EWMA Journal May 2007

EWMA Council

The EWMA Journal ISSN number: 1609-2759 Volume 7, No 2, May, 2007 The Journal of the European Wound Management Association Published three times a year Editorial Board Carol Dealey, Editor

Marco Romanelli President Elect

Sue Bale Michelle Briggs Peter Franks Finn Gottrup E. Andrea Nelson Zbigniew Rybak Peter Vowden EWMA web site www.ewma.org For membership application, correspondence, prospective publications and advertising please contact: EWMA Business Office Congress Consultants Martensens Allé 8 1828 Frederiksberg C · Denmark.

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

Peter Franks President

Peter Vowden Immediate Past ­President

Finn Gottrup Recorder

Luc Gryson Treasurer

Sue Bale

Zena Moore Secretary

Judit Daróczy

Carol Dealey

Katia Furtado

EWMA Journal Editor

Deborah Hofman

Layout: Birgitte Clematide Printed by: Kailow Graphic A/S, Denmark Copies printed: 13,000

Christina Lindholm

Christine Moffatt Position Document Editor

E. Andrea Nelson

Patricia Price

Javier Soldevilla

Carolyn Wyndham-White

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 October 2007.

Prospective material for publication must be with the editors as soon as possible and no later than 15 July 2007 The contents of articles and letters in EWMA Journal do not necessarily reflect the opinions of the Editors or the European Wound Management 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.

Zbigniew Rybak

Salla Seppänen

Panel Members Editorial Board Members Carol Dealey, UK (Editor) Sue Bale, UK Michelle Briggs, UK Peter Franks, UK Finn Gottrup, Denmark E. Andrea Nelson, UK Zbigniew Rybak, Poland Peter Vowden, UK Co-operating Organisations’ Board Rokas Bagdonas Pauline Beldon Claudia Caula Mark Collier Rodica Crutescu Bülent Erdogăn Milada Franců Marie Gamlem Sheila Gilmartin Peter Hanga Mária Hok Lydia Jack

Aníbal Justiniano Aleksandra Kuspelo M.A. Lassing-Kroonenberg Martin Koschnik Guðbjörg Pálsdóttir Helena Peric Vivianne Schubert Maciej Sopata José Verdú Soriano Luc Tèot Deborah Thompson Gerald Zöch

Scientific Review Panel Caroline Amery, UK Mark Collier, UK Madeleine Flanagan, UK Milada Franců, Czech Republic Peter Franks, UK Luc Gryson, Belgium Deborah Hofman, UK Zena Moore, Ireland E. Andrea Nelson, UK Ralf-Uwe Peter, Germany Patricia Price, UK Rytis Rimdeika, Lithuania Marco Romanelli, Italy Salla Seppänen, Finland José verdu Soriano, Spain Carolyn Wyndham-White, Switzerland Gerald Zöch, Austria

For contact information, see www.ewma.org

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Journal 2007 vol 7 no 2

EWMA 3 Editorial

Peter J Franks

is more than a conference

Scientific Articles 7 Is it safe to use saline ­solution to clean wounds?

João Carlos Gouveia, Christina Miguens

15 The cost of pressure ulceration Peter J Franks

21 Epidemiology of wounds treated in Community Services in Portugal Elaine Pina

29 Improving wound assessment through the ­provision of digital ­cameras across a Primary Care Trust Alison Hopkins

Background Articles 35 The use of telemedicine in wound care Rolf Jelnes

39 Lord Joseph Lister: the rise of antiseptic surgery and the modern place of ­antiseptics in wound care David Leaper

EBWM 44 Abstracts of recent ­Cochrane Reviews Sally Bell-Syer

EWMA 48 EWMA Position Document 2007: Topical Negative Pressure in Wound Management Christine Moffatt

50 EWMA Journal previous issues 50 International Journals 52 EWMA Corporate Sponsors contact data

Conferences 54 Conference calendar

Organisations 55 The XIth Finnish National Wound Management Conference, 1-2 February 2007 in Helsinki

A

s my time as president comes to a close I wish to reflect back on my time, to see where EWMA has come from and to look to the future of EWMA and its activities.

For those who may not be familiar with the history of the organisation, EWMA was founded at a meeting in Cardiff in 1991, “to promote advancement of education and research into native epidemiology, pathology, diagnosis, prevention and management of wounds of all aetiologies”. For the first 10 years, it undertook an annual meeting held each year mainly in Harrogate, organised by Macmillan (then EMAP). However in 2000, we had the opportunity of developing our own way forward. The EWMA Council elected to work to develop their own meetings, and contracted Congress Consultants to organize our meetings, starting in Stockholm.

While this was a time of great change, the model we now have has become so robust that other societies are adopting many of the innovations developed since that time. It is a great testimony to the past presidents, Council members and other supporters that EWMA is the organization it is today.

It is difficult to identify all the innovations that have taken place, but one of the areas that deserve specific mention is the development of the Cooperating Organizations which currently number 38 national organizations in 29 countries. Indeed EWMA has been instrumental in helping to establish wound organizations in countries that previously did not have one. EWMA today is widely acknowledged as the umbrella organization that brings together these organizations and represents them on a European level. We will be seeking to develop this representation further with closer ties with Eucomed, an organization that represents the wound care industry in the EU.

Salla Seppänen

56 The SSiS is an association for ­registered nurses with a professional interest in wounds Christina Lindholm

57 What’s new in Slovenia?

Helena Kristina Peric

58 Co-operating Organisations

Other developments of note include the EWMA publications. The EWMA Journal is now in its seventh year, and provides an opportunity to present original research as well as reports from the national societies. It is a testament to Carol Dealey and her team that the journal is now indexed in CINAHL. Interest in EWMA journal has never been higher and we receive many approaches from companies, authors and even publishing houses, who are interested in publishing EWMA Journal.

Our other voice is through the Position Documents. The original concept of Christine Moffatt, these papers have set a high standard and achieved 

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international recognition as reference documents for key issues in wound management. We are particularly pleased that they are free to access through the EWMA website and are in five major European languages (English, French, Italian, Spanish & German). While budgetary issues prevent us from translating them into other languages we do allow all national societies the opportunity to translate them into their own languages for free (subject to permission). Please contact EWMA Business Office (ewma@ ewma.org) for more information.

Another area of rapid development has been through the Educational Panel, originally led by Madeleine Flanagan and Finn Gottrup, now led by Zena Moore. There are many wound care courses undertaken throughout Europe, with a range of quality. The Educational Panel has developed EWMA curriculum frameworks by which these courses can be compared.

Provided the courses fit the framework, EWMA can endorse the wound care course. Other innovations include the development of a University module to run in parallel with the EWMA meetings, and a Teach the Teacher project.

For my part, I have developed an interest in supporting societies in developing evidence to support quality improvements in the care they can provide to patients. The Central and East European Leg Ulcer project aims to examine how models of implementation can be used to provide evidence that can justify the application of evidenced based care to patients.

The study in Poland, the Czech Republic and Slovenia will give the much needed evidence to justify appropriate education, organization and access to modern wound care products that Governments require in order to justify their adoption. It is hoped that this could be a model for other wound aetiologies and countries to adopt to develop their services further.

As I am about to hand over the presidency to Marco Romanelli, I hope that EWMA members feel that I have represented them fairly, and continued to work in the same spirit as previous presidents. I would like to thank all society members, our industry partners and others who have contributed so much to EWMA over the past 18 months. Standing down as President is hard, as one would like to have achieved more within the time given. I would have liked to attend more national wound care meetings, though when I have been unable to do so other Council members have been superb in representing the organization. EWMA is an amazingly dynamic organization. What is often forgotten is that the people who do much of the work do so without payment for their time. It is a great testament to all who are involved with EWMA that so much can be achieved with the good will of a small group of individuals committed to making life better for people in Europe and beyond.

Peter J Franks EWMA President www.ewma.org

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Scientific Article

Is it safe to use saline ­solution to clean wounds?

INTRODUCTION The delivery of wound care has become increasingly technology based. However, some of the main problems related to impaired healing in wounds may be related to basic aspects such as cleansing, when it would be expected that, since enough evidence exists to indicate best practice in relation to the procedure (Blunt, 2001; ­Ellis, 2004), healthcare professionals should have knowledge of this evidence.

(with a swab held on a forceps) from the clean area to the dirty area, up and down and from the center to the border, only resulted in distribution of bacteria upon the surface of the wound. Additionally, the use of the swab and vigorous rubbing can cause trauma, especially in epithelial cells, as well as leave residues (little filaments of the swabs) that could delay healing by acting as foreign bodies that could remain in the deep tissues and serve as a focus of infection (Wood, 1976).

In primary health care in Portugal, wounds (chronic or acute) are usually cleansed with a sterile 0.9 % (w/v) sodium chloride solution, usually termed physiological saline because it is isotonic for human cells (Flanagan, 1997) and innocuous and it is, therefore, generally the first choice solution for cleaning wounds (Davies, 1999). Isotonic sodium chloride solution is one of the best agents for cleaning open wounds because it removes debris and bacteria without cell destruction (Pina, 1999, Cochrane, 2004). The major aim in wound cleaning is removal of organic and inorganic residues before application of the dressing thus maintaining an optimal environment at the wound site for healing (Morison et al., 1997). Other benefits of wound cleaning are: (i) to hydrate the wound surfaces and create a moist medium more favorable for healing; (ii) to preserve the surrounding skin, removing residues of glue and excess of humidity that can cause maceration, as well as erosion by action of enzymes of the exudates and toxic bacteria present on skin; (iii) to facilitate the visualization of the size and extension of the wound; (iv) to minimize the trauma of the wound due to the continuous use of adherent materials; (v) to reduce the risk of infection; and (vi) to promote the comfort of the ill person. (Morison et al., 1997; Agreda & Bou, 2004):

In conclusion, the best choice for wound cleansing is the irrigation technique. Irrigation consists of gently removing residues on the surface of the wound as well as other contaminants (Lawrence, 1997-1998). This is achieved by using fluids at constant pressure or pulsated pressure (Cooper et al., 2003).

The optimal pressure for irrigation is achieved using a 35 ml syringe with a 19 G caliber needle.

The disadvantages of this method are mainly: - the detachment of the needle during irrigation with the risk of causing injury to the patient and/or the professional; - the production of aerosols that could conta­ minate the environment or the professionals.

The technique of wound cleansing has evolved through time. Thomlinson (1987) has demonstrated that the technique of rubbing the wounds

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João Carlos Gouveia Christina Miguens C. S. Pampilhosa Serra, P. Serra., Portugal gouveia.miguens@sapo.pt

At present, the professionals of the Health Sub­region of Coimbra perform the cleaning of wounds by irrigation, using flasks of sodium chloride solution of 100 cc, 500 cc or 1000 cc, with a transfer attached. The same flask with transfer is used in several patients with resulting risk of contamination.

OBJECTIVES The present study was undertaken with the objective of evaluating the level of microbial contamination of physiological saline flasks used in health centers for wound cleaning and identifying those  microorganisms found.

MATERIALS AND METHODS Samples From February to April of 2005, 44 saline solutions from 22 health care centers localized in the health sub-region of Coimbra were collected. From each centre two flasks in use were randomly selected, one from the ER (Emergency Room) ward and the other from the outpatient clinic. A triple blind methodology for data analysis was used so that the professionals in the clinic were not aware at the time that the study was under way, the microbiologists did not know where the flasks came from and the person who analyzed the data also had no idea of the origin of the flasks.

The samples were transported at 4ºC and maintained at this temperature until processing.

of medium in the optimal incubation conditions. Every morphological type was observed using Gram’s stain for the definition of biochemical tests employed to identify bacterial species (or genera). Catalase and oxidase tests were then performed on the developed colonies, followed by biochemical genera and species identification tests which used four standardized micro-method systems: API Staph, API Strep, API 20 E and API Coryne strip test (BioMérieux, France).

Processing of samples At the time of sampling, the flasks of saline solutions were thoroughly mixed, and 5 ml fractions were removed by syringe and needle after disinfection of flask surfaces with Sodium Hypochlorite. The undiluted suspensions were seeded by the pour-plate technique. For this, 1.0 ml aliquots were deposited at the center of sterile empty Petri dishes, followed by 19.0 ml of plate count agar (PCA) (Biomérieux, France). After homogenization and solidification of the mixture, the plates, for all samples, were incubated at 28ºC and 37ºC for 48 hours.

The saline solutions 0.1 ml fractions were evenly spread over the surface of Blood Agar (Biomérieux, France) and Sabouraud Chloramphenicol Agar (SAB CHL-D; Biomérieux, France) with individual sterile, bent-glass Lrods. We have also tested the transfer of the flasks of saline solutions for microbial contamination with a sterile cotton swab that was rubbed vigorously, with rotation, over the transfer surface. Swabs were immediately applied directly on Blood agar media by rubbing, with rotation, over the entire surface twice. These blood Agar plates were incubated at 37°C for 48 hours and the SAB CHL-D plates were incubated at 28ºC and 35ºC and examined daily for a period of 30 days before being declared as culture negative.

The number of colony forming units (CFU) was determined in each plate after incubation and the CFU/ml of saline solutions was calculated by number of colonies x dilution factor.

Amplification and sequencing When microbial identification was not conclusive when employing only conventional morphological and biochemical tests, additional 16S rRNA gene sequence determination and phylogenetic analysis were used for bacterial strains and in the case of moulds we performed the amplification and sequencing of ITS (Internal Transcriber Spacers) region of 5.8S gene.

Isolation of bacteria The specimens with no bacterial growth were considered as negative. Bacterial colonies grown in PCA and Blood Agar media were selected by their morphological features, including all observed bacterial varieties. From each culture, the colonies were transferred to the original type

Isolation of Fungi Culture positive specimens were identified macroscopically by observation of morphological colonial characteristics such as texture and color and also microscopically by examination of conidial morphology.

Statistical analysis Statistical analysis was performed with the use of SPSS 11.0 (SPSS Inc., Chicago, USA) for parametric tests. We used the t Student for dependent samples; a P value of less than 0.05 was considered statistically significant.

RESULTS Of the 44 saline solutions analyzed, 54.5% were contaminated. The saline solutions’ CFU/ml ranged between 1 and 230. The relative distribution of contamination due to the transfer or the saline solution itself was diverse, corresponding 50% to saline solution, 37.5% to the transfer and 12.5% to both sources. In terms of relation between types of ward/contamination, we realized that the flasks used in the ER were present in a ratio of 2:1 contaminated flasks to clean, when compared with the flasks collected in the outpatient clinic with a statistical difference (p= 0,01) [IC 95%: mean 0,363: 0,143]. A total of 38 strains were isolated, 66% could be identified to species level using morphological and biochemical tests, the remaining 34% were identified by gene amplification and sequencing. About 69.6% of the identified strains were Gram-positive cocci, the second dominant type of strains were Gram-positive bacilli (13%), and the third dominant type of strains were Gram-negative bacilli and moulds, both with 8.7%.

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Scientific Article

Figure 1.

Relative distribution of different microbial taxa in saline solutions and transfers. The Gram-positive cocci group included: Micrococcus, Staphylo­ coccus, Enterococcus, Streptococcus, Kytococcus and Jeotgalicoccus. The Gram-positive bacilli group comprised: Bacillus, Corynebacterium, Paenibacillus and Lactobacillus. The Gram­negative bacilli group was represented by: ­Ochrobactrum, Massilia, Serratia, Klebsiella and Pantoae. Finally, the filamentous fungi group was constituted by: Aspergillus, Cladosporium and Penicillium.

The distributions of microbial taxa from saline solutions and transfers are shown in Figure 1. The figure shows that the number of different taxa in saline solutions was considerably higher than in transfers.

The most frequent contaminants belonged to normal human flora (64%), namely Staphylococcus aureus (3 strains), Kytococcus sedentarius (3 strains), Staphylococcus epidermidis (2 strains), Enterococcus faecalis (2 strains), Klebsiella pneumoniae (2 strains), Micrococcus sp. (2 strains), Micrococcus luteus (1 strain), Staphylococcus haemolyticus (1 strain), Staphylococcus cohnii cohnii (1 strain), Staphylococcus lugdunensis (1 strain), Staphylococcus hominis (1 strain), Streptococcus salivarius (1 strain), Lactobacillus johnsonii (1 strain), Corynebacterium pseudodiphtheriticum (1 strain) and Corynebacterium striatum/amycolatum (1 strain).

The second dominant group of microorganisms (36%) was saprophytes in nature such as, Bacillus sp. (2 strains), Ochrobactrum sp. (2 strains), Serratia marcescens (2 strains), Paenibacillus sp. (2 strains), Pantoea spp 3 (1 strain), Jeotgalicoccus sp. (1 strain), Massilia sp. (1 strain), Aspergillus fumigatus (1 strain), Aspergillus nidulans (1 strain), Cladosporium sp. (1 strain) and Penicillium sp. (1 strain).

The number of microbial strains isolated from saline solutions and transfers are shown in Figure 2. Of the 38 strains isolated, 26 were recovered from saline solutions and 12 from transfers.

DISCUSSION In this study, it was observed that the majority of the saline solutions in use for cleaning wounds were contaminated.

This is due, mainly, to the use of these saline solutions in multiple patients (through direct or indirect contact or

Figure 2.

Number of strains isolated from saline solutions and transfers.

droplets). This could constitute a major problem because the Healthcare Centers from which the samples were collected provide assistance to an average of 250000 patients and perform around 35000-50000 dressings annually, for either chronic or acute wounds.

All the saline solutions collected were flasks of volume above 100 cc (500 cc or 1000 cc), which are used in consecutive patients, until the contents are exhausted. No statistical difference was found between the type of flasks and the contamination degree. Although the samples were 

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Scientific Article

Table 1.

Microbial species identified from saline solutions and transfers.

In total, 38 strains were independently isolated at 28, 35 and 37ÂşC, and identified by morphological and biochemical tests, gene amplification and sequencing. aIdentified

by gene amplification and sequencing.

bRepresents

probably a new species of Jeotgalicoccus, partial 16S gene sequence was most similar to Jeotgalicoccus pinnipedialis (95%, strain A/G14/99/10T). cRepresents

probably a new species of Massilia, 16S gene ­sequence was most similar to Massilia timonae (97%, strain UR/MT95T).

collected in the clinic, the same procedure is adopted in home care and the flasks may remain in use for several days.

After perforation of the saline solution flask by the transfer, it loses its sterility and so it is recommended that each saline solution flask should be of single-use.

In order to re-use contents, the flasks are fitted with a transfer that remains attached and consequently there is additional loss of sterility. It also represents an entrance point for microorganisms present in the environment, increasing the probability of contamination. In this context, the manipulation of the transfer by health professionals represents an additional source of contamination.

Our results show that, the contamination was mainly (50%) due to the saline solutions as well as the transfers (37.5%). Additionally, from some of the contaminated saline solutions we were able to isolate more than one î‚Š

10

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Scientific Article

bacterial species (data not shown) thus increasing the risk of wound contamination with multiple species.

Trengove et al. (1996) demonstrated that the presence of several bacterial species (four or more) colonizing a wound significantly increases the probability of delayed healing.

With respect to identification of microorganisms isolated, we observed that in most cases (64%) they belonged to the normal human flora, suggesting that the main source of contamination was human manipulation of the patient, while the other 36% were probably from the environment.

It is disturbing to conclude that most of the wounds cleaned with these flasks, even if they were not colonised or infected before the treatment, have a higher risk of becoming infected after it, with all the associated costs both human and economic. We wished to change practice and looked for the evidence that the saline could be contaminated. Although we do not know infection rates in Portugal, it is logical to conclude that if we use contaminated solutions there will be a higher inoculum and therefore a greater risk of infection.

CONCLUSION The false concept of economic benefits from multi-use products without taking into account other aspects such as effectiveness, has led to erratic practices with negative consequences for patients, namely: (i) increase in the period of time for the necessary treatments for wound healing; (ii) increase in the use of systemic antibiotic therapy for infections; (iii) increased possibility of nosocomial infections; (iv) increase of costs relative to the wound treatments; and (v) significant decreasing of quality life of patients (not published data). In summary, it is urgent that healthcare professionals adopt single use cleaning solutions in order to decrease or even eliminate a significant source of wound contamination. More than the flask size, the level of contamination will depend on the time it remains in use after being opened since it is known that each bacterium can divide in two in a period of just 20 minutes (one bacterium could yield one million bacteria in six hours) (Alfa & Sitter, 1991).

It is important that those responsible for wound management should be alerted to the importance of avoiding in-use contamination of wound cleansing solutions, but

12

that is not all. Besides the standard precautions such as hand hygiene and appropriate use of gloves, it is important to consider that all materials in the proximity of the patient can become contaminated during wound cleansing through production of droplets and aerosol particles and that there is, therefore, also the risk of contamination via hands and gloves during the procedure.

In relation to the use of transfers, our results suggest the need of adopting the use of single use saline solution flasks for wound cleaning, with a system of delivery that will permit wound irrigation without risk of manipulation.

Although this study refers to saline solutions, the results should be extrapolated to all materials used in wound care which are in the proximity of the patient and are used for other patients (for example, hydrogel, swabs, ointments, and scissors).

Finally, the results of this study were presented to head nurses from all the health centers in the region followed by an educational programme on prevention of cross contamination of infection during wound care.

We hope that this study may lead to other more allinclusive studies, which can be lead in hospital wards, to examine and understand if these results may be extrapolated to all kind of healthcare services. m Bibliography Alfa MJ., Sitter DL. In hospital evaluation of contamination of duodenoscopes: a quantitative assessment of the effects of drying. J. Hospital Infection, 1991; 19: 89-98.

Agreda, J. & Bou, J. (2004). Atención integral de las heridas crónicas. Madrid, SPA, Sl. Blunt J (2002) Wound cleansing: ritualistic or research-based practice? Nursing Standard.

16, 1, 33-36.

Cooper, R. et al. (2003). Wound Infection & Microbiology. London, Medical ommunications, UK Ltd, Johnson & Johnson Medical.

Davies, C. (1999). Wound care. Cleansing rites and wrongs. Nursing Times, 95 (43): 71-72, 75.

Ellis T. CPD: Understanding the act of contamination in wound dressing procedure, ­Collegian, Vol. 11, nº 3, 2004, p. 39-41 Fernandez, R., Griffiths, R., Ussia, C. Water for wound cleansing, Cochrane database Syst Rev, 2002 (4) Flanagan, M. (1997). Wound Management. Edinburgh: Churchill Livingstone.

Lawrence, H. (1997 Dec 17-1998 Jan 6). Nursing in 1998: on with the new?

Nurs Stand, 12(13-5): 36-37.

Morison, M. et al. (1997). A Colour Guide to the Nursing Management of Chronic Wounds. London, Mosby.

Pina, E. (1999). Aplicação tópica de antimicrobianos no tratamento de feridas. In Nursing : formação contínua em enfermagem, 137: 31-34.

Thomlinson, D. (1987). Journal of Infection Control Nursing. To clean or not to clean?

Nursing Times, 83(9): 71-75.

Trengove, N. J. et al. (1996). Qualitative bacteriology and leg ulcer healing. J Wound Care, 5(6): 277-280.

Wood, R. A. (1976). Disintegration of cellulose dressings in open granulating wounds.

British Medical Journal, 1(6023): 1444-1445.

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References: 1. Parsons D, Bowler PG, Myles V, Jones S. Silver antimicrobial dressings in wound management: a comparison of antibacterial, physical, and chemical characteristics. Wounds. 2005;17(8):222-232. 2. Walker M, Hobot JA, Newman GR, Bowler PG. Scanning electron microscopic examination of bacterial immobilisation in a carboxymethyl cellulose (AQUACEL®) and alginate dressings. Biomaterials. 2003;24:883-890.

3. Bowler PG, Jones SA, Davies BJ, Coyle E. Infection control properties of some wound dressings. J Wound Care. 1999;8(10):499-502. 4. Walker M, Cochrane CA. Protease sequestration studies: a comparison between AQUACEL® and PROMOGRAN® in their ability to sequester proteolytic enzymes. WHRI 2494 WA139. May 27, 2003. Data on file, ConvaTec. 5. Jones SA, Bowler PG, Walker M, Parsons D. Controlling wound bioburden with a novel silver-containing Hydrofiber® dressing. Wound Rep Reg. 2004;12:288-294. ®/TM The following are trademarks of E.R. Squibb & Sons, L.L.C.: AQUACEL Ag and Hydrofiber. ConvaTec is an authorised user. ©2006 E.R. Squibb & Sons, L.L.C. July 2006 GO-06-1047.1

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Scientific Article

The cost of pressure ulceration Introduction Pressure ulcers are a major cause of morbidity in the population, yet it is largely an unseen problem.

It is known that the treatment and prevention of pressure ulcers is costly to health services, but as yet there is still little information on precise costs.

Moreover, there is a cost to patients of pressure ulceration, both in financial terms, but also in terms of their quality of life. This paper will review some of the key evidence in respect to both the costs to society and the costs to individual patients.

Measuring the burden of pressure ulceration on relatives and carers It is important to examine both the costs of providing the health services to patients suffering from the disease in question, but also to determine the costs to patients and relatives since care falls increasingly outside the formal health services, and on to patients and their families. Indirect costs should be derived from estimates of lost production by the patient or family members caused by the disease, losses to society caused by the patient being unable to function to their potential, and quality of life issues, particularly problems associated with pain, poor mobility, discomfort and distress. Relatives and carers provide substantial support to health services, without which it is argued that health and social services would collapse under the burden if such informal care was not available. In is estimated that some 6.8 million people in the UK could be defined as carers1.

These carers provide support and care to relatives and friends who are unable to care for themselves independently. In England the value of informal carers providing care in the community is estimated to be £57 billion per year2.

The Financial Costs of Pressure Ulceration The costs of pressure ulcer care and prevention are largely unknown, perhaps due to the fact that it is a condition largely secondary to other diseases.

However, there has been a long-standing interest in estimating the costs of pressure ulcers, sometimes using these costs to calculate which other services (surgery and bed stays) could instead be provided3.

In 1993, the UK government commissioned accountants Touche Ross to provide them with an estimate of health service costs of pressure ulcers4. They used existing research where available and expert opinion where necessary to provide a theoretical cost of prevention and treatment of pressure ulceration in an average 600 bedded hospital. Different models were proposed, depending on whether the hospital was high or low cost, and depending on whether there was an active prevention strategy with treatment, or treatment alone.

The final estimates indicated that with a treatment strategy alone a low cost hospital would spend e 901,000 (£644,000) per year on pressure ulcers whilst a high cost hospital would spend in the region of e 1,614,000 per year in 1993.

When including a prevention strategy into the care of patients the low cost hospitals used a similar budget (e 901,000), but the high cost hospitals used e 3,794,000.

Most the excess cost associated with prevention was consumed by additional nursing time spent assessing and turning the patients. This report concluded that the cost of pressure prevention and treatment would cost the UK health ­service approximately 0.4-0.8% of the total annual budget. This analysis was limited in that it only estimated costs in the acute (hospital) services and was unable to estimate costs in the community.

Moreover, there was no attempt to estimate indirect costs, costs to patients, nor any value placed on the patients’ quality of life.

Peter J Franks Professor of Health Sciences & EWMA President Centre for Research & ­Implementation of Clinical Practice Faculty of Health & Human Sciences Thames Valley University 32-38, Uxbridge Road, London W5 2BS Tel: 0208 280 5020 Fax: 0208 280 5285 peter.franks@tvu.ac.uk

A more global investigation of cost of pressure ulceration was undertaken in the Netherlands, examining the costs in different care settings in EWMA

Journal 2007 vol 7 no 2

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Scientific Article

cluding home care; nursing homes; general hospitals and university hospitals5. Prevalence figures for different pressure ulcer stages were determined from estimates given by the Health Council for the Netherlands on Pressure Ulcers6. These data were combined with expert opinion (Dutch Society of Pressure Ulcer Experts) to determine personnel time, extra days of care, use of special beds and medical materials. Both low and high estimates were given to indicate the potential range of costs. Costs were dependent not only on ulcer stage, but were also highly dependent on where care took place. As an example of this mean low and high daily costs of stage II pressure ulcers were highest when treated in a university hospital (low e 71.6, high e 110.2) and lowest in the general hospital (low e 23.7, high e 25.1) with conversion factor e 1= $1.3.

Home care was similar to University Hospital costs whereas nursing home care was similar to that of the general hospital costs. The authors estimated annual costs of pressure ulcer care to be in the range e 371 million to e 1,695 million per annum for a country with a population of just 16.5 million, or 1% of the Dutch health care budget.

opportunity cost of AU$ 285 million (e 170.7 million) in a population of 20.3 million9,10.

More recently, a model of costs of pressure ulcers has been developed in the UK, which adopted a more epidemiological approach7. It also looked at different health states for pressure ulcers, namely normal healing; critical colonisation, cellulitis and osteomyelitis. Each health state and pressure ulcer grade was ascribed a cost based on the research evidence and/or expert opinion. The average cost of healing the different pressure ulcer grades was estimated at e 1489 for a grade I, e 6,162 for grade II, e 10,238 for grade III and e 14,771 for grade IV. In the UK (population 60 million) annual incidence (new cases) was estimated at 140,000 for grade I, 170,000 for grade II, 50,000 for grade III and 50,000 for grade IV based on available incidence data8. By combining average costs and number of cases the total cost of pressure ulcers was estimated at e 214 million (grade I), e 1047 million (grade II), e 544 million (grade III) and e 670 million (grade IV), giving a total cost of all pressure ulcers at e 2,473 million. This is equivalent of approximately 2.6% of the total current NHS budget.

As expected most cost (90%) was associated with nursing time, though in-patient stays accounted for 8% of overall costs and 30% for grades III and IV. Cost for antibiotics, dressings and pressure relieving equipment was all relatively low.

The pressure ulcer had effects on the patients in terms of their physical, ability, their ability to function socially, their financial situation, changes in their perceived body image, and loss of independence and control of their own lives. Patients who had an ulcer for longer than six months experienced pessimism and a poorer adherence to treatment, which left them feeling depressed and frustrated.

Coping with the pressure ulcer was difficult, and patients felt isolated, particularly when they were often left in a side room on their own. Patients felt humiliated that health care professionals were seeing parts of their body which were normally kept private. The odour from the pressure ulcer made them feel dirty and they often resorted to deodoriser to mask the smell. Financial costs were associated with having to miss work, for medical care, prescriptions and travel. The theme of living a restricted lifestyle was examined more recently, with more detail given for the impact on families13.

Other studies have concentrated on specific costs of pressure ulceration. In Australia a study was undertaken to examine the bed days lost to pressure ulceration in 2001-2.

It was estimated that a pressure ulcer led to an extra 4.31 days per patient leading to 398,432 bed days lost and an 16

Costs to the patient: Quality of life Health related quality of life (HRQoL) is an important measure of the impact of a condition on the patient’s physical and mental well being and their ability to function socially. While most clinicians would accept that HRQoL is an important measure to determine the impact of disease on the patient relatively few studies have been undertaken to assess this.

One influential qualitative study used a phenomenology approach to determine the impact of the condition on 8 subjects who mostly were suffering (or had suffered from) a stage IV pressure ulcer in the USA11,12. Key themes identified were: n Perceived aetiology of the ulcer n Life impact and changes n Psycho spiritual impact n Extreme painfulness associated with the PU n Need for knowledge and understanding n Grieving process

Pain associated with the pressure ulcer appears to have a substantial impact on patients and their lives13,14. In the study by Szor 84% of patients with a grade II to IV experienced pain, even at rest, with 18% reporting this as excruciating14. In addition 88% reported pain at dressing change. Only 6% reported pain relief being prescribed, with nursing staff frequently denying the pain their patients’ experienced.

A further study was undertaken using a generic quality of life tool (SF-36) in 60 patients in the community15.  EWMA

Journal 2007 vol 7 no 2

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1 Jørgensen B et al. Pain and quality of life for patients with venous leg ulcers: proof of concept of the efficacy of Biatain - Ibu, a new pain reducing wound dressing. Wound Repair and Regeneration 2006, 14 (3), 233-239.

2 Steffansen B et al. Novel wound models for characterizing the effects of exudate levels on the controlled release of ibuprofen from foam dressings. European Wound Management Association, Poster, May 2006, Prague, Czech Republic.

3 Sibbald, RG et al. Decreased chronic (persistent) wound pain with a novel sustained-release ibuprofen foam dressing.

European Wound Management Association, Poster, May 2006, Prague, Czech Republic.

4 Flanagan M et al. Case series investigating the experience of pain in patients with chronic venous leg ulcers treated with a foam dressing releasing ibuprofen. WorldWideWounds April 2006.

5 Gottrup F et al. Lower pain with Biatain - Ibu: Initial findings from a randomised controlled double-blind clinical investigation on painful venous leg ulcers. International Wound Journal, Supplement 1, March 2007. and Biatain are registered trademarks of Coloplast A/S. © 2007-2102. All rights reserved Coloplast A/S, 3050 Humlebæk, Denmark.

Compared with the general population, patients with pressure ulcers experienced greater problems with physical and social functioning. At present no studies have examined utility scores of patients with pressure ulceration to determine the potential deficit associated with the condition and the potential cost in terms of QALYs (Quality adjusted life years).

17TH CONFERENCE OF THE EUROPEAN WOUND MANAGEMENT ASSOCIATION

Discussion In the area of pressure ulceration there has been some interest in the evaluation of outcomes of treatment, but very little attention to the overall cost of care, nor impact on the patients’ quality of life. Surprisingly, health services do not appear to be aware of the financial burden that pressure ulceration causes. As an example, the e 2.5 billion spent on pressure ulceration is equivalent to the cost of treating mental health in the UK or all community health services7. The cost estimates are highly dependent on the incidence of pressure ulcers, although few studies have been undertaken on a population basis to determine this important aspect of pressure ulcer evidence. The results from studies so far undertaken have shown that pressure ulcers lead to a clear deficit in quality of life, though again, these are based on small local studies of patients.

Evidence, Consensus and Driving the Agenda forward EWMA2007 · GLASGOW 2-4 MAY · 2007

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There is a clear need for governments to understand that pressure ulceration causes a major financial burden on them and on patients’ lives. Until the magnitude is appreciated it is hard to push for cost effective treatments and prevention strategies on a national basis to rationalise the care of patients who suffer from this distressing condition. m References 1. Maher, J., Green, H. (2000) Carers 2000. London, Office of National Statistics 2. Carers UK (2002a) Without us carers. London, Carers UK. 3. Hibbs, P. (1990) The Economics of Pressure Sore Prevention. In: Pressure Sores: Clinical Practice and Scientific Approach. Ed Bader, D. London, Macmillan Press Ltd. 4. Touche Ross. ‘Pressure sores: a key quality indicator’. Department of Health, ­Heywood 1993 5. Severens JL Habraken JM, Duivenvoorden S, Frederiks CMA. The cost of illness of pressure ulcers in the Netherlands. Adv Skin & Wound Care 2002; 15: 72-77.

6. Health Council of the Netherlands. Pressure Ulcers. The Hague: Health Council of the Netherlands 1999 (In Dutch).

7. Bennett G, Dealey C & Posnett J. The cost of pressure ulcers in the UK. Age & Ageing 2004; 33(3):230-5 8. Clark M Watts S. The incidence of pressure sores within a national health service trust hospital during 1991. J Adv Nurs 1994: 20; 33-6 9. Graves N, Birrell F, Whitby M. Effect of pressure ulcers on length of hospital stay.

Infect Control Hosp Epidemiol 2005; 26(3): 293-7 10. Graves N, Birrell FA Whitby M. Modelling the economic losses from pressure ulcers among hopsitalized patients in Australia. Wound Repair Regen 2005; 13 (5):462-7 11. Langemo DK, Melland H, Hanson D, Olson B, Hunter S. The lived experience of having a pressure ulcer: a qualitative analysis. Adv. Skin Wound Care 2000; 13: 225-35 12. Langemo DK. Psychosocial aspects in wound care. Quality of life and pressure ulcers: what is the impact? Wounds 2005 17(1): 3-7.

13. Hopkins A, Dealey C, Bale S, Defloor T, Worboys F. Patient stories of living with a pressure ulcer J Adv Nurs. 2006 56(4):345-53.

14. Szor JK, Bourguignon C. Description of pressure ulcer pain at rest and at dressing change. J Wound Ostomy Continence Nurs. 1999; 26(3):115-20.

WWW.EWMA.ORG/EWMA2007

15. Franks PJ, Winterberg H, Moffatt CJ. Health related quality of life and pressure ulceration: assessment in patients treated in the community. Wound Repair & Regeneration 2002; 10 (3): 133-140.

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Extended Abstract · PragUE 2006

Scientific Article

Epidemiology of wounds treated in Community Services in Portugal

Abstract Aim: To characterize patients and types of wounds treated in community services and assess patients’ views with regard to wounds and care received.

Materials and methods: Cross-sectional study of a sample of patients with wounds of duration longer than two weeks. A representative national sample was calculated taking into account regional dimensions, population density and urban/rural mix. Then 148 health centres were randomly selected and patient information was completed for a sample of patients in the clinics.

Results: In all 1424 wounds in 1115 patients aged ≥ 18 yrs were assessed. Of these 57.4% were treated in the clinic and 42.6% in the home. There was a predominance of female patients (57.7%) and the average age was 69.9 (clinic) and 77.1 (home) years. Over 80% of patients were retired.

Leg ulcers were the main type of wound followed by pressure ulcers. Average wound duration was 7.4 months for pressure ulcers and 19.4 months for leg ulcers. Of 574 clinic patients a significant number complained of discomfort and pain but over 90% were satisfied with care received.

Discussion: Patient population was characterized as elderly, low income and suffering from chronic underlying disease. Expectations regarding healing are low. An education / intervention project has been started to promote evidence-based practice.

Introduction Chronic wounds are a major health care concern in the community. They cause substantial morbidity and their management is both time consuming and costly. Phillips1 studied the aetiology and epidemiology of chronic cutaneous ulcers in the USA and found that pressure ulcers and leg ulcers were the most commonly encountered cutaneous ulcers. The Canadian Association of Wound Care2 combined data of significant studies surveying over 14000 patients from 45 Health Care Institutions

and found that 13-17% of pressure ulcers were found in community care. They found the prevalence of all types of wounds in persons receiving community care to be 34-37%. In Germany3, a study of chronic wounds in home care identified a prevalence of 4.1% for pressure ulcers, 2.7% for leg ulcers and 1% for diabetic foot ulcers. In India Gupta et al4 conducted a prevalence study in an urban and a rural community and found a prevalence of 15.03 per 1000 with a predominance of untreated acute traumatic wounds.

Elaine Pina MD, Clinical Microbiologist Rua Professor Hernani Cidade 3-2A 1600-630 Lisboa Portugal Tel: 351 217583027 elainepina@netcabo.pt

Graham et al5 conducted a systematic review of prevalence studies in lower limb ulceration in the adult population. They identified 22 reports but differences in populations studied, study design, case identification procedures, and clinical validation of wounds prevented pooling of estimates.

They recommend that future studies should include large numbers of subjects and total populations. Briggs and Closs6 reviewed the literature on the prevalence of leg ulceration and encountered similar limitations. They therefore suggested that a combination of questionnaires to health professionals and a random sample of the population provide the best method of establishing the true prevalence.

Until recently, wound management has been a low priority in Portugal and heavily dependent on hospital care (outpatient and inpatient). The approach is traditional, care is not evidence based, healing rates are low and very little information is available about the type of wounds treated in primary care. We conducted a study of leg ulceration in an urban area in Lisbon7 and identified a prevalence of 1.41 per 1000 population. The incidence of pressure ulcers has been studied in hospital populations in around 80 thousand patients8 for implementation of the Braden risk assessment scale but little is known about their burden in the community. Some aspects related to patients’ 

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views regarding their wounds are also not known. As part of the leg ulcer study mentioned, a quality of life study 9 reported that patients with leg ulcers showed significantly higher scores compared with Portuguese normative data for all domains of the Nottingham Health Profile. Education programmes are regularly held, many of them sponsored by industry, but do not seem to be reflected in the quality of care provided.

This study was conducted in order to identify the burden of wounds on the individual and the community services in order to enable us to devise the most appropriate educational strategies to improve the quality of care in these patients. Because of the known limitations of definitions and denominators5, 6, 10, we did not attempt to calculate prevalence rates. We conducted case assessments of persons with wounds to determine the type of wounds treated in community services, their care and the patient’s perceptions related to their wounds and the care received.

Methods This was a cross sectional, multicentre, descriptive study of a sample of patients with wounds presenting at primary care services in Portugal. The sampling units were the health centres. After an initial calculation of the probable number of wounds treated in previous years it was estimated that to obtain a sample of 1000-1500 wounds in patients it would be necessary to visit around 120 Health Centres. The sampling method was undertaken in two phases. In the first phase the country was stratified by region (5 regions) taking into account dimensions and population density so as to obtain a representative national sample. In the next phase, regions were further subdivided into their sub-regions and councils in order to account for the urban/rural mix. Following this, 148 Health Centres were randomly selected as sampling units. Approval was obtained from the National Data Protection Committee. A pilot test was carried in one sub-region (16 health centres), during one month, involving 127 patients/219 wounds. Only minor changes were made to the questionnaires. Data were collected between May 2004 and December 2005 (19 months). Twenty professional interviewers were trained with respect to the content of the questions and general characteristics of the wounds studied. They visited each health centre for a period of 1 to 2 days, monitoring all patients with wounds treated at the clinic and in home care. The number of home care visits was determined based on the usual proportion of visits in relation to the patients seen in the clinic at each centre.

All patients aged 18 or above, with wounds having a duration of more than two weeks, were included in the study.

22

Informed consent was obtained for all participants. Since no validated tools were identified for this type of study, three data collections tools were devised for use during the study. They were based on the objectives of the study and guidelines of best practice. The first one was related to information provided by the nurse who cared for each patient and was related to clinical information and care given. A second questionnaire was directed to the patients in order to assess their views and satisfaction with the care received. A classification scale from 1 (minimum) to 5 (maximum) was used to categorize the importance factor.

Finally a third tool was used to assess the resources used in terms of nursing time and consumables. Statistical analysis was performed with the SPSS 13.0. A descriptive analysis of all variables with the absolute and relative frequencies for the categorical variables and average, standard deviation, maximum and minimum values for the continuous variables was obtained. This paper will report on the epidemiology of wounds treated and patients’ views with respect to their wounds and treatment received.

Results Of the 18 sub-regions in the country, 17 (144 health centres) participated in the study. A total of 1424 wounds from 1115 individuals (57.7% women and 42.3 men; national average 52% women) were studied. Of these, 57.4% were seen in the clinic and 42.6% in the home.

The majority of the patients was of low socio-economic status (only 3% graduated from secondary school). The average age of patients in the clinic was 69.9 (SD 13.6 min 18 max 96) years (national average is 47 years) and in the home the average age was 77.1 (SD 10.7 min 22 max 104). Over 80% were retired.

Distribution of wounds by type is presented in table 1.

Leg ulcers (35.6% venous, 2% arterial and 4.3% mixed) were predominant in the clinic and pressure ulcers in the home. Pressure ulcers were located predominantly in the hip (27.3%) sacrum (19.8%) and heel (19.6%). Of the traumatic wounds, 93% were in the lower limb. Chronic wounds (n = 981) were analysed in more detail. The median duration was of three months for pressure ulcers, 12 months for leg ulcers and three months for diabetic foot ulcers. Because of the long duration of a number of wounds we established a cut-off of 100 months. Results showed that, for a cut-off of 100 months, the average duration was of 7.4 (SD 11.9) months for pressure ulcers and 19.4 (SD 23.8) months for venous leg ulcers (48 leg ulcers had a duration of over 8 years) and 9.8 (SD 15.3) î‚Š months for diabetic foot ulcers.

EWMA

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Scientific Article

Table 2. Signs of inflammation or infection

Table 1-Distribution of wounds by type

Table 3. Most frequent medications prescribed

Because of the difficulties in the diagnosis of infection, we only collected information on the presence of related signs/symptoms. In 1108 patients, signs of inflammation or infection (oedema, erythema, pain, local warmth, exudate, odour) were present (Table 2). About 3% of pressure ulcers and leg ulcers showed all signs, and around 19% of ulcers referred showed at least three of them.

Associated co-morbidities: 19.8% of patients with pressure ulcers and 16% of those with leg ulcers suffered from diabetes. Venous disease was present in 13.2% of patients with pressure ulcers and 10% of patients with diabetic foot ulcer. Of the pressure ulcer patients 9.2% had suffered a stroke and 3% suffered from hypertension. Other risk factors studied were malnutrition, smoking habits and alcohol intake. This was information reported by the health professionals (no definitions were supplied). Malnutrition was noted in 31.8% of pressure ulcer patients, in 4.5% of venous ulcers patients and in 8.2% of diabetic foot ulcer patients. Less then 4% of the patients referred smoking and alcohol intake was referred in about 6%. Around 20% of patients were on antibiotics. The most frequent medications are presented in table 3.

Patientsâ&#x20AC;&#x2122; views: The questionnaire about patientsâ&#x20AC;&#x2122; views was completed for 574 patients who attended the clinic.

Day-to-day discomfort due to the wound was referred to as being significant or very significant in more than 41.2%.

Only 18% referred little discomfort. A high number of patients (70.9%) complained of pain, which ranged from little (7.5%) to significant or very significant (45%). Prolonged pain was referred by 57% of those referring pain.

Twenty per cent complained of pain at dressing changes,

15% of pain on movement and 8% at both; 45% used analgesic drugs. It is interesting to note that nurses only mentioned presence of pain in about 30% of the patients (Table 2).

More than 90% of the patients were satisfied or very satisfied with the care received and only 7.5% had complaints.

Disinfection of the wound (89.9%) and the dressing used were considered to be the most significant part of care followed by communication with the nurse (77.6%).

One third of the patients came to the clinic on foot and 37% used public transport. Others used a motorbike or family car and 6.8% were transported by ambulance or the health centre or day care centre transport. About 38% were accompanied by family or friends but, in most cases, this did not require absence from work. Waiting time for attendance was on average 21.4 minutes (SD19.0) with a minimum of 1 minute and a maximum of 2 hours.

Discussion This is the first study in the country to address the problem of wounds treated in community services. In this type of study in which the health professional supplies information on patients, some weaknesses can be expected, due to the high number of people involved, variable knowledge on î&#x201A;Š

24

EWMA

Journal 2007 vol 7 no 2

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wound management and attention given to the questions asked. Discrepancies were identified in relation to wound categorization. However, because the method of data collection ensured confidentiality it was not possible to go back for clarification. Nevertheless, it was possible to characterize the population of patients treated in primary care in Portugal as aged, with a low socio-economic status and suffering from chronic underlying disease. Leg ulcers are the predominant wounds in the clinic and pressure ulcers are more frequent in the home. Wound duration is prolonged and healing rates are not known.

However, we conclude that expectations with regard to healing are low not only in patients, since they are satisfied with the care received in spite of the discomfort and pain, but also in the health professionals. Analysis of the data related to care and costs (to be published) has also confirmed that there is a gap between actual practice and existing evidence that needs to be addressed in order to improve quality of care. In October 2006 we started a project based on education/ intervention that will be implemented through 2007 and early 2008. At the end of this period we will repeat the survey in order to assess the effectiveness of our intervention. m

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Acknowledgements

First name(s):

This study was sponsored by Johnson & Johnson Wound Management a division of Ethicon- Johnson & Johnson Medical, Portugal.

Profession:

Data collection and statistical analysis was performed by Keypoint, Scientific Consultants (an independent company working in the field of clinical trials).

Physician

Surgeon

Dietician

Nurse

Pharmacist

Other

Work Address:

References 1. Phillips TJ. Chronic cutaneous ulcers: aetiology and epidemiology.

J Invest Dermatology 1994 Jun; 102(6):38S-41S

Address for Correspondence (if different from above):

2. Woodbury G. and Houghton P. Canadian Association of Wound Care www.cawc.net/open/library/research/pandi/index.html accessed 1-11-06 3. Panfil EM, Mayer H et al Wound Management in patients with chronic wounds in ambulatory nursing – a pilot study. Pflege 2002 Aug; 15(4): 169-176 (German, abstract in PubMed) 4. Gupta N, Gupta SK et al An Indian community-based epidemiological study of wounds. J Wound Care, 2004 Sep; 13(8): 323-325 5. Graham ID, Harrison MB et al Prevalence of lower-limb ulceration: A Systematic Review of Prevalence Studies Advances in Skin and Wound Care, Nov 2003 findarticles.com/p/articles/mi_qa3977/is_200311/ai_n9342478 Accessed on 25.10.2006 6. Briggs M and Closs SJ The prevalence of leg ulceration: a review of the literature. EWMA Journal 2003; 3(2): 14-18 7. Pina E. Furtado K. et al. Leg ulceration in Portugal: prevalence and clinical history. Eur J Vasc Endovasc Surg. 2005 May, 29(5):549-53

Tel:

Fax:

E-mail: I enclose a cheque of 25e. Please indicate cheque no.: ___________________________________ Please make cheques payable to: European Wound Management Association Or: Please debit my account by 25e: Credit Card type: (Delta, Master Card or Visa). Credit card no:

8. Ferreira PL, Miguens C et al. Risco de desenvolvimento de úlceras de pressão ­Implementação nacional da Escala de Braden, 2006 (in press) 9. Furtado K. Pina E et al. Quality of life in patients with leg ulcers in Portugal. Rev Port Cir Cardiotorac Vasc. 2005 Jul-Sep;12(3):169-74.

10. Fletcher J. Measuring the prevalence and incidence of chronic wounds. Mar 2003. Profession Nurse; 18(7) 384-388

Expiry Date: Exact name and initials on the credit card:

_____________________________________ Please return form and enclose cheque to: EWMA Business Office, Congress Consultants Martensens allé 8, DK-1828 Frederiksberg C, Denmark

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Extended Abstract · PragUE 2006

Scientific Article

Short Paper

Improving wound assessment through the provision of digital ­cameras across a Primary Care Trust

Abstract This paper describes a Trust wide project initiated by the Tissue Viability service to improve wound care services and outcomes. Tower Hamlets is an inner city Primary Care Trust that has both Elderly Service in-patients plus District Nursing services. Project funding was secured to provide digital cameras across the Trust with the aim of: 1. Reducing delay in diagnosis and referral for specialist review.

2. Improving wound assessment and evaluation 3. Promoting patient partnership 4. Improving multidisciplinary collaboration within and across services Meeting the aims of the project was not difficult because the benefits of digital cameras are plain for both staff and patients, providing unambiguous discussion, facilitating patient and staff understanding, plus instant referral. Whilst the benefits for utilising this technology are clear, the issues surrounding the safe handling and storage of data were a challenge. Different protocols were required for the various Trust venues and were dependent on whether computer systems were networked or linked to GP software; the protocols required for secure archiving and the associated training will be presented. This paper also addresses the greatest challenge of the project, which has proved to be embedding camera use and the secure archiving of patient information across the wards and district nursing teams.

Introduction Tower Hamlets Primary Care Trust (THPCT) has an urban population of 200,000 residents for whom the District Nursing service is managed across 17 teams. In addition there are 6 in-patient wards for Older Peoples services including four dedicated wound care beds. The Tissue Viability service works across the Trust and service boundaries and referrals for wound care advice and assessments are received by telephone from

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nursing, medical and allied health professionals.

Guidelines are in place for management of all wound types and practitioners are expected to utilise the specific wound, leg ulcer or pressure ulcer assessment forms.

Project Aims Several issues were identified that resulted in the process of referral, wound assessment and evaluation not being as robust as they could be, specifically that: n Phone referrals and descriptions of the wound bed could be ambiguous, causing either a delay in review or an inappropriate referral. n Digital cameras were only used by the Tissue Viability team; Polaroid cameras were used by some district nursing teams but obtaining the film was always problematic. n There was poor wound and surrounding skin assessment and evaluation. n There was incomplete wound information passed between community and rehabilitation services. n The patient’s General Practitioner and even some patients (due to its site) rarely saw the wounds thereby preventing partnership and valuable discussion.

Thus the aims of the project were: 1. To reduce delay in diagnosis and referral for specialist review through email referral and photography.

2. To improve wound assessment and evaluation and enhance documentation and team discussion.

3. To promote patient partnership 4. To improve multidisciplinary collaboration across and within services Funding was secured for the provision of digital cameras and quality colour printers for each District Nursing team and ward. The aim was for nursing teams to photograph wounds and email

Alison Hopkins MSc, DN Cert, RGN. Clinical Nurse Specialist (Tissue Viability) Tower Hamlets Primary Care Trust Correspondence: Tissue Viability Primary Care Mile End Hospital Bancroft Road London E1 4DG alison.hopkins@ thpct.nhs.uk



29

Scientific Article

Fig 1

them to the specialist team for advice and discussion. The next step was to ensure a correct process for data collection and storage.

Secure data collection and storage In order to ensure the safe use of digital images, a clear protocol for use needed to be developed. This was necessary to enable practitioners to follow a clear process for image production, storage/archiving and retrieval. This protocol was based on the THPCT’s guidelines ‘Consent to Examination and Treatment’ (see original source, Department of Health guide1). Practitioners needed to be aware of the legal issues surrounding photographic consent and the use of the photograph outside patient records, such as education or publication. [See Box 1] Box 1

Photographic consent issues • Informed consent (patient or their relative/carer) can be obtained through written or verbal means and documented.

• Obtaining consent is a continuous process and not a one off event.

• Information must be provided: why the photograph is required, how it will be used, who will see it and how often photographs may be taken.

• Photographs can be used for education purposes if the patient cannot be identified.

• Photographs must never be used for publication without written consent

It is essential that the practitioners were aware that the photograph is part of the patient’s medical history and thus must be retrievable at any time. This requires good

30

archiving and images must be saved without alteration.

Records must be kept of the nurse specialist advice given by phone or email. Thus an email referral form was developed [Fig 1] that enabled attachment of the photograph and sections that addressed the assessment and concerns.

The protocol made it explicit that NHS encrypted email addresses must be used.

One of the problems identified when developing the protocol was that the IT systems varied across the trust; not all the nursing teams had access to the GP patient record systems and thus could not attach the photograph to the patient’s records. For those teams that were not networked, we had to ensure that the photographs were not stored on the computers (in case of theft) and thus had to be deleted after printing. These variations meant that the protocol had to be specific to each team’s requirements. However, this is now no longer an issue because the IT systems have been standardised across the trust.

Email encryption was also an essential part of ensuring a secure process. For this reason only trust or NHS servers must be used. Referrals are usually received by phone in the specialist service thus it is incumbent on the team to regularly check emails for referrals. The referring teams have also been instructed to leave phone messages so that no delays are incurred.

Two practitioners from each ward or team were trained in the use of the camera and printer, archiving of photographs and use and storage of the referral documents.

Project Outcomes The development of protocols and training has enabled the project aims to be met:

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1. To reduce delay in diagnosis and referral for specialist review through email referral and photography: With a photograph on the monitor the ensuing discussion is now based on what is seen and not imagined!

This has enabled the prompt commencement of treatment and prioritising of specialist ­assessments.

2. To improve wound assessment and evaluation and enhance documentation and team discussion: there is now a clear link to assessment and evaluation. There is clear evidence of progress and efficacy of treatment or deterioration of the wound bed and surrounding skin. Photographs have added clarity to team discussions and aided education.

3. To promote patient partnership: patients are not always able to see their wounds, thus digital photography has promoted understanding, education and partnership. This outcome has been of particular benefit as the immediacy of the image can give hope and encouragement; patients like to have their own prints often in sequence!

4. To improve multidisciplinary collaboration across and within services: on discharge or transfer across services, photography has helped to improve communication.

Discussion This project has had successful outcomes and the tissue viability service has provided digital cameras and a framework for their use across the trust. However, like any new initiative there have been some challenges that we are still working on. The greatest challenge to the project, despite piloting and refining the process, has been to get some teams to use the cameras and email referral forms.When discussing the diffusion of innovation, Rogers2 states succinctly that ‘Getting a new idea adopted, even when it has obvious advantages, is often very difficult’.

Here, many innovations thus require a lengthy period before they become widely

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adopted. Rogers’ model describes an innovation curve that separates people into innovators, early adopters, early majority, late majority and laggards. Identifying why we have had so many ‘late majorities’ and laggards can probably be explained by the poor use of email and computers by practitioners whose key role is clinical. This has been identified as a problem for the trust and is therefore is being addressed. Despite the enthusiasm for the cameras and the opportunities this would bring, it is still another thing for the clinical staff to do and in a world of competing priorities camera use is low in some teams. Thus, the encouragement and team training continues.

It is worth noting why the trust has not used camera phones as these are now in common use and would therefore be an easier technology to adopt. Firstly, the cameras were purchased before camera phones were of a high enough quality.

Secondly, there is the issue of secure archiving of photographic images; photographs will be easy to take but not necessarily downloaded appropriately or the advice/discussion provided will not be recorded. The lack of encryption is also a concern. Given due consideration, cameras give the trust more control over the images and so more security.

This paper has presented the development of a framework that enables digital images to be recorded within a secure system. The outcomes have been successful but, despite the enthusiasm, some practitioners have been very slow to adopt the new technology. It is essential that patients have access to the same assessment, wound evaluation and referral process wherever they are in the borough thus adoption of this new process needs to be pursued. m References 1. Department of Health. Good Practice in consent implementation guide: consent to examination or treatment.

Department of Health. 2001. http://www.dh.gov.uk/ PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/ en?CONTENT_ID=4005762&chk=7ENk2Q (1.12.06) 2. Rogers EM. Diffusion of Innovations. Simon and Schuster International. 5th Edition. (2003) Page 1

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Faster wound healing – by reducing the barriers to wound healing

Background Article

The use of telemedicine in wound care

M

ost patients suffering from chronic wounds are attended to by local district nurses and may geographically be far away from specialist centres. A need for specialist advice may, however, turn up often resulting in a tedious process for the patient. A remission note is forwarded to the hospital and the patient is allocated an appointment, perhaps days or weeks later in the outpatient clinic. During the waiting time the wound may have worsened and become more resistant to treatment.

To deal with this, we have introduced telemedicine in Soenderjylland, Denmark, as a tool to communicate, in a fast way, between the wound care nurses in the local communities and the hospitals. This concept we have named “Saar-I-Syd” (“Wounds-in-the South”).

We applied the experiences, from two PhD projects based in the Department of Endocrinology M, Aarhus Universityhospital and Centre for Pervasive Health Care, Alexandra Instituttet, ISIS Katrinebjerg, Aarhus. In these studies the technology was developed and tested1. In the sec-

ond study2 local district nurses in Aarhus participated in the development of a real-time on-line teleconsultation, which was proven to be fully exchangeable to a standard in-hospital consultation. In “Saar-I-Syd” the web-based database was adapted to our needs through collaboration with the software company Dansk Telemedicin A/S. Telemedical consulations are now used in Soenderjylland (220.000 inhab.) as an interdisciplinary tool to remit patients with venous leg ulcers, arterial ulcers, diabetic foot ulcers, pressure sores and inflammatory ulcers to the specialists in the hospitals, to communicate between the different sectors, thus avoiding visits to the outpatient clinic, to control quality of the treatment given and to support the district nurses in their handling of the patients with chronic wounds.

Rolf Jelnes, MD1 Niels Ejskjaer, MD2 1Saar-I-Syd,

Department of Vascular Surgery, Sygehus Soenderjylland, Aabenraa, Denmark 2Diabetic

Foot Centre, ­ epartment of Medicine M, D Aarhus University Hospital, Denmark rolf.jelnes@get2net.dk

How is this done?

When the district nurse sees a patient with a chronic wound, the patient is registered in our web-based electronic database. Only healthcare 

Fig 1.

The set-up, diagram

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35

Background Article

Fig 2. Screendisplay – part of Wound Assessment table

professionals, chosen from the list in the database, have access to the data and the patients give informed consent.

The following data are submitted: personal identification, medication, concurrent disease, allergy, duration of wound and a description of the wound. Ankle pressure and ABI is measured, investigations for neuropathy such as monofilament and tip term are performed and data on hgb1ac and swabs are entered and other parameters relevant for that particular wound.

The district nurse uses a mobile phone to take a photo of the wound and sends this photo electronically to the web-based database. We use the N73 with 3.2 megapixels, giving us photos of outstanding quality. At the same time data on the treatment of the wound is recorded – wound status, wound size, the surrounding skin, pain at change of bandage and during the day – type and VAS. The type of treatment is entered – debridement – product-compression-pressure relief etc. All this can be done in the home of the patients using the mobile telephone and an electronic pen. A preliminary diagnosis is made.

Finally, the district nurse decides to whom information is to be submitted. A choice has to be made weather it is routine or calling for an urgent answer.

The specialists get the information by an sms on their mobile telephone, indicating that new information has been entered the database. This means, that advice can be given, in case of an urgent problem if e.g. the specialist is attending a conference in South Africa. The only need is access to the web.

By looking at the data, compression therapy can be prescribed and, if necessary, a future appointment to the outpatient’s clinic can be forwarded on the same day, – typically for duplex scanning of the veins, toe pressure measurement or a consultation at a chiropodist. Further medical advice such as glycaemia control is submitted at the same time.

36

Fig 3. Reduction in wound area over time – quality control

We have now worked with this system for 12 months. 270 patients are now registered in our database. Our personal experience, working with telemedicine, is as follows: n A proper diagnosis is made at an early stage n Adequate treatment – conservative and surgical – can be started much earlier than previously, thus shortening the wound ­treatment period. n In cases of wound deterioration the ­patients can be seen on the same day and an ­evaluation can be made. n Fewer visits to the outpatient’s clinic, as we do not need to see those patients, which heal according to our standard. n Much less troublesome for the patients, as they can stay in their own surroundings n Specialist support to the districts nurses, thus improving their skills – education.

Once the wound is healed, a decision is made on when to follow up on the recommendations given. This is done by a notification from the database to the mobile telephone to the district nurse 14 days prior to the decided followup time.

We are still working on improving our set-up – i. e.: communication systems to the GP’s, district nurses records as well as healthcare economic expenses.

In conclusion, our set-up based on an electronic webbased wound care record, to which all medical staff have access, is simple to work with and reliable. We are aware, that our statements concerning our experiences are undocumented. Documentation will follow at a later stage. m References

1. Larsen SB, Clemensen J, Ejskjaer N. UMTS and telemedicine: a feasibility study. ­Accepted for publication oct 2006 J Telem Telecare 2. Clemensen J, Larsen SB, Ejskjaer N. Telemedical treatment at home of diabetic foot ulcers. J Telem Telecare. 2005;11 Suppl 2:S14-6.

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Background Article

Lord Joseph Lister: the rise of antiseptic surgery and the modern place of ­antiseptics in wound care Evidence, Consensus and Driving the Agenda forward EWMA Glasgow 2-4 May 2007

David leaper gives us his views on Lord Lister and the role of antiseptics in current surgical practice.

Introduction It is appropriate to remember Lord Joseph Lister as the European Wound Management Association comes to Glasgow for its annual meeting in May of 2007. It was here in Glasgow that the world witnessed the birth of antiseptic surgery which was introduced by Lister in the 1860s.

Although antiseptic surgery was superseded by aseptic surgery, because of its toxicity to operating theatre personnel as well as the patientsâ&#x20AC;&#x2122; tissues, it was a major breakthrough in infection control at the time. All forms of surgery, but particularly trauma surgery which Lister specialised in, were prone to high morbidity and mortality in relation to surgical site infection1. Nevertheless, there is a still a major role for the use of antiseptics in wound care, which will have to be reconsidered on a more widespread basis, as the overuse of antibiotic therapy is threatening to produce increasing numbers of resistant and emerging bacteria. There is some evidence that any microbial resistance has developed against antiseptics but this is limited, probably as their action is so general and multifaceted on bacteria, fungi and viruses as well as spores.

Lord Lister Joseph Lister was born in Essex in 1827 and later entered University College London as a medical student where he qualified in 1852. He almost certainly saw Robert Liston undertake one of the first amputations there under ether anaesthesia.

For the first time such operations could be undertaken without the need for excessive speed with a patient held down by several burly theatre attendants, and allowed time for a more careful procedure!1 After qualification Lister went to Edinburgh where he was apprenticed to the famous surgeon James Syme, who was obviously another surgeon adept at amputation as he has an eponymous operation named after him for amputation of the foot. It is clear that Lister made a good impression as he was appointed to the Regius Chair of Surgery in Glasgow in 1860 where he laid down his foundations of antiseptic surgery. His ability to impress continued and he was subsequently appointed as Professor of Clinical Surgery in Edinburgh in 1869 and ended his clinical career in the Chair of Surgery at Kings College Hospital in London1. Throughout his life his clinical practice was really that of an orthopaedic/trauma surgeon (see figure 1). He contributed to surgical education and for a time was a member of Council of the Royal College of Surgeons of England.

Lister was honoured further with the award of a Baronetcy in 1883; he became a Lord in 1897 and was awarded the Order of Merit. He died in 1912 and has a superb public monument left to his memory in Portland Place in London2.

David Leaper Professor Wound Healing Research Unit University of Wales College of Medicine Cardiff Wales profdavidleaper@ doctors.org.uk

It is interesting to speculate how he devised the concept of antiseptic surgery. At the time postoperative infection was rife after the increasingly ambitious elective surgery, and particularly after trauma, and was attended by a high complication rate and mortality. Apparently the public engineers of Carlisle had taken up the concept, presumably from their contemporaries in Paris, î&#x201A;Š

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39

Background Article

Figure 1. Lord Lister on a ward round

of treating stinking sewage with phenol. Lister became aware of this and visited Carlisle2. One wonders whether he subsequently may have had some similar thoughts when walking along the Clyde, which would have been a similarly unpleasant experience in those days. He was also aware of the contemporary work of Louis Pasteur; only a Frenchman would have made the connection between the spoiling of wine to vinegar because of the recently recognised, offending bacteria and not simply exposure to air as was generally thought2. Whatever the train of thought was he brilliantly realised that the destruction of bacteria, rather than their exclusion which was to come later as aseptic surgery, from an operative or traumatic site might reduce the risk of infection. His hypothesis proved correct.

Lister’s next patient was a boy of 11 years who had suffered a compound fracture of his left leg. He was treated with undiluted “carbolic” to all parts of the wound of the leg, which was simply splinted. The wound was treated with similar dressings and splits and the patient walked out of the hospital some six weeks later. A second 32 year old male patient with a compound fracture of the thigh was similarly and successfully treated.3 Before too long the operating theatre in Glasgow was witnessing the introduction of 1:20 carbolic hand washing, skin preparation and of course the famous carbolic spray which can still be seen at the Royal College of Surgeons of England in London.

The operating theatre environment could not have been pleasant and certainly would not have impressed modern theatre managers and health and safety committees.

40

The success of these measures was nevertheless spectacular. Between 1864-1866 there had been 16 deaths after 35 amputations (a 46% mortality) and between 18671870, after introduction of antiseptic surgery, there were 6 deaths after 40 operations (a 15% mortality). (I make that statistically significant; Yates’ X 2, p<0.01).

Lord Lister also left us with the memorable surgical aphorism that “success depends on attention to detail”.

The place of antiseptics in modern surgery and wound care The use of alcoholic antiseptics for patient skin preparation prior to surgery, and aqueous antiseptics for the operating team “scrub”, is part of established surgical technique4 5. The antiseptics which have had the most widespread use in the United Kingdom are povidone iodine and chlorhexidine. Although there is no level I meta-analysis to prove their worth in this respect there is convincing corroborative evidence-based medicine for their use based on long experience, and experimental and microbiological data5. There is also evidence that these antiseptics are superior to the use of soap and water and that they do not need to be part of a prolonged “scrub”.

In fact only the fingernails need to be brushed at the first operation of a list as excessive scrubbing can cause damage and mobilise bacteria from the deeper layers of the skin to the surface. Between operations a short wash using an aqueous antiseptic or immersion in an alcoholic antiseptic  is all that is required5.

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Journal 2007 vol 7 no 2

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Even better than you think

Background Article

Alcoholic hand rubs have largely replaced antiseptic solutions for the infection control process against MRSA. However, they are no substitute for hand washing in soap and water, or an aqueous antiseptic solution, with adequate hand drying during an epidemic of Clostridium difficile enteritis, when patients are in isolation.

It is difficult to understand why dilute aqueous antiseptics have fallen out of favour for lavage in surgery, for example as a peritoneal lavage for faecal peritonitis.

It is probably related to a perceived impression of local and systemic toxicity, particularly with regard to povidone iodine. In fact allergy is rare and the reports of thyroid dysfunction sporadic and probably unjustified. It must be remembered that antiseptics have had little, if any proven, resistance shown following their use. With the rise of antibiotic resistance and emergence then a whole rethink about antiseptic use may have to be made.

Antibiotic impregnation of surgically-implanted, prosthetic devices and intravascular catheters may also have to be reconsidered for these same reasons of antibiotic resistance. Nevertheless some type of antimicrobial prophylaxis must be used as infection of a vascular or orthopaedic prosthesis can be a disaster. The recent introduction of a widely used and safe antiseptic, triclosan, into sutures for widespread surgical practice, for example, holds great promise for the prevention of postoperative infection. The incidence of surgical site infection (SSI) has been found to be high, with attendant increased healthcare costs, when appropriate post discharge surveillance is undertaken6. A move away from antibiotic prophylaxis, particularly in clean surgery where its use is unclear anyway, or for inappropriate treatment of SSIs has to be welcomed. However, there is unquestioned value with level I evidence, of antibiotic prophylaxis in the clean-contaminated and contaminated categories of surgical operations and this should not be discarded7.

The emergence of antibiotic resistance is a reason to turn back to the safe use of the aqueous antiseptics, such as povidone iodine and chlorhexidine, for wound cleansing and the reduction of bacterial colonisation of open wounds.

These antiseptics have a role as prophylactics against critical colonisation and invasive infection. Thereby antibiotic use may be avoided altogether or be reserved for their use in treating spreading infection, particularly when there are systemic signs and the patient needs admission to hospital.

There are entirely adequate and more effective alternatives to disinfectants such as the hypochlorites for debridement, and a wider use of topical antiseptics is inevitable if antibiotics are to be used less.9

In chronic wound care the use of antiseptics has been and continues to be controversial. There was a time when hypochlorite solutions were widely used in open wound management, including acute wounds such as abscess cavities, and chronic wounds such as pressure sores and leg ulcers. Their use for debridement, and preparation of a recipient wound bed for split thickness grafting, still has their advocates. However, it is widely held that these agents should not be used in routine wound management at all and reserved for their unquestioned role as disinfectants for clinical surfaces and lavatory seats, and sterilising babiesâ&#x20AC;&#x2122; bottles8.

6. Leaper DJ, van Goor H, Reilly J, Petrosillo N, Geiss HK, Torres AJ, Berger A. Surgical site infection â&#x20AC;&#x201C; a European perspective of incidence and economic burden. International Wound Journal 2004; 1: 247-273

42

One of the difficulties of antiseptic-impregnated surgical dressings relates to the fact that most antiseptics are rapidly inactivated on contact with body fluids, exudate and necrotic tissue. Slow-release povidone iodine dressings are already available and their effectiveness is being improved and, together with the recent introduction of silver-containing dressings, overcome this disadvantage.

These dressings also offer a barrier to transmission of resistant of resistant organisms10.

Lord Lister would probably be pleased to know that antiseptics not only have a continued role in modern clinical practice, but also that their contribution, particularly in surgery and wound management, is likely to increase. m References 1. Fisher RB. Joseph Lister 1827-1912. Macdonald and James, London. 1977 2. Ellis H. The first antiseptic operations (1867). In: Surgical Case Histories of the Past.

Royal Society of Medicine Press, London. 1994 3. Lister J. On a new method of treating compound fracture, abscess, etc, with observations on the conditions of suppuration. Lancet 1867; 1: 326 4. de Lalla F. Surgical prophylaxis in practice. J Hosp Infect 2002; 50(Suppl A): S9 - S12. Edwards P S, Lipp A, Holmes A. Preoperative skin antiseptics for preventing surgical wound infections after clean surgery. Cochrane Database Syst Rev. 2004 (3):CD003949.

7. Wong PF, Gilliam AD, Kumar S, Shenfine J, Oâ&#x20AC;&#x2122;Dair GN, Leaper DJ. Antibiotic regimens for secondary peritonitis of gastrointestinal origin in adults. Cochrane Database of Systematic Reviews 2005; 2: CD004539 8. Leaper DJ. Eusol. Editorial. British Medical Journal 1992; 304:930-931 9. Teot L, Coessens B, Cooper R, Flour M, Gryson L, Henry F, Lachapelle J-M, Lamme E, Leaper DJ, Lubbers M, Magliaro A, Meaume S, Monstrey S, Pierard GE, Scuderi N, Van den Bulck R, Vermassen F, Vranckx JJ. Wound Management. Changing ideas on antiseptics. De Coker Belgium 2004 10. Leaper DJ. Silver dressings; their role in wound management International wound Journal 2006; 3: 282-294

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ABSTRACTS OF RECENT ­COCHRANE REVIEWS Topical agents and dressings for ­fungating wounds [Review] Adderley U, Smith R The Cochrane Database of Systematic Reviews Copyright © 2005 The Cochrane Collaboration. ­Published by John Wiley & Sons, Ltd.2007 Issue2.

Sally Bell-Syer, MSc Review Group Co-ordinator Cochrane Wounds Group Department of Health Sciences Area 4 Seebohm Rowntree ­Building University of York York, United Kingdom sembs1@york.ac.uk

ABSTRACT Background: Fungating wounds arise from primary, secondary or ­recurrent malignant disease and are ­associated with advanced cancer. A small proportion of patients may achieve healing following surgical excision but treatment is usually palliative. Fungating wound management usually aims to slow disease progression and ­optimise quality of life by alleviating physical symptoms, such as copious exudate, malodour, pain and the risk of haemorrhage, through appropriate dressing and topical agent selection.

Objectives: To conduct a systematic review of the ­evidence of the effects of dressings and topical agents on quality of life and symptoms that impact on quality of life in people with fungating malignant wounds.

Search strategy: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) and the Wounds Group Specialised Register in August 2006.

The Cochrane Breast Cancer Group and the Pain and Palliative Care Group were contacted for relevant studies. The Allied and Complementary Medicine (AMED) database was searched in January 2007.

There was no restriction on language or date of publication.

Selection criteria: Randomised controlled trials (RCTs) or, in their absence, controlled clinical trials (CCTs) with a concurrent control group, both published and unpublished, and written in any language, were eligible for inclusion.

Data collection and analysis: Data extraction was ­ ndertaken by one author and checked for accuracy u by a second author. Two review authors independently assessed trial quality.

Main results: Two trials involving 63 people were i­ncluded. One RCT in women with superficial breast ­lesions compared 6% miltefosine solution with placebo and found that miltefosine delayed tumour progression.

However, this trial had methodological limitations.

A second trial compared topical metronidazole with placebo and found that metronidazole reduced ­malodour. However, this trial also had methodological limitations and was underpowered.

44

Authors’ conclusions: There is weak evidence from one small trial that 6% miltefosine solution applied topically to people with superficial fungating breast lesions (smaller than 1cm) who have received either previous radiotherapy, surgery, hormonal therapy or chemotherapy for their breast cancer may slow disease progression. There is insufficient evidence in this review to give a clear direction for practice with regard to improving quality of life or managing wound symptoms associated with fungating wounds. More research is needed.

Synopsis Fungating wounds sometimes occur in people with advanced cancer. Care usually aims to slow down disease progression and improve quality of life by relieving physical symptoms using appropriate dressings and other ­applied treatments.

There is weak evidence to suggest that patients with ­superficial fungating breast lesions (smaller than 1cm) who have received either previous radiotherapy, surgery, hormone therapy or chemotherapy for their breast ­cancer may extend the time to disease progression by receiving topical 6% miltefosine solution. There is ­insufficient evidence to direct practice with regard to improving quality of life or managing other wound ­symptoms associated with fungating wounds.

Preoperative bathing or showering with skin antiseptics to prevent surgical site ­infection [Review] Webster J, Osborne S The Cochrane Database of Systematic Reviews Copyright © 2005 The Cochrane Collaboration. ­Published by John Wiley & Sons, Ltd.2007 Issue2.

ABSTRACT Background: Surgical site infections (SSIs) are wound infections that occur after invasive (surgical) procedures.

Preoperative bathing or showering with an antiseptic skin wash product is a well-accepted procedure for ­reducing skin bacteria (microflora). It is less clear ­whether reducing skin microflora leads to a lower ­incidence of surgical site infection.

Objectives: To review the evidence for preoperative bathing or showering with antiseptics for the prevention of hospital-acquired (nosocomial) surgical site infection.

Search strategy: We searched the Cochrane Wounds Group Specialised Register (December 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 4, 2005), MEDLINE (January 1966 to December 2005) and  ­reference lists of articles.

EWMA

Journal 2007 vol 7 no 2

COPA™

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Selection criteria: Randomised controlled trials comparing any antiseptic preparation used for preoperative full-body bathing or showering with non-antiseptic preparations in patients under­ going surgery.

Data collection and analysis: Two authors independently ­assessed studies for selection, trial quality and extracted data.

Study authors were contacted for additional information.

Main results: Six trials involving a total of 10,007 participants were included. Three of the included trials had three comparison groups. The antiseptic used in all trials was 4% chlorhexidine gluconate (Hibiscrub). Three trials involving 7691 participants compared chlorhexidine with a placebo. Bathing with chlorhexidine compared with a placebo did not result in a statistically significant reduction in SSIs; the relative risk of SSI (RR) was 0.91 (95% confidence interval (CI) 0.80 to 1.04). When only trials of high quality were included in this comparison, the RR of SSI was 0.95 (95%CI 0.82 to 1.10). Three trials of 1443 participants compared bar soap with chlorhexidine; when combined there was no difference in the risk of SSIs (RR 1.02, 95% CI 0.57 to 1.84). Two trials of 1092 patients compared bathing with chlorhexidine with no washing, one large study found a statistically significant difference in favour of bathing with chlorhexidine (RR 0.36, 95%CI 0.17 to 0.79). The second smaller study found no difference between patients who washed with chlor­ hexidine and those who did not wash ­preoperatively.

Authors’ conclusions: This review provides no clear evidence of benefit for preoperative showering or bathing with chlorhexidine over other wash products, to reduce surgical site infection.

Efforts to reduce the incidence of nosocomial surgical site infection should focus on interventions where effect has been demonstrated.

Synopsis It is unclear whether using chlorhexidine for preoperative bathing or showering prevents surgical site infection.

Surgical site infection is a serious complication of surgery and may be associated with increased length of hospital stay for the patient and higher hospital costs. The use of an antiseptic solution for pre-operative bathing or showering is widely practiced in the belief that it will help to prevent surgical site infection.

However, the review found six trials that included over 10,000 patients that did not show clear evidence of benefit for the use of chlorhexidine solution over other wash products.

Skin grafting for venous leg ulcers [Review]

applied as a sheet of bioengineered skin grown from donor cells (allograft). Preserved skin from other animals, such as pigs, has also been used (xenografts).

Objectives: To assess the effect of skin grafts for treating venous leg ulcers.

Search strategy: We searched the Cochrane Wounds Group Specialised Register (February 2006) and the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2006).

Selection criteria: Randomised controlled trials (RCTs) of skin grafts in the treatment of venous leg ulcers.

Data collection and analysis: Two reviewers independently undertook data extraction and assessment of study quality.

Main results We identified 15 trials – generally of poor methodological quality – involving 768 participants. In 11 trials participants also received compression bandaging. One trial (31 participants) compared a dressing with an autograft. Three trials (74 participants) compared frozen allografts with dressings, and three trials (47 participants) compared fresh allografts with dressings. Two trials (345 participants) compared tissue-engineered skin (bilayer artificial skin) with a dressing. In two trials (71 participants) a single-layer dermal replacement was compared with standard care. Four trials compared skin grafting techniques: one trial (92 participants) compared autografts with frozen allograft, a second (51 participants) compared a pinch graft (autograft) with a porcine dermis (xenograft), the third (seven participants, 12 ulcers) compared tissue-engineered skin with a split-thickness graft, the fourth (10 participants) compared a fresh allograft with a frozen allograft.

The trials comparing bilayer artificial skin with a dressing reported a significantly higher proportion of ulcers healing with artificial skin. There was not enough evidence from the other trials to determine whether other types of skin grafting increased the healing of venous ulcers.

Authors’ conclusions: Bilayer artificial skin, used in conjunction with compression bandaging, increases the chance of healing a venous ulcer compared with compression and a simple dressing. Further research is needed to assess whether other forms of skin grafts increase ulcer healing.

Jones JE, Nelson EA The Cochrane Database of Systematic Reviews Copyright © 2005 The Cochrane Collaboration.

Published by John Wiley & Sons, Ltd.2007 Issue2.

Synopsis Applying bilayered tissue-engineered skin under compression improves healing of venous leg ulcers compared with simple dressings and compression, but the effect of other types of graft is not clear.

ABSTRACT Background: Venous leg ulceration is a recurrent, chronic, ­disabling condition. It affects up to one in 100 adults at some time. Standard treatments are simple dressings and compression bandages or stockings. Sometimes, despite treatment, ulcers remain open for months or years. Sometimes skin grafts are used to stimulate healing. These may be taken, or grown into a dressing, from the patient’s own uninjured skin (autografts), or

Approximately 1% of people in industrialised countries have a leg ulcer at some time, mainly caused by poor blood flow back from the legs towards the heart. Skin grafts, either using the patient’s own skin or donor skin/cells, have been evaluated to see whether they improve the healing of ulcers. The review of trials found evidence that tissue-engineered skin composed of two layers increases the chance of healing. There was not enough evidence to recommend any other type of graft, and further research is required.

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EWMA

Journal 2007 vol 7 no 2

EWMA Position Document 2007:

Topical Negative Pressure in Wound Management

M Prof. Christine Moffatt EWMA Position Document Editor Director, Centre for Research and Implementation of Clinical Practice Christine.Moffatt@ exchange.tvu.ac.uk

Correspondence to: Kathy Day MEP Ltd, 53 Hargrave Road, London N19 5SH kday@mepltd.co.uk

ore than a decade after pioneering researchers experimented with crude suction apparatus to promote wound healing, topical negative pressure (TNP) therapy has revolutionised the field of wound management. TNP therapy substantially broadens the scope of treatment and has rapidly become a first-line intervention for a wide range of complex wounds. This important development in wound care is being shown in a growing number of randomised controlled trials, as well as case studies, to produce dramatic improvements in clinical outcomes such as healing rates, hospitalisations and, in the case of mediastinitis and the open abdomen, mortality.

The indications and advantages of TNP therapy have been reviewed extensively (Box 1), however there remains a crucial need for a better understanding of when and how to effectively integrate this therapy into clinical practice.

Box 1 Studies using TNP therapy in various wound types n Burn wounds1 n Chronic leg ulcers2 n Diabetic foot ulcers3 n Open abdomen including management of fistulae4 n Pressure ulcers5 n Securing a skin graft6 n Sternal wound infections7 n Surgical, non-healing wounds8 n Trauma9

With these issues in mind, the 2007 EWMA position document – Topical negative pressure in wound management – presents a European perspective on the pathophysiological effects and the technical and practical issues involved in using TNP therapy. The aim is to provide insights into the use of the intervention in the clinical setting,

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and to enable healthcare professionals to select and apply therapy safely. The document is published in five languages (Figure 1) and is available online at: www.ewma.org.

It should be noted that most clinical trials of TNP therapy have used the vacuum assisted closure (V.A.C.® Therapy) system and therefore it is this specific device that is described throughout the document.

In the first of the four papers presented, Gustafsson, Sjögren and Ingemansson set the scene by outlining the historical development of TNP therapy and describing the key components of the VAC system.

Although TNP therapy has obvious clinical advantages, it is often considered expensive compared with alternative options and this may have been a barrier to its use, particularly in community set-

Figure 1. The 2007 EWMA position document is available in five languages.

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Journal 2007 vol 7 no 2

EWMA

Figure 2. Patient and wound specific issues and the role of TNP therapy

tings. Trueman therefore puts forward an economic case for the intervention in the second paper of the document.

He proposes that we consider the factors listed in Box 2 when analysing the true cost of dressings. He shows that these may often be sufficient to offset the higher acquisition costs of the VAC dressings.

Box 2 Factors affecting the cost of wound treatment The cost of managing chronic wounds can be influenced by: n Frequency of dressing changes and associated nurse time n Healing rates n Impact on hospitalisations and adverse events

This EWMA position document is published at a time when treatment initiatives in wound care are extremely common and the requirements of healthcare professionals and patients are equally challenging. The information provides a sound overview of TNP therapy, which – in the hands of clinicians with appropriate, up-to-date knowledge and practical skills – is producing impressive results in a variety of wound types. The task now is to ensure that all suitable patients benefit maximally from its use, both in the hospital and community setting. m References 1. Kamolz LP, Andel H, Haslik W, et al. Use of subatmospheric pressure therapy to prevent burn wound progression in human: first experiences. Burns 2004; 30(3): 253-58.

2. Vuerstaek JD, Vainas T, Wuite J, et al. State-of-the-art treatment of chronic leg ulcers: a randomized controlled trial comparing vacuum-assisted closure (V.A.C.) with modern wound dressing. J Vasc Surg 2006; 44(5): 1029-37.

3. Armstrong DG, Lavery LA; Diabetic Foot Consortium. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomised controlled trial. Lancet 2005; 366(9498): 1704-10.

In the third paper Vowden, Téot and Vowden present a general therapeutic strategy (using the concept of wound bed preparation) that can be applied to many different wound types to help clinicians identify when to use TNP therapy and how to integrate the technique into overall wound management (Figure 2). In doing so they stress that if selected it must be introduced with defined treatment objectives and clinical endpoints.

For treatment to be safe and effective, however, it is important to understand how the specific requirements of individual wound types may affect the application of TNP therapy. In the final paper, Wild uses the management of the open abdomen to demonstrate this point. TNP therapy in this context is effective because it offers the advantages of the traditional open abdomen technique while preventing many of the complications.

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Journal 2007 vol 7 no 2

4. Wild T, Stortecky S, Stremitzer S, et al. [Abdominal dressing – a new standard in therapy of the open abdomen following secondary peritonitis?] Zentralbl Chir 2006; 131(Suppl 1): S111-14.

5. Ford CN, Reinhard ER, Yeh D, et al. Interim analysis of a prospective, randomized trial of vacuum-assisted closure versus the Healthpoint system in the management of pressure ulcers. Ann Plast Surg 2002; 49(1): 55-61; discussion: 61.

6. Jeschke MG, Rose C, Angele P, et al. Development of new reconstructive techniques: use of Integra in combination with fibrin glue and negative-pressure therapy for reconstruction of acute and chronic wounds. Plast Reconstr Surg 2004; 113(2): 525-30.

7. Sjögren J, Gustafsson R, Nilsson J, et al. Clinical outcome after poststernotomy mediastinitis: vacuum-assisted closure versus conventional therapy. Ann Thorac Surg 2005; 79(6): 2049-55.

8. Moues CM, Vos MC, van den Bemd GJ, et al. Bacterial load in relation to vacuum-assisted closure wound therapy: a prospective randomized trial. Wound Repair Regen 2004; 12(1): 11-17.

9 Stannard JP, Robinson JT, Anderson ER, et al. Negative pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma 2006; 60(6): 1301-06.

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EWMA Journal Previous Issues Volume 7, no 2, January 2007 Self-care activities of venous leg ulcer patients in Finland Salla Seppänen Smoking is not contra-indicated in ­maggot ­debridement therapy in the chronic wound Pascal Steenvoorde Effectiveness of non-alcohol film forming skin protector on the skins isles inside the ulcers and the healing rate of venous leg ulcers Tanja Planinsek Rucigaj Wound measurement: the contribution to practice Georgina T. Gethin Improving education in wound care: ­crossing the boundaries of inter­professional learning Caroline McIntosh Waterjet debridement of deep and ­indeterminate depth thermal injuries Mayer Tenenhaus Volume 6, no 2, Fall 2006 The number of leg ulcers ­increases – a 20-year-questionnaire study in ­Pirkanmaa Health Care in Finland Anna L Hjerppe An ex-vivo model to evaluate dressings & drugs for wound healing Johanna M. Brandner, Pia Houdek, Thomas Quitschau, Ute Siemann-Harms, Ulrich Ohnemus, Ingo Willhardt, Ingrid Moll Compression therapy of ­venous ulcers Hugo Partsch Seasonal variation of onset of venous leg ulcers Marian Simka Determinants and estimation of wound healing achievement after minor amputation in patients with diabetic foot Robert Bém, A. Jirkovská, V. Fejfarová, J. Skibová, B. Sixta, P. Herdegen Leg ulcer prevalence in the Czech ­Republic: Omnibus survey results 2006 Zdenek Kucera Volume 6, no 1, Spring 2006 Focus on silver Jean-Yves Maillard, Stephen P Denyer Factors that influence the frequency of rebandaging Una Adderley Microengineered hydrogel as a vehicle for grafting ­ human skin cells Stephen Britland, Annie Smith Wound Care in Anatolia Ali Barutcu Implementation of a Leg Ulcer Strategy in Central & Eastern Europe Peter J. Franks Post Graduate Wound Healing Course Modena, Italy Deborah Hofman From The Laboratory to the Patient: Future Organisation and Care of Problem Wounds. A New Experience Finn Gottrup Volume 5, no 2, Fall 2005 Retrospective analysis of topical ­application of factor XIII in patients with chronic leg ulcers Mirjana Ziemer, Claudia Scheumann, Martin Kaatz, ­Johannes Norgauer An overview of surgical site infections: aetiology, incidence and risk factors Finn Gottrup, Andrew Melling, Dirk A. Hollander Regulating research and associated activity in the UK Sue Bale Article Review – The effectiveness of a hyperoxygenated fatty acid ­compound in preventing pressure ulcers Joan-Enric Torra i Bou, T. Segovia Gómez, J. Verdú Soriano, A. Nolasco Bonmatí, J. Rueda López, M. Arboix i Perejamo Article Review – Extended commentary on a trial E. Andrea Nelson UK Lymphoedema Framework Project Philip A. Morgan, Christine J. Moffatt, Debra C. Doherty, ­Peter J. Franks German Wound Surgeons 1450-1750 Carol Dealey

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

Italian

Acta Vulnologica, vol. 4, no 4, 2006 www.aiuc.it A Proposal for a bill of rights in wound care Brambilla R., Coppi C. Diabetes mellitus and pressure sores: interactions and strategies Gallo M., Furlini S., Somà K. Ulcers induced during therapy with hydroxyurea in patients with myeloproliferative disorders Venturi C., Pandolfi R., Motolese A.

English

Advances in Skin & Wound Care, vol. 20, april 2007 www.aswcjournal.com Pressure Ulcers in Neonates and Children: An NPUAP White Paper Mona Mylene Baharestani, Catherine R. Ratliff Treatment of Ischemic Wounds with Noncontact, Low-Frequency Ultrasound: The Mayo Clinic Experience, 2004-2006 Steven J. Kavros, Jenny L. Miller, Steven W. Hanna The Treatment of Diabetic Foot Ulcers: Reviewing the Literature and a Surgical Algorithm Steven R. Kravitz, James B. McGuire, Sid Sharma

Finnish

Haava, vol. no 1, 2007 www.suomenhaavanhoitoyhdistys.fi How MD can utilize the microbiological tests Sakari Vuorinen Drains, wound suction an their treatment Ansa Iivanainen, Helvi Hietanen Planning of wound treatment Marja Nidkasaari Treatment of bullet wounds Lauri Handolin Polyurethane foams and amputation wounds Sirpa Arvonen Silver in the treatment of burns Helena Asikainen, Juha M. Venäläinen The mystery of green net Jaana Ruohoaho Vacuum assisted closure in wound management Tiina Pukki Honey in the treatment of lec ulcers Maria Nevalainen Wound management in intensive care unit Ritva Sipinen Developing documentation in wound management Jonna Saarela, Satu Tuovinen Tissue viability nurse in communities – a project work Eija Luotola Developing infection controlling models for practise of wound care Kirsi Terho, Tiina Kurvoien, Marianne Routamaa Quality of care of diabetic foot Senja Torvinen Living with scars Virpi Hämeen-Anttila

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

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Journal 2007 vol 7 no 2

EWMA

Spanish

Helcos 2007, vol 18, no 1

English

Journal of Wound Care, April issue, vol. 16, no 4, 2007 www.journalofwoundcare.com; jwc@emap.com Use of polarised light as a method of pressure ulcer prevention in an adult intensive care unit J. Verbelen Can translocated bacteria reduce wound infection?

V.I. Nikitenko Venous leg ulcer treatment and practice – part 4: surgery and pharmaceutical therapies S. Rajendran, A.J. Rigby, S.C. Anand Management of bioburden with a burn gel that targets nociceptors L. Martineau, H-M. Dosch Can cycloidal vibration plus standard treatment reduce lower limb cellulitis treatment times?

S. Johnson, K. Leak, S. Singh, P. Tan, W. Pillay, R.J. Cuschieri, E. Mostyn Bacterial profiling using skin grafting, standard culture and molecular bacteriological methods A. Andersen, K.E. Hill, P. Stephens, D.W. Thomas, ­B. Jorgensen, K.A. Krogfelt A prospective observational study of the efficacy of a novel hydroactive impregnated dressing F. Meuleneire, P. Zoellner, M. Swerev, O. Holfeld, J. Effing, S. Bapt, N. Tholon, E. Felder, B. Streit, H. Kapp, H. Smola

Scandinavian

Wounds (SÅR) vol. 15, no 1, 2007 www.saar.dk

Efficiency of the products for pressure ulcers treatment: a systematic review with meta-analysis García Fernández F.P., Pancorbo Hidalgo P.L., Verdú Soriano J., Soldevilla Agreda J.J., Rodríguez Palma M., Gago Fornells M., Martínez Cuervo F., Rueda López J. Clinical judgement or assessment scales to identify patients at risk of developing pressure ulcers?

Rodríguez Torres Mª. del C., Soldevilla Agreda J.J.

English

International Wound Journal, Mar. 2007, vol. 4, Issue 1 www.blackwellpublishing.com OASIS® wound matrix versus Hyaloskin® in the treatment of difficult-to-heal wounds of mixed arterial/venous aetiology M Romanelli, V Dini, M Bertone, S Barbanera, C Brilli Successful management of deep facial burns in a patient with extensive third-degree burns: the role of a nanocrystalline silver dressing in facilitating resurfacing M Marazzi, A De Angelis, A Ravizza, MN Ordanini, L Falcone, A Chiaratti, F Crovato, D Calò, S Veronese, V Rapisarda Paediatric partial-thickness scald burns – is Biobrane the best treatment available?

A Mandal Wound bed preparation of difficult wounds: an evolution of the principles of TIME C Ligresti, F Bo Clinical predictors of treatment failure for diabetic foot infections: data from a prospective trial BA Lipsky, P Sheehan, DG Armstrong, AD Tice, AB Polis, MA Abramson The role of vascular endothelial growth inhibitor in wound healing KP Conway, P Price, KG Harding, WG Jiang Randomised clinical trial of Hydrofiber dressing with silver versus povidone-iodine gauze in the management of open surgical and traumatic wounds F Jurczak, T Dugré, A Johnstone, T Offori, Z Vujovic, D Hollander Negative pressure wound therapy via vacuum-assisted closure following partial foot amputation: what is the role of wound chronicity?

DG Armstrong, LA Lavery, AJM Boulton Negative pressure wound therapy: treating a venomous insect bite MS Miller, M Ortagon, C McDaniel

English

The International Journal of Lower Extremity Wounds vol. 6, no 1, 2007 http://ijlew.sagepub.com Wound Healing at the Crossroads Raj Mani Developing guidelines in the absence of ­traditional research evidence: an example from the lymphoedema framework project Peter J. Franks, Philip A. Morgan Growth factors: the promise and the problems Jeffrey M. Davidson The development and application of diabetic foot protocol in Chiang Mai University Hospital with an aim to reduce lower extremity amputation in thai population: a preliminary pommunication K. Rerkasem, N. Kosachunhanun, S. Tongprasert, K. Khwanngern, A. Matanasarawoot, C. Thongchai, K. Chimplee, S. Buranapin, S. Chaisrisawadisuk, A. Manklabruks An evaluation of the value of group education in recently diagnosed diabetes mellitus G. S. Ooi, C. Rodrigo, W. K. Cheong, R. L. Mehta, G. Bowen, C. P. Shearman The diabetic foot: perspectives from Chennai, South India Vijay Viswanathan Growth Factors in the Treatment of Diabetic Foot Ulcers: New Technologies, Any Promises?

N. Papanas and E. Maltezos

EWMA

Journal 2007 vol 7 no 2

Care and treatment of people with cancer wounds Betina Lund-Nielsen Compression therapy of venous leg ulcers – how can we make it more cost-effective?

Rie Nygaard, Susan F. Jørgensen Terra Sigillata – a pharmaceutical product used for more than 2000 years Annette Frölich Lymphoedema clinic at Copenhagen Wound Healing Centre – much-needed developments for patients where no ­treatment is possible Jens Fonnesbech Higher level and a stronger scientific foundation: New diploma in wound management Jens Fonnesbech Prevention and treatment of diabetic foot ulcers – commenting on the debate in the Norwegian Parliament Stortinget Kirsti Espeseth

German

Wund Management Issue 2, 2007 Overview Incidence of Ulcus cruris in Germany: Data of the German Federal Health Monitoring K. Kröger Standards in the Treatment of Wounds Obsolete products and methods in the treatment of chronic wounds W. Sellmer

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EWMA Corporate Sponsor Contact Data Corporate B

Corporate A

Coloplast Holtedam 1-3 DK-3050 Humlebæk Denmark Tel: +45 49 11 15 88 Fax: +45 49 11 15 80 www.coloplast.com

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

Ethicon GmbH Johnson & Johnson Wound Management Oststraße 1 22844 Norderstedt Germany Tel: +49 40 52207 230 Fax: +49 40 52207 823 www.jnjgateway.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

52

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

Smith & Nephew Po Box 81, Hessle Road HU3 2BN Hull, United Kingdom Tel: +44 (0) 1482 225 181 Fax: +44 (0) 1482 328 326 www.smith-nephew.com

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

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

Activa Healthcare Ltd 1 Lancaster Park Newborough Road Needwood Burton on Trent Staffordshire DE13 9PD Tel: +44 (0) 8450 606 707 Fax: +44 (0) 1283 576808 www.activahealthcare.co.uk

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

Comvita UK Ltd Unit 3, 55-57 Park Royal Road London NW10 7LP United Kingdom Tel: +44 208 961 4410 Fax: +44 208 961 9420 www.comvita.co.uk

EWMA

Journal 2007 vol 7 no 2

EWMA

EWMA Position Document 2007

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.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

Topical Negative Pressure in Wound Management Editor: Christine Moffatt The document is available in English, French, German, Italian and Spanish, and can be downloaded from www.ewma.org

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Journal 2007 vol 7 no 2

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Conferences

Conference Calendar Conference

Theme

SAWC & WHS 2007 (National) 17th Conference of the European Wound ­Management Association (EWMA 2007)

Apr/May Evidence, Consensus and Driving the Agenda forward

5th international symposium on the Diabetic Foot EADV 16th Congress

European Dermatology and Venereology – Strong Past, Stronger Future

28-1 Tampa, Florida

USA

May

2-4

Scotland

May

9-12 Noordwijkerhout The Netherlands

May

16-20 Vienna

Glasgow

Austria

SAfW 4th Congress (National)

May

24

Morges

Switzerland

11th Symposium of modern Woundhealing (National)

Jun

1-2

Bregenz

Switzerland

12th Congress of the ESDaP (National)

Jun

Wounds UK Summerconference (National)

Jun

22

Warwickshire

UK

Jul

3

London

UK

14-17 Wroclaw

Poland

Tissue Viability and Wound Care Management (National)

Improving Practise on the Wards

EPUAP 10th European Meeting

Ten years of progress, the present and Aug/Sep 30-01 Oxford the future in Pressure Ulcer Prevention and Management

UK

VI Congresso Nazionale AIUC

Alla scoperta dell’ulcera cutanea cronica

Italy

SSiS National Congress

Sep Sep

ETRS 17th Annual Meeting

Measurements in wound healing – the conduit between the laboratory and the clinic

ILDS 21st World Congress of Dermatology

Global Dermatology for a globalized world

Sep

12-15 Genova 24

Sweden

26-28 Southampton

UK

Oct

1-5

Buenos Aires

Argentina

APTFeridas 2007 National Congress

Nov

7-9

Porto

Portugal

Wounds UK 2007 (National)

Nov

VII Nacional Congress GNEAUPP

Nov

National Meeting DSFS

Cancer Wounds

Nov

12-14 Harrogate

UK Spain

16-17 Nyborg

Denmark

2008 XIIth National Wound Management Conference NIFS National Conference

Jan/Feb Pressure Ulcers

SAWC & WHS 2008 (National)

Feb

Finland Norway

Apr

18th Conference of the European Wound ­Management Association (EWMA 2008)

Wound Healing · Wound Management – Responsibility and Actions

May

WUWHS – 3rd Congress

Wound Care Efficacy, Effectiveness & Efficiency

Jun

Oxford – European Wound Healing Summer School

Different aspects of patient wound ­management based on therapy innovation and clinical research

Jul

7th Scientific Meeting of the Diabetic Foot Study Group (DFSG) of the EASD

31-1 Helsinki 14-15 Bergen

Sep

USA 14-16 Lisbon 4-8

Portugal

Toronto

Canada

Oxford

UK

11-13 Pisa

Italy

For web link please visit www.ewma.org

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Organisations

The XIth Finnish National Wound Management Conference 1-2 February 2007 in Helsinki

FWCS

Finnish Wound Care Society

Salla Seppänen, RGN, Specialist in MedicalSurgical Nursing, MNSc, Principal Lecturer, Oulu University of Applied Sciences, Oulainen Department of Health Care Finland salla.seppanen@pp.inet.fi www.suomenhaavanhoitoyhdistys.fi

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Journal 2007 vol 7 no 2

The Finnish Wound Care Society organised its annual wound management conference for 2007 on the theme of “Special Issues in Wound Management”.

The programme included sessions discussing lower limb amputation, wound infection, costs of wound care, seamless ­services in wound care and wound patients’ quality of life, which focused on pain, nutrition and living habits.

EWMA organised the con­ference keynote speaker Professor John Posnett from the UK. He presented a lecture on the costs and effectiveness of wound care in which he estimated that the average cost of chronic wounds in Finland is now at least 194 billion euros per year. This presents the Finnish Wound Care Society with the challenge to develop evidence-based wound management, which covers the whole care path of the patient.

The feedback of participants was positive and encouraging; 75.4% of participants assessed the conference as good and 21.7% assessed it as excellent. Most of the participants (73.4%) stated that they felt that the conference was useful for their work.

According to the conference feedback, the content of sessions was relevant, interesting and professional providing useful tips for clinical practice.

The conference also attracted corporate healthcare professionals with 26 corporate members participating in the conference exhibition.

The XIIth National Wound Management Conference will be held on 31/1-1/2.2008 in Helsinki on the theme of “Modern Wound Management”.

The national conference collected together about 700 health professionals from all over Finland.

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SSiS

Sårsjuksköterskor i Sverige Tissue Viability Nureses in Sweden

The SSiS is an association for ­registered nurses with a professional interest in wounds Wound healing is an important field, in which nursing competence must improve and become more visible.

Sårsjuksköterskor i Sverige (SSiS)/ Tissue ­ iability Nurses in Sweden is a part/section of V the Swedish Society of Nursing (SSF) and also a Co-operating Organisation within EWMA since 2006.

The SSiS is an association for registered ­nurses with a professional interest in wounds.

Christina Lindholm President christina.lindholm@hv.hkr.se www.sarsjukskoterskor.se

The main purpose of the SSiS is to address nation wide, strategic issues in wound management, in close co-operation with politicians, other national societies and EWMA. We aim to – promote evidence-based medical and nursing practice in agreement with laws and regulations in order to increase quality of care for persons with wounds or at risk of developing wounds – become a meeting place for co-operation and exchange of knowledge between ­interest groups from various specialist areas in wound healing – cover, disseminate and promote research, development and education in wound healing – strengthen and clarify the nurse’s role in wound healing – improve the wound patients’ physical, practical and emotional situation

Conferences Two conferences have been held, both at the Karolinska University Hospital. They have attracted more than 400 participants. ­International speakers include Tom Defloor, Mark Collier and Keith Harding. The next conference on the theme Wound management – practical aspects and ethical issues – an interactive session will be held September 24. The Annual General Meeting has been held on March 26, combined with a meeting for representatives from the companies.

At present our main efforts are directed towards expanding the website, planning the next conference, preparing problem inventories in the wound healing area, drawing up competency standards for Swedish nurses specialising in wound healing and recruiting more members.

Membership in the SSiS includes free issues of the EWMA Journal and the Danish SÅR journal, reduced subscription fees for the new Swedish journal Sår and reduced registration fees for SSiS and EWMA conferences.

Since being established in late 2005, the SSiS has recruited around 350 members, arranged two conferences, set up working teams, established co-operation with the companies, started a website, www.sarsjukskoterskor.se, and acted as a point of reference to the authorities in different wound-related subjects.

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Organisations

What’s new in Slovenia?

WMAS

Slovenian Wound ­Management Association

Helena Kristina Peric Slovenian Wound Management Association Cankarjeva 8 1236 Trzin Slovenia helena.peric@siol.net

Slovenian Wound Management Association (WMAS) has been very active in the past couple of years. As a very young association it still suffers from some “childhood” problems but we are overcoming them more and more.

WMAS is run by professor Zoran M. Arnež.

Vice-presidents are Vanja Vilar and Zdenka Kramar. The executive board consists of different professions- doctors of various specializations, nurses, pharmacists…

As Slovenia is a small country (population less then 2 million) we always struggle with man power, so last year we decided to hire a part time secretary to assist us with administration.

This proved to be a good decision as our plan of activities is always ambitious enough to keep us busy.

Some of the major achievements of the association in the last 2 years are: n publishing Recommendations for prevention and treatment of pressure ulcers, Recommendations for treatment of venous leg ulcers, Recommendations for treatment of diabetic foot ulcers and Recommendations for treatment of malignant wounds. The Recommendations are very appreciated by health care professionals. Of course we are aware that this is just the first step out of many required to bring wound care in Slovenia to the level where all patients will be treated adequately and equally. We would like to expand these recommendations into detailed guidelines but what is even more important, we need to find a way to assist health care professionals to

implement them in practice as much as possible. In order to do so, some changes have to be made at macro level (health care organization, reimbursement…) and some changes have to be made at micro level (health care professionals interest and attitude towards wound care…) n organization of many educational events on prevention and treatment of chronic wounds, including workshops and discussion forums. Over the past 2 years, more than thousand people attended these activities.

We also support activities organized by other institutions who serve as wound care centers of excellence. n influencing health care politics to improve wound care services in Slovenia.

Representatives of WMAS wrote many letters and paid many visits to Reimbursement agency, Ministry of health, Health council etc. Members of WMAS also cooperated with articles and interviews on the radio, TV and in the printed media in order to raise awareness of wound care problematic. n cooperating with European Wound Care Association: we maintain regular cooperation with EWMA. Last year we started a joint project “Implementing leg ulcer strategy in Eastern Europe” under the leadership of Peter Franks. We are hoping that this project will provide evidence which can be used in our efforts to improve wound care services in Slovenia. It is one of our major activities for 2007.

This year we are planning similar activities as in previous years. We have an ambitious plan we hope to fulfill with EWMA support. We are also looking forward to have some of our representatives visiting EWMA conference as this is an excellent opportunity to exchange experience, refresh knowledge and gain new ideas.

Warm regards from Slovenia on behalf of WMAS executive board!

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Co-operating Organisations ABISCEP

Wound Management Association in Belgium

AISLeC

Associazione ­Infermieristica per lo Studio Lesioni Cutanee Italian Nurse Association for the Study of Cutaneous Wounds www.aislec.it

AIUC

Associazione Italiana Ulcere Cutanee.

Italian Association for Cutaneous Ulcers www.aiuc.it

APTFeridas

Portuguese Wound Management Association www.aptferidas.com

AWA

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

FWCS

Finnish Wound Care Society www.suomenhaavanhoitoyhdistys.fi

GAIF

Grupo Associativo de ­Investigacão em Feridas www.gaif.net

GNEAUPP

Grupo Nacional para el ­Estudio y ­Asesoramiente en Ulceras por Presión y Heridas Crónicas www.gneaupp.org

GWMA

Greek Wound Management Association

HWMS/MSKT

Hungarian Lymphoedema and Wound Managing Society

ICW

Initiative Chronische Wunden

CNC/BFW

Wound Management Organisation www.befewo.org www.wondzorg.be

CSLR

Czech Wound Management Society www.cslr.cz

CWMA

Croatian Wound ­Management Association

DGfW

Deutsche Gesellschaft für Wundheilung www.dgfw.de Danish Wound Healing Society

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DWHS

Danish Wound Healing Society www.dsfs.org

IWHS

Iceland Wound Healing ­Society www.sums-is.org

LBAA

Latvian Wound Treating ­Organisation

LF

Lymphoedema Framework www.lymphoedemaframework.org

LSN

The Lymphoedema Support Network www.lymphoedema.org/lsn

LUF

The Leg Ulcer Forum www.legulcerforum.org

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Journal 2007 vol 7 no 2

Organisations

LWMS

SWHS

NATVNS

SWMA

Lithuanian Wound Management Society National Association of ­Viability Nurse Specialists (Scotland) www.natvns.com

NIFS

Norwegian Wound Healing Association www.nifs-saar.no

NOVW

Dutch Organisation of Wound Care Nurses www.novw.org

PWMA

Polish Wound Management Association

ROWMA

Romanian Wound ­Management Association

SAfW

Swiss Association for Wound Care www.safw.ch

Svenskt ­Sårläk­ningssällskap www.sarlakning.com Serbian Wound Management Association

TVNA

Tissue Viability Nurses ­Association www.tvna.org

TVS

Tissue Viability Society www.tvs.org.uk

WMAI

Wound Management ­Association of Ireland www.wmaoi.org

WMAS

Slovenian Wound ­Management Association

WMAT

Wound Management ­Association Turkey

SEBINKO

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

SFFPC

La Société Française et ­Francophone de Plaies et Cicatrisations www.sffpc.org

Present your national wound management organisation or write a report about your organisation’s latest meeting. ewma@ewma.org

SISS

Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

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Journal 2007 vol 7 no 2

Deadline for incoming material for the next issue is 15 July 2007

59

3 Editorial

Peter J Franks

Scientific Articles 7 Is it safe to use saline ­solution to clean wounds?

João Carlos Gouveia, Christina Miguens

15 The cost of pressure ulceration Peter J Franks

21 Epidemiology of wounds treated in Community Services in Portugal Elaine Pina

29 Improving wound assessment through the ­provision of digital ­cameras across a Primary Care Trust Alison Hopkins

Background Articles 35 The use of telemedicine in wound care Rolf Jelnes

39 Lord Joseph Lister: the rise of antiseptic surgery and the modern place of ­antiseptics in wound care David Leaper

EBWM 44 Abstracts of recent ­Cochrane Reviews Sally Bell-Syer

EWMA 48 EWMA Position Document 2007: Topical Negative Pressure in Wound Management Christine Moffatt

50 EWMA Journal previous issues 50 International Journals 52 EWMA Corporate Sponsors contact data

Conferences 54 Conference calendar

Organisations 55 The XIth Finnish National Wound Management Conference, 1-2 February 2007 in Helsinki Salla Seppänen

56 The SSiS is an association for ­registered nurses with a professional interest in wounds Christina Lindholm

57 What’s new in Slovenia?

Helena Kristina Peric

58 Co-operating Organisations