Haava no 4, 2009

English

International Journal of Lower Extremity Wounds vol. 8, no 4, 2009 http://ijlew.sagepub.com Does Translational Apply to Research in Wound Care?

Raj Mari Admission Trends Over 8 Years for Diabetic Foot Ulceration in a Specialized Diabetes Unit in Cameroon Andre Pascal Kengne, Catherine F. T. Djouogo, Mesmin Y. Dehayem, Leopold Fezeu, Eugene Sobngwi, Alain Lekoubou, Jean-Claude Mbanya Increased Transcutaneous Oxygen Tension in the Skin Dorsum Over the Foot in Patients With Diabetic Foot Disease in Response to the Topical Use of an Emulsion of Hyperoxygenated Fatty Acids J.L. Lázaro-Martínez, J.P. Sánchez-Ríos, E. García-Morales, A. Cecilia-Matilla, T. Segovia-Gómez Venous Leg Ulcers and Emotional Consequences Graziela Souza Nogueira, Carla Rodrigues Zanin, Maria Cristina O. S. Miyazaki, José Maria Pereira de Godoy A Comparison of Superficial and Deep Bacterial Presence in Open Fractures of the Lower Extremities A.K. Ako-Nai, I.C. Ikem, F.V. Daniel, D.O. Ojo, L.M. Oginni

EWMA JOURNAL

2010 VOL 10 NO 1

EWMA Spanish

Helcos vol. 20, no 4, 2009

English

Pressure ulcers in operating room. Intraoperative incidence in patients undergoing cardiac surgery D. Gomez, M Rodriguez-Palma, F. Garcia-PAvón, R. Almozara, J.E. Torra Valuation of hydrophilic polymeric foam dressing Skinfoam® behavior in the patients’ treatment with vascular venous ulcers and pharmaceutical economic analysis S. Riera, M. Barahona, E. Roche

English

International Wound Journal, vol. 6, Issue 6, 2009 http://www3.interscience.wiley.com/journal/117982033/home

Foam properties of Sklerosierungsschaum Wollmann JC Foam sclerotherapy M. Stücker Vascular surgery. The post-thrombotic syndrome. Part 1: Pathophysiology (training, CME-post) Hach W Peritoneo-venous shunt implantation as a therapy for chylous ascites (case report) G. Tasnádi, I. Bihari, P. Bihari

Swedish

Fewer pressure ulcers with fast actions on patients floor “We have no pressure ulcers on our ward” Pressure ulcers- sequelae of care?

Do we measure prevalence of pressure ulcers in the same way?

To prevent pressure ulcers- a research-based quality improvement project at Akademiska sjukhuset, Uppsala Present research regarding pressure ulcers at Linkšping University Pressure ulcer prevalence- a comparison between two county councils New method facilitates the right choice of mattresses English

Tissue Viability Society: Trustees annual report for the year ended 31st December 2008

Journal of Wound Care, vol. 18, no 12, 2009 www.journalofwoundcare.com Quality is your safeguard Tracy Cowan The PREPARE pilot RCT of home-based progressive resistance exercises for venous leg ulcers A. Jull, V. Parag, N. Walker, R. Maddison, N. Kerse, T. Johns Marjolin’s ulcer associated with chronic osteomyelitis M. Pandey, P. Kumar, A.K. Khanna Effects of biofilm treatments on the multi-species Lubbock chronic wound biofilm model S.E. Dowd, Y. Sun, E. Smith, J.P. Kennedy, C.E. Jones, R. Wolcott A review of the current research on the role of bFGF and VEGF in angiogenesis M. Przybylski Pyoderma gangrenosum: from misdiagnosis to recognition, a personal perspective L. Hemp, S. Hall

Lithuanian

German

EWMA JOURNAL

2010 VOL 10 NO 1

Wund Management, vol. 3, no 6, 2009 English abstracts are available from www.mhp-verlag.de Electronic wound documentation systems: market research and evaluation criteria U. Hübner, D. Flemming, A. Schulz-Gödker Computerized structured assessment and report generation, exemplified by wound documentation J. Ingenerf Wound photography – A picture is worth a thousand words S. Radünz, M. Henning, W. Niebel The digital wound diagnostics and documentation tool W.H.A.T. as a basis for an integrated health care T. Wild, T. Hölzenbein, T. Grechenig, M. Bernhart, A. Binder, B. Horn, S. Strobl, J. Unosson, M. Prinz, A. Wujciow

Lietuvos Chirurgija, vol. 7, no 3-4, 2009 The European Hernia Society (Ehs) Abdominal Hernia Classification Sigitas Tamulis Balloon Pulmonary Artery Valvuloplasty – Immediate, Mid-Term And Long-Term Follow-Up Results: 20-Year Experience Sigitas Cibiras, Eugenijus Kosinskas Post-Traumatic Splenic Pseudocyst: Case Report and Review of the Literature Ieva Martinaityté, Jonas PivoriÐnas, Jonas Jurgaitis, Marius Paškonis, Anatolij Ostapenka, Kestutis Strupas Risk Factors for Postoperative Intracranial Haemorrhage after Neurosurgical Procedures Gytis Šustickas, Jelena Šcerbak, Jolita Šustickiené Bowel Obstruction Caused By Biliary Stones Algimantas Stašinskas, Juozas Stanaitis Arteriovenous Malformations of the Brain Irena Bickuté, Mindaugas Avižonis

Wound Repair and Regeneration, vol. 17, no 6, 2009 Human skin wounds: A major and snowballing threat to public health and the economy Chandan K. Se, et al.

Treatment of nonhealing diabetic foot ulcers with a plateletderived growth factor gene-activated matrix (GAM501): Results of a Phase 1/2 trial Gerit Mulder, et al.

Increased fluid intake does not augment capacity to lay down new collagen in nursing home residents at risk for pressure ulcers: A randomized, controlled clinical trial Nancy A. Stotts, et al.

Mechanism leading to the development of pressure ulcers based on shear force and pressures during a bed operation: Influence of body types, body positions, and knee positions Maki Mimura, et al.

Modulation of scarring in a liquid environment in the Yorkshire pig Richard G. Reish, et al.

Development of a new chitosan hydrogel for wound dressing Maximiano P. Ribeiro, et al.

Ultrasound accelerates healing of normal wounds but not of ischemic ones Mariane Altomare, et al.

Journal of Tissue Viability, vol. 18, no 4, 2009 Seating and pressure ulcers: Clinical practice guideline Lesley Stockton, Kryzstof S. Gebhardt, Michael Clark Correlation of donor age and telomerase activity with in vitro cell growth and replicative potential for dermal fibroblasts and keratinocytes M.H. Ng, B.S. Aminuddin, S. Hamizah, C. Lynette, A.L. Mazlyzam, B.H.I. Ruszymah Abstracts of the Tissue Viability Society Annual Meeting, Llandudno, Wales, 2009

English

Tidskriften Sår vol. 3, no 3, 2009 Theme: Pressure ulcers

Wound cleansing, topical antiseptics and wound healing Bishara S Atiyeh, Saad A Dibo, Shady N Hayek Intra-lesional injections of recombinant human epidermal growth factor promote granulation and healing in advanced diabetic foot ulcers: multicenter, randomised, placebocontrolled, double-blind study José I Fernández-Montequín, et al.

Hypertrophic versus non hypertrophic scars compared by immunohistochemistry and laser confocal microscopy: type I and III collagens Gisele V Oliveira, et al.

A clinical investigation into the microbiological status of ‘locally infected’ leg ulcers Rose A Cooper, Hanar Ameen, Patricia Price, Dorothy A McCulloch, Keith G Harding

English

Phlebologie, no 1, 2010

Scandinavian

Wounds (SÅR) vol. 17, no 4, 2009 www.saar.dk Treatment costs of healing neuropathic diabetic foot ulcers Beate Sørgård, Eline Aas, Odd Erik Johansen Six prevalence studies for pressure wounds Susan Bermark, Liselotte Brostrup Jensen, Esther Krejberg, Annette V. Norden, Rikke Trangbæk, Jette Palmberg, Anne Ørskov Hand hygiene for patients – how hard can it be!

Britta Østergaard Melby, Angelique Wiene van Ooijen AnyBody – Pressure ulcer project at Aalborg University Christian Gammelgaard Olesen, John Rasmussen

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20th Conference of the European Wound Management Association

EWMA 2010 26-28 MAY 2010 · GENEVA · SWITZERLAND

T

he EWMA 2010 Conference will be held in Geneva, Switzerland and it is organised in cooperation with the Swiss Association for Wound Care – the Swiss German section and the Swiss French section.

The theme of this year’s conference is “Get the Timing Right”, and the reason for choosing this theme is that timing is important in many aspects of life but especially, with regards to wound care and wound healing, it is very important when to act, when to begin the right treatment in the right order. Healing time is – among others – a consequence of treatment time. In relation to timing, treatment guidelines become important not only when we speak of chronic wounds but also trauma wounds.

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䡲

䡲

The European Federation of National Associations of Orthopaedics and Traumatology (EFORT) will contribute with a guest session entitled “The Complicated Wound after Orthopaedic Surgery”.

DEBRA International (the alliance of national patient support groups worldwide representing people with epidermolysis bullosa (EB)) contributes with a guest session on epidermolysis bullosa, which is a rare genetic condition in which the skin and mucosa blister at the slightest trauma.

In addition to the above, the conference programme will consist of key sessions, free paper sessions, workshops and satellite symposia on the topics listed below.

EWMA 2010 is a trilingual conference and the conference languages are English, French and German. Plenary sessions, key sessions, some free paper sessions and all conference material will be in all three languages.

The EWMA conference is not only scientific presentations and educational courses but it is also much more than that. It is a platform for networking, for research groups to meet, for committees to take implementation projects forward and it is a very important forum for scientific and clinical exchange of knowledge. Thus, the objective of the conference is to bring together people with different experiences and different educational backgrounds from different disciplines and different countries in order to further the development and implementation of wound management practices across Europe and ultimately, together with our international partners, all over the world.

KEY SESSIONS 䡲 Time to implement (opening plenary session) 䡲 The value of health economics in Wound Healing 䡲 Wound care concepts in countries with low resources (under the patronage of the WHO) 䡲 Vascular Ulcers 䡲 Wound care in older people 䡲 Wound Models 䡲 Diabetic Foot Infection 䡲 Pressure Ulcers – Guidelines 䡲 Global relief and acute wound care in disrupted environments (under the patronage of the International Committee of the Red Cross.)

Several organisations involved in wound management have guest sessions at EWMA 2010.

In 2010, two organisations that EWMA recently started collaborating with will have a guest session for the first time at a EWMA conference:

Early registration deadline: 15 March 2010 Please register online at www.ewma2010.org/registration For more information about the EWMA 2010 conference, please visit www.ewma2010.org

EWMA JOURNAL

2010 VOL 10 NO 1

EWMA

GET THE TIMING RIGHT SWISS SYMPOSIUM: TIMING IN WOUND CARE – WHERE IT MATTERS The Conference will be held in cooperation with the Swiss Association for Wound Care – the Swiss German section and the Swiss French section.

WORKSHOPS 䡲 Artificial skin 䡲 Critical appraisal 䡲 How to make a good case story 䡲 How to make an oral presentation/ poster presentation 䡲 Partnership between patient and health care provider 䡲 Atypical wounds 䡲 Prevention and infection 䡲 Cancer and wounds 䡲 Compression 䡲 Debridement 䡲 Guest session by Debra International Please note that for some workshops the number of participants is limited. This will be highlighted in the Final Programme.

FREE PAPER AND POSTER TOPICS Free papers and posters can be submitted for any topic in wound healing and wound management.

Primary categories are (in alphabetical order): 䡲 Acute Wounds (Burns and Surgical) 䡲 Devices and Intervention 䡲 Diabetic Foot Ulcers 䡲 Dressings 䡲 Education 䡲 Health Economics and Outcomes 䡲 Health Organisation 䡲 Infection 䡲 Leg Ulcers 䡲 Pressure Ulcers 䡲 Quality of Life 䡲 Basic Science 䡲 Wound Assessment EWMA JOURNAL

2010 VOL 10 NO 1

Thursday 27 May 2010 The Swiss symposium will follow several time points of a patient’s journey in four sessions and emphasize points, where timing matters. The four sessions will cover: 䡲 Time for diagnosis: A diagnosis should always come first.

Some important diagnoses must not be missed. 䡲 Time to deal with the wound Insights into the psychosocial burden a chronic wound can be. 䡲 Time to heal the wound How to plan and implement the treatment. 䡲 Time to be reimbursed How is wound care reimbursed in Switzerland and how can it be made more economical.

The Swiss Symposium is organised by the Swiss Association for Wound Care (SAfW). The symposium will be held in French and German only. Presentations held in German will be simultaneously translated into French and vice versa (no English translation).

SOCIAL EVENTS Registration event Date: Tuesday 25 May Time: 17.00-20.00 Place: Geneva Palexpo (conference venue) Price: Included in the registration fee All participants are invited to attend the welcome reception at Geneva Palexpo Conference Centre.

This is an opportunity to register for the conference and meet other participants while enjoying a drink and a light snack.

Conference evening Date: Thursday 27 May Time: 19:30-24:00 Place: The Grand Hotel Kempinski Price: 80 EUR per person The EWMA 2010 conference evening will be held on 27 May 2010 at the Grand Hotel Kempinski located at the banks of Lake Geneva. It will be an informal seated dinner with a taste of local, food, wine and entertainment. It will be possible to reserve tables for groups of 10 persons or more.

Remember to buy your ticket for the conference evening, when you register for the conference.

NB! Please note that tickets for the conference 䊳 evening are non-refundable.

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EWMA

EWMA UNIVERSITY CONFERENCE MODEL (UCM) DURING THE EWMA 2010 CONFERENCE Since 2007, EWMA has successfully offered students of wound management from institutes of higher education across Europe the opportunity to take part of their academic studies whilst participating in the EWMA Conference.

In 2010, students from the following teaching institutions in Belgium, Ireland, Portugal, Switzerland and UK are expected to participate in the EWMA UCM in Geneva:

However, the opportunity of participating in the EWMA UCM is available to all teaching institutions with wound management teaching programs for health professionals.

EWMA strongly encourages teaching institutions and students from other countries to benefit from the possibility of international networking and access to lectures by many of the most experienced wound management experts in the world.

For further information about the EWMA UCM, please visit the Education section of the EWMA website www.ewma.org or contact the EWMA Secretariat at ewma@ewma.org.

AWARDS Poster prizes These awards are designed to reward the considerable work that goes into preparing a poster for presentation at the conference. To be eligible for consideration you must have a paper accepted for poster presentation at the EWMA 2010 conference. Posters that have been submitted/presented elsewhere are not eligible for a poster prize. A panel of judges will attend the poster sessions, and authors are strongly encouraged to be present at these sessions in order to answer questions concerning their work. The panel will award 3-5 poster prizes.

The value of each poster prize is EUR 200.

Your accepted poster will automatically be considered for this award, provided that it has not previously been submitted elsewhere.

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EWMA First Time Presenter Prize This award is designed to encourage people who have not previously presented their work at an international conference. To be eligible for this prize you must have submitted your abstract to EWMA and you must be a “novice presenter”. That is, you should not have presented previously at an international conference.

The value of the First Time Presenter Prize is EUR 450.

Please confirm that you are applying for this award when submitting your abstract online. Furthermore, you should send a letter to the EWMA Secretariat stating that this is your first presentation at an international conference, and you should enclose a letter from your employer/supervisor/manager confirming that you have not previously presented at an international conference.

THE CONFERENCE CITY Situated along the banks of Lake Geneva at the foot of the Alps, Geneva sparkles as one of Europe’s most beautiful cities. Home to the European headquarters of the United Nations, Geneva has a long history of diversity and tolerance dating back to the Protestant Reformation. Today, the city of Geneva is a cultural centre second to none featuring world class entertainment, top rated restaurants and unlimited opportunities for recreation.

Geneva’s most famous monument, the Jet d’eau, is the world’s tallest water fountain and provides a constant landmark for exploring the city. Geneva’s ancient Old Town offers a living glimpse of the past while Geneva’s more than thirty museums and art galleries capture the rich and vibrant history of the city including the International Red Cross and Red Crescent Museum and the Museum of Modern and Contemporary Art (MAMCO). For a change of pace take a cruise on the lake or relax in one of Geneva’s man waterfront parks.

Geneva is the perfect home base for exploring the surrounding countryside. Whether you enjoy boating, hiking, biking or wine tasting Geneva offers easy access to paradise as well as numerous organized tours. Day trips to the nearby towns of Montreux, Chamonix and Lausanne are also popular.

Conference venue The venue chosen for the EWMA 2010 Conference is Geneva Palexpo (www.geneva-palexpo.ch), which is located right next to Geneva International Airport only 6 minutes from the city centre by train and 10 minutes by car. 䡵

For more information about Geneva please visit www.geneve-tourisme.ch

EWMA JOURNAL

2010 VOL 10 NO 1

20th Conference of the European Wound Management Association EWMA2010 · 26 -28 MAY GENEVA · SWITZERLAND

GET THE TIMING RIGHT IMPORTANT DATES 15 March 2010: Early registration deadline 26-28 May 2010: Conference dates

WWW.EWMA.ORG/EWMA2010 Organised by the European Wound Management Association in cooperation with Swiss Association for Wound Care, SAfW (Swiss German Section) and Swiss Association for Wound Care, SAfW (Swiss French Section)

Introducing the Swiss Association

M Severin Läuchli, M.D. President, Swiss Association for Wound Care (Swiss German Section) Department of Dermatology, University of Zurich, Switzerland www.safw.ch

Hubert Vuagnat, M.D. President, Swiss Association for Woundcare (Swiss French Section) Department of rehabilitation and Geriatrics, Continuous care service, University hospitals of Geneva, Switzerland

ore than ten years ago, the idea of moist wound care started to be widely accepted amongst the few medical doctors who made the treatment of patients with chronic wounds their main focus of interest.

Industry had come up with a variety of modern wound dressings to make wound treatment according to modern standards possible. However, wound care had always been a multidisciplinary field and it seemed difficult to get the message of how to apply modern principles to wound care across to the many health professionals involved in this field.

In this context, the Swiss Association for Woundcare was founded in 1996 by a vascular surgeon, the late Prof. Urs Brunner. It currently has over 500 members in the Swiss German part and over 150 in the Swiss French part, including M.D.’s of different specialties (e.g., vascular surgeons, dermatologists, diabetologists), specialized wound care nurses and representatives of other health care professions dealing with chronic wounds.

Switzerland is made up of four linguistic communities (German, French, Italian and Romantsch). Hence, in a second step, the French speaking members created their own association in order to facilitate the organization of continuing education events in their linguistic areas. The two associations co-operate closely in all matters of national interest, especially where professional political issues are concerned.

www.safw-romande.ch

The main purpose of the Swiss Association for Woundcare is to promote modern wound care.

This is done through education and the establishment of interdisciplinary co-operation and education of M.D.’s and specialized wound care nurses as well as the promotion of scientific projects in this area. Furthermore, the association is the primary partner of the health authorities where regulatory and professional political matters in wound care are concerned. For example, SAfW

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Cathedrale Saint Pierre, Geneva

cooperated with the Swiss Society of Dermatology on a mandate of the Swiss health ministry to establish guidelines for the use of bioengineered skin substitutes and certification of M.D.’s and centers allowed to employ these expensive, but highly effective procedures.

One of the main pillars of the association’s activities is the annual symposium on modern wound care which is held separately in the Swiss German and the Swiss French part of the country. It is very popular amongst health professionals in wound care in Switzerland, each drawing hundreds of participants. After two annual meetings in 2007 and 2009 held in collaboration with the Austrian Wound Care organization, SAfW is very proud to be hosting this year’s meeting of the European Wound Management Association (EWMA) from May 26h-28, 2010 in Geneva.

EWMA JOURNAL

2010 VOL 10 NO 1

EWMA

for Wound Care

Geneva is situated along the banks of Lake Geneva at the foot of the Alps.

The most famous monument is the Jet d’eau – the world’s tallest water fountain.

The education of wound care specialists is a further mainstay of SAfW’s activities. In 2004, for the first time in Switzerland, SAfW co-operated with the Association of Swiss hospitals (H+) to provide a course leading up to a wound care expert diploma. Since its inception, there have been 300 graduates from this diploma program. In line with the Bologna educational reforms in Europe which allows greater mobility between universities with a uniform credit point system, as of this year, a course leading up to a certificate of advanced studies in wound care will be offered in collaboration with a Swiss university (WE’G in Aarau).

For the French speaking students, a similar certificate of advanced studies has been offered for four years by the University for Nursing Skills in Geneva (HEDS), which also participates in EWMA’s UCM model.

In order to promote scientific studies in the area of wound management, the SAfW awards a substantial annual sum of money to support research activities in this area.

EWMA JOURNAL

2010 VOL 10 NO 1

In order to ensure standardized quality levels amongst selfappointed wound care centers, SAfW has created guidelines for the certification of wound care centers.

SAfW maintains regular contact and co-operation with the German and Austrian Associations for Wound Care (DGfW and AWA) as well as with the French and French speaking society for wound care (SFFPC).

SAfW, with other international Woundcare societies is actively engaged in promoting Woundcare in underprivileged settings.

The three German speaking societies publish a German language wound care Journal (Zeitschrift für Wundheilung) which is their official organ of communication and which is in the process of acquiring Medline accreditation. The French speaking SAfW is associated to the French journal of wound care. 䡵

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EWMA

The EWMA Teach the Teacher Project The EWMA Education Committee has since early 2008 been engaged in a project with the working title “Teach the Teacher”.

Zena Moore EWMA President and Chair of the Education Committee zmoore@rcsi.ie

Background and aim of the Project The project is aimed at raising the awareness of and improving the comprehensiveness of undergraduate nursing education in wound management.

The project is supported by 3M with an unrestricted educational grant. Financing of the implementation of the project will primarily be sought from the European Comission Lifelong Learning Programme. However, other funding sources will be approached as well including the corporate sponsors of EWMA. The background for the project is a concern within the Education Committee that undergraduate nursing education across most European countries is not sufficiently focused on wound management to develop the necessary level of competence of the students.

The results of a survey carried out as part of the preparation for the project amongst the 45 EWMA Cooperating Organisations in December 2009 confirms this concern. In addition to being used for the application to be handed in to the European Commission on the 26 February 2010, the survey will also provide the basis for an article to be published in the May 2009 issue of the EWMA Journal.

The European Commission Lifelong Learning Programme 2007-2013 consists of several sub-programmes.

For detailed information please visit: eacea.ec.europa.eu/llp/about_llp/about_llp_en.php The application for the EWMA Teach the Teacher project aims at the Leonardo da Vinci sub-programme: ec.europa.eu/education/lifelong-learning-programme/doc82_en.htm Amongst other issues, this sub-programme provides support for the training and continuous education of teachers on areas of Vocational Education and Training (VET) at undergraduate levels.

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Expected activities and results The aim of the Teach the Teacher project will be achieved through the implementation of an ICT-based continuous education programme for nurse educators.

The planning and coordination of the project will be carried out by a consortium involving a limited number of teaching institutions and the persons who have actively participated in the project development (see below). The products/results of the project will be made available for all EWMA Cooperating Organisations.

The consortium partners include: 䡲 Paulo Alves, Universidade Catolica (Porto), Portugal 䡲 Milada Franců, University Hospital Brno, Czech Republic 䡲 䡲

Luc Gryson, Hogeschool-Universiteit Brussel, Belgium Edda Johansen & Marte Ljosaa, Buskerud Univ.

College, Norway

䡲

Christina Lindholm, Red Cross University College

䡲

Nada Kecelj, University Medical Centre, Ljubljana,

Stockholm, Sweden Croatia 䡲 䡲 䡲

Zena Moore, Royal College of Surgeons, Ireland Marco Romanelli, University of Pisa, Italy Salla Seppänen, Mikkeli University of Applied Sciences, Finland

The implementation of the project is envisaged to take place in close coordination with other EWMA activities. Thus, inspired by the current EWMA University Conference Model, training activities will take place in connection with the EWMA Conference as well as other EWMA activities.

The project is expected to engage in the development and implementation of: 䡲 A blended learning education programme for nurse educators; 䡲 Building and supporting professional networks amongst nurse educators and their institutions across Europe; 䡲 Liaison between education, research & development and the clinical practice of wound management; 䡲 Evidence-based knowledge and recommendations regarding continued lifelong learning at national and European levels.

For any comments or further information regarding the Teach the Teacher project please contact Zena Moore, Chair of the EWMA Education Committee, or the EWMA Secretariat at ewma@ewma.org 䡵

EWMA JOURNAL

2010 VOL 10 NO 1

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• Cradles the calf to promote circulation.

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EWMA Activities Update Update from the EWMA Patient Outcome Group The next meeting of the EWMA Patient Outcome Group will be held in the end of March 2010. The current focus of the group is to finalise a proposal for revised recommendations on clinical data collection for chronic/problem wounds, with a particular focus on data collection in clinical trials.

The group aims to present a final document at the EWMA 2010 Conference in Geneva, Switzerland.

About the Patient Outcome Group The EWMA Patient Outcome Group consists of clinicians as well as representatives from wound care companies. The primary objectives of the group are currently to deliver recommendations on clinical data collection for chronic /problem wounds, create consensus and influence national and European policy making by participating in public debates.

EWMA joins the World Alliance on Wound and Lymphoedema Care (WAWLC)

EWMA collaboration with EFORT A new collaboration has been established between the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) and EWMA. Like EWMA, EFORT is a non-profit organisation and the collaboration presents a good opportunity to raise awareness of the importance of wound management in connection with orthopaedic surgery.

As a first initiative, EWMA will organise a 3-hour symposium at the EFORT 2010 conference which will take place in Madrid 2-5 June 2010.

The programme will include two main topics, Problem wounds and Pressure ulcers, and will target surgeons as well as nurses. Likewise EFORT has been invited by EWMA to organise a guest session at the EWMA 2010 conference.

Furthermore, collaboration has been established between EWMA and representatives from the orthopaedic nurse representatives in EFORT in order to strengthen multidisciplinary collaboration within the field.

EFORT invites all interested nurses to submit an abstract for the EFORT Nurse Day. For details please see www.efort.org/nurse.

EWMA is proud to enter as one of the founding partners of the WAWLC. The mission of the WAWLC is to work in partnership with communities worldwide to advance sustainable prevention & care of wounds & lymphoedema in settings with limited resources.

At the recent meeting of the WAWLC in Geneva, the EWMA President Zena Moore was appointed as a member of the Advisory Board. Further, the EWMA Secretariat Director Henrik J. Nielsen was appointed coordinator of the working group on fundraising and advocacy.

Wound care event in the EU Parliament, Brussels 6 October 2009 In cooperation with EWMA, the Eucomed Advanced Wound Care Sector Group (Eucomed AWCS) group arranged an awareness event on wound care during the Med Tech Week in Brussels. The event was held on 6 October 2009.

Read more about the event on page 53.

Read more about WAWLC on page 58.

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EWMA JOURNAL

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EWMA

Welcome to our new Corporate A Sponsor

EWMA initiates wound surveys to document resource impact of wounds in Europe In collaboration with the Eucomed Advanced Wound Care Sector Group, EWMA has initiated a survey on the prevalence of wounds & resource impact in the primary (home care) as well as the secondary (hospital) sector.

The survey will identify the number and types of wounds under treatment and will provide an estimate of the amount of clinician time and inpatient bed-days directly attributable to wound care at an organisational level.

Pilot studies supported by EWMA will commence in three European countries.

The final goal will be to have more countries contributing to this European data collection project when the pilot studies have been finalised.

The first pilot is being carried out in Denmark and commenced in October 2009.

In connection with the start up of the Danish wound survey, a number of pressure ulcer prevalence surveys made at several Danish hospitals were identified. 6 of these have been gathered in an article published in the journal of the Danish Wound Healing Society, SÅR, in December 2009. The article has also been submitted for publication in the May 2010 issue of EWMA Journal.

For more than 80 years, Abbott Nutrition has been recognized as a world leader in delivering world-class clinically proven, sciencebased nutrition products to support the growth, health and wellness of people of all ages. In addition to developing the first infant formula Similac, Abbott Nutrition created the first medical nutritional with Ensure. We also introduced the first diabetic nutritional with Glucerna, the first critical care nutritional with Oxepa, and, the first therapeutic nutritional specially designed for cancer, Prosure.

Today, Abbott Nutrition develops and markets a wide range of science-based medical nutritionals, nutrition and energy bars, infant formulas, and related products. Our internationally recognized brands include medical foods clinically shown to address the distinct dietary needs of people with serious health conditions or special nutrient requirements, such as nutrition shakes and bars for people with diabetes; complete and balanced nutrition for adults; and therapeutic, balanced nutrition designed for cancer patients. Abbott Nutrition also offers specialized nutrition products to meet the unique needs of athletes, as well as all natural nutrition bars for busy people.

Additionally, Abbott Nutrition is a leader in pediatric nutrition and offers infant formulas; follow-on formulas and growing-up milks for older babies and toddlers; pre-school milk for children 3 years and beyond; and balanced nutrition and snacks for children.

Abbott Nutrition also offers Abound, a targeted nutrition therapy clinically shown to help support wound healing. Abound consists of a unique trio of key active ingredients Arginine and Glutamine, which are both amino acids, and HMB, a metabolite of the amino acid leucine. Representing the newest nutritional science, the advanced formulation of Abound delivers conditionally-essential nutrients needed to help build lean body mass and meet the high demands of wound healing.

Abbott Nutrition believes that current approaches to wound healing (debridement, antibiotic creams, wound dressings, and pills) are insufficient without considering nutritional therapy. As a result, the prevalence of hard-to-heal wounds and the costs of wound management, both emotional and financial, continue to rise. Fortunately, when the latest principles of wound management are paired with the newest nutritional science, it is possible to design medical nutrition therapy that helps to target the needs of patients with hard-to-heal wounds.

Abbott Nutrition products are made in manufacturing facilities around the world, including the United States, Canada, The Netherlands, Ireland, Spain and Singapore.

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41

EWMA Travel Grants EWMA is committed to the advancement of wound care and wound management in Europe and it encourages international understanding and learning between nurses, doctors and other healthcare workers. Therefore, EWMA provides travel grants to young practitioners who wish to develop their skills within wound care and wound management abroad.

The travel grants will primarily be given for educational purposes or clinical experiences outside the applicants’ own countries. Novice practitioners have priority, but more experienced applicants are also accepted.

Requirements: • Applicants must have been a member of EWMA for 1 year.

• The grants are limited to travelling within Europe.

• The maximum amount that can be applied for per applicant is 3000 EUR • All grant receivers must write a report of 1-2 pages about their stay abroad.

This report will be published in EWMA Journal How to apply: 1. Write a letter in English to EWMA stating a. the purpose of your travels b. what you aim to achieve during your travels c. where you are traveling to (address(es), institution(s) etc.) d. dates and duration of your stay 2. Attach a letter of acceptance from centre/institution to be visited 3. Address the letter to Zena Moore, Chair of the Travel Grant Committee and send the letter and the letter of acceptance electronically and via regular post to: EWMA Secretariat Martensens Allé 8 DK-1828 Frederiksberg C Denmark ewma@ewma.org Deadline for submission of applications is 15 February 2010 You will receive notification of whether or not you have been given a travel grant by 15 March 2010.

After your travels: 1. It is obligatory to write a report (1-2 pages) about your travels and what your outcome of the stay was.

This report will be published in EWMA Journal.

2. Please send this report to EWMA Business Office Fur forther information about travel grants please contact EWMA Business Office at ewma@ewma.org

Healing Chronic Wounds -

Completely.

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t 1SPWFO TBGF OPO JOWBTJWF UIFSBQZ t (SFBUFS UIBO DPNQMFUF XPVOE DMPTVSF SBUFT t 4UJNVMBUFT BOHJPHFOFTJT BOE DPMMBHFO QSPEVDUJPO t &òFDUJWF JOGFDUJPO DPOUSPM CZ FMJNJOBUJOH QBUIPHFOT t 4JHOJöDBOU SFEVDUJPO JO XPVOE SFMBUFE QBJO t 4P TJNQMF UP VTF UIBU ZPV DBO USFBU QBUJFOUT JO UIFJS IPNF t 4JHOJöDBOU DPTU TBWJOHT To learn more and review references, go to:

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Corporate Sponsor Contact Data Corporate A

Abbott Nutrition 200 Abbott Park Road Abbott Park Illinois 60064 USA www.abbottnutrition.com

Paul Hartmann AG Paul-Hartmann-Strasse D-89522 Heidenheim Germany Tel: +49 0 7321 / 36-0 Fax: +49 0 7321 / 36-3636 www.hartmann.info

ConvaTec Europe Harrington House Milton Road, Ickenham, Uxbridge UB10 8PU United Kingdom Tel: +44 0 1895 62 8300 Fax: +44 0 1895 62 8362 www.convatec.com

Covidien 154, Fareham Road PO13 0AS Gosport United Kingdom Tel: +44 1329 224479 Fax: +44 1329 224107 www.covidien.com

KCI Europe Holding B.V. Parktoren, 6th floor van Heuven Goedhartlaan 11 1181 LE Amstelveen The Netherlands.

Tel: +31 0 20 426 0000 Fax: +31 0 20 426 0097 www.kci-medical.com

Lohmann & Rauscher P.O. BOX 23 43 Neuwied D-56513 Germany Tel: +49 0 2634 99-6205 Fax: +49 0 2634 99-1205 www.lohmann-rauscher.com

Mölnlycke Health Care Ab Box 13080 402 52 Göteborg, Sweden Tel: +46 31 722 30 00 Fax: +46 31 722 34 08 www.molnlycke.com

Ferris Mfg. Corp.

16W300 83rd Street Burr Ridge, Illinois 60527-5848 U.S.A. Tel: +1 (630) 887-9797 Toll-Free: +1 (630) 800 765-9636 Fax: +1 (630) 887-1008 www.PolyMem.eu

Systagenix Wound Management Gargrave North Yorkshire BD23 3RX United Kingdom Tel: +44 1756 747200 Fax: +44 1756 747590 www.systagenix.com

Use the EWMA Journal to profile your company Deadline for advertising in the May 2010 issue is 1 April 2010

44

EWMA JOURNAL

2010 VOL 10 NO 1

EWMA

Corporate B

3M Health Care Morley Street, Loughborough LE11 1EP Leicestershire United Kingdom Tel: +44 1509 260 869 Fax: +44 1 509 613326 www.mmm.com

AOTI Ltd. Qualtech House Parkmore Business Park West Galway, Ireland Tel: +353 91 660 310 Fax: +353 1 684 9936 info@aotinc.net www.aotinc.net

Argentum Medical LLC Silver Antimicrobial Dressings 2571 Kaneville Court Geneva, Illinois 60134 U.S.A. Tel: +1 630-232-2507 Fax: +1 630-232-8005 international@silverlon.com www.silverlon.com

ArjoHuntleigh 310-312 Dallow Road Luton Bedfordshire LU1 1TD United Kingdom Tel: +44 1582 413104 Fax: +44 1582 745778 www.ArjoHuntleigh.com

B. Braun Medical 204 avenue du Maréchal Juin 92107 Boulogne Billancourt France Tel: +33 1 41 10 75 66 Fax: +33 1 41 10 75 69 www.bbraun.com

Flen pharma NV Blauwesteenstraat 87 2550 Kontich Belgium Tel.: +32 3 825 70 63 Fax: +32 3 226 46 58 info@flenpharma.com www.flenpharma.com

HILL-ROM 83, Boulevard du Montparnasse 75006 Paris France www.hill-rom.com

Life Wave 1 Azrieli Center, Round Tower 41st floor Tel Aviv 67021 Israel Tel: +972-3-6095630 Fax: +972-3-6095640 sales@life-wave.com www.life-wave.com

Nutricia Advanced Medical Nutrition Schiphol Boulevard 105 1118 BG Schiphol Airport The Netherlands www.nutricia.com

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2010 VOL 10 NO 1

Organogenesis Switzerland GmbH Baarerstrasse 2 CH-6304 Zug Switzerland Tel: +41 41 727 67 89 www.organogenesis.com

Polyheal Ltd. 42 Hayarkon St. 81227 Yavne Israel Tel: +972 8 932 4031 Fax: +972 8 932 4001 info@polyheal.co.il www.polyheal.co.il

Sorbion AG Von-Braun-Strasse 7a D-48346 Ostbevern Germany Tel: +49 (0) 2532 959353 Fax: +49 (0) 2532 959351 info@sorbion.de www.sorbion.com

Laboratoires Urgo 42 rue de Longvic B.P. 157 21300 Chenôve France Tel: +33 3 80 44 70 00 Fax: +33 3 80 44 71 30 www.urgo.com

Welcare Industries SPA Via dei Falegnami, 7 05010 Orvieto ( TR ) Italia Tel: +39 0763-316353 Fax +39 0763-315210 www.welcaremedical.com 45

Welcome to our new Corporate A Sponsor

The employees of Ferris Mfg. Corp. work every day to provide effective and easy-to-use products with exceptional quality. Ferris has heavily invested resources into the advancement of wound care.

Therefore, we design, manufacture, evaluate, and distribute our products; and design, build, and operate our equipment in our facilities. Ferris seeks to share its innovative philosophy of wound care worldwide.

Ferris was founded by Robert W. Sessions, a former director of biomedical research at Chicago’s Rush-Presbyterian St. Luke’s Medical Center. In his craving to add science to the art of wound care he realized that traditional therapies discourage, even inhibit, healing. Responding to this problem, Sessions began his quest for a wound-friendly dressing. After researching thousands of different formulations, he discovered a drug-free and irritantfree blend that creates an ideal warm, moist healing environment. In 1988, the original PolyMem® formulation was patented and introduced to the professional wound care market.

This truly unique formulation contained components which together provide added healing and pain relief benefits, including a tissue-friendly wound cleanser, a moisturizer, and super- absorbents. Despite its foam-looking appearance, PolyMem should never be confused with foams.

Multi-functional PolyMem dressings effectively cleanse, fill, absorb, and moisten wounds throughout the healing continuum. In addition, PolyMem

helps relieve persistent wound pain, often eliminating the pain associated with wound care procedures.

Through the inspiration provided by Mr. Sessions, Ferris has proceeded on a path that led to numerous patents, trademarks, awards, and recognitions for excellence in medical product design and contributions to the medical profession. The awards include 䡲 Illinois Governor’s Export Award (1998 and 1999), 䡲 KPMG Peat Marwick High-Tech Entrepreneur

Award, 䡲 Medical Device and Diagnostic Industry’s Medical

Design Excellence Awards® (2000), 䡲 Industry Week’s Top 25 Growing Companies Award

(2000), 䡲 WOCN Case Study Merit Award (2006), 䡲 Frost & Sullivan 2006 North-American Product

Differentiation Innovation Award.

This latest award was for its most recent line, Shapes® by PolyMem – a large range of pre-cut, easy-to-use dressings that reduce the need to manually cut dressings to size.

After three years as a Corporate-B sponsor, and as a sign of satisfaction with the cooperation with EWMA, Ferris is happy to join the elite group of EWMA Corporate-A sponsors.

Ferris takes this opportunity to gratefully thank our regional partners as well as clinicians and users for all their support.

To learn more about Ferris Mfg. Corp. and PolyMem, please visit www.PolyMem.eu.

EWMA Membership Become a member of the European Wound Management Association and you will receive EWMA Journal three times a year.

In addition, you will have the benefit of obtaining the membership discount, which is normally 15%, when registering for the EWMA Conferences.

A membership only costs 25 EUR a year.

Read more about all the other benefits of a EWMA membership and register as a EWMA member at

WWW.EWMA.ORG

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EWMA JOURNAL

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EWMA

EWMA Position Documents

Spring 2008

Spring 2007

Spring 2006

Autumn 2005

Autumn 2005

Spring 2004

Spring 2003

Spring 2002

Editor: Christine Moffatt The EWMA Position Documents are available in English, French, German, Italian and Spanish, and can be downloaded from www.ewma.org It is possible to obtain permission to translate the EWMA Position Documents into other languages.

Please contact EWMA Business Office.

Future EWMA guidance documents EWMA is currently planning to produce a guidance document on implementation, in order to support the implementation of existing knowledge in wound care and thereby support change according to treatment guidelines and consensus papers.

EWMA JOURNAL

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For further details contact MEP Ltd, Unit 3.05, Enterprise House 1-2 Hatfield, London SE1 9PG United Kingdom www.mepltd.co.uk or EWMA Business Office, Congress Consultants, Martensens Allé 8, 1828 Frederiksberg, Denmark Tel: +45 7020 0305 Fax: +45 7020 0315 ewma@ewma.org

47

Conferences

Conference Calendar Conferences

Theme

2010

NIFS Annual Meeting

Difficult wounds or difficult wound healing?

Days

City

Country

Feb

4-5

Tønsberg

Norway

Diabetes UK Annual Conference (APC)

Mar

3-5

Liverpool

UK

DF Con - Diabetic Foot Global Conference

Mar

18-20

Hollywood

USA

2nd Australasian Wound & Tissue Repair Society

Mar

22-24

Perth

Western Australia

2nd ILF Conference

Mar

23-25

Brighton

UK

2010 Wound Healing Society Meeting

Apr

17-20

Orlando, Florida

USA

GAIF Annual Meeting

Theme: From Eminence to Evidence.

May

20-21

Lisbon

Portugal

20th Conference of the European Wound Management Association (EWMA 2010)

Theme: Get the timing right

May

26-28

Geneva

Switzerland

11th EFORT Congress

Jun

2-5

Madrid

Spain

Nurse Session at the 11th EFORT Congress

Jun

3

Madrid

Spain

DGfW Annual Meeting

Jun

17-19

Freiburg

Germany

14th Annual Oxford-European Wound Healing Summer School,

Jul

4-7

Oxford

UK

13th Annual EPUAP Meeting

Pressure Ulcers: The Flourishing of Science to Support Prevention and Healing

Sep

1-4

Birmingham UK

UBUNTU conference - A Global Wound Healing Initiative

Theme: Uncovering the hidden wound

Sep

5-8

Cape Town

South Africa

20th ETRS Congress

Basic and Clinical Research: Building Blocks in the Puzzle of Tissue Repair

Sep

16-18

Gent

Belgium

9th Scientific Meeting of the Diabetic Foot Study Group (DFSG) of the EASD

Sep

17-19

Stockholm

Sweden

EWMA Education Seminar

Oct

Pisa International Diabetic Foot Courses

Oct

7-9

Pisa

Italy

VIII Simposio Nacional sobre Ulceras por Presión y Heridas Crónicas

Nov

10-12

Santiago de Compostela

Spain

For web addresses please visit www.ewma.org

In the autumn of 2010,

the EWMA Educational Seminar will be introduced.

The Educational Seminar will focus on a practical approach to wound management and wound care and it will support the implementation of best practice wound management.

Please keep an eye on the EWMA website

www.ewma.org for updates.

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See what Gelling Foam can do for your patients VersivaÂŽ XCâ&#x201E;˘ Gelling Foam DressingThe only dressing with the gelling foam advantage, redefining patient care

Offers more for wound management than just a moist wound environment

1

2

References: 1. Vanscheidt W, MĂźnter K-C, KlĂśvekorn W, Vin F, Gauthier J-P, Ukat A. A prospective study on the use of a non-adhesive gelling foam dressing on exuding leg ulcers. J Wound Care 2007; 16: 261-265. 2. Bishop S. VersivaÂŽ XCâ&#x201E;˘ Gelling Foam Dressing cushioning and protection claims R&D justification.

WHRI2749 MS002 June 2005. Data on file, ConvaTec. Ž/TM The following are trade marks of E.R. Squibb & Sons, L.L.C.: Versiva, Versiva XC and Hydrofiber. ConvaTec is an authorised user. Š2008 E.R. Squibb & Sons, L.L.C. 2008. EU-08-780

ZZZ FRQYDWHF FRP

Welcome to our new Corporate A Sponsor

DEAR EWMA MEMBERS: The Japan Society for Surgical Wound Care and the Japanese Society of Pressure Ulcers will proudly host the 4th congress of the World Union of Wound Healing Societies in 2012 (WUWHS 2012) in Yokohama, Japan, September 2 to 7, 2012.

The main theme of this important event in the

HARTMANN was founded in 1818 as a cotton spinning mill, becoming the first German wound dressing company when starting to manufacture absorbent cotton in 1873.

wound healing societies around the world is

Today HARTMANN is a global supplier of a wide variety of high quality medical products with a long tradition and high reputation. Its product portfolio ranges from wound care and incontinence products to material for operating theatres and personal health care.

The WUWHS is held every 4 years,

The wound care segment has the longest history of all and comprises of moist, antimicrobial, textile and post-operative wound dressings, dressing retention products and products for compression therapy. While this comprehensive portfolio already enables us to provide the right solution for both acute and chronic wound care in all different healing stages, we constantly continue our path of improvement and innovation.

This largest wound care product portfolio is united under the CombiSensation roof – a customer oriented concept focusing on individual user competence, greatest possible therapeutic success and maximized treatment quality. It helps us to communicate our unique strength – providing complete, single source solutions for all possible indications, no matter if a gauze bandage, a sterile post-op dressing is needed or a hydroactive product for efficient wound cleansing combined with an effective compression therapy.

“Better Care, Better Life”.

starting in Melbourne in 2000, Paris in 2004 and Toronto in 2008.

It is the first time to be held in Asia.

Over 5,000 delegates are expected to join and unique and vibrant experiences of wound healing, exchanging knowledge, information and friendship.

Further details are depicted at website of http://wuwhs2012.com/index.html.

We very much welcome EWMA members in early September of 2012 in Japan.

We focus on the people in everything we do – on both patients treated with our products and users applying them. It is our aim and passion to work together with health professionals as partners, empowering them in every possible way to do their best for the good of our mutual patients.

Sincerely,

We are aware of our responsibility. As Albert Schweitzer put it, “much in the world depends on those who help – and those who help to help.” This quote expresses our guiding principle leading all our actions to the same goal:

WUWHS2012-Organizer Kiyonori Harii, MD, PhD, President Takehiko Ohura, MD, PhD, Honorary President Sadanori Akita, MD, PhD, Secretary General S

HARTMANN helps healing.

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Conferences

Meeting Report

12th European Pressure Ulcer Advisory Panel Meeting Amsterdam September 3rd - 5th The theme of the meeting this year was: Pressure Ulcers; not just a disease of the elderly – are your patients at risk? The aim of this was to attract a broader range of delegates therefore the conferences presentations focussed on neonates / paediatrics, spinal cord injured patients, patients with diabetes and those requiring palliative wound care in addition to some of the more usual subjects.

The programme had a good mix of clinical and scientific sessions. The science theme started with an excellent review session from Dr Matthew Hardman on the physiological differences in the skin of paediatrics and neonates which made them more vulnerable to pressure ulcers and other types of skin problems, and was followed by exciting new research such as that by Sandra Loerakker on the effect of intermittent loading on skeletal muscle damage, and 4 shorter sessions on basic science from scientists from across Europe which presented new data which may challenge some of our current beliefs and practices.

There were of course several presentations from the EPUAP / NPUAP guideline groups following their extensive piece of collaborative working over the last 5 years, with Carol Dealey and Katrien Vanderwee presenting the final outcome of the International Guideline Initiative. This phenomenal piece of work can truly be said to be representative of International consensus as not only did the main work occur between the European and American societies but the output was also reviewed and commented on by amongst others the Japanese Pressure Ulcer Society and the Australian Pressure Ulcer Society. The short versions of the clinical guidelines on both prevention and treatment are now available to download free of charge from www.epuap.org/guidelines.html.

Free papers covered a wide range of topics crossing clinical practice, education and science and throughout the free papers the focus on the broader patient group was clearly evident.

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There was also a comprehensive poster display addressing a wide range of topics. EPUAP are keen to support the use of posters – often seen as of less ‘real‘ value than presenting a free paper – and in light of this award prizes for the 3 best posters.

The winning posters were: Management and prevention of pressure ulcers in neonates and paediatrics.

Maria Dolores Candela Zamora, Carmen Paterson Munoz, Clinical Hospital San Carlos Madrid Spain

Jacqui Fletcher

Incontinence management and pressure ulcer prevention: back to essentials usings millenium technology Tracy Nowiki, The Prince Charles Hospital, Brisbane, Australia

j.fletcher@herts.ac.uk

Senior Professional Tutor, Department of Wound Healing, Cardiff

A framework of assessment of patients at risk of heel pressure ulcers Jacqui Fletcher, Department of Wound Healing Cardiff University There was an extensive exhibition comprising both local and international companies with 4 companies (KCI, Arjo / Huntleigh, Covidien and Danone) sponsoring symposia and a very well attended (for an 8am start) breakfast meeting focussing on heel ulcers from EHOB. The conference was well attended with 424 delegates attending from 24 different countries. The majority of delegates were from The Netherlands, UK, Belgium, USA but there was a good spread of delegates from the rest of Europe and also as far away as Hong Kong and Australia. (France, Germany, Ireland, Sweden, Finland, Norway, Italy, Israel, Hong Kong, Austria, Hungary, Cyprus, Spain, Portugal, Croatia, Switzerland, Lebanon, Turkey, Malta, Australia).

This was an excellent conference with a slightly different feel because of the mix of people there many of whom hadn’t previously attended as they felt that there was nothing relevant to their clinical practice area – this was particularly evident with the paediatric representation with children’s nurses being present from all over the world. 䡵

The next EPUAP meeting will be in Birmingham 1st - 4th September 2010

51

Make a difference in clinical practice Become a Member of EWMA Make a difference in clinical practice

About EWMA

The most important aspect of becoming a member of the European Wound Management Association (EWMA) is that it enhances your opportunity to make a real difference in clinical practice by impacting positively on patient outcomes. It also gives you the opportunity to contribute to the drive for and development of evidence based clinical decision-making in wound management.

The European Wound Management Association (EWMA) was founded in 1991 to address clinical and scientific issues associated with wound management; represented by medical, nursing, scientific and pharmaceutical interests.

EWMA actively supports the improvement and development of clinical practice within wound management in Europe.

As a member of EWMA you will have a direct influence on this development. Further, as a EWMA member you can vote and, after 1 year’s membership, you can stand for election to the EWMA Council, which will give you further influence on the future development of wound management in Europe.

Benefits of your EWMA Membership: 䡲 You make a difference in clinical practice 䡲 䡲 䡲 䡲 䡲

within wound management in Europe EWMA Journal sent directly to you three times a year EWMA news and statements send directly to you A discount on your registration fee for EWMA Conferences Right to apply for EWMA travel grants Right to vote and stand for EWMA Council

EWMA is an umbrella organisation linking wound management associations across Europe. EWMA is also a multidisciplinary group bringing together individuals and organisations interested in wound care.

EWMA primarily reaches its objectives by being an educational resource providing travel grants for novice practitioners (for educational purposes), conferences, information and publications on all aspects of wound care.

Objectives 1. To promote the advancement of education and research into epidemiology, pathology, diagnosis, prevention and management of wounds of all aetiologies.

2. To arrange conferences on aspects of wound management throughout Europe.

3. To arrange multi-centre, multi-disciplinary training courses on topical aspects of wound healing.

4. To create a forum for networking for all individuals and organisations interested in wound management These objectives are mainly achieved through the 42 Cooperating Organisations (national wound management associations in Europe) of EWMA, the EWMA Education initiatives, the EWMA projects and the EWMA conferences.

EWMA is the largest wound management association in Europe and the annual EWMA Conferences attract 1500-2500 participants.

Please register as a EWMA member at WWW.EWMA.ORG EWMA Secretariat Martensens Allé 8, DK-1828 Frederiksberg C, Denmark Tel: +45 7020 0305 · Fax: +45 7020 0315 · ewma@ewma.org www.ewma.org

Conferences

Recap from the EWMA-Eucomed AWCS Wound in Brussels 6 October 2009 In cooperation with EWMA, the Eucomed Advanced Wound Care Sector Group (Eucomed AWCS) arranged an awareness event on wound care during the Med Tech Week in Brussels.

The event was held on 6 October 2009.

The overall aim of the event was to advocate in favour of an increased role in EU policy in improving patient access to quality treatment and improving health outcomes within wound care.

The event consisted of a lunch debate, co-hosted

by MEP Françoise Grossetête (EPP-ED, France) and MEP Antonyia Parvanova (ALDE, Bulgaria), and a number of meetings between MEPs and delegations consisting of representatives from EWMA, industry and the patients.

Jan Apelqvist and myself represented EWMA at the lunch debate, while Luc Gryson, EWMA Treasurer, took part in some of the meetings held with MEPs and members of the ENVI Committee.

Meetings were arranged with: 䡲 Vittorio Prodi, MEP and ENVI member, Italy 䡲 Boguslaw Sonik, ENVI member, Poland 䡲 Andrés Perelló Rodriguez, ENVI member, Spain 䡲 Sergio Berlato, ENVI member, Italy

A follow up meeting was arranged with MEP Prodi on 5 November 2009 with the objective to prepare a question to the EU Commission on the data available at EU level on wound care and how this relates to access of patients to better treatment.

As chairman on the EWMA Patient Outcome Group Finn Gottrup attended this meeting together with the chairman of the Eucomed AWCS, Hans Lundgren from Mölnlycke Healthcare.

The lunch debate attracted over 40 participants from various sectors, including health associations and industry, representatives from national permanent representations, members of the European Parliament and members of the European Commission. It generated a very positive discussion that will certainly contribute to the effectiveness of future policies.

1Member

of the European Parliament

2The

ENVI Committee is the Committee on Environment, Public Health and Food Safety, established by the European Parliament

Public Helath Director, DG Sanco, Andrzej Rys and Lunch debate hosts MEP Antonyia Parvanova and MEP Françoise Grossetête.

2010 VOL 10 NO 1

zmoore@rcsi.ie

The Eucomed AWCS and EWMA also hope that this event will contribute to a better understanding between European decision makers, the medical industry, patients and civil society in relation to the continued development of wound management. 䡵

Lunch debate in the European Parliament

Jan Apelqvist, EWMA Council, at the lunch debate

EWMA JOURNAL

Zena Moore EWMA President

Hans Lundgren, MEP Prodi and Finn Gottrup at the follow up meeting 5 November 2009.

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DEBRA International Contact information: DEBRA International Am Heumarkt 27/3 1030 Vienna Austria Tel: +43 1 876 40 30-0 Fax: +43 1 876 40 30-30 office@debra-international.org www.debra-international.org

International Partner Organisation of EWMA

DEBRA International is delighted to have become an International Partner Organisation of EWMA and looks forward to fruitful collaborations over the coming months and years.

DEBRA International is the alliance of national patient support groups worldwide representing people with epidermolysis bullosa (EB), a rare genetic condition in which the skin and mucosa blister at the slightest trauma. There are a number of forms of the condition, all of which require complex wound care. In its mildest forms blistering may be localised to hands or feet; in more severe forms all areas of the body may be affected with wounds taking a long time to heal, often accompanied by scarring. In its most extreme form, EB is fatal in early childhood. There are estimated to be approximately 500,000 people with the condition worldwide.

The association was legally constituted in 2008 but its history and achievements extend back to 1992 with the foundation of DEBRA Europe, the precursor organisation. Membership is open to patient support groups that are legally registered as not-for-profit organisations in their own countries. Representation is particularly strong in Europe, North and South America and Australasia and efforts are being made to assist groups to form in regions with less strong traditions of voluntary engagement by patients. At present, official DEBRAs exist in over 30 countries with 10-15 more in various stages of formation.

condition and provide support to specialist clinical centres. A number of forums for specific specialisms have been established to enable professionals to communicate more easily across national borders, regional symposiums are organised and support given in establishing new centres of reference, particularly by EB nurse consultants and clinical nurse specialists, many of whom are employed by the national DEBRAs. 䡲 Patient support – whilst much of the day-to-day work is undertaken at national level, DEBRA International aims to provide member groups with best international practice to underpin their activities.

The EB Without Borders campaign seeks to utilise the strengths within the association to support groups in more economically challenged parts of the world.

In addition to the above, two current priorities for action deserve mention. Access to, and reimbursement of, good quality dressings remains patchy worldwide, even in some countries with well-developed healthcare systems. Even when a wide range of products is available, none to date have been specifically developed with the needs of people with EB in mind due to the perceived small size of the market (although individuals with the condition consume great volumes). DEBRA International is seeking, through collaborations with a number of interests, to influence the design process so that it starts with the EB patient.

DEBRA International’s main activities include; 䡲 Research – approximately € 2.5 million each year is committed to EB research by member groups, successful projects going through a centralised peer-review process overseen by DEBRA International’s medical and Scientific Advisory Panel of internationally respected scientists and clinicians. Horizon scanning conferences are held every three years to determine priorities and early stage clinical trials are now in progress, or planned, for various forms of gene and cell therapy. 䡲 Professional support and liaison – DEBRA International recognises the crucial role played by healthcare professionals in delivering specialist care in a rare condition like EB and seeks to encourage interest in the

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In research, regulation of clinical trials and Health Technology Assessment are becoming increasingly of interest as we start to chart the progress of current exciting developments in the laboratory into potential treatments in the clinic. Our role in funding new work is undiminished but will need to be buttressed by increased contact and visibility with national and international regulators, working with partner organisations such as 䡵 EWMA, EURORDIS and EPPOSI.

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SUMS 5 Years Anniversary 25 September 2009 SUMS Iceland Wound Healing Society www.sums-is.org

Finn Gottrup MD, DMSci., Professor of Surgery Copenhagen Wound Healing Center, Department of Dermatology, D42, Bispebjerg University Hospital, DK-2400 Copenhagen NV

One of EWMA’s co-operating organisations the Iceland Wound Healing Society, SUMS organised their 5 Years Anniversary in Reykjavik in September 2009.

Iceland has been hit hard by the economical crises in the World and the currency has been devaluated to 25% of its original value. This has resulted in very high costs for all types of expenses, for instance is the prize of a normal MacDonald burger for an Icelandic inhabitant comparable to almost € 15. This may be the reason for that MacDonald is leaving Iceland at the moment!

Based on these circumstances the expectation to the meeting was that some of the members might not be able to participate because of the high costs for travel and registration. For these reasons it was a pleasure for the organizers that 125 participants showed up, which is equal to earlier meetings. This number has to be compared to the fact, that the whole population in Iceland of only 400.000 inhabitants.

At the first SUMS meeting in 2004 invited speakers were Christine Moffatt from England and Kirsten Müller, Henrik Nielsen and Finn Gottrup from Denmark. At the 5 Years Anniversary the organizers have been so kind again to invite the author (as a represent of EWMA) together with Bo Jørgensen from Denmark.

SUMS have during the years been very active in regard to education and spreading out knowledge on wound management and care in Iceland. This resulted in a very lively discussion after each talk in the morning program and in the two afternoon workshops (1. Debridement and 2. Doppler and Compression). Bo Jørgensen and the author were both lecturing and participating in the workshop on debridement.

It was a very pleasant experience for both of us to participate in Reykjavik, and we are very grateful to the organiser from SUMS, especially Gudbjorg Palsdottir, for hospitality and friendship. Many congratulations on the 5 Years Anniversary of SUMS, with a hope of further development of the society in the next 5 years. 䡵

Keynote speakers Bo Jørgensen and Finn Gottrup together with Gudbjorg Palsdottir from SUMS.

Participants of the 5 Years Anniversary Meeting of SUMS

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Report from the third PWMA congress PWMA Polish Wound Management Association www.ptlr.pl

Arkadiusz Jawien, M.D., Ph.D. Department of Surgery, Collegium Medicum of Nicolai Copernicus University in Bydgoszcz, Poland Maria T. Szewczyk, M.D. Ph.D. Department of Surgical Nursing, Collegium Medicum of Nicolai Copernicus University in Bydgoszcz, Poland

Bydgoszcz, Poland The Art of Wound Healing was the main motto of the third Congress of the Polish Wound Management Association (PWMA) which took place in Bydgoszcz on October 21-24th 2009.

The congress was held in the magnificent, world renowned concert hall of the Ignacy Paderewski Pomeranian Philharmonic. More than 1000 participants, including invited guests and speakers from Poland, Denmark, England, Slovenia, Germany and the Czech Republic came to take part in our Congress.

The scientific program of the congress consisted of ten main sessions covering the following topics: bedsores, diabetic foot, biofilm, burns, and venous ulcers as well as sessions concerning the latest concepts and achievements of local and general procedures on patients suffering from chronic wounds. In the bedsores session, the initial results of the newly developed bedsores registration program in Poland were presented. In addition, a number of concepts in patient care for patients suffering from bedsores were part of the oral presentations.

Welcome The opening ceremony was led by the president of the Polish Wound Management Association, Professor Arkadiusz Jawien. Among the honourable guests were Professor Finn Gottrup, who was representing EWMA; the first president of PWMA Professor Zbigniew Rybak; the presidents of other Polish scientific associations; the President of Bydgoszcz, Mr. Konstanty Dombrowicz, and representatives from other regional and state government departments. The Congress was opened by Professor Arkadiusz Jawien, who, after some welcoming words, presented the inaugural lecture, where he discussed the medical achievements in chronic wounds treatment from the ancient era up to the present day.

The Ignacy Paderewski Pomeranian Philharmonic

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The scientific programme

In the “diabetic foot” and “diabetic foot and complications” sessions, the main presentations discussed the results of current research in this field carried out on patients with different stages of development. A live, online internet transmission from the one of the outpatient clinics for wound treatment in Poland was broadcast and this allowed the congress participants to observe and learn new methods of cleansing and different ways of providing a diabetic foot with dressings to support appropriate treatment. There were also presentations showing the concepts of treatment, cost-effectiveness and pharmacotherapy of difficult to heal chronic wounds.

The president of the Polish Wound Management Association, Professor Arkadiusz Jawien, awarded Professor Gottrup with the title of honorary member of the PWMA.

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Participants’ attention was drawn to the session entitled: “Not only the time can heal the wounds”. President of PWMA, Professor A. Jawien gave a very stimulating lecture about the practical usefulness of the T.I.M.E. strategy in healing chronic wounds. Additionally, he discussed the use of modern antiseptics in prevention and treatment of chronic wounds.

One of the most important aspects of this congress was the presence of Professor Finn Gottrup of EWMA. He has already attended several PWMA meetings in the past, but he is always warmly welcome here because of his high standard of presentations and broad knowledge of wound healing. This time he shared his outstanding achievements and experience in wound healing by presenting the lecture entitled “Wound Fluid / Exudate: Background and Importance”. After the lecture, the president of the Polish Wound Management Association, Professor Arkadiusz Jawien, awarded Professor Gottrup with the title of honorary member of the PWMA, granted to our guest by the Board of PWMA. Honorary membership of the PWMA was also granted to Professor Zbigniew Rybak the first president of our Society.

A special session was dedicated to chronic venous insufficiency and venous leg ulcers. All current modalities available for the treatment of venous leg ulcer were presented, including VAC system; different compression therapy devices; bandages and stockings; polarized light; role of growth factors, especially platelet-derived growth factors; fly larva Lucilla sericata and others. Among the popular topic sessions were the ones concerning local treatment methods of patients with extensive burns, including Integra treatment of children’s burns, as well as those sessions concerning the creating of biofilm as a pathomechanism of chronic wounds infections.

During the Congress, the importance of an interdisciplinary and complex approach to the treatment of chronic wounds was widely emphasized and the whole medical process was described as being an art of “constant search”. All sessions were very well attended and were full of scientific discussions which extended from the conference halls to the coffee break tables. Thus proving the topics of the congress were well selected and the lectures both good, and stimulating.

General Assembly During the General Assembly, a new Board of the Society was elected. Professor Arkadiusz Jawien was re-elected as President of PWMA for 2009-2012; Dr Maciej Sopata was re-elected as the vice-president; Associate-professor Maria T. Szewczyk was re-elected as secretary of PWMA, and the new, elected treasurer is Mrs. Irena Samson. There were also two new members elected to the Board, Dr Anna Chrapusta and Professor Marek Kucharzewski.

The Exhibitors Numerous medical and pharmaceutical companies were present during the Congress. The gold sponsor of the Congress was Schulke. Most of the companies had interesting expositions of modern dressings, wound cleansing devices, nutritious preparations and compression materials, bandages and devices.

The third Congress of PWMA was a great scientific event and a huge organizational success. It is now the milestone event and has left a real legacy of success and knowledge sharing for the newly developing interdisciplinary field of wound care in Poland. 䡵

The Lecture Room.

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WAWLC World Alliance for Wound and Lymphoedema Care John M Macdonald MD, FACS Secretariat The World Alliance for Wound and Lymphoedema Care (WAWLC) trappermac@aol.com www.wawlc.org

WAWLC Beginning with initial meetings in October 2007 and 2008, the Global Initiative for Wound and Lymphoedema Care (GIWLC) was established. It was designed as a new global health partnership created to harmonize and intensify actions at country regional and global levels in support of optimal care for people suffering from chronic wounds and lymphoedema.

Short presentations reviewing the expectations and future involvement of the following organizations completed the first day session. These presentations and comments were given by:

Association for the Advancement of Wound Care (AAWC) Australian Wound Care Association Canadian Association for Wound Care European Wound Management Association (EWMA) The organization took a giant step during a Handicap International three day meeting in October, 2009 in Institute for Advanced Wound Care (USA) Geneva, Switzerland. The meeting was International Lymphoedema Framework attended by a collection of many of the world’s International Lymphoedema Society wound and lymphoedema, expert clinicians.

Korle-Bu Teaching Hospital (Ghana) Forty + participants representing the WHO, Medcine sans Frontieres 43 nations (counting EWMA), 11 medical Mexican Wound Care Society societies, 4 NGOs and 2 medical industry National Pedorthic Services, Inc., (USA) observers were in attendance. The first order of Netherlands Institute for Tropical Disease business was to officially change the name to Oxford University (UK) WAWLC – The World Alliance for Wound and Penn North Centers for Advanced Lymphoedema Care. One clinician, remarked Wound Care (USA) with a smile, “If we are going to TALK the SFFPC (France) TALK we must WAWLC the WAWLC!” SOBEST (Brazil) University of Miami (USA) The mission statement was defined for the University of Pittsburgh (USA) WAWLC: “Working in partnership with World Health Organisation (WHO) communities worldwide to advance sustainable Wound Healing Society of South Africa prevention of wounds and lymphoedema in settings with limited resources”.

Day # 2 was devoted to the formation and strategic plan development of four focused Proceedings on Day # 1 of the meeting working groups. emphasized commitment to the WAWLC philosophy of education in the basics of wound #1 Program Development and lymphoedema care. The prime motivation #2 Advocacy & Fund raising #3 Country Development is to “Teach the Teachers.” and to promote # 4, Monitoring & Research. capacity building within existing health Target dates in January 2010 were set for the programs. Recent site evaluation visits and teaching seminars in Cameroon, Sierra Leone, initial reports of these Working Groups. It should be noted that EWMA is represented in Ghana and Uganda were presented. The WHO White Paper addressing the Principles of each of the WAWLC working groups and that a number of EWMA members chair important Wound and Lymphoedema care was divisions of WAWLC. announced to be in it’s final layout stage and hopefully ready for publication in early 2010.

Day # 3 concluded with summary reports and defined plans for 2010 and 2011.

The WAWLC is to be established as a not for profit, legal entity based in Geneva, Switzerland.

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The WAWLC group

The WAWLC web site was established www.wawlc.org

was a very strong positive for the Geneva meeting and for the future of WAWLC.

WAWLC officers, Secretariat and Advisory Board were appointed for 2010.

In summary, the WAWLC has established a beginning foundation that will provide a unique opportunity for wound and lymphoedema clinicians, societies, NGOs and Ministries of Health. An opportunity to collectively meet the wound and lymphoedema needs of millions suffering in resource poor locations.

Modern wound and lymphoedema care is a global imperative. The World Alliance for Wound and Lymphoedema Care is positioned to respond to that imperative. A paradigm shift in global wound and lymphoedema education and training has begun. 䡵

Plans for WAWLC participation in “EWMA2010” in Geneva, Switzerland were announced.

The two invited, Industry Observers from 3M and KCI discussed their thoughts and recommendations. It was agreed by all participants that the involvement of these industrial leaders

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GIWLC

Uganda Site Visit

Global Initiative for Wound and Lymphedema Care (now Global Alliance for Wound and Lymphedema Care (WAWCL)) info@wawlc.org www.wawlc.org

In late June 2009, as part of the Global Initiative for Wound and Lymphedema Care, Dr. David Keast, Dr Anna Towers and Mrs Patricia Coutts, a nurse with expertise in wound care, conducted a site visit to Uganda. The purpose was to evaluate the state of wound and lymphedema care to determine the possibility of developing education programs under the direction of Health Volunteers Overseas. The visit was sponsored by the Association for the Advancement of Wound Care Global Alliance. The team visited the Mulago Hospital Complex in Kampala which is associated with Makerere University and the Mbarara University Hospital in Mabarara in western Uganda. At each site the team met with doctors, nurses and allied health personnel and did observation ward rounds with the Uganda teams. Sixteen key informant interviews were conducted. The team provided education to the Department of Surgery in Mabarara and had an opportunity to meet with the Deputy Commissioner of Health Services for Mulago Hospital, the Principal of the Mulago School of Nursing and Midwifery and the Director for Clinical and Health Services in the Ministry of Health. The team also was able to visit a Level 4 Health Centre.

Public health care is delivered through a system of Health Centres with increasing capabilities from Level 1 to Level 4. Only Level 4 Health Centres are staffed by a physician. The majority of the care is provided by nurses, nurses’ aides or clinical officers. There are a series of District Hospitals serving small areas and approximately 100 health regions some of which some have a Regional Hospital. There is only one tertiary care national referral hospital for medical conditions, the Mulago Hospital Complex. Mulago Hospital officially has 1500 beds but the actual occupancy is estimated to be 4500 patients. There are also a number of private hospitals and faith based hospitals in Uganda which the team was unable to visit.

Few trained pharmacists are available to dispense medications. At the level of the regional hospital and higher, allied health-care professionals such as physiotherapists are available, but their numbers are small.

Given the relatively short life expectancy of Ugandans compared with that of people who live in developed nations, the major health problems in the country are those which affect younger people.

The burden of chronic diseases as seen in older, more developed populations (such as heart Demographic data demonstrate the sharp contrast disease, chronic obstructive lung disease, cancer between Uganda and more developed countries. and diabetes) is relatively low. Most wounds seen In Uganda 45 per cent of the population is under by the team related to the following: the age of 15 years, there is an average of seven 䡲 Burns, both heat- and acid-related children per female and 80 per cent of the popula- 䡲 Trauma, specifically from motor vehicle tion lives in rural areas. The average life expectaccidents or from agriculture-related problems ancy at birth is 50 years for both sexes. (WHO 䡲 Post-operative (e.g., dehisced Cesarean-section 2006 data accessed August 2009 at www.who.int/ incisions) whosis/en/index.html ) 䡲 Infection-related problems 䡲 HIV-related problems, such as Kaposi’s sarcoma 䡲 Skin malignancies 60

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At the two centres visited, lymphedema is not recognized as a common problem, and filariasisrelated lymphedema is seen as a problem affecting only the northern part of the country.

The prevailing opinion is that, because lymphedema is not painful, it is under recognized.

Patients do not present at primary care centres until the condition is already well advanced. At that point, the fatalistic view that nothing can be done is prevalent among health-care providers.

The only dressings available are gauze based and use of advanced dressings common in the devolved world is unknown. Compression therapy is rarely used and is seen as too expensive. Buruli ulcer while recognized as existing was not treated in either teaching centre visited.

There is a genuine need for education and training in wound and lymphedema care. There are both perceived and unperceived needs at the national level. At the two hospitals visited, there is a perceived need for improved care for burns, trauma and post-operative wounds. While there is recognition that other types of wounds (e.g., diabetic foot ulcers, venous leg ulcers, Buruli ulcers, skin breakdown due to leprosy) exist, these are not seen routinely at this level. However, the Commissioner of Clinical and Health Services in the Ministry of Health does recognize the need for wound and lymphedema care in regional areas.

After visiting a number of facilities and interviewing clinicians in Uganda, the Canadian team recommends the creation of a joint initiative coordinated by the World Alliance for Wound and Lymphedema Care to address the identified deficiencies. The initiative would be based around an interprofessional “train the trainer” approach, starting at the national level and working down through the structure of the health-care system to primary care delivery. To ensure its effectiveness and sustainability, the initiative needs to be seen as a partnership between both the Ministry of Education and Sport and the Ministry of Health, as both ministries have responsibilities in the training of clinicians. Both wound- and lymphedema-care 䡵 education should occur together.

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Expert Panel Issues Final Consensus Statement on Skin Changes At Life’s End (SCALE) The SCALE Final Consensus Statement has recently been released and we enclose a condensed version here.

Launched in April 2008 in Chicago with an unrestricted educational grant from Gaymar Industries, members of the SCALE Panel have concluded that there are observable changes in the skin at the end of life, and they used a modified, three-phase Delphi Method approach to reach consensus on 10 statements. The statements were developed and reviewed by the18-member expert panel and also 51 internationally recognized clinicians, caregivers, medical researchers, legal experts, academicians and leaders of professional organizations.

The SCALE Panel determined that current understanding of this complex phenomenon is limited, and additional research is necessary to assess the aetiology of SCALE, to clinically describe and diagnose the related skin changes, and to recommend appropriate pathways of care. Also, the panel recommends that clinicians, laypeople, and policy makers need to be better educated in the medical, social, legal and financial ramifications of SCALE. The SCALE Final Consensus Statement as well as an annotated bibliography on SCALE are available from the Gaymar website at www.gaymar.com/SCALE. The SCALE Panel encourages distribution of the SCALE document to healthcare professionals and stakeholders, and also welcomes feedback on the Final Consensus Statement. Comments may be directed to Dr. Krasner at dlkrasner@aol.com.

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Cooperating Organisations AFIScep.be

GNEAUPP

Francophone Nurses’ Association in Stoma Therapy, Wound Healing and Wounds

National Advisory Group for the Study of Pressure Ulcers and Chronic Wounds www.gneaupp.org

AISLeC

ICW

Italian Nurses’ Association for the Study of Cutaneous Wounds www.aislec.it

Chronic Wounds Initiative www.ic-wunden.de

AIUC

LBAA

Italian Association for the study of Cutaneous Ulcers www.aiuc.it

Latvian Wound Treating Organisation

APTFeridas

LUF

Portuguese Association for the Treatment of Wounds www.aptferidas.com

AWA Austrian Wound Association www.a-w-a.at

BFW Belgian Federation of Woundcare www.befewo.org

BWA Bulgarian Wound Association

The Leg Ulcer Forum www.legulcerforum.org

LWMA Lithuanian Wound Management Association

MASC Maltese Association of Skin and Wound Care

MST Hungarian Wound Care Society www.euuzlet.hu/mskt/

CNC Clinical Nursing Consulting – Wondzorg www.wondzorg.be

MWMA

CSLR

Macedonian Wound Management Association

Czech Wound Management Society www.cslr.cz

NATVNS

CWA

National Association of Tissue Viability Nurses, Scotland www.natvns.com

Croatian Wound Association www.huzr.hr

NIFS Norwegian Wound Healing Association www.nifs-saar.no

DGfW German Wound Healing Society www.dgfw.de

NOVW

DSFS

Dutch Organisation of Wound Care Nurses www.novw.org

www.dsfs.org

PWMA

FWCS

Polish Wound Management Association www.ptlr.pl

Finnish Wound Care Society www.suomenhaavanhoitoyhdistys.fi

ROWMA

GAIF

Romanian Wound Management Association www.artmp.ro

Danish Wound Healing Society Danish Wound Healing Society

Associated Group of Research in Wounds www.gaif.net

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SAfW

SWHS

Swiss Association for Wound Care www.safw.ch www.safw-romande.ch

Swedish Wound Healing Society www.sarlakning.se

TVS

SAWMA

Tissue Viability Society www.tvs.org.uk

Serbian Advanced Wound Management Association

URuBiH

SEBINKO

Association for Wound Management of Bosnia and Herzegovina

Hungarian Association for the Improvement in Care of Chronic Wounds and Incontinentia www.sebinko.hu

V&VN

SFFPC

Decubitus and Wound Consultants, Netherlands www.venvn.nl

The French and Francophone Society of Wounds and Wound Healing www.sffpc.org

WMAOI Wound Management Association of Ireland www.wmaoi.org

SSiS Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

WMAK Wound Management Association of Kosova

SSOOR Slovak Association for Wound Care

WMAS Wound Management Association Slovenia

SUMS WMAT

Iceland Wound Healing Society www.sums-is.org

Wound Management Association Turkey www.yaradernegi.org

SWHS Serbian Wound Healing Society www.lecenjerana.com

For more information about EWMAâ&#x20AC;&#x2122;s Cooperating Organisations please visit www.ewma.org

Associated Organisations Leg Club

LF

LSN

Lindsay Leg Club Foundation www.legclub.org

Lymphoedema Framework www.lymphoedemaframework.org

The Lymphoedema Support Network www.lymphoedema.org/lsn

International Partner Organisations AWMA Australian Wound Management Association

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AAWC

NZWCS

Association for the Advancement of Wound Care www.aawconline.org

New Zealand Wound Care Society www.nzwcs.org.nz

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SOBENFeE Brazilian Wound Management Association www.sobenfee.org.br

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Science, Practice and Education 5 Systematic review of Repositioning for the Treatment of Pressure Ulcers Zena Moore, Seamus Cowman

14 Analysis of wound care in nursing care homes as part of a district-wide wound care audit Peter Vowden, Kathryn Vowden

19 Chronic leg ulcers among the Icelandic population Guðbjörg Pálsdóttir, Ásta Thoroddsen

24 Cross-sectional Survey of the Occurrence of Chronic Wounds within Capital Region in Finland Anita Mäkelä

EBWM 28 Abstracts of recent Cochrane Reviews Sally Bell-Syer

EWMA 30 EWMA Journal Previous Issues and International Journals 32 20th Conference of the European Wound Management Association, 26-28 May 2010 Geneva, Switzerland – Get The Timing Right 36 Introducing the Swiss Association for Wound Care Severin Läuchli, Hubert Vuagnat

38 The EWMA Teach the Teacher Project Zena Moore

40 EWMA Activities Update 44 Corporate Sponsor Contact Data

Conferences 48 Conference Calendar 51 12th European Pressure Ulcer Advisory Panel Meeting Jacqui Fletcher

53 Recap from the EWMA-Eucomed AWCS Wound in Brussels 6 October 2009 Zena Moore

Organisations 54 DEBRA International – an International Partner Organisation of EWMA 55 SUMS 5 Years Anniversary, 25 September 2009 Finn Gottrup

56 Report from the third PWMA Congress, Bydgoszcz, Poland Arkadiusz Jawien, Maria T. Szewczyk

58 WAWLC John M Macdonald

60 GIWLC – Uganda Site Visit 61 SCALE – Final Consensus Statement on Skin Changes At Life’s End 62 Cooperating Organisations 63 Associated Organisations 63 International Partner Organisations