EWMA Journal October 2007

Volume 7 Number 3 October 2007 Published by European Wound Management Association

EDUCATION

EWMA Council

The EWMA Journal ISSN number: 1609-2759 Volume 7, No 3, October, 2007 The Journal of the European Wound Management Association Published three times a year Editorial Board Carol Dealey, Editor

Marco Romanelli President

Sue Bale Michelle Briggs Peter Franks Finn Gottrup Deborah Hofman E. Andrea Nelson Marco Romanelli Zbigniew Rybak Peter Vowden

Finn Gottrup Recorder

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 Immediate Past ­President

Sue Bale

Judit Daróczy

Luc Gryson Treasurer

Zena Moore Secretary

Carol Dealey

Marcus Gürgen

Deborah Hofman

EWMA Journal Editor

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

Individual subscription per issue: 7.50€ Libraries and institutions per issue: 25€ The next issue will be published January 2008.

Prospective material for publication must be with the editors as soon as possible and no later than 1 November 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.

Christina Lindholm

Christine Moffatt Position Document Editor

E. Andrea Nelson

Patricia Price

Zbigniew Rybak

Salla Seppänen

Rita Videira

José Verdu Soriano

Peter Vowden

PANEL MEMBERS Editorial Board Members Carol Dealey, UK (Editor) Sue Bale, UK Michelle Briggs, UK Peter Franks, UK Finn Gottrup, Denmark Deborah Hofman, UK E. Andrea Nelson, UK Marco Romanelli, Italy Zbigniew Rybak, Poland Peter Vowden, UK

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

Co-operating Organisations’ Board Rokas Bagdonas Suzana Baric Pauline Beldon Andrea Bellingeri Mark Collier Rodica Crutescu Valentina Dini Bülent Erdogăn Milada Franců

Katia Furtado Georgina Gethin Mária Hok Gabriela Hösl Aníbal Justiniano Aleksandra Kuspelo Martin Koschnik M.A. Lassing-Kroonenberg Sandi Luft

Christian Münter Guðbjörg Pálsdóttir Vivianne Schubert José Verdú Soriano Luc Tèot Deborah Thompson Rosine van den Bulck Anne Wilson Carolyn Wyndham-White

EWMA

For contact information, see www.ewma.org

Journal 2007 vol 7 no 3

Editorial 3 Editorial

Carol Dealey

Science, Practice and Education 5 Vacuum assisted closure for chronic wounds: a review of the evidence E. Andrea Nelson

13 General practitioner support to care homes: collaboration with a tissue viability nurse specialist and prescribing support pharmacist Lynne Watret, Rachel Bruce

19 Integrated system of chronic wound care healing – creating, managing and cost reduction Heinz J. Janßen, Roland Becker

27 Guidelines for the management of partial­thickness burns in general hospital-recommen­ dation of a European working party Bjarne Alsbjørn, Annelea Buntzen

31 Diabetic Foot Ulcer – From Fiction to Management. The development of global guidelines Jan Apelqvist, Karel Bakker, Gerlof D Valk

Background Articles 35 Wound Healing in Medieval England Carol Dealey

EBWM 38 Abstracts of Recent ­Cochrane Reviews Sally Bell-Syer

EWMA 40 EWMA Journal previous issues 41 International Journals 42 Book Review: Leg Ulcers – a Problem Based Approach Deborah Hofman

44 Development of Clinical Practice Guideline on Pressure Ulcers Katrien Vanderwee

48 Evaluating the pilot of the first course delivered using the University Conference Model at the EWMA Conference Glasgow, May 2007 Madeleine Flanagan

52 Conference Report, EWMA 2007, Glasgow Michael Clark

56 EWMA Corporate Sponsors contact data

Conferences

T

hese days we seem to need evidence for everything – even politicians provide ‘evidence’ to support their arguments. I, too, believe in the importance of evidence, but recognise that there can be problems for everyday practitioners. Even if they have the skills to critically appraise the evidence, do they have the time or the access to a wide range of sources? I certainly have a pile of journals waiting to be read and I cannot imagine that I am alone in this.

Systematic reviews can be very helpful in synthesising information.

The Cochrane Wounds Group regularly provide us with high quality reviews and details of the latest reviews can be found on page 38.

However, sometimes more is needed to assist in applying the evidence to practice. This is where clinical guidelines can be really helpful.

Clinical guidelines are recommendations on the appropriate care and treatment of people with different diseases or conditions1. They take the evidence and provide statements for clinical practice which can guide our decision making. In this issue we showcase a number of wound care related guidelines either newly published or in the process of development relating to: partial thickness burns, diabetic foot ulcers and pressure ulcers. Each of these guidelines has been developed by multi-national groups and they demonstrate the benefits of working at an international level. They are great examples of cooperation and collaboration and it is useful to understand how they came to be developed.

The guidelines on the management of small partial-thickness burns being managed in the community are specifically aimed at healthcare professionals who do not regularly care for burn-injured patients.

It is impossible to maintain awareness of the current evidence for all the different types of wounds, so this is a most timely guideline.

Delegates at EWMA conferences have frequently benefited from papers presented by members of the International Working Group on the Diabetic Foot. Their guidelines on the management of diabetic foot ulcers provide a useful resource on all aspects of managing these complex wounds. The pressure ulcer guidelines being developed by the EPUAP and NPUAP are still very much a work in progress. I hope that many of the readers of EWMA Journal will feel inspired to register as stakeholders and comment on the draft guidelines when they are produced.

58 Conference Calendar

Organisations 60 Annual Meeting of the Lithuanian Wound Management Association Loreta Pilipaityte

62 Co-operating Organisations

Of course, guidelines are not all that is on offer in this issue of the Journal and I hope that in the mix of scientific papers, EWMA news and information from the co-operating societies that you will find something of interest. Happy reading!

Carol Dealey, EWMA Journal Editor Reference 1. NICE (2004) Clinical Guideline 10: type 2 diabetes, prevention and management of foot problems.

NICE, London

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Journal 2007 vol 7 no 3

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Science, Practice and Education

Vacuum assisted closure for chronic wounds: a review of the evidence INTRODUCTION Wounds with tissue loss usually heal by secondary intention; new tissue fills any deficit before epithelium covers the gap. The majority of wounds heal with simple dressings but a significant minority fail to heal and require additional therapies.

Vacuum assisted closure (also called topical negative pressure, negative pressure wound therapy and sub-atmospheric pressure wound therapy) has been used in many acute and chronic wounds and this summaries the effectiveness and cost-effectiveness of this treatment.

BACkGROUND Wounds that fail to heal may be accompanied by local oedema thought to prevent effective oxygen and nutrient exchange, and act as a substrate for infection. The application of a negative pressure dressing increases perfusion (Argenta and Morykwas 1997) and this may be important for tissue repair. Suction may also remove bacteria and factors that impede healing in chronic wounds such as matrix metalloproteinases. In addition, researchers have identified relationships between mechanical stress applied to cells and cellular proliferation and protein synthesis (Morykwas and Argenta 1997), suggesting that applying forces may kick start healing.

The technique involves placing a dressing made of an open-pored foam into the wound, inserting a tube between the foam and a source of negative pressure, and sealing the system with an adhesive film. Suction is applied at between 50 and 125 mmHg, and wound fluid is drawn into a disposable collection receptacle. Dressings are usually changed every 48 hours. The treatment options can be modified by varying pressure, applying it intermittently or continuously, choosing one of two foams, a portable and standard method of applying negative pressure, or an instillation version for use with fluids such as topical antiseptics. The majority of studies have used a commercial vacuum assisted closure device (VAC™, KCI) and this has been available since 1995.

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EVIDENCE OF EFFICACy AND SAFETy A number of reviews (e.g. Evans et al 2001, Samson et al 2004, Ontario Ministry of Health and Long-Term Care 2004; Mendonca et al 2006, Pham et al 2006, Pilatakis and Molnar 2006) have summarised the evidence for vacuum assisted closure. Searching the Cochrane Library in November 2006 using the search terms ‘vacuum assisted closure’ or ‘negative pressure therapy’ or ‘topical negative pressure’ yielded 54 citations to potential randomised controlled trials. In order to identify unpublished work, the KCI website and bibliographies of studies retrieved from electronic searching were also inspected. These searches identified eleven randomised controlled trials (RCTs) in open wounds published between 2000 and 2006 (16 citations). A further 11 trials are only described in conference abstracts (Orgill and Bayer 2004, Stannard 2004, Niezgoda 2004, Molnar 2004, Greer 2004, Bayer and Orgill 2004, John Lantis 2004, Stremitzer 2006, Foo et al 2004, Obdeijn et al 2004, Payne 2004) and insufficient information was available within these to appraise study quality or obtain full results . Other studies were excluded as they were not trials: commentaries (5), investigated acute wounds (8), not about vacuum assisted closure (4), controlled clinical trials without randomisation (10), retrospective analyses (1), or reported a study investigating physiological effects of vacuum closure (1).

Description of studies (see table 1) Pressure ulcers Two RCTs (n=50) reported on the effect of vacuum closure on pressure ulcers (Ford 2002, Wanner 2003).

Ford (2002) reported on 22 people with 35 full thickness pressure ulcers. The proportion of ulcers healing with vacuum assisted therapy was 10% (2/20), similar to that healing moist wound products (13%, 2/15). There was no significant difference in reductions in reduction in volume (51.8% with vacuum therapy and 42.1% with dressings). Problems with this trial included lack

E. Andrea Nelson BSc(Hons) RGN PhD Reader in Wound Healing Scool of Healthcare University of Leeds Leeds LS2 9UT United Kingdom e.a.nelson2@leeds.ac.uk

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Table 1. Characteristics of studies Study identifier Ford

Type of wound Pressure ulcers, grade 3 or 4

Participants 28 people with 41 ulcers

TNP therapy TNP changed 3 times a week

Wanner

Pressure ulcers, grade 3 or 4

34 people

TNP changed every 2-7 days

McCallon 2000

DFU

10 people

vacuum therapy

Eginton 2003

DFU

Armstrong 2005

DFU

Ten patients with 11 wounds: cross-over trial 162 people with partial foot ­amputation wounds

with two weeks of vacuum assisted therapy (125 mmHg continuous) 16 weeks of vacuum therapy ­(regimen not reported)

Verstaek 2006

Patients with ulcers of at least 6 months duration

n=60

Vacuum assisted therapy (125 mmHg continuous pressure)

Joseph 2000

Mixed wound population: 78% due to pressure, rest due to venous insufficiency, surgical wound dehiscence, ­radiation, trauma)

24 people with 36 wounds

or vacuum closure changed every 48 hours.

Moues 2004

Wounds requiring open wound management before 54 people ­surgical closure. Thirty seven percent of the wounds were secondary to pressure; the others were caused by ­infection, dehiscence or ‘miscellaneous’ aetiologies.

Large defects requiring grafting with an artificial skin 12 people ­replacement. Fifty percent of the wounds were traumatic, the rest were due to melanoma, burn, healing delay, ­decollement and fibroleimyosarcoma.

Jeschke 2004

Moisidis 2004,

Acute and chronic wounds requiring grafting (5 trauma, 4 burns, pressure ulcer, sternal dehiscence, wound infection, extravasation, necrotising fasciitis, ­degloving, venous insufficiency and cellulitis).

Randomised Braakenburg 2006 People with acute or chronic wounds secondary to ­surgery (48%), pressure (29%), diabetes (9%), trauma (8%), and venous insufficiency (6%)

of information on randomisation, the assumption that multiple ulcers were independent, lack of baseline characteristics, and attrition rate.

Wanner (2003) reported on 22 people (from an initial study population of 34) with grade 3 or 4 pressure ulcers.

The primary outcome was time to ulcer reduction of 50%.

There was no significant difference in the mean time to achieve a 50% reduction in area: 27 (SD 10) days in the vacuum group and 28 (SD 7) days in the gauze group.

Problems with this trial included a high rate of attrition, lack of information on method of randomisation, and the assumption that multiple ulcers were independent. In two small, poorly reported trials, therefore, there was no significant difference in reduction in area / volume, nor in the number of ulcers healing between vacuum therapy and either moist wound healing products or gauze dressings.

vacuum therapy (continuous 125 mmHg) changed every 48 hours.

or fixation with fibrin glue and vacuum therapy (continuous 150 mmHg)

22 people. Wounds were grafted and then each half (proximal / distal) was treated with TNP or control

(100 mmHg continuous).

included 65 people (66 wounds)

vacuum (125 mmHg continuous) changed three times a week

Foot wounds in people with diabetes Three RCTs (182 participants) evaluated vacuum closure in people with diabetic foot ulcers, or post amputation wounds (McCallon 2000, Eginton 2003, Armstrong 2005).

The first study (McCallon 2000) studied 10 people allocated (initially by a coin flip and then alternately ) to vacuum therapy or saline gauze changed twice daily. Patients were non-weight bearing throughout. Patients were ‘healed or ready for surgical closure / grafting’ in 22.8 days with vacuum closure and 42.8 days in the gauze group.

They also reported the change in wound area at 2 weeks; vacuum group had a 28% decrease (+/-24) and standard care had a 10% increase (+/-17). They do not indicate whether values are means or medians, and standard errors or standard deviations, therefore determining statistical significant is not possible. Problems with this trial include

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Science, Practice and Education

Control therapy Moist wond healing products from Healtpoint system Wet to dry or wet to wet gauze saline gauze changed twice daily

hydrocolloid gel / gauze dressing moist wound therapy

Modern dressings (alginates or hydrogels)

wet-to-moist gauze dressings covered by a film (changed three times a day) moist gauze (changed twice a day)

standard graft fixation (compression dressings and daily ­dressing changes for 14 days)

A hydrocolloid dressing

Results 1. Wounds healed: 2/20 vs 2/15 (NSD).

2. Reuction in wound volume, 51.8% vs 42.1% (NSD) Time to achieve 50% reduction in volume: 27 days vs 28 days (NSD) 1. ‘healed or ready for surgical closure / grafting’: 22.8 days vs 42.8 days 2. change in wound area at 2 weeks; 28% decrease vs 10% increase 1. reduction in wound volume: 59% +/- 9.7 versus ­increase of 0.1% +/-14.7; p < 0.005).

1. complete wound closure (either primary intention or surgical closure): 56% versus 39%;p=0.04 2. wounds healing time: 56 days (median) vs. 77 days (p = 0.005).

1. Time to complete healing: 29 days vs 45 days (p=0.0001) 2. Time to grafting: 7 days vs 17 days; p = 0.005.

3. Wound care costs were higher in the dressings group, mainly due to higher bandage and dressings costs (5452 vs 3881; p = 0.001).

1. Reduction in wound volume: 78% vs 30%.

2. Time to 90% reduction in volume said to be shorter for the TNP group. Data not presented, authors p=0.04 log rank).

1. Time to a clean, red, granulating wound, 6 days vs 7 days (NSD).

2. Reduction in area: 3.8% per day vs 1.7% per day; p<0.05).

The time to skin transplantation was shorter with fibrin and vacuum closure than compression alone (10 days compared with 24 days; p<0.002). Graft take was higher with fibrin and vacuum closure (78% compared with 98%; p <0.003).

1. Degree of graft take at two weeks: 86% vs 87%.

2. A qualitative appraisal of graft take by a clinician found this to be equivalent in 7 cases, worse with vacuum in 3 and better with vacuum in 10.

Comment No data on 65 people with 6 ulcers Data on 22 people

Data was reported on six patients (7 wounds).

More chronic ulcers in the control group

Differences in healing time were robust to ­imbalances in the groups at baseline (TNP ­median area 33 cm2, dressings group 43 cm2).

Quality of life was lower in the TNP group in the first week of therapy.

Complication rate was higher for the TNP group: not significant (p = 0.17).

The method of randomisation was not reported and the people in the vacuum group were older and had larger ulcers than the dressings group.

No outcomes on 2 people

conventional care using dressings from 1. Time to complete granulation or being ready for the formulary (hydrocolloids, alginates, grafting: 16 days vs 20 days hazard ratio 1.33, 95% acetic acid, Eusol).

CI 0.74 to 2.4: log rank p = 0.32). NSD

an open method of allocation and lack of baseline wound measurements.

Ten patients with 11 wounds had their wounds randomised (Eginton 2003) into a cross-over trial with two weeks of vacuum assisted therapy (125 mmHg continuous) and two weeks of hydrocolloid gel / gauze dressing.

Data was reported on six patients (7 wounds). There was a greater reduction in wound volume with vacuum closure than moist dressings (59% +/- 9.7 reduction versus increase of 0.1% +/- 14.7; p < 0.005). Problems in this trial included the analysis did not take into account the crossover design, there may have been selection bias, baseline characteristics were not reported, and multiple ulcers were considered as independent.

The largest study (Armstrong 2005) randomized 162 people with partial foot amputation wounds to 16 weeks of vacuum therapy (regimen not reported) or moist wound therapy. Allocation was concealed and patients received EWMA

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off-loading therapy with a pressure relief walker or sandal. The control group had ulcers of longer duration (1.8 months compared with 1.2 months) than the vacuum closure group. After 16 weeks more people with had complete wound closure (either healing by primary intention or surgical wound closure) in the vacuum closure group (56% versus 39%; p=0.04) than the dressings group. The vacuum closure wounds healed in a median of 56 days compared with 77 days in the standard care group (authors’ p = 0.005). Problems with this trial included the lack of an adjusted analysis to control for the more chronic ulcers in the control group.

Vacuum closure was associated with more rapid healing of post-amputation wounds in people with diabetic foot ulcers in one trial. In two small, poorly reported trials, vacuum assisted closure was associated with higher rates of area or volume reduction but insufficient information 

is presented on baseline risk in these two small studies to determine any potential biases.

Venous leg ulcers One RCT (n=60) randomised patients with ulcers of at least 6 months duration to vacuum assisted therapy (125 mmHg continuous pressure) or modern dressings (alginates or hydrogels) (Verstaek 2006). Once the wounds were completely granulated full thickness punch skin grafts were applied. After grafting the vacuum assisted closure group had 4 days of vacuum treatment then compression therapy; the control group had compression therapy.

Patients were on almost complete bed rest throughout.

The time to complete healing was 29 days in the vacuum assisted closure group and 45 days in the dressings group (p=0.0001) The trial also reported shorter time to grafting with vacuum assisted therapy (7 days to 17 days; p = 0.005). The differences in healing time were robust to imbalances in the groups at baseline (vacuum group median area 33 cm2, dressings group 43 cm2). Quality of life was lower in the vacuum group in the first week of therapy, and this difference disappeared during therapy. The complication rate was higher for the vacuum assisted closure group but this was not significant (p = 0.17). Wound care costs were higher in the dressings group, mainly due to higher bandage and dressings costs (5452 vs 3881; p = 0.001) and this did not include the lower costs of hospital care as it is not usual to keep people in hospital until complete healing.

In one trial, vacuum closure accelerated the healing of recalcitrant venous ulcers for in-patients on bed-rest treated with punch skin grafting. It was also associated with lower treatment costs. This trial is relevant to a small proportion of the leg ulcer population as few are offered skin grafting and long term hospitalisation.

Mixed wound populations Five RCTs recruited a mixed population (Joseph 2000, Moues 2004, Jeschke 2004, Moisidis 2004, Braakenburg 2006). Two studied the effect of vacuum therapy on fixation rates of grafts (Moisidis 2004, Jeschke 2004), the others studied the effect of vacuum closure on wound healing.

The studies included 190 wounds (in 177 people) due to, pressure (36%), trauma, infection, dehiscence, radiation, burns and venous insufficiency, and other unique causes such as melanoma.

Joseph (2000) randomised 24 people with 36 wounds (78% due to pressure, rest due to venous insufficiency, surgical wound dehiscence, radiation, trauma) to wet-tomoist gauze dressings covered by a film (changed three times a day) or vacuum closure changed every 48 hours.

It is not clear if allocation was concealed and ulcers were larger in the vacuum assisted closure group; 38cc compared with 24cc. Assessment was supposed to be by personnel

unaware of allocation to the treatment groups at 3 and 6 weeks, but other investigators indicated that assessment could not be blinded (Braakenburg 2006). Ten patients were cared for at home, the remainder were in residential care or hospital in-patients. There was a greater reduction in wound volume in the vacuum group than the dressings group (78% compared with 30%) and the time to 90% reduction in volume was shorter for the vacuum group, even when adjusted for imbalances in the baseline characteristics (data not presented, authors p=0.04 log rank). Problems with this trial included the assumption that multiple ulcers were independent, and the imbalance in areas at baseline may be evidence of selection bias.

In a second study (Mouës et al 2004), 54 people who needed open wound management before surgical closure were randomised to moist gauze (changed twice a day) or vacuum therapy (continuous 125 mmHg) changed every 48 hours. Thirty seven percent of the wounds were secondary to pressure; the others were caused by infection, dehiscence or ‘miscellaneous’ aetiologies. The endpoint was time to a clean, red, granulating wound, and there was no difference between vacuum therapy (median 6 days) and moist gauze (median 7 days). The study reported a greater reduction in area in the vacuum group than conventional therapy (3.8% per day vs 1.7% per day; p<0.05).

Problems with this trial include the lack of baseline data which means the difference in outcomes may be due to differences in baseline areas.

The third study included 65 people (66 wounds) with acute of chronic wounds secondary to surgery (48%), pressure (29%), diabetes (9%), trauma (8%), and venous insufficiency (6%)(Braakenburg et al 2006). They were randomised to vacuum (125 mmHg continuous) changed three times a week or conventional care using dressings from the formulary (hydrocolloids, alginates, acetic acid, Eusol). The outcome was time to complete granulation or being ready for grafting healing and Cox regression analysis showed no difference between groups (16 days with vacuum, 20 days with dressings; hazard ratio 1.33, 95% CI 0.74 to 2.4: log rank p = 0.32). Problems with this trial include the modest sample size.

Two small studies with methodological weaknesses reported a higher healing rate in people treated with vacuum than those treated with wet-to-moist gauze. One study (Braakenburg et al 2006) found no difference in time to achieve a granulated wound ready for grafting between various wound dressings and vacuum therapy.

Skin graft fixation Two studies (n=34), evaluated vacuum therapy in fixing skin grafts (Jeschke et al 2004, Moisidis et al 2004). In the first study, twelve people with large defects requiring grafting with an artificial skin replacement (Integra™, Johnson and Johnson, Hamburg, Germany) were ranEWMA

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Science, Practice and Education

domised to either standard graft fixation (compression dressings and daily dressing changes for 14 days) or fixation with fibrin glue and vacuum therapy (continuous 150 mmHg)(Jeschke et al 2004). Fifty percent of the wounds were traumatic, the rest were due to melanoma, burn, healing delay, decollement and fibroleimyosarcoma.

The method of randomisation was not reported and the people in the vacuum group were older and had larger ulcers than the dressings group. The time to skin transplantation was shorter with fibrin and vacuum closure than compression alone (10 days compared with 24 days; p<0.002). Graft take was higher with fibrin and vacuum closure (78% compared with 98%; p <0.003). Problems with this trial include the Iack of information on randomisation, the ulcers in the control group were smaller and the people were younger. In addition, it is not possible to determine whether this difference is due to the fibrin glue, vacuum therapy of a combination of both.

The second study (Moisidis et al 2004) evaluated vacuum therapy in a study including 22 people with acute and chronic wounds requiring grafting (5 trauma, 4 burns, pressure ulcer, sternal dehiscence, wound infection, extravasation, necrotising fasciitis, degloving, venous insufficiency and cellulitis). Wounds were grafted and then each half (proximal / distal) was randomised to compression dressings or vacuum therapy (100 mmHg continuous).

A hydrocolloid dressing at the junction of the two areas prevented transmission of pressure and dressings were left intact for five days. Outcomes were reported on 20 people. There was no significant difference in the degree of graft take at two weeks: 86% with vacuum and 87% with compression dressings. A qualitative appraisal of graft take by a clinician found this to be equivalent in 7 cases, worse with vacuum in 3 and better with vacuum in 10. Problems with this trial included the use of an unvalidated assessment scale used, blinded outcome assessment may not be possible, and the suction dressing may have also exerted a vacuum effect on the control dressing.

One very small study reported that vacuum therapy and fibrin fixation of Integra was associated with accelerated skin transplantation and graft take compared with compression dressing alone. One small study in which divided wounds were treated with vacuum therapy and dressings found no difference in degree of graft take.

Costs Two studies included formal analyses of costs (Moues 2004, Braakenburg 2006).

Moues (2004) found that vacuum therapy was associated with lower labour costs (233 minutes compared with 283; p<0.0001) and higher material costs 2414 versus 215; p <0.0001). As people treated with vacuum therapy were ready for grafting sooner, they had lower hospitalisation costs and this partly offset the higher treatment costs.

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Overall, there was no difference in the costs of treatment (material, staff and hospitalisation) with vacuum and moist gauze. Moist gauze is not standard care in many settings, therefore the relevance of this finding is unclear.

Braakenburg (2006) reported that total costs per day were higher in the vacuum therapy group compared with the conventional group (material costs 259 euro cf 94 euro: labour 81 euro cf 176 euro). Because the vacuum therapy was used for fewer days, then the increased material costs were offset by lower labour costs, therefore the overall costs were not significantly different (353 euro with vacuum therapy and 273 euro with conventional dressings; p = 0.09).

In a hospital the reduced labour costs are unlikely to be realised by the organisation, and therefore the use of vacuum therapy may result in higher material costs with only a potential saving of nursing time, and similar or improved outcomes.

Modern wound dressings require changing less often than gauze and comparison of vacuum therapy costs using gauze as a comparison may be biased in favour of vacuum therapy. This is particularly of importance in countries where twice daily wet-to-dry gauze is no longer used to heal wounds. Future studies examining cost-effectiveness should use modern dressings as a comparator. None of the studies included the depreciation or repair costs of the machines, nor the cost of training nurses to apply, monitor and renew the vacuum dressings.

Adverse effects A number of studies reported adverse effects associated with vacuum therapy. These include pain at the initiation of the vacuum (Braakenburg 2006), foam being left in the wound cavity, removal of foam leading to wound bed trauma (McCallon 2000), maceration of skin around the wound (McCallon 2000) and immobilisation of the patients as it requires connection to a pump for 22 hours per day. In one RCT (Vuerstaek 2006) people in the vacuum group had a lower quality of life that the control group in the first week of therapy, which rapidly increased after this time. The effect of vacuum therapy on quality of life was studied in a cohort study of 26 people (Mendonca et al 2007) where it was also reported that the use of vacuum closure was associated with a deterioration in health related quality of life (11/26 people). The authors surmised that this might be due to the limitations on undertaking activities of daily living (Mendonca 2007). One RCT also reported more adverse effects, particularly skin damage caused by the treatment in the vacuum group compared with the control group (7/30 vs 2/30)(Vuerstaek 2006).

Some trials (e.g. McCallon 2000) mentioned the difficulties in maintaining the seal around the wounds, and the RNAO guidelines point out that nurses need high levels of training and skill to be able to use the vacuum therapy

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effectively (RNAO 2002). In one trial the learning curve with the technology was specifically referred to (Braakenburg 2006) and nurses needed an average of two demonstrations of the system to be able to apply it with eroding the skin around the ulcer or the ulcer bed.

Recommendations in Guidelines Some clinical practice guidelines for the management of pressure ulcers, venous ulcers, and pressure ulcers have considered vacuum assisted closure within the search for effective interventions, usually as adjuvant to care after healing has not progressed. One guideline on diabetic foot disorders (Frykberg et al 2006) recommend it for use in initial foot ulcer treatment (page 19) for simple foot ulcers, for infected foot ulcers (page 29) as well as over exposed bone, tendons, and hardware (page 26) to promote granulation tissue. This is based on professional consensus; it does not grade the recommendations or link recommendations and evidence.

Two clinical practice guidelines for venous ulcers mention vacuum closure. The first guideline recommends it as a treatment to be used if conservative therapy does not work in 30 days (Grade B evidence: result of two or more trials (not RCTs), or a single RCT) (AAWC 2005). A later guideline (RCN 2006) concluded there was no research evidence that vacuum assisted closure speeds the healing of any wounds. Both Guidelines were completed before the single study in venous ulcers (Verstaek 2006) was published. In venous ulcers, therefore, the guidelines differ – one recommending vacuum closure for recalcitrant ulcers and the other not recommending it at all.

Four clinical guidelines in the management of pressure ulcers refer to vacuum closure. The 2002 Canadian guideline included a recommendation (grade B) that vacuum therapy could be recommended for chronic pressure ulcers, but no definition of chronicity was given. Grade B evidence required well conducted studies but no RCTs (RNAO 2002). A second guideline stated that vacuum therapy could be considered ‘on an individual basis for those wounds that do not respond to more traditional therapies and osteomyelitis has been ruled out’ (Evidence grade C: observational studies or controlled trials with inconsistent results)(Folkedahl et al 2002). Topical negative pressure was recommended for recalcitrant stage III and IV wounds in a third guideline (WOCN 2003) (level of evidence = A: two or more supporting RCTs or a systematic review).

The fourth guideline states that that using vacuum therapy should be based on a full patient assessment, previous positive effects of the therapy, patient preference, and practitioner’s competence (evidence Grade D, i.e. based on consensus or cohort studies) (RCN 2005).

In pressure ulcers, therefore, guidelines recommend the use of vacuum assisted closure with levels of evidence from all points on the hierarchy of evidence for effectiveness, 10

even accounting for the fact that different evidence grading systems were used, from multiple RCTs / systematic review to consensus.

Outcomes used in vacuum therapy trials There are a number of outcomes used in these trials. Accelerating time to complete ulcer healing, whether by grafting or by secondary intention, is the primary objective but as this may require months of follow-up many investigators report surrogate outcomes such as reduction in area or volume, or time to attainment of a clean ulcer bed. It is assumed that earlier debridement or surgery will lead to earlier closure but this is not clear from clinical studies how valid these surrogate outcomes are. One study used a qualitative measure of graft take using a simple scale, and the validity of this tool is not known. Assessing wound area / volume and wound bed outcomes in this area is complicated by the fact that vacuum therapy usually leaves marks on the wound or skin and hence the person assessing the wound is inevitably aware of the allocation (Moues 2004, Braakenburg 2006).

The use of wound volume as an outcome is problematic as in some wounds there are undermined wound edges, and changes in volume with patient position.

Wound area is not a sensitive indicator of healing in large wounds with considerable tissue loss as in the initial stages of healing there may be considerable reduction in wound depth and hence volume, but no change in area.

Bradley et al (1999) reported that imbalances in size of wound at baseline may lead to biased reporting if authors only present relative or absolute reduction in size (area or volume).

As there is no clear evidence of the validity of surrogate outcome measures, then complete wound closure should be used as the primary outcome, even if the vacuum therapy is only used for one part of care, and future studies should collect information on the validity of reduction in volume (both relative and absolute) and the time to surgery in predicting healing.

Studies in progress A number of studies of vacuum assisted closure have been mentioned in the literature. There were conference abstracts identified in this search describing another 8 trials (Orgill and Bayer 2004, Stannard 2004, Niezgoda 2004, Molnar 2004, Greer 2004, Bayer and Orgill 2004, John Lantis 2004, Stremitzer 2006). Two reviews (Samson 2004; Pham 2005) list 2 completed but unpublished RCTs, and three more ongoing RCTs in wounds healing by secondary intention. It is not possible, however, to determine whether there is any overlap in these reports as only one of the trials reported (Armstrong 2006) had a trial registration number.

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Conclusion There is no good quality evidence that vacuum therapy helps the healing of pressure ulcers or mixed populations of wounds. In people with diabetes and post-amputation foot wounds, there is some evidence that vacuum therapy leads to more rapid healing; whereas in simple diabetic foot ulcers there is no high quality evidence of an effect on healing. In chronic venous ulcers, vacuum therapy accelerated healing in people treated with bed rest and punch grafts, but few patients are likely to be offered hospitalization and bed rest due to the costs. Vacuum therapy appeared to help graft take when used in conjunction with fibrin glue.

Analysis of costs in two studies found that vacuum therapy is associated with lower staff costs and higher material costs if compared against traditional or regular formulary dressings. Local decision makers should determine if any reduction in staff time is likely given their pattern of care, as one of these studies used moist gauze needing changed 2-3 times a day. They may also consider the potential for

realizing the savings due to lower nursing time as it is unlikely to lead to lower staff costs as the nurses will be deployed elsewhere.

There are some adverse effects associated with vacuum therapy, such as pain, damage to skin around the ulcer, and for some, poorer quality of life initially as mobility is impaired. Care must be taken in application and renewal to ensure no damage is done to the wound bed, the seal is maintained and an appropriate treatment (foam /suction device / pressure) is selected. There have been no studies comparing outcomes in different treatment regimens and this seems to be determined from clinical experience.

Many trials are in progress or completed and it is important that their results are made available so that future summaries of effectiveness are based upon the full set of clinical trials rather than a selected sub-set which may lead to publication bias. m

References Andros G, Armstrong DG, Attinger CE, Boulton AJ, Frykberg RG, Joseph WS, Lavery LA, Morbach S, Niezgoda JA, Toursarkissian B; Tucson Expert Consensus Conference.

Consensus statement on negative pressure wound therapy (V.A.C. Therapy) for the management of diabetic foot wounds. Ostomy Wound Manage. 2006 Jun;Suppl:1-32.

Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg 1997;38:563-77.

Ontario Ministry of Health and Long-Term Care. Vacuum assisted closure therapy for wound care. Toronto: Ontario Ministry of Health and Long-Term Care; 2004 Orgill DP and Bayer L. Preliminary Results Indicate Vac Therapy Facilitates Faster Closure of Open Abdominal Wounds. 2nd World Union of Wound Healing Societies’ Meeting.

77. 2004

Association for the Advancement of Wound Care (AAWC). Summary algorithm for venous ulcer care with annotations of available evidence. Malvern PA. 2005 1-25.

Pham C, Middleton P, Maddern G. Vacuum-assisted closure for the management of wounds: an accelerated systematic review. 2003. Australian Safety and Efficacy ­Register of New Interventional Procedures – Surgical (ASERNIP-S).

Bayer L, A-C P, and Orgill DP. Has the Wound Vac Become the Standard of Care for Sternal Wounds? 2nd World Union of Wound Healing Societies’ Meeting. 76. 2004. Paris.

Pham CT, Middleton PF, Maddern GJ. The safety and efficacy of topical negative pressure in non-healing wounds: a systematic review. J Wound Care. 2006 Jun;15(6):240-50.

Braakenburg A, Obdeijn MC, Feitz R, van Rooij IA, van Griethuysen AJ, Klinkenbijl JH. The clinical efficacy and cost effectiveness of the vacuum-assisted closure technique in the management of acute and chronic wounds: a randomized controlled trial. Plast Reconstr Surg. 2006 Aug;118(2):390-7; discussion 398-400.

Plikaitis CM, Molnar JA. Subatmospheric pressure wound therapy and the vacuum-assisted closure device: basic science and current clinical successes. Expert Rev Med Devices.

2006 Mar;3(2):175-84. Review.

Bradley M, Cullum N, Nelson EA, Petticrew M, Sheldon T, Torgerson D. Systematic reviews of wound care management: (2) Dressings and topical agents used in the ­healing of chronic wounds. Health Technol Assess 1999;3 (17 Pt 2).

Evans D, Land L. Topical negative pressure for treating chronic wounds. Cochrane Database Syst Rev. 2001;(1):CD001898. Review.

Folkedahl BA, Frantz R. Treatment of pressure ulcers. Iowa City. University of Iowa Gerontological Nursing Interventions Research Centre, Research Dissemination Core. 2002.

Frykberg RG, Zgonis T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR et al . Diabetic foot disorders:a clinical practice guideline. The Journal of Foot & Ankle Surgery 2006;45 (5): Supplement 1-68.

Greer SE, Longaker MT, and Margiotta M. Preliminary results from a multicenter, randomized, controlled study of the use of subatmospheric pressure dressing for pressure ulcer healing. Wound Repair and Regeneration 1999;A255.

John Lantis JC and Gendics C. Vac Therapy Appears to Facilitate STSG Take When ­Applied to Venous Leg Ulcers. 2nd World Union of Wound Healing Societies’ Meeting.

42-43. 2004. Paris Mendonca DA, Papini R, Price PE. Negative-pressure wound therapy: a snapshot of the evidence. Int Wound J. 2006 Dec;3(4):261-71 Molnar JA, Heimbach DM, Tredgett EE, and Mozingo DW. Prospective, Randomized, Controlled, Multicenter Trial Applying Subatmospheric Pressure to Acute Hand Burns: An Interim Report. 2nd World Union of Wound Healing Societies’ Meeting. 16. 2004.

Paris Morykwas MJ, Argenta LC. Nonsurgical modalities to enhance healing and care of soft tissue wounds. J South Orthop Assoc 1997;6(4):279-88.

Morykwas MJ, Simpson J, Punger K, Argenta A, Kremers L, Argenta J. Vacuum-assisted closure: state of basic research and physiologic foundation. Plast Reconstr Surg. 2006 Jun;117(7 Suppl):121S-126S. Review.

Registered Nurses Association of Ontario (RNAO) Assessment and management of stage I to IV pressure ulcers. RNAO. Toronto (ON). 2002 Royal College of Nursing. The nursing management of patients with venous leg ulcers.

Recommendations. 2006. RCN, London.

Royal College of Nursing and National Institute for Health and Clinical Excellence. The management of pressure ulcers in primary and secondary care?: A Clinical Practice Guideline. London, 2005.

Samson D J, Lefevre F, Aronson N. Wound-healing technologies: low-level laser and vacuum-assisted closure. Rockville: Agency for Healthcare Research and Quality (AHRQ); 2004 (Report No 111) Shirakawa M, Isseroff RR. Topical negative pressure devices: use for enhancement of ­healing chronic wounds. Arch Dermatol 2005;141(11):1449-53 Stannard JP, Volgas DA, Robinson J, and De Los Santos A. Topical Negative Pressure Therapy For Soft Tissues Management Of Open Fractures: Preliminary Results. 2nd World Union of Wound Healing Societies’ Meeting. 19. 2004. Paris Stremitzer S, Budzanowski A, Hoelzenbein T, Ludwig C, and Wild T. Definition of efficiency in vacuum therapy - Redon vs VAC-therapy. 16th Conference of the European Wound Management Association. 2006.

Vuerstaek JD, Vainas T, Wuite J, Nelemans P, Neumann MH, Veraart JC. State-of-the-art treatment of chronic leg ulcers: A randomized controlled trial comparing vacuum-assisted closure (V.A.C.) with modern wound dressings. J Vasc Surg. 2006 Nov;44(5):102937; discussion 1038. Epub 2006 Sep 26.

Willy C. Comparison of TNP therapy applications. J Wound Care. 2006 Sep;15(8):360; author reply 360-1. Review. No abstract Wound, Ostomy, and Continence Nurses Society (WOCN) Guideline for prevention and management of pressure ulcers. Glenview (IL) Wound Ostomy and Continence Nurses Society (WOCN) 2003.

Moues CM, van den Bemd GJ, Meerding WJ, Hovius SE. An economic evaluation of the use of TNP on full-thickness wounds. J Wound Care. 2005 May;14(5):224-7.

Niezgoda JA. A Comparison of Vacuum Assisted Closure Therapy to Moist Wound Care in the Treatment of Pressure Ulcers: Preliminary Results of a Multicenter Trial. 2nd World Union of Wound Healing Societies’ Meeting. 53 . 2004. Paris

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Find out more during EWMA at the KCI Booth and at the KCI Symposium ©2007 KCI Licensing, Inc. All Rights Reserved. All trademarks designated herein are property of KCI, its affiliates and licensors. Those KCI trademarks designated with the “®”, “TM” or “*” symbol are registered in at least one country where this product/work is commercialized, but not necessarily in all such countries. Most KCI products referenced herein are subject to patents and pending patents.

Science, Practice and Education

General practitioner support to care homes: collaboration with a tissue viability nurse specialist and prescribing support pharmacist Abstract The key requirement of any health care delivery system is that services are delivered efficiently and effectively and that the total cost of doing so is kept under control (Harrison, 2003). The Greater Glasgow Nursing Homes Medical Practice is a General Practitioner (GP) led service set up in November 2002 to promote the specialization of patient care in the care home setting. The GPs are the driving force in structuring pathways of care for this vulnerable client group, which comprises mostly an elderly population, but also alcoholic brain injury and young chronic sick.

One innovative approach developed by the team is to monitor medication usage, wound dressings and sip feeds which streamline the service of prescription provision and provide cost containment. This is achieved by the support of a dedicated pharmacy team working as an integral part of the team. The primary care tissue viability nurse specialist dovetails into the service and offers education and clinical support to care homes to promote best practice in tissue viability.

This unique service is successful in demonstrating that a cost effective care system is possible when care home service delivery is supported by specialists in the field.

(67%) of these are seen by assisting practices and 900 (33%) are seen by salaried GPs in the central team.

The central team comprises of a clinical director, 6 GPs, pharmacist, 2 pharmacy technicians, practice nurse, practice manager and 3 administrators. This central team is supported by 12 assisting GP practices, who provide a service to the care homes in their locale.

By 2021 the number of older people (>75 years) will increase by around 27% (Partnerships for Care, NHS Scotland, 2003). In 20052006 74% of the patients cared for by the team were over 75 years old, with 10% over 95 years ­(Table 1). Currently in Greater Glasgow there is a significant patient turnover, with approximately 700 new admissions per annum to care homes.

The National Council for Palliative Care (2007) estimated in England around 20% of all deaths of patients over the age of 65 years happen in care homes.

Introduction The Greater Glasgow Nursing Homes Medical Practice (GGNHMP) is a unique service which was set up in response to “a history of significant variations in general practitioner care for those living in care homes. The aim was to deliver an enhanced personal medical service” (Hannah and Durkan, 2005).

The GGNHMP provides dedicated medical care to roughly half of all “nursing” care home residents in Greater Glasgow and is the largest provider of GP care to care homes in the UK. There are currently 2700 patients registered with GGNHMP (75% of total GGNHS beds); 1800

Table 1: age range of patients in Care Homes, GGNHMP

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Journal 2007 vol 7 no 3

Co-morbidity problems present a challenge to the team with 65% of patients having a mental health diagnosis recorded (Table 2). Prescribing analysis showed that their nursing home population, on

Lynne Watret, MN, MA, RGN Clinical Nurse Specialist ­Tissue Viability NHS Greater Glasgow & Clyde Primary Care Division Rachel Bruce, PhD, MPharm. MRPharmS Prescribing Support ­Pharmacist Rehabilitation and ­Assessment Directorate NHS GG & Clyde Work attributed to NHS Greater Glasgow & Clyde Correspondence to Lynne.Watret@glacomen. scot.nhs.uk Acknowledgement: Dr Jean Hannah, Clinical Director GGNHMP



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average, receive eight times more prescriptions than those cared for in their own home. A dedicated specialist GP in a care home allows for a range of conditions to be addressed by the same person at the same time to promote continuity and personalized quality of care.

There is a responsibility by the service to prevent unnecessary hospital admissions that not only increases the cost of health care but is traumatic and distressing for the patient and their families.

Challenges of working in elderly care service in care homes Fundamental to the care of the older person is to consider that the typical medical model of diagnosis, treatment and curative expected outcome does not fit neatly into their model of care. “Older people have varying complex needs and often experience more than one health problem at any one time” (NHSQIS, 2005). Much of the care provided is conservative with proactive symptom control in a way that optimizes quality of life.

The need for wound care provides an additional challenge for the team. The primary care tissue viability nurse dovetails into the service when required to provide clinical support and education. The most common wound types encountered are skin tears, leg and diabetic foot lesions and pressure ulcers and less commonly fungating wounds and post operative wound infections. Management includes preventative and palliative care strategies to be in place as well as clinical interventions.

Cost containment and quality of care an achievable outcome As with all health care initiatives, services did not start with a blank sheet (Harrison, 2003) and a review of the GGNHMP service was necessary to identify areas where improvements to service delivery and cost reduction could be achieved whilst ensuring quality of care.

To demonstrate the effectiveness of this approach two areas will be explored; the first being the development of a pharmacy model to improve cost-effectiveness of prescribing of both medicines and dressings to enhance the role of the GPs; and the second is the introduction of a Nurse Practitioner, with the support of the Primary Care Tissue Viability Nurse, to explore methods to promote appropriate use of dressings and provide education to meet the needs of the care home staff.

Rationalising prescribing practice and review of patients medication Reviews of patients repeat medications often identified medication for which there was no longer an indication or which may no longer be required. Patient medication was reviewed against clinical parameters such as blood tests, HbA1c and blood pressure. Medication could then 14

Table 2: co morbidity problems identified by team (Nov. 2005) • • • • • • • • •

65% of patients have a mental health diagnosis recorded 14% of those with mental health diagnosis are <65 years old 32% have a current Adults with Incapacity Certificate in place 41% of 359 patients identified as having a dementia diagnosis 12% have an alcohol dependence or alcohol psychosis ­related diagnosis 10% have an epilepsy or seizure related diagnosis 5% have Parkinsons disease 12% have had a fractured neck of femur 10% have diabetes

be rationalised which would improve the quality of patient care and reduce inappropriate prescribing. In some instances, stock piling of products on repeat prescriptions, in particular dressings and appliances could also be discontinued.

Sufficient cost reduction could be identified through an improved repeat prescribing system to justify two pharmacy technician posts to monitor monthly prescription ordering in a selected number of care homes within the service. Of note, when a trial discontinuation of monitoring and intervention by the technician was carried out in six care homes for a few months, the costs of medication reverted back to previous levels, demonstrating the need for ongoing technician input to the team.

A major challenge for the practice in terms of repeat prescribing is that the main areas of spend are not in fact drugs, but wound management products and sip feeds for nutritional support. These are products subject to a great deal of stock piling and waste from excess supplies. The pharmacy technicians monitor the use of wound management products and sip feeds to prevent inappropriate use of resources.

Cost effectiveness of medication and repeat prescribing review Total savings generated from this method of monitoring repeat prescribing of medication, wound care products and sip feeds from June 2005 to March 2006 was £120,000 (€177,372) which would result in annual savings of £160,000. (€236,560). This is achieved with two pharmacy technicians responsible for ordering and generating repeat prescriptions for 44 care homes. Clinical medication reviews by the pharmacist result in savings of £100 (€147.83) per patient per annum.

Wound dressing prescribing habits Wound dressings prescribed for the care homes amount to £210,000 (€310,506) per annum which constitutes a substantial amount of the practice prescribing budget.

There is therefore an ongoing requirement to ensure that appropriate use of products is taking place.

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Prior to the commencement of the service care home staff would receive prescriptions from the patient’s GP for wound dressings. In many instances repeat prescriptions were raised with no established review period. Other orders were raised by phone from the care homes for the GP receptionist to action.

There were no formal systems in place to monitor this service provision and stock piling of dressings was not uncommon.

The care home team in the first instance received monthly orders for dressings which were deemed necessary for the forthcoming month. Additional prescriptions may also have been raised over and above this for individually identified complex wounds. The pharmacy team decided to stop the practice of monthly ordering and would only accept faxed tissue viability forms for dressings on a named patient basis.

The technician queried large orders and asked how often dressing ware being changed and dispensed an appropriate number of dressings which would allow for a two week time zone. The understanding is that wound reassessment is carried out and if the wound is progressing, the nursing home can raise a prescription for additional dressings or alternatively seek further advice from the GP or refer the patient to the tissue viability nurse.

In one respect this increases the pharmacist team’s workload however it does ensure closer monitoring of dressings for individualised patient care. This process will continue to evolve and be reviewed to ensure individual patient needs are met whilst achieving cost containment.

A valuable asset to the team was the introduction of a Nurse Practitioner and as part of her role worked closely with the pharmacy team and scrutinised faxed requests for dressings for any anomalies and trends in ordering.

An anomaly may be a request made for a hydrogel and a hydrofibre dressing for one wound. The nurse practitioner contacts the care home staff, discusses rationale for choice and offers hands-on clinical support as well as formulating an appropriate treatment plan.

Equity of access to dressing products Patients should receive equity of care and access to service regardless of their care environment. In Scotland information on all dressings raised by prescription can be accessed through the Prescribing Information System for Scotland known as PRISMS. It is therefore possible to determine whether dressings prescribed for patients in their own home are similar to that of patients in the care home setting. Glasgow primary care service is split into 5 main geographical areas called Community and Health Care Partnerships (CHCP).

The PRISMS information was used to determine the most frequently used dressing types in Scotland; a randomly chosen CHCP; and the Care homes supported by the team for a period of one year. This would give us an indicator if the care homes were accessing similar dressing types to other health care providers.

The review demonstrated that the same dressings were accessed. The most commonly used product range included foam dressings, hydrogels, hydrofibre and a range of silver dressings as most frequently used dressings of choice. Honey was also used, however, it appeared to be concentrated in small areas as a popular choice in one group of homes but little in others. The CHCP did not use routinely use honey, whilst over Scotland isolated areas of usage were apparent.

These results indicate that care home patients under the team receive equity of access to dressings for complex wounds. The team would have expected this result due to the support provided to care homes in terms of education, tissue viability and promotion of evidence based practice.

Care homes are also visited by wound care company representatives who may also influence choice of dressings.

It should be noted that this was small review and it cannot be extrapolated to assume that dressings are used appropriately in all areas. It would make an interesting topic for a further study.

Provision of dressings for “new” wounds TIME to Start is an initiative which is currently being piloted with the nurse practitioner, pharmacist and TVN. Patients who develop a wound such as a skin tear require an appropriate dressing to be at hand. This is particularly important out of hours. A grant has been awarded by the Queens Institute for Nursing for Scotland to pilot a scheme to have dressings available for such eventualities.

The pilot study is due to end in October 2007 and involves 13 of the care homes. Information is collected on types of wounds encountered, tissue type, wound dressings used and identifying the need for additional support in wound care. The TIME framework provides a structured approach to wound assessment. (Schultz et al, 2003) The framework is displayed on a laminated sheet with appropriate dressings choices indicated for each tissue type. Dressings are provided in a box with audit forms for completion each time the system is used. The provision of dressings is maintained by a dedicated pharmacy technician. So far preliminary results show that the most common wounds are skin tears or patients admitted with heel pressure ulcers.

Follow up prescriptions tend to be orders for dressings which were initially used from the TIME to Start dressing’s box. This appears to indicate that the care home 

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Science, Practice and Education

staff are satisfied with the choice of wound care products provided and continuity of care may be achieved. Choice of dressing is therefore based on TIME assessment and dressings provided for this and not what happens to be in the cupboard.

This also allows staff to work within their sphere of professional conduct and is not using dressings which were previously prescribed for another patient. The GPs support the project and depending on the recommendations from the pilot would like to work towards developing an action plan to provide this service in the remaining care homes.

Equity of Access to education In Glasgow all staff that care for patients with wounds are encouraged to use Wound Bed Preparation (WBP) and TIME as a structured approach to wound assessment (Schultz et al, 2003). In primary care study days are regularly carried out to develop skills of implementation of the TIME framework to promote consensus in assessment of wounds (Watret, 2005). The aim is that regardless of where the patient is on their journey of care and regardless of which health care professional is providing that care they would be assessed using the same structured TIME approach. Study days were extended to secondary care staff however, it soon became apparent that the problem based learning approach the study days took used wounds such as infected post operative wounds or complex wounds in a group of patients who may not have the same problems of the care home group e.g. dementia or advanced degenerative disorders.

It was therefore decided that we should carry out separate study days entitled TIME for the Older Person. It was the primary care TVN’s experience that wound challenges in care homes, elderly care secondary care wards, mental health dementia units tended to be similar. The standard set for the older persons’ day used the same approach but with examples of wounds typical to the area such as skin tears and pressure ulcers. The days promote an interactive environment for all nurses and podiatrists who care for the older person and it is hoped that this engenders networking and a shared culture. The days are free to attend and well attended by care home staff.

Ageing skin can be easily compromised “a breach of skin integrity can result from a variety of occurrences and cause a range of consequences some of which can be life threatening” (Kemp, 1994). The older patient also suffers from skin disorders (Sibbald et al 2003) and on evaluation forms and throughout the TIME wound assessment days, questions were raised around pressure ulcer prevention and management of common skin conditions in the elderly. The primary care TVN in collaboration with the dermatology liaison sister, who also has a city wide remit,

16

developed a study day in 2007. This covered pressure ulcer prevention in the morning session and dermatological conditions and bandaging skills in the afternoon. Days are open to the same group and again are well attended by care home staff. To date, evaluations have been positive and we plann to continue them.

The GPs are supportive of the educational provision and also prompt staff on visits to care homes to encourage attendance. They also support the use of the WBP and TIME framework and are therefore aware of terminology to use when discussing wound care with care home staff which promotes continuity of care and a common language between health care professionals.

In conclusion This unique service demonstrates that a model for delivery of cost effective quality of care to the older person in a care home can be achieved.

The National Council for Palliative Care (2007) state that “the most difficult scenario is multiple GPs with no common procedure or protocols” in care homes. This situation is avoided with the benefits of having a dedicated GP to deliver care with pharmacy support. The benefits far outweighs any disadvantages to patients who may have been asked if they would change GP when admitted to the care home. The GP can specialise in this important field of work and develop the service to meet the needs of this growing number of patients today and for the future.

The care home staff members can build up a good working relationship with one dedicated GP with the GGNHMP team and can carry out regular ward rounds to meet the patients’ needs. The TVN also receives more appropriate referrals. Above all the patient and their families can be assured that they will receive continual monitoring by a dedicated team with an established support network. m References Hannah, J. & Durkan, M. (2005) Greater Glasgow Primary Care Trust. Annual Report Enhanced Services: Nursing Home Medical Practice Report and Recommendations Harrison, A. Making the Right Connections: The design and management of health care delivery. Great Britain. Kings Fund Bookshop. 2001 Kemp, M.G. (1994) Protecting the skin from moisture and associated irritants. Journal of Gerontological Nursing 20 (9) 8 NHS National Council for Palliative Care: End of Life Care Programme. Improving end of life care in care homes: examples of innovative practice. June 2007. http://www.ncpc.org.uk/download/publications/BuildingOnFirmFoundations.pdf NHS Quality Improvement Scotland. Healthcare Services Used by Older People in Scotland. Report on the Consultation on the Draft Standards and Proposed Peer Review Process. (2005) www.nhshealthquality.org/nhsqis/files/older_people-review.pdf Partnership for Care: Scotland’s Health White Paper. February 2003. http://www.sehd.scot.nhs.uk/publications/partnershipforcarehwp.pdf Schultz. G.S., Sibbald, R.G., Falanga, V., Ayello, E.A., Dowsett, C., Harding K et al.

(2003) Wound Bed Preparation: a systematic approach to wound management.

Wound Repair and Regeneration 11 Suppl 1: S1-S28 Sibbald, G.S.¸Campbell, K., Coutts, P., Queen, D (2003) Intact skin – An Integrity Not To Be Lost. Ostomy/wound management 49 (6) 27-41 ) Watret, L. (2005) Teaching wound management: a collaborative model for future education. http://www.worldwidewounds.com/2005.november/Watret/Teaching-WoundMgt-Collaborative-Model.html

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Biatain - Ibu Advanced moist wound healing and release of ibuprofen

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Advanced moist wound healing • Biatain - Ibu is a unique combination of excellent exudate management and local sustained release of ibuprofen1,2 • Biatain - Ibu may reduce wound pain caused by tissue damage1,3,4,5 • Biatain - Ibu releases ibuprofen locally with no observed systemic effect1

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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: 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. © 2007-02. All rights reserved Coloplast A/S, 3050 Humlebæk, Denmark.

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Science, Practice and Education

Integrated system of chronic wound care healing – creating, managing and cost reduction Abstract The high costs associated with chronic wounds can, in the main, be attributed to the frequency in dressing changes and to the respective wound care management. In the following paper we want to present and discuss our experiences and results with regard to the establishment of a wound care centre in the free Hanseatic city of Bremen, Germany. In order to document the creation, management, quality and cost improvement offered by integrated care systems we used a range of different methods including project management, data collection and documentation as well as data analysis. Our data analyses show that both the costs and duration of treatment are significantly higher in a conventional wound care setting when compared to that in an integrated wound care provision system. The implementation of an integrated wound care system can significantly reduce both costs and treatment duration. In addition, we found that there are two variables that have an essential impact on the reduction of treatment duration: firstly, the structural quality assurance i.e. the inclusion of healthcare professionals with relevant experience and understanding with regard to medical services and therapies, and, secondly, the process-related quality assurance, which includes a an integrated, planned, quality-steered case management approach to wound care.

professionals in the health care sector regard the combination of integrated, multidisciplinary and modern wound care as the right solution. It might be that, at first glance, the wound treatment appears to be cheaper in other countries, but, when measuring the success and/or cost-effectiveness of a treatment, one has to include the effects on the quality of life of the patient himself as well as on society as a whole. To our mind, the sustainability of wound care is crucial, i.e. the reduction of the recurrence rate which is, in turn, especially influenced by measures of prevention and a high level of communication within the wound healing network.

INTRODUCTION From a socio-demographic point of view, chronic wounds are a widespread, cost-intensive, and therefore very challenging, problem not just in Germany, but also in other European countries, especially because of the rising age of society and because of increasing expenses in the health care sector.

In Germany wound care management can be divided roughly into integrated and modern wound care on the one hand and into conventional and traditional wound care on the other. Many

THE CHANGING PROCESS In order to document the creation, management, quality and cost improvement in integrated care systems we used the methods of project management, data collection and documentation as well as data analysis which will be presented in the fol-

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According to first analysis, modern and integrated wound care management may reduce up to 40% of treatment costs. This can be 2 billion euro p.a.[2]. In the following we want to present and discuss our experiences and results with regard to the setting up of a wound care centre in the free Hanseatic city of Bremen1. The wound care centre is affiliated to a medical centre. In addition to the medical centre as the executive headquarter and the University of Applied Sciences as the project leader and investigator, the wound care centre network included a health insurance company, physicians, nursing services, product suppliers, and, of course, the patient.

Heinz J. Janßen Prof. Dr. public health Institutional affiliation: – chair of General Business Economics and Management in the health care sector – director of Institute of Health Care Economics (IGP) – course director of two international study programmes.

Contact: Institut für Gesundheits- und Pflegeökonomie Bremen University of Applied Sciences Prof Dr Heinz J Janßen Neustadtswall 30 D-28199 Bremen hjanssen@fbsw.hs-bremen.de www.igp.hs-bremen.de

Roland Becker, M.A. Soz. Institutional affiliation: – project manager at the IPG Contact: See above robecker@fbsw.hs-bremen.de

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Informed consent was obtained from each patient in order to fulfil our investigations. Moreover the study protocol conforms to the ethical guidelines of the 1975 Declaration of Helsinki as reflected in the approval by the institution’s human research review committee.

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lowing. At the beginning of the project, structured paths of treatment were developed by the whole project group and improved during the course of the project. In addition, a special working group was established to deal with the “quality assurance” process, monitoring the project permanently. Together with this, a catalogue of quality criteria was developed. In the following two graphics the management of the new multidisciplinary wound care centre, as well as the associated changing process is shown.

Figure 1: The changing process

The changing process from conventional wound care to an integrated wound care is presented in figure 1. Through the creation and the management of a multidisciplinary network, better communication between all those involved in the wound care process is achieved. Due to the new network structure, the wound treatment can be optimized, e.g. double treatment can be avoided and inpatient health care, as well as amputations and recurrence rates, can be reduced. As a consequence, the quality of life of the patients can be improved while the costs of treatment are reduced. In terms of service delivery, the main difference between integrated and traditional care provision lies in the better coordination of the whole care situation within the integrated care provision system. The wound centre acts like a gatekeeper and translator: the main tasks are mediating between all partners involved, paying attention that the right (i.e. modern and appropriate) wound treatment regimen is followed and monitoring that the documentation is completed correctly. In addition, case conferences take place on a regular basis whereby interventions, amendments and improvements can, if necessary, be introduced at an early stage (e.g. specific hard-to-healulcers can be identified and treatment can be prematurely adopted). The service delivery within the “new” integrated care system is much more coordinated and transparent, and, as a result, patients report that they feel more confident and satisfied. Moreover, they especially appreciate the fact that they receive more attention than within the “old” 20

system, mainly because they now have the opportunity to always communicate and stay in contact with a health care professional from the wound centre. Due to this, they feel much more involved in their treatment and confident with its progress and, possibly more importantly, they are able to follow every step taken within the care process.

Networking In figure 2 the tasks of each partner are described. The wound care centre takes on the process leading management role and arranges a contract with a health insurance company. It plays, therefore, a central role, with regard to the case management (including training) and the finance management. But beside the wound care centre, the other people (nurses, physicians, and health service professionals) and their professional skills are regarded as equally important and relevant within the wound treatment process. The wound centre and its management can be seen as the main partner and coordinator of the physicians, nurses and patients. By leading the networking and case and quality management, the patients will be guided and appropriately controlled by the wound centre. As can be seen in figure 2, the patient takes centre stage and the network is built around him. Throughout a target oriented leadership of the patients, which additionally includes a treatment controlling system – by which patients, who deviate from defined targets can systematically be identified – the wound treatment process can be optimized to improve results for patients and healthcare systems.

Figure 2: Illustration of the network and related network tasks

General network tasks: Developing and management of algorithm of treatment Continuous quality assurance Partnerspecific network tasks: (1) Process leading management

Contract with Health Insurance Company

Networking including case management

Finance Management (2) Close cooperation with and continuous trained by wound care Centre (3) Close cooperation with network

Product information and continuous training (4) Close cooperation with and continuous trained by wound care Centre EWMA

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Science, Practice and Education

With regard to the successful implementation of an integrated wound care system, two aspects were identified as crucial and central: firstly, the development management, including the strict application of the developed algorithm of treatment (and its monitoring), and, secondly, a system by which continuous quality assurance is both sustainable and secured.

Data Management Within the scope of the integrated wound care provision, data were collected with regard to clinical parameters, quality of life (with a focus on pain reduction) and costs.

The documentation process included the following elements: n an anamnesis, i.e. data of patient, vascular situation, wound situation etc., n a check list and data control, n a conduction document, including, among other things, the wound classification, the aims of therapy, the level of pain (VAS-scale), as well as recommendations on nutrition n a follow-up documentation form, including photo documentation and detailed nursing documentation n an extensive collection of data with regard to the costs of the treatment, including costs for personal and material n a questionnaire to assess the quality of life, including the NHP as a generic instrument and the so-called “Würzburger Wundscore” as a wound-specific instrument. Furthermore, dates of the patient’s treatment, duration of condition and especially progress of the wound status using a medical wound score, were collected. This questionnaire was used at four points in time in order to map changes.

First resultsi The initial output and result of the project work is the demonstration and realisation of an integrated care contract. Through this the quality of chronic wound care provision can, especially with regard to quality of care and cost charges related to all involved partners, be noticeably improved. Systematic case management with regard to the care network was shown to be a determining and active factor in this context. Thus, introduction of an integrated system can realise cost savings of around 40% or possibly even more. An international cost comparison with regard to the relative costs of providing leg ulcer care in Sweden, the United Kingdom and Germany [2] [3] showed high differences which can mainly be explained by differences in the dressing change frequency and by the adopted process of wound care management.

With regard to the conventional treatment of decubitus ulcers, our analyses, based on original data from a health care insurance company, including outpatient care as well as home care, revealed an average treatment duration of 217 days, with regard to the conventional treatment of leg ulcers the treatment duration increased to not less than 280 days on average2. The average costs with regard to conventional wound treatment were recently estimated in a study undertaken by Wessig [4]. The average costs were estimated at 124.25€ per week with 61% of costs for staff and about 39% for material. According to the weekly costs, the daily costs add up to 17.75€ per day. By combining these average costs with the estimated treatment duration, the total cost of a pressure ulcer was estimated at 3852€ on average, and the total cost of a leg ulcer at 4970€ on average. Our data clearly confirm what is already known by everyone but seldom precisely demonstrated: the treatment costs (costs for prevention aren’t yet integrated) of pressure ulcers and leg ulcers are enormous in a conventional care setting. The costs are even higher if one includes the period of disability caused by the chronic wound into the calculations. At the same time, the duration of treatment is long, which could be confirmed in a study, recently undertaken

by Pina with regard to patients with wounds presenting at primary care services in Portugal [5]. Therefore one can assume even higher impact on costs, as well as on the patients’ quality of life.

In the following table, the specific costs with regard to the  conventional wound treatment can be seen.

Figure 3: Conventional treatment duration [1] and cost calculation:

[1] Original data of health insurance company, outpatient care and homecare, [2] Period of authorization of home care treatment, authorization by health insurance company [3] Wessig, K. (2006): Fremdbeobachtung der interdisziplinären Versorgung in den Wundmanagement-zentren des Deutschen Facharztverbandes. EFH Darmstadt, 2006.

2

These numbers were calculated on the basis of the period of ­ uthorization of home care treatment authorised by the health a ­insurance company.

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Science, Practice and Education

Further analyses of the quality and effectiveness of an integrated system was based on data provided by another health insurance company [6]. After implementing the integrative wound care contract, which has proved popular with doctors, medical specialists, medical and nursing services and outpatients, an analysis of patient data revealed that 50% of the population could be healed in eight weeks, and 25% in twelve weeks. The costs of treatment can be calculated, in three-quarter of cases, at clearly under 3.000€ per patient. Figure 4 shows the healing rate and related costs of an integrated wound treatment.

Figure 4: Integrated treatment: Healing up rate and related costs

We assume that the savings within the integrated wound management are mainly due to the more coordinated wound care provision throughout which the resources (material and personnel) are used more appropriately and effectively. Moreover one can suggest that the better healing rate increases the compliance and motivation of the patient whereby in turn again the healing rate can be improved. We assume that the compliance and the healing rate have some sort of an interdependent relationship to each other: the interplay of both aspects lead to an improved wound management and, as a consequence, to reduced costs.

Beside this, first analyses, which were executed in the context of the setting up of the integrated wound centre, confirm these results and show improvements towards costs, duration of treatment and, as a consequence, towards the patients’ quality of life.

The comparison between an integrated and a conventional wound care setting is shown in figure 5. It can be seen that cost savings of (at least) more than 30% are possible. We assume that the “real” savings are even higher and vary from 30 to 50%. The average costs of the conventional treatment of decubitus and leg ulcer together are 4.411€ (see figure 3). The average costs of integrated treatment are “clearly under” 3.000€ (see figure 4). These are the results of our first data analysis. Further studies are in process.

Figure 5: Comparison between costs of conventional and integrated treatment

With regard to the duration of the period of disability, we found that, in general, there are two variables that seem to have an essential impact on reducing the duration: the structural quality assurance including the securing of relevant understanding and qualifications in the medical professionals and therapists on the one hand, and the process-related quality assurance including a quality steered case management.

Discussion The “Bremen project” is just the beginning of creating a stable and sustainable structure of an integrated care system. With its involvement, problems are “treated” directly in the German health system. The first results show clear potential for a high-quality modern wound care programme with improved cost effectiveness.

Beside this, our analyses and experiences show that there are two variables with a significantly high impact on the reduction of the duration of the patient’s incapacity for work: 1. the assurance of the structural quality (through provision of experienced and relevantly qualified healthcare professionals) 2. the assurance of the process-related quality (the integrated, quality-steered case management system) It seems as if there still exists a gap between “theoretical” knowledge, especially with regard to possible improvements of the patients’ quality of life, on the one hand and possible savings on the other through an adequate, i.e. an integrated and multidisciplinary, wound care provision, and its practical realisation. Not until society and the important decision-makers realise the significant impact in terms of costs and quality of life (to the patients and

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their relatives, to society as a whole especially through a raised incapacity for work, as well as to the state) caused by chronic wounds, it is difficult to promote cost-efficient solutions.

However, integrated care arrangements which can guarantee an assurance of the structural quality, as well as of the process-related quality, can be regarded as an effective and adequate answer to the challenge of chronic wound healing. m References 1. Franks P.J. (2007): The cost of pressure ulceration. EWMA Journal, Volume 7, Number 2: 15-18.

2. Janßen H., Becker R., Kuhlmann H. (2007): Wundzentrum Bremen: Aufbau und Vertrag, Wundkongress Bremen 2007 3. Ragnarson Tennvall G., Hjelmgren J. (2005): Annual costs of treatment for venous leg ulcers in Sweden and the United Kingdom.

Wound Rep Reg (2005); 13: pp.13-18.

4. Wessig K. (2006): Fremdbeobachtung der interdisziplinären ­Versorgung in den Wundmanagementzentren des Deutschen ­Facharztverbandes. EFH Darmstadt, 2006.

5. Pina, E. (2007): Epidemiology of wounds treated in Community Services in Portugal, EWMA Journal, Volume 7, Number 2: 21-27.

6. Janßen H., (2006): Integrationsversorgung und Begleitstudie, Pflegekongress Bremen 2006

i

Acknowledgements

Results are based on data from two local health insurances (BKK and AOK) and on data which was generated in the context of the setting up of a wound care centre in the city of Bremen, Germany.

About the authors: Prof. Dr. Heinz J. Janssen represents the chair of Business Administration and Health Care ­Management at the University of Applied ­Sciences, Hochschule Bremen. Prof. Janssen leads the Institute of Health Economics, as well as the international study programmes “Nursing and Health Care Management” (Bachelor of Arts) and “Health and Social Care Management” (Master of Arts).

Roland Becker is project manager at the ­Institute for Health Care Economics (IPG) in Hochschule Bremen. After studying sociology, he was employed in a European project working with family care­givers (Eurofamcare).

Currently he is studying for a PhD in the ­investigation and evaluation of an integrated wound care provision system, including analyses with regard to costs and quality of life.

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

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

The most important aspect of becoming a member of EWMA is the influence this membership can give you.

As a EWMA ­member you can vote and even stand for election for the EWMA Council, which will give you direct influence on future developments within European wound healing.

Please register as a EWMA member at

WWW.EWMA.ORG A membership only costs 25 EUR a year.

You can pay by credit card as well as bank transfer.

Existing members of EWMA can also renew their membership online.

EWMA Business Office Danske Bank, London Cash Management 75 King William Street, London EC4N 7DT, UK Account No: 93406336. IBAN: GB69DABA30128193406336 BIC/SWIFT: DABAGB2L. Sort code 301281

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Science, Practice and Education

Guidelines for the management of partial-thickness burns in general hospital-recommendation of a European working party Introduction The vast majority of partial-thickness burns in Europe are treated by non-specialists in the general hospital or community setting. For best outcomes, partial-thickness burns should be properly managed in non-specialists centres, with referrals to burns units being reserved for appropriate cases.

However, the identification of appropriate referrals can sometimes be problematic, and the clinical management of partial-thickness burns by non-specialists can have variable results. For example, sequelae such as hypertrophic scarring and contractures after deep partial-thickness burns are now considered unacceptable in the Western world. These guidelines were produced out of a desire by burns specialists from European countries to provide clear and up-to-date advice on the management of partial-thickness burns in general hospitals and community setting. Their aim is to raise the standard of community-treated patients across the whole Europe and to reduce the number of preventable late referrals to specialists units, those about it is said: “If only ... “ Developing a consensus The management of partial-thickness is a neglected area in literature. This treatment algorithm has been developed by an expert working party of European burn specialists, in the aim of improving the standard of community burns care across the expanding European Union. The guidelines are specifically intended for healthcare professionals who are involved in burns management in a general hospital or community setting. They have been developed to provide a more consistent standard of burns management particularly in the early stages, including the most appropriate use of specialist intervention.

The guidelines Referral One of the principle aims is to determine whether or not a burn should be referred to a specialist burn unit. Burn depth is an important measure EWMA

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in this regard. As a partial rule to distinguish between superficial and deep burns in a non specialist environment, partial-thickness burns are wet, painful, blistering, red, white or pink, whereas full-thickness burns are dry, painless, gray, white or brownish and can look like normal skin but lack sensation. Full-thickness burns should always be referred. The total body surface area (TSBA) affected by burn, should always be assessed using the “rules of nines” for adult patients: the front, the back and legs are each 18% of the TSBA; the genitals are 1% of TSBA, and the hand constitute 1% of TSBA each. Assessment of paediatric burns is different due to differences in body proportions and should be based on Lund and Brown charts of children. Extensive partial-thickness burns should be referred to a burns unit. For this purpose, extensive burns are defined as burns that affect more than 15% of TSBA in adults, and more than 10% of TSBA in children and the elderly. Chemical, electrical, or burns associated with inhalational injury, trauma, or burns located to the face, neck, hands, feet, armpits, popliteal regions, genitals or are circumferential, should all be referred, in order to improve functional outcomes. Specialist referral also is necessary for burns that do not show signs of healing within the first two weeks after injury.

Under normal circumstances, superficial partialthickness burns heal within 10-14 days without scarring. Deep-partial and full-thickness burns take longer to heal and are likely to scar. Patients with certain pre-existing medical conditions such as diabetes1 should be referred, and patients with presentation of pain, redness, exudates formation, fever, odour or malaise after the injury, may be sign of infection and can also be an indication for referral.

Wound preparation The aim is to achieve a clean and visible wound that is ready for dressing. One major factor in reducing burn wound severity is the early application of cool water, which has been shown to reduce wound damage and to increase wound healing2.

Bjarne Alsbjørn Chief consultant Dr.med Annelea Buntzen Clinic for plastic surgery and burns Rigshospitalet, Copenhagen, Denmark bjarne.alsbjoern@ rh.regionh.dk

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This should be done as close to the time of injury as possible â&#x20AC;&#x201C; at the accident site, if appropriate. Water temperature should be cool around 8 C. The duration of cooling should be adjusted for each patient to achieve maximum pain relief, and the patients clothing should be removed, but the patients should always be kept warm. The wound should be cleaned and disinfected with a water based disinfectant and tetanus prophylaxis should be provided to all patients whose vaccinations are not up to date (vaccinated within 5 days)3. Pain relief should be offered to all patients as early as possible. Loose skin, opening blisters should be removed prior to dressing. To reduce pain, closed blisters of less than 2% TSBA can be punctured and re-evaluated within five days. Blisters larger than 2% TSBA should be removed, as they may hinder burn wound assessment.

Wound covering As a rule, wound dressing should maintain a moist environment to aid healing. Wound dressing should have sufficient capacity to absorb excess that can lead to skin maceration, delayed wound healing and infection. Wound dressing should provide an effective barrier to the exterior, to reduce the risk of infection. Wound dressing should be able to fit well to the contours of the skin to support pain relief. They should adhere to the wound, and should be easy to apply and remove with minimal pain. Ideally a wound dressing should stay on the wound for 10 days, unless there are specific reasons (e.g. recurring blisters) that might require dressing changes. Modern dressings utilising hydrocolloids, silicones, alginates and polyurethane, fulfil many of the criteria above. Traditional dressing such as silver sulfadiazine and paraffin gauze are now used less often as they can cause wound to dry up may allow micro-organisms to access and do not effectively support optimal healing. It is advisable to make a list of wound dressing in order of preference, which should be updated periodically.

Post-wound care Healthcare professionals should ensure adequate followup subsequent to wound healing. It is also important to be aware of the potential need for psychological support.

Patients should be fully advised that healed wounds should be moisturised on a regular basis. There are many suitable lotions, creams and ointments available. Itching can be a major problem and should be taken seriously.4 To reduce symptoms, extra moisturisers can be applied, and oral medications may be required. Patients should be advised to protect themselves from the sun, to prevent further thermal damage and pigmentation changes to the affected area, using adequate sun-screen if exposed to excessive amount of sunlight. A SPF of at least 25 is recommended.

If surface changes occur, (e.g. hypertrophic skin, blisters or a new wound appear) the patient should be advised to return to the hospital or clinic for evaluation and eventual late referral to burns unit.

Conclusion These guidelines on the management of partial-thickness burns are intended to provide non-burns specialists with comprehensive guidance on improving patient outcomes.

We recognize the pivotal role of non-specialists who treat the vast majority of burn injuries and believe it is the responsibility of burns specialists to ensure adequate guidance. We encourage national burns associations and professional bodies involved with wound care across Europe to put forward these recommendations to their members to develop strategies for communicating the guidelines to the relevant healthcare workers. m References 1. McCampbell B, Wasif N, Rabbitts A, Staiano-Coico L, Yurtr RW, Schwartz S. Diabetes and burns: a retrospective cohort study. Journal of Burn Care & Rehabilitation. 2002: 23: 157-166 2. Jandera V, Hudson DA, de Wet PM, Innes PM, Rode H. Cooling the burn wound: evaluation of different modalities. Burns, 2000: 2: 265-270 3. Committee on Trauma, American College of Surgeons. A guide to prophylaxis against tetanus in wound management. The American College of Surgeons, 1984 4. Willibrand M, Low A, Dyster-Aas J et al. Pruritis, personality traits and coping in longterm follow-up of burn-injured patients. Acta Derm Vernereol. 2004; 84: 375-380

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Science, Practice and Education

Diabetic foot ulcer – from fiction to management The development of global guidelines Summary It is estimated that approximately 246 million people have diabetes – 5.9% of the world’s population. Every year, more than 1 million people with diabetes lose a leg as a consequence of their condition. This means that every 30 seconds a lower limb is lost to diabetes somewhere in the world.

The majority of these amputations are preceded by a foot ulcer. Ulcers of the foot in diabetes are the source of major suffering and cost. Investing in a diabetic foot care guideline can be one of the most cost-effective forms of healthcare expenditure, provided the guideline is goal-focused and properly implemented. The objective of the International Working Group on the Diabetic Foot (IWGDF), founded in 1996, is to develop guidelines that will reduce the impact of diabetic foot disease through cost-effective and quality healthcare, based on the principles of evidencebased medicine. Three IWGDF working groups had been invited to write specific consensus guidelines on different subjects, according to the current standard of evidence-based medicine. So for the first time, new 2007 texts were produced according to a systemic review of the literature, in order to inform protocols for routine care and to highlight areas which should be considered for further study. After reaching worldwide consensus, the review reports and specific guidelines were launched in May 2007.

Keywords: Diabetic Foot, foot ulcers, guidelines, IWGDF, implementation, consensus.

Introduction It is estimated that approximately 246 million people have diabetes – 5.9% of the world’s population. By 2025, the global estimate is expected to rise to some 380 million – 7.1 % of the adult population. Worryingly, type 2 diabetes is increasing among young people around the world.

Every year, more than 1 million people with diabetes lose a leg as a consequence of their condition. This means that every 30 seconds a lower limb is lost to diabetes somewhere in the world.

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The majority of these amputations are preceded by a foot ulcer. Ulcers of the foot in diabetes are the source of major suffering and cost (1, 2). Of all diabetic foot ulcers, only two-thirds will eventually heal (3-5) and the median time to healing of all ulcers is approximately six months and up to 28% may result in some form of amputation (6).

Investing in a diabetic foot care guideline can be one of the most cost-effective forms of healthcare expenditure, provided the guideline is goalfocused and properly implemented (7, 8).

International Working Group on the Diabetic Foot In 1996, the International Working Group on the Diabetic Foot (IWGDF) was created to improve outcomes of diabetic foot problems, and to improve communication and collaboration between the many professionals involved in diabetic foot care and those in a position to decide healthcare policy and provide funding. The objective of IWGDF is to develop guidelines that will reduce the impact of diabetic foot disease through cost-effective and quality healthcare, based on the principles of evidence-based medicine. In addition, IWDGF is a large network that facilitates worldwide implementation of the aforementioned guidelines. In this implementation, the principles described are adapted for local use, taking into account regional differences in socio-economic circumstances and access to healthcare.

In 1999, the IWGDF, a Consultative Section of the International Diabetes Federation since 2000, published the International Consensus on the Diabetic Foot and Practical Guidelines on the Management and the Prevention of the Diabetic Foot. To date, these publications have been translated into 26 languages, and more than 80,000 copies have been distributed globally. In order to implement the International Consensus, IWGDF recruited local champions – 88 people representing countries around the world.

Jan Apelqvist, MD PhD Dpt of Endocrinology, University Hospital, Milo, S-205 02 Malmö, Sweden Jan.apelqvist@skane.se

Karel Bakker, MD PhD* IDF, Heemsteedse dreef 90, 2102 KN Heemstede, The Netherlands. karel.bakker@hetnet.nl Gerlof D Valk, MD PhD Department of Internal Medicine University Medical Center Utrecht P.O. Box 85500 3508 GA Utrecht The Netherlands

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Figure 1: Delegates from all over the world participated on the Consensus Day.

The IWGDF consensus project is an ongoing process.

In 2003, three new supplements were added, which were launched on an interactive DVD-ROM. In 2005, IWGDF decided that the International Consensus texts should be updated and expanded.

IWGDF is very much in step with developments in the guidelines field. Nowadays, recommendations must be based on sound scientific evidence. Three working groups of experts in the field of diabetic foot had been invited to write specific consensus guidelines. So for the first time, the new 2007 texts on n ‘Footwear and offloading’ n ‘Osteomyelitis in the diabetic foot’ n ‘Wound healing’ were produced according to a systemic review of the literature, in order to inform protocols for routine care and to highlight areas which should be considered for further study.

METHODOLOGy USED TO DESIGN GUIDELINES The recommendations were linked to supporting scientific evidence. To identify the available literature, a systematic search was performed of the currently available electronic databases using pre-defined search strategies. The search was confined to clinical studies in people with diabetes.

Relevant papers were graded according to methodological quality, and thus the strength of the evidence available for different interventions was assessed. Extracted data were summarized, and evidence tables were compiled following collective discussion by the working parties. Conclusions were drawn in the review reports and recommendations formulated as specific guidelines. In this way, the link was

made between the scientific evidence and recommendations for daily clinical practice.

CONSENSUS After careful consideration by the IWGDF editorial board the review reports and specific guidelines were sent to the IWGDF representatives from over 80 countries for comments. On a special Consensus Day prior to the 5th International Symposium on the Diabetic Foot (ISDF), May 8th 2007, in Noordwijkerhout, the Netherlands, all representatives were invited to reach consensus on the three specific guidelines (fig 1). During that day some additional comments were incorporated in the texts and the final texts were eventually unanimously signed and approved by all representatives present.

INTERACT

IVE VERSI ON ON DVD

2007 International Cons ensus

Practical Guideline s

on the Diabetic Foot & on the Managem ent and Preventio n of the Diabetic Foot nal Working Grou p on the Diabetic Foot

by the Internatio

Figure 2: IWGDF Guidelines on a DVD-ROM as has been launched in May 2007

Click here to start

©2007 International

Working Group

on the Diabetic

Foot/Consultative

Section of IDF

EWMA

Journal 2007 vol 7 no 3

Science, Practice and Education

A DVD-ROM with the fully updated consensus text and guidelines was produced in the following days and handed to all delegates of the 5th ISDF on May 12th, the last day of the symposium (fig 2).

Conclusion The future will see the further implementation and evaluation of the 2007 IWGDF Guidelines. These will be further developed to keep in step with advances in research and practice. They will also be expanded to include more topics that pass the evidence-based consensus process.

More than ever before, it is imperative that appropriate action be taken to ensure access to quality care for all people with diabetes, regardless of their age, geographic location or social status (10). IWGDF hopes that global awareness of diabetes and foot complications will continue to increase. The need for improved foot care for people with diabetes throughout the world must be recognized.

If the recommendations contained in this DVD-ROM are followed, they will result in improved management of the diabetic foot and a subsequent worldwide reduction in limb loss.

IWGDF DVD-ROM’s can be purchased through the IDF website at: www.idf.org/bookshop. Costs are 20 Euros or 27 US dollars (not including shipping). m

Literature 1 Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet 2003; 361: 1545-51.

2 Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet 2005; 366: 1719-24.

3 Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Armstrong DG, Harkless LB, Boulton AJ. The effects of ulcer size and site, patient’s age, sex and type and duration of diabetes on the outcome of diabetic foot ulcers. Diabet Med 2001; 18: 133-8.

4 Apelqvist J, Larsson J, Agardh CD. Long-term prognosis for diabetic patients with foot ulcers. J Intern Med 1993; 233: 485-91.

5 Jeffcoate WJ, Chipchase SY, Ince P, Game FL. Assessing the outcome of the ­management of diabetic foot ulcers using ulcer-related and person-related measures.

Diab Care 2006; 29: 1784-7.

6 Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation.

Diab Care 1998; 21: 855-9.

7 Clinical Guidelines Task Force. Guide for Guidelines, A guide for clinical guideline development. International Diabetes Federation. Brussels, 2003. ISBN2-930229-31-4 (www.idf.org).

8 Van Houtum WH. Barriers to the delivery of diabetic foot care. Lancet 2005; 366:1678-9.

9 Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines. BMJ 2001; 323: 334-6.

10 Bakker K, Foster AVM, van Houtum WH, Riley PC. Time to Act, Diabetes and Foot Care. International Diabetes Federation. Brussels, 2003. ISBN 2-930229-31-4 (www.idf.org).

The authors state that they don’t have a conflict of interest.

7th Scientific Meeting of the

Conference theme

Diabetic Foot Study Group

Advancement of knowledge on all aspects of diabetic foot care

of the EASD 11-13 September 2008

Lucca, Italy

www.dfsg.org

Main subjects during conference:  Epidemiology  Basic and clinical science  Diagnostics  Classification  Foot clinics  Biomechanics, Osteoarthropathy  Orthopaedic surgery  Infection  Revascularisation  Uraemia  Wound healing/outcome

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Background Article

Wound Healing in Medieval England Abstract This paper investigates the practices in wound healing in medieval England. The writings of two medieval authors have been translated into modern English and provide an insight into the art of wound healing. John of Mirfield was not a qualified doctor, but he worked at St Bartholomewâ&#x20AC;&#x2122;s Hospital and made many observations of the patients there. He wrote the Breviarium Bartholomei which provides much useful information on wound care. Thomas Morstede was a military surgeon and wrote a Fair Book of Surgery, again providing details regarding wound care. This paper describes some of the practices recommended by these authors and highlights the spread of knowledge across Europe and its impact on practice in England.

smaller than their French and Italian counterparts, with far fewer graduates. In the 14th century the medical school at Oxford comprised only 40 graduates and teachers and at Cambridge only fiftynine medical students graduated between 1300 and 1499.6 The curriculum was very broad, for example, at Cambridge all doctoral medical students were first required to first study grammar, rhetoric and logic (trivium), followed by mathematics, music, geometry and astronomy (quadrivium).6 Teaching methods involved questions and disputations with much analysis of theory.

However, nothing was tested clinically and the students had little opportunity to observe patients.

Surgery and anatomy were not included in the curriculum, resulting in little understanding of physiology.7

Introduction This paper is part of a series that has followed developments in wound healing in medieval Europe, starting in Spain and then moving to Italy, France and Germany.1,2,3,4 The aim of this paper is to identify wound healing practices in medieval England

In the early medieval period universities in Italy and France had offered training in both medicine and surgery.2 However, many doctors were also in clerical orders and thus also subject to decrees issued by the Pope. In 1163, the Pope forbade clergy to undertake surgery and a further edict was issued in 1215 which required all subdeacons, deacons and priests to abstain from surgical practices including cutting or burning. Those who disobeyed risked excommunication. In monasteries where there was a tradition of caring for the sick, surgery was handed over to the barbers who were employed to shave the tonsures on the monksâ&#x20AC;&#x2122; heads.8 Gradually barbers outside the monasteries also gained a knowledge of surgery and many started to call themselves barber-surgeons or even just surgeon. Thus, surgery and, by association, wound healing became the province of barbersurgeons and surgeons.

Background to the practice of wound healing in medieval England In medieval England developments in medicine in general and wound healing in particular lagged behind those in Italy and France. Most advances in England occurred in the 13th and 14th centuries, often in the light of what was happening in the great universities of Bologna, Padua, Montpellier and Paris, although wars also resulted in some developments in wound healing. During the Middle Ages it was perfectly acceptable for students to travel to different countries to attend a university.

As most scholarly activity was in Latin, language was not a barrier. Many students from England traveled to France or Italy for their education, some spending time at several universities.5 Oxford and Cambridge were the first English universities and their medical schools were much EWMA

Journal 2007 vol 7 no 3

Carol Dealey PhD RGN University Hospital Birmingham NHS Foundation Trust Correspondence Dr Carol Dealey Research development Team University Hospital Birmingham NHS Foundation Trust 4th Floor Nuffield House Queen Elizabeth Hospital Birmingham B17 9RE UK carol.dealey@uhb.nhs.uk

Methods Medline, CINAHL, the Wellcome History of Medicine Library and the Centre for the History of Medicine at University of Birmingham databases were all searched. In addition, bibliographies and reference lists from relevant papers and books î&#x201A;Š were also reviewed.

35

Results The majority of the information about wound healing practices comes from John of Mirfield (died 1407) and Thomas Morstede (c1380-1450). John of Mirfield had no formal medical education and was in minor clerical orders. Importantly, he was on the staff of St Bartholomew’s Hospital and learned much from his observations of patients. Figure 1 shows the hospital at this time. Mirfield’s Breviarium Bartolomei contained one section (Part IX) on surgery with much information on wound care which has fortuitously been translated into English.9 Mirfield was very influenced by the writings of an Arab physician called Albucassis (936-1013) and Henri de Mondeville (1260-1320), a French physician and surgeon. Thomas Morstede was a military surgeon to Henry V and participated in the French Wars. He was also a Warden of the Fellowship of Surgeons and is believed to have been very rich.7 He wrote a Fair Book of Surgery in the early 15th century.10 Translations of sections of these treatises into modern English provide some interesting insights.

Acute Wounds John of Mirfield proposed that acute wounds should be categorised as follows: n Simple wounds: no loss of tissue n Wound with loss of tissue: concavity or concave wound n Deep wound n Contusion: when the body has been struck and the skin and the flesh torn and rent Simple wounds “can be cured with poultices soaked in red wine, as hot as he can bear it, somewhat wrung out and applied to the spot; having first made an approximation of the lips of the wound by suturing or bandaging.”9 Wounds with tissue loss should be managed with a “compress of fine lint soaked in egg white or a spider’s web, cleansed of dust and with all parts of the spider removed as it could easily infect the whole body”.9 Deep wounds made with a knife were to be packed with a tent (pack) “made from lard from salt pork or bacon wrapped around with soft cloth and introduce it to the very base of the wound ”. This pack was remain in place for 3 days and then, after cleansing the wound, it was replaced with a pack soaked in a healing ointment. He recommended shortening the pack each day as the wound healed and to be aware of superficial healing. Interestingly, packs were to be changed three times a day in summer, but only twice a day in winter, although no reason was given. Mirfield also recommended a medication made from honey, milk and egg white with meal (a type of barley flour), which would cleanse any wound. 9 36

Sword wounds received special instructions. “Wash with warm white wine and clean it out; then a poultice of hempseed may be soaked in warm white wine and squeezed in the wound…” The poultice was left on the wound until it was dry. “If there is need apply, lengthwise on both sides of the wound, two bolster-like plasters or close the lips of the wound so they are approximated. Then put over a plaster of clothe as before ... then linen cloth. Leave for up to 3 days.

Redress, it can go as long as 7 days. You should nothing else, but it will be cured by this method, according to Master Henry de Mondeville.” 9 John of Mirfield also made some general comments about wound management, quoting Avicenna. “according to what Avicenna says, the reason why evil flesh is generated in a wound is that the physician omitted the proper cleansing of a wound ”.

He reinforced this later in his treatise, noting the importance ensuring that “no hair or ointment or oil or anything fall inside the lips of the wound ” as “their agglutination will be retarded ”.9 Mirfield was not just interested in how wounds should be dressed, but also in how they should be bandaged.

Bandages should be applied from the injury and go on to the “part above”. A second bandage was then to be applied, again starting at the point of injury, and going to the “part below”. The bandages were to be applied tightly over the injured area and become looser the further they were from the wound. However, he added a caveat to these instructions to the effect that this was not advised by all, especially “that new surgeon de Mondeville” who suggested that linen cloth should be applied and sewn in place. He concluded: “Now choose what you wish, according to your discretion and according to the location of the spot.” 9 This sounds rather petulant, but, given the university practice of questions and disputations, was probably in accordance with his academic training.

Morstede’s writing on chronic ulcers has been translated from medieval English into modern English and his proposed strategies reviewed. Some of the statements resonate today. An ulcer was defined as a wound that took more than two or three months to heal. He also suggested that if an ulcer was caused by blood pooling in the veins of the legs and feet, the affected limb should be bandaged with narrow bandages. Nutrition was also important and patients were to be encouraged to eat “clean and wholesome food ”. This included “good wine of Gascony” and a wide range of meat, but not vegetables.10

EWMA

Journal 2007 vol 7 no 3

Background Article

Discussion Several points of interest have been highlighted in this paper. Although, the developments in England were later than in Italy and France, there seems to have been free movement of knowledge and ideas across much of Europe during this period. Considering the difficulties in travel at the time, this is important, as it is easy to assume that England would have been isolated from the rest of Europe. It must also be acknowledged that wars also played a part in spreading knowledge as England took part in a number on wars on mainland Europe during this period as well as individuals going to fight in the crusades to the Holy Land (present day Israel) in the early medieval period.

Figure 1 St Bartholomew’s Hospital in the Medieval Period.

Wellcome Library, London

Both John of Mirfield and Thomas Morstede used a similar classification for ulcers, based on the writings of Avicenna and using Latin nomenclature.9,10 John of Mirfield suggested a variety of treatments for these ulcer types.

For example, for a putrid ulcer (one which continuously discharges pus) he suggested washing the ulcer twice daily with warm wine and applying a plaster of dwarf elder.9 Morstede recommended a treatment regime for treating ulcers that comprised five steps. n Step 1: Enlarge the ulcer mouth. This was achieved by applying a corrosive ointment containing ferrous sulphate onto linen and laying it over the wound. n Step 2: Mortification. This seems to be the process of debridement. Debris and necrotic tissue were cleared from the ulcer either by chemical methods, such as the use of a mixture of white wine, saltpetre and copperas powder, or surgery. Surgery was particularly important if the ulcer had “corrupt bone (as) it will not heal until this has been removed ”. Failure to remove the affected bone would delay healing, possibly by years. n Step 3: Mundification. This term means cleansing and one recipe for a cleanser included sage leaves and wormwood boiled in water and then mixed with white Gascony wine, alum and honey. n Step 4: Fleshing. In this step the production of granulation tissue was encouraged by the use of a dressing containing wax, tallow and turpentine resin, all melted together with the addition of verdigris, rose oil, frankincense powder and mastic. n Step 5: “If all these steps are taken, then the ulcer will heal .”10

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Journal 2007 vol 7 no 3

The main providers of wound care were surgeons rather than physicians, as was the case in other parts of Europe.

Generally, surgeons were less well educated than physicians, but had much more clinical experience during their training. This lack of formal education had an impact on the social standing of surgeons as they were seen as subservient to physicians.11 Surgeons emphasised their practical skills and knowledge of anatomy. In fact Morstede stressed the importance of anatomy as he saw it as a potential bridge between medicine and surgery.6 However the gulf between medicine and surgery remained and Gottfried suggests that it was the experience of surgeons on the battlefield that made English surgery so dynamic during this period.

Conclusion Wound care in medieval England was predominantly in the hands of the surgeons. Their practice indicated an awareness of practices from elsewhere in Europe. m

References 1. Dealey C. Wound Healing in Moorish Spain. EWMA Journal. 2002: 2(1): 2. Dealey C. Wound healing in Medieval and Renaissance Italy: was it art or science?

EWMA Journal. 2003: 3(1): 33-35 3. Dealey C. The contributions of French surgeons to wound healing in Medieval and Renaissance Europe. EWMA Journal. 2004: 4(1): 33-35 4. Dealey C. German Wound Surgeons 1450 – 1750. EWMA Journal. 2005: 5(2): 48-51 5. Reisman D. The Story of Medicine in the Middle Ages. New York: Paul B. Hoeber Inc. 1935 6. Rawcliffe C. Medicine & Society in Later medieval England. Stroud: Alan Sutton Publishing Ltd, 1995 7. Gottfried RS. Doctors and Medicine in Medieval England 1340-1530. Princeton: Princeton University Press, 1986 8. Dobson J, Milnes Walker R. Barbers and Barber-Surgeons of London. Oxford: ­Blackwell Scientific Publications, 1979 9. Colton JB. John of Mirfield. New York: Halfner Publishing Company Inc. 1969 10. Kirkpatrick JJR, Naylor IL. Ulcer management in medieval England.

Journal of Wound Care, 1997: 6(7): 350-352 11. Grigsby B. The social position of the surgeon in London, 1350-1450.

Proceedings of the Illinois Medieval Association. 1996: 13:71-79

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ABSTRACTS OF RECENT COCHRANE REVIEWS Topical negative pressure (TNP) for partial thickness burns Wasiak J, Cleland H The Cochrane Database of Systematic Reviews Submitted for publication in Issue 3, 2007 Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. 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: A burn wound is a complex and evolving injury, with both local and systemic consequences.

Treatment includes using variety of dressings, but newer strategies such as topical negative pressure therapy have been developed to try and promote the wound healing process and minimize burn wound progression to involve deeper tissue in the acute phase.

Topical negative pressure uses a suction force to drain excess fluids.

Objectives: To assess the effectiveness of TNP for those people with partial thickness burns.

Search strategy: We searched the Cochrane Wounds Group Specialised Register (searched April 2007), the Cochrane Central Register of Controlled Trials (CENTRAL)(The Cochrane Library Issue 2, 2007), Ovid MEDLINE (1950 to April Week 4 2007), Ovid EMBASE (1980 to Week 18 2007) and Ovid CINAHL (1982 to April Week 4 2007).

Selection criteria: All randomised controlled trials (RCTs) and controlled clinical trials (CCTs) that evaluated the safety and effectiveness of TNP for partial thickness burns.

Data collection and analysis: Two authors using standardised forms extracted the data independently. Each trial was assessed for internal validity with differences resolved by discussion. A narrative synthesis of results was undertaken as the absence of missing data, poor reporting, or both precluded the authors to undertake any formal statistical analysis.

Main results: One RCT satisfied the inclusion criteria.

The methodological quality of the trial was poor.

Authors’ conclusions: There is a paucity of high quality RCTs on TNP for partial thickness burn injury with insufficient sample size and adequate power to detect differences, if there are any, between TNP and conventional burn wound therapy dressings.

Plain language summary: There is a lack of evidence about whether topical negative pressure therapy is effective in treating people with partial thickness burns.

Topical negative pressure (TNP) therapy is the applica-

tion of negative pressure across a wound to aid in wound healing. In this instance, the pressure is used to aid and drain excess fluid, reduce infection rates and increase localised blood flow, thereby supplying the burn wound with oxygen and nutrition to promote accelerated healing. Alternative names for TNP include vacuumassisted closure (VAC) and sealed surface wound suction.

Pentoxifylline for treating venous leg ulcers [Updated Review] Jull A, Arroll B, Parag V, Waters J The Cochrane Database of Systematic Reviews Submitted for publication in Issue 3, 2007 Copyright © 2005 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Date of Most Recent Substantive Amendment: 5 April 2007 ABSTRACT Background: Healing of venous leg ulcers is improved by the use of compression bandaging but some venous ulcers remain unhealed, and some people are unsuitable for compression therapy. Pentoxifylline, a drug which helps blood flow, has been used to treat venous leg ulcers. An earlier version of this review included 9 randomised controlled trials, but more research has been since been conducted and an updated review is required.

Objectives: To assess the effects of pentoxifylline (oxpentifylline or Trental 400) for treating venous leg ulcers, compared with placebo, or other therapies, in the presence or absence of compression therapy.

Search strategy: For this second update we searched the Cochrane Wounds Group Specialised Register, CENTRAL, MEDLINE, EMBASE and Cinahl (date of last search was February 2007), and reference lists of relevant articles.

Selection criteria: Randomised trials comparing pentoxifylline with placebo or other therapy in the presence or absence of compression, in people with venous leg ulcers.

Data collection and analysis: Details from eligible trials were extracted and summarised by one author using a coding sheet. Data extraction was independently verified by one other author.

Main results: Twelve trials involving 864 participants were included. The quality of trials was variable. Eleven trials compared pentoxifylline with placebo or no treat

EWMA

Journal 2007 vol 7 no 3

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(1) Hospitals in European Link for Infection Control through Surveillance (HELICS) 2001 (2) The Reduction of Vascular Surgical Site Infections with the Use of Antimicrobila Gauze Dressing; Robert G.Penn, MD, Sandra K Vyhlidal, RN, MSN, CIC, Sylvia Roberts, RN, Susan Miller, RN, BSN, CIC. Dept. of Epidemiology, Nebraska Methodist Hospital, Omaha, NE, USA.Observation of Nosocomial Surgical-Site Infection rates with Utilization of Antimicrobial Gauze Dressing in an Acute Care Setting: Mary Jo Beneke, RN BS, CWOCN: Josephine Doner, RN BSN MA CIC. Yuma Regional Medical Center, Yuma AZ. (3) Observation of Nosocomial Surgical-Site Infection Rates with Utilization of Antimicrobial Gauze Dressing in an Acute Care Setting Mary Jo Beneke, RN, BS, CWOCN; Josephine Doner, RN, BSN, MA, CIC Yuma Regional Medical Center, Yuma, AZ

Protect surgical sites with TELFA™ non-adherent dressing Protect exit sites and IV sites with EXCILON™ exit site dressing

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ment; in seven of these trials patients received compression therapy. In one trial pentoxifylline was compared with defibrotide in patients who also received compression. Combining 11 trials that compared pentoxifylline with placebo or no treatment (with or without compression) demonstrated that pentoxifylline is more effective than placebo in terms of complete ulcer healing or significant improvement (RR 1.70, 95% CI 1.30 to 2.24). Significant hetero­ geneity was associated with differences in sample populations (hard-to-heal samples compared with “normal” healing samples). Pentoxifylline plus compression is more effective than placebo plus compression (RR 1.56, 95% CI 1.14 to 2.13). Pentoxifylline in the absence of compression appears to be more effective than placebo or no treatment (RR 2.25, 95% CI 1.49 to 3.39). A comparison between pentoxifylline and defibrotide found no statistically significant difference in healing rates. More adverse effects were reported in people receiving pentoxifylline (RR 1.56, 95% CI 1.10 to 2.22). Nearly three-quarters (72%) of the reported adverse effects were gastro­ intestinal.

Authors’ conclusions: Pentoxifylline is an effective adjunct to compression bandaging for treating venous ulcers and may be effective in the absence of compression. The majority of adverse effects were gastrointestinal disturbances.

Plain language summary: Pentoxifylline increases the healing of venous leg ulcers. Venous leg ulcers are a common, recurring disabling condition. The mainstay of treatment is the use of firm compression bandages or stockings to support the veins of the leg. Some leg ulcers take many months or years to heal and treatment is aimed at preventing infection and speeding up healing. Pentoxifylline is a tablet taken to improve blood circulation. The review of trials suggests that pentoxifylline, 400 mg tablet taken three times a day, increases the chance of healing. m

EWMA Journal Previous Issues Volume 7, no 2, May 2007 Is it safe to use saline ­solution to clean wounds?

João C. F. Gouveia, Cristina I. M. Miguéns, Célia L. S. Nogueira, Marta I. P. Alves The cost of pressure ulceration Peter J Franks Epidemiology of wounds treated in Community Services in Portugal Elaine Pina Improving wound assessment through the ­provision of digital ­cameras across a Primary Care Trust Alison Hopkins The use of telemedicine in wound care Rolf Jelnes Lord Joseph Lister: the rise of antiseptic surgery and the modern place of ­antiseptics in wound care David Leaper Volume 7, no 1, 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

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

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Journal 2007 vol 7 no 3

EWMA

International Journals English

Finnish

Advances in Skin & Wound Care, vol. 20, sep 2007 www.aswcjournal.com Bismuth Subgallate/Borneol (Suile) Is Superior to Bacitracin in the Human Forearm Biopsy Model for Acute Wound Healing Thomas Serena, Laura K.S. Parnall, Carrie Knox, Julia Vargo, Amanda Oliver, Sarah Merry, Andrew Klugh, Nicole Bubar, Neil Anderson, Lynn Rieman, Wade Walnoha, Holly Smith and Samantha Rice Skin Substitutes and Alternatives: A Review Jaimie T. Shores, Allen Gabriel, and Subhas Gupta

English

EWMA

English

Helcos 2007, vol 18, no 3 Monitorization of pressure ulcers in a critical care Unit J A Esperón Güimil, C Angueira Castelo, A I Escudero Quiñones, A Ocampo Piñeiro, J M Pérez Jiménez, S M Poceiro Salgado, M D Vilas Pastoriza Hypergranulation of chronic wounds: an occasional but not infrequent problem D Chaverri Fierro Prevalence of pressure ulcers in an assisted residence for the elderly J M Díaz Pizarro, A S García Sánchez, A Núñez Ballestero, R Osorio Díaz Journal of Wound Care, April issue, vol. 16, no 8, 2007 www.journalofwoundcare.com; jwc@emap.com Effect of medical honey on wounds colonised or infected with MRSA G. Blaser, K. Santos, U. Bode et al.

Pressure ulcers and deep tissue injury: a bioengineering perspective L. Agram and A. Gefen Pain and quality of life in patients with vascular leg ulcers: an Italian multicentre study G. Guarnera, G. Tinelli, D. Abeni et al.

Silver dressings versus other dressings for chronic wounds in a community care setting J. Wang, J. Smith, W. Babidge, G. Maddern Topical diphenylhydratoin sodium can improve healing in a diabetic incisional animal wound model F.C. Chan, C. Kennedy, R.P. Hanson et al Ultrasonographic evaluation of an unusual peri-anal ­induration: a possible case of deep tissue injury T. Nagase, I. Koshima, T. Maekawa et al.

Journal 2007 vol 7 no 3

International Wound Journal, September 2007, vol. 4, Issue 3 www.blackwellpublishing.com To oxygenate or not to oxygenate that is the question!

D. Queen, K. G. Harding Guest Editorial: Oxygen balance What’s that?

P. Davis, R. G. Sibbald Perfusion, oxygenation and warming D. Leaper Wound bed preparation and oxygen balance a new component?

R. G. Sibbald, K. Y Woo, D. Queen How might we achieve oxygen balance in wounds?

P. J. Davis

Haava, vol. no 3, 2007 www.suomenhaavanhoitoyhdistys.fi Stop Smoking – Promote Wound Healing Sirkku Vilkman, Petra Ranta Aseptic in Wound Management Tiina Pukki Selecting a Dressing for Surgical Wound Päivi Mäntyvaara Treatment of Patients with Lower Limb Amputation, Part 1 Helvi Hietanen Wound Management after Scar Hernia Operation Helena Asikainen When the surgical wound is infected?

Mikko Tuuliranta Infection of Surgical Wound – diagnostic and risk factors Vesa Juutilainen Infected Wound – antibiotics or antiseptics?

Anna Hjerppe, Salla Seppänen Antibiotics in Postoperative Wound Infections Kari Hietaniemi Hyperbaric Oxygen in Wound Treatment Erkki Kentala Use of Remifentanyl (Ultiva®) in small operations Petri Volmanen Evidence Based Wound Management – Reflection of EWMA Conference in Glasgow Asna Iivanainen, Tiina Pukki

Spanish

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

English

The International Journal of Lower Extremity Wounds vol. 6, no 2, 2007 http://ijlew.sagepub.com A First Evaluation of an Educational Program for Health Care Providers in a Long-Term Care Facility to Prevent Foot Complications Zoltan Pataky, Alain Golay, Annick Rieker, Raphaël Grandjean, Laura Schiesari, and Hubert Vuagnat Effects of Hibiscus rosa sinensis L (Malvaceae) on Wound Healing Activity: A Preclinical Study in a Sprague Dawley Rat Shivananda Nayak, S. Sivachandra Raju, F.A. Orette, and A.V. Chalapathi Rao The Extracellular Matrix in Wound Healing: A Closer Look at Therapeutics for Chronic Wounds Magnus S. Agren and Maria Werthen Civilian Gas Gangrene: A Clinical Challenge Arcot Rekha and T.R. Gopalan Arthrodesis With External Fixation in the Unstable or Misaligned Charcot Ankle in Patients With Diabetes Mellitus Jesper Fabrin, Kirsten Larsen, and Per E. Holstein Improvement of Idiopathic Pyoderma Gangrenosum During Treatment With Anti-Tumor Necrosis Factor Alfa Monoclonal Antibody Valentina Dini, Marco Romanelli, MariaStefania Bertone, Sara Talarico, Stefano Bombardieri, and Paolo Barachini Utilizing a Crossover Reverse Sural Artery Flap for Soft Tissue Reconstruction of the Plantar Forefoot After a Severe Degloving Injury Thomas Zgonis, Douglas T. Cromack, and John J. Stapleton

Scandinavian

Wounds (SÅR) vol. 15, no 3, 2007 www.saar.dk Intermittent Pneumatic Compression: Healing of an 89 year old’s non-healing venous leg ulcers through 55 years Wilja Dam, Karsten Fogh Good news for venous leg ulcers in Aarhus (Denmark) Jens Fonnesbech New wound concept using Hydrobalance bandages Trials in the primary sector Susan F. Jørgensen, Rie Nygaard Registration of pressure ulcers on the island of Bornholm (Denmark) Jette Pelle, Gulla Steenberg First impressions count Hanne Konradsen Love and specialist knowledge – the prosthetist is the ­stubborn helper Jens Fonnesbech About scoliosis corsets Jens Peter Tovgaard

German

Wund Management Issue 4, 2007 Case study Treatment of superficial and deep dermal burns with the VAC glove A. Rüttgers If existing English abstracts are available from www.mhp-verlag.de

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Book Review Leg Ulcers â&#x20AC;&#x201C; a Problem Based Approach Moya Morrison Deborah Hofman RGN, BA Hons, Dip. Nurse, FETC,Lic.Ac. Senior Research Nurse Involved in work for the RCN Pressure Ulcer Guidelines Trustee for the European Pressure Ulcer Advisory Panel deborah.Hofman@ orh.nhs.uk

This latest book on leg ulcers is an original concept insofar it is designed as an educational tool as well as a work of reference. It is well illustrated throughout and is excellently referenced which makes it a very useful resource tool.

The book is clearly laid out into three sections.

The second section comprises 14 case studies of different types of leg ulceration. These give the practitioner an idea of the range of types of ulceration which they may come across. All but the first case study follow the patient through to final outcome so that the reader is given ideas on appropriate management. However, there is but there is no forum for self-assessment which might have been helpful in such a book.

The third section is made up of chapters by selected authors on various topics associated with leg ulceration ranging from chapters on causes of ulceration, assessment and care planning to more recherchĂŠ topics such as inflammatory ulcers, tropical ulcers and skin equivalents. Most of these are of extremely high quality, as would be expected from such an august selection of authors.

I found the chapters on pharmacology and inflammatory ulcers of particular interest. It is very useful for the learner and the practitioner to have all these topics gathered together in one volume for easy reference.

Disappointingly not all the chapters maintain such a high standard and some of the material is not supported by evidence and would appear only to reflect the individual authorâ&#x20AC;&#x2122;s opinion.

The concern is that once these opinions have been cited in a book of such authority they become accepted as gold standard practice without further question.

Another disappointment is that although the problem of pain at dressing change is covered in some detail, the topic of ongoing ulcer-related pain is not covered in any depth in this book.

However these are minor criticisms in what is overall a book of high quality which will be of immense value for all those working or hoping to work in the field of leg ulcer management. m

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

Please submit possible topics for future conference sessions.

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

Please contact the Journal Secretariat at ewma@ewma.org

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Journal 2007 vol 7 no 3

Development of Clinical Practice Guideline on Pressure Ulcers Katrien Vanderwee: written on behalf of the Guideline Development Group: EPUAP M. Clark C. Dealey T. Defloor L. Schoonhoven A. Witherow NPUAP M. Baharestani J. Black J. Cuddigan L. Edsberg S. Garber D. Langemo M.E. Posthauer C. Ratliff G.Tale Correspondence to epuap@aol.com

A European Pressure Ulcer Advisory Panel & National Pressure Ulcer Advisory Panel Collaboration to Produce Clinical Practice Guidelines for the Prevention and ­Treatment of Pressure Ulcers

1. Introduction Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances (http://www. nice.org.uk). Guidelines have become increasingly popular in response to concerns regarding wide variation in health care as well as the fact that much of this care is of poor quality.

There is a pressing need for guidelines in pressure ulcer prevention and care.

Considerable uncertainty exists among practitioners regarding best practices and a thorough literature review for guidelines has not been done over a decade. Additionally, there have been considerable advances in pressure ulcer prevention and care over the past decade. These include new technologies such as pressure mapping, new techniques for reducing pressure and new dressings.

These new therapies lead to further uncertainty among clinicians regarding best practices.

Current guidelines do not fill this need. The only guidelines of national stature in the USA were published by the then Agency for Healthcare Policy and Research in 1992 and 1994 and later used as a basis for organisational specialty guidelines by the Paralyzed Veterans of America, American Medical Directors Association, Wound, Ostomy and Continence Nurses and the Wound Healing Society. The European guidelines were published by the European Pressure Ulcer Advisory Panel in 1998 and 1999. All these guidelines, in part, are now clearly outdated. Despite the fact that the management of pressure ulcers is clearly an international issue and much relevant research appears in the non-English literature, an international guideline does not exist.

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The National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Ulcer Advisory Panel (EPUAP) are proposing to fill this need and are developing guidelines that systematically analyze the world literature on pressure ulcer prevention and treatment and comment on the current evidence regarding prevention and treatment strategies. The EPUAP are leading on the pressure ulcer prevention guideline in collaboration with the American NPUAP. The NPUAP are leading the pressure ulcer treatment guideline in collaboration with the EPUAP.

2. Purpose of the Guidelines A scope document was developed to define exactly what the guideline will and will not examine and what the guideline developers will consider.

Prevention Guideline The aim of the guideline is to prevent the development of pressure ulcers. The guideline recommendations will apply to all patients and vulnerable people of all age groups. The guideline is intended for the use of health care professionals who are involved in the care of patients and vulnerable people that are at risk of developing pressure ulcers, whether they are in hospital, long-term care, assisted living at home or any other setting, and regardless of their diagnosis or health care needs.

It will also help to guide patients and carers on the range of prevention strategies that are available.

Treatment Guideline The aim of this guideline is to recommend evidence-based care for patients with existing pressure ulcers. The guideline recommendations will apply to all patients and vulnerable people of all age groups, whether they are in hospital, longterm care, assisted living at home or any other setting. The guideline is intended for the use of health care professionals who are involved in the care of patients with existing pressure ulcers. Patients with pressure ulcers are usually at risk for additional pressure ulcers, therefore the prevention guideline should be followed for these individuals.

Based on the results of a gap analysis of existing EWMA

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pressure ulcer treatment guidelines, recommendations regarding the unique needs of several special populations will be addressed where evidence exists. These include spinal cord injured individuals, infants and children, critically ill patients, patients requesting palliative care and bariatric patients.

ing or excluding the study. The methodology checklists, based on the Scottish Intercollegiate Guidelines Network, helped the reviewers to judge on the quality of the study.

All papers were evaluated by two members of the SWGs. The GDG are undertaking a quality check of a random sample of 10% of the completed evidence tables.

3. Methods The EPUAP and NPUAP nominated six representatives each to form the Guideline Development Group (GDG).

This GDG determines and controls the guideline development process. In order to have broader multidisciplinary representation to address the wider scope of the treatment guideline, three additional members have been added to the NPUAP core group. In addition the guidelines have been broken down into topics and Small Working Groups (SWGs) formed to review each topic. All GDG and SWG members have been screened for conflicts of interest. Representatives of industry were excluded from these groups, but are invited to participate as stakeholders.

Each SWG will formulate conclusions about the body of available evidence based on the evidence tables. Based on these conclusions, a first draft of recommendations will be developed. The GDG will review the draft recommendation.

Identify evidence To identify the scientific literature on pressure ulcer prevention and treatment, several electronic databases were consulted such as PubMed, Cinahl, EMBASE, The Cochrane Database of Systematic Reviews, The Cochrane Central Register of Controlled Trials, Health Technology Assessment, and AMED databases.

A sensitive search strategy was developed by the GDG. All the references retrieved by the electronic literature search were screened by the GDG based on the following inclusion criteria. The articles must be primarily focused on pressure ulcer prevention, risk assessment and treatment.

The articles must be published in a peer reviewed journal.

An abstract must be available. The studies have to use one of the following designs: randomised controlled trials, controlled clinical trials, cohort studies, case-control studies and case series. At least 10 subjects should be included in the case series. Systematic Reviews or meta-analysis are included if they use the Cochrane methodology. There is no restriction on the basis of language of study. Economic evaluations were excluded because of few literature and differences in health care systems across countries Evaluating the Evidence The full papers of selected references were obtained and divided according to topic and then sent to the relevant SWGs. The SWGs consist of trustees and members of the EPUAP and NPUAP. The members of the SWGs create evidence tables and score a methodology checklist developed by the GDG for each study. The template of the evidence table consisted of reference of the study, type of study, sample, intervention, outcome measures and length of follow-up, results, limitation and the question includEWMA

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Stakeholder involvement The entire process of developing the guideline can be followed by stakeholders on a website (www.pressureulcerguideline.org). A stakeholder is someone who has interest in pressure ulcers and wishes to contribute to the guideline by reading the draft guideline, ensuring that all relevant evidence has been included and commenting on the draft guideline within the timeframe allowed. Anyone can become a stakeholder, either as an individual or as a representative for a society / organization. The list of existing stakeholders is available on the website. All members of EPUAP and NPUAP are encouraged to sign up as stakeholders and participate in this process.

4. Small Working Groups Prevention Guideline There are six SWGs for the pressure ulcer prevention guideline with each a SWG leader: n Pressure Ulcer Etiology: n Risk Assessment / SWG Skin Assessment n Nutrition n Positioning n Support Surfaces Treatment Guideline n Staging / Grading n Methods of monitoring healing n Support surfaces n Nutrition for healing n Principles of wound bed preparation n Wound cleansing n Debridement n Assessment and treatment of infection n Dressings n Adjunctive therapies eg hyperbaric oxygen, light and energy therapies n Growth factors and biological dressings n Pain management n Palliative care of chronic wounds n Operative repair 

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5. Progress so far Prevention Guideline The GDG have developed a sensitive search strategy. Key words were: pressure ulcer and (prevention or aetiology or skin care or risk assessment or mattress or cushion or posture or repositioning or nutrition) and design and human studies.

The databases PubMed, Cinahl, EMBASE, The Cochrane Database of Systematic Reviews, The Cochrane Central Register of Controlled Trials, Health Technology Assessment, and AMED were searched starting from 1998.

In total 2488 studies were retrieved of which 242 were included based on the inclusion criteria. At this moment the different SWGs are in the final phase of preparing evidence tables and scoring the methodology checklists. The GDG is undertaking the quality check of the completed evidence tables.

Treatment Guideline A search of Medline database was conducted using the search terms: pressure ulcer or pressure sore or decubitus, using the time period 1994 â&#x20AC;&#x201C; 2007 and was restricted to studies on humans. There were no restrictions on language. Multiple follow-up searches were made using the key terms relevant to each SWG topic. Cochrane reviews

were also included as appropriate. Searches have been expanded by searching bibliographies of included papers.

In this way, it has been possible to identify large studies of chronic wounds which have reported pressure ulcers separately and so are worthy of inclusion.

SWGs have focused on the newer evidence (2000 â&#x20AC;&#x201C; 2007) in developing evidence tables. To gain an appreciation for the entire body of evidence on each topic, evidence tables developed by the Agency for Healthcare Policy and Research (now Agency for Healthcare research and Quality), the Paralyzed Veterans of America and the Registered Nurses of Ontario have been used to provide an overview of pre-2000 research. The NPUAP gratefully acknowledges the support of these organisations, particularly as the initial searches yielded over 5000 abstracts. Work continues on reviewing the evidence prior to developing draft statements.

Conclusion We believe that this is an exciting development and we hope that many will want to participate in the process by becoming stakeholders. The aim is to complete the guidelines development process by 2008 and our progress will be reported at the World Union of Wound Healing Societies conference in Toronto. m

S 02 04 - * Trademark of Johnson & Johnson - X-STATIC is a registered Trademark of Noble Fiber Technologies Inc

Progressive Strength

SILVERCEL* dressing uses new hydro-alginate technology to complement the effectiveness of silver release. It is a dressing that becomes stronger as it absorbs, facilitating removal from the wound. Clinically tested, SILVERCEL* dressing encourages healing even in very wet wound situations by providing an optimal moist wound environment. The sustained and balanced release of silver ions kills a broad spectrum of microorganisms associated with the bacterial colonization and infection of wounds, including MRSA, MRSE and VRE.

Evaluating the pilot of the first course delivered ­using the EWMA University Conference Model at the EWMA Conference Glasgow, May 2007

Madeleine Flanagan MSC, BSC (HONS), DIP, RGN Principal lecturer in tissue viability School of Continuing ­Professional Development Faculty of Health & Human Sciences University of Hertfordshire, Hatfield, UK m.flanagan@herts.ac.uk The EWMA Education Committee: Zena Moore (Chair) Finn Gottrup (Co-Chair) Madeleine Flanagan Katia Furtado Luc Gryson Christina Lindholm Patricia Price Carolyn Wyndham-White

Abstract A new postgraduate course which has had one of its modules delivered at the recent EWMA conference could set a precedent for widening international participation in wound education. The course ‘Specialist Wound Management’ which forms the first of two modules of a Post Graduate Certificate awarded by the University of Hertfordshire in the UK was delivered to students from all over Europe, at the European Wound Management Association (EWMA) Conference in Glasgow, Scotland in May. 15 students participated in this innovative programme from Denmark, Portugal, Greece, Slovenia, Czech Republic, UK, Iceland and Taiwan. The majority of students were supported by educational grants from Coloplast, others were supported by Smith & Nephew, ConvaTec and KCI.

Introduction The University Conference Model (UCM) has been developed to provide universities who have wound healing courses approved by EWMA to use the conference programme to deliver the main taught component of the curriculum. Following this intense period of conference activity, the model recommends that participants engage in a period of E-tivities which is the term coined by Salmon1 to describe active and interactive online learning by individuals or groups before completing an assessed piece of course work.

This approach was piloted earlier this year during the last EWMA conference and proved to be very popular with participants. The group consisted of 3 doctors (2 Dermatologists and 1 Plastic Surgeon) and specialist nurses caring for a variety of patients with acute and chronic wounds. Participants had a wealth of professional experience between them which greatly enhanced the learning opportunities available during the course. All were experienced health professionals who specialise in wound management in their respective countries and some were motivated by a sense of

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professional isolation and were looking forward to the networking opportunities that the UCM could provide.

Facilitating adult learning The teaching and learning styles implicit in the UCM are centred on the principles of adult learning pioneered by Knowles which today are recognised as the values underlying modern adult educational theory2. As adult learners, health professionals want their learning to be clinically relevent, personalised, problem-based, and self directed. By engaging in the real world environment of an international conference, the UCM actively involves participants in the dynamic process of teaching and learning where the outcomes of activities such as participation in a plenary debate or workshop cannot be controlled by the course facilitator and all experiences have the potential to become a learning experience.

Students attended a pre-conference briefing session which gave them the opportunity to meet each other and the group facilitators and discuss the planned conference activities. A unique study programme had been devised in advance from the EWMA scientific programme so that students participated in a varied mix of learning activities.

Participants were actively engaged throughout the conference by attending selected sessions on the scientific programme such as workshops, debates, plenary, satellite symposia and free paper sessions in addition to participating in activities related to other learning opportunities available at the conference. Some activities were specifically designed to improve networking skills and facilitate group cohesion. Participants were asked to discuss the organisation of wound management services with a delegate from a different country and most did this within the student group before repeating the exercise again several times during social events.

Other activities such as reviewing the posters and identifying the evidence base used to support exhibitor’s claims in the exhibition were planned to develop participant’s analytical skills. These activiEWMA

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Group tutorial at the end of a busy day

ties helped the group facilitators to acknowledge the wealth of experiences that participants bring to the course and allowed them to express their opinions. Time was also built into the programme for informal networking with peers, colleagues, and wound healing experts at social events and in between the scheduled conference programme.

Academic staff from the University of Hertfordshire were available during the conference to provide group and individual student support. Participants valued being supported in small tutorial groups as this made it possible for some activities to be done with tutors which facilitated lively and critical discussion of both content and delivery of the programme. A classroom was available for major briefing sessions before and after the main conference programme and a quiet study area provided a convenient place for group facilitators and students to meet at the end of each day to reflect on the days activities.

Following the conference, participants on the course continued to be supported by remote access to on-line resources at the University which provide course information, lecture notes, access to electronic databases and journals, links to websites, electronic learning resources, online tutorials, discussion groups and bulletin boards.

Participants enjoyed creating a personal profile in the form of a short Powerpoint presentation which shared details of their families, homes, work and interests. These were posted onto the Universities on-line managed learning resource system after the conference and provided a point of contact during the rest of the course.

A significant amount of the total student effort is achieved by personal private study as participants are expected to develop their understanding of the topic areas covered beyond the taught lectures and conference activities. The conference provided many relevant sources of information that helped participants complete their coursework including learning resources, academic papers, clinical guidelines, and direct access to expert practitioners, researchers and scientists.

Advantages of UCM Student feedback is a key component of the UCM and participants are expected to submit a written critical evaluation of their learning experience as well as keep a photo diary during the conference. This generated a wealth of information that has enabled us to appraise the value of this educational approach.

The students greatly valued: n Meeting and sharing best practice with international colleagues from diverse health care environments n Participating in a dynamic mix of learning activities whilst attending a major international conference n Having structure and guidance through the complex conference programme n The unique and stimulating â&#x20AC;&#x2DC;real worldâ&#x20AC;&#x2122; learning environment which made effective use of available expert resources n The learning opportunities which encouraged development of critical analysis within a safe environment î&#x201A;Š

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n

The high level of tutorial support and opportunity to work in small tutor groups n The opportunity to be able to interact with each other and tutors following the conference This is the first time that an academic course has been delivered in this way at a EWMA Conference and it provided not just an opportunity to widen participation, but allowed participants to share best practice from diverse health care backgrounds. Most participants were pleased to have the conference sessions and activities pre-planned and appreciated the element of negotiated free choice.

Some commented that the UCM had shown them how to get the best out of a complex conference programme and would influence their approach to future conferences.

Suggestions for improvement As with any new development, lessons were learned and suggestions made to enhance future courses. These were mainly logistical and included: n Inclusion of longer pre and post conference briefing sessions despite requiring a longer time away from home n More time to look around product exhibition n Longer, non timetabled breaks as the pace of planned activities was tiring n Difficulty maintaining motivation to complete coursework following conference However, on balance most participants felt that the intense social interaction at the conference was counterbalanced by the reduced face to face contact from peers and tutors following the conference. The use of on-line discussion forums, teleconferences, telephone, Skype™ and email were available to lessen student’s isolation after the conference and were used to emphasis that the learning experience didn’t end at the conference closing ceremony. Some participants commented that they enjoyed the on-line learning aspect of the course as they could control the pace of learning and choose when to study and access resources.

For the academic staff involved, the pilot was a rewarding but tiring experience as the planning and co-ordination of activities at the conference was demanding. Following the pilot, it was felt that a teacher: student ratio of 1:5 was necessary to provide a quality learning experience for participants. This was achieved by bringing a small team of University lecturers to the conference and an advantage of the UCM is that these facilitators do not need to be subject specialists which is important as not all Universities have sufficient staff with specialist expertise. Another strength of this model is that participants do not need to be physically in the same place or from the same country.

Participants from the pilot group came from all over Eu50

rope and beyond which promoted inter-professional team working within a multi-cultural context and has created a network of professional wound healing specialists that will hopefully continue to interact after the course has finished. Finally, adoption of the UCM gave permission for the academic staff to give up some of the control over the teaching processes and learning activities and share them with the experts participating in the conference and the learners themselves fulfilling an important principle of adult learning3

Conclusion This pilot of the UCM model effectively demonstrated that the EWMA conference provides an ideal learning environment to present student’s with a challenging, analytical conference experience, from which they can develop both personally and professionally. A period of personal study and participative online learning following the conference component of the course gives students a much broader perspective on international practice and enables them to benefit from a range of learning styles and experiences which are not available in a single institution.

Indications are that most students are keen to complete the final module at the EWMA conference in Lisbon next year in order to complete their Postgraduate Certificate in Specialist Wound Management.

From the outset, the UCM appears to be fulfilling its ambitions of being an effective, collaborative, educational project that demonstrates what can be achieved when subject specialists, academics, clinicians and industry work together to provide a unique and clinically relevent learning experience. Plans are already well advanced for the UCM model to be used to deliver this course at the next EWMA Conference in Lisbon, Portugal in May 2008 and discussions are underway with local Portuguese Universities leading the way for different educational institutions to offer courses alongside each other at the same conference.

The EWMA Education Committee are hopeful that over the next five years, more European universities will utilise this model to offer the opportunity for health professionals to study specialist qualifications at major conferences using the UCM approach which is transferable to many other subject areas. m

Further information about the University Conference Model is available from Madeleine Flanagan, m.flanagan@herts.ac.uk or EWMA, EWMA Business Office, C/O Congress Consultants, Martensens Allé 8, DK-1828 Frederiksberg, Denmark, ewma@ ewma.org References 1. Salmon G (2006) E tivities: The key to active online learning. Routledge Falmer Oxon.

2. Atherton J S (2005) Learning and Teaching: Knowles’ andragogy: an angle on adult learning [On-line] UK: Available: http://www.learningandteaching.info/learning/knowlesa.htm Accessed: 29 July 2007 3. Brookfield S (1990) The Skillful Teacher. San Francisco:Jossey-Bass.

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NEW

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• Designed to protect periwound skin and reduce the risk of maceration • Comforts patients over time whilst the dressing is in situ and upon removal1 • Offers more for wound management than just a moist wound environment • Gel cushions in a way that only a Gelling Foam dressing can2 For more information, please contact ConvaTec Wound Therapeutics Helpline Freephone quoting VXC1 on 0800 289 738 (UK) 1 800 946 938 (Republic of Ireland) References: 1. A phase II non-comparative study of non-adhesive Versiva® XC™ on leg ulcers (N=46). CW-501-04-U331. April 29, 2005. Data on file, ConvaTec. 2. Bishop S. Versiva® XC™ Gelling Foam Dressing cushioning and protection claims R&D justification. June 2005. Data on file, ConvaTec. ®/TM The following are trade marks of E.R. Squibb & Sons, L.L.C.: Versiva XC and Hydrofiber.

ConvaTec is an authorised user. ©2007 E.R. Squibb & Sons, L.L.C. January 2007. GB-07-354 UKCT-K0003

www.convatec.com

EWMA 2007· GLASGOW

Conference Report 2-4 May 2007

By Michael Clark, the Tissue Viability Society

Fiona Murphy, winner of the First Time Presenter Prize

A SURVEY OF NURSES’ AND DOCTORS’ KNOWLEDGE IN RELATION TO THE PRACTICE OF WOUND SWABBING Fiona Murphy Papworth Hospital, Cambridge, United Kingdom Aim: A prospective descriptive survey (questionnaire) was designed to collect demographics on the sample participants and data on current clinical practice in a cardiothoracic hospital in the areas of: identifying wound infection; and the practice surrounding the acquisition of a wound swab.

Method: Questionnaires were sent to a sample population of all 32 surgeons working within the Trust and a probability sample of 200 nurses who had been selected by simple random selection. Response rate was 128/232 (55.1%).

Results: Results showed participants were confused in recognising signs and symptoms of infection with only 12/128 (9.7%) swabbing for friable granulation tissue, but 117/127 (92.1%) always swabbing for the leakage of serous exudate. In the actual practice of performing a wound swab: 76/123 (61.8%) were not cleansing the wound prior to swabbing; it was identified if the participant cleansed prior to swabbing they were more likely to take the swab from the correct place, this was significant p=0.027. Also, significant was participants cleansing a wound who would also correctly use a swab with transport medium (p=0.001).

Lastly, participants showed much confusion in the area of storing an acquired swab prior to transportation to the laboratory if there is a 20 minute delay with only 26/120 (21.7%) correctly storing in a refrigerator at 4oC temperature.

Conclusion: Confusion was found in identifying infection and around the practice of wound swabbing.

Recommendations from this study include: signs and symptoms infection checklist with definitions and training to be made available to staff; introduction of a Trust policy/ protocol in the correct practice of wound swabbing including storage guidance for acquired swab specimens; further research in the area within the Trust possibly utilising a structured interview technique; and the identified need for a comparative trial looking at different storage methods of acquired swabs and the possible effects this has on microbial viability.

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T

he 17th Conference of the European Wound Management Association was held in Glasgow, Scotland over the 2nd to the 4th of May 2007. The theme of the event was ’Evidence, Consensus and Driving the Agenda forward’ and with over 1800 delegates hailing from 55 separate countries Glasgow 2007 proved to be as successful as previous EWMA events.

A major contributor to the success of the EWMA 2007 conference was the active involvement of several United Kingdom wound management societies including the Leg Ulcer Forum, the Tissue Viability Society, the Tissue Viability Nurses Association and the National Association of Tissue Viability Nurses – Scotland. The participation of EWMA cooperating organisations within the development and execution of the EWMA conference programme is an important step towards creating networks of associations that will help drive the wound agenda in future years. Perhaps one of the lasting effects of this year’s EWMA conference will be the strengthening of collaborative links between UK associations and also between the groups and with EWMA itself. All UK associations involved in the Glasgow meeting welcomed working with members from EWMA and it was highly enjoyable for the UK groups to be able to welcome so many colleagues from around Europe and beyond to Glasgow. The UK support for the EWMA conference was sufficiently strong for the Tissue Viability Society not to host its own annual conference which traditionally would take place a few weeks before the May dates selected by EWMA. The conference programme provided a wealth of material with 133 oral and 254 poster presentations available for delegates. Again it was encouraging to see the high standard of these presentations and to reflect upon the continued strong interest in wound healing across Europe. Over the duration of the event three oral presentations by first-time presenters were recognised as being outstanding by EWMA and UK association judges.

Five poster presentations were also awarded prizes during the conference – the prize winners are presented on these pages.

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Amy Oldfield, winner of the First Time Presenter Prize

Shu Fen Lo, winner of the First Time Presenter Prize

PREVENTING PRESSURE ULCER DEVELOPMENT IN A MATERNITY DEPARTMENT

A COST-EFFECTIVENESS ANALYSIS OF A MULTIMEDIA LEARNING EDUCATION PROGRAMS (MLEPS) FOR STOMA PATIENTS

Fiona Burton, Amy Oldfield Coventry University, Coventry, United Kingdom Aim of Poster: This poster will demonstrate how the authors reduced the risk and incidence of labouring women developing pressure ulcers in one acute hospital maternity unit, from an incidence of 10 patients in a twelve month period to zero in the following six months.

Method: The Tissue Viability Team had noted a gradual increase over the year May 2005 – May 2006 in the number of labouring women who were developing pressure ulcers and therefore needed to address this issue.

A literature search was then carried out to identify any international literature on the subject and so help identify possible solutions to the problem.

An action plan was formulated in June 2006 with support from the modern matron and practice facilitator in the maternity department. This was then implemented the aim being to reduce the incidence of pressure ulcers in labouring women. The action plan covered the following areas.

• Education of midwives on pressure ulcer prevention • Patient education leaflet on pressure ulcer prevention • Link midwives for Tissue Viability • Dissemination of the published literature to the maternity department • Evaluation of delivery beds/ mattresses/ sheets by Tissue Viability Team • Discussion/ development of a risk assessment tool for pressure ulcers

Shu Fen Lo, Yun-Tung Wang Tzu Chi College of Technology, Hualien, Taiwan, Province of China Aim: The purpose of this study was to estimate the cost and effectiveness enterostomal therapists used MELPS for stoma patients in Taiwan. In the meantime, we comparing the outcome with conventions education service(CES) and give medical and policy suggestion.

Methods: The study design was a two group randomly assigned design. A total of 54 patients with stoma patients were randomly assigned to MLEPs (n=27) or CES (27) nursing care with a minimum follow up of one week. The outcome measures we used for interviews were cost, self-care knowledge, self-care attitude, and self- care behaviour. The cost for each patient was the sum of costs all direct health cost, the costs of change dressing, MLEPs costs, and the costs of family burden.

Results: This analysis showed that the subjects in the MLEPs revealed a significantly better outcome in selfcare knowledge (p=0.000), self-care attitude (p=0.000), and self- care behaviour (p=0.000), The cost-effectiveness ratio showed that the costs of the MLEPs(1549.04) were lower than those CES (2514.20).

Conclusion: Policy maker may consider this results as they allocate resources and encourage nurse staffs learning and making the multiple learning education film for the health care. This research also provides information for those who to improve the self-care capacity of care stoma patients.

• Improving awareness of equipment available • Clinical incident for every new incidence of pressure ulcer development Results: The action plan was very successfully implemented and the incidence of pressure ulcer development has been zero for a 6 month period following the implementation. This project is on going and now includes education for all newly qualified midwives in their preceptorship programme Discussion: This project has shown that through staff education, leadership and collaboration between specialities can bring about improvement in patient outcomes.

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In addition to the main conference programme there were also innovative tracks offering wound healing education to General Practitioners along with introductory and advanced day-long courses for nursing staff. These events helped to extend the appeal of the EWMA meeting to those with growing interest in  wound healing.

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Loreta Pilipaityte and Rytis Rimdeika. Department og Plastic and ­reconstructive surgery, Kaunas Medical Hospital, Lithuania

Judy Harker & Deborah Ruff. Pennine Acute Hospitals NHS Trust, Manchester, UK

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As always the EWMA conference was well supported by the commercial organisations that supply innovative wound care interventions â&#x20AC;&#x201C; the exhibition hall held over 100 companies, organisations and associations for delegates to visit.

Informal networking freely occurred during the social events within the conference programme with delegates experiencing Scottish hospitality during the main evening event held in the Glasgow Science Centre.

Glasgow 2007 was undoubtedly an enjoyable and informative experience for delegates marking yet another EWMA event that brings together the European wound healing community and perhaps most importantly creates and strengthens links between national associations striving to heighten the profile of wound management within their respective countries. The Glasgow conference closed with a display of the venue for the 18th EWMA conference to be held in Lisbon, Portugal over May 14-16 2008 (www.ewma.org). Let us hope that Lisbon 2008 further develops the growing strength and visibility of the EWMA conference as a major platform for developing consensus and for driving the wound management agenda forward across Europe. m

Jan Stryja, Riha Daniel, Bulejcik Jan. Center of vascular and miniinvasive surgery, Podlesi Hospital, Trinec, Czech Republic

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Journal 2007 vol 7 no 3

EWMA

Zena Moore presents the poster prize to the winners: Britta Oestergaard Melby, Helle Boye Soerensen and Vanessa Veldman from Bispebjerg Hospital, ­Copenhagen, Denmark

Britta Oestergaard Melby, Vanessa Veldman, Helle Boye Soerensen, Susan Bermark, Kirsten Weibel, Vonnie Zimmerdahl.

Copenhagen Wound Healing Center, Bispebjerg Hospital, Denmark EWMA

Journal 2007 vol 7 no 3

Stella Dragoutsou, Eftichia Zouridaki, Georgia Griva, Nikoletta Zakopoulou, Adreas Katsambas. Leg Ulcer Unit, A. Syggros Hospital, Athens, Greece

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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

56

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

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

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Journal 2007 vol 7 no 3

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

Sorbion AG Hobackestraße 91 D-45899 Gelsenkirchen Tel: +49 (0)2 09-95 71 88-0 Fax: +49 (0)2 09-95 71 88-20 www.sorbion.com

The document is available in English, French, German, Italian and Spanish, and can be downloaded from www.ewma.org

For further details contact MEP Ltd, 53 Hargrave Road, London N19 5SH. www.mepltd.co.uk or EWMA Business Office, Congress Consultants, Martensens Allé 8, 1828 Frederiksberg, Denmark Tel: +45 7020 0305 Fax: +45 7020 0315 ewma@ewma.org

Previous Position Documents:

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

Use the EWMA Journal to profi le your company Deadline for advertising in the January 2008 issue is 7 December 2007

EWMA

Journal 2007 vol 7 no 3

5

Conferences

Conference Calendar Conference

Theme

9th National Conference of the Wound ­Management Association of Ireland (WMAI) ILDS 21st World Congress of Dermatology

2-3

Naas, Co Kildare Ireland Buenos Aires

Argentina

Culemborg

Netherlands

Oct

1-5

NOVW Praktikum

Oct

3

11th Annual Wound Care Congress

Oct

APTFeridas 2007 National Congress

Global Dermatology for a globalized world

2007 Oct

Epidemiologia, protocolos, evidência na cicatrização

Nov

23-27 Houston, Texas 7-9

USA

Maia

Portugal

Lugano

Switzerland

Union of Vascular Societies of Switzerland

Nov

8 -10

Wounds UK 2007 (National)

Nov

12-14 Harrogate

UK

VII Nacional Congress GNEAUPP

Nov

14-16 Arnedillo

Spain

Nov

16-17 Nyborg

Denmark

29-1

Turkey

National Meeting DSFS

Cancer Wounds

Wound Management Association of Turkey

Nov/Dec

Istanbul

2008 11ème Conférence Nationale des Plaies et ­Cicatrisations

Prévention et traitement

VI. celostátní kongres s mezinárodní úcastí XIIth National Wound Management Conference NIFS National Conference

Jan

27-29 Paris

France

Jan

25-26 Pardubice

Czech Republic

31-1

Finland

Jan/Feb Pressure Ulcers

The 7th Australasian Lymphology Association Conference Austrian Wound Association

Helsinki

Feb

14-15 Bergen

Norway

Mar

27-29 West Act

Australia

Mar

28-29 Vienna

Austria

Duplous Ultrasound and endovenous treatment

Apr

4.-5.

Italy

Apr

24-27 San Diego

USA

7th National Australian Wound Management Association Conference

Dreams, Diversity, Disasters

May

7.-10

Darwin

Australia

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

Wound Healing-Wound Management – Responsibility and Actions

May

14-16 Lisbon

Portugal

WUWHS – 3rd Congress

Wound Care Efficacy, Effectiveness & Efficiency

Jun

9th International Congress of Phlebology SAWC & WHS 2008 (National)

Deutsche Gesellschaft für Wundheilung und Wundbehandlung

4-8

Bologna

Toronto

Canada

Jun

13-14 Berlin

Germany

17th World Council of Enterostomal Therapists meeting

Stoma care, Wound Management & Incontinemce

Jun

15-19 Ljubljana

Slovenia

Oxford – European Wound Healing Summer School

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

Jun

17-21 Oxford

UK

11th Annual European Pressure Ulcer Advisory Panel Meeting 18th ETRS Annual Meeting

Sep

3-6

Bruges

Belgium

Sep

10-12

Malta

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

Advancement of Knowledge on all Aspects of Diabetic Foot Care

Sep

11-13 Lucca

Italy

VII Congresso Nazionale AIUC

La terapia dell' ulcera cutanea: un ponte tra tradizione e innovazione

Sep

24-27 Rome

Italy

Nov

13-15 Napoli

Italy

XVIII Congresso Nazionale SIMSI For web link please visit www.ewma.org

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EWMA

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LWMA

Lithuanian Wound Management Association Loreta Pilipaityte, MD Member of Lithuanian Wound Management Association Specialist in Plastic and Reconstructive Surgery Department of Plastic and Reconstructive Surgery Kaunas Medical University Hospital Eiveniu 2, LT 50009, Kaunas, Lithuania loreta.pilipaityte@gmail.com

Annual Meeting of the Lithuanian Wound Management Association The annual meeting of the Lithuanian Wound Management Association on the theme of “Wound Infection” was held in Kaunas University of Medicine on the 6th of April, 2007. The subject of the conference attracted more than 250 participants from various specialties – plastic and trauma surgeons, out-patient and primary care doctors, specialists in medical microbiology and experts in public health. Numerous experts discussed the criteria for identification of infection and methods of treatment together with the features of infection in different types of wounds – burns, chronic ulcers, diabetic ulcers, pressure sores, and acute wounds.

The key-note lecture “Diagnosis and topical management of wound infection” was delivered by invited guest speaker Dr. Keith Cutting from Buckinghamshire Chilterns University College in the UK. Professor Rytis Rimdeika, president of the Lithuanian Wound Management Association, gave an introduction to the EWMA position documents “Identifying Criteria for Wound Infection” (2005) and “Management of Wound Infection” (2006). These documents were discussed by the participants and widely accepted as valuable instruments in clinical practice.

During the conference, the concepts of wound contamination, critical colonization and infection were examined and discussed. Specialists in medical microbiology presented the basic techniques and innovations in identification of microorganisms while specialists in public health introduced and discussed nosocomial infections and the prevention of resistance in microorganisms. In conclusion the conference established recommendations for the local treatment of wounds.

Numerous exhibitors placed their stands in the exhibition area. Innovations in wound care products were presented by major medical companies including ConvaTec, 3M, Mölnlycke, Coloplast, Johnson & Johnson, Gedeon Richter, Egis, Servier, local medical distributors (Tamro, Oriola, and Orivas) and local manufacturers.

The board of the Lithuanian Wound Management Association decided to assign the closest future annual meetings to discussion of EWMA position documents.

The organisers of the conference would like to thank ConvaTec, general sponsor of the conference, and extend special thanks to the invited guest speaker Dr. Keith Cutting.

Key-note speakers of the conference (from the left): Prof. R. Rimdeika, Dr. K. Cutting, Dr. A. Vitkauskiene, Dr. R. Grigaite, Prof. V. Pilvinis, Dr. V. Kaikaris

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Journal 2007 vol 7 no 3

At the general sponsor’s stand: Head of ConvaTec Lithuanian office Dr. R. Daunoraviciene, invited lecturer Dr. K. Cutting, President of LWMA Prof. R. Rimdeika

Good cheer in the Coloplast stand… … and in the Orivas stand.

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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

62

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

EWMA

Journal 2007 vol 7 no 3

Organisations

LWMA

SWHS

NATVNS

SAWMA

Lithuanian Wound Management Association 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 www.ptlr.pl

ROWMA

Romanian Wound ­Management Association www.artmp.ro

SAfW

Svenskt ­Sårläk­ningssällskap www.sarlakning.com Serbian Advanced 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 www.yaradernegi.org

Swiss Association for Wound Care www.safw.ch

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

SSiS

Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

SWHS

Serbian Wound Healing Society www.lecenjerana.com

EWMA

Journal 2007 vol 7 no 3

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

Deadline for incoming material in the January 2008 issue is 1 November 2007

63

3 Editorial

Carol Dealey

Science, Practice and Education 5 Vacuum assisted closure for chronic wounds: a review of the evidence E. Andrea Nelson

13 General practitioner support to care homes: collaboration with a tissue viability nurse specialist and prescribing support pharmacist Lynne Watret, Rachel Bruce

19 Integrated system of chronic wound care healing – creating, managing and cost reduction Heinz J. Janßen, Roland Becker

27 Guidelines for the management of partial­thickness burns in general hospital-recommen­ dation of a European working party Bjarne Alsbjørn, Annelea Buntzen

31 Diabetic Foot Ulcer – From Fiction to Management. The development of global guidelines Jan Apelqvist, Karel Bakker, Gerlof D Valk

Background Articles 35 Wound Healing in Medieval England Carol Dealey

EBWM 38 Abstracts of Recent ­Cochrane Reviews Sally Bell-Syer

EWMA 40 EWMA Journal previous issues 41 International Journals 42 Book Review: Leg Ulcers – a Problem Based Approach Deborah Hofman

44 Development of Clinical Practice Guideline on Pressure Ulcers Katrien Vanderwee

48 Evaluating the pilot of the first course delivered using the University Conference Model at the EWMA Conference Glasgow, May 2007 Madeleine Flanagan

52 Conference Report, EWMA 2007, Glasgow Michael Clark

56 EWMA Corporate Sponsors contact data

Conferences 58 Conference Calendar

Organisations 60 Annual Meeting of the Lithuanian Wound Management Association Loreta Pilipaityte

62 Co-operating Organisations