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Volume 17 19 Number 1 2018 April 2016 Published Published by by European Wound Wound Management Management Association






PolyMem® wound dressings are designed to focus inflammation to where it is needed – the wound site – while minimizing inflammation where it isn’t needed, in uninjured tissue surrounding the wound.1

more healing • less pain Focusing the inflammatory process helps reduce secondary cell damage and pain caused by the typical swelling and bruising usually observed beyond the wound site.1,2,3 PolyMem has been shown to reduce secondary cell damage by reducing the recruitment of adjacent inflammatory nerve endings (also referred to as nociceptors or free nerve endings).1 These populous nerve endings, found in the epidermis, dermis, muscle, joints and viscera, are responsible for triggering and spreading the inflammatory reaction into surrounding uninjured tissues.4,5,6,7,8 The spreading of inflammation is often clinically evidenced by increased temperature, bruising, swelling, increased sensitivity to stimuli, and pain beyond the immediate zone of injury.5,7 Reduced bruising without compression

Learn more and order at References: 1. Beitz, AJ, Newman A, Kahn AR, Ruggles T, Eikmeier L. A Polymeric Membrane Dressing with Antinociceptive Properties: Analysis with a Rodent Model of Stab Wound Secondary Hyperalgesia. The Journal of Pain. Feb 2004;5(1):38-47 2. Knight KL. Chapter 3. Inflammation and Wound Repair In Cryotherapy in Sport Injury Management. Human Kinetics. 1995. Champaign, IL 3. Merrick MA. Secondary injury after musculoskeletal trauma: a review and update. Journal of Athletic Training 2002;37(2):209-217 4. Clay CS, Chen WYJ. Wound pain: the need for a more understanding approach. Journal of Wound Care. April 2005;14(4):181-184 5. Abraham SE. Pain Management in wound care. Podiatry Management. June/July 2006:165168 6. Wulf H, Baron R. The Theory of Pain in European Wound Management Association Position Document Pain at Wound Dressing Changes, Medical Education Partnership, London UK, 2002; page 8-11 7. Levine JD, Reichling DB. Chapter 2 Peripheral Mechanisms of Inflammatory Pain. In Wall PD, Melzak R, Editors. Textbook of Pain. 4th edition. Edinburgh, UK: Churchill Livingstone, 1999. pages 59-84. 8. Fields HL. Chapter 1 Introduction & Chapter 2 The Peripheral Pain Sensory System In Pain New York; McGraw-Hill 1987 pages 1-40

©2018 Ferris Mfg. Corp. Trademarks are owned by or licensed to Ferris. The marks may be registered or pending in several countries.

MKL-745 R0 0218

5 Editorial. Sebastian Probst, Editor of EWMA Journal

Science, Practice and Education 7 Opinions that matter: Patient’s perspective of their perioperative management during surgery for diabetic foot Piaggesi A, Bonaventura L, Giusti S, Goretti C, Menichini C 15 Skin tears in the aging population: Remember the 5 Ws Vanzi V, LeBlanc K 23 Recommendations to improve health care for people with chronic diseases. Maggini M, Zaletel J 29 Bioburden levels of spools of surgical tape in different healthcare settings. Yu V, Deing V, Nehrdich T, Struensee B 35 Specific risk factors for pressure ulcer development in adult critical care patients – a retrospective cohort study Ahtiala M, Soppi E, Tallgren M 45 Prevalence of chronic wound in different modalities of care in Germany Kröger K, Jöster M

Cochrane Reviews



EWMA 2019

51 Abstracts of Recent Cochrane Reviews. Rizello G

Book Review 58 The Diabetic Foot Syndrome. Gershater M A

EWMA 60 EWMA Journal Previous Issues and Other Journals 62 EWMA 2018 Conference in Krakow, Poland 67 New EWMA document: Advanced therapies in wound management Alberto Piaggesi 72 EWMA Publications 75 EWMA & EPUAP added-value to OECD efforts Moore Z, Soriano J V, Pokorna A, Schoonhoven L, Vaugnat H 78 Updates from the EWMA Committees 80 New Corporate Sponsors 83 EWMA News

Organisations 86 WHO Save Lives Clean Your Hands Campaign 2018 Tartari E, Saito H, Borzykowski T, Kilpatrick C, Pires D, Allegranzi B, Pittet D 88 The European Council of Enterostomal Therapy Kraboth G, Batas R 92 Chinese Tissue Repair Society Liang G, Xie T 95 Wounds Australia Rice J 96 Portuguese Wound Society Furtado K 98 Corporate Sponsors 100 Conference Calendar 102 Cooperating Organisations, International Partners and Other Collaborators


The EWMA Journal ISSN number: 1609-2759 Volume 19, No 1, April, 2018 The Journal of the European Wound Management Association Published twice a year

EWMA Council Sue Bale

Severin Läuchli


Immediate Past President

Editorial Board Sebastian Probst, Switzerland, Editor Sue Bale, UK Vickie R. Driver, USA Georgina Gethin, Ireland Salla Seppänen, Finland Andrea Pokorna, Czech Republic EWMA website

Georgina Gethin Honorary Secretary

Selcuk Baktiroglu

Editorial Office please contact: EWMA Secretariat Nordre Fasanvej 113 2000 Frederiksberg, Denmark Tel: (+45) 7020 0305 Fax: (+45) 7020 0315

Gregory Bohn

The next issue will be published in October 2018. Prospective material for publication must be with the EWMA Secretariat as soon as possible and no later than August 15th 2018. The contents of articles and letters in EWMA Journal do not necessarily reflect the opinions of the Editors or the European Wound Management Association. All scientific articles are peer reviewed by EWMA Scientific Review Panel. Copyright of published material and illustrations is the property of the European Wound Management Association. However, provided prior written consent for their reproduction, including parallel publishing (e.g. via repository), obtained from EWMA via the Editorial Board of the Journal, and proper acknowledgement, 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. All issues of EWMA Journal are CINAHL listed.


Scientific Recorder

Barbara den Boogert-Ruimschotel

Magdalena Annersten Gershater

Edward Jude

Christian Münter

Julie Jordan O’Brien

Massimo Rivolo

Sara Rowan

Kylie SandyHodgetts

Layout: Nils Hartmann, Open design/advertising Printed by: Kailow Graphic, Denmark Copies printed: 8.500 Prices: The EWMA Journal is distributed in hard copies to members as part of their EWMA membership. EWMA also shares the vision of an “open access” philosophy, which means that the journal is freely available online. Individual subscription per issue: 7.50€ Libraries and institutions per issue: 25€

Jan Stryja

Alberto Piaggesi

Samantha Holloway

Sebastian Probst

Kirsi Isoherranen

EWMA Journal Editor

Pedro PancorboHidalgo

Luc Teot

Evelien Touriany

COOPERATING ORGANISATIONS’ BOARD Esther Armans Moreno, AEEVH Christian Thyse, Valentina Vanzi, AISLeC Corrado Maria Durante, AIUC Ana-Maria Iuonut, AMP Romania Aníbal Justiniano, APTFeridas Gilbert Hämmerle, AWA Jan Vandeputte, BEFEWO Vladislav Hristov, BWA Els Jonckheere, CNC Lenka Veverková, CSLR Mirela Bulic, CWA Arne Buss, DGfW Susan Bermark, DSFS Heli Kallio, FWCS Rosa Nascimento, GAIF J. Javier Soldevilla, GNEAUPP

Georgios Vasilopoulos, HSWH Aleksandra Kuspelo, LBAA Loreta Pilipaityte, LWMA Corinne Ward, MASC Hunyadi János, MSKT Suzana Nikolovska, MWMA Øystein Karlsen, NIFS Louk van Doorn, NOVW Arkadiusz Jawień, PWMA Sebastian Probst, SAfW (DE) Maria Iakova, SAfW (FR) Goran D. Lazovic, SAWMA Tânia Santos, ELCOS Ján Koller, SSPLR Mária Hok, SEBINKO F. Xavier Santos Heredero, SEHER Sylvie Meaume, SFFPC

Susanne Dufva, SSIS Jozefa Košková, SSOOR Leonid Rubanov, STW (Belarus) Guðbjörg Pálsdóttir, SUMS Saša Milievic, SWHS Serbia Magnus Löndahl, SWHS Sweden Jasmina Begić-Rahić, URuBiH Ellie Lenselink, V&VN Peter Quataert, WCS Caroline McIntosh, WMAI Skender Zatriqi, WMAK Dragica Tomc, WMAS Mustafa Deveci, WMAT

EWMA JOURNAL SCIENTIFIC REVIEW PANEL Paulo Jorge Pereira Alves, Portugal Caroline Amery, UK Jan Apelqvist, Sweden Sue Bale, UK Michelle Briggs, UK Stephen Britland, UK Mark Collier, UK Javorka Delic, Serbia Corrado Durante, Italy Bulent Erdogan, Turkey Ann-Mari Fagerdahl, Sweden Madeleine Flanagan, UK Milada Franců, Czech Republic Peter Franks, UK Francisco P. García-Fernández, Spain Magdalena Annersten Gershater, Sweden Georgina Gethin, Ireland

Luc Gryson, Belgium Marcus Gürgen, Norway Eskild W. Henneberg, Denmark Alison Hopkins, UK Gabriela Hösl, Austria Dubravko Huljev, Croatia Arkadiusz Jawien, Poland Gerrolt Jukema, Netherlands Nada Kecelj, Slovenia Klaus Kirketerp-Møller, Denmark Zoltán Kökény, Hungary Martin Koschnick, Germany Knut Kröger, Germany Severin Läuchli, Schwitzerland David Tequh, Netherlands Sylvie Meaume, France Zena Moore, Ireland

Christian Münter, Germany Andrea Nelson, UK Pedro L. Pancorbo-Hidalgo, Spain Hugo Partsch, Austria Elaine Pina, Portugal Patricia Price, UK Elia Ricci, Italy Rytis Rimdeika, Lithuania Zbigniew Rybak, Poland Salla Seppänen, Finland José Verdú Soriano, Spain Hubert Vuagnat, Switzerland Richard White, UK Marc Cornock, UK Gerald Zöch, Austria

EWMA Journal editorial

What is a care bundle? Dear readers


ou may ask yourself why EWMA is dedicating an issue to care bundles. One objective during the presidency of Prof Sue Bale is to implement good wound management practice by increasing the support of wound care professionals and their interdisciplinary teams. In doing so, EWMA will work with the Institute for Health Care Improvement to develop care bundle programmes for wound aetiologies not yet defined in care bundles. This elaboration aims to improve patient safety and quality of care in all care settings. Care bundles are recognised in Anglo-Saxon countries as an important strategy to explore further in the quality and safety agenda and are gaining importance in clinical practice (Chaboyer et al. 2016).1

wound care are the ones for pressure ulcer prevention for hospitalized adults in intensive care units (ICUs)1,3 as well as for neonatal children with pressure ulcers.4 These bundles are based on the best available evidence, including international guidelines, by identifying five key elements of pressure ulcer prevention: risk assessment, skin assessment, support surfaces, nutrition and repositioning. The implementation of all five elements into clinical practice can assure all interventions needed to prevent pressure ulcers for a high-risk patient.

What is a care bundle? “A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices that, when performed collectively and reliably, have been proven to improve patient outcomes.2 ” It is a collection of quality of care management ideas that can be implemented for example in wound care. Each care bundle contains three to six elements that are underpinned by evidence using randomized controlled trials (RCTs) or systematic reviews. All suggested interventions have to be implemented simultaneously to be effective, as care bundles work as a sum of all interventions. Such interventions can have a beneficial impact on patients, their families and the health care system, through improved quality of life and reduced length of hospital stay. The described interventions in each care bundle might be familiar to health care professionals but, despite this, they are often not performed uniformly. The best described and developed care bundles within

This issue includes a number of scientific papers in the area of wound care management. One paper outlines the patient’s perspective of diabetic foot surgery, where the patient’s perspective of the perioperative experience is related to surgical management of diabetic foot in a highly specialised centre. Additionally, you will find a book review of the recently published book “Diabetic Foot Syndrome” by Prof Piaggesi and Prof Apelqvist.

This issue of the EWMA Journal is dedicated to news from EWMA and its cooperating organisations, and also to the subjects of care bundles and diabetic foot syndrome.

I hope you all enjoy this issue. Sebastian Probst, Editor and Council Member Professor in Wound Care, School of Health Sciences, University of Applied Sciences and Arts Western Switzerland Geneva, Switzerland

REFERENCES 1. Chaboyer W, Bucknall T, Webster J, McInnes,E, Gillespie BM, Banks M, et al.). The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial. International Journal of Nursing Standard 2016 64: 63-71.

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2. Institute of Health Improvement. What is a care bundle? (2018 March 20) Available at: resources/Pages/ImprovementStories/WhatIsaBundle. aspx 3. Tayyib N, Coyer F. & Lewis, PA Implementing a pressure ulcer prevention bundle in an adult intensive care. Intensive Critical Care Nursing. 2016 37:27-36.

4. Courtwright SE, Maestro KA, Preuster C, Dardashti N, McGill S, Madelon M, et al. Reducing hospitalacquired pressure ulcers using bundle methodology in pediatric and neonatal patients receiving extracorporeal membrane oxygenation therapy: An integrative review and call to action. Journal of Specialists in Pediatric Nursing 2018 doi: 10.1111/jspn.12188.


EPUAP2018 The 20th Annual Meeting of the European Pressure Ulcer Advisory Panel

12 – 14 September 2018 Rome, Italy


A winning approach to pressure ulcer management

Conference venue

Angelicum University Congress Center, Pontifical University of Saint Thomas Aquinas Abstract submission deadline:

15th March 2018 Review notification deadline:

4th May 2018 Early registration deadline:

4th June 2018

EPUAP Business Office Codan Consulting; Provaznicka 11, Prague 1, Tel.: +420 251 019 379 Organised by The European Pressure Ulcer Advisory Panel (EPUAP) in partnership with Bambino Gesu’ Children’s Hospital, Research Institute, Unit of Plastic and Maxillofacial Surgery, International Society for Pediatric Wound Care (ISPeW), Italian Association for Pressure Ulcers (AIUC) and Italian Nursing Society for Wound Care (AISLeC).

Science, Practice and Education

Opinions that matter:

Patient’s perspective of their perioperative management during surgery for diabetic foot ABSTRACT Introduction

than in phases II (1.2±0.7) and III (1.1±0.8).

To obtain patients’ perspective of the perioperative experience related to surgical management of diabetic foot (DF) in a highly specialised centre.


Method In total, 34 consecutive patients undergoing surgery at our specialised DF centre in November 2015 met our inclusion criteria. Patients completed the Diabetic Foot Surgical Experience Inventory questionnaire about their experience. The questionnaire included three parts: phase I, the pre-operative preparatory phase; phase II, the surgical period; and phase III, the post-operative observation period in the recovery room. For each phase, five yes/no questions were asked about the main aspects of the procedure, and pain, stress, and satisfaction were evaluated using a numerical rating scale (NRS; 0-10, with 10 = maximum).

Results Overall, 28 patients (age, 62.8±17.4 y; diabetes duration, 19.3±8.9 y; HbA1c, 8.3±1.25%) completed the questionnaire. Phase I satisfaction VAS score was 7.9±2.1; 7 patients noted a long delay before admission to the operating room (OR), 5 indicated pain during their local anaesthetic procedures (LAPs), and 3 indicated that LAPs were stressful. Phase II VAS satisfaction score was 8.8±1.2; 1 patient reported problems with OR bed positioning and 1 noted that the surgery was stressful. Phase III satisfaction VAS score was 8.9±1.7, with 1 patient noting a long delay before transfer to the ward. VAS pain scores were similar in all phases. Stress was significantly (p<0.05) higher in phase I (3.1±2.1) EWMA Journal 

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Alberto Piaggesi MD

Luca Bonaventura RN

In a generally well-tolerated context, the pre-operative phase and LAPs seem to be more problematic and painful for patients with DF compared with other aspects of the perioperative experiences. This was possibly related to perceived anticipatory stress.

INTRODUCTION Diabetic foot (DF) is a frequent and complex chronic ulcerative condition affecting 20% of patients with diabetes at least once in their life.1 Its progressive clinical course and increasing severity are associated with a 20 times higher risk of lower extremity amputation than in the general population, as well as a mortality rate higher than that of many forms of cancer.2, 3 The therapeutic approach to DF is multidisciplinary and encompasses many different aspects aimed at addressing factors that create and sustain the pathology. It involves either surgical or endovascular revascularization to restore blood flow in the ischemic foot, offloading to prevent negative effects of postural trauma on the affected foot, and systemic antibiotic therapy to combat infections4. A crucial aspect of DF treatment involves local care of foot ulcers, which represent the cause of lower extremity amputation in 85% of patients.5 Beyond local care and dressings, surgical management of ulcers associated with DF has become increasingly common and important in the overall multidisciplinary management of this pathology.6, 7

Serena Giusti RN

Chiara Goretti MD

Chiara Menichini RN Diabetic Foot Section, Department of Medicine, University of Pisa, Italy Corresponding Author: Alberto Piaggesi MD Diabetic Foot Section University of Pisa Via Paradisa 2, Cisanello 56124, Pisa, Italy

Correspondence: Conflicts of interest: None


Indications for DF surgery have increased over the years, and a classification system for DF surgery has been introduced and implemented. This has helped caregivers identify the correct surgical procedure for a growing number of indications. The procedures range from correction of neuropathic deformities that would eventually lead to ulceration, to the removal of infected and necrotic tissues that interfere with wound healing, to the transposition of tendons to correct an unbalanced foot, among many others8. With the expanded indications, patients with DF have increasingly more occasions to undergo a surgical procedure in the course of their disease, for both conservative and more aggressive interventions. In this context, subjective evaluation of the surgical experience from the patients’ perspective - an issue neglected by the current literature - would be of extreme interest to understand how pain, stress, and discomfort associated with DF surgery is perceived by patients. The ultimate goal would be to use this knowledge to improve quality of care from the patients’ point of view. Investigating these outcomes directly in the clinical setting by the same nurses who participate in preparation and management of patients undergoing DF surgery would help bridge the gaps between perioperative nursing protocols and the factors considered most important by patients. Aim The aim of this study is to explore patients’ perceptions of their perioperative experience related to surgery for DF. To accomplish this, we studied a group of consecutive patients undergoing surgery at in our DF Section, a highly specialised referral centre for DF in Tuscany, Italy. METHODS We designed this study to evaluate patients’ perception of stress, pain, and discomfort related to their surgical procedures for DF pathology. The study was submitted to and approved by the ethics committee of our hospital. Written informed consent was obtained upon arrival in the operating room (OR) area, one hour before surgery. All patients consecutively undergoing surgery at our specialised DF centre during November 2015 were screened for the following inclusion criteria: type 1 or type 2 diabetes, presence of an acute DF ulcer, and a surgical procedure proposed by an experienced specialist of the DF Team. Exclusion criteria were the presence of an emergent/urgent condition, diagnosis of a psychiatric disease, chronically receiving medications that may interfere with mood, inability to provide informed consent for the intervention, inability to understand the questionnaire questions, and a DF ulcer-related surgical procedure in the previous 12 months. 8

In all patients, the surgery was performed under locoregional anaesthesia, which consisted of popliteal and saphenous nerve blocks at the knee. These blocks (referred to collectively as local anaesthetic procedures in this report) were administered pre-operatively. No sedation was admistered to patients before or during the operations. The patients’ perioperative experience was assessed using the Diabetic Foot Surgical Experience Inventory (DFSEI) questionnaire (Appendix 1). This questionnaire was divided into three parts, corresponding to the three perioperative phases: the first explored the pre-operative preparatory phase (phase I), which included admission to the OR area, identification of the patient, confirmation of the surgical indication and procedure, and preparation and execution of local anaesthetic procedures; the second part involved the surgical phase (phase II), which included entry into the OR, preparation for the operation, and the surgery itself; and the third part explored the post-operative observation period in the post-anaesthesia care unt (PACU) (phase III), during which patients were transferred to the PACU and continuously monitored until discharged to the ward. The DFSEI was designed to explore how much stress, discomfort, or pain patients experienced for each of the three phases, through the use of direct simple questions. It was created by one of the authors (AP) and validated in patients undergoing surgical procedures in the same setting but for non-DF pathologies. For each phase, five yes/ no questions asked about the main aspects of the phase. The questionnaire also assessed pain, stress, and overall satisfaction during each phase using a Numerical Rating Scale (NRS; 0 = none to 10 = maximum). The questionnaire was administered by one of the nurses who assisted with the DF surgical procedure (LB, SG, CM). Most questions were completed immediately before the patient left the PACU, although the question related to transfer from the PACU to the ward was completed after arrival on the ward. The total time required to complete the questionnaire was 5 minutes or less, from the first to the last question. Statistical Analysis The DFSEI results were collected and analysed as both qualitative and quantitative data. The yes/no answers were grouped for each phase to identify problems related to specific aspects characterizing each phase. They were expressed as percentages. NRS scores were analysed as continuous data. They were expressed as mean±standard deviation and analysed with the Mann-Whitney test for non-parametric data, setting the value of significance at 5% (p<0.05).

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Table 1: Number and characteristics of patients. Number or characteristic


Patients fulfilling inclusion criteria (n)


Patients completing the questionnaire (n)


Males/Females (n)


Age (years)


Duration of diabetes (years)


Glycated haemoglobin (%)


Data are number or mean±standard deviation.

Table 2: Rate of patients indicating problems in each perioperative phase. Item

Pre-operative phase

Operative phase

Post-operative phase


0 0 0


0 3.6% 0


25.0% 0 3.6%


10.7% 3.6%



17.8% 0


RESULTS Of the 48 patients undergoing surgery during the study period, 34 fulfilled the inclusion criteria, but only 28 were enrolled in the study and completed the questionnaire. Of the 6 non-participants, 3 had one or more exclusion criteria and 3 did not provide informed consent. The patient characteristics are shown in Table 1. The surgical interventions were conservative surgery in 18 patients and minor amputation in 10 patients. The latter were performed for gangrene or chronic osteomyelitis and involved amputation of one or more lesser toes in 4 patients, amputation of the first toe in 3 patients, and transmetatarsal amputation in 3 patients. No major amputations were performed in this group of patients. The DFSEI questionnaire results for problems related to each phase are summarized in Table 2. The majority of perceived problems occurred in the pre-operative phase, whereas the post-operative phase was the least problematic period. In the pre-operative phase, 7 patients indicated that there was a long delay before admission to the OR, 5 noted pain during the local anaesthetic procedures, and 3 indicated that the local anaesthetic procedures were stressful. In phase II, 1 patient noted that positioning on the OR bed was a problem and 1 patient noted that the surgical procedure was stressful. In phase 3, 1 patient indicated that there was a long delay before transfer to the ward.

The results of NRS scores for overall satisfaction during each phase are shown in Figure 1. The NRS satisfaction score was 7.9±2.1 for phase I, 8.8±1.2 for phase II, and 8.9±1.7 for phase III. These were not significantly different. Figure 1: see next page NRS scores for pain and stress are shown in Figure 2. Pain was not significantly different among the three phases. However, stress was significantly (p<0.05) higher in phase I (3.1±2.1) compared with phases II (1.2±0.7) and III (1.1±0.8). Figure 2: see next page No differences were detected when the results were analysed separately for conservative surgery versus minor amputations for all of the items evaluated. DISCUSSION Surgery is a potentially stressful event for patients; even minor interventions, performed under locoregional anaesthesia may be negatively perceived by patients, irrespective of the indications and clinical outcomes.9 A recent study, performed in a group of 21 patients undergoing surgery for Dupuytren’s disease identified how patients’ character, previous experiences, and expectations influenced their perceived experience and appraisal of the results, and 

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Pre-operative Operative



80 60 40 20 0 NRS score Figure 1: Numerical rating scale (NRS) scores for level of overall satisfaction (0 - 10, with 10 indicating maximum satisfaction) reported by patients in each of the three perioperative phases.




Operative Post-operative

3,5 3 2,5 2 1,5 1 0,5 0 Stress


Figure 2: Numerical rating scale (NRS) scores for levels of stress and pain (0 - 10, with 10 indicating maximum stress or pain) reported by patients in each of the three perioperative phases. *p<0.05 pre-operative vs operative and post-operative phases.

potentially affected their clinical outcomes.10 Although this close relationship has been confirmed for a number of conditions and their surgical management, the role of perioperative stress in DF surgery has not been heretofore ascertained.11,12 DF is a chronic condition associated with stress and anxiety, which has been demonstrated to negatively affect wellbeing.13 Our current study demonstrates that DF surgery performed in a dedicated setting using locoregional anaesthesia is generally well tolerated, providing an overall positive evaluation of the experience. However, 10

some aspects are still perceived as problems. Dividing the surgical experience into the three phases composing the full perioperative course of DF surgery (from admission to the OR area to transfer back to the ward), we noted that the pre-operative phase was the main period when patients reported problems and the phase during which stress was highest. Our results are not unexpected, as a patient’s anxiety, and thus the level of perceived stress is amplified by the uncertainty of a new experience. This “catastrophic thinking” may not only influence the experience of patients, but it EWMA Journal 

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may also negatively impact outcomes, such as increasing complications and reducing mobility and autonomy [14]. The most common problem reported by patients for the pre-operative phase was related to the long delay before surgery (25%). This may have been at least partly due to anticipatory anxiety. Additionally, 18% of patients reported pain and 11% reported stress associated with the pre-operative local anaesthetic procedures. The importance of this study lies mainly in its provision of a better understanding of patients’ perspectives of their perioperative experience and the finding that the pre-operative phase is the most stressful period. Better preparation of patients, with more proactive nursing in this phase and paying close attention to patients’ psychological reactions, may improve the patients’ experience of the surgical procedure which has been demonstrated to also influence wound healing outcomes.15-17 We acknowledge some limitations of the present study. For example, the study had no control group. Furthermore, the results were based on subjective assessments by patients, using a questionnaire that has not been standardised in other institutions. In addition, the study was performed in a single centre, which limits the generalizability of its results.18,19 CONCLUSIONS Our study, the first of its kind in DF surgery, identified that the perioperative experience is well perceived and tolerated by the majority of patients, when adequately performed by a dedicated team. Some aspects of the preoperative phase, related to both pain associated with the local anaesthetic procedure and anxiety associated with anticipation, emerged as problematic in approximately 1 out of 4 patients. However, perceptions in the pre-operative phase did not appear to influence perceptions in the later phases. The results of our study are important in a field like DF surgery, which is rapidly expanding and for which no such information is available. Understanding patients’ perception of management-related stressful events may facilitate the development of strategies to greatly improve the quality of the perioperative experience and possibly improve clinical outcomes.

n Patient awareness regarding their condition may influence their level of anxiety related to the surgical procedure. A study evaluating patient knowledge and its relationship to the perceived surgical experience might aid in better preparing patients for surgery.

Implications for clinical practice n The personal and psychological dimensions of surgical patients with DF are often inadequately considered by caregivers. n The

role of nurses in helping patients navigate the complex phases of a surgical intervention for DF is important to help reduce patient stress and pain in this setting. n All

health professionals involved in preparing and delivering surgery for patients with DF should realize that the pre-operative phase is the most critical period from the patient’s perspective and should focus on efforts to try to shorten the phase and prevent pain related to the pre-operative anaesthetic procedures. Acknowledgements/Authors’ Contributions: LB, SG, CM, CG, and AP conceived and designed the study; LB, SG, and CM collected the data; CG supervised and double-checked the data collection; AP and CG wrote the manuscript; and LB, SG, CM, CG, and AP revised the manuscript and approved it for publication. 

Further research n Patients undergoing DF surgery may interpret their perioperative experience in different ways depending on their personal experiences. Thus, a further study might inquire about the possible relationship between previous surgical interventions and perceived levels of stress.

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Appendix 1 Diabetic Foot Surgical Experience Inventory (DFSEI) Pre-operative phase

1. Was the transfer from the ward to the preparatory room adequate?

 Yes

 No

2. Did you find the waiting time in the preparatory room adequate?

 Yes

 No

3. Did you find the local anaesthesia procedure stressful?

 Yes

 No

4. Did you find the local anaesthesia procedure painful?

 Yes

 No

5. Was the transfer from the preparatory room to O.R. adequate?

 Yes

 No

Please score 0 to 10 the amount of stress in the pre-operative phase Please score 0 to 10 the amount of pain in the pre-operative phase Please score 0 to 10 your overall satisfaction for the pre-operative phase

Operative phase

1. Was the positioning on the operatory bed adequate?

 Yes

 No

2. Did you find the waiting time in the O.R. adequate?

 Yes

 No

3. Did you find the surgical procedure stressful?

 Yes

 No

4. Did you find the surgical procedure painful?

 Yes

 No

5. Was the transfer from the O.R. to the recovery room adequate?

 Yes

 No

Please score 0 to 10 the amount of stress in the operative phase Please score 0 to 10 the amount of pain in the operative phase Please score 0 to 10 your overall satisfaction for the operative phase

Post-operative phase

1. Was the positioning in the recovery room adequate?

 Yes

 No

2. Did you find the waiting time in the recovery room adequate?

 Yes

 No

3. Did you find the post-operative monitoring procedures stressful?

 Yes

 No

4. Did you find the post-operative monitoring procedures painful?

 Yes

 No

5. Was the transfer from the recovery room to the ward adequate?

 Yes

 No


Please score 0 to 10 the amount of stress in the post-operative phase Please score 0 to 10 the amount of pain in the post-operative phase Please score 0 to 10 your overall satisfaction for the post-operative phase

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REFERENCES 1. Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global Epidemiology of Diabetic Foot Ulceration: A Systematic Review and Meta-Analysis. Ann Med. 2016 Sep 1:1-21

7. Allahabadi S, Haroun KB, Musher DM, Lipsky BA, Barshes NR. Consensus on surgical aspects of managing osteomyelitis in the diabetic foot. Diabet Foot Ankle. 2016 Jul12;7:30079.

2. Baba M, Davis WA, Norman PE, Davis TM. Temporal changes in the prevalence and associates of diabetes-related lower extremity amputations in patients with type 2 diabetes: the Fremantle Diabetes Study. Cardiovasc Diabetol. 2015 Dec 18;14:152.

8. Armstrong DG, Frykberg RG. Classifying diabetic foot surgery: toward a rational definition. Diabet Med. 2003 Apr;20(4):329-31.

3. Walsh JW, Hoffstad OJ, Sullivan MO, Margolis DJ. Association of diabetic foot ulcer and death in a population-based cohort from the United Kingdom. Diabet Med. 2016 Nov;33(11):1493-1498. 4. Bakker K, Apelqvist J, Lipsky BA, Van Netten JJ, Schaper NC. The 2015 IWGDF guidance on the prevention and management of foot problems in diabetes. Int Wound J. 2016 Oct;13(5):1072. 5. Reiber GE, Vileikyte L, Boyko EJ, del Aguila M, Smith DG, Lavery LA, Boulton AJ. Causal pathways for incident lower-extremity ulcers in patients with diabetes from two settings. Diabetes Care. 1999 Jan;22(1):157-62. 6. Wu T, Chaer RA; Society for Vascular Surgery Young Surgeons Committee., Salvo NL; American Podiatric Medical Association Young Physicians’ Leadership Panel. Building Effective Partnerships Between Vascular Surgeons and Podiatric Physicians in the Effective Management of Diabetic Foot Ulcers. J Am Podiatr Med Assoc. 2016 Jul;106(4):308-11.

9. Szabo S, Tache Y, Somogyi A (2012) The legacy of Hans Selye and the origins of stress research: a retrospective 75 years after his landmark brief “letter” to the editor# of nature. Stress 15(5):472–478. 10. Engstrand C, Kvist J, Krevers B. Patients’ perspective on surgical intervention for Dupuytren’s disease - experiences, expectations and appraisal of results. Disabil Rehabil. 2016 Dec;38(26):2538-49. 11. Appels A, Bär FW, Bär J, Bruggeman C, de Baets M (2000) Inflammation, depressive symptomatology, and coronary artery disease. Psychosom Med 62(5):601–605 12. Rosenberger PH, Jokl P, Ickovics J (2006) Psychosocial factors and surgical outcomes: an evidencebased literature review. J Am Acad Orthop Surg 14(7):397–405 13. Fejfarová V, Jirkovská A, Dragomirecká E, Game F, Bém R, Dubský M, Wosková V, Křížová M, Skibová J, Wu S. Does the diabetic foot have a significant impact on selected psychological or social characteristics of patients with diabetes mellitus? J Diabetes Res. 2014;2014:371938.

14. Conrod PJ1.The role of anxiety sensitivity in subjective and physiological responses to social and physical stressors. Cogn Behav Ther. 2006;35(4):216-25. 15. Maes M, Song C, Lin A, De Jongh R, Van Gastel A, Kenis G, Bosmans E, De Meester I, Benoy I, Neels H, Demedts P, Janca A, Scharpé S, Smith RS (1998) The effects of psychological stress on humans: increased production of pro-inflammatory cytokines and a Th1-like response in stress-induced anxiety. Cytokine 10(4):313–318. 16. Gouin JP, Kiecolt-Glaser JK (2011) The impact of psychological stress on wound healing: methods and mechanisms. Immunol Allergy Clin N Am 31(1):81– 93. 17. Broadbent E, Petrie KJ, Alley PG, Booth RJ (2003) Psychological stress impairs early wound repair following surgery. Psychosom Med 65(5):865–869 18. Wewers ME, Lowe NK (1990) A critical review of visual analogue scales in the measurement of clinical phenomena. Res Nurs Health 13:227–236. 19. Bodian CA, Freedman G, Hossain S, Eisenkraft JB, Beilin Y (2001) The visual analog scale for pain: clinical significance in postoperative patients. Anesthesiology 95(6):1356–1361


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EWMA Journal 

2018 vol 19 no 1


"the Original"

Wound treatment for chronic- and acute wounds as well as ямБrst- and second degree burns



Science, Practice and Education

Skin tears in the aging population:

Remember the 5 Ws Valentina Vanzi1

Skin tears (STs) are among the most common forms of skin injury to affect frail and older individuals, yet their impact is often minimized by health care professionals.

Definition, Classification and Differental Diagnosis

Populations at risk and risk factors


Where Anatomical location and Setting-related

Kimberly LeBlanc2 1RN,

CNS in Wound Care, IRCCS Bambino Gesù Children’s Hospital, Center of Excellence of Nursing Scholarship (CECRI), Rome, Italy



MN, RN, CETN (C) Canadian Association for Enterostomal Therapists Academy Chair, Ottawa, Canada

When/ Why Main Causes and Situationrelated

Figure 1: The five Ws of skin tears. ABSTRACT Skin tears represent a relevant clinical consequence of age-associated skin vulnerability, and are extremely common among frail and older individuals. They are acute wounds with the potential to be closed by primary intention, however they are often mismanaged and misdiagnosed and transition to become chronic and complex wounds. Reported skin tear prevalence suggests they are a growing healthcare problem which have a profound impact on the health and wellbeing of affected individuals and a great financial burden to healthcare systems. With the aging global population, it can be assumed that the prevalence of skin tears will continue to increase

proportionally with the aging population. In order to minimize the impact of skin tears clinicians must to be aware of what skin tears are, who is at risk, why and when they occur, and how to manage skin tears when they do occur. The purpose of this article is to assist clinicians with the prediction, prevention, assessment and management of skin tears among the aging population across healthcare sectors. Skin tears (STs) are among the most common forms of skin injury to affect frail and older individuals, yet their impact is often minimized by health care professionals (Carville et al, 2014; Stephen-Haynes, 

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2018 vol 19 no 1

Correspondence to: Conflicts of interest: None


Figure 2: International Skin Tear Advisory Panel (ISTAP) Skin Tear Classification System (LeBlanc et al, 2013).

(a) Type 1 (No skin loss)

(b) Type 2 (Partial skin loss)

2012). Although STs start as acute wounds, they frequently become painful chronic and complex wounds, which have a high propensity to develop infections. It is important for health care professionals to identify STs as adverse and reportable events that compromise patient safety. For this reason, clinicians must be able to recognize what STs are; identify who is at risk of developing them; understand where, when and why they usually occur; and learn how to treat them in the appropriate way (Fig.1). Thus, to prevent serious complications and promote wound healing, health care professionals must complete a comprehensive assessment and institute ST-specific wound care practices that both promote wound healing and respect fragile skin (Holmes et al, 2013; Vanzi and Toma, 2017). The purpose of this article is to define STs; identify individuals at risk for ST development; explore when, where and why STs normally occur; and determine how to manage STs if they do occur.

What: Defining skin tears The International Skin Tear Advisory Panel (ISTAP) defines a skin tear (ST) as “‘a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers” (LeBlanc and Baranoski, 2011). The wounds resulting from STs may be of partial or full thickness depending on the extent of the injury. Individuals suffering from STs complain of increased pain and decreased quality of life (Carville et al, 2014). In addition, those who are at the highest risk for STs are individuals at the extremes of age and the critically or chronically ill; therefore, these patients are at a higher risk for developing secondary wound infections and also may have co-morbidities that contribute to the transition of STs from acute to chronic complex wounds. 16

(c) Type 3 (Total skin loss)

STs are acute wounds that, in cases with no skin loss, have the potential to be closed by primary intention. It has been hypothesized that because of their high prevalence and perceived insignificance, however, STs often do not receive the attention they deserve (Carville et al, 2014; LeBlanc et al, 2014). For example, LeBlanc et al (2014) reported that more than half of STs were found without topical wound dressings or documentation of their causality. Given their acuity, STs are expected to heal in a timely manner, i.e. 21 to 40 days (Sanada et al, 2015). The literature suggests, however, that acute STs have a high risk of developing into complex chronic wounds with delayed wound healing, localized infection, cellulitis or generalized sepsis if the damaged area remains untreated or is treated inappropriately (Carville et al, 2014; LeBlanc et al, 2017). Chronic wounds adversely affect the individual’s physical, social and psychological health, which imposes a huge cost on the community (Sussman and Golding, 2011). Morphologically, STs usually are jagged and irregular in shape. STs generally tend to be low exudating wounds, but they may be high exudating wounds when they occur in conjunction with other co-morbidities, such as uncontrolled peripheral oedema (Baranoski et al, 2016). Additionally, at the time of the initial injury, bleeding may be an issue, particularly if the individual is on anticoagulation therapy (LeBlanc et al, 2011). Such bleeding may be uncomplicated, e.g. a partial thickness linear tear of the skin, or potentially more complex, involving full thickness skin loss, blood clots, and ecchymosis. Recent publications have highlighted the clinical challenges inherent in differentiating STs from pressure ulcers EWMA Journal 

2018 vol 19 no 1

Science, Practice and Education

Figure 3: A skin tear on the right elbow of an 86-year-old patient.

and have emphasized the importance of correctly diagnosing each as a distinct and separate wound type (Black et al, 2015; LeBlanc et al, 2016) to ensure that effective prevention and management strategies are implemented (LeBlanc and Baranoski, 2014). To date, there exists no consensus on the definition of STs, which may explain the absence of a specific category for coding STs in the World Health Organization International Classification of Diseases 10th edition (ICD-10). Misdiagnoses of individuals with STs is a considerable issue which, when it occurs, contributes to prolonged wound healing and additional pain and suffering (LeBlanc et al, 2017). Once the clinical diagnosis of an ST has been made, it is imperative that health care professionals utilize a reliable and valid method for classification to properly communicate and manage the ST. ISTAP developed and validated an ST classification system (LeBlanc et al, 2011; LeBlanc et al, 2013), which was adapted from both the Payne and Martin classification system (Payne and Martin, 1990) and the Skin Tear Audit Research (STAR) ST classification system (Carville et al, 2007). The ISTAP classification divides STs into three categories of epidermal and dermal loss, depending on the symptoms of the skin flap (Fig.2a, b, c). Who is at risk for STs? The individuals who are at the greatest risk for STs include those at the extremes of age, i.e. neonates and the elderly; critically and chronically ill patients; and those who are disabled and/or need assistance with personal care (LeBlanc et al, 2011). It is essential to identify the factors that predispose an individual to developing an ST, and how best to prevent an ST from occurring (Sussman and GoldEWMA Journalâ&#x20AC;&#x201A;

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ing, 2011). Lewin et al (2016) identified that one of the strongest predictors of developing an ST was a history of previous STs. Rayner et al (2015), however, emphasized that there is a lack of quantifiable research for identifying individuals most at risk for STs despite apparent correlations between various patient and specific skin characteristics (Rayner et al, 2015). Moreover, it is not known which risk factors are independent of one another, and whether one risk factor is more important than another (Ratliff et al, 2007; Vanzi and Toma, 2018). Several systematic reviews have been conducted to address this issue. Serra et al (2017) categorized ST risk factors into seven main areas: age-related skin changes, dehydration, malnutrition, sensory changes, mobility impairment, pharmacological therapies and mechanical factors related to skin care practices. Similarly, Strazzieri-Pulido et al (2015) cited advanced age, dependence on basic activities of daily life (ADL), frail elderly, level of mobility, agitated behaviour, non-responsiveness, greater risk for concurrent development of pressure ulcers, cognitive impairment, spasticity and photoaging as common ST risk factors. Moreover, Rayner et al (2015) reported history of STs, use of steroidal or non-steroidal medications, elderly and frail individuals, and those dependent on others for ADL as common patient characteristics of those with STs, and also cited an equally broad range of common skin features, such as ecchymosis, senile purpura, fragile skin (Fig.3), dry skin, or oedema of the lower limbs. The authors of these studies emphasized, however, that such characteristics are not consistently recorded across all studî&#x201A;Š


ies. Such a discrepancy may be due primarily to the largely anecdotal and/or experiential nature of the research design. Lewin et al (2016) conducted a case-control study, from which they proposed a parsimonious model for predicting the development of STs based on six variables: ecchymosis (bruising), senile purpura, haematoma, evidence of a previously healed ST, oedema, and inability to reposition oneself independently, but noted that the predictive ability of these six characteristics needed to be validated in a prospective study (Lewin et al, 2016). Overall, the prompt

identification of individuals at risk for STs may be limited by the failure to identify specific patient and skin characteristics (Rayner et al, 2015). Further research is needed to identify risk factors that are associated with STs, which will enable the development of a personalized prevention program that considers each patient’s risk and facilitate the correct diagnosis of this wound type. When and why do STs occur? There are numerous factors that can cause STs to develop,

Table 1: ISTAP Risk Reduction Program© ISTAP 2014 used with permission Risk Factor


Care giver/provider

General • Educate the patient on skin tear prevention & • Create a safe patient environment Health promote active involvement in treatment decisions • Educate client +/ circle of care / caregivers (if cognitive function is not impaired) • Protect from self-harm • Optimize nutrition & hydration • Provide a dietary consult if indicated • Take extra caution with extremes of BMI (<20 or >30) • Review polypharmacy for medication reduction /optimization Mobility • Encourage active involvement if physical function • Conduct daily skin assessment & is not impaired monitor for skin tears • Facilitate appropriate selection & use of assistive • Ensure safe patient handling techniques/ devices equipment & environment (trauma, ADL, self-injury) • Encourage proper transferring/ repositioning • Initiate fall prevention program • Remove clutter • Ensure proper lighting • Provide pad equipment/furniture (bedrails, wheel chair etc.) • Avoid patient contact with sharp fingernails/ jewellery Skin • Be aware of medication-induced skin fragility • Individualize skin hygiene (warm or tepid (e.g. topical & systemic steroids) but not hot water, soapless or pH neutral • Wear protective clothing (shin guards, cleaners, skin moisturizer) long sleeves, etc.) • Avoid strong adhesives, dressings, and tapes • Moisturize skin (lubrication and hydration) • Avoid patient contact with sharp fingernails/ two times per day jewellery • Keep fingernails short Health care setting

• Implement a comprehensive Skin Tear Reduction Program • Include skin tears in audit programs • Utilize validated classification system • Develop a consultative team (Wound care / dietary specialists, rehab/pharmacists)

Abbreviations: ISTAP, International Skin Tear Advisory Panel; BMI, body mass index; ADL, activities of daily living.


EWMA Journal 

2018 vol 19 no 1

Science, Practice and Education

few of which can be controlled. STs are the result of shear and friction (either independently or in combination) or blunt force trauma. Frequently, the causes of STs are attributed to mechanical trauma in relation to an accident (e.g., bumping into something, such as a wheelchair pedal or a door knob, or applying or removing stockings) (LeBlanc et al, 2017). Additionally, particularly in the acute care setting, STs have been attributed to medical adhesive related skin injury (McNichol et al, 2013). STs also are found with no apparent cause, however (Ratliff and Fletcher, 2007). In older adults, STs are often environmentally related (Ratliff and Fletcher, 2007) and they can occur in conjunction with daily activities such as dressing, bathing or toileting. For this reason, several patient-centred strategies should be adopted to prevent STs from occurring, as suggested by the ISTAP risk prevention program (Tab.1) Where do STs occur? Although STs have been reported to occur anywhere on the body, they are found predominantly on the extremities (LeBlanc et al, 2011). There exists limited literature addressing the burden of STs, but research in this area is growing. Available epidemiological studies confirm that STs are common, with a prevalence of 3.3% to 22% in the hospital setting and 5.5% to 19.5% in home care settings (Strazzieri-Pulido et al, 2017; Skiveren et al, 2017; Chang et al, 2016; Koyano, et al, 2014; LeBlanc et al, 2013). Reported incidence rates of STs ranged from 2.23% to 92% in long-term care facilities and varied from 2.1% among men to 4.6% among women living in the community (Strazzieri-Pulido et al, 2017). Epidemiological studies pertaining to STs are needed across all health care sectors and in all age groups, however, to determine the extent of the problem (Vanzi and Toma, 2017). Monitoring of ST prevalence and incidence in various health care settings also will facilitate benchmarking and implementation programs (LeBlanc et al, 2013). Accurate documentation of STs is therefore needed to track and monitor their prevalence. To date, there is no robust ST prevalence data available for many countries, and the benchmarking of STs is difficult due to the paucity of published studies and the lack of standardized assessment. Managing skin tears Ultimately, the goal of ST management is ST prevention. Given the multiple interconnecting causal factors and the skin fragility of those at heightened risk for ST, some STs will be unavoidable. When STs do occur, it is imperative that they are properly managed to prevent them from becoming chronic and complex wounds (LeBlanc et al, 2013). Initial ST management: n Control any bleeding EWMA Journalâ&#x20AC;&#x201A;

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n n n n n n n n n n n n

Re-approximate the wound edges Classify, measure and document the ST Treat the cause (identify those at risk) Implement a prevention protocol Provide moist wound healing Avoid additional trauma Protect fragile peri-wound skin Manage exudate Avoid infection Provide pain control Avoid new risks for trauma Assess co-morbidities (e.g. venous disease, arterial disease, pressure)

STs are acute wounds that have the potential to close by primary intention. Given the fragility of the skin among the elderly, however, sutures and staples are not viable options for Type 1 STs in this population. Health care providers should consider, when possible, securing Type 1 ST flaps with topical cyanoacrylate adhesives, i.e. skin glue, rather than more traditional methods such as medical adhesive strips, sutures or staples (LeBlanc et al, 2017). Choose a dressing that will: n maintain a moist wound healing (method of choice compared to a dry dressing) n be appropriate for the local wound environment n protect the peri-wound skin n control or manage exudate n control or manage infection n optimize caregiver time Many types of skin and wound care products are used to promote healing. Best practice supports that a skin flap/ pedicle should be approximated if possible, and covered with one of the following types of dressings: cyanoacrylate topical skin adhesive, hydrogel, alginate, non-adherent contact layers dressings, silicone foam dressings, absorbent clear acrylic dressing or non-adherent impregnated gauze mesh dressing. The actual product selection will depend on the type and location of the ST and the wound bed characteristics (LeBlanc et al, 2013). Hydrocolloids and transparent film dressings are not recommended over STs, as they may cause skin stripping and injury to the healing skin tear if not removed properly (LeBlanc et al, 2013). Conclusion STs are acute wounds found frequently in the aging population. Despite presenting as acute wounds that should progress to closure in a timely fashion, STs often become chronic and complex as the result of minimization and mismanagement by health care professionals. By understanding what STs are, who is at risk, why and when they î&#x201A;Š


occur and how to manage STs when they do occur, health care professionals can improve patient outcomes, which will decrease pain, suffering and costs to the health care system. m

Key messages • Skin Tears are common wounds found among frail and older individuals, and they represent a troubling consequence of trauma to aging skin.

• Skin tears are acute wounds, which have a high risk of converting to painful complex and chronic wounds if they are mismanaged and mis diagnosed.

• Clinicians must be able to recognize, assess and treat a skin tear to promote patients’ safety, to minimize the risk of further trauma and to improve skin outcomes following an injury.

REFERENCES Baranoski S, LeBlanc K, Gloeckner M. CE: Preventing, Assessing, and Managing Skin Tears: A Clinical Review. Am J Nurs 2016;116(11):24-30. Bianchi J. Preventing, assessing and managing skin tears. Nurs Times 2012;108(13):12-16 Black J, Brindle C, Honaker J. Differential diagnosis of suspected deep tissue injury. Int Wound J 2016 ;13(4):531-9. Carville K, Lewin G, Newall N, et al. STAR: a consensus for skin tear classification. Primary Intent 2007;15(1):18-28. Carville K, et al. STAR: a consensus for skin tear classification. Primary Intention 2007;15(1):18-28. Carville K, Leslie G, Osseiran-Moisson R, Newall N, Lewin G. The effectiveness of a twice-daily skin-moisturizing regimen for reducing the incidence of skin tears. Int Wound J 2014; 11(4):446-53. Chang YY, Carville K, Tay AC. The prevalence of skin tears in the acute care setting in Singapore. Int Wound J 2016;13(5):977-83. Ewart J. Caring for people with skin tears. Wound Essentials 2016;11(1):13-17

LeBlanc K, Baranoski S, Christensen D, Langemo D, Sammon MA, Edwards K, et al. International Skin Tear Advisory Panel: a tool kit to aid in the prevention, assessment, and treatment of skin tears using a simplified classification system. Adv Skin Wound Care 2013;26(10):459-76. LeBlanc K, Baranoski S, International Skin Tear Advisory Panel, 2013. Skin tears: best practices for care and prevention. Nursing. 2014;44(5):36-46.

Stephen-Haynes J.Skin tears: achieving positive clinical and financial outcomes. Br J Community Nurs 2012;Suppl:S6, S8, S10 passim.

LeBlanc K, Alam T, Langemo D, Baranoski S, Campbell K, Woo K. Clinical challenges of differentiating skin tears from pressure ulcers. EWMA Journal 2016; 16, 17–23.

Strazzieri-Pulido KC, Peres GR, Campanili TC, Santos VL. Skin tear prevalence and associated factors: a systematic review. Rev Esc Enferm USP. 2015;49(4):674-80.

LeBlanc K, Woo K, Christensen D, Forest-Lalonde, L, O’Dea J, Varga M, McSwiggan J.Canadian beast practice recommendations for the prediction, prevention, assessment and management of skin tears across the health care continuum. Wounds Canada 2017:1-40.

Strazzieri-Pulido KC, Peres GR, Campanili TC, de Gouveia Santos VL. Incidence of Skin Tears and Risk Factors: A Systematic Literature Review.J Wound Ostomy Continence Nurs 2017 ;44(1):29-33.

Holmes RF, Davidson MW, Thompson BJ, Kelechi TJ. Skin tears: care and management of the older adult at home. Home Healthc Nurse 2013;31(2):90-101. Koyano Y, Nakagami G, Iizaka S, Minematsu T, Noguchi H, Tamai N, et al. Exploring the prevalence of skin tears and skin properties related to skin tears in elderly patients at a long-term medical facility in Japan. Int Wound J 2016;13(2):189-97.

McNichol L, Lund C, Rosen T, Gray M.Medical adhesives and patient safety: state of the science: consensus statements for the assessment, prevention, and treatment of adhesive-related skin injuries. Orthop Nurs. 2013;32(5):267-81.

LeBlanc, KA, Christensen D, Orsted HL, Keast DH. Best practice recommendations for the prevention and treatment of skin tears. Wound Care Canada 2008;6(1): 14–30.

Payne RL, Martin ML. The epidemiology and management of skin tears in older adults. Ostomy Wound Manage 1990; 26:26-37.

LeBlanc K, Christensen D, Cook J, Gutierrez O. Prevalence of skin tears in a long-term care facility. J Wound, Ostomy, Cont Nurs 2013;40(6):580–584. LeBlanc K, Baranoski S, Holloway S, Langemo D. Validation of a new classification system for skin tears. Adv Skin Wound Care 2013;26(6): 263-5.


Skiveren J, Wahlers B, Bermark S. Prevalence of skin tears in the extremities among elderly residents at a nursing home in Denmark. J Wound Care 2017;26(Sup2):S32-S36.

LeBlanc K, Baranoski S. Skin tears: The forgotten wound. J Nurs Manag 2014;45(12): 36-46.

Lewin GF, Newall N, Alan JJ, Carville KJ, Santamaria NM, Roberts PA. Identification of risk factors associated with the development of skin tears in hospitalised older persons: a case-control study. Int Wound J 2016 ;13(6):1246-1251.

LeBlanc K, Baranoski S, Skin Tear Consensus Panel Members. Skin tears: state of the science: consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Adv Skin Wound Care 2011;24(9 Suppl):2-15.

Serra R, Ielapi N, Barbetta A, de Franciscis S. Skin tears and risk factors assessment: a systematic review on evidence-based medicine. Int Wound J. 2018 ;15(1):38-42.

Sussman G, Golding M. Skin tears: should the emphasis be only their management?. Wound Pract Res. 2011;19(2):66-71. Vanzi V, Toma E. How to prevent and avoid common mistakes in skin tear management in the home setting. Br J Community Nurs 2017;1;22(Sup9):S14S19. Vanzi V, Toma E. Recognising and managing age-related dermatoporosis and skin tears. Nurs Older People 2018 in press.

Ratliff CR, Fletcher KR. Skin tears: a review of the evidence to support prevention and treatment. Ostomy Wound Manage 2007;53(3):32-4, 36, 38-40 passim. Rayner R, Carville K, Leslie G, Roberts P. A review of patient and skin characteristics associated with skin tears. J Wound Care 2015;24(9):406-14. Sanada H, Nakagami G, Koyano Y, Lizaka S, Sugama J. Incidence of skin tears in the extremities among elderly patients at a long-term medical facility in Japan. Geriatr Gerontol Int. 2015 ;15(8):1058-63.

EWMA Journal 

2018 vol 19 no 1

EWMA 2018 | 9-11 May | Krakow, Poland

Come and visit us at Stand #W410

Diabetic foot ulcers (DFUs) are a major issue globally, with considerable economic and human cost. About 8.5% (422 million) of the world’s adult population has diabetes1 and of these up to 25% will develop a DFU2,3. ‘Compromised’ patients are at greater risk of developing a DFU3. DFUs are associated with increased morbidity and mortality, with half of patients dying within 5 years4,5. DFUs are also expensive to treat. The costs associated with diabetes in the US and in Europe respectively are increasing by approximately US$9-13bn and up to €10bn per year6,7. At KCI, we take DFUs seriously. Our portfolio of Advanced Wound Dressings and Negative Pressure Wound Therapy are designed to offer you the right solution at the right stage of healing process.

You are invited to our symposium

Go Beyond: a Multi-disciplinary approach for the management of DFUs Thursday 10th May 16.00-17.00, Room: Wisla Hall Come and learn about the new clinical evidence demonstrating improved patient outcomes in the management of DFU with innovative solutions.

You are also invited to a series of international DFU expert sessions hosted at our stand. References 1. World Health Organization (WHO). Global report on diabetes. World Health Organization, 2016. : (access date February 2018). 2. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. Journal of the American Medical Association 2005; 293(2):217–28. 3. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. The New England Journal of Medicine 2017; 376: 2367–75. 4. Jupiter DC, Thorud JC, Buckley CJ, Shibuya N. The impact of foot ulceration and amputation on mortality in diabetic patients. I: From ulceration to death, a systematic review. International Wound Journal 2016; 13: 892–903. 5. Brennan MB, Hess TM, Bartle B et al. Diabetic foot ulcer severity predicts mortality among veterans with type 2 diabetes. Journal of Diabetes and Its Complications 2017; 31(3): 556–61. 6. Prompers L, Huijberts M, Schaper N et al. Resource utilization and costs associated with the treatment of diabetic foot ulcers. Diabetologia. 2008 Oct;51(10):1826-34 DOI: 10.1007/s00125-008-1089-6. 7. Rice JB, Desai U, Cummings AKG et al. Burden of diabetic foot ulcers for Medicare and private insurers. Diabetes Care 2014; 37(3): 651–68. Copyright 2018 KCI Licensing, Inc. All rights reserved. Unless otherwise designated, all trademarks are proprietary to KCI Licensing, Inc., its affiliates and/or licensors. PRA-PM-EU-00018 (03/18)

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Science, Practice and Education

Recommendations to improve health care for people with chronic diseases

Marina Maggini DBiol1

Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS) has identified quality criteria and formulated recommendations for improving the prevention and quality of care for people with diabetes and other non-communicable diseases (NCDs). INTRODUCTION The main challenges facing decision makers and leaders in health care are: 1) how to strengthen chronic disease prevention and control and 2) how to re-design the healthcare system to better meet the complex needs of people with chronic diseases such as diabetes.1-3 In 2014, the European Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle (JA-CHRODIS) was launched in response to the European Commission’s encouragement to Member States to join forces to improve care and prevent major chronic diseases.4 CHRODIS is the first Joint Action on chronic diseases co-financed under the third EU Public Health Programme. It has brought together numerous partners, representing 25 European countries that worked together from March 2014 to March 2017 ( The primary goal of the JA-CHRODIS was to study the practices and policies related to chronic diseases in Europe to promote and facilitate the exchange and transfer of good practices among countries and regions, for effective action against chronic diseases, with a specific focus on health promotion, chronic disease prevention, multimorbidity, and diabetes.3 The final objective was to improve the well-being of citizens by paving the way for better health policies and interventions. In the frame of the JA-CHRODIS, diabetes is considered a case study on strengthening health care for people with chronic diseases. Diabetes can be regarded as a tracer condition to demonstrate the importance of holistic approaches for prevention and treatment of NCDs. Furthermore,

Jelka Zaletel MD PhD2

diabetes can be used as a model to demonstrate the potential for intersectorial collaboration, which allows countries to gain valuable experience that can be more broadly applied to NCDs.5 An extensive process was developed to identify quality criteria and formulate recommendations for improving the prevention and quality of care for people with diabetes and NCDs. The objective was to define a core set of criteria that can be applied across various domains (e.g., prevention, care, health promotion, education, and training) but are also general enough to be applied to all types of chronic diseases and in countries with different political, administrative, social, and healthcare organizations.

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Institute of Health, National centre for drug research and evaluation, Italy 2National

Institute of Public Health, Centre for Prevention and Health Promotion Programmes, Slovenia Corresponding author: Marina Maggini National Institute of Health, Viale Regina Elena 299, Rome, Italy

METHODS The RAND-modified Delphi method was used to define the core quality criteria and recommendations. A thorough description of the method can be obtained on the JA-CHRODIS website.6 A literature review was conducted on quality criteria and effective strategies for the prevention and care of diabetes.7-9 The results were then used to define the questionnaire for the Delphi process. The process followed a structured methodology, involving experts with a variety of professional backgrounds and from a wide number of organizations across Europe. Consultation with the expert panel followed the RAND-modified Delphi methodology. The process led to the agreement on nine quality criteria comprising 39 categories that were ranked and weighted.6 

EWMA Journal 

On behalf of the Joint Action on Chronic Diseases and Promoting Healthy Ageing Across the Life Cycle (JACHRODIS)

Correspondence: Conflicts of interest: None


10 Common Chronic Conditions for Adults 65+


High Cholesterol


Ischemic Heart Disease







Chronic Kidney Disease

Heart Failure


Alzheimerâ&#x20AC;&#x2122;s Disease and Dementia

Chronic Obstructive Pulmonary Disease





(High Blood Pressure)

RESULTS As a result of the extensive process that was carried out for the definition of quality criteria, nine recommendations were generated. These recommendations will help guide practices or interventions regarding prevention, health promotion, care management, education, and training. In addition, the recommendations may help improve the quality of care for and prevention of chronic diseases.10 1-Design the practice The design should clearly specify aims, objectives, and methods, and rely upon relevant data, theory, context, evidence, and previous practices, including pilot studies. The structure, organization, and content of the practice is defined, and established together with the target population, that is clearly described (i.e. exclusion and inclusion criteria and the estimated number of participants). Human and material resources should be adequately estimated in relation with committed tasks. Relevant dimensions of equity have to be adequately taken into consideration, and targeted. 2-Promote the empowerment of the target population The practice should actively promote the empowerment of the target population by using appropriate mechanisms, such as self-management support, shared decision making, education-information or value clarification, active participation in the planning process and in professional 24

(or Coronary Heart Disease)


training, and considering all stakeholders needs in terms of enhancing/acquiring the right skills, knowledge and behaviour. 3-Define an evaluation and monitoring plan The evaluation outcomes should be linked to action to foster continuous learning and/or improvement and/or to reshape the practice. Evaluation and monitoring outcomes should be shared among relevant stakeholders, and linked to the stated goals and objectives, taking into account social and economic aspects from both the target population, and formal and informal caregiver perspectives. 4-Comprehensiveness of the practice The practice should consider relevant evidence on effectiveness, cost-effectiveness, quality, safety, the main contextual indicators, as well as the underlying risks of the target population using validated tools to individual risk assessment. 5-Include education and training The practice should include educational elements to promote the empowerment of the target population (e.g. strengthen their health literacy, self-management, stress managementâ&#x20AC;Ś). Relevant professionals and experts are trained to support target population empowerment, and trainers/educators are qualified in terms of knowledge, techniques and approaches. EWMA Journalâ&#x20AC;&#x201A;

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Science, Practice and Education

6-Ethical considerations The practice should be implemented equitably (i.e., proportional to need). The objectives and strategy are transparent to the target population and stakeholders involved. Potential burdens (i.e. psychosocial, affordability, accessibility, etc.) should be addressed to achieve a balance between benefit and burden. The rights of the target population to be informed, to decide about their care, participation and issues regarding confidentiality should be respected and enhanced. 7-Governance approach The practice should include organizational elements, identifying the necessary actions to remove legal, managerial, financial, or skill barriers, with the contribution of the target population, carers and professionals that is appropriately planned, supported and resourced. There is a defined strategy to align staff incentives and motivation with the practice objectives. The practice should offer a model of efficient leadership, and should create ownership among the target population and several stakeholders considering multidisciplinarity, multi-/inter-sectoral, partnerships and alliances, if appropriate. The best evidence and documentation supporting the practice (guidelines, protocols, etc.) should be easily available for relevant stakeholders (e.g. professionals and target populations), which should support the multidisciplinary approach for practices. The practice should be supported by different information and communication technologies (e.g. medical record system, dedicated software supporting the implementation of screening, social media etc.), defining a policy to ensure acceptability of information technologies among users (professionals and target population) to enable their involvement in the process of change.

The sustainability strategy should consider a range of contextual factors (e.g. health and social policies, sex and gender issues, innovation, cultural trends and general economy, and epidemiological trends), assessing the potential impact on the population targeted. DISCUSSION AND CONCLUSIONS Nine recommendations were defined by the work package on diabetes within the JA-CHRODIS. These recommendations are general enough to be applied to all chronic diseases and can be implemented in countries across the EU, regardless of the type of political, administrative, social, and healthcare organization. Moreover, the recommendations may be applied to various domains, such as prevention, care, health promotion, patient education, and training for professionals. The adoption of an agreed upon core set of quality criteria should also help to decrease inequalities in health within and across European countries. Ultimately, it will contribute to the cultural shift needed to redesign the care systems with and around the needs of people with chronic diseases. Implications for clinical practice The recommendations constitute a valuable and practical tool that can be used by decision makers, healthcare providers, healthcare personnel, and patients to support the implementation of good practices and to improve, monitor, and evaluate the quality of chronic disease prevention and care. Acknowledgement This publication arises from the Joint Action CHRODIS, which has received funding from the European Union, in the framework of the Health Programme (2008-2013). Sole responsibility lies with the authors. The Consumers, Health, Agriculture and Food Executive Agency is not responsible for any use that may be made of the information contained therein. î&#x201A;Š

8-Interaction with regular and relevant systems The practice should be integrated or fully interacting with the regular health, care, and/or further relevant systems, enabling effective linkages between all relevant decisionmakers and stakeholders, and enhancing and supporting the target populations ability to effectively interact with the regular, relevant systems. 9-Sustainability and scalability The continuation of the practice should be ensured through institutional anchoring and/or ownership by the relevant stakeholders or communities, and supported by those who implemented it. EWMA Journalâ&#x20AC;&#x201A;

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Science, Practice and Education

REFERENCE 1. World Health Organization. Global status report on noncommunicable diseases 2014. Geneva, WHO, 2014. Available from: ncd-status-report-2014/en/ 2. United Nations General Assembly - Draft Resolution 16 September 2011. A/66/L.1. Available from: www. L.1&Lang=E%20 3. Maggini M, Zaletel J. Towards better prevention and management of diabetes - The Joint Action CHRODIS. Health-EU. Newsletter 172,14 April 2016 ec. 4. European Commission. The 2014 EU Summit on Chronic Diseases. Conference conclusions. Available from: docs/ev_20140403_mi_en.pdf

The following partners contributed to this report: Brigitte Domittner, Sabine Weissenhofer (Austria), Valentina Strammiello (Belgium), Anne-Marie Felton (FEND), Jaana Lindström, Ingvild Felling Meyer (Finland), Alain Brunot (France), Ulrike Rothe, Ulf Manuwald, Andrea Icks, Silke Kuske (Germany), Theodore Vontetsianos, Thodoris Katsaras (Greece), Marina Maggini, Angela Giusti, Bruno Caffari, Flavia Pricci, Marika Villa, Roberto D’Elia (Italy), Zydrune Visockiene (Lithuania), Monica Sørensen (Norway), José Manuel Boavida, Cristina Portugal, Joao Jose Malva, Rogerio Ribeiro (Portugal), Jelka Zaletel, Milivoj Piletič (Slovenia), Antonio Sarría Santamera, Maria del Mar Polo de Santos (Spain), Dimitri


5. Maggini M, Lombardo F, Caffari B, Giusti A, Icks A, Lindström J, et al, on behalf of the Joint Action on Chronic Diseases and Promoting Healthy Ageing Across the Life Cycle (JA-CHRODIS). Diabetes: a case study on strengthening health care for people with chronic diseases. Ann Ist Super Sanità 2015;51:1836. 6. JA-CHRODIS. Interim Report 4: Delphi panel in the area of diabetes. available from: com/file/d/0B8Xu4R_n0-nzT3R4RVRDSnZ1UGc/view 7. Lindström J, Wikstrom K, Maggini M, Icks A, Kuske S, Rothe U, et al, on behalf of the Joint Action on Chronic Diseases and Promoting Healthy Ageing Across the Life Cycle (JA-CHRODIS). Quality indicators for diabetes prevention programs in health-care targeted at people at high risk. Ann Ist Super Sanità 2015;51:187-91.

Varsamis (UK), Jan N. Kristensen, A. Piaggesi (EWMA), Peggy Maguire, and Vanessa Maria Moore (EIWH). We would like to thank: Enrique Bernal-Delgado, Paco Estupiñán-Romero, Maria J. Vicente-Edo, S. García-Armesto, F. SalcedoFernandez, JI Martin-Sánchez, M. ComendeiroMaalooe, and D. Bordonaba-Bosque (Aragon Health Science Institute, Spain), who conducted the Delphi on Diabetes,

8. Sørensen M, Korsmo-Haugen HK, Kuske S, Rothe U, Lindström J, Zaletel J, et al, on behalf of the Joint Action on Chronic Diseases and Promoting Healthy Ageing Across the Life Cycle (JA-CHRODIS). Health promotion interventions in type 2 diabetes. Ann Ist Super Sanità 2015;51:192-8. 9. Kuske S, Icks A, Zaletel J, Rothe U, Lindström J, Sørensen M, et al, on behalf of the Joint Action on Chronic Diseases and Promoting Healthy Ageing Across the Life Cycle (JA-CHRODIS). Education and health professionals training programs for people with type 2 diabetes: a review of quality criteria. Ann Ist Super Sanità 2015;51:199-205. 10. JA-CHRODIS. Recommendations to improve early detection, preventive interventions, and the quality of care for people with diabetes. Definition and agreement on a common minimum set of indicators.

Daval-Cichon, Ingvild Felling Meyer, Anne-Marie Felton, Filippo Graziani, Eva-Maria Kernstock, Jana Klavs, Silke Kuske, Tiina Laatikainen, Marie Laure Le Pommelec, Jaana Lindström, Peggy Maguire, Konstantinos Makrilakis, João Malva, Eduard Montanya Mias, Stefano Nervo, Alberto Piaggesi, Milivoj Piletič, Andrea Pizzini, Jan Schulze, Lurdes Serrabulho, Monica Sørensen, Manuel Teixeira Veríssimo, and Dimitri Varsamis.

... and the experts who participated in the Delphi panel: Cristian Andriciuc, Andreas Birkenfeld, Alain Brunot, Xavier Cos Claramunt, Roberto D’Elia, Agnieszka


EWMA Journal 

2018 vol 19 no 1

A perfect fit. Every time.

Biatain Silicone with its unique 3DFit Technology® conforms to the wound bed to fill the gap and reduces exudate pooling for optimal wound healing conditions.

Let´s make every day count The Coloplast logo is a registered trademark of Coloplast A/S. © 2018-03. All rights reserved Coloplast A/S, 3050 Humlebaek, Denmark. PM-03663

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Avelle and Hydrofiber are trade marks of ConvaTec Inc. ©2017 ConvaTec Inc. AP-017861-MM

* Based on the physical properties of Hydrofiber ® Technology as demonstrated in-vitro.1,2 1. Waring MJ, Parsons D. Physico-chemical characterisation of carboxymethylated spun cellulose fibres. Biomaterials. 2001;22:903-912. 2. Walker M, Hobot JA, Newman GR, Bowler PG. Scanning electron microscopic examination of bacterial immobilisation in a carboxymethylcellulose (AQUACEL®) and alginate dressings. Biomaterials. 2003;24(5):883-890.

Science, Practice and Education

Bioburden levels of spools of surgical tape in different healthcare settings

Victoria Yu (PharmD)1

Analyses show that the contamination levels of spools and snap rings of medical tape, which have frequent contact with healthcare providers, are a source of bioburden in the healthcare setting. INTRODUCTION Healthcare-associated infections (HCAI) remain a major cause of patient morbidity and mortality. In European countries, an average prevalence of 7.1% has been reported with approximately 4,544,100 episodes of HCAI every year.1 The impact of HCAI includes prolonged hospital stays, long-term disability, increased resistance of microorganisms to antimicrobials, massive financial burden for health systems, high costs for patients and their family, and unnecessary deaths.1 The burden of disease is also reflected in annual financial losses estimated at approximately 7 billion, including direct costs only.1 Contamination of inanimate surfaces has often been described as a source for outbreaks of nosocomial infections. Inanimate surfaces and objects, such as high-touch (or frequently touched) surfaces in the immediate vicinity of a patient, are often reservoirs for nosocomial pathogens and may play a role in the transmission of these pathogens2, especially for microorganisms that are able to survive on surfaces for long periods of time. Studies indicate that nosocomial pathogens can persist in the environment for several days to several months. For example, Staphylococcus aureus (including MRSA) can persist between 7 days and 7 months, providing a continuous source of transmission if regular preventative measures are not taken.6 Additionally, hand contact with contaminated surfaces results in different degrees of transmission depending on the organism. Escherichia coli, Salmonella spp., and Staphylococcus aureus have 100% transmission rates, while Candida albicans has a 90% transmission rate and rotavirus has a 16% transmission rate.6 Examples EWMA Journal 

2018 vol 19 no 1

Birgit Struensee2

of high-touch surfaces include doorknobs, bed rails, light switches, and surfaces in and around toilets in patients´ rooms2; however, often-overlooked high-touch surfaces include frequently used medical equipment items and objects, such as spools and snap rings of medical tape. Thus, a major addition to current infection control strategies is the identification of high-contact surfaces prone to contamination.7 Contamination may occur by transfer of microorganisms via healthcare workers’ hands or direct patient shedding of microorganisms in the immediate environment of a patient’s bed.2 A large percentage of HAI are preventable through effective infection prevention and control measures.5 As hands are the most common vehicle for transmission of organisms, “hand hygiene” is a core element of all infection prevention bundles; however, studies have shown that average compliance with hand hygiene practices is unacceptably low.3 In a sample of 40 hospitals in the United States, Larson and colleagues found that even after the implementation of new guideline recommendations, hand hygiene rates remained low at a mean of 56.6% compliance, and in 42.2% of the hospitals, there was no evidence of a multidisciplinary program to improve compliance.4,5 Additionally, antimicrobial surfaces can serve as a useful adjunct to effective infection control protocols by providing a surface that continuously reduces bioburden counts. In this study, we analysed the contamination levels of spools and snap rings of medical tape, as these

Thorben Nehrdich1

Verena Deing (Ph.D.)1 1BSN

medical GmbH, Hamburg, Germany 2MMC–Marketing

& Medical Competence, Hamburg, Germany

Correspondence and reprints: Victoria Yu BSN medical GmbH Quickbornstrasse 24 20253 Hamburg, Germany

Correspondence: Conflicts of interest: This evaluation was funded by BSN medical GmbH


Figure 1: Average (Ø) total bioburden of used and unused spools.

Ø 73 colonyforming units (cfu) Ø 156 colony-forming units (cfu)

Used spools (n=40) Unused spools (n=12)

objects have frequent contact with healthcare providers, and sought to define these objects as a source of bioburden in the healthcare setting. Secondly, we discuss the introduction of an antimicrobial surface for the spools and snap rings as a potential solution and useful adjunct to infection prevention protocols in medical settings. METHODS Fifty-two surgical tape spools, both used and unused (Table 1), from different manufacturers were collected from a total of six test centres throughout Hamburg, Germany for analysis. Spools from different manufacturers were collected to illustrate use of surgical tape under routine clinical conditions. Unused spools were taken directly out of the original packaging and tested. Used spools were collected after use and transported separately in a sterile bag to the laboratory. The test centres included two hospitals, two doctors´ offices, one outpatient clinic, and one blood transfusion clinic. Testing of the bioburden of all surfaces was performed in accord with ISO 11737-1/ SGS SOP M 943*. Using aseptic techniques to minimize risk of secondary contamination, the collected spools were rinsed with 100 ml of a rinsing liquid for 10 min on a shaking platform. The liquid was then divided and analysed as follows: n 30 ml for total aerobic colony count by membrane filtration; n 30

ml for yeasts and moulds by membrane filtration;

n 10 ml for S. aureus, E. coli, P. aeurginosa, and enterococci by enrichment methods; and n 10


ml for C. albicans by an enrichment method.

After isolation of specific microorganisms, the total bioburden (colony-forming units cfu/mL) was measured. The bioburden of a product was determined in order to assess the number of viable microorganisms present on the device as an indicator of the hygienic standard in a clinical setting. Manufacturers must ensure a low bioburden in finished products through the implementation of the current guidelines of Good Manufacturing Practice during the manufacture, storage, and distribution of pharmaceutical preparations.13 Thus, unused spools served as the control in this experiment and to provide a baseline for comparison of used spools. A bioburden threshold of 50 cfu/g (or mL) was set for used spools according to the suggested threshold for assessment of surface hygiene of 5 cfu/cm2, proposed as a microbiologic standard for safer hospital environments8, and using an average surface area of 10 cm2 for the spools.12 In support of this threshold, Dancer8 suggested that identification of ≥ 5cfu/cm2 on a high-contact surface indicates the potential for increased risk of infection for the patient in that environment. RESULTS The number of cfu per spool differed between the six test centres. However, in general, used spools had a higher bacterial load than unused spools with an average of 156 cfu per used spool (n=40) and an average of 73 cfu per unused spool (n=12; Fig. 1). The numbers of contaminated spools from each test centre and the identified microorganisms are presented in Table 3. However, as growth of contaminants is dependent on the growth media selected (Table 2), microorganisms other than those presented in Table 3 may have been present on the spool. The highest bioburden was found in the hospital (site A) with 853 cfu and an average of 353 cfu for used spools, respectively. The second highest bioburden was found at the doctor’s office (site B) with the highest values at 643 cfu and an average of 256 cfu for used spools, respectively. Only one of six test centres (17%), transfusion clinic (site F), had contamination levels below the threshold value of 50 cfu per spool (Fig. 2). As far as the prevalence of contamination, in the hospital setting, 2 of 4 used spools (site A) and 1 of 8 used spools (site E) were identified with potential pathogens on the surface. In the doctor´s office, 1 of 4 used spools (site B) harboured pathogens; whereas, 1 of 8 used spools (site C) in the outpatient clinic and 3 of 8 used spools in the blood transfusion clinic (site F) were found to have isolated microorganisms on the surface. Amongst the microorganisms isolated from the spools, hospital pathogens such as Staphylococcus aureus, Staphylococcus epidermidis, and Enterococcus gallinarium were identified. These are amongst the most commonly reported pathogens that EWMA Journal 

2018 vol 19 no 1

Science, Practice and Education

Figure 2: Average bioburden found on spools from each study site.

Average bioburden (cfu per spool)

400 350

Used spools 300

Unused spools

300 256

250 200









50 0

0 Hospital (A)

Doctor’s Office (B)

Outpatient Clinic

cause nosocomial infections. These results suggest that spools may be a potential source of health care-associated infections in daily practice and support the need to generate antimicrobial surfaces to reduce the risk of pathogen transmission and distribution in these settings. DISCUSSION Infections, some of which may lead to serious complications, of patients in healthcare facilities are usually transmitted via high-touch surfaces of supplies or equipment that are contaminated by microorganisms (nosocomial infections). Current efforts to generate surfaces that reduce or inhibit the ability of microorganisms to grow are met by product limitations and perceived risks.9 Accordingly, an antimicrobial material surface that can reduce or inhibit microorganism growth without the associated risks is warranted. As evident from this study, spools of medical tape are an easy to contaminate surface that is a potential source of pathogen transmission. This is especially true in the hospital setting, where the cfu per spool was found to be the highest. Importantly, this study represents only a snapshot


Doctor’s Office (D)


Hospital (E)


Transfusion Medicine

of the everyday reality in clinical settings, suggesting the potential for several limitations. For one, causal relationships are hard to establish. The study did not specifically examine the correlation between the spools and infection occurrence in the healthcare institutions. Thus, this point may be addressed in future studies. Further limitations include a small sample size and as the study aimed to show the use of spools under diverse clinical settings; the frequency of usage, exposure to pathogens and infection prevention protocols may be different across the institutions. The results of this study highlighted the need for a material surface to aid in the reduction of pathogen transmission and distribution. The surface of the spools and snap rings of medical tapes have been modified to incorporate a special metal oxide into the polymer, as part of the packaging. The presence of the metal oxide and water from the air results in the generation of H3O+ ions, reducing the pH value of the spools’ surface to approximately 4-5 (Fig. 3). This pH value lies within the range of that of the human skin (pH 4-6).11 Such acidic surfaces are known to slow down bacterial and fungal growth and effectively kill mi

Figure 3: Effect of a reduction in pH levels on active antimicrobial properties. Humidity H20


Antimicrobial component H30+ ions

Material surface The antimicrobial component incorporated into the spool material reacts with the atmospheric moisture on the surface.

EWMA Journal 

2018 vol 19 no 1

Material surface An acidic environment is formed, in which pathogens such as MRSA are destroyed.


croorganisms at pH values of 3.5-4. This mechanism is fairly non-specific and active against a broad spectrum of Gram-positive and -negative bacteria.9 Organisms such as Staphylococci, Streptococci, Enterococci, Legionella pneumophila, Lactobacillus acidophilus spp., Candida spp., and Aspergillus spp. are susceptible to these effects at low pH. The antimicrobial activity of these polymers is based on the formation of the acidic surface that ultimately impairs cell growth and proliferation of microbes and the formation of biofilms that lead to the elimination of infectious agents. Thus, in contrast to disinfectants and antibiotics, microbial resistance to a metalloacid material with this mode of action is unlikely to emerge,9,10,11 supporting its effectiveness in infection control. According to ISO 22196, initial in vitro testing with the antimicrobial spools (BSN medical GmbH, Hamburg Germany) showed very high efficacy against S. aureus (MRSA) and S. epidermis and good efficacy against E. coli. In particular, the tested samples showed a bacterial pathogen reduction within 3 h with a reduction of more Table 1: Total number of spools. Spools

Total (n = 52)

Used, n


Unused, n


Hospital (Site A), n


Doctor´s office (Site B), n


Outpatient´s clinic (Site C), n


Doctor´s office (Site D), n


Hospital (Site E), n


Transfusion medicine (Site F), n


Study Site

than 99.9% (>log 3) of S. aureus (MRSA) within 6 h. Additionally, antifungal tests showed efficacy of the material within 3h against Candida tropicalis, Candida glabrata, and within 6h against Candida albicans. Depending on the institution setting and volume of patients, the medical tape on the spools can be used up in 1 day or last for 3 weeks, thus the antimicrobial spools are most beneficial to limit environmental contamination between consecutive cleaning procedures. It is also worth mentioning that basic standards in infection prevention should be the core of infection prevention protocols; however, in certain situations, such as in patients with a weak immune system, the proposed spool may certainly serve as a useful adjunct to the normal protocol. Based on the results of these promising in vitro tests, the continuous biocidal effect of H3O+ oxides against potentially pathogenic microorganisms (including multidrug-resistant microorganisms) is a valuable addition to infection prevention protocols.11 CONCLUSION Prevention of cross-transmission of nosocomial pathogens, such as S. aureus and P. aeruginosa, is of particular interest to healthcare institutions where the transfer of these pathogens may lead to serious complications in patients with weak immune systems. The modification of spools of medical tape with antimicrobial properties has the potential to reduce the overall risk of bioburden and contamination in clinical use, thus decreasing the sources of cross-transmission. Future investigations may focus on the use of the antimicrobial spools and its role in the prevention of the transmission of nosocomial pathogens in comparison with non-antimicrobial spools commonly used in the clinical setting. m

Table 2: Methods used for each parameter. Parameter


Total aerobic colony count (Bioburden)

DIN EN ISO 11737-1/ TSA / 3-7d/30-35°C

Yeast (Bioburden)

DIN EN ISO 11737-1/ Sabo / 5-7d/20-25°C

Mold (Bioburden)

DIN EN ISO 11737-1/ Sabo / 5-7d/20-25°C

E. coli (Bioburden)

SGS SOP M 943 / McConkey-Agar / 48h/44°C

Staphylococcus aureus (Bioburden)

SGS SOP M 943 / BP / 48h/37°C

Pseudomonas aeruginosa (Bioburden)

SGS SOP M 943 / Cetrimid / 48h/37°C

Enterokokken (Bioburden)

SGS SOP M 943 / Enterococcosel-Agar / 48h/37°C

Candida albicans (Bioburden)

SGS SOP M 943 / Candid-Chromogen-Agar / 48h/30-35°C


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Table 3: Number of contaminated spools and identified pathogens for each test centre. Centre (No. of Spools)

Contaminated spools

Identified microorganism

A: Hospital (n=6)

2 (2/4 used spools)

Enterococcus gallinarium

Staphylococcus aureus

Bacteria spores

Bacillus infantis

Bacillus pumilus

B: Doctor´s Office (n=7)

Paracoccus yeei

1 (1/4 used spools)

Bacillus infantis

Kocuria rhizophila

Micrococcus luteus

Bacillus simplex

C: Outpatient Clinic (n=8)

Staphylococcus epidermis

1 (1/8 used spools)

Micrococcus luteus

Corynebacerium sp.

Staphylococcus capitis

D: Doctor´s Office (n=10)

Staphylococcus aureus

1 (1/7 used spools)

Micrococcus luteus

E: Hospital (n=10)

Staphylococcus hominis

1 (1/8 used spools)

Alcaligenes faecalis

Arthrobacter cumminsii

F: Transfusion Medicine (n=11)

Staphylococcus pasteuri

3 (3/8 used spools)

Staphylococcus warneri

Cellulosmicrobium cellulans

Micrococcus luteus

Staphylococcus aureus

Staphylococcus warneri

REFERENCES 1. World Health Organization; Infection Prevention and Control. The burden of health care-associated infection worldwide, a summary. Geneva(Switzerland): World Health Organization; 2011. 2. Huslage K, Rutala WA, Sickbert-Bennett E, Weber DJ. A Quantitative Approach to Defining “High-Touch” Surfaces in Hospitals. Infection Control & Hospital Epidemiology. Cambridge University Press; 2010;31(8):850–3. 3. Pittet D. Improving adherence to hand hygiene practice: a multidisciplinary approach. Emerging Infectious Diseases.2001;7(2):234-240. 4. Larson EL, Quiros D, Lin SX. Dissemination of the CDC’s Hand Hygiene Guideline and impact on infection rates. American Journal of Infection Control. 2007;35(10):666-675.

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5. World Health Organization; Infection Prevention and Control. WHO guidelines on hand hygiene in health care. Geneva(Switzerland): World Health Organization; 2009.

9. Zollfrank C, et al. Antimicrobial activity of transition metal acid MoO3 prevents microbial growth on material surfaces. Materials Science and Engineering. 2012;32(1):47-54.

6. Kramer A, Schwebke I, Kampf G. How long do nosocomial pathogens persist on inanimate surfaces? A systematic review. BMC Infectious Diseases. 2006;6(130)

10. Ali SM, Yosipovitch G. Skin pH: From Basic Science to Basic Skin Care. Acta Derm Venereol. 2013; 93: 261–267

7. Russotto V, Cortegiani A, Raineri SM, Giarratano A. Bacterial contamination of inanimate surfaces and equipment in the intensive care unit. Journal of Intensive Care. 2015; 3:54. 8. Dancer SJ. How do we assess hospital cleaning? A proposal for microbiological standards for surface hygiene in hospitals. Journal of Hospital Infection. 2004; 56:10-12.

11. Tétault N, Gbaguidi-Haore H, Bertrand X, Quentin R, Mee-Marquet N. Biocidal activity of metalloacidcoated surfaces against multidrug-resistant microorganisms. Antimicrobial Resistance and Infection Control. 2012; 1(35) 12. BSN medical GmbH. Delivery specifications Leukoplast. 2017 13. Council of Europe. European Pharmacopoeia 8.0 Capt. 5.1.4 acc. table 5.1.4.-1. Strasbourg: Council of Europe; 2014.


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HydroTherapy Efficacy. And Simplicity. [1] Atkin, L. and Ousey, K. (2016). Wound bed preparation: A novel approach using HydroTherapy. British Journal of Community Nursing 21 (Supplt. 12), pp. S23-S28. [2] Ousey, K. et al. (2016). Hydro-Responsive Wound Dressings simplify T.I.M.E. wound management framework. British Journal of Community Nursing 21 (Supplt. 12), pp. S39-S49. [3] Spruce, P. et al. (2016). Introducing HydroClean® plus for wound-bed preparation: a case series. Wounds International 7(1), pp. 26-32. [4] Ousey, K. et al. (2016). HydroClean® plus: a new perspective to wound cleansing and debridement. Wounds UK 12(1), pp. 94-104. [5] Ousey, K. et al. (2016). HydroTherapy Made Easy. Wounds UK 12(4).

Science, Practice and Education

Specific risk factors for pressure ulcer development in adult critical care patients - a retrospective cohort study

Maarit Ahtiala1

Patients in intensive care units have a high risk for developing pressure ulcers (PUs). This study assesses the overall risk for the development of PUs in a large cohort of adult intensive care patients.

Esa Soppi2

ABSTRACT A modified Jackson/Cubbin (mJ/C) scale was used to assess the overall risk for the development pressure ulcers (PUs) in a large cohort of adult intensive care patients (N = 3,196). We retrospectively analysed the roles of the type of patient, sedation status, length of stay (LOS), and haemoglobin level as indicators, along with the mJ/C scale for the development of PUs. The incidence of PUs at our hospital in 2010–2011 was 8.7%, and 77.4% of the patients with PUs had a LOS of ≥3 days and developed significantly more PUs than patients treated for a shorter period. Significantly more patients with a LOS of ≥3 days were sedated. Longer LOS and low mJ/C scores indicated higher PU risk; sedation seems not to be a risk indicator for PU development. Haemoglobin levels of <100 g/l at admission may predispose patients in intensive care to PU development, even when the LOS was ≥3 days.

INTRODUCTION Patients in intensive care units (ICUs) are severely ill and their ability to move is limited. They may have difficulties in expressing pressure-induced discomfort, pain, and the need to change positions. As a result, these patients have a high risk for developing pressure ulcers (PUs). The prevalence of PUs in ICUs ranges from 5 to 30%, and the trend has been decreasing during the last two decades.1-8,9 PUs induce a considerable risk of complications, and the care and management of PUs carry high costs and workloads.10,11 PUs are multifactorial in origin, with more than 100 different risk factors highlighted recently for their development.8,9,12-14 Of these, risk factors inEWMA Journal 

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volving mobility (49 items), nutrition (37 items), incontinence (35 items), activity (32 items), skin condition (25 items), and mental state/sensory perception (23 items) appear in more than 20 different scales. Many of these risk factors derive from common pathophysiological bases, with mobility, activity, and mental state/sensory perception in particular having overlapping interpretations in various risk scales. These risk factors are often confused with states of consciousness and/or sedation, as in the Braden scale15 and the Jackson/ Cubbin (J/C) risk scale.16,17 For example sedation produces immobility, which is a well-known and important risk factor for PUs.10,11,13,14 There are also indications that the length of stay (LOS)8,18,19 and anaemia13-15,18,20 may influence the risk for PUs, but the data are not consistent3 and it is not clear if they pertain to populations with a low PU incidence, such as in the current population of intensive and high dependency care (HDC) patients. Further studies using large cohorts of consecutive ICU and HDC patients will help to elucidate this. To assess PU risk in ICU patients, Cubbin and Jackson created the J/C risk scale in 199117 and later revised it in 1999.16 The J/C scale contains 12 main and 3 minor risk categories relevant to risk assessment in intensive care.16,21 A modified J/C (mJ/C) scale was implemented in 2010, when a research program began investigating PU risk factors in ICUs to reduce the PU incidence.21. It is considered a viable option for PU risk assessment in intensive care, but requires more analysis 

Minna Tallgren1 1Service

Division, Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, FI-20520 Turku, Finland 2Eira

Hospital, FI-00150 Helsinki, Finland Corresponding author: Maarit Ahtiala, Service Division, Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, FI-20520 Turku, Finland.

Correspondence: Conflicts of interest: Esa Soppi was the chairman of board of Carital group that globally manufactures and markets mattresses for PU prevention and treatment. He has never had any ownership.


and testing.5,18,22,23 Indeed, we previously showed that the J/C risk scale does not provide an optimal PU risk assessment in an ICU setting.21,24 In the present study, we retrospectively investigated a cohort of >3,000 adult patients treated in a large mixed ICU to identify the pathophysiological factors likely related to PU development that are not included in the J/C risk scale.16,21 such as patient type, LOS in the ICU, sedation, and haemoglobin (Hb) concentration. METHODS Hospital unit The Turku University Hospital serves as a tertiary referral hospital for approximately 700,000 individuals. The adult ICU, staffed by 160 nurses, had 24 beds and serves as a national centre for hyperbaric oxygen therapy. Patients with major burns and organ transplantation are treated elsewhere. Both surgical and medical patients needing intensive care or HDC (i.e., as a step-down unit) are treated. On admission, patients are classified as ICU or HDC patients by the treating physician on the basis of their treatment needs. He/she determines the main admission and other diagnoses and is responsible for the input of their data into the electronic ICU database. The nurses provided with special training, which includes the deployment of the mJ/C risk scale as well as wound identification and care, assist with these definitions. Patient care In the mixed ICU, one registered nurse is responsible for one or two patients per shift. The care regarding PU prevention is in accordance with general guidelines.10 The patients are washed twice a day and their skin is inspected during every turn or position change, if their condition allows. The patients’ positions are changed approximately every 2 h, if there are no contraindications. Patients with a high or extremely high risk for PUs (mJ/C score, ≤2916,21,24) are transferred to an appropriate protective mattress if they are not on one already, and positioning therapy is intensified as their condition allows. The standard care of patients includes the use of urine catheters, and a catheter is also used in cases of diarrhoeal faeces. Both of

these procedures diminish the exposure of the skin of the patients to moisture and are documented in the database by the registered nurse. mJ/C PU risk scale The mJ/C scale was introduced to increase the reproducibility of the scale in clinical use21,24 and includes modifications to categories of weight/tissue viability, respiration, and incontinence as well to the deduction points. The scale consists of 12 main categories graded from 1 (high risk) to 4 (low risk) to describe certain variables of the clinical situation of ICU patients. The minimum score is 9 and the maximum score is 48, with a lower score indicating a higher risk for PUs.23 The first PU risk assessment is made when the patient is admitted to the ICU, and assessments are made daily by the registered nurse thereafter. An electronic version of the mJ/C scale was introduced in the clinical database (Clinisoft; GE Healthcare) for use by the ICU staff after appropriate training. Study design This is a retrospective cohort study using data retrieved from the ICU database by the database administrator. The study plan was approved by the ethics committee of the hospital district of southwest Finland (T25/2011, 14.06.2011 §172). All adult (≥ 18 years of age) patients admitted to the ICU in 2010 and 2011 were included in the study (Table 1). The average LOS in the ICU was 3.6 days, and 30.2% of patients had a LOS of ≥3 days. The mean age of the patients was 60.5 years, and 62.7% were male patients (Table 1). The PUs included stage I–IV and unstageable ulcers according to National Pressure Ulcer Advisory Panel and European Pressure Ulcer Advisory Panel guidelines.10 Patients who had a PU on admission or for whom data in the patient classification were not available were excluded from the study. The inclusion of patients and data collection are shown in Figure 1. The primary endpoint was the development of PUs during the ICU stay. The primary variable was the mJ/C score. The secondary variables were the LOS in the ICU, patient type (i.e., medical or surgical and ICU or HDC patients), sedation status, and Hb concentration.

Table 1: Description of patient cohorts of the study. Patients Year N % male Age (yrs [range]) N*

PU* Prevalence Incidence (% [N]) (% [N])




60.5 (18–93)


11.8 (192)




60.4 (18–91)





60.5 (18–93)


SOFA score (mean [SD])

Apache II score (mean [SD])

11.1 (181)†

6.9 (3.2)

18.3 (7.2)

9.6 (156)

6.2 (101)†

6.8 (3.2)

17.9 (7.1)

10.7 (348)

8.6 (282)

6.9 (3.2)

18.2 (7.1)

SOFA, Sequential Organ Failure Assessment31 score of the first day; Apache, Acute Physiology and Chronic Health Evaluation II (32) score of the first day; SD, standard deviation. *Excluding patients with PUs present on admission (see Figure 1). †p < 0.001 by χ2 test.


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Flow chart

Data on mJ/C score (N=9) not available

Data on Hb (N=5) not available

Total N=3262 Table 1

N=3196 Table 4

N=3191 Table 5

PUs present-on-admission (N=66) excluded

N=3110 Table 2

N=3101 Table 3

Information about medical/surgical (N=81) division not available

Figure 1: Flow chart indicating the order of analysis to maximize the number of patients. The data on missing values are presented.

Data collection and analysis The mJ/C scores, LOS, sedation status, and Hb concentrations were collected retrospectively. For analysis, the LOS was graded as 1 (LOS ≥3 days) or 4 (LOS <3 days), as this cutoff was previously suggested to define high and low risk patients (18,19), respectively. Hb concentration was graded as 1 (Hb <100 g/l) or 4 (Hb ≥100 g/l). Sedation status was graded as 1 (sedated) or 4 (not sedated). If any of the data points were not available for a given patient, the patient was excluded pre hoc from further analysis. The results were tabulated on the basis of the patient type, LOS, sedation status, mJ/C score, and Hb concentration. As a measure of risk, mJ/C scores were compared via receiver operating characteristic (ROC) curves in combination with the above variables to examine their additive value. Statistical methods The Wald χ2 test was used to test statistical significance

between the distributions of different patient groups. The differences between the ROC curves were compared as described by DeLong et al.26 The analyses were performed with SAS version 9.4. Multivariate analysis was not carried out since it has been calculated that more patients are needed to perform more extensive analysis of the risk factors than included in this study. RESULTS Of the patient cohort, 74.1% were ICU patients and 25.9% were HDC patients, and 73.2% were surgical and 26.8% were medical patients (Table 2). On the basis of the main admission diagnoses, there were four main groups of patients, namely, those with (i) central nervous disturbances (15%; ICD10: A80-A89, C69-C72, G00-G09, I60-I69, S00-S09), (ii) ischemic heart diseases (15%; ICD10: I20-I25, I10-I15), (iii) heart diseases (14%; ICD10: I00-I99, excluding I10-I15, I20-I25, I46, and I60-I69), and (iv) miscellaneous diagnoses (20%). The detailed information is presented elsewhere.25 

Table 2: Association between the length of stay at ICU and risk of PU development. Medical Surgical PU (N [%]) Patients ICU LOS N N (days) Yes No

PU (N [%]) Total Yes No (N)


< 3


20 (3.2)



20 (1.2)





82 (22.4)*



106 (21.4)*





102 (12.0)



126 (6.6)






4 (3.0)



8 (1.0)





15 (27.3)*



27 (16.0)*





19 (12.7)



35 (4.4)











The table includes the patients (N = 3,110) for whom the classification to medical or surgical groups and the LOS were available. *In all subgroups, significantly more PUs developed in the patients whose length of stay was ≥3 days; p < 0.001 by χ2 test. EWMA Journal 

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There was a significant decrease in the PU incidence from year 2010 to year 2011 (p < 0.001 by χ2 test; Table 1). Of the PUs, 72.1% (n = 203) were stage I and II PUs, which was not different between the two years. Three of four ulcers were on the sacrum, buttocks, or heels. The PU incidence was 2.4% (52/2,171) when the LOS was <3 days and 24.5% (230/939) when the LOS was ≥3 days (p < 0.001 by χ2 test; Table 2). The longer the LOS, the more PUs that developed in each subgroup of patients (p < 0.001) (Table 2).

The influence of Hb concentration and LOS on PU development was further examined (Table 5). There was an inverse association between the development of PUs and low Hb concentrations at admission (p < 0.001). The PU incidence was especially high (10.6%) among patients with an Hb concentration of <100 g/l. The results were the same when the lowest Hb concentration on the third ICU day was used (data not shown). Thus, a low Hb concentration and a long LOS (≥3 day) seem to be additive risk factors for PU development.

Overall, 47.8% of patients had a high PU risk (mJ/C score, ≤29), and 59.6% of PU patients had a high risk of PU (mJ/C score, ≤29) (p < 0.001). In total, 69% of patients were sedated, of which 11.4% (245/2,147) had PUs; 3.8% of the non-sedated population had PUs (p < 0.001 by χ2 test; Table 3). In the sedated population, 33.9% of patients had a low PU risk (mJ/C score, ≥30), whereas 92.3% of the non-sedated population had a low risk (p < 0.001 by χ2 test).

DISCUSSION The decrease in PU incidence in 2011 from that in 2010 may reflect an improvement in documentation due to continued training, where existing PUs may have been more correctly documented at admission in 2011 than in 2010. Indeed, formalized training on risk assessment was initiated in 2010, and a continued emphasis on the human and economic burdens of PUs as well as on a focused approach to managing patients at risk for PUs would be expected to reduce the incidence figures. There was no change in the patient populations on the basis of the admission ICD10 diagnosis. The stage and location of the PUs were the same as generally detected in ICUs.8,21 There was also a trend towards more PUs in medical patients than in surgical patients in accordance with previous studies.21,26 which may be related to the presence of a higher number of disorders, which is not reflected in the initial mJ/C risk scale.16 However, among the mechanically ventilated patients, surgical patients may develop more PUs.9,19

In addition, 58.5% of the patients with a LOS of <3 days in the ICU were sedated, whereas 90.5% of those with a longer LOS were sedated (p < 0.001 by χ2 test). Among the patients with PUs, 59.6% with a LOS of <3 days were sedated and 89.2% with a longer stay were sedated (p < 0.001 by χ2 test; data not shown). The numbers of patients with and without PUs according to the LOS are shown in Table 4. Patients with PUs had a significantly longer LOS, and the duration of their sedation was longer than those without PUs (p < 0.001). The relationships between the mJ/C risk score and the variables were analysed in ROC analyses by adding the LOS, sedation status, or Hb concentration score to the mJ/C score (Figure 2). The area under the curve (AUC) for the mJ/C scores is 0.60 (Figure 2A); the AUC was not changed when the mJ/C score was combined with that for the sedation status (Figure 2B). However, the incorporation of the LOS score significantly improved the performance of the mJ/C scale (AUC, 0.67 vs. 0.60; p < 0.001; Figure 2C); the AUC was 0.66 when the mJ/C score was combined with LOS and sedation status scores (Figure 2D), indicating that sedation status has no additive value as a risk factor on the top of the mJ/C score or LOS. Similarly, the addition of the Hb concentration score improved the performance of the mJ/C scale (from 0.60 to 0.62; p < 0.001; Figure 2E), which was further increased by inclusion of the LOS score (AUC, 0.68; p = 0.0242) (Figure 2F). The displacements of ROC curves indicate that the knowledge of Hb concentration or LOS improves the true-positive rate and reduces the false-positive rate by ~20–30% (Figure 2A, C, E, F) around the mJ/C cutoff score of 29 (mJ/C scores, 26–34). 38

More severely ill patients tend to stay longer in the ICU, 1,9,18,19 and immobility is a major risk for PUs. Our data corroborate this, as patients treated for ≥3 days together with the low mJ/C scores ≤29 had more PUs than patients treated for <3 days. Indeed, those in critical care for a longer time would be expected to have a greater number of events, as the exposure period is longer. We also found that the LOS score improved the performance of the mJ/C for risk assessment. Although it is difficult to predict the LOS in the ICU, as the patients’ conditions are highly dynamic and the treatment decisions are in accordance with the condition of each patient, an estimation of the 

Figure 2: ROC curve analyses. AUCs for mJ/C score only (A) and in combination with scores for sedation status (p = 0.473 vs. A) (B) LOS (p < 0.001 vs. A) (C), LOS plus sedations status (p = 0.774 vs. C) (D), Hb concentration (p < 0.001 vs. A) (E), and LOS and Hb concentration (p = 0.0242 vs. E) (F). EWMA Journal 

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1.0 38












True positive rate

True positive rate

30 0.6 0.5





0.5 0.4


26 0.3








AUC = 0.60





AUC = 0.60


0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

False positive rate

False positive rate



0.0 34

0.8 0.7





0.5 0.4






0.5 30

0.4 0.3


0.2 0.1



True positive rate

True positive rate







AUC = 0.67


28 26



AUC = 0.60


0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

False positive rate

False positive rate







38 0.8


0.7 32


True positive rate

True positive rate



0.5 0.4 28 0.3


0.6 32 0.5 30

0.4 0.3 28




0.1 22 0.0



AUC = 0.62


0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 False positive rate EWMA Journalâ&#x20AC;&#x201A;

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AUC = 0.68

0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 False positive rate


Table 3: Incidence of PUs with regard to mJ/C score and sedation status Patients


mJ/C score, ≤29

mJ/C score, ≥30

165/1,419 (11.6)

80/728 (11.0)

3/74 (4.1)

34/890 (3.8)

Not sedated Total

No. of PU patients/total (%)

168/1,483 (11.3)*

114/1,618 (7.0)*

The table includes the patients whose first day mJ/C scores were available (N = 3,101). *p < 0.001 by χ2 test. The distributions of patients with or without PUs both in the sedated and nonsedated populations were similar between groups with mJ/C score ≤29 or ≥30 (p > 0.05 by χ2 test).

Table 4: Duration of sedation and incidence of PUs during ICU stay Duration of sedation (days)

PUs during ICU

Total (N)

New (N [%])*

None (N)


56 (2.9)




50 (7.1)




176 (30)




282 (8.8)



The table includes all patients. *PU incidence increased with the increasing duration of sedation, p < 0.001 by χ2 test.

Table 5: LOS, Hb concentrations, and the incidence of PUs LOS (days)

PUs (N [%])

Total (N)

Hb (g/l)





4 (3.0)




22 (2.6)




19 (2.2)




7 (1.7)




52 (2.3)




17 (24,3)




108 (30.3)




69 (19.0)




31 (20.9)




225 (24.0)



277 (8.7)





The table includes the all patients from whom the information was available; p = 0.6754 for LOS <3 days and p = 0.0034 for LOS ≥3 days (χ2 test).

LOS can provide the medical and nursing staff with a tool in addition to the mJ/C score to assess clinically the PU risk at admission and daily thereafter. Positioning therapy in the ICU is always carried out when possible, which together with appropriate support surfaces, decreases the influence of sedation-caused immobility. 40

This is particularly important, as we observed a higher incidence of PUs with longer durations of sedation. In our cohort, nearly half (47.8%) of the patients had a high risk for PUs (mJ/C score, ≤29), and 95.7% of these patients were sedated, supporting the notion that sedation is a risk factor for PU.23 Nevertheless, the mJ/C score and LOS were the most decisive prognosticators, not sedation, as EWMA Journal 

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shown in Figure 2. This observation may help to explain the finding of Nijs et al.3 that sedated patients had a lower risk of PUs. We also found that low Hb concentrations were associated with the occurrence of PUs. This result contradicts Nijs et al.3, who reported that patients with anaemia had a decreased risk for PUs. However, Bly et al.8 reported that PU patients have lower Hb concentrations than those without PUs, though the mean Hb concentrations in both groups were under 100 g/l. Our findings are also in accordance with previous reports20,23 that showed an inverse association between Hb concentration and the occurrence of PUs, despite the fact that the patients in our report were more severely ill than the patients in the previous studies. One point is deducted from the J/C risk scale (increasing the risk) if the patient required blood or clotting factors within 24 h before assessment.16,21,24 On the basis of the current data, the assessment of the blood Hb concentrations at admission may more accurately predict the PU risk than the need for transfusion, as transfusion practices vary from one centre to another. A low Hb concentration impairs the transport of oxygen to tissues, making them vulnerable to injury,8,23,24 and anaemia in surgical patients is associated with increased mortality, independent of the administration of blood products.28,29 Whether these are related to the development of PUs in anaemic patients is not known. In the present study, anaemia even on the third ICU day was associated with the development of PUs, which raises the question as to whether the transfusion or correction of iron deficiency strategies are too strict. A timely transfusion of red blood cells to correct anaemic conditions reduces hospital mortality.13,28,29 It is interesting that both Hb and LOS were found to improve the performance of the mJ/C score as a PU risk indicator.

long LOS in the ICU and low Hb concentration are major risk factors for PU development for most patients. Specifically, anaemia contributes to the development of PUs even when a LOS of ≥3 days is taken into consideration. However, sedation, which is included in the assessments of the mental subcategory of the J/C scale and other scales, does not seem be a risk factor for PUs among ICU patients. Implications for Clinical Practice and Further Research When using PU risk scales, it is necessary to critically assess what their subcategories really measure and if some definitions are overlapping or superfluous. A low Hb concentration (<100 g/l) and long LOS (≥3 days) are risk factors that are not included in the commonly used risk scales. Even though it is difficult to predict the LOS, this information can improve the clinical judgement of the nursing and medical staff at admission and help them forecast the PU risk of critically ill patients. These results encourage us to further evaluate the potential PU risk prognosticators in the search for a simpler and more reliable risk scale for critically ill patients. Acknowledgements Funding: The study was supported by grants from the Service Division, Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital, and from the Turku University Hospital Foundation (to M.A.). Riku Kivimäki, MSc in statistics, provided invaluable contributions for the data management and analysis of the study. The language of the article was reviewed by Robert Paul, MD PhD, certified translator. 

A limitation of this study is that it was retrospective in nature. However, it did include a large number of patients. Additionally, the exclusion of patients with missing data (rather than imputation), even if their number is small, can be a minor source of bias. We also cannot confirm that preventive measures were always carried out, which may have influenced the development of PUs. In particular, we do not know how the postural changes were carried out or the percentage of pre-established postural changes that were missed due to clinical reasons, such as haemodynamic or spinal column instability or severe brain injury. CONCLUSIONS Although not all important risk prognosticators are included in the J/C risk scale, it is still a useful tool for PU risk assessment and predicts future PU development for the first 3–4 ICU days30 very well. This study shows that a EWMA Journal 

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14. García-Fernández FP, Soldevilla Agreda JJ, Verdú J, Pancorbo-Hidalgo PL. A new theoretical model for the development of pressure ulcers and other dependence-related lesions. J Nurs Scholarsh 2014 Jan; 46(1):28–38. 15. Bergstrom N, Braden BJ, Laguzza A, Holman V. The Braden scale for predicting pressure sore risk. Nursing Research 1987 Jul-Aug; 36(4):205–10. 16. Jackson C. The revised Jackson/Cubbin pressure area risk calculator. Intensive and Critical Care Nursing 1999 Jun; 15(3):169-75. 17. Cubbin B, Jackson C. Trial of a pressure area risk calculator for intensive therapy patients. Intensive Care Nurs 1991 Mar;7(1):40–44. 18. Theaker C, Mannan M, Ives N, Soni N. Risk factors for pressure sores in the critically ill. Anaesthesia 2000 Mar; 55(3):221-4. 19. Manzano F, Navarro MJ, Roldán D, Moral MA, Leyva I, Guerrero C, Sanchez MA, Colmenero M, Fernández-Mondejar E & Granada UPP Group. Pressure ulcer incidence and risk factors in ventilated intensive care patients. J Critical Care 2010 Sep; 25(3):469– 76. 20. Nixon J, Nelson EA, Cranny G, Iglesias CP, Hawkins K, Cullum NA, Phillips A, Spilsbury K, Torgerson DJ, Mason S on behalf of the PRESSURE Trial Group. Pressure relieving support surfaces: a randomised evaluation. Health Technol Assess 2006 Jul; 10(22):1-179. 21. Ahtiala M, Soppi E, Wiksten A, Koskela H, Grönlund J. Occurrence of pressure ulcers and their risk factors in mixed medical-surgical ICU – A cohort study. Journal of Intensive Care Society 2014 Oct; 15(4):2-4. 22. Seongsook J, Ihnsook J, Younghee L. Validity of pressure ulcer risk assessment scales; Cubbin and Jackson, Braden, and Douglas scale. Int J Nursing Studies 2004 Feb; 41(2):199–204.

24. Ahtiala M, Soppi E, Kivimäki R. Critical evaluation of the Jackson/Cubbin pressure ulcer risk scale – A secondary analysis of a retrospective cohort study population of intensive care patients. Ostomy Wound Manage 2016 Feb; 62(2):24-33. 25. Ahtiala M, Kivimäki R, Soppi E. Characteristics of ICU patients with pressure ulcers present on admission, acquired IN ICU or no ulceration: a retrospective cohort study. Wounds Int 2018 March; 9(1):10-16. 26. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: A nonparametric approach. Biometrics 1988 Sep; 44(3):837– 45. 27. Bergquist-Beringer S, Gajewski BJ, Davidson J. Pressure ulcer prevalence and incidence: Report from the National Database of Nursing Indicators® (NDNDQI®) with the National Pressure Ulcer Advisory Panel (NPUAP). In Pieper B, editor. Pressure Ulcers: Prevalence, incidence, and implications for the future. Washington DC; 2012. p. 175-188. 28. Beattie WS, Karkouti K, Wijeysundera DN, Tait G. Risk associated with preoperative anemia in noncardiac surgery: a single center cohort study. Anestesiology 2009 Mar; 110(3):574-81. 29. Carson JL, Stanworth SJ, Roubinian N, Fergusson DA, Triulzi D, Doree C, et al. Transfusion thresholds and other strategies for guiding allogeneic red cell transfusion. The Cochrane Database of Syst Rev 2012 Apr; 4:CD002042. 30. Ahtiala M, Soppi E. Improving Jackson/Cubbin risk scale is demanding. 26th EWMA meeting; 2016 May 11-13; 2016, Bremen, Germany. 31. Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, et al. The SOFA (Sepsisrelated Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med 1996 Jul; 22(7):707-10. 32. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Critical Care Medicine 1985 Oct; 13(10):818–29.

23. García-Fernández FP, Pancorbo-Hidalgo PL, Soldevilla Argeda JJ, Rodrigez Torres M del C. Risk assessment scales for pressure ulcers in intensive care units: A systematic review with meta-analysis. EWMA Journal 2013 Oct; 13(2):7-13.


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Science, Practice and Education

Prevalence of Chronic Wounds in Different Modalities of Care in Germany

Knut Kröger Moritz Jöster

Klinik für Gefäßmedizin, Helios Klinikum Krefeld, Germany Correspondence: K. Kröger, MD, FASA, EFMA Klinik für Gefäßmedizin Helios Klinikum Krefeld Lutherplatz 40 47805 Krefeld Germany

Wound survey from Germany has analysed the prevalence of chronic wounds, using data from different German health and care settings. ABSTRACT Background Data regarding the prevalence of chronic wounds in Germany indicate varying numbers, from 1 to 4 million people. The survey presented here analysed the prevalence of chronic wounds in Germany, using data from different German health and care settings.

Patients and Methods This survey is a point prevalence study of chronic wound patients from the city of Duisburg (n = 486,816 inhabitants, eight hospitals, 52 nursing homes, and 71 outpatient care services) and the rural district of Altenkirchen (n = 129,166 inhabitants, two hospitals, 22 nursing homes, and 19 outpatient care services). Importantly, we took into account the treatment structures and services of the German healthcare sector. All hospitals, nursing homes, and outpatient care services were requested to take part in the survey. Return rates varied between hospitals, nursing homes, and outpatient care services, and ranged from 51% to 69%. Single patients were not contacted.

Results In Duisburg, pressure ulcers were most frequent in nursing homes, with 4.6% of all residents affected; leg ulcers were most frequent in hospitals, with 3.8% of patients affected; and foot ulcers were most frequent in patients who were cared for by outpatient services, making up 2.0% of this population. Considering the total population of Duisburg, EWMA Journal 

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the point prevalence of pressure ulcers was 0.09%, that of leg ulcers was 0.09%, and that of foot ulcers was 0.06%. In Altenkirchen, all three ulcer types were most frequent in nursing homes, with 6.9%, 5.2%, and 4.9% of all residents presenting with pressure ulcers, leg ulcers, or foot ulcers, respectively. Considering the total population of Altenkirchen, the point prevalence of pressure ulcers was 0.08%, that of leg ulcers was 0.09%, and that of foot ulcers was 0.07%.

Conclusion This analysis shows that around 0.24% of the population in Germany is affected by chronic wounds. The rates of pressure ulcers, leg ulcers, and foot ulcers varied only between 0.07 and 0.09%.

Recommendation to practice Acute surgical wounds in hospitals are much more frequent than chronic wounds. Although pressure ulcers are more frequent in nursing homes, there is no specific pattern of different chronic wounds that differentiates hospitals, nursing homes, and outpatient care services. Our analysis of the different health and care settings in Germany likely underestimates the true prevalence of chronic wounds, because patients treated by their doctors on an outpatient basis were not included.

Correspondence: knut.kroeger@ Conflicts of interest: None


INTRODUCTION The care and management of patients with chronic wounds, and their widespread effects challenge both the patient and the practitioner. Further complicating this situation is the paucity of evidence-based treatment strategies for chronic wound care. It is thought that in Germany, more than 4.5 million people are treated for chronic wounds per year, with resulting costs to the public health system of up to five billion Euros.1,2,3 More recent data, however, reported much lower numbers. Secondary analysis of German statutory health insurance data concluded that in 2012, 1.04% (95% CI 1.03–1.05) of insured patients had a wound diagnosis, including 0.70% with leg ulcers and 0.27% with diabetic ulcers. Extrapolated to the German population, this reflects a prevalence of 786,407 and an incidence of 196,602 chronic wounds.4 Large-scale studies in the Rhineland region of Germany have revealed a current venous ulcer prevalence of about 0.01%, which would imply that about 50,000 to 80,000 persons in Germany suffer from this condition.5 Studies of diabetic foot ulcers in various countries have yielded prevalence figures ranging from 2% to 10% of the diabetic population, with an annual incidence of 2% to 6%.6 To overcome this dilemma of discrepant figures, improve evidence-based wound care, and spread the understanding of the challenges related to wound care research, the European Wound Management Association (EWMA) formed the “Patient Outcome Group” in 2008.7,8,9 As part of this group’s initiative, the EWMA Wound Surveys aim to uncover the resource costs of wound care in different European countries. A survey from Denmark reported the number of pressure ulcers, leg ulcers, and diabetic foot ulcers in inpatients as 3.3%, 1.7%, and 1.6%, respectively. In the municipalities, the authors reported a prevalence of 0.7/1000 pressure ulcers, 0.5/1000 leg ulcers, and 0.3/1000 diabetic foot ulcers). Thus, this survey aimed to generate data about the prevalence of chronic wounds in Germany. As the German healthcare system is divided into different health and care settings, we analysed the prevalence of chronic wounds in each setting. METHOD We performed a point prevalence study, which took into account the treatment structures and services of the German healthcare sector. The city of Duisburg and the rural district of Altenkirchen participated, requesting that their hospitals, nursing homes, and outpatient care services take part in the survey. Duisburg is a large city in the industrial Ruhr area in Western Germany. The number of inhabitants is given as n = 486,816. The city counts


eight hospitals, 52 nursing homes, and 71 outpatient care services. Altenkirchen is a smaller rural district in Western Germany covering 7 smaller villages. Together, the number of inhabitants of this district is given as n = 129,166. The district counts two hospitals, 22 nursing homes, and 19 outpatient care services. Data collection A point prevalence survey was carried out during a 2-week period in February 2015 in Duisburg and in June 2015 in Altenkirchen. The questionnaires and a motivation letter, which explained the necessity of the survey, were sent out by the head of the health department of Duisburg, and by the Chief of the district, called the “Landrat”, in Altenkirchen. We involved these political institutions to increase the regional acceptance of the survey. The letters were sent to the nursing officers of all hospitals and nursing homes. They were asked to hand out the questionnaires to the responsible ward nurses and instruct them to complete it with their team on one specific day. In addition, all outpatient care services were asked to participate. The questionnaires were sent to the chiefs of the outpatient care services, and they were asked to complete it with their team on one specific day. All questionnaires were returned in an enclosed stamped envelope to the head of the health department of Duisburg and the Chief of the district of Altenkirchen. Return rates varied between hospitals, nursing homes, and outpatient care services, ranging from 51% to 69%. Single patients were not contacted. Thus, ethical approval was not needed. RESULTS Point prevalence of wounds In Duisburg, 50.6% of all hospitalised patients presented with surgical wounds. As expected, the rates of surgical wounds were much lower in other settings, and reached 1.8% in nursing homes and 2.5% in patients who were cared for by outpatient services. Pressure ulcers were most frequent in nursing homes, occurring in 4.6% of all residents; leg ulcers were most frequent in hospitals, presenting in 3.8% of patients; and foot ulcers were most frequent in patients who were cared for by outpatient services, occurring in 2.0% of this group. Considering the total population of Duisburg, the point prevalence of pressure ulcers was 0.09%, that of leg ulcers was 0.09%, and that of foot ulcers was 0.06% (Table 1), for a total overall prevalence of 0.24%. In Altenkirchen, 62.0% of all hospitalised patients presented with surgical wounds. In nursing homes, the total was 2.6%, and in patients who were cared for by outpatient

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n = 4,200

n = 4,388

n= 7,846

n = 468,816


2123 (50.6)

79 (1.8)

197 (2.5)

2399 (0.49)

Pressure ulcer

112 (2.7)

200 (4.6)

129 (1.6)

441 (0.09)

Leg ulcer

162 (3.8)

46 (1.0)

224 (2.9)

432 (0.09)

Foot ulcer

54 (1.3)

68 (1.6)

153 (2.0)

275 (0.06)


65 (1.6)

117 (2.7)

115 (1.5)

297 (0.06)


n = 411

n = 839

n = 1607

n = 129,166

255 (62.0)

22 (2.6)

76 (4.6)

353 (0.28)

Pressure ulcer

13 (3.3)

58 (6.9)

33 (2.0)

104 (0.08)

Leg ulcer

10 (2.5)

44 (5.2)

58 (3.5)

112 (0.09)

Foot ulcer

12 (2.9)

41 (4.9)

36 (2.2)

89 (0.07)


15 (3.6)

22 (2.6)

51 (3.1)

88 (0.07)


Table 1: Point prevalence of surgical wounds and pressure ulcers, leg ulcers, and foot ulcers in the city of Duisburg and the district of Altenkirchen in Germany. Given are the absolute numbers (n) and the rates (%) of affected patients from all estimated patients in these settings and of the total population in these areas.

services, it was 4.6%. Pressure ulcers, leg ulcers, and foot ulcers were most frequent in nursing homes, with 6.9%, 5.2%, and 4.9% of all residents presenting with each, respectively. Considering the total population of Altenkirchen, the point prevalence of pressure ulcers was 0.08%, that of leg ulcers was 0.09%, and that of foot ulcers was 0.07% (Table 1), for a total overall prevalence of 0.24%. Finally, when we extrapolated to the German population 18 years and older (n = 68.85 million in 2015), our analysis suggests that only 165,240 individuals would be affected by pressure, leg, and foot ulcers. DISCUSSION Our analysis shows that around 0.24% of the German population is affected by chronic wounds. Additionally, we found that the prevalence rates of pressure ulcers, leg ulcers, and foot ulcers are rather similar. Acute wounds predominantly occur in hospitalised patients. According to our analysis, 50.6% to 62.0% of inpatients have surgical or traumatic wounds. The EWMA survey in Denmark reported that 33% of all inpatients had a wound. The majority of these were surgical/trauma wounds (25%).8 Another wound survey from the UK, carried out over a one-week period in March 2007, covering three hospitals in two acute trusts, district nurses, nursing homes, and residential homes, reported a point prevalence of wounds in inpatients of 30.7%. The majority (78.8%) of these patients had surgical or traumatic wounds.9 In Germany, 19.75 million patients were hospitalised in 2015. Of these cases, 55.36 million procedures EWMA Journalâ&#x20AC;&#x201A;

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were documented, of which 29.7% (n = 16.42 million) were surgical procedures. Thus the rates in our analysis are relatively high and may be influenced by the specifications of the hospitals. The number of chronic wounds was lower than expected, but is comparable to those reported in other analyses. A secondary analysis of German statutory health insurance data concluded that in 2012, 1.04% (95% CI 1.03â&#x20AC;&#x201C;1.05) of insured patients had a wound diagnosis.4 However, the standardised prevalence rate in 2012 was estimated to be 0.4%, representing 330,000 treated persons.2 The difference in our analysis might be due to the fact that we only detected patients with chronic wounds who were hospitalised, in nursing homes, or cared for by outpatient services. Patients outside these settings, whose wounds were treated by a doctor were therefore not included. The EWMA Wound Surveys from Denmark report the number of chronic wounds (pressure ulcers, leg ulcers, and diabetic foot ulcers) in municipalities as 0.15%.8 The UK wound survey from March 2007 reported that the prevalence of patients with a wound was 0.36%.9 The figure from the UK is therefore more comparable to that from the German population reported here (0.24%), as the authors of that study tried to calculate the rates of chronic wounds in all settings. In Denmark, the rate of ulcers in hospitals was 3.3% for pressure ulcers, 1.7% for leg ulcers, and 1.6% for diabetic foot ulcers.8 The in-hospital rates in the UK were 3.6% for pressure ulcers, and 2.7% for leg and foot î&#x201A;Š


ulcers together.9 Importantly, these figures were similar to our findings in the German population. The unique feature of our analysis is the inclusion of chronic wound rates in the three different health and care settings that characterise the German healthcare system. We are not aware of any other study that has followed such a concept. All studies listed in Table 2 focused on only one of these settings. We found that there were more patients with chronic wounds in hospitals, nursing homes, and outpatient care settings in Altenkirchen compared to Duisburg. One explanation for this observation might be an increased concentration of these patients living in Altenkirchen, which has fewer hospital beds, nursing homes, and patients cared for by outpatient care services than does Duisburg, as a percentage of total inhabitants (22.1/1000 vs. 35.1/1000 inhabitants). We also found that pressure ulcers in nursing homes are twice as frequent as in hospitals or in patients cared for at home, while this is not true for leg ulcers or foot ulcers. Limitations Firstly, our survey was not based on individual investigation of patients. We only received information from the responsible person in hospitals, nursing homes, and outpatient settings. Thus, we cannot provide any information regarding the accuracy of the reporting.



Heyer et al. / 2016

1.04% / 0.7% / 0.27%

Secondly, return rates ranged from 51% to 69%, and we extrapolated to all institutions of the same settings. Higher rates would increase the validity of our results, but there is no reason to assume that those who did not return the questionnaire have higher or lower rates of chronic wounds. Finally, our survey included only two regions of Germany, one that represented a large city in the industrial Ruhr area, and one smaller rural district. Although both regions are completely different and represent typical regions in Germany, both are in Western Germany and may not be representative of the total German population. CONCLUSION Today, point prevalence of chronic wounds in Germany seems to be much lower than in most previously published reports. A population-based analysis representing the entire country is therefore necessary to provide exact data and judge the effectiveness of future German healthcare strategies for chronic wound treatment and prevention. Acknowledgement We appreciate the support of the head of the health department of Duisburg and the chief of the district, called the “Landrat” of Altenkirchen.



insurance data

chronic wounds / leg ulcer / foot ulcer

nursing home / outpatient care service

pressure ulcer (I-IV)



pressure ulcer

Lahmann et al. / 2012



pressure ulcer (I-IV)

Kottner et al. / 2010


nursing home

pressure ulcer

Wilborn et al. / 2010


nursing home

pressure ulcer (II-IV)

Klingelhöfer-Noe 3.9% / 2.3% et al. / 2015 Eberlein-Gonska et al. / 2013

Lahmann et al. / 2010

12.5% – 5% nursing home 6.6% – 3.5%

Kottner et al. / 2009

3.9% / 7.9%

nursing home / hospital

pressure ulcer (I-IV)

Hoppe et al. / 2008

7.3% / 12.7%

nursing home / hospital

pressure ulcer (I-IV)

Kottner et al. / 2008

13.9% – 7.3%


pressure ulcer (I-IV) 2001-2007

Sämann et al. / 2008

3.6% / 2.8%

pressure ulcer (I-IV) 2002-2008 pressure ulcer (II-IV) 2002-2008

diabetic ulcer type 1 / 2

Stausberg et al. / 2005



pressure ulcer (I-IV)

Stausberg et al. / 2005



pressure ulcer (I-IV)

Laible et al. / 2000


outpatient care service

leg ulcer

Table 2: List of studies that published prevalence data of chronic wounds or specific ulcer types in Germany. 48

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REFERENCES 1. Karl T, Gussmann A, Storck M. Chronic wounds-perspective for integrated care. Zentralbl Chir. 2007;132:232-235. 2. Deutsche Gesellschaft für Wundheilung und Wundbehandlung e.V. Lokaltherapie chronischer Wunden bei Patienten mit den Risiken periphere arterielle Verschlusskrankheit, Diabetes mellitus, chronische venöse Insuffizienz. 2012. http://www.–001l_S3_ Lokaltherapie_chronischer_Wunden_2012–06.pdf (abgerufen am 29 Juli 2014) 3. Expertenstandard Pflege von Menschen mit chronischen Wunden. Deutsches Netzwerk für Qualitätsentwicklung in der Pflege (Hrsg.). Osnabrück; 1. Aktualisierung (September 2015). 4. Heyer K, Herberger K, Protz K, Glaeske G, Augustin M. Epidemiology of chronic wounds in Germany: Analysis of statutory health insurance data. Wound Repair Regen. 2016;24:434-442. 5. Pannier-Fischer F, Rabe E. Epidemology of Chronic venous diseases. Hautarzt 2003;54:1037-1044 6. German Agency for Quality in Medicine (ÄZQ): Type-2-diabetes 2006 – National disease management guideline. Diabetic foot –prevention and therapy 60. In. Edited by Gin; 2008. 7. Gottrup F, Henneberg E, Trangbæk R, Bækmark N, Zøllner K, Sørensen J. Point prevalence of wounds and cost impact in the acute and community setting in Denmark. J Wound Care. 2013;22:413-422.

8. Gottrup F. The EWMA Patient Outcome Group. J Wound Care 2009;18:460 9. Vowden K, Vowden P, Posnett J. The resource costs of wound care in Bradford and Airedale primary care trust in the UK. J Wound Care. 2009;18:93-102 10. Klingelhöfer-Noe J, Dassen T, Lahmann, NA Nursing Homes versus assisted Living Facilities: Outcome Quality regarding Pressure ulcers, Falls and Malnutrition. Z Gerontol Geriatr. 2015:48;263-269 11. Eberlein-Gonska M, Petzold T, Helaß G, Albrecht DM, Schmitt J. The Incidence and Determinants of Decubitus ulcers in Hospital care: an Analysis of routine Quality Management data at an University Hospital. Dtsch Arztebl int. 2013:110:550-556 12. Lahmann NA, Dassen T, Kottner J. Frequency of Pressure ulcers in German Hospitals Gesundheitswesen 2012;74:793-7 13. Kottner J, Dassen T, Lahmann NA. Pressure ulcers in German nursing Homes: Frequencies, Grades and Origins Z Gerontol Geriatr. 2011;44:318-322. 14. Wilborn D, Grittner U, Dassen T, Kottner J. The national Expert standard Pressure ulcer prevention in Nursing and Pressure ulcer prevalence in German Health care Facilites: A multilevel Analysis. J Clin Nurs. 2010;19:23-24 15. Lahmann NA, Dassen T, Poehler A, Kottner J. Pressure ulcer prevalence rates from 2002-2008 in German long-term care Facilities. Aging Clin Exp Res. 2010;22:152-156

16. Kottner J, Lahmann N, Dassen T. Pressure ulcer prevalence: Comparison between Nursing homes and Hospitals. Pflege 2010;63:228-231 17. Hoppe C, Kottner J, Dassen T, Lahmann NA. Pressure ulcer risk and Pressure ulcer prevalence in German Hospitals and Nursing homes. Pflege 2009;62:424-428 18. Kottner J, Wilborn D, Dassen T, Lahmann NA. The trend of pressure ulcer prevalence rates in German Hospitals: Results of seven cross-sectional studies. J Tissue Viability 2009;18:36-46 19. Sämann A, Tajiyeva O, Müller N, Tschauner T, Hoyer H, Wolf G, Müller UA Prevalence of the Diabetic foot Syndrom at the primary care level in Germany: A cross-sectional study. Diabet Med 2008;25:557-63 20. Stausberg J, Kröger K, Maier I, Niebel W, Schneider H, Frequency of Decubitus ulcer in patients of a University Medical Center: Combination of routine documentation and cross-sectional study. DMW 2005:130; 2311-2315 21. Stausberg J, Kröger K, Maier I, Schneider H, Niebel W. Pressure ulcers in secondary care: Incidence, Prevalence and Relevance. Adv Skin Wound Care 2005:18;140-145 22. Laible J, Mayer H, Evers GC. Prevalence of Ulcus cruris in Home care Nursing: An epidemiological study in North Rhine-Westphalia. Pflege 2002;15:1623


Submit your paper to EWMA Journal Volume 17 16 Number 1 2016 April 2016 Published Published by by European Wound Wound Management Management Association

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Come to the Smith & Nephew booth at EWMA 2018 to see our latest products and find out how we can help you get CLOSER TO ZERO™ delay in wound healing. NEW

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Also at the booth will be our innovative plan-on-a-page (POP) tool, which has been developed in partnership with nurses and specialist woundcare clinicians. The POP is a unique wound care support tool to help improve consistency of care and assist clinicians in selecting the right product at the right time to help optimise outcomes.

Join us at one of our 2 symposia at EWMA 9 May - 11 May Expo Centre, Krakow, Poland: Symposia A Topic: A fresh approach to challenging wounds by combining T.I.M.E. with pioneering solutions Date: Thursday, 10th May Time: 13.15 – 14.15 Room: Bratyslawa †

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Presentations are in English. Simultaneous Polish translation provided. ™Trademark of Smith & Nephew | All Trademarks acknowledged | ©March 2018 Smith & Nephew | 13852 | † Reference: 1. Schultz GS, Sibbald RG, Falanga V et al., Wound Rep Reg (2003);11:1-28.

Cochrane Reviews

ABSTRACTS OF RECENT ­COCHRANE REVIEWS Publication in The Cochrane Library Issue 8, 2017

Systemic antibiotics for treating malignant wounds Darshini A Ramasubbu, Valerie Smith, Fiona Hayden, Patricia Cronin Citation example: Ramasubbu DA, Smith V, Hayden F, Cronin P. Systemic antibiotics for treating malignant wounds. Cochrane Database of Systematic Reviews 2017, Issue 8. Art. No.: CD011609. DOI: 10.1002/14651858.CD011609.pub2. ABSTRACT Background: Malignant wounds are a devastating complication of cancer. They usually develop in the last six months of life, in the breast, chest wall or head and neck regions. They are very difficult to treat successfully, and the commonly associated symptoms of pain, exudate, malodour, and the risk of haemorrhage are extremely distressing for those with advanced cancer. Treatment and care of malignant wounds is primarily palliative, and focuses on alleviating pain, controlling infection and odour from the wound, managing exudate and protecting the surrounding skin from further deterioration. In malignant wounds, with tissue degradation and death, there is proliferation of both anaerobic and aerobic bacteria. The aim of antibiotic therapy is to successfully eliminate these bacteria, reduce associated symptoms, such as odour, and promote wound healing. Objectives: To assess the effects of systemic antibiotics for treating malignant wounds. Search methods: We searched the following electronic databases on 8 March 2017: the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL; the Cochrane Library, 2017, Issue 3), Ovid MEDLINE, Ovid Embase and EBSCO CINAHL Plus. We also searched the clinical trial registries of the World Health Organization (WHO) International Clinical Trials Registry Platform (apps. and on 20 March 2017; and OpenSIGLE (to identify grey literature) and ProQuest Dissertations & Theses Global (to retrieve dissertation theses related to our topic of interest) on 13 March 2017.

Selection criteria: Randomised controlled trials that assessed the effects of any systemic antibiotics on malignant wounds were eligible for inclusion. Data collection and analysis Two review authors independently screened and selected trials for inclusion, assessed risk of bias and extracted study data. A third reviewer checked extracted data for accuracy prior to analysis. Main results: We identified only one study for inclusion in this review. This study was a prospective, doubleblind cross-over trial that compared the effect of systemic metronidazole with a placebo on odour in malignant wounds. Nine participants with a fungating wound and for whom the smell was troublesome were recruited and six of these completed both the intervention and control (placebo) stages of the trial. Each stage lasted fourteen days, with a fourteen day gap (washout period) between administration of the metronidazole and the placebo. The study, in comparing metronidazole and placebo, reported on two of this review’s pre-specified primary outcomes (malodour and adverse effects of the treatment) and on none of the review’s pre-specified secondary outcomes. Malodour The mean malodour (smell) scores for the metronidazole group was 1.17 (standard deviation (SD) 1.60) and the mean for the placebo group was 3.33 (SD 0.82). It is unclear if systemic antibiotics were associated with a difference in malodour (1 study with 6 participants; MD —2.16, 95% CI —3.6 to —0.72) as the quality of the evidence (GRADE) was very low for this outcome. The study was downgraded due to high risk of attrition bias (33% loss to follow-up) and very serious imprecision due to the small sample size. Adverse effects: No adverse effects of the treatment were reported in either the intervention or control group by the trial authors.

Correspondence: gill.rizzello@

Authors’ conclusions: It is uncertain whether systemic metronidazole leads to a reduction in malodour in patients with malignant wounds. This is because we were only able to include a single study at high risk of 

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Gill Rizzello Managing editor Cochrane Wounds, School of Nursing, Midwifery and Social Work, University of Manchester.

More information: Conflicts of interest: None


bias with a very small sample size, which focused only on patients with breast cancer. More research is needed to substantiate these findings and to investigate the effects of systemic metronidazole and other antibiotics on quality of life, pain relief, exudate and tumour containment in patients with malignant wounds.

dence came from a very small study with serious study design flaws, and more research is needed involving more people with different types of cancer. Trials looking at how antibiotics can affect other outcomes, such as quality of life, pain relief and reducing any bleeding or ooze from the wound are also needed. This plain language summary is up to date as of March 2017.

Plain language summary Systemic antibiotics for treating malignant wounds Publication in The Cochrane Library Issue 10, 2017 Review question: We reviewed the evidence about the effect of systemic antibiotics on malignant wounds. We were looking for evidence relating to possible side effects of this treatment, and the impact on quality of life and other symptoms. Background: Malignant wounds occur in people who have advanced cancer. They usually develop in the last six months of life, at or near the site of a tumour. They occur when a tumour spreads and invades surrounding skin and blood vessels, causing them to break down. The area loses nourishment due to poor blood flow, and eventually the tissues die, resulting in a malignant wound. This type of wound can be very painful, can smell, and can bleed or ooze fluid. These symptoms can be very difficult for people with advanced cancer. Treatment for malignant wounds does not normally aim to heal the wound, but to limit symptoms that affect people’s quality of life. Antibiotics are medicines that fight bacterial infections. Systemic antibiotics affect the whole body. They can be given by mouth in tablet form, or in other ways such as via injections. We looked for evidence as to whether systemic antibiotics can prevent malignant wounds from getting worse, and help reduce the smell, pain and other complications associated with these wounds. Study characteristics: In March 2017 we searched for randomised controlled trials looking at the effects of systemic antibiotics on malignant wounds. We found only one trial, dating from 1984, which compared the effectiveness of the antibiotic metronidazole with a placebo (sugar pill) on six participants with malignant wounds resulting from breast cancer. The trial was a cross-over trial which means that participants receive both the treatment being tested and the comparison treatment, at different time-points, with a break between the treatments to ensure that the effects of the first treatment have worn off before the second treatment is taken. This is called the ‘washout’ period. In the one trial in this review, half the participants took the antibiotic first, for 14 days, and half took the placebo. Both groups then had 14 days with no medication before swapping over (cross-over) and trying the alternative treatment for 14 days. Key results: It is unclear if metronidazole reduces the smell of malignant wounds when taken orally (by mouth) in tablet form, without any side effects occurring. Its effectiveness in relation to other outcomes such as pain or quality of life was not measured in this trial. No change in the size or appearance of participants’ tumours was reported. Quality of the evidence: It is uncertain whether metronidazole reduces the smell of malignant wounds when taken orally in tablet form because the quality of the evidence is very low. This evi52

Foam dressings for treating pressure ulcers Rachel M Walker, Brigid M Gillespie, Lukman Thalib, Niall S Higgins, Jennifer A Whitty Citation example: Walker RM, Gillespie BM, Thalib L, Higgins NS, Whitty JA. Foam dressings for treating pressure ulcers. Cochrane Database of Systematic Reviews 2017, Issue 10. Art. No.: CD011332. DOI: 10.1002/14651858.CD011332.pub2. ABSTRACT Background: Pressure ulcers, also known as pressure injuries and bed sores, are localised areas of injury to the skin or underlying tissues, or both. Dressings made from a variety of materials, including foam, are used to treat pressure ulcers. An evidence-based overview of dressings for pressure ulcers is needed to enable informed decision-making on dressing use. This review is part of a suite of Cochrane Reviews investigating the use of dressings in the treatment of pressure ulcers. Each review will focus on a particular dressing type. Objectives: To assess the clinical and cost effectiveness of foam wound dressings for healing pressure ulcers in people with an existing pressure ulcer in any care setting. Search methods: In February 2017 we searched: the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; EBSCO CINAHL Plus and the NHS Economic Evaluation Database (NHS EED). We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, meta-analyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria: Published or unpublished randomised controlled trials (RCTs) and cluster-RCTs, that compared the clinical and cost effectiveness of foam wound dressings for healing pressure ulcers (Category/Stage II or above). Data collection and analysis: Two review authors independently performed study selection, risk of bias and data extraction. A third reviewer resolved discrepancies between the review authors. Main results: We included nine trials with a total of 483 participants, all of whom were adults (59 years or older) with an existing pressure ulcer Category/Stage II or above. All trials had two EWMA Journal 

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arms, which compared foam dressings with other dressings for treating pressure ulcers.

reported but again, we assessed the evidence as being of very low certainty.

The certainty of evidence ranged from low to very low due to various combinations of selection, performance, attrition, detection and reporting bias, and imprecision due to small sample sizes and wide confidence intervals. We had very little confidence in the estimate of effect of included studies. Where a foam dressing was compared with another foam dressing, we established that the true effect was likely to be substantially less than the study’s estimated effect.

None of the included trials reported quality of life or pressure ulcer recurrence.

We present data for four comparisons. One trial compared a silicone foam dressing with another (hydropolymer) foam dressing (38 participants), with an eightweek (short-term) follow-up. It was uncertain whether alternate types of foam dressing affected the incidence of healed pressure ulcers (RR 0.89, 95% CI 0.45 to 1.75) or adverse events (RR 0.37, 95% CI 0.04 to 3.25), as the certainty of evidence was very low, downgraded for serious limitations in study design and very serious imprecision. Four trials with a median sample size of 20 participants (230 participants), compared foam dressings with hydrocolloid dressings for eight weeks or less (short-term). It was uncertain whether foam dressings affected the probability of healing in comparison to hydrocolloid dressings over a short follow-up period in three trials (RR 0.85, 95% CI 0.54 to 1.34), very lowcertainty evidence, downgraded for very serious study limitations and serious imprecision. It was uncertain if there was a difference in risk of adverse events between groups (RR 0.88, 95% CI 0.37 to 2.11), very low-certainty evidence, downgraded for serious study limitations and very serious imprecision. Reduction in ulcer size, patient satisfaction/acceptability, pain and cost effectiveness data were also reported but we assessed the evidence as being of very low certainty. One trial (34 participants), compared foam and hydrogel dressings over an eight-week (short-term) follow-up. It was uncertain if the foam dressing affected the probability of healing (RR 1.00, 95% CI 0.78 to 1.28), time to complete healing (MD 5.67 days 95% CI -4.03 to 15.37), adverse events (RR 0.33, 95% CI 0.01 to 7.65) or reduction in ulcer size (MD 0.30 cm2 per day, 95% CI -0.15 to 0.75), as the certainty of the evidence was very low, downgraded for serious study limitations and very serious imprecision. The remaining three trials (181 participants) compared foam with basic wound contact dressings. Follow-up times ranged from short-term (8 weeks or less) to medium-term (8 to 24 weeks). It was uncertain whether foam dressings affected the probability of healing compared with basic wound contact dressings, in the short term (RR 1.33, 95% CI 0.62 to 2.88) or medium term (RR 1.17, 95% CI 0.79 to 1.72), or affected time to complete healing in the medium term (MD -35.80 days, 95% CI -56.77 to -14.83), or adverse events in the medium term (RR 0.58, 95% CI 0.33 to 1.05). This was due to the very low-certainty evidence, downgraded for serious to very serious study limitations and imprecision. Reduction in ulcer size, patient satisfaction/acceptability, pain and cost effectiveness data were also EWMA Journal 

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Authors’ conclusions: It is uncertain whether foam dressings are more clinically effective, more acceptable to users, or more cost effective compared to alternative dressings in treating pressure ulcers. It was difficult to make accurate comparisons between foam dressings and other dressings due to the lack of data on reduction of wound size, complete wound healing, treatment costs, or insufficient time-frames. Quality of life and patient (or carer) acceptability/satisfaction associated with foam dressings were not systematically measured in any of the included studies. We assessed the certainty of the evidence in the included trials as low to very low. Clinicians need to carefully consider the lack of robust evidence in relation to the clinical and cost-effectiveness of foam dressings for treating pressure ulcers when making treatment decisions, particularly when considering the wound management properties that may be offered by each dressing type and the care context.

Plain language summary Foam dressings for treating pressure ulcers What is the aim of this review? The aim of this review was to find out whether foam dressings (designed to absorb fluid from wounds whilst keeping them moist) have any advantages or disadvantages in healing pressure ulcers compared with other dressings (such as silicone foam dressings, hydrocolloid, hydrogel or basic wound dressings). Researchers from Cochrane collected and analysed all relevant studies (randomised controlled trials) to answer this question and found nine relevant studies. Key messages: There is no clear evidence from any of the studies included in this review that foam dressings are more effective at healing pressure ulcers than other types of dressings; or that foam dressings are more cost effective than other dressings. This is due in part to the low quality of the studies, many of which had small numbers of participants and did not provide accurate details of their methods. What was studied in the review? Pressure ulcers (pressure injuries or bed sores) are wounds that develop on bony parts of the body such as the heels, hips and lower back. Sitting or lying in the same position for long periods can cause damage to the skin and underlying tissue. People at risk of developing pressure ulcers include those with limited physical mobility such as people with spinal cord injuries, older people, or those ill in hospital. Pressure ulcer treatment is a significant burden to patients, their carer(s) and healthcare systems worldwide. Treatments for pressure ulcers include dressings, antibiotics and antiseptics, and pressure-relieving mattresses or cushions. There are many wound dressings available to treat pressure ulcers, which vary in cost and may have differing degrees of effectiveness. Foam dressings are designed to absorb fluid (exudate) that comes from some pressure ulcer wounds, and to maintain a 


moist environment. We wanted to find out how foam dressings affected pressure ulcer healing and recurrence rates. We also wanted to find out whether foam dressings had an impact on participants’ quality of life and satisfaction with treatment, and whether there were any side effects such as infection or pain. We also evaluated the cost of foam dressings compared to other treatments. What are the main results of the review? We found nine studies published between 1994 and 2016 involving a total of 483 participants with pressure ulcers at Category/Stage II or above (open wounds). Seven of the nine trials had more female participants than male. On average people in these studies were 59 years or older. The studies compared foam dressings with other types of dressings, however, there was no clear evidence to indicate foam dressings were more effective at healing pressure ulcers than other types of dressings, or more cost effective. Evidence regarding reduction in ulcer size, patient satisfaction and pain is very uncertain. None of the studies reported on participants’ quality of life or pressure ulcer recurrence. The majority of studies found the dressings evaluated were no better or worse than others on the market. So, while foam dressings can be safely used for the treatment for pressure ulcers, their effect on wound healing is not supported by scientific evidence. Generally, the studies we found did not have many participants and the results were often inconclusive. Overall the evidence that exists is of very low quality. How up to date is this review? We searched for studies that had been published up to February 2017.

Intracavity lavage and wound irrigation for prevention of surgical site infection Gill Norman, Ross A Atkinson, Tanya A Smith, Ceri Rowlands, Amber D Rithalia, Emma J Crosbie, Jo C Dumville Citation example: Norman G, Atkinson RA, Smith TA, Rowlands C, Rithalia AD, Crosbie EJ, Dumville JC. Intracavity lavage and wound irrigation for prevention of surgical site infection. Cochrane Database of Systematic Reviews 2017, Issue 10. Art. No.: CD012234. DOI: 10.1002/14651858.CD012234.pub2. ABSTRACT Background: Surgical site infections (SSIs) are wound infections that occur after an operative procedure. A preventable complication, they are costly and associated with poorer patient outcomes, increased mortality, morbidity and reoperation rates. Surgical wound irrigation is an intraoperative technique, which may reduce the rate of SSIs through removal of dead or damaged tissue, metabolic waste, and wound exudate. Irrigation can be undertaken prior to wound closure or postoperatively. Intracavity lavage is a similar technique used in operations that expose a bodily cavity; such as procedures on the abdominal cavity and during joint replacement surgery.


Objectives: To assess the effects of wound irrigation and intracavity lavage on the prevention of surgical site infection (SSI). Search methods In February 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase and EBSCO CINAHL Plus. We also searched three clinical trials registries and references of included studies and relevant systematic reviews. There were no restrictions on language, date of publication or study setting. Selection criteria: We included all randomised controlled trials (RCTs) of participants undergoing surgical procedures in which the use of a particular type of intraoperative washout (irrigation or lavage) was the only systematic difference between groups, and in which wounds underwent primary closure. The primary outcomes were SSI and wound dehiscence. Secondary outcomes were mortality, use of systemic antibiotics, antibiotic resistance, adverse events, re-intervention, length of hospital stay, and readmissions. Data collection and analysis: Two review authors independently assessed studies for inclusion at each stage. Two review authors also undertook data extraction, assessment of risk of bias and GRADE assessment. We calculated risk ratios or differences in means with 95% confidence intervals where possible. Main results: We included 59 RCTs with 14,738 participants. Studies assessed comparisons between irrigation and no irrigation, between antibacterial and non-antibacterial irrigation, between different antibiotics, different antiseptics or different non-antibacterial agents, or between different methods of irrigation delivery. No studies compared antiseptic with antibiotic irrigation. Surgical site infection: Irrigation compared with no irrigation (20 studies; 7192 participants): there is no clear difference in risk of SSI between irrigation and no irrigation (RR 0.87, 95% CI 0.68 to 1.11; I2 = 28%; 14 studies, 6106 participants). This would represent an absolute difference of 13 fewer SSIs per 1000 people treated with irrigation compared with no irrigation; the 95% CI spanned from 31 fewer to 10 more SSIs. This was low-certainty evidence downgraded for risk of bias and imprecision. Antibacterial irrigation compared with non-antibacterial irrigation (36 studies, 6163 participants): there may be a lower incidence of SSI in participants treated with antibacterial irrigation compared with non-antibacterial irrigation (RR 0.57, 95% CI 0.44 to 0.75; I2 = 53%; 30 studies, 5141 participants). This would represent an absolute difference of 60 fewer SSIs per 1000 people treated with antibacterial irrigation than with nonantibacterial (95% CI 35 fewer to 78 fewer). This was low-certainty evidence downgraded for risk of bias and suspected publication bias. Comparison of irrigation of two agents of the same class (10 studies; 2118 participants): there may be a higher incidence of SSI in participants treated with povidone iodine compared with superoxidised water (Dermacyn) (RR 2.80, 95% CI 1.05 to 7.47; EWMA Journal 

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low-certainty evidence from one study, 190 participants). This would represent an absolute difference of 95 more SSIs per 1000 people treated with povidone iodine than with superoxidised water (95% CI 3 more to 341 more). All other comparisons found low- or very low-certainty evidence of no clear difference between groups.

What is the aim of this review?: The aim of this review was to find out whether intracavity lavage and wound irrigation (washing out a wound during surgery) can help to prevent surgical site infection (SSI). Researchers from Cochrane collected and analysed all relevant studies (randomised controlled trials) to answer this question and found 59 relevant studies.

Comparison of two irrigation techniques: two studies compared standard (non-pulsed) methods with pulsatile methods. There may, on average, be fewer SSIs in participants treated with pulsatile methods compared with standard methods (RR 0.34, 95% CI 0.19 to 0.62; I2 = 0%; two studies, 484 participants). This would represent an absolute difference of 109 fewer SSIs occurring per 1000 with pulsatile irrigation compared with standard (95% CI 62 fewer to 134 fewer). This was low-certainty evidence downgraded twice for risks of bias across multiple domains.

Key messages: The certainty of all the evidence we gathered on the effect of washing out wounds on SSIs was low or very low. This was due to problems with how results were reported, some small sample sizes and concern that not all relevant evidence was published. This means that the true effects of treatments may be substantially different from our results. Washing out surgical wounds may make no clear difference to SSI rates compared with not washing out. Using antibacterial solutions to wash out wounds may reduce infection rates compared with non-antibacterial products. Pumping the washing solution into the wound may reduce infections compared with other methods of washing out. Side effects were not well reported.

Wound dehiscence: Few studies reported wound dehiscence. No comparison had evidence for a difference between intervention groups. This included comparisons between irrigation and no irrigation (one study, low-certainty evidence); antibacterial and non-antibacterial irrigation (three studies, very low-certainty evidence) and pulsatile and standard irrigation (one study, lowcertainty evidence). Secondary outcomes: Few studies reported outcomes such as use of systemic antibiotics and antibiotic resistance and they were poorly and incompletely reported. There was limited reporting of mortality; this may have been partially due to failure to specify zero events in participants at low risk of death. Adverse event reporting was variable and often limited to individual event types. The evidence for the impact of interventions on length of hospital stay was low or moderate certainty; where differences were seen they were too small to be clinically important. Authors’ conclusions: The evidence base for intracavity lavage and wound irrigation is generally of low certainty. Therefore where we identified a possible difference in the incidence of SSI (in comparisons of antibacterial and non-antibacterial interventions, and pulsatile versus standard methods) these should be considered in the context of uncertainty, particularly given the possibility of publication bias for the comparison of antibacterial and non-antibacterial interventions. Clinicians should also consider whether the evidence is relevant to the surgical populations under consideration, the varying reporting of other prophylactic antibiotics, and concerns about antibiotic resistance. We did not identify any trials that compared an antibiotic with an antiseptic. This gap in the direct evidence base may merit further investigation, potentially using network meta-analysis; to inform the direction of new primary research. Any new trial should be adequately powered to detect a difference in SSIs in eligible participants, should use robust research methodology to reduce the risks of bias and internationally recognised criteria for diagnosis of SSI, and should have adequate duration and followup.

Plain language summary ‘Washout’ during surgery for prevention of surgical site infection

What was studied in the review? Infections can often develop in wounds following surgery. This can prevent the wound from healing and can lead to infection spreading through the body. People with SSIs spend longer in hospital and are more likely to need a repeat operation. Techniques used to reduce the risk of infection include intracavity lavage or wound irrigation (washing out the wound during surgery using water or medicated solutions). We wanted to find out if this reduced SSI rates, and improved wound healing. We also wanted to find out about serious consequences such as severe infections that cannot be treated with antibiotics, abscesses, and lengthy hospital stays. What are the main results of the review? We found 59 studies involving 14,738 participants (both adults and children). Some studies enrolled only women because of the type of surgery (e.g. caesarean sections). The studies compared washing out wounds with no treatment, antibacterial and non-antibacterial washing solutions, and different methods of washing. Follow-up times ranged from a few days to several months but most were between two and eight weeks. Most studies did not state how they were funded, but when funding was reported it was mostly non-commercial. Twenty studies involving 7192 participants compared washing out with no washing. The results showed no clear difference in SSI rates (low-certainty evidence). Antibacterial washing solutions may reduce infection rates compared with non-antibacterial solutions (low-certainty evidence from 36 trials involving 6163 participants). Two studies involving 484 participants compared standard washing methods (pouring using a jug or a syringe) with pumping or pulsing the washing solution. There may be fewer SSIs when the solution is pumped into the wound (low-certainty evidence). There may be fewer SSIs when a solution of povidone iodine is used compared with an alternative antiseptic (superoxidised water, Dermacyn) (low-certainty evidence from 1 trial with 190 participants). The results for all other comparisons showed no clear differences or were very uncertain. Wound reopening (dehiscence), infections, which are hard to treat with antibiotics, and deaths were not widely reported. 

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Washing out wounds may not affect the length of time people stay in hospital (low- or moderate-certainty evidence). How up to date is this review? We searched for studies that had been published up to February 2017.

Publication in The Cochrane Library Issue 2, 2018

Intraoperative interventions for preventing surgical site infection: an overview of Cochrane Reviews Zhenmi Liu, Jo C Dumville, Gill Norman, Maggie J Westby, Jane Blazeby, Emma McFarlane, Nicky J Welton, Louise O’Connor, Julie Cawthorne, Ryan P George, Emma J Crosbie, Amber D Rithalia, Hung-Yuan Cheng Citation example: Liu Z, Dumville JC, Norman G, Westby MJ, Blazeby J, McFarlane E, Welton NJ, O’Connor L, Cawthorne J, George RP, Crosbie EJ, Rithalia AD, Cheng H-Y. Intraoperative interventions for preventing surgical site infection: an overview of Cochrane Reviews. Cochrane Database of Systematic Reviews 2018, Issue 2. Art. No.: CD012653. DOI: 10.1002/14651858. CD012653.pub2. ABSTRACT Background: Surgical site infection (SSI) rates vary from 1% to 5% in the month following surgery. Due to the large number of surgical procedures conducted annually, the costs of these SSIs can be considerable in financial and social terms. Many interventions are used with the aim of reducing the risk of SSI in people undergoing surgery. These interventions can be broadly delivered at three stages: preoperatively, intraoperatively and postoperatively. The intraoperative interventions are largely focused on decontamination of skin using soap and antiseptics; the use of barriers to prevent movement of micro-organisms into incisions; and optimising the patient’s own bodily functions to promote best recovery. Both decontamination and barrier methods can be aimed at people undergoing surgery and operating staff. Other interventions focused on SSI prevention may be aimed at the surgical environment and include methods of theatre cleansing and approaches to managing theatre traffic. Objectives: To present an overview of Cochrane Reviews of the effectiveness and safety of interventions, delivered during the intraoperative period, aimed at preventing SSIs in all populations undergoing surgery in an operating theatre. Methods: Published Cochrane systematic reviews reporting the effectiveness of interventions delivered during the intraoperative period in terms of SSI prevention were eligible for inclusion in this overview. We also identified Cochrane protocols and title registrations for future inclusion into the overview. We searched the Cochrane Library on 01 July 2017. Two review authors independently screened search results and undertook data extraction and ‘Risk of bias’ and certainty assessment. We used the ROBIS


(risk of bias in systematic reviews) tool to assess the quality of included reviews, and we used GRADE methods to assess the certainty of the evidence for each outcome. We summarised the characteristics of included reviews in the text and in additional tables. Main results: We included 32 Cochrane Reviews in this overview: we judged 30 reviews as being at low risk of bias and two at unclear risk of bias. Thirteen reviews had not been updated in the past three years. Two reviews had no relevant data to extract. We extracted data from 30 reviews with 349 included trials, totaling 73,053 participants. Interventions assessed included gloving, use of disposable face masks, patient oxygenation protocols, use of skin antiseptics for hand washing and patient skin preparation, vaginal preparation, microbial sealants, methods of surgical incision, antibiotic prophylaxis and methods of skin closure. Overall, the GRADE certainty of evidence for outcomes was low or very low. Of the 77 comparisons providing evidence for the outcome of SSI, seven provided high- or moderate-certainty evidence, 39 provided low-certainty evidence and 31 very low-certainty evidence. Of the nine comparisons that provided evidence for the outcome of mortality, five provided low-certainty evidence and four very low-certainty evidence. There is high- or moderate-certainty evidence for the following outcomes for these intraoperative interventions. (1) Prophylactic intravenous antibiotics administered before caesarean incision reduce SSI risk compared with administration after cord clamping (10 trials, 5041 participants; risk ratio (RR) 0.59, 95% confidence interval (CI) 0.44 to 0.81; high-certainty evidence assessed by review authors). (2) Preoperative antibiotics reduce SSI risk compared with placebo after breast cancer surgery (6 trials, 1708 participants; RR 0.74, 95% CI 0.56 to 0.98; high-certainty evidence - assessed by overview authors). (3) Antibiotic prophylaxis probably reduce SSI risk in caesarean sections compared with no antibiotics (82 relevant trials, 14,407 participants; RR 0.40, 95% CI 0.35 to 0.46; moderate-certainty evidence; downgraded once for risk of bias - assessed by review authors). (4) Antibiotic prophylaxis probably reduces SSI risk for hernia repair compared with placebo or no treatment (17 trials, 7843 participants; RR 0.67, 95% CI 0.54 to 0.84; moderate-certainty evidence; downgraded once for risk of bias - assessed by overview authors); (5) There is currently no clear difference in the risk of SSI between iodine-impregnated adhesive drapes compared with no adhesive drapes (2 trials, 1113 participants; RR 1.03, 95% CI 0.66 to 1.60; moderate-certainty evidence; downgraded once for imprecision - assessed by review authors); (6) There is currently no clear difference in SSI risk between shortterm compared with long-term duration antibiotics in colorectal surgery (7 trials; 1484 participants; RR 1.05 95% CI 0.78 to 1.40; moderate-certainty evidence; downgraded once for imprecision - assessed by overview authors). There was only one comparison showing negative effects associated with the intervention: adhesive drapes increase the risk of SSI compared with no drapes (5 trials; 3082 participants; RR 1.23, 95% CI 1.02 to 1.48; high-certainty evidence - rated by review authors). Authors’ conclusions: This overview provides the most up-todate evidence on use of intraoperative treatments for the prevention of SSIs from all currently published Cochrane Reviews.

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There is evidence that some interventions are useful in reducing SSI risk for people undergoing surgery, such as antibiotic prophylaxis for caesarean section and hernia repair, and also the timing of prophylactic intravenous antibiotics administered before caesarean incision. Also, there is evidence that adhesive drapes increase SSI risk. Evidence for the many other treatment choices is largely of low or very low certainty and no quality-of-life or cost-effectiveness data were reported. Future trials should elucidate the relative effects of some treatments. These studies should focus on increasing participant numbers, using robust methodology and being of sufficient duration to adequately assess SSI. Assessment of other outcomes such as mortality might also be investigated as part of non-experimental prospective follow-up of people with SSI of different severity, so the risk of death for different subgroups can be better understood. Plain language summary: Overview of Cochrane Reviews of interventions used during surgery for preventing surgical site infection What is the aim of this overview of reviews? To identify and summarise all evidence from Cochrane Reviews on interventions to prevent surgical site infections (SSIs) that are delivered while surgery is taking place (during the intraoperative period). Key messages: We cannot be certain about the effectiveness in preventing SSI of the majority of intraoperative interventions, as we judged the certainty of the evidence to be generally low or very low. In some circumstances (listed below), antibiotics were effective for the prevention of SSI. There is no high- or moderate-certainty evidence for the relative effects of intraoperative interventions on mortality, and no data at all for quality of life or costs. For these reasons, we cannot be certain whether these antibiotics, which are effective at preventing SSI, have any negative effects on mortality or quality of life. Larger trials with appropriate methods are needed to measure the outcomes that are important to both patients and health professionals.

cal gloves, the use of oxygen during surgery, antiseptics for hand washing, patient skin preparation and cleaning the vagina before caesarean section, methods of surgical incision and skin closure and use of antibiotics to prevent infection. Evidence of at least moderate certainty indicates that the following interventions reduce SSI risk: (1) antibiotics administered via drip before caesarean incision reduce SSI risk compared with administration after cord clamping (high-certainty evidence); (2) giving antibiotics before surgery reduces SSI risk compared with placebo after breast cancer surgery (high-certainty evidence); (3) antibiotics used to prevent wound infections probably reduce SSIs for caesarean section compared with no antibiotics (moderate-certainty evidence); (4) antibiotics used to prevent wound infections probably reduce SSI risk for hernia repair compared with placebo or no treatment (moderate-certainty evidence); (5) iodine-impregnated adhesive drapes probably make no difference to SSI risk compared with no adhesive drapes (moderatecertainty evidence); (6) there is probably no difference in SSI risk when antibiotics are given in the short-term compared to the long-term during colorectal surgery (moderate-certainty evidence). One comparison showed that adhesive drapes increase the SSI risk compared with no drapes (high-certainty evidence). Overall, we judged the certainty of evidence for our primary outcomes (SSIs and death) to be low or very low. Clinicians can use the evidence summarised in this overview to choose the best intervention for people having surgery. However, many of the comparisons were supported by low- or very lowcertainty evidence and so require further evidence to support future decision making. This overview can also be used by policymakers in developing local and regional protocols or guidelines and can reveal knowledge gaps for future research. How up to date is this overview? We searched for reviews that had been published up to July 2017. Of the 32 reviews included in this overview, 13 reviews had not been updated in the past three years. m

What was studied in the overview? If bacteria get into a surgical cut during surgery, this can result in a wound infection commonly called an SSI. SSIs are one of the most common forms of healthcare-associated infections, with around 1 in 20 surgical patients developing an SSI in hospital. SSIs can also develop after people have left hospital. SSIs can result in delayed wound healing, increased hospital stays, increased use of antibiotics, unnecessary pain and, in extreme cases, death. Their prevention is therefore a key aim for health services. Many interventions are used to reduce the risk of SSI in people having surgery. These interventions can be delivered at three stages: before, during and after the operation. It is therefore important to identify interventions that can reduce the incidence of SSIs. This overview focuses only on interventions delivered during surgery. What are the main results of the overview? In July 2017 we searched for Cochrane Reviews involving interventions for preventing SSIs during surgery. We found a total of 32 Cochrane Reviews that could be included in this overview. Two reviews had no relevant data to extract so we extracted data from 30 reviews with 349 included trials, totaling 73,053 participants. Interventions assessed included use of disposable face masks and surgi-

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Book Reviews

Book Review The Diabetic Foot Syndrome Editors A. Piaggesi & J. Apelqvist Frontiers in Diabetes, Editor: M. Porta, Vol. 26 Karger 2017. Magdalena Annersten Gershater RN PhD Senior Lecturer Diabetes Malmö University, Sweden

In recent years, “diabetic foot” has become the common name for chronic complications of diabetes mellitus in the lower limb. This book, written by distinguished researchers in the field, provides a picture of the clinical scenario, background mechanisms, current standard of therapy, and a multidisciplinary team approach for meeting the complex needs of each patient. The chapters follow a logical sequence and are of a reasonable size, and the content is clearly stated in the objectives outlined at the beginning of each chapter. In addition, key points, definitions, and facts are highlighted in appropriate boxes. This makes the book easy to read. The book covers a description of the complexity of factors leading up to the diabetic foot’s clinical pathology, Charcot Foot, neuropathy and angiopathy, as well as the role of the comorbidities.

Correspondence: magdalena.gershater@


Treatment strategies are presented such as re-vascularisation, surgical interventions, treatment of infections, the threat of multi-resistant bacteria, different methods for local treatment, as well as the importance of off-loading. The organisation of the team is presented as a time-dependent network. Finally, strategies for keeping the foot in remission ulcer free are presented, as a once-healed foot will always have a high-risk of re-ulceration. The book has many illustrative tables and illustrations (36 figures and 12 tables) that help the reader to understand the messages. The English is clear and easy to understand throughout the different chapters, which will enable its use in higher education for the different healthcare professionals that constitute the multidisciplinary team. EWMA Journal 

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Explorer is the first clinical trial that has been conducted in neuro-ischaemic diabetic foot ulcer to evaluate the efficacy of UrgoStart2 • It is a double-blind randomized controlled trial conducted on 240 patients, in 5 European countries • UrgoStart allowed patients to reach complete wound closure 60 days sooner vs standard of care alone1

1. Edmonds M, Lázaro JL, Piaggesi A, et al. Sucrose octasulfate dressing versus control dressing in patients with neuroischaemic diabetic foot ulcers (Explorer): an international, multicentre, double-blind, randomised, controlled trial. The Lancet Diabetes & Endocrinology. Published online December 20, 2017. 2. D.R. Shanahan. The Explorer Study: the first double-blind RCT to assess the efficacy of TLC-NOSF on DFUs. Journal of Wound Care Vol. 22, Iss. 2, 14 Feb 2013, 78 - 81


EWMA Journal Previous Issues

Volume 18, no 2, October 2017 Evaluation of a newly designed moisture management product for use in women giving birth at the Canberra Centenary Hospital for Women and Children. Broom M, Dunk A M, Sheridan D, McLeod M Advancing professional health care practice and the issue of accountability. Cornock M The changing US healthcare climate: What does it mean for wound care? Nusgart M Core outcome set for Venous leg ulceration “CoreVen” Hallas S, Nelson A, O’Meara S, Gethin G Negative Pressure Wound Therapy: Future Perspectives Apelqvist, J, Willy C, Fagerdahl A, Fraccalvieri M, Malmsjö M, Piaggesi A, Probst A, Wowden P

Volume 17, no 1, April 2017

Other journals EWMA wishes to facilitate the exchange of information on wound healing in a broad perspective with this section on International Journals. English  Open Access!

Authors have the option to set their articles for free access. See the author guidelines on our website:


The International Journal for Prevention and Healing



Use of Oxidized Regenerated Cellulose/Collagen Matrix in Chronic Diabetic Foot Ulcers: A Systematic Review Hypoperfusion and Wound Healing: Another Dimension of Wound Assessment Testing Elevated Protease Activity: Prospective Analysis of 160 Wounds CASE REPORT

Vertical Profunda Artery Perforator Flap for Plantar Foot Wound Closure: A New Application PLUS

Infolink • Payment Strategies • Practice Points

Lippincott Williams & Wilkins


Illness, Normality, and Self-management: Diabetic Foot Ulcers and the Logic of Choice Andersen SL, Pedersen M, Steffen V Spanish

Efficiency in wound care: The impact of introducing a new foam dressing in community practice Kronert GT, Roth H, Searle RJ Negative pressure wound therapy in the treatment of acute pyoinflammatory diseases of soft tissues Obolensky VN, Ermolov AA, Rodoman GV

Volume 16, no 1, April 2016 Development of an Evidence-Based Global Consensus for Diabetic Van Netten JJ, Bakker K, Apelqvist J, Lipsky BA, Schaper NC, Clinical challenges of differentiating skin tears from pressure ulcers LeBlanc K, Alam T, Langemo D, Baranoski S, Campbell K, Woo K Primary Care Patient Safety (PISA) Research Group Samuriwo R, Evans HP, Carson-Stevens A, Rees P, Hibbert P,

Diagnostic and Therapeutic Ultrasound on Venous and Arterial Ulcers: A Focused Review Steven J. Kavros, Robert Coronado Making Keys, Looking for Locks: Technology-Driven Versus Patient-Focused Medical Devices Richard Salcido Use of Oxidized Regenerated Cellulose/Collagen Matrix in Chronic Diabetic Foot Ulcers: A Systematic Review Gisele Chicone, Viviane Fernandes de Carvalho, André Oliveira Paggiaro Hypoperfusion and Wound Healing: Another Dimension of Wound Assessment Wendy Smollock, Paul Montenegro, Amy Czenis, et al.

Haava, no. 4, 2017

Helcos, vol. 28, no. 4, 2017 Norton scaled modified by INSALUD and its differences in clinical practice B Romanos Calvo Validity and Quality indices of the Braden and Norton scales ZM Roa Diaz; DI Parna; FA Camargo-Figuera Pressure Ulcer in heel, in fragile patient multiresistant to antibiotics JC Peralta Polo Venous etiology ulcer with hydrodetersive dressing and multilayer compression bandage E Delgado Roche; B Malla Clua; C Marquilles Bonet

Volume 16, no 2, October 2016

The WAWLC Wound Care Kit for less resourced countries: a key tool for modern adapted wound care Vuagnat H, Comte E

Advances in Skin & Wound Care, Feb, 2018

Wound care research – challenging but essential Leena Salminen, Riitta Suhonen, Minna Stolt Evidence based practice is multidimensional process Anne Korhonen, Hannele Siltanen, Arja Holopainen The graduating nurse and podiatric students´ competence in wound care is inadequate Emilia Kielo, Leena Salminen, Minna Stolt EWMA documents – aiming good and evidence based wound care Salla Seppänen

Lived experiences of life with a leg ulcer - a life in hell Lernevall LSD, Fogh K, Nielsen CB, Dam W, Dreyer PS

The use of clinical guidelines during the treatment of diabetic footulcers in four Nordic countries Annersten M

Volume 31 Number 2 February 2018


Diagnostic and Therapeutic Ultrasound on Venous and Arterial Ulcers: A Focused Review

Debridement method optimisation for treatment of deep dermal burns of the forearm and hand Zacharevskij E, Baranauskas G, Varkalys K, Kubilius D, Rimdeika R

Essential microbiology for wound care Pina E

Advances in


Italian Journal of Wound Care, March, 2018 Community role in caring process for patients with Chronic Wounds Isabella Lo Castro Ultrasonic assisted Wound debridement for Scleroderma Digital Ulcers Antonella Marcoccia, Carlo Salvucci, Tina D’Alesio, Tarquinia Nuzzo, Anoush Vartanian, Tiziana Guastafierri, Maria Grazia Modesti Skin tears: a quantitative study on the phenomenon and proposal for a prevention and management procedure Giulia Candeloro

Challenges faced by healthcare professionals in the provision of compression hosiery to enhance compliance in the prevention of venous leg ulceration Tandler SF Pressure Ulcer Incidence: Do patients retain information? Vowden K, Warner V, Collins J.

The EWMA Journals can be downloaded free of charge from


EWMA Journal 

2018 vol 19 no 1

Journal of Tissue Viability, vol. 27, no 1, 2018

nr 1 • 2018



Risks and prevalence of pressure ulcers among patients in Finland A histological analysis of chronic wounds treated with NPWT Restoring balance: biofilms and wound dressings Evaluation by clinicians and patients of a superabsorbent polymer dressing

Subtheme: Measuring wounds

Att mäta sår 1



Volume 24 Number 1 Pages 1-158 January/February 2017

Volume 25 Number 1 January/February 2017

ISSN 1067-1927


Leczenie Ran vol. 14, no 4, 2017

Assessment and monitoring the risk of bedsores development according to the Norton scale among patients hospitalized in four wards Popow A, Szewczyk MT, Cierzniakowska K et al. Prospective role of ghrelin in wound healing Szczerba K, Janerka M, Jonczyk P et al. Application of dressing for treatment of chronic wounds protracted with infection caused by biofilm microorganisms Bartoszewicz M, Junka A A new method of treatment and debridement of chronic wounds Sopata M, Banasiewicz T, Kucharzewski M et al. Lietuvos chirurgija, vol. 16, 2017

Sår (Wounds), no. 4 - 2017 Moisture damage – or diaper dermatitis Åse Fremmelevholm Fewer wounds – the Danish city Aalborg is best! Jens Fonnesbech Compression guide - For the treatment of oedema in patients with wounds Else Godsk Vestergaard Surgical wounds - the primary sector’s hidden challenge Jane Hampton, Irene Kruse Henriksen, Henriette Rothbøll Neubert Wound Repair and Regeneration, vol. 25, no. 4, 2017


Unphosphorylated PTEN Inhibits TGF-β Mediated β-Catenin Translocation


The Wound Healing Society

The European Tissue Repair Society

The Japanese Society for Wound Healing

The Australian Wound Management Association

WRR_C1-C4.indd 1


Presentation of the The E-medicine for the D-foot



Effectiveness of a monofilament wound debridement pad at removing biofilm and slough: ex vivo and clinical performance Gregory S. Schultz, Kevin Woo, Dot Weir, Qingping Yang Cost-effectiveness of using a collagen-containing dressing plus compression therapy in non-healing venous leg ulcers  Julian F. Guest, Karan Rana, Heenal Singh, Peter Vowden Biological effects of amniotic membrane on diabetic foot wounds: a systematic review André Oliveira Paggiaro, Andriws Garcia Menezes, INTRODUCING Alexandra Donizetti Ferrassi et al Risks and prevalence of pressure ulcers among patients in an acute hospital in Finland Making wound care better, for everyone. Marita Koivunen, Anna Hjerppe, Eija Luotola et al ®



Fotsår vid diabetes

Journal of Wound Care, vol. 27, no 8, 2017

Meek micrografting: history, indications, technique, physiology and experience

Papers from a foot therapist, an orthopaedic engineer, a physician, and nurses. Different aspects of foot ulcer care

volume 27. number 2. february 2018

Official journal of the World Union of Wound Healing Societies

nr 1

En tidskrift från Sårsjuksköterskor i Sverige


Developing the tissue viability seating guidelines Melanie Stephens, Carol Bartley, Ria Betteridge, et al Understanding the association between pressure ulcers and sitting in adults what does it mean for me and my carers? Seating guidelines for people, carers and health & social care professionals M Stephens, C.A Bartley Adaptation of a MR imaging protocol into a real-time clinical biometric ultrasound protocol for persons with spinal cord injury at risk for deep tissue injury: A reliability study Jillian M. Swaine, Andrew Moe, William Breidahl, et al Monitoring the biomechanical and physiological effects of postural changes during leisure chair sitting Peter R. Worsley, Dan Rebolledo, Sally Webb et al English

SÅRmagasinet no 1, 2018 Foot ulcers in Diabetic patients


December 2017


06/03/17 4:18 PM


Cadexomer iodine provides superior efficacy against bacterial wound biofilms in vitro and in vivo DJ Fitzgerald, PJ Renick,EC Forrest, et al. Relationship between Opioid Treatment and Rate of Healing in Chronic Wounds. VK Shanmugam, KS Couch, Sean McNish, et al. Biofilm detection by wound blotting can predict slough development in pressure ulcers: a prospective observational study G Nakagami, G Schultz, DJ Gibson, et al. Evidence of invasive and non-invasive treatment modalities for hypertrophic scars: a systematic review M Kafka, V Collins, Lars-Peter Kamolz, et al.

Wund Management, no 1, 2018 Real-world management of patients with diabetic foot syndrome and peripheral artery disease N. Malyar Biofilms and debridement in case of diabetic foot ulcers A. Elend, C. Hoppe, M. Augustin Below-the-knee revascularizations for the treatment of critical limb ischemia C.A. behrendt, W.P. tigges, H.C. Rieß et al

Pelvic insufficiency fractures: diagnostic and treatment priorities Vaitukaitis G, Petryla G, Satkauskas I, et al. Epidemiologic comparative burn analysis in LUHS hospital Kaunas Clinics during 2003–2005 vs. 2013–2015 Grigaite A, Rainys D, Rimdeika R, et al. First experience of implanting AMS 800 urinary sphyncter Cerniauskienė A, Valatka P Comparison of results of aortic valve replacement through median sternotomy and mini sternotomy in overweight patients Aliahmed HMA, Podkopajev A, Samenienė P, et al. German

Phlebologie, vol. 6, 2017 Quality of life assessment and use of patient-reported outcomes in practice R. Sommer; M. Augustin; C. Blome Direct oral anticoagulants for the treatment of cancerassociated venous thromboembolism - What do we know so far? M. Voigtlaender; F. Langer Local wound therapy of a chronic resistant venous ulcer with Omega3 wound matrix An unconventional procedure for the therapy of chronic wounds A. Cyrek, J. Bernheim, B. Juntermanns, A. Paul Progressive pigmented purpuric dermatosis C. Mitschang; T. Goerge

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EWMA 2018 Conference in Krakow, Poland 9 -11 May 2018 The 28th conference of the European Wound Management Association will be a great event in many ways. The scientific programme will consist of a variety of key sessions, workshops, focus sessions, full-day streams and satellite symposia involving scientists from Europe and other countries around the world. EWMA 2018 is organised in cooperation with the Polish Wound Management Association (PWMA). 62

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The EWMA 2018 Conference gathers the European and international wound management communities with the common goal of improving the care of wound patients. THE CONFERENCE THEME IS

Krakow: New Frontiers in Wound Management The EWMA 2018 Conference will focus on the importance of improved and continued education for physicians, nurses, physical therapists and other healthcare professionals engaged in wound management. EWMA Journalâ&#x20AC;&#x201A;

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Wound care technologies are developing rapidly, offering new treatment options that should be used when proven cost-effective and beneficial to patients. These developments further stress the importance of up-to-date and continued education in an interdisciplinary environment. The technological and educational aspects are two important elements of seeking and expanding new frontiers in wound management. For the first time, the EWMA Conference will be held in Poland, in the historic city of Krakow. With its long history of intellectual heritage and a modern dynamic development, Krakow is an ideal venue for the EWMA 2018 Conference to gather the European and international wound management communities with the common goal of improving the care of wound patients.



PROGRAMME HIGHLIGHTS KEY SESSIONS Topics to be highlighted at EWMA 2018 cover the advancement of research in relation to epidemiology, pathology, diagnosis, prevention and wound management. Additional guest sessions will be held to discuss wound healing and management and to promote cooperation and networking.


How to Read a Paper. Understanding the Basics




Eczema in Leg Ulcer Patients


Diabetic Foot – Assessments, Offloading and Footwear

Patient Repositioning and the Properties of the Patient Support Surfaces Used n

KEY SESSIONS INCLUDE: n Opening Key Session: Krakow: New Frontiers in Wound Management

Core Outcome Set for the Reporting of Trials in Venous Leg Ulceration (CoreVen) Consensus Meeting

n Leg Ulcers and the Prevention of Recurrence - The Current State of the Art

n Cooperating Organisations’ Wound Centre Experiences

n Atypical Wounds - Tools for Diagnostics and Modern Treatment n Information Technology

in Wound Care

n When Wound Management Meets the Economic Dimension n

Wound Diagnostics and Assessment

n Advanced Therapies in Wound Management Challenges and Opportunities

Focus on Skin Heath: Preventing Skin Tears, Pressure Injuries and Moisture-Associated Skin Damage n


FOCUS SESSIONS EWMA focus sessions foster more in-depth discussions than the workshops allow. Focus sessions include: n Why Doesn’t Every Wound Care Patient Adhere to Health Regimens? n

Wounds, Taking Pain into Account


Atypical Wounds - What Is Your Diagnosis?

n The Challenges, Innovations and Collaborations in Lymphoedema/Chronic Oedema Management n




Scar Management: What Is New?


Undergoing Operations Safely with an Aspect of SSI

n Diabetic Foot Symposium: IWGDF Guidance: Wound Management

WORKSHOPS EWMA 2018 will also offer a variety of interactive workshops, giving participants an opportunity to address and elaborate on particular aspects of the session themes. WORKSHOPS INCLUDE: n Managing Wounds after Discharge - Case Studies Discussion Workshop

n The Role of the Micro-Environment for Bacterial Persistence in Chronic Wounds

GUEST SESSIONS The 2018 programme offers guest sessions from several organisations that are active in thematic issues related to wound healing and management. These organisations include: n

Association of Diabetic Foot Surgeons (ADFS)

Cardiovascular and Interventional Radiological Society of Europe (CIRSE) n

n Dystrophic Epidermolysis Bullosa Research Association (DEBRA) n


Wounds across the Life Span

European Burns Association (EBA)

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European Council of Enterostomal Therapy (ECET)


European Pressure Ulcer Advisory Panel (EPUAP)

n European Society for Clinical Nutrition and Metabolism (ESPEN)

Chinese partner, Chinese Tissue Repair Society (CTRS), on Thursday 10 May, 11.15–12.15. A number of abstracts will also be presented in high-level free paper sessions, and as e-posters and paper posters on display throughout the event.

n European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) n

European Tissue Repair Society (ETRS)


International Lymphoedema Framework (ILF)

World Alliance for Wound & Lymphedema Care (WAWLC) n

Stay informed by visiting the conference website,, for more information about the programme. You can also find updates on EWMA’s social media platforms.

An international partner session will be hosted by EWMA’s EWMA Journal 

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KRAKOW, POLAND MAY 09 – 11, 2018 Visit us at Booth W308

SILPURAN® – The biocompatible silicone from Wacker Chemie gives you consistent high quality for efficient manufacturing processes. SILPURAN® provides an optimal wound healing environment and enables atraumatic wound dressing changes. Minimizing pain. Maximizing quality of life. Wacker Chemie AG, München, Germany, Tel. +49 89 6279-0 Contact: Dr. Manuela Beckmann,,


New EWMA document:

Advanced therapies in wound management Presentation of the “Advanced Therapies in Wound Management” document is the main topic of a key session at EWMA 2018 scheduled for Wednesday, 9 May in “Wisla Session Room”.

Alberto Piaggesi, Document Editor

MD, Prof. Director of the Diabetic Foot Section of the Pisa University Hospital, Department of Endocrinology and Metabolism, University of Pisa, Italy EWMA Scientific Recorder

This article introduces a new document from the European Wound Management Association (EWMA), aiming to outline the current situation, challenges and opportunities related to the introduction of new advanced therapies in wound management in the clinic. Here, the document contents and structure are briefly presented to the potential readers of the full document. This will be published as an online supplement to the Journal of Wound Care in May 2018. Backgrounds and aims With this document, the European Wound Management Association (EWMA) aims to investigate the barriers and possibilities of advanced therapies in next-generation wound management, including technologies based on cellular therapies, tissue engineering and tissue substitutes, which are all associated with the clinical discipline of regenerative medicine. The document also describes new treatments based on physical therapies and the potential of sensors, software and internet technologies. EWMA wishes to be on the forefront of the development of new, sustainable, cost-effective advanced therapies and to examine further how these may support the continuous improvement of wound management with regard to patients’ quality of life while also providing a more effective and efficient approach to wound management. EWMA Journal 

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The objectives of this document are to: n Review and discuss clinical experiences and the scientific evidence where this is available; n Provide an objective and exhaustive overview

of the available therapies and their potential roles in clinical practice and make recommen dations for the implementation of these therapies in the different areas of wound management;

n Analyse


n Discuss the regulatory framework for advanced therapies in Europe, providing a point of referral for future discussions and negotiations with health care providers and payers. 

Conflicts of interest: The document is supported by unrestricted educational grant from: Aurealis Pharma, Klox Technologies, MiMedx, Organogenesis, Reapplix, URGO.

and debate cost-effectiveness issues related to the included therapies; and


Due to the general lack of scientific documentation for many of these emerging therapies, the document is based on the available literature and experts’ opinions. It includes an evaluation of the potentials for future use in clinical practice and a call for research in recommended areas.

n Epidermal substitutes, dermal substitutes and dermo-epidermal substitutes

Definition of advanced therapies The group of authors responsible for this document agreed on the following definition for the term ‘advanced therapies’. It has been adopted as a basis for selecting relevant technologies for inclusion in this publication.

Physical therapies: This section describes advanced therapies using shock waves (ESWT), electro-magnetic fields (EMF), photobiomodulation (PMB) and nanotechnologies (NT).

The therapies related to chronic wound management can be defined as ‘advanced’ when they are based on novel principles and technologies, or when they refer to a novel application of consolidated principles and technologies, including either a singular mechanism of action or a strategy with different levels of action, given that some evidence has been produced in a measurable and comparable way by the manufacturers/developers. For the sake of this document, advanced therapies will be grouped according to their nature in four different categories: materials, cell and tissue engineering, physical and bio-physical, and sensors and IT-related. Document contents The document is organised into six sections; four of them deal with the different areas of advanced therapies and are, in order of position in the document, dedicated to: Materials: This section describes advanced therapies based on films, foams, hydrocolloids, hydrogels, alginates and acellular matrices, including their previous, current and future uses. Cell- and tissue-based therapies: This section includes a chapter highlighting advanced therapies based on cells, including: n Stem cells, including bone marrow stem cells, keratinocytes and fibroblasts, adipose-derived stem cells and other cells n Scaffolds,

including carrier systems

n Skin substitutes, including cellular non-living allografts, placental-based allografts, bioengineered skin substitutes and skin substitutes for in-vitro and in-vivo applications n Tissue-based therapies, including autologous blood derivatives for wound care and advanced cell therapies;


n Melanocytes,

vessels and genetic manipulation, and


Smart technologies: This section describes the wearables and applications available to manage chronic ulcers ‘smartly’, including: n Wearable devices; n Wearable n Modern n Mobile

wound therapy;

wound dressings, including sensors;

health (m-health); and

n The ‘Internet of Things’ in the remote management of wounds.

The document also includes two sections dedicated to the economic and regulatory aspects of advanced therapies in wound management. The aim of these sections is to provide a different perspective on this complex and fastevolving field, bridging the gap between the technologies and their inception in the real world of wound healing. The document is concluded with a “wish list”; a separate concise section including ten points that highlights crucial aspects to be addressed with regards to supporting proper evaluation and potential implementation of relevant advanced therapies in wound management. This final section is included as a potential tool for addressing future issues and controversies in this challenging and promising field. This tool targets health care professionals as well as administrators, decision makers and regulators. The list is followed by a paragraph in which EWMA describes the potential role of a European clinical and scientific association with regards to supporting the realisation of the promises that advanced therapies makes to wound healing. The authors hope that reading this document will be not only interesting for scientists and clinicians, but also helpful for all the stakeholders in the field of wound management, assisting them in building a better future for our patients. The wish list - for a better future Based on an extensive review and critical reappraisal of the existing evidence, and of the problems related to the EWMA Journal 

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implementation of new technologies in wound healing, the authors responsible for this EWMA position document agree on the following recommendations for future developments:

related to poor knowledge of the basic principles of the new technologies and their materials among health care professionals. Their level of knowledge may eventually be improved by translational science initiatives aimed at bridging the technological gap.

1. Development of new technologies: As the development

of new technologies is a time- and resource-consuming process, often lasting several years, companies interested in developing and introducing both new technologies and medical devices for wound healing are advised to consult preliminarily with an interdisciplinary team of stakeholders, including basic scientists, bioengineers and clinicians with a specific expertise in wound healing, in order to test the originality and applicability of their ideas/projects.

5. The need for investments in research: Important

2. Health technology assessments (HTAs): The limited

6. Access to new technologies in the EU: The possibility

financial resources in all health care systems across Europe (which are typically financed via a taxpayer system) emphasise the need for an adequate allocation of resources based on updated evidence and principles of cost-effectiveness. HTAs have become the standard approach whenever new technologies are proposed for introduction in the field. The fact is that HTA procedures vary from country to country, or, in some cases, from region to region within a country. As part of a rationalisation process, which should be promoted and endorsed by the EU in the framework of legislative action, HTA procedures should be defined and standardised across the EU. This would simplify the process of bringing new technologies from the lab to the patients. It would also reduce the amount of resources that companies must invest in these procedures, eventually saving them further research activities.

of accessing new technologies varies significantly across the different countries in the EU, not only for the reasons described below in Items 7 and 8 in this list. Another key factor in ensuring the accessibility of new technologies is that the companies are willing to market the new technologies in all European countries, despite the economic arguments for targeting certain countries before others. When new technologies are not available across the European health care systems, this creates idiosyncrasies in the actual possibility of patients being treated with new technologies. Companies are thus advised to extend their diffusion of new technologies across Europe to the extent that it is possible.

3. Implementation of new technologies in clinical practice: In order to bridge the gaps that almost unavoidably

develop between the realisation of new technologies and their implementation in clinical practice, it is important to define minimum standard requirements for testing/ implementation in clinical practice. These requirements must be related to Items 1 and 2 in this list, tested under controlled conditions and following the recommendations of good clinical research. RCTs are the preferred approach. However, due to the cost- and method-related difficulties linked with the organisation of an RCT, prospective observational trials may be considered, if they are independent and relevant for wound management. 4. Translational science: Despite the increasing number of

options in terms of the variety and quality of technologies available for clinical use in wound management, there is a diffuse underuse of new technologies the moment they become available to clinicians. Often, the implementation in clinical practice does not meet the expectations of the manufacturers. One major component of this bias is EWMA Journalâ&#x20AC;&#x201A;

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economic resources are needed to sustain the growth of research and the development of new technologies for wound management. Beyond the commercial interests of the industries in the field, institutions at the European level must also recognise the importance of investing in a field that will interest one out of four EU citizens over the next decades.

7. Regulatory controversies: Regenerative medicine is on

the rise and about to shift the focus from replacing and repairing tissue to regenerating it. Although regenerative medicine is not yet a reality in wound management, the on-going development of activities in the field of Advanced Therapy Medicinal Products (ATMPs) holds the realistic promise of revolutionising standard treatment. Gene therapies producing wound-healing factors may soon become a reality and open new horizons for treatments. Most regenerative medicines are classed as ATMPs and are thus confronted with high product and development standards. Thus, their development can be very challenging for companies due to the inherent complexity of the products. In particular, detailed EU guidance related to emerging gene editing technologies is available, but it is missing, so far, for wound management-related endeavours. It would be advisable to engage with regulatory authorities in the future, in order to make them aware of the challenges related to the development of medical products for wound management, and this lack of guidance. This will hopefully lead to the development of specific guidelines from which product developers can benefit in the future. î&#x201A;Š



8. Definition of outcomes, direct and indirect costs: Cost

studies vary in approach and quality. The wide variety of outcome measures and costs hinder comparisons of interventions and progress. Thus, there is an increasing need to define outcomes, direct costs and indirect costs that should be included in the economic evaluations clearly. Promoting research and clinical trials on advanced therapies, and involving health economists and health statisticians in the planning, execution and analysis of the studies, is essential for ensuring the appropriate economic assessment of the impact of these interventions. Moreover, given the paucity of studies on the quality of life of patients, more analyses focusing on this dimension should be performed.

This is how life feels to people with EB. Their skin is as fragile as a butterflyâ&#x20AC;&#x2122;s wing. They have Epidermolysis Bullosa, a painful and currently incurable skin blistering condition.

9. The growth of a wound care-centred research field within the telemedicine and wearables milieus: Technologies

such as telemedicine and wearables enable the reduction of in-person visits and allow physicians to check on patients remotely, track patient adherence to prescribed therapies, detect the early stages of serious medical conditions and triage those who need immediate supervised care. While the application of such technology for effectiveness of diabetic foot care is still in its infancy, and its cost-effectiveness is still debated, it is anticipated that general healthcare and chronic wound care delivery will change dramatically in the near future. Thus, more research is recommended in this field to translate these telehealth technologies into better management of chronic wounds and improve patient-centred outcomes, including the number of in-person visits. 10. Evaluation of outcomes: A major challenge for a fair

comparison between new technologies and conventional therapies is the lack of consensus and guidelines for the standardisation of reporting of outcomes. In addition, new outcomes that are more sensitive to new technologies should be defined and standardised (e.g., number of inperson visits for telehealth applications, levels of restriction in mobility during the wound healing phase, etc.). Moreover, most research in the area of chronic wound management is currently focused on wound outcomes during the wound-healing phase, not taking into consideration the high rate of recurrences. It is recommended that the time to recurrence of ulcers, as well as their frequency, also be taken into consideration when examining the effectiveness of new technologies. m



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EWMA Publications

New and coming soon: Publications in 2017- 2018 New EWMA document:

ADVANCED THERAPIES IN WOUND MANAGEMENT CELLS AND TISSUE-BASED THERAPIES, PHYSICAL AND BIO-PHYSICAL THERAPIES, SMART AND IT-BASED TECHNOLOGIES. HEALTH ECONOMICS AND REGULATORY ISSUES The document will be published as an online supplement to the Journal of Wound Care in May 2018. With this document, EWMA aims to investigate the barriers and possibilities of advanced therapies in the next generation of wound management, including technologies based on cellular therapies, tissue engineering and tissue substitutes, which are all technologies associated with the clinical discipline of regenerative medicine. The document will also describe new treatments based on physical therapies and the potential of sensors, software and internet technologies. The topic will be presented and discussed in a key session and debate session during the EWMA 2018 Conference: Wednesday 9 May 16.45-18.30 Room: WISLA SESSION ROOM

New EWMA document:

WOUND CURRICULUM FOR NURSES POST-REGISTRATION QUALIFICATION WOUND MANAGEMENT EUROPEAN QUALIFICATION FRAMEWORK LEVEL 5 The wound curriculum for nurses (EQF level 5) was published as an online supplement to the Journal of Wound Care in December 2017. EWMA has just finalised this first curriculum in a series of several curricula intended for use in levels 5–7 of the European Qualifications Framework (EQF). The aim of these is to support a common approach to post-registration qualification in wound management for nurses across Europe. EWMA hopes for and will work towards a close collaboration with European nurse organisations, as well as educational institutions, to implement these common curricula. The curriculum will be presented and discussed in the EWMA Education session during the EWMA 2018 Conference: Wednesday 9 May 16.45-17.45 Room: Praga A


EWMA Journal 

2018 vol 19 no 1

A SURVEY OF PRACTICE AND OPINIONS ON THE USE OF TOPICAL ANTIBIOTICS TO PREVENT SURGICAL SITE INFECTION: MORE CONFUSION THAN CONSENSUS The paper was published in the Journal of Antimicrobial Chemotherapy in March 2018 and can be downloaded free of charge via EWMA has taken part in this survey which was made among EWMA and BSAC members. The objectives of this survey were to determine the extent of the use of topical antibiotics to prevent surgical site infections (SSI) in clinical practice, and to gather the opinions of healthcare professionals most likely to be involved in their use.

WOUND HEALING CENTRES: HOW DO WE OBTAIN A HIGH QUALITY? EWMA WOUND CENTRE ENDORSEMENT PROJECT The paper is accepted for publication in the Journal of Wound Care and will be published in the May 2018 issue. This article describes the background and objectives of the EWMA Wound Centre Endorsement Project. This project aims to describe the minimum requirements for a wound management centre, as a basis for evaluation and endorsement of wound centres inside as well as outside a hospital setting.

NON-ANTIBIOTIC ANTIMICROBIAL INTERVENTIONS AND ANTIMICROBIAL STEWARDSHIP IN WOUND CARE The paper is accepted for publication in the Journal of Wound Care and will be published in the June 2018 issue. This paper is written by Rose Cooper and Klaus Kirketerp-Møller and is published as a deliverable under the EWMA/BSAC Antimicrobial Stewardship Programme. In this narrative review, current and emerging non-antibiotic antimicrobial strategies will be considered and the need for antimicrobial stewardship in wound care will be explained.

PREVENTING AND MANAGING SURGICAL SITE INFECTIONS The document will be published winter 2018/2019. While guidelines for preventing and managing surgical site infections in hospitals are in place in many countries, there is still a need for guidance on how to deal with SSI management and prevention in community care. A set of recommendations on this topic – covering both primary and secondary care, and targeting health care professionals in hospitals as well as community based nurses and general practitioners (GPs) – does not yet exist. EWMA has therefore decided to focus on surgical site infections (SSI) in a new project aiming to provide guidance on management of SSI across the primary and secondary health care sectors.

For download or more information about the above publications and initiatives, please visit or contact the EWMA Secretariat:

EWMA Journal 

2018 vol 19 no 1



EWMA 2018


The EWMA UCM programme offers students of wound management from institutes of higher education across Europe the opportunity to take part of their academic studies whilst participating in the EWMA Conference.


The opportunity of participating in the EWMA UCM is available to all teaching institutions with wound management courses for health professionals. The UCM programme at the EWMA 2018 Conference in Krakow will offer networking opportunities between the students from variours UCM groups, UCM Lectures as well as assignments and workshops arranged specifically for the UCM Students. EWMA strongly encourages teaching institutions and students from all countries to benefit from the possibilities of international networking and access to lectures by many of the most experienced wound management experts in the world.

For further information about the EWMA UCM, please visit the Education section of the EWMA website or contact the EWMA Secretariat

Yours sincerely Christian MĂźnter Chair of the Education Committee


Zena Moore1 Professor of Nursing and Head of the School of Nursing & Midwifery, Royal College of Surgeons in Ireland Jose Verdu Soriano1 Senior Lecturer and researcher at the Faculty of Health Sciences. University of Alicante, Spain Andrea Pokorna2 Associate Professor, Department of Nursing, Faculty of Medicine, Masaryk University, Brno Schoonhoven2

Lisette Professor of Nursing, Faculty of Health Sciences, University of Southampton Hubert Vuagnat2 Head of Division of the Department of Rehabilitation and Palliative Care. University Hospitals of Geneva 1 Chair of the Joint EPUAP & EWMA Pressure Ulcer Prevention & Patient Safety Advocacy Project 2 Member of the Joint EPUAP & EWMA Pressure Ulcer Prevention & Patient Safety Advocacy Project

Since 2016, The European Pressure Ulcer Advisory Panel (EPUAP) and EWMA have collaborated on a joint European advocacy project. The overall aim is to establish a joint EPUAP - EWMA engagement in the Pressure Ulcer (PU) prevention and patient safety agendas at the European level as well as at the national level in selected European countries. Looking at the patient safety agenda from a wound care perspective, the topic of PU prevention has always been central due to the fact that most PU’s are preventable if the patient is managed correctly by health care staff. This is the fourth article published by the joint EPUAP-EWMA initiative regarding European perspectives on PU prevention. All four articles are available for free download at where further information about the joint initiative also can be found.

EWMA & EPUAP addedvalue to OECD efforts Since its inception in 1948, OECD has provided a forum where member countries can compare and exchange policy experiences, identify good practices and promote recommendations. In this framework, in January 2017, Health Ministers asked OECD to help them reorienting health systems to become more patient-centred, shifting the focus towards the needs of individuals, and changing the way health systems are structured and how their performance is measured in the future.1

Correspondence: Conflicts of interest: None EWMA Journal 

In the past ten years, the work of OECD has provided a valuable contribution in fostering patient safety policies and studies throughout data collection and data measurement (i.e. OECD indicators). The core of OECD’s work on patient safety is defined by the Health Care Quality Indicators (HCQI), which are underpinned by a continuous programme of research and development to improve their international comparability. As for the other OECD indicators, the research on the HCQI on patient safety data is carried out to improve international comparisons and eco-

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nomic analyses of health systems. The results of the research are included in the annual publication “Health at a Glance” which reports the most recent comparable data on the health status of populations and health system performance in OECD countries.2 Initiated in 2001, the Health Care Quality Indicators project aims at measuring and comparing the quality of health service provision in different countries. The HCQI collects comparable data on two types of patient safety events: ‘sentinel events’ that should never occur (e.g. failure to remove surgical foreign bodies) and ‘adverse events’ which cannot be fully avoided given the high-risk nature of some procedures (e.g. postoperative sepsis, infections, post-operative wound dehiscence). From 2016, OECD Patient Safety Indicators and their uses have been monitored 



through the reports on their implementation and, more recently, through the OECD report on the Economics of Patient Safety.3 OECD is not alone in this effort: financially supported by the European Commission, the organisation can count on 250 committees, working groups and expert groups, including representatives of the 35 OECD member countries, civil society and associations working in related fields. Towards the years, the health expert groups have developed a set of quality indicators at the health systems level, which allows to assess the impact of particular factors on the quality of health services. EPUAP and EWMA contribute to the ongoing activities of the Health Care Quality Indicators Expert Group, bringing attention to their important inputs on wound care and pressure ulcer prevention. For example, the EPUAP and EWMA commitment and expertise have been instrumental in building support for a consistent measurement methodology and definitions, training surveyors for direct patient observation and comparing results against organizational, national and/or international data sets.

events on how to share information about pressure ulcers. In line with this, the Declaration of Rio was launched in 2012 speaking out against people developing pressure ulcers. As part of the OECD HCQI work on international measurement methodology, the organisation is in a good position to reach out to the European community and inform them more about pressure ulcers. This possible collaboration could boost the ties between the organisation, civil society and patients. OECD can benefit from the combined efforts, skills and knowledge of both EWMA and EPUAP to raise the awareness of pressure ulcer prevention and management at the European level, as well as at the national level of several European countries. REFERENCES 1. OECD Health Ministerial Meeting, Ministerial Statement: The Next Generation of Health Reforms, 17 January 2017. Available at: ministerial/ministerial-statement-2017.pdf 2. OECD, Health at a Glance 2017, 10 November 2017. Available at: http://www.oecd. org/health/health-systems/health-at-a-glance-19991312.htm 3. OECD, Health Care Quality Indicators Project and Patient Safety. Available at: http://

In this regard, both EWMA and EPUAP are now working with the OECD to explore approaches to international calculation and reporting on pressure ulcer indicators in acute and long-term care settings, to help underpin the monitoring of national pressure ulcer prevention programmes. In particular, the EPUAP and EWMA are currently involved in the discussion on the progress in scoping of alternative measurement systems for assessing patient safety in longterm care including data collection. In the frame of their collaboration with OECD, the two organizations strongly advocate for a consistent methodology on data measurement by suggesting tackling the dichotomy between prevalence and incidence data, which yield two very different data. Incidence measures the probability of occurrence of a given medical condition in a population within a specified period of time, while prevalence is the proportion of cases in the population at a given time rather than rate of occurrence of new cases. The initial focus of international measurement efforts by the OECD is focussed on establishing prevalence measurement by key care settings. EPUAP and EWMA can give further contribution to OECD activities and expert groups. Among the initiatives open to collaboration, it is worth mentioning the EPUAP campaign “Stop Pressure Ulcers” aiming at boosting educational activities on prevention and treatment of pressure ulcers, and organising awareness campaigns and


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15 Scientific Meeting of the th

Diabetic Foot Study Group of the WASD

Joint 4th ADFS Annual Conference and King’s Charcot Foot Reconstruction Symposium 28 - 29 June 2018 London · United Kingdom Venue: The Kia Oval

Berlin · Germany · 28 - 30 September 2018 Conference theme

Advancement of knowledge on all aspects of diabetic foot care Main subjects during conference ● ● ● ● ● ● ● ● ● ● ●

Epidemiology Basic and clinical science Diagnostics Classification Foot clinics Biomechanics Orthopaedic surgery Infection Revascularisation Uraemia Wound healing and outcome International speakers

Early registration deadline

6 June 2018

Luca D. Paola (IT) Dane K. Wukich (US) Robert G. Frykberg (US) Klaus Kirketerp-Møller (DK) Armin Koller (DE) Alberto Piaggesi (IN)

Javier A. Sánchez (ES) Thomas Zgonis (US) Arun B. Bal (IN) Chris Attinger (US) Alexandru Georgescu (RO) Talal Elenizi (QA)


Updates from the EWMACommittees

COOPERATING ORGANISATIONS LIAISON GROUP (COLG) The COLG consists of the five members of the EWMA Council who are elected by the Cooperating Organisations Board and the Chair of the Cooperating Organisations Board (the EWMA Immediate Past President). The COLG is responsible for coordinating and overseeing activities related to EWMA’s collaboration and activities with the cooperating organisations. In particular, this includes the planning and coordination of the annual Cooperating Organisations Board meeting and participation in meetings with representatives of the cooperating organisations, which often take place during the EWMA conference. CURRENT MEMBERS: Severin Läuchli, Switzerland (EWMA Immediate Past President, Chair), Selcuk Baktiroglu, Turkey, Barbara den BoogertRuimschotel, the Netherlands, Pedro L. Pancorbo Hidalgo, Spain, Kirsi Isoherranen, Finland, Massimo Rivolo, United Kingdom

EDUCATION COMMITTEE The objectives of the EWMA Education Committee are to propose flexible frameworks for the delivery of interdisciplinary wound management education across Europe and to raise the profile of wound care education in relevant educational institutions in Europe and internationally. Current activities include the development and updating of topic-specific Education Modules, the endorsement of European wound management courses provided by other organisations or institutions around the world, the development and publication of curricula for nurses covering European Qualification Framework (EQF) levels 5–7 and the development of an e-learning tool on the basics of wound management targeting non-specialists. CURRENT MEMBERS: Christian Münter, Germany (Chair), Luc Gryson, Belgium (Co-chair), Selcuk Baktiroglu, Turkey, Samantha Holloway, United Kingdom, Edward Jude, United Kingdom, Julie Jordan O’Brien, Ireland, Kirsi Isoherranen, Finland, Andrea Pokorná, Czech Republic, Jürg Traber, Switzerland, Sebastian Probst, Switzerland, Sara Rowan, Italy, Evelien Touriany, Belgium

SCIENTIFIC COMMITTEE The Scientific Committee is responsible for the organisation and planning of EWMA’s scientific conferences. In particular, this committee is responsible for designing the scientific programme of the conferences, including the selection of focus topics and speakers and the evaluation of abstracts. CURRENT MEMBERS: Alberto Piaggesi, Italy (EWMA Scientific Recorder), Magdalena Annersten Gershater, Sweden, Georgina Gethin, Ireland, Severin Läuchli, Switzerland, Edward Jude, United Kingdom, Jan Stryja, Czech Republic, Christian Münter, Germany, Kirsi Isoherranen, Finland, Sebastian Probst, Switzerland, Sue Bale, United Kingdom, Maciej Sopata, PWMA (EWMA 2018), Arkadiusz Jawien, PWMA (EWMA 2018), Britt Ebbeskog, SSiS (EWMA 2019), Eila Sterne, SSiS (EWMA 2019)


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PATIENT LIAISON GROUP The objectives of the EWMA Liaison Group are to establish a closer link between EWMA and patient representatives, to strengthen the involvement of patients and their relatives in the wound management process and to develop and maintain guidance information for patients with non-healing wounds. The overall aim of the Patient Liaison Group is to ensure that patients are aware of their rights to treatment, and the group aims to support equal access to high quality wound management across Europe. Currently, the group is working to establish a panel of patient representatives and to further develop patient information for the EWMA website. CURRENT MEMBERS: Sebastian Probst, Switzerland (Chair), Mark Collier, United Kingdom, Georgina Gethin, Ireland, Luc Gryson, Belgium, Arkadiusz Jawien, Poland, Salla Seppänen, Finland

PATIENT OUTCOME GROUP The overall objective of the Patient Outcome Group is to address topics that are relevant to health care professionals, patients and the industry. The group includes current and previous members of the EWMA Council and medical directors or regulatory affairs managers from the wound care industry. Topics discussed may relate to the structure of treatment, how to raise the quality of wound management studies, reimbursement issues and legislation related to the introduction of traditional products or advanced therapies in clinical practice. In the end, each of these topics has an influence on the outcomes of patients’ treatment. CURRENT MEMBERS: Jan Apelqvist, Sweden (Chair), Christian Münter, Germany, Alberto Piaggesi, Italy, Luc Teot, France, Pedro L. Pancorbo Hidalgo, Spain, Industry representatives

WOUND CENTRE ENDORSEMENT COMMITTEE The Wound Centre Endorsement Committee is working on a programme for wound centre endorsements in collaboration with the cooperating organisations of EWMA. The EWMA Wound Centre Endorsement Programme aims to support the establishment of European and international collaboration and knowledge sharing about the development and maintenance of high quality wound centres. The endorsement process focuses, among other things, on the centres’ access to a multidisciplinary team of health care professionals, referral routes and evidence-based wound management. The group has just finalised the first endorsement of a European wound centre. During the EWMA 2018 Conference in Krakow, a course for reviewers representing national associations will take place for the first time. This is a pilot version of the final course to be developed for wound centre reviewers who will represent EWMA and the national associations that decide to engage in the programme. CURRENT MEMBERS: Hubert Vuagnat, Switzerland, Luc Gryson, Belgium, Andrea Pokorna, Czech Republic, Finn Gottrup, Denmark, Barbara Esther den Boogert-Ruimschotel, the Netherlands, Christian Münter, Germany

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KCI an Acelity Company A global advanced wound care company committed to developing innovative healing solutions for customers and patients across the wound care continuum.

We deliver value through solutions that aim to speed healing and lead the industry in quality, safety and customer experience, offering unparalleled service to support clinicians in the management of patients and therapies. Available in 90 countries, KCI products offer wound healing solutions to manage all types of wounds including complex acute and chronic wounds, open abdomen and closed surgical incisions. Headquartered in San Antonio, Texas, Acelity employs nearly 5,000 people around the world. We have a global commitment to advancing the science of healing. Our portfolio includes negative pressure wound therapy, advanced wound dressings, negative pressure surgical incision management and epidermal harvesting. At KCI, we take Diabetic Foot Ulcers (DFUs) seriously. DFUs are a major issue globally with considerable economic and human cost. Our portfolio of Advanced Wound Therapy is designed to offer you the right solutions at the right stage of healing. For wound cleansing, V.A.C. VERAFLO CLEANSE CHOICE™ Dressing, when used with V.A.C. VERAFLO™ Therapy, can be used to initiate immediate wound cleansing therapy and it may be considered when surgical debridement is not appropriate. V.A.C. VERAFLO™ Therapy consists of NPWT coupled with automated, controlled delivery and removal of wound topical treatment solutions from the wound bed. 80

For delayed healing as, inflammatory protease activity increases and the probability of healing decreases without appropriate intervention, PROMOGRAN PRISMA™ Wound Balancing Matrix helps promote healing and prevent infection; for infected wounds we offer a full range of antimicrobial solutions to include: SILVERCEL™ NON-ADHERENT Hydro-Alginate Antimicrobial Dressing with Silver with EASYLIFT™ Precision Film Technology, TIELLE™ PHMB Antimicrobial Foam Dressings, INADINE™ PVP-I Non-Adherent Dressing. V.A.C. VERAFLO™ Therapy can be used in the management of infected wounds through the removal of infectious material. For an effective management of exudate, KCI offers a full range of foam TIELLE™ Dressings and the new addition of gelling fibre, BIOSORB™ Gelling Fibre Dressing. Our NPWT solutions like V.A.C.® Therapy can be used to manage heavily exuding, deep DFUs following surgery. As an alternative to conventional forms of NPWT, KCI offers single-use disposable NPWT solutions to treat smaller DFUs, with low to moderate exudate levels. Easy to use and portable, the SNAP™ Therapy System combines the simplicity of a SNAP™ advanced wound dressing with the benefit of negative pressure therapy in a discreet design. Visit us at EWMA 2018 at our stand W410, ask for a demo and learn more about how we can help you with managing DFUs.

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Fidia Pharma Group Several decades of unparalleled experience have enabled the company to develop innovative solutions in key therapeutic areas where hyaluronic acid properties can be effectively, efficiently, and rationally exploited, such as joint care and wound care.



Hyaluronic acid (HA), in particular LMW (200 kDa) HA, promotes physiological cellular processes that are essential in tissue repair. The local use of HA, combined with other active components, supports the various stages of tissue repair and wound healing, thereby creating the ideal conditions for migration and proliferation of cells that form new tissue. Fidia Pharma Group has developed a unique and exclusive product portfolio, based on hightech, hyaluronan bioactive treatments, to manage acute and chronic lesions.

The launch of the new Advanced Dressing line and of the Regenerative Medicine products, is a milestone in the relaunch of Fidia Pharma Group’s tissue repair project, and a further step in the expansion of the company’s AWC portfolio. In addition, it will anticipate new upgrades in the bioactive and advanced medication portfolio, as well as in the Regenerative Medicine market segment, thereby enabling Fidia Pharma Group to build a sustainable, global leadership position in the AWC market segment, with new products and upgrades.


The company is also increasing its global portfolio, including products and line extensions in women’s health and aesthetic medicine, and continues to be strongly focused on the CNS and ophthalmic therapeutic areas, with important R&D projects at various stages of development.

More recently, the company has announced the expansion of its Advanced Wound Care (AWC) portfolio and entry into the Advanced Dressing and Regenerative Medicine market, with a new line of polyurethane foams and hydrocolloid dressings, as well as some innovative technologies for the processing of vascular stromal fraction and blood. The objective is the development of a synergic protocol with HA-based products and cell therapies, to evolve from the current wound management approach to an innovative protocol of wound treatment. EWMA Journal 

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Juzo - The effective oedema therapy

When the lymphatic flow is interrupted or impaired, fluid and proteins are retained in the tissue and an oedema develops. Possible causes are missing or damaged lymph nodes. Effective oedema therapy is based on four building blocks: Manual Lymphatic Drainage (MLD), compression therapy, skin care and exercise therapy. These four components are called Complex Physical Decongestive Therapy (CPDT), which consists of two phases – decongestion and maintenance. Oedema therapy aims to improve the lymphatic flow, soften hardened tissue and reduce connective tissue proliferation. Furthermore the movement of the affected extremity should be improved in order to increase the efficiency of the muscle and joint pump. Phase 1: Decongestion phase The transport capacity of the lymphatic system is first increased with the aid of Manual Lymphatic Drainage to enable the protein-rich oedema fluid to be moved and transported away. Compression is then applied to the decongested extremity using compression dressings, bandages or adjustable compression systems. This prevents the fluid from flowing back and reduces connective tissue proliferation.


Phase 2: Maintenance phase During the second phase, the number of MLD sessions is reduced and the compression dressings / bandages are replaced by flat knitted compression garments in order to optimise the therapeutic results and maintain them over the long-term. Consistent skin care during this phase protects against drying and minimises the risk of infections. Physical activity and decongestive exercises aid in stimulating lymphatic function. The Julius Zorn GmbH offers different compression products and accessories for the therapy of both phases of the CPDT. The employees of the family business in Aichach, Germany giving their best every day to ensure that the products improve the patients’ quality of life and provide lasting relief for their symptoms. It is this conviction that gave rise to our motto “Freedom in Motion”, which is followed by each and every employee of our company.

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Based on an initiative by the current EWMA President, Sue Bale, the EWMA Council has decided to establish a working group which will focus on the development of care bundles for wound management. The care bundles approach is further described in the editorial of this issue. The objective of this initiative is to use care bundles to support the implementation of good wound management practice across Europe. EWMA wishes to do this by providing tools to support the front line staff engaged in wound management, which may also support the establishment of interdisciplinary teams in wound management. The care bundles constitute an existing system for improving care, and the EWMA Council believes that this provides a useful tool to support the implementation of wound management guidelines. EWMA plans to initiate a collaboration with the Institute of Healthcare Improvement (IHI) to develop care bundle programmes for the selected wound aetiologies not yet addressed in care bundles. THE EWMA CARE BUNDLES WORKING GROUP CURRENTLY INCLUDES THE FOLLOWING MEMBERS: Sue Bale (EWMA President, chair, UK), Sara Rowan (Italy), Julie Jordan O’Brien (Ireland), Evelien Touriany (Belgium), Jan Stryja (Czech Republic)

For more information about ‘Care bundles’, please visit the Institute for Healthcare Improvement (IHI),

WOUND CENTRE ENDORSEMENT PROGRAMME & COURSE FOR REVIEWERS The Wound Centre Endorsement Committee is working on a programme for wound centre endorsements in collaboration with the cooperating organisations of EWMA. This initiative is described in an article published in the Journal of Wound Care in May 2018. During the EWMA 2018 Conference in Krakow, a course for reviewers representing national associations in Europe will take place for the first time. This is a pilot version of the final course to be developed for wound centre reviewers who will eventually represent EWMA and the national associations that decide to engage in the programme. The EWMA Wound Centre Endorsement programme will be discussed with representatives of the national associations in Europe during the EWMA Cooperating Organisations Board meeting. Furthermore, you can hear about national wound centre endorsement/certification programmes in the session Cooperating Organisations Wound Centre Experiences held during the EWMA 2018 Conference, Wednesday 9 May at 16.45-18.00.

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SUCCESSFUL SESSION ON NON-ANTIBIOTIC ANTIMICROBIAL ALTERNATIVES AT FIS2017 IN BIRMINGHAM At the Federation Infection Societies Conference (FIS2017) on 30 November 2017, EWMA and the British Society for Antimicrobial Chemotherapy (BSAC) hosted a joint symposium on non-antibiotic antimicrobial alternatives for treating wounds. Professor Rose Cooper and Dr Klaus Kirketerp-Moller presented the results of their paper on the topic, which will be published in the Journal of Wound Care in June 2018. Matthew Dryden presented on the use of an antimicrobial wound gel in his presentation entitled ‘Reactive Oxygen, clinical applications for a novel antimicrobial agent’. Joint EWMA/BSAC session: Antimicrobial Stewardship in Wound Management Promoting non-antibiotic antimicrobial technologies in wound care At EWMA 2018, in Krakow, EWMA and BSAC will join forces again to present a session on antimicrobial stewardship. It will be held Thursday 10 May, from 11.15–12.15. In this session, you will learn about a new review paper on the use of topical antibiotics to prevent surgical site infections (SSIs). Data were collected from the members of the British Society for Antimicrobial Chemotherapy (BSAC) and EWMA and shows little consensus about the appropriate use of topical antibiotics. We will also look into the use of negative pressure wound therapy with instillation (NPWTi) as a means to prevent or treat infection. Finally, Rose Cooper will share her thoughts on why we should work towards a stewardship strategy for the use of biocides in in wound management.

THE JOURNAL OF WOUND CARE 2018 AWARDS WINNERS The award winners were announced on 6 March 2018. EWMA would like to congratulate: n Kylie Sandy-Hodgetts, member of the EWMA Council (representing Wounds Australia), for receiving the ‘Best Clinical Research Award’ and finishing third in the ‘Innovation in Surgical Site Infection’ category. n

Massimo Rivolo, member of the EWMA Council, for coming in second in the ‘Innovation in Chronic Wound Healing’ category. n Georgina Gethin, EWMA Honorary Secretary, for her third place finish in the Patient Wellbeing Award’ category. n Andrea Pokorná, former member of the EWMA Council, for a third place finish in the ‘Professional Education Award’ category.

EWMA REPRESENTED AT THE AAWC PU PREVENTION SUMMIT 2018 EWMA Honorary Secretary, Dr Georgina Gethin, represented EWMA at the Association for Advancement of Wound Care (AAWC) at their first annual Pressure Ulcer Summit in Atlanta, Georgia, USA, on 9-11 February 2018. During two stimulating days an international forum of experts and key stakeholders in PU prevention and management tried to better define pressure-related tissue damage and wounds, assess the state of the science, and identify research opportunities with the ultimate goal to create new pathophysiologic models that clinicians can understand and use to make decisions at the bedside, thus advancing patient care. The proceedings will be incorporated into a white paper, to be published later this year. Meanwhile, further information is available at 84

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Organisations Ermira Tartari1,2 Hiroki Saito3 Tcheun Borzykowski1 Claire Kilpatrick3 Daniela Pires1,4 Benedetta Allegranzi3 Didier Pittet1

SAVE LIVES: Clean Your Hands campaign 5 May 2018

“It’s in your hands - prevent sepsis in health care”- World Health Organization (WHO)


Control Programme and WHO Collaborating Centre on Patient Safety, University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland 2Department

of Nursing, Faculty of Health Science, University of Malta, Msida, Malta 3Infection Prevention and Control Global Unit, Department of Service Delivery and Safety, World Health Organization, Geneva, Switzerland

“It’s in your hands - prevent sepsis in health care” 5 May 2018 World Health Organization SAVE LIVES: Clean Your Hands campaign slogan and main promotional image (2018 hashtags: #HandHygiene #Sepsis). Campaign participants are invited to submit photos/ selfies of them holding a board with the slogan and hashtags at www.Clean


of Infectious Diseases, Centro Hospitalar Lisboa Norte and Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal

FUNDING World Health Organization (WHO) and Infection Control Programme & WHO Collaborating Centre on Patient Safety (SPCI/WCC), University of Geneva Hospitals and Faculty of Medicine, Geneva, Switzerland; hand hygiene research activities at the SPCI/WCC are supported by the Swiss National Science Foundation (32003B_163262).

The authors alone are responsible for the views expressed in this article and they do not necessarily represent the views, decisions or policies of the institutions with which they are affiliated.

More information: Conflict of interest: None


Sepsis is a life-threatening organ dysfunction caused by a dysregulated host response to infection.1 It is estimated to affect more than 30 million people worldwide every year with high mortality and morbidity.2 Sepsis was reported as a key global health issue at the Seventieth World Health Assembly (WHA) in 2017 where a resolution on sepsis was adopted by Member States.3

Sepsis can result from care practices and complicate healthcare-associated infections. Hand hygiene, a core of infection prevention and control (IPC), plays a critical role in preventing such avoidable events.4,5 Each year, the World Health Organization (WHO) SAVE LIVES: Clean Your Hands campaign aims to bring people together in support of hand hygiene improvement globally on

5 May 2018 World Health Organization SAVE LIVES: Clean Your Hands campaign calls to action Health workers

“Take 5 moments* to clean your hands to prevent sepsis in health care”

IPC** leaders

“Be a champion in promoting hand hygiene to prevent sepsis in health care”

Health facility leaders

“Prevent sepsis in health care, make hand hygiene a quality indicator in your hospital”

Ministries of health

“Implement the 2017 WHA*** sepsis resolution. Make hand hygiene a national marker of health care quality”

Patient advocacy groups

“Ask for 5 Moments of clean hands to prevent sepsis in health care”

*refers to the “My 5 Moments for Hand Hygiene” as published in the WHO guidelines on hand hygiene in health care” (see ref 4) **IPC: Infection prevention and control ***WHA: World Health Assembly EWMA Journal 

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or around 5 May.6 In 2018, the campaign focuses on supporting the prevention of sepsis in health care. WHO urges ministries of health, health facility leaders, IPC leaders, health workers and patient advocacy groups to take action on hand hygiene to prevent sepsis in health care (Table and Figure). WHO also invites health facilities to join the global campaign to demonstrate ongoing commitment to hand hygiene and IPC ( Each hand hygiene action contributes to preventing sepsis in health care. Let’s act together: “It’s in your hands – prevent sepsis in health care.”

REFERENCES 1. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810. 2. Fleischmann C, Scherag A, Adhikari NK, et al. Assessment of Global Incidence and Mortality of Hospital-treated Sepsis. Current Estimates and Limitations. Am J Respir Crit Care Med. 2016;193(3):259-272. 3. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive care medicine. 2017;43(3):304-377. 4. World Health Organization. WHO guidelines on hand hygiene in health care: first global patient safety challenge: clean care is safer care Geneva, Switzerland: World Health Organization; 2009. 5. World Health Organization. Guidelines on core components of infection prevention and control programmes at the national and acute health care facility level. Geneva, Switzerland: World Health Organization; 2016. 6. World Health Organization. SAVE LIVES: Clean Your Hands WHO’s Global Annual Campaign Advocacy Toolkit. pdf?ua=1. Accessed 31 January 2018.

s r u o l o C Tren d 2018

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- stunning green


- power ful pink


Plea visit u se booth s at W210

- unique taupe - inspiring navy


- passionate red


Juzo also offers therapy concepts for different diseases: The Juzo Phlebology Concept for example consits of a compression wrap, a compression stocking system and compression strockings. For more information please visit our booth.

Julius Zorn GmbH · Juliusplatz 1 · 86551 Aichach · Germany · · ·

Juzo ®. Freedom in Motion


ECET NEWS ECET European Council of Enterostomal Therapy

The European Council of Enterostomal Therapy The European Council of Enterostomal Therapy (ECET) â&#x20AC;&#x201C; is a professional nursing society that supports its members by promoting educational, clinical and research opportunities to advance the practice and guide the delivery of expert healthcare to individuals with ostomy, incontinence and wounds.

Gabrielle Kraboth ECET President

Renata Batas ECET Public Relations Manager

More information

EWMA International Partner Organisation


The objective of the association is to develop a professional identity at European level for all nursing personnel and healthcare professionals concerned with or active in the area of stoma therapy, incontinence and/or the treatment of wounds. n The main aims of ECET are: to establish European recognition of nurses specialised in the area of stoma care, incontinence care and/ or the treatment of wounds; n to bring together healthcare professionals involved in the care of stoma patients; the association must ensure the protection and defence of the professional interests of its members; n to promote research and ensure that know ledge remains up to date; n to encourage contacts and collaboration with the industry, distributors or official healthcare insurance organisations with the aim of improving the quality of the care and the various devices; n to organise conferences, seminars and short training courses; n to break down national barriers and to promote European identity; n to promote the exchange of information between various European countries by establishing efficient communication systems; n to develop teaching standards that are generally acceptable; n to promote stoma care according to quality and ethical standards.

Christel Ravenschlag, Jean Preston, Rosine Van den Bulck and Kirsten Bach-Olsen founded

ECET in 2002. The Association is located in Brussels, Belgium. During the ECET Conference 2013 in Paris, a new board was elected including Gabriele Kroboth (new president), Werner Droste (new vice president) and Renata Batas. The first board meeting was held in Salzburg in 2014. 2014 was a difficult year for ECET and it was uncertain whether the Association would be able to continue its work. During the WCET conference in 2014 it was therefore decided to skip the 2015 conference and focus on a reorganisation of the ECET. A new ECET The board members of ECET started on a very small budget. The initial objective was to establish a closer contact with all the European stoma associations and initiate a dialogue with them about the future role of ECET. One of the primary goals was to establish pan-European projects initiated by ECET in collaboration with the national stoma associations. In the process of rebuilding the Association, ECET re-designed the website,, with kind support from Coloplast and Hollister. The new website was launched in March 2017, and ECET is continuously working to develop the content. ECET also created a new logo and opened social media profiles on Facebook and LinkedIn. ECET was also supported by EWMA, as the EWMA Council invited the EWMA Journalâ&#x20AC;&#x201A;

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From left to right: Werner Droste (ECET Vice President), Gerlinde Wiesinger (Previous ECET co-opted Treasurer), Gabriele Kroboth (ECET President), Renata Batas (ECET PR Manager).

From left to right: Renata Batas (ECET PR Manager), Laurent Chabal (WCET President Elect), Gabriele Kroboth (ECET President), Werner Droste (ECET Vice President).

ECET Board to arrange a guest session during the EWMA 2015 conference in London. This was the beginning of a new ECET. During the EWMA conference in London, the ECET Board had a meeting with EWMA Council members to discuss further cooperation, and the EWMA council members introduced their organiser, CAP Partner, to ECET. CAP Partner is now supporting the ECET with association management and conference organisation.

ECET Conference 2017 in Berlin The 13th Conference of the European Council of Enterostomal Therapists (ECET 2017) took place 18–21 June 2017 in Berlin, Germany, and was organised in cooperation with the local stoma care association Fachgesellschaft Stoma, Kontinenz und Wunde (FGSKW).

ECET ACTIVITIES ECET creates European guideline for stoma site marking ECET is currently working on a European standard for stoma site marking, based on national and international guidelines as well as a thorough literature research. A European expert group will discuss and develop common standard criteria for European countries. Items that cannot be supported by available research are discussed and the experts agree on a joint statement. Nursing researcher Gian Carlo Canese, Head of the Working Group, had to end his engagement due to personal reasons, so the work was continued with a new chairperson, MSc Tamara Štemberger Kolnik, in 2017. The literature search which will serve as a basis for the guideline has now been finalised.

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The theme of the ECET 2017 conference was “Building bridges – from west to east, from south to north. Ostomy – Continence – Wounds”. The conference was a great success, with more than 1,300 participants, 12 sponsors and 22 exhibitors. The conference included high-quality presentations on the latest research on incontinence, peristomal skin disorders and wound care from various European countries. Many participants attended workshops on faecal and urinary incontinence, peristomal wounds and LSD-Score System, how to prepare good photographs in ostomy and wound care. We were also honoured to include the EWMA guest session, with presentations on the diabetic foot, leg ulcers and modern wound dressings. At the congress, a podium discussion on “Europe-wide activities to ensure the quality of care for people with ostomies and incontinence” was held in which Ria Smijers



(EOA), Gabriele Kroboth (ECET), Ilona Schlegel (ASBH), Erich Grohmann (ILCO), Klaus Grunau (BVMed) and Dr. Domurath (DMGP) participated. As a concluding remark, we can say that the congress was a great success. Cooperation with European stoma care associations ECET is highly interested in establishing a closer cooperation with all European stoma care associations. To accomplish this, a meeting with representatives of each association was held in Berlin, during the ECET conference. The interest of ECET lies in the exchange of professional knowledge of all nurses working in this specialist area in Europe. Our end goal is to support the further development of this specialisation. Research and education must be developed together. The first initiative was to start the development of a European guideline on “stoma site marking”, but ECET plans to continue developing guidelines in the coming years. We hope that we will be able to create a network for exchanging ideas with the national stoma and continence associations, and decide together how the guidelines may be promoted by ECET. To create a common basis for the work of stoma associations across Europe, a mission statement was created by an Austrian group of stoma care nurses in 2016. The mission statement is currently being translated into several European languages and is available for download via:

90 All national associations are invited to translate the mission statement into their own language and publish this on their website. The ECET Board also wish to establish programmes for training and research. There are many ideas, but these need to be further developed. ECET Conference 2019 The ECET Board has decided to arrange the next ECET conference in Rome in 2019. Danila Maculotti, the new treasurer of the ECET Board, will be the president of this conference and will organise it in collaboration with Gabriele Roveron, the president of AIOSS (Associazione Italiana Operatori Sanitari di Stomaterapia). The ECET Executive Board looks forward to welcoming you again in 2019 in Rome, Italy. So, stay updated on news at ECET EXECUTIVE BOARD: Gabriele Kroboth, ECET President Werner Droste, ECET Vice President Renata Batas, ECET PR Manager Danila Maculotti, ECET Treasurer m

EWMA Journal 

2018 vol 19 no 1

Management of the Diabetic Foot 10th Course · 19 - 22 September 2018 · Pisa · Italy

37th annual meeting of the

European Bone and Joint Infection Society SAVE THE DATE Welcome to Pisa This 4-day theoretical course and practical training gives participants a thorough introduction to all aspects of diagnosis, management and treatment of the diabetic foot. Lectures will be combined with practical sessions held in the afternoon at the diabetic foot clinic at the Pisa University Hospital. Lectures will be in agreement with the International Consensus on the Diabetic Foot and Practical Guideline on the Management and Prevention on the Diabetic Foot.

6 - 8 September 2018 · Helsinki · Finland

Main conference theme: Infection After Trauma Important deadlines: Abstract submission 20 April 2018 Early registration 29 June 2018

Pisa International Diabetic Foot Course

We look forward to seeing you in Helsinki!

The course is endorsed by EWMA


CTRS NEWS CTRS Chinese Tissue Repair Society

China delegates double in EWMA conference – The international cooperation between CTRS and EWMA moves forward

Guangping Liang Managing editor of Burns & Trauma

Ting Xie Vice President of the Chinese Tissue Repair Society (CTRS)

More information:

During 3–6 May 2017, the 27th EWMA conference was held in Amsterdam, a city full of beautiful tulips in this blossoming season. As the biggest delegation outside Europe, the Chinese Tissue Repair Society (CTRS) organised more than 70 delegates, almost twice as many as in 2016. As a partner society of EWMA, CTRS has made dedicated efforts in promoting the translational research in tissue repair and regeneration, as well as establishing an international academic exchange platform in China. During EWMA 2017 CTRS President Prof. Xiaobing Fu and other core members, including Prof. Shuliang Lu, Chunmao Han, Ting Xie and Bin Wen, had a short meeting with EWMA President Severin Lauchli and Head of Projects Jan N. Kristensen, sharing ideas and possibilities for future collaboration. After a comprehensive discussion, both sides agreed to deepen cooperation in knowledge exchange and an education project in wound management.

EWMA International Partner Organisation


One major event for CTRS in 2017 was the establishment of the Asia Pacific Society for Wound Healing with Prof. Xiaobing Fu and Sadanori Akita as the presidents. CTRS co-hosted the 1st Asia-Pacific Summit Forum of Wound Healing and Scar Medicine with the Asia-Pacific Society for Scar Medicine Council (with Prof. Yixing Zhang and Rei Ogawa as presidents) during 3–5 November 2017. This was the first joint event to include a fantastic gathering of great minds in wound healing and scar research, including more than 1,000 top scholars and representatives from Asia, Europe and America.

Severin Läuchli and Jan N. Kristensen were invited to attend the conference and had a brief high-level meeting with CTRS standing committee members. Strategic goals were set by both sides during the meeting, including launching a Chinese version of EWMA guidelines, setting up a Chinese session at the 2018 EWMA conference, seeking opportunities for journal promotion during EWMA, and further cooperation in the area of EWMA endorsement courses. Since the foundation of CTRS in 1995 by Prof. Xiaobing Fu, it has developed into a society composed of a thousand committee members all over China engaged in basic and clinical research in wound repair and tissue regeneration. CTRS is dedicated to promoting translational research in wound repair and tissue regeneration in China, setting up the standardised application of new techniques in wound management, especially regarding efforts on training, access system and standardised operation for chronic wounds, and constructing an international communication platform in the field. Since 2000, CTRS attached more importance to international cooperation with internationally influential associations such as EWMA. Every year, CTRS plays a leading role in organising Chinese scholars to join international events, and the EMWA conference is one of them.. Now we are full of expectations for the upcoming 28th EWMA conference, which will be held in Krakow, Poland, during 9–11 May. Let’s meet together in Krakow again in 2018!

EWMA Journal 

2018 vol 19 no 1

• Official organ of the German and Swiss Phlebological Society • Online access to all articles, even to the online archive! • All publications available in English too, since 2013! • Always stay up to date by signing up for the Electronic Table of Contents (eTOC) at: Phlebologie 6 issues per volume ISSN 0939-978X

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Founded in 1972, the journal Phlebologie has served for decades as the leading European peer-reviewed journal advancing knowledge in the field of venous disorders. As the official journal of the German and Swiss Societies of Phlebology it is the field’s most important scientific journal in the German speaking countries to date. The journal publishes original and review articles on all aspects of the field as well as theme-oriented issues on new and emerging diagnostic procedures, therapies, or preventative medicine. Since 2013, all scientific articles are translated into English and published online as articles freely accessible to everyone. All scientific manuscripts are strictly peer-reviewed in a blinded fashion by international renowned experts. The journal strictly follows the ethical guidelines and recommendations provided by the International Committee of Medical Journal Editors and related organizations. Free print copy (articles mainly in German) available on request.

Profit from a 35% discount using the promotional code EWMA18 Frontiers in Diabetes Editor: M. Porta Vol. 26

The Diabetic Foot Syndrome Editors

A. Piaggesi J. Apelqvist

The Diabetic Foot Syndrome Editors


Chronic Metabolic Disturbance




Cardiac Failure




Visual Impairment


Alberto Piaggesi Jan Apelqvist

Ulcer Progressive Retinopathy






Progressive Cognitive Disorders

Frontiers in Diabetes, Vol. 26 Series Editor: Porta, M. (Turin) ISSN 0251–5342 / e-ISSN 1662–2995 Fields of Interest: Endocrinology; Infectious Diseases; Cardiovascular System, Diabetes, Microcirculation, Neurology, Nursing, Orthopedics, Plastic Surgery, Public Health, Surgery

In recent years, “diabetic foot” has become the common name given to chronic complications of diabetes mellitus in the lower limb. This book provides an up-to-date picture of the clinical scenario, the latest understanding of the mechanisms in regard to pathology, the current standards of therapy, and the organizational tasks that a modern approach to such a complex pathology warrants. All contributors have delivered articles that are as informative and straightto-the point as possible, including not only their own experience in the field, but also giving a wider picture to link each article to the other. The Diabetic Foot Syndrome is not only relevant to specialists, but also to all the caregivers involved in the management of the patients at risk for developing the pathology, those affected, and those who are at risk of recurrences.

Contents Preface: Piaggesi, A.; Apelqvist, J. • The Diabetic Foot Syndrome Today: A Pandemic Uprise: Apelqvist, J.

• A Complication of the Complications: The Complexity of Pathogenesis and the Role of Co-Morbidities in the Diabetic Foot Syndrome: Meloni, M.; Izzo, V.; Giurato, L.; Uccioli, L.

• Re-Evaluating the Outcomes in Diabetic Foot Management: Clerici, G.; Iacopi, E.; Caminiti, M.S.; Casini, A.; Curci, V.; Faglia, E.; Piaggesi, A.

• The Charcot Foot Revisited: How the New Pathogenetic Findings Explain the Clinical Course of the Disease: Petrova, N.L.

• Diabetic Peripheral Arteriopathy: A Tale of Two Diseases: Edmonds, M.E.; Shanahan, C.; Petrova, N.L.

• Does Microangiopathy Contribute to the Pathogenesis of the Diabetic Foot Syndrome?: Coppelli, A.; Abbruzzese, L.; Goretti, C.; Iacopi, E.; Riitano, N.; Piaggesi, A.

• The Organization of Care for the Diabetic Foot Syndrome: A Time-Dependent Network: Piaggesi, A.; Abbruzzese, L.; Coppelli, A.; Iacopi, E.; Riitano, N.; Goretti, C.

• Offloading the Diabetic Foot: The Evolution of an Integrated Strategy: Bus, S.A. • Surgical Management of the Charcot Foot: Dalla Paola, L.; Scavone, G.; Carone, A.; Vasilache, L.; Boscarino, G.

• Indications to Revascularization in the Ischaemic Diabetic Foot: Ferraresi, R.; Losurdo, F.; Lorenzoni, R.; Ferraris, M.; Caminiti, M.S.; Casini, A.

• An Integrated Approach for the Effective Management of Limb-Threatening Ischaemia in the Diabetic Foot: Mills, J.L. • Resistant Infections in the Diabetic Foot: A Frightening Scenario: Tascini, C. • Antibacterial Treatment in Diabetic Foot Infections: Senneville, E.

• The Role of Surgery in the Management of the Infected Diabetic Foot: Aragón-Sánchez, J. • Local Management of Diabetic Foot Ulcers, Dressings and Other Local Treatments: Game, F.L. • Towards Extending Ulcer-Free Days in Remission in the Diabetic Foot Syndrome: Boghossian, J.A.; Miller, J.D.; Armstrong, D.G.

Author Index/Subject Index

The easiest way to order: w w id Karger – Medical and Scientific Publishers CH–4009 Basel, Switzerland, f: +41 61 306 12 34


The Diabetic Foot Syndrome Editors: Piaggesi, A. (Pisa); Apelqvist, J. (Lund) X + 224 p., 36 fig., 14 in color, 12 tab., 2018 Special price: CHF 125.00 / EUR 116.00 / USD 147.00 (hard cover or online) Hard cover or online prices for personal customers Prices subject to change, VAT not included EUR price for eurozone countries, USD price for USA and Latin America only ISBN 978–3–318–06144–4 e-ISBN 978–3–318–06145–1



It is a pleasure to update EWMA members on the activities of Wound Australia Wounds Australia has the pleasure to invite you all to come and join the Australian Wound Management Community in what is shaping up to be an exciting conference from Wednesday 24 October to Friday 26 October 2018 in the beautiful city of Adelaide, South Australia. The conference theme is “Advancing healing horizons- towards the cutting edge in wound care”. Through this theme, we will be exploring new and innovative topics, issues and technologies. The scientific committee under the guidance and stewardship of Terry Swanson and Bill McGuiness have selected a number of top innovative speakers to give presentations such as:

Jan Rice Board Director Wounds Australia More information:


Now and into the future on diabetes


From laboratory to healing and further –hopefully without scars


Cuttingedge vascular options, now and into the future


Innovations in developing resource-poor communities


What’s new in infection and biofilms


Pain, pressure injury, models of practice and aging


Mycobacterium Ulcerans-marching ever forward-where is it now!


Bariatric considerations


Epidermolysis Bullosa – a patient perspective


Lotions and potions for skin which one when and why


Palliative care considerations


Psychological impact of poor healing or a wound

The Conference will also have a full social program that will give everyone the opportunity to network, reconnect with colleagues and make new connections. It will also highlight the worldrenowned wines and foods of South Australia. The social committee have been working hard to ensure that your every need is met-too-good food, good wine, and fantastic music with some fun on the side. Visit the website for more info Jan Rice Board Director Wounds Australia

EWMA International Partner Organisation

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2018 vol 19 no 1




Portuguese Wound Society

It is a pleasure to update EWMA members on the activities of the Portuguese Wound Society ELCOS was founded by several co-founders and representatives of counterpart organisations at both the national and international level with the intention to embody a project on the national scene: a multidisciplinary organisation with the ultimate goal of promoting public health.

Katia Furtado President ELCOS

We aim to be ambitious but conscientious in regard to policy that will be outlined within the existing limits. Therefore, the human capital of ELCOS consists of professionals at various levels of the scientific community. This includes doctors, who specialise in general surgery, vascular surgery, plastic surgery, endocrinology and dermatology; nurses, who are specialists in a variety of areas; pharmacists; and media engineers who specialise in the areas of telemedicine as well as university professors. To fulfil its goal, ELCOS-Portuguese Healing Society is organized by geographical locations into Regional Councils, whose aim is to address the regional nosology in terms of chronic wounds through the involvement of interested professionals in each region (doctors, nurses, pharmacists, nutritionists, physiotherapists, etc.) in partnership with other healthcare and educational institutions at the local level.

EWMA Cooperating Organisation


is evidence that social factors, including education, employment status, income level, gender and ethnicity, have a marked influence on how healthy a person will be. Health inequities are systematic differences in the health status of different population groups. During the Symposium, we discussed these health inequities and the influence of these differences on diabetes management in Portugal. These inequities have significant social and economic costs both to the individuals and to society.

In 2017, following the agenda developed by the International Diabetes Federation and joining the global diabetes community to produce a powerful voice for diabetes awareness and advocacy, we organised the 3rd Iberia Symposium on Diabetes. It was a tremendous success with the presence of both national and international representatives from the fields of politics and healthcare. From this event that took place in Beja, one of the cities with the highest rate of diabetes in Portugal, came a position statement on diabetes with an emphasis on prevention.

Also, accessibility to health care, which is also a real problem, can be defined as a measure of people’s abilities to pay for services without financial hardship. This takes into account not only the price of the healthcare services but also indirect and opportunity costs. The European financial crisis has a complex set of causes and reinforcing dynamics that negatively affect people’s access to quality healthcare. A financial crisis can have an impact on health through two mechanisms: (i) a ‘social risk effect’ of increasing unemployment, poverty, homelessness and other socio-economic risk factors during a period when governments are cutting effective social protection programmes that might mitigate these risks to health; and (ii) a ‘healthcare effect’ through cutbacks to healthcare services as well as reductions in healthcare coverage, which restrict an individual’s access to healthcare. ELCOS wanted to alert the community to the impact of this crisis and the restrictions that existed for accessibility to health care.

Inequities in healthcare are a real concern, and ELCOS wanted to raise awareness of this issue. There

According to estimates from World Health Organization (WHO), 422 million people suffer from dia-

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betes worldwide, and the number continues to grow steadily. Fortunately, there are numerous resources and health innovations for diabetes patients available, and diabetes management has been improving steadily for years. However, innovations, in and of themselves, are insufficient. You also need to create adequate healthcare policies and make financial resources available to improve people’s access to these innovations. ELCOS wanted to point out that managing and preventing diabetes is not only the responsibility of healthcare professionals but also a concern for policymakers and, above all, citizens. People need to be aware of both their rights and their duties so that prevention can be more effective.

As a non-profit organisation, ELCOS counts on its members, who are mostly professionals and students from all areas of healthcare, including nurses, doctors, physiotherapists, psychologists, nutritionists, pharmacists, among others. Join us! Katia Furtado President ELCOS

ELCOS also hosts an annual Iberia Forum, and in 2018, the IX Iberia Forum took place in Aveiro, with 1,200 participants. International speakers were invited, such as Julie O´Brien, who presented the EWMA document entitled “Managing Wounds as a Team,” which was recently translated by ELCOS into the Portuguese language. Following the mission of covering clinical practice, teaching and scientific research in partnership with health and educational institutions, we offer post-graduate educational courses on Tissue Viability in partnership with universities throughout Portugal as well as basic and advanced courses on Wound Management.

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2018 vol 19 no 1


Corporate Sponsors Corporate A

KCI an Acelity company

BSN medical GmbH


ConvaTec Europe


Wound Management Smith & Nephew Medical Ltd

Lohmann & Rauscher

URGO Medical/Laboratoires Urgo

Mölnlycke Health Care Ab

Wacker Chemie AG

Ferris Mfg. Corp.

Corporate B Beier Drawtex Healtcare 3M Health Care Fidia farmaceutici S.p.A. ABIGO Medical AB

Aurealis Pharma, Itd

B. Braun Medical



Flem Pharma NV

Freudenberg Performance Materials SE & Co. KG

Frontier Medical Group

Juzo Julius Zorn GmbH


KLOX Technologies Inc

Medela AG

SastoMed GmbH



Medi GmbH & Co. KG Vancive Medical Technologies Mimedx Group, Inc.

Nutricia Advanced Medical Nutrition

Welcare Industries Spa

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2018 vol 19 no 1

3rd Nordic Diabetic Foot Symposium 2018 Helsinki, Finland 6 - 7 November 2018

21 - 23 June 2018 ¡ Rheine ¡ Germany

The 4th International course on the

Neuropathic Osteoarthropathic Foot (Charcot) The three day theoretical & practical course gives participants a thorough view of the different aspects of the diagnosis, treatment and management of the Charcot Foot. The course will consist of practical sessions in small groups, where the main focus will be on training the diagnostic and treatment skills necessary for the interdisciplinary treatment of Charcot patients. In addition, state of the art lectures and presentations will be given by international specialists in the field.


All photos c by Helsinki Marketing


Mathias-Spital Interdisciplinary Diabetic Foot Centre Rheine, Germany


Mathias-Spital University of Applied Sciences Rheine, Germany


Hands-on workshops/training in clinic combined with lectures



Conference Calendar 2018/19 Conferences 2018


For web addresses please visit





15th Spring Symposium of European Academy of Dermatology and Venereology (EADV)


3 - 6



European Wound Management Association 2018 Conference (EWMA)


9 - 11



Wounds Canada Spring Conference


11 - 12



Deutsche Wundkongress Chronic Wounds Initiative (ICW)


16 - 18



12th Symposium of National Advisory Group for the Study of Pressure Ulcers and Chronic Wounds (GNEAUPP)


16 - 18



17th Malvern Diabetic Foot Conference


16 - 18



European Pressure Ulcer Advisory Panel Pressure Ulcers in a Pediatric Focus Meeting 2018 (EPUAP) and Adult ICU Population: Science and Practice United Kent State University College of Podiatric Medicine Seminar 2018 (KSUCPM)


21 - 23




24 - 26






The Netherlands

New Frontiers in Wound Management

Annual congress

19th Congress of European Federation May – June 30 - 1 of National Associations of Orthopaedics and Traumatology (EFORT) ETRS Congress 2018 Linking knowledge to heal scars May – June 31 - 2 8th International Lymphoedema Framework Conference (ILF)


6 - 9


The Netherlands

Spanish Association of Vascular Nursing and Wounds (AEEVH)






21 - 23



50th Annual Conference of the Wound, Annual congress June Ostomy and Continence. Nurses Society 4th Symposium of Association of Diabetic Annual congress June Foot Surgeons (ADFS)

3 - 6

Philadelphia, PA USA

28 - 29


United Kingdom

37th Annual meeting of European Bone and Joint Infection Society (EBJIS)

6 - 8



Annual congress

4th International course on the Neuropathic Osteoarthropathic Foot (Charcot)


Association for Wound Management of 5th Euro-Asian Forum: September 7-9 Sarajevo Bosnia and Herzegovina (AWMinB&H) Past, present and future in wound management 20th Annual Meeting of European Pressure September 12 - 14 Rome Ulcer Advisory Panel (EPUAP)

Bosnia and Herzegovina

Annual conference of Austrian Wound Association (AWA)








14 - 16

27th Congress of European Academy September 12 - 16 of Dermatology and Venereology (EADV) 2nd Common Congress of Swiss Association September 19-20 for woundcare (SAfW)


Pisa International Diabetic Foot Course


19 - 22



The 18th Annual Leg Club Conference 2nd European Burns Association (EBA) Educational Course

The Challenge of Improving Practice in Wound Management


26 - 27



Innovations in burn care


28 - 29


The Netherlands

15th Conference of Diabetic Foot Study Group (DFSG)


28 - 30



The European Association for the Study of Diabetes Annual meeting 2018 (EASD)


1 - 5




EWMA Journal 

2018 vol 19 no 1

Conference Calendar 2018/19 Conferences 2018





Diabetic Foot Global Conference (DFCon)


11 - 13

Houston, TX


Wounds Australia National Conference

Advancing Healing Horizons: Towards the cutting edge in wound care


24 - 26



AAWC, Symposium on Advanced Wound Care Fall (SAWC Fall)

Annual congress



Las Vegas, NV


Wounds UK

Annual congress


5 - 7


United Kingdom


6 - 7









For web addresses please visit

Nordic Diabetic Foot Symposium 2018

Portuguese Assiociation for the Treatment of Wounds (APTF)

Annual congress

1st Conference of Wound Management On the same road: Wound- December Nuremberg in Nuremberg healing research and wound management


Conferences 2019 Theme Month Days City Conference of the French Society for Annual congress January 20 - 22 Paris Woundcare (SFFPC)


Conference of the Czech Wound Management Society

Annual congress




Czech Republic

Conference of the Finnish Wound Care Society

Annual congress





Diabetic Limb Salvage Congress

Annual congress





Congress of the Chronic Wounds Initiative (ICW)

Annual congress


8 - 10



AAWC, Symposium on Advanced Wound Care Spring (SAWC Spring)

Annual congress


7 - 11

San Antonio, TX USA

8th International Symposium of the Diabetic Foot

Symposium held every fourth years May

22 - 25


The Netherlands

9th International Conference of the International Lymphoedema Network (ILF) 2019

Annual congress





29th conference of the European Wound Management Association 2019 (EWMA)

Annual congress





Conference of the European Council of Enterostomal Therapy (ECET)

Biennial congress


23 - 26



Conference of the Wound Ostomy and Continence Nurses Society

Annual congress


23 - 26

Nashville, TN



27 - 29



19th congress of DGFW

EWMA Journalâ&#x20AC;&#x201A;

2018 vol 19 no 1



Cooperating Organisations AEEVH

Spanish Association of Vascular Nursing and Wounds

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


Italian Nurses’ Cutaneous Wounds ­Association


Italian Association for the study of Cutaneous Ulcers

AMP Romania

Wound Management Association Romania


Portuguese Association for the Treatment of Wounds


All Wales Tissue Viability Nurse Forum


Austrian Wound Association


Belgian Federation of Woundcare


Portuguese Wound Society


Finnish Wound Care Society


Associated Group of Research in Wounds


National Advisory Group for the Study of P ­ ressure Ulcers and Chronic Wounds


Hellenic Society of Wound Healing and Chronic Ulcers


Chronic Wounds Initiative


Latvian Wound Treating ­Organisation


The Leg Ulcer Forum


Lithuanian Wound Management Association


Macedonian Wound Management Association

National Association of Tissue Viability Nurses, S ­ cotland


Hungarian Association for the Improvement in Care of Chronic Wounds and Incontinentia


The Spanish Society of Wounds www.sociedadespanolaheridas. es


The French and Francophone Society f Wounds and Wound Healing


Swedish Wound Care Nurses Association


Slovak Wound Care Association


The Slovak Wound Healing Society

STW Belarus

Icelandic Wound Healing ­Society


Serbian Wound Healing Society


Swedish Wound Healing Society




Croatian Wound Association



German Wound Healing Society

Polish Wound Management Association



Danish Wound Healing Society


Norwegian Wound Healing Association

Dutch Organisation of Wound Care Nurses


Serbian Advanced Wound Management Association


Hungarian Wound Care Society






Czech Wound Management Society

Swiss Association for Wound Care (French section)

Society for the Treatment of Wounds (Gomel, Belarus)




Maltese Association of Skin and Wound Care

Bulgarian Wound Association

Clinical Nursing Consulting – Wondzorg



Tissue Viability Society

Association for Wound Management of Bosnia and Herzegovina


Ukrainian Wound Treatment Organisation

Swiss Association for Wound Care (German section)

EWMA Journal 

2018 vol 19 no 1


Cooperating Organisations (cont.) V&VN

Decubitus and Wound Consultants, ­Netherlands

WCS Knowledge Center Woundcare


Wound Management ­Association of Ireland


Wound Management Association of Kosova


Wound Management Association Slovenia


Wound Management ­Association Turkey


European Pressure Ulcer Advisory Panel

Alliance of Wound Care Stakeholders www.woundcarestakeholders. org


Association for the Advancement of Wound Care


Canadian Association of Wound Care


Chinese Tissue Repair Society

Debra International

Dystrophic Epidermolysis Bullosa Research Association


European Council of Enterostomal Therapy


European Federation of National Associations of ­Orthopaedics and Traumatology

EWMA Journal 

2018 vol 19 no 1

European Society for Vascular Surgery





European Tissue Repair Society

International Federation of Podiatrists - Fédération Internationale des Podologues


International Lymphoedema ­Framework


Int. Wound Infection Institute www.woundinfection-institute. com


Korean Wound Management Society


New Zealand Wound Care Society


International Partner Organisations


Iberolatinoamerican Society of Ulcers and Wounds


Brazilian Wound M ­ anagement ­Association


World Alliance for Wound and Lymphedema Care

Eucomed Advanced Wound Care Sector Group

International Compression Club

Associated Organisations Leg Club

Lindsay Leg Club Foundation


The Lymphoedema Support Network

Media Partner JWC

Journal of Wound Care


Practical Patient Care

For more information about EWMA’s Cooperating Organisations please visit

Wounds Australia

Wounds Australia

Other Collaborators DFSG

Diabetic Foot Study Group


European Academy of Dermatology and Venereology


European Burns Association


The European Society for Clinical Nutrition and Metabolism


5 Editorial. Sebastian Probst, Editor of EWMA Journal

Science, Practice and Education 7 Opinions that matter: Patient’s perspective of their perioperative management during surgery for diabetic foot Piaggesi A, Bonaventura L, Giusti S, Goretti C, Menichini C 15 Skin tears in the aging population: Remember the 5 Ws Vanzi V, LeBlanc K 23 Recommendations to improve health care for people with chronic diseases. Maggini M, Zaletel J 29 Bioburden levels of spools of surgical tape in different healthcare settings. Yu V, Deing V, Nehrdich T, Struensee B 35 Specific risk factors for pressure ulcer development in adult critical care patients – a retrospective cohort study Ahtiala M, Soppi E, Tallgren M 45 Prevalence of chronic wound in different modalities of care in Germany Kröger K, Jöster M

Cochrane Reviews 51 Abstracts of Recent Cochrane Reviews. Rizello G

Book Review 58 The Diabetic Foot Syndrome. Gershater M A

EWMA 60 EWMA Journal Previous Issues and Other Journals 62 EWMA 2018 Conference in Krakow, Poland 67 New EWMA document: Advanced therapies in wound management Alberto Piaggesi 72 EWMA Publications 75 EWMA & EPUAP added-value to OECD efforts Moore Z, Soriano J V, Pokorna A, Schoonhoven L, Vaugnat H 78 Updates from the EWMA Committees 80 New Corporate Sponsors 83 EWMA News

Organisations 86 WHO Save Lives Clean Your Hands Campaign 2018 Tartari E, Saito H, Borzykowski T, Kilpatrick C, Pires D, Allegranzi B, Pittet D 88 The European Council of Enterostomal Therapy Kraboth G, Batas R 92 Chinese Tissue Repair Society Liang G, Xie T 95 Wounds Australia Rice J 96 Portuguese Wound Society Furtado K 98 Corporate Sponsors 100 Conference Calendar 102 Cooperating Organisations, International Partners and Other Collaborators

Profile for EWMA European Wound Management Association

EWMA Journal April 2018, Volume 19 (1)  

EWMA Journal April 2018, Volume 19 (1)