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O F T H E E U R O P E A N W O U N D M A N A G E M E N T A S S O C I AT I O N

Volume 20 ¡ Number 1 ¡ May 2019

Patient-centred wound care


PolyMem® wound dressings are designed to modulate 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 Modulating 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 Learn more at www.polymem.com

Visit us at Stand B07:42 during EWMA 2019 in Gothenburg, Sweden 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 2006:165-168 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 MKL-745 R4 0419


O F T H E E U R O P E A N W O U N D M A N A G E M E N T A S S O C I AT I O N

5 Editorial. Probst S

Science, Practice and Education 7 Letter to Editor. Piaggesi A, Apelqvist J 11 Finnish Nurses’ Perception of Client-centred Wound Care. Seppänen S 23 Optimising Wellbeing in Patients with Diabetic Foot Ulcers. McIntosh C, Ivory J D, Gethin G, MacGilchrist C 31 Taking Care of an Individual’s Needs at Home: Experiences of a Community Care Nursing Group. Ghilardi S, Noris M, Negroni A, Paggi B, Giunni L 37 Post-surgical Pyoderma Gangresonum: A Retrospective Analysis of four Clinical Cases. Isoherranen K 43 A Case Report: Toxic Edipermal Necrolysis in Children. Ferreira J, Santos M, Souza M, Silva G, Monteiro A, Yogui H, Santana I 49 Factors that create Obstacles and Opportunity for Patient Participation in Orthopaedic Nursing Care. Stålenhag S, Sterner E 61 Effectiveness and Safety of Patient-centred Care Compared to Usual Care for Patients with Pressure Ulcers in Inpatient Facilities. Pokorná A, Klugar M, Kelnarová Z, Klugarová J 73 A Case Report: Pilonidal Sinus Management with Medical-Grade Honey. Hermanns R, Rodrigues B

CONFERENCE 29 OF THE EUROPEAN TH

WOUND MANAGEMENT ASSOCIATION

EWMA 2019

Cochrane Reviews 79 Abstracts of Recent Cochrane Reviews. Rizzello G

Book Reviews 90 Antiseptic Stewardship. Cooper R 92 Infermieri. Piagessi A

EWMA 94 EWMA Journal Previous Issues and Other Journals 96 EWMA 2019 Conference in Gothenburg, Sweden 100 New EWMA Document: Atypical Wounds. Isoherranen K, O’Brien J 104 New EWMA Document: Surgical Site Infections. Stryja J, Sandy-Hodgetts K 106 EWMA Publications 109 EWMA Wound Curriculum for Nurses EQF Level 6. Probst S, Holloway S, Rowan S, Pokorná A 115 A Storytelling Journey: Living With Chronic Wounds. Piaggesi A 121 New EU Medical Device Regulation: Challenges and Opportunities. Apelqvist J 124 A retrospective Audit and Case-note Review at a large Ethiopian Referral Hospital. Rose A 126 Time is not on our side. We need urgent action. Stryja J 129 Management of the Diabetic Foot – Theory and Practice. Piagessi A 130 New Corporate Sponsors

Organisations 132 Swiss Association for Wound Care. Siebenthal D, Benecke U 135 Skin Wounds, and Trauma (SWaT) Research Centre. Walsh S, Patton D, O’Connor T, Moore Z 138 The International Skin Tear Advisory Panel. Cambell K 140 Malaysian Society of Wound Care Professionals. Nair H 141 Swedish Wound Care Nurses Association. Sterner E 142 Conference Calendar 144 Cooperating Organisations, International Partner Organisations and Corporate Sponsors

GOTHENBURG SWEDEN 5 – 7 JUNE 2019 WWW.EWMA2019.ORG // WWW.EWMA.ORG WWW.SARSJUKSKOTERSKOR.SE


Journal of the European Wound Management Association ISSN number: 1609-2759 Volume 20, No 1, May, 2019

EWMA Council

Journal of the European Wound Management Association Published twice a year

Alberto Piaggesi

Sue Bale

Scientific Recorder President-Elect

President

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

Georgina Gethin

Jan Stryja

Honorary Secretary

Treasurer

EWMA website www.ewma.org

Selcuk Baktiroglu

Nicoletta Frescos

Luc Gryson

Samantha Holloway

Kirsi Isoherranen

Edward Jude

Elisabeth Lindahl

Christian Münter

Alexandra Marques

Julie Jordan O’Brien

Pedro PancorboHidalgo

Andrea Pokoma

Editorial Office please contact: EWMA Secretariat Nordre Fasanvej 113 2000 Frederiksberg, Denmark Tel: (+45) 7020 0305 Fax: (+45) 7020 0315 ewma@ewma.org Layout: Nils Hartmann, Open design/advertising Printed by: Kailow Graphic, Denmark Copies printed: 8.500 Prices: Journal of the EWMA 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€ The next issue will be published in October 2019. Prospective material for publication must be with the EWMA Secretariat as soon as possible and no later than 24 June 2019 The contents of articles and letters in Journal of the EWMA 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 Journal of the EWMA Editor for final approval. All issues of Journal of the EWMA are CINAHL listed.

Sebastian Probst Journal of EWMA, Editor

Sara Rowan

Thomas Serena

Luc Teot

Evelien Touriany

COOPERATING ORGANISATIONS’ BOARD Gilbert Hämmerle, AWA Sonja Koller, AWA Leonid Rubanav, STW Belarus Christian Thyse, AFISCeP.be Jan Vandeputte, BEFEWO Els Jonckheere, CNC Jasmina Begić-Rahić, URuBiH Vladislav Hristov, BWA Marin Marinovic, CWA Lenka Veverková, CSLR Annette Høgh, DSFS Heli Kallio, FWCS Luc Téot, SFFPC Arne Buss, DGfW Christian Münter, ICW Georgios Vasilopoulos, HSWH Hunyadi János, MSKT Mária Hok, SEBINKO

Guðbjörg Pálsdóttir, SumS Caroline McIntosh, WMAI Battistino Paggi, AISLeC Ciro Falasconi, AIUC Skender Zatriqi, WMAK Aleksandra Kuspelo, LBAA Loreta Pilipaityte, LWMA Suzana Nikolovska, MWMA Corinne Scicluna, MASC Louk van Doorn, NOVW Yvonne Siebers, V&VN Peter Quataert, WCS Bodo Erhardt Günther, NIFS Arkadiusz Jawien, PWMA Aníbal Justiniano, APTF Tania Santos, ELCOS Rosa Maria Nascimento, GAIF Razvan Scurtu, AMP R

Goran D. Lazovic, SAWMA Saša Milićevic, SWHS Beata Gress Halasz, SSOOR Ján Koller, SSPLR Dragica Tomc, WMAS Esther Armans Moreno, AEEVH J. Javier Soldevilla, GNEAUPP Aranzaxu Pérez Plaza, SEHER Susanne Dufva, SSIS Sebastian Probst, SAfW German Section Maria Iakova, SAfW French Section Hubert Vuagnat, SAfW Umbrella Hakan Uncu, WMAT Susan Knight, LUF Ray Samuriwo, TVS Ruth Ropper, NATVNS Sofia Siekunova, UWTO Christine Harris, AWTVNF

JOURNAL of EWMA, 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


Journal Editorial

Patient-centred Care Dear readers

I

n this issue, we understand ‘patient-centred care’ to be healthcare that is provided consistent with the values, desires, needs and perspectives of patients. It respects patients’ preferences and values, involves their social networks (family and friends), reinforces shared decision making and goal setting and supports the exchange of information (Mead & Bower, 2000). According to the alliance of international patient organisations, patientcentred healthcare must be based on the following five principles (IAPO, 2006):

decision-making with their clinicians to design and manage a customised and comprehensive care plan. Fearns and colleagues (2017) demonstrate in their qualitative synthesis that the persistence, recurrence and symptoms of chronic wounds have severe physical, psychological and social consequences for patients and their families. In a patient-centred approach, the treatment should be focused on symptom management, including facilitating shared decision-making and self-management, as well as wound healing, (Fearnset et. al., 2017).

1. Respect: Patients and carers have the right for their needs, preferences and values, as well as their autonomy and independence, to be respected.

To support patients and clinicians in the process of shared decision-making, the European Wound Management Association (EWMA), along with its cooperative and international partner organisations, carries out different activities. These activities include providing educational resources, hosting scientific conferences, contributing to international projects related to wound management, actively supporting the implementation of existing knowledge and providing information on all aspects of wound management. Recently, EWMA commenced a project group to develop a document focused on patient-centred care aiming to develop materials that may help wound management practitioners to improve their communication with patients and to identify the most effective strategies for involving patients in the wound management processes. This document will be published in 2020.

2. Choice and empowerment: Patients have the right to be treated and to act as responsible partners in making healthcare decisions. 3. Patient involvement in health policy: Patients and patients’ organisations deserve to share the responsi bility of healthcare policy-making through meaning ful and supported engagement, in all levels and at all points of decision-making, to ensure that they are designed with the patient at the centre. 4. Access and support: Patients must have access to safe, quality and appropriate services, treatments, preventive care and health-promotion activities. 5. Information: To enable patients and clinicians to make informed decisions about healthcare treatment, accurate, relevant and comprehensive information is essential. Further information can be found at www.patientsorganizations.org.

In this issue, we provide our readers with scientific and professional articles on how patients are involved in wound care in different European countries. I hope you all enjoy this issue, Sebastian Probst, Editor and Council Member Professor of Tissue Viability and Wound Care

Literature focussed on ‘patient-centred care’ is increasing, including in the field of wound care. These studies’ outcomes show how patients are encouraged to take an active role in collaboration and to engage in shared

REFERENCES Alliance of International Patient Organisations (2006). Declaration on: Patient-centred healthcare. Retrieved from https://www.iapo.org.uk/sites/default/files/files/ IAPO_declaration_ENG_2016.pdf

Fearns, N., Heller-Murphy, S., Kelly, J., & Harbour, J. (2017). Placing the patient at the centre of chronic wound care: A qualitative evidence synthesis. J Tissue Viability, 26(4), 254–259. doi:10.1016/j. jtv.2017.09.002

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2019 vol 20 no 1

Mead, N., & Bower, P. (2000). Patient-centredness: A conceptual framework and review of the empirical literature. Soc Sci Med, 51(7), 1087–1110.

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Science, Practice and Education

Letter to Editor Why Heel Pressure Injuries in Diabetic Patients are a Manifestation of Diabetic Foot Syndrome and should be managed by Diabetic Foot Units

Alberto Piaggesi MD, Director, Diabetic Foot Section, Department of Medicine, University of Pisa (I), Scientific Recorder and President-Elect of EWMA

Commentaries on Rivolo and Marcadelli (EWMA Journal 2018; 19(2), 15–21)

Diabetic foot is the most frequent, progressive and destructive complication of diabetes mellitus (DM), affecting some 25% of the patient population worldwide, with a tremendous morbidity and mortality that can be compared with that of many forms of cancer.1 More than this, disabilities related to the high frequency of major and minor amputations in these patients greatly reduces their quality of life and implies a consumption of resources that accounts for 40% of the total amount of expenditures for DM worldwide.2 In their paper entitled ‘Heel pressure injuries: the need for a structured evidence-based approach for assessment and treatment. A preliminary literature review,’ published in the last issue of the Journal of the European Wound Management Association, Rivolo and Marcadelli focused on the increasing prevalence of heel pressure injuries (HPI) in patients’ feet related the increasing number of aged, multi-morbid people exposed at the risk of decubitus because of being bedridden or the frequency and duration of admissions due to chronic illness.3 The authors, after an exhaustive revision of the existing literature on HPI, identified three main areas of interest and intervention: adult HPI, paediatric HPI and diabetes-related HPI, for which they suggested an integrated therapeutic approach with the creation of a specifically dedicated multidisciplinary service based on the model of diabetic foot units and called the ‘interdisciplinary heel pressure ulcer service (IHPIS)’.

There are some critical aspects in this approach to the problem, both on the theoretical side and on the practical one, that are in contrast with this hypothesis. An ulcer located in the heel of a patient with diabetes is a serious complication; in a larger cohort of foot ulcers, regardless of ulcer location, heel ulcers made up 10–15% of all foot ulcers.4 Most studies of ulcers located in the heel of a patient with diabetes have small numbers, or only a selected category of patients.5 From a conceptual point of view, diabetes-related HPI cannot and should not be combined with non-diabetic ones, either in younger adults or geriatric patients, because their pathogenesis is by far more complex and has both systemic (i.e., peripheral and autonomic neuropathy, diabetic macroangiopathy) and systematic (i.e., immunopathy, chronic metabolic imbalance) components, together with local peculiar features (i.e., non-enzymatic glycation of the proteins of the connective tissue) that exert their role in the determining of HPI in diabetic patients, in adjunct to the traditional ones.6 The cluster of these components in the same patient creates a high-risk condition that is most often unnoticed by the patient and underestimated, when not ignored, by caregivers because of the masking activity of the peripheral neuropathy. There is also a dramatic tendency toward criticism for the contemporary presence of districtual ischemia and infection, which puts the limb at risk 

journal of the european wound management association 

Jan Apelqvist MD, Director, Diabetes Foot Centre Department of Endocrinology University Hospital of Skåne, Division for Clinical Sciences University of Lund, Sweden

2019 vol 20 no 1

Correspondence: alberto.piaggesi@ med.unipi.it Conflicts of Interest: None

7


of amputation if not adequately and timely managed by specialists in the appropriate setting.7 Moreover, the pathogenetic pathways of HPI in diabetes are not confined to the condition of reduced motility: an ulcer located on the heel often has a decubitus origin, but it may also be caused by repetitive trauma and mechanical stress. A significant number of HPI in these patients are related to the conflicts with poorly fitting shoes in insensate neuropaths; these lesions, frequently involving the Achilles tendon, are extremely dangerous because of their tendency to progress proximally, leading to abscesses and fasciitis on the leg.8 These considerations lead to the second group of critical issues that relates to the practical and clinical aspects of the management of HPI in DM. The authors correctly stated that such a localisation of diabetic foot ulcers (DFU) has not yet been adequately addressed, in terms of diagnosis and proper treatment, inside the current guidelines on DF, and that they should attract more attention within the organisational models of DF care because of their peculiar features. The IHPIS model cannot be proposed as a solution of this situation, however, for many important reasons: 1. Classifications and diagnostic approaches to HPI adopted in non-diabetic people are not applicable to diabetics because of their reduced inflammatory response and their insensitivity, which make it difficult to stage the severity of the actual conditions. This might lead to a false negative objectivation and possible bad outcomes for the patients. The same is true for the vascular assessment; as the authors note, this is parti cularly tricky in diabetic patients, as, if not performed by skilled and extremely specialised personnel, it may again lead to a false sense of security.9 2. HPI in diabetic patients are not lesions with an independent pathogenetic mechanism, but a variant of the multidimensional complex pathology that has been recently identified as ‘diabetic foot syndrome’, a nosographic entity that refers to both local, systemic and systematic aspects of the disease to provide an integrated diagnostic workout and therapy according to the severity of the disease and its components.10 3. An approach focused on the lesion, instead of a global taking charge by the specialist team, is not only at risk of being ineffective, it may also delay adequate therapeutic measures and significantly increase the risk

8

of the patient developing complications such as sepsis or critical ischemia gangrene, which would lead to amputation and eventually death. It has been demonstrated how only the prompt referral to an experienced and adequately organised DF unit can change the prognoses of these patients, and how the insisted care of the local manifestation of the disease, when not ac companied by the necessary systemic measures, is the most frequent determinant of delayed referrals and dramatic consequences.11

4. Diabetic foot is a chronic progressive disease that recurs in a time-dependent way; HPI are thus to be considered a part of this complex clinical scenario and managed accordingly. Also, because they frequently occur in a patient admitted or treated for another lesion or acute manifestation of the disease, it would make no sense for him or her to be managed by two different teams1,12 These and other considerations eventually related to the long experience that DF units have accumulated in the last 30 years, and which is a strong added value for the patients, given that they are followed along their clinical progressive pathway by the same team, are strong motivations for maintaining HPI in diabetic patients under the responsibility of DF units. A confirmation of the validity of this approach can be found in the paper by Orneholm et al, significantly titled ‘Heel ulcers do heal in patients with diabetes’. In it, a large cohort of diabetic patients with heel ulcers with heterogeneous etiopathogenesis - pressure ulcers, neuroischemia/ischemic ulcers and ulcers caused by trauma and or cracked skin - was managed by an experienced foot clinic team with a healing rate of 74% and a median healing time of 17 weeks. In this study, like in the Eurodiale study, outcomes were predicted by precipitating factors and co-morbidity, infection, ischemia and the extent of tissue involvement at inclusion, indicating a need for a more extensive and multifactorial approach due to the complexity of the underlying disease.13 Nevertheless, the point raised by Rivolo and Marcadelli in their review of the existing literature on HPI is well taken, since the information is scarce and there are no dedicated guidelines for managing this pathology, especially in diabetic patients. Further, the guidance document by the International Working Group on Diabetic Foot, (IWGDF) the universal reference for those who manage the pathology, does not specifically focus on HPI, which is an increasing menace for our frail patients.14 We recommend that HPI be addressed in the next revision of the guidance on DF, so to fill the existing gap. m

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Science, Practice and Education

REFERENCES 1. Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017 Jun 15;376(24):2367–75. 2. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005 Nov 12;366(9498):1719–24. 3. Rivolo M, Marcadelli S. Heel pressure injuries: The need for a structured evidence-based approach for assessment and treatment. A preliminary literature review. EWMA Journal 2018; 19(2), 15–21. 4. Pickwell KM, Siersma VD, Kars M, Holstein PE, Schaper NC; Eurodiale consortium. Diabetic foot disease: impact of ulcer location on ulcer healing. Diabetes Metab Res Rev. 2013 Jul;29(5):377–83. 5. Gershater MA, Löndahl M, Nyberg P, Larsson J, Thörne J, Eneroth M, Apelqvist J. Complexity of factors related to outcome of neuropathic and neuroischaemic/ischaemic diabetic foot ulcers: a cohort study. Diabetologia. 2009 Mar;52(3):398– 407. 6. Armstrong DG, Fisher TK, Lepow B, White ML, Mills JL. pathophysiology and principles of management of the diabetic foot. In: Fitridge R, Thompson M, editors. Mechanisms of Vascular Disease: A Reference Book for Vascular Specialists [Internet]. Adelaide (AU): University of Adelaide Press; 2011.

1-141-01-03-19 Anzeige Wundkongress Go theborg_RZ.indd 1

7. Prompers L, Schaper N, Apelqvist J, Edmonds M, Jude E, Mauricio D, Uccioli L, Urbancic V, Bakker K, Holstein P, Jirkovska A, Piaggesi A, RagnarsonTennvall G, Reike H, Spraul M, Van Acker K, Van Baal J, Van Merode F, Ferreira I, Huijberts M. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia. 2008 May;51(5):747–55. 8. Yosuf MK, Mahadi SI, Mahmoud SM, Widatalla AH, Ahmed ME. Diabetic neuropathic forefoot and heel ulcers: management, clinical presentation and outcomes. J Wound Care. 2015 Sep;24(9):420–5. doi: 10.12968/jowc.2015.24.9.420. 9. Formosa C, Chockalingam N, Gatt A. Diabetes foot screening: challenges and future strategies. Foot (Edinb). 2018 Oct 6;38:8–11. 10. Meloni M, Izzo V, Giurato L, Uccioli L. A complication of the complications: the complexity of pathogenesis and the role of co-morbidities in the diabetic foot syndrome. In: Piaggesi A and Apelqvist J (Editors). The Diabetic Foot Syndrome. Basel (CH): Karger; 2018.

11. Manu C, Iacopi E, Bouillet B, Vouillarmet J, Ahluwalia R, Lüdemann C, Garcia-Klepzig JL, Meloni M, De Buruaga VR, Sánchez-Ríos JP, Edmonds M, Apelqvist J, Lázaro-Martínez JL, Van Acker K. Delayed referral of patients with diabetic foot ulcers across Europe: patterns between primary care and specialised units. J Wound Care. 2018 Mar 2;27(3):186–92. 12. Boghossian JA, Miller JD, Armstrong DG. Towards extending ulcerfree days in remission in the diabetic foot syndrome. In: Piaggesi A. and Apelqvist J. (Editors). The Diabetic Foot Syndrome. Basel (CH): Karger; 2018. 13. Örneholm H, Apelqvist J, Larsson J, Eneroth M. Heel ulcers do heal in patients with diabetes. Int Wound J. 2017 Aug;14(4):629–35. 14. Bakker K, Apelqvist J, Lipsky BA, Van Netten JJ; International Working Group on the Diabetic Foot. The 2015 IWGDF guidance documents on prevention and management of foot problems in diabetes: development of an evidence-based global consensus. Diabetes Metab Res Rev. 2016 Jan;32 Suppl 1:2–6.

18.02.19 14:47


‘Skin prevalence audits revealed annual increases in incidence of pressure ulcers of the ear.’ * *Incidence, Correlates, And Interventions Used For Pressure Ulcers of the Ear. Mary Ann Turjanica, Lynn Clark, Christine Martini, Pauline Miller, Barbra L. Turner, and Susan Jones Medsurg Nursing. September-October 2011 • Vol. 20/No. 5 P241-246

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Science, Practice and Education DOI: 10.35279/jewma201905.01

Finnish Nurses’ Perception of Clientcentred Wound Care

Salla Seppänen RN, MNSc, Director of Faculty of Health Care, Social Services, Culture and Rural Industries Savonia University of Applied Sciences

Client-centred wound care includes the dimensions of the client, professional, and care organisation, which are equal. The aim of this study was to describe the perception of client-centred wound care of nursing professionals in Finland who are interested and involved in wound care practice. ABSTRACT Introduction Client-centred care improves patient and process outcomes. According to previous studies and reviews, client-centred care focuses on the client´s participation and involvement in care. Clientcentred care includes holistic and responsive care. Client-centred care has not been studied in wound patients.

Methods The aim of this study was to describe the perception of client-centred wound care of nursing professionals in Finland who are interested and involved in wound care practice. The data were collected using surveys from 28 Finnish RNs who studied in the National Wound Management Specialisation programme. The survey included structured and open-ended questions. The structured questions focused on the profile of the respondent and the open-ended questions were used to describe the respondent’s perception of client-centred wound care. The data from the open-ended questions were analysed using qualitative inductive content analysis.

Results The results categorise client-centred wound care into three main categories: client, professional, and care organisation. The client is defined as an actor in wound care. The client´s motivation and adherence to care promote implementation of client-centred care. The professional is defined as a client´s advocate, whose task is to facilitate the client´s participation in the care process by informing and supporting the client. The professional´s positive

journal of the european wound management association 

and respectful attitude toward the client enables the creation of a client-professional relationship that supports client´s adherence to care. In clientcentred wound care, the holistic care philosophy of the care organisation is implemented through the care process by holistic assessment and personalised wound care. In addition to holistic care, interdisciplinary cooperation and continuity of care support the implementation of client-centred wound care.

Conclusions The main categories are equally important and thus the development of client-centred wound care needs to integrate the dimensions of the client, professional, and care organisation. The client needs to be involved in decision-making for wound treatment and the professionals´ knowledge and experience in wound care need to be increased and strengthened. In the care organisation, holistic care challenges include time allocation for wound care and the working models of nurse and nurse-physician pair, which were highlighted as examples to promote client-centred wound care.

Recommendations for practice The flexible consultation model between specialists and professionals as well as continuity of care between primary and specialised care facilitate the implementation of client-centred wound care.

BACKGROUND OF THE STUDY This study assessed client-centred care in the context of wound care patients. The concepts patientcentred, client-centred, and person-centred care 

2019 vol 20 no 1

Correspondence: salla.seppanen@savonia.fi

Conflicts of interest: None

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are used as synonyms.1,2 Since the beginning of 2000, a paradigm shift has occurred in health care toward patientor client-centred care, which increases the quality of care resulting in improved patient and process outcomes.3,4,5,6 The reviews of patient-centred care focus on components such as collaborative care, which includes a patient´s participation, involvement7, as well as empowerment.8 In Sinadi and Fox’s (2014) literature review9, patient-centred care also includes holistic and responsive care. Client-centred care focuses on a client with the living environment as the centre of the care process. Thus, the client´s values, needs, and expectations are the basis for care provision. Client-centred care advocates the client´s autonomy and position. The cooperative client-professional relationship is one of the main premises of client-centred care.9,7 Person-centred care is comprised of four items: attributes of the nurse, the care environment, care process, and personcentred outcomes.2 Finnish national social and health care highlights clientcentred care as one of the main premises for providing future care. Client-centred care focuses on the client´s equality and participation. The client’s experience of participation increases personal wellbeing, and implementation of client´s participation promotes development of ongoing services, while the client´s experience is valued in addition to the science.10 Client-centred care in wound patients is not defined, and thus it is important to understand professionals’ perception of the concept. Nurses are the main professionals involved in wound care and their perception of client-centred care is essential for the development of client-centred wound care. THE AIM AND RESEARCH QUESTIONS OF THE STUDY The aim of study was to describe the content of clientcentred wound care in Finland using the perception of nursing professionals interested and involved in wound care practice. The research questions were: n How do nurses describe client-centred care in wound patients? n What issues do nurses think promote and impede client-centred wound care? n How would nurses develop client-centred wound care in practice?

DATA COLLECTION The data were collected using a Webropol survey (15.1115.12.2018) from Finnish RNs who studied in the Na12

tional Wound Management Specialisation programme (N=86). The studies are 30 ECTS and last one year. The nurses began their studies in September 2018. The link for the survey was provided to nurses by e-mail and 28 responded (32.55%). The survey was not included as part of their wound management specialisation studies, so the nurses answered voluntarily, and it was not possible to recognise who had responded to the survey. The survey included both structured and open-ended questions.11 Structured questions reported sex, age, earlier education, working experience in wound care, and assessment of the implementation of client-centred wound care in practice by classification (poor, satisfactory, fairly good, good, or excellent). The open-ended questions focused on the content of client-centred wound care. The nurses were asked to define client-centred wound care and describe the factors that promote and impede the implementation of client-centred care for wound patients. The nurses were also asked to present ideas about how to develop clientcentred wound care in practice. In the last open-ended question, the nurses could write other issues that they wanted to highlight related to client-centred wound care. DATA ANALYSIS The data from the structured questions were analysed statistically using frequencies, percentages, and mean values. The data from open-ended questions were in text format and totalled 12 pages of text. The qualitative data were analysed by qualitative inductive content analyses. The unit of analysis was a meaningful theme and a unit of meaning was a word, sentence, or more than one sentence. The manifest content was analysed.12 First, the text was read by question, focusing on the elements of client-centred wound care. Units of meaning were recognised, and condensed meaning units were formulated under each question. Codes for the condensed meanings were developed and the data were reorganised under each question based on the codes and sorted into subcategories, which were compared under each question and linked to each other by developing the main categories.13 Table 1 presents examples of analysis from the meaning unit, condensed meaning units, and codes to subcategories and main categories, which were client, professionals, and care organisation. The nurses used both the concepts of patient and client in their answers, and thus the units of meaning used either patient or client, depending on which the responding nurse had written. Table 1 First, the results of the structured question data are summarised and then the results of open-ended question analysis with qualitative content analysis based on the research questions is summarised.

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Table 1. Examples of qualitative, inductive content analysis in the study. UNIT OF MEANING

CONDENSED MEANING UNIT

CODE

SUBCATEGORY

‘Client´s needs, expectations, and wishes are taken into consideration.’

Client’s needs, expectations, and wishes are valued

Client needs, expectations, wishes

Client initiation

‘The client needs to be heard as an expert in his/her own situation.’

Client is recogniSed as an expert in their own situation

Client´s expertise in own life

Client as an expert

‘Wound care is planned together with a client.’

Client’s participation in planning of wound care

Client´s active role in wound care planning

Client as an actor

‘Patient is involved in decisionmaking of wound care, for example, in selection of wound care products.’

Client´s partnership on decision-making in wound care

Client’s active role in decision-making

Client as an actor

‘Being the advocate of the patient.’

Being an advocate for the client

Advocate of client

Role of advocate

‘I listen to the patient and implement wound care in agreement with the patient, but based on research results.’

Listening to the client and integrating research to care

Implementation of research into client situation physical-social and emotional support of client

Implement evidence-based care

‘Supporting and encouraging the patient and also emotional support.’

Support and encourage client, also emotionally

‘Assessment of a client’s physical, psychological, and social situation.’

Physio-psycho-social assessment of client’s need

Holistic assessment

Holistic care philosophy

‘Assessment of a client´s whole situation, like nutrition, functional capacity, and pain.’

Assessment of client’s whole situation

Holistic assessment

Holistic care philosophy

‘The wound care is tailored according to the needs of the client.’

Wound care is based on client’s need

Personalized/tailored wound care

Holistic care philosophy

Client

Professional

Holistic support

Profile of nurses who responded to the survey The survey respondents were 28 registered nurses who studied in the Finnish National Wound Management Specialisation program, one male and 27 females. Over 82% (n= 23) of the RNs had a bachelor’s level education and 17.86% (n=5) had diploma level education. They had graduated when higher education in nursing was not available in Finland. The average age was 41.6 years; the youngest was 28 and the oldest was 58 years. Only 10.7% 8 (n=3) of the nurses were under 30 years of age, 39.29% (n=11) were 30–39 years, 21.43% (n=6) were 40–49 years, and 28.57% (n=8) were 50–59 years. Most of the nurses 46.43% (n=13)) worked in primary health care, 32.14% journal of the european wound management association 

MAIN CATEGORY

Care organisation

(n=9) of the nurses (worked in specialised health care, 10.71% (n=3) in home care, and 10.71% (n=3) in elderly care. The nurses´ working experience with wound patients was long; 42.8% (n=12) had more than 10 years and 32.2 % (n=9) had 6 to 10 years of working experience with wound patients. Most of the nurses [60.71% (n=17)] assessed the implementation of client-centred care in wound patients in Finland to be good. However, 35.5% of nurses (n=10) assessed it as a fairly good and one (3.57%) as satisfactory. None of nurses assessed client-centred care for wound pa tients to be excellent or poor.

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Nurses’ description of client-centred care for wound patients The nurses´ description of client-centred wound care was classified into the main categories of client, professional, and care organisation. The subcategories specify the content of the main categories. The client-centred care for wound patients was described by the main categories with the defined subcategories. The links between the main categories are presented. Authentic quotations are used to verify the nurses’ perception. Client as an actor in wound care In the description of client-centred care for wound patients, the nurses define the client as an expert in his/her own life. The client has wishes, expectations, and experiences of their illness as well as their care that professionals need to understand and take into consideration in all phases of the wound care process. The client was defined as an actor in the wound care process. The client´s role was described in all phases of the care process: planning, implementation, and evaluation of wound care. The nurses highlighted the client´s role in decision-making for wound care as essential. Thus, the client was described as a key person in the decision-making for all issues related to wound care including selection of bandages, changing the wound treatment, or consulting a GP or Specialist. ‘The patient´s opinion is asked, and it is taken in consideration in the decision-making for wound care products and medical consultation.’ The nurses stressed that the client´s opinion needs to be asked and the message needs to be appreciated by professionals. ‘The client can tell what kind of treatment is good, and which bandages feel comfortable and which are uncomfortable or even painful.’ The nurses stressed that too often a professional decides wound treatment and forgets to explain the reason why the selected dressing is the best for client´s wound and ask the client´s opinion of the wound treatment. ‘The patient should not be shifted outside of the decisionmaking in wound care. Too often the professional takes over the planning of treatment without discussion with the patient.’ A client also has the right to refuse treatment, if a client is fully aware of the wound healing situation and consequences of his/her decision. Thus, a client should have

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knowledge of individual wound healing and be committed to the objective of care. The client´s adherence to wound care was very important for implementation of client-centred care. The nurses recognized that a client´s motivation and optimism in wound care was essential. The role of the nurse was to inform and encourage a client. The aim of wound care was to improve client´s quality of life, so that the client’s everyday life was as smooth as possible, and the wound care was not causing stress. The nurses recognized that the wound and its treatment might dominate a client´s life. When treatment of a wound takes a lot of time and controls too much of the client´s daily life, it causes client exhaustion and non-adherence to care. ‘When treatment of the wound restricts a lot of the patient´s life and takes a lot of time, it affects the patient in many way. Now and then, I have recognized that patients are exhausted from the treatment.’ The nurses pointed out that in planning wound treatment, the client´s time resources and need for help is important to realise, because these affect the client´s adherence to care. ‘While planning the local treatment of the wound, we need to be sure the client has time for treatment and that it is possible for the client to have helping hands if needed.’ Nurses stressed that the appointment for treatment in the clinic or at the client´s home needs to be planned in cooperation with the client to minimise the impact to the client’s daily activities. The nurses stressed that wound care at home is preferred by most clients, if it is safe and possible to implement based on the wound condition. The home as a care environment increases the importance of the client´s participation in planning wound care to ensure that treatment is easy to implement at home and does not take too much of the client´s time. Professional as an advocate for a client In client-centred wound care, the nurses described the professional as an advocate for the client. ‘We are so-called patient´s advocates.’ The professional as an advocate of the client facilitates a client´s participation in decision-making. The nurses stressed the professional´s responsibility to inform a client and ensure they understand the diagnosis, individual wound healing, and possibilities of treatment. A client

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should also understand effects of personal living habits for wound healing and prevention of ulcers. ‘From the very first appointment with a client, it is important to take notice of a client´s background, functional capacity, and understanding of treatment.’ ‘A patient should be informed of living habits that effect wound healing, like nutrition, physical exercise, and smoking.’ The professional´s task is to find out the client´s care needs as well as the existing resources and thus the holistic assessment includes physical, psychological, social, and emotional aspects of the client´s situation. The assessment includes the client´s background, medical history, comorbidities, medication, functional capacity, living habits, motivation, values, expectations, social network, and need for financial support. The nurses pointed out that the costs of wound care are important to realise together with the client before the treatment decision, especially if the client buys wound care products and the costs are not reimbursed. ‘If a client buys wound care products by him/herself, it is crucial that products and prices are compared, and total cost is calculated and estimated together with a client.’ The nurses pointed out that compromises need to be made between optimal wound healing and costs of treatment. ‘Wound care products need to support wound healing and the total costs need to be a price appropriate for a client to buy. In selection of wound care products, a client’s financial situation needs to be taken into consideration and all extra costs should be avoided that might be caused by wrong selection of products. Usually, we find the compromise solution together.’ Client-centred wound care focuses on a professional’s attitude, know-how, and relationship with a client. The nurses stressed that the basis for client-centred care is the professional’s positive and respectful attitude towards a client and the ability for empathy. ‘In client-centred care with wound patients, the most important aspect is the professional´s positive attitude and empathy.’ The nurses stressed a professional´s respectful attitude toward the client’s experience, expectations, and wishes. Client-centred wound care was described as an ongoing interaction between a client and a professional, and thus it is important to focus on a client from the first appointment to create a trusting relationship with open communication. A client needs to be heard by the professional. The

nurses highlighted that a professional´s ability to listen to the client and take into consideration the client´s view of treatment, dressings, bandages, and wound care techniques enable client-centeredness in wound care. ‘Listening to a client; which bandages feels comfortable, how a client would like the wound to be treated, what kind of dressings and bandages a client prefers. We need to take seriously and respond to client´s expressions and stories, for example, in pain.’ Good pain management was defined as an important issue in client-centred wound care. The client´s experience of pain and pain relief were described as important parts in the client’s holistic assessment as well as professional´s local treatment of the wound. Cooperation with family members and significant others was also highlighted by the nurses as part of client-centred wound care. ‘A client is cared for in good cooperation with him- or herself as well as with significant others.’ The professional´s role as an advocate highlights the importance of supporting the client to make decisions in personal wound care. This means that a professional has good knowledge and skills in wound care. ‘The professional needs to have enough know-how in wound care.’ Holism as an organisation´s philosophy in wound care The nurses described client-centred wound care in the main category care organisation through holistic philosophy of care, interdisciplinary cooperation, and continuance of care. The holism or holistic care philosophy is based on the holistic assessment of client´s needs and tailoring the care. ‘Holistic care means that care is tailored according to the client´s need. The client´s situation needs to be assessed in different views, not only focusing on the wound, but taking into consideration the client’s whole life situation.’ According to holistic care, planning client-centred wound care focuses on the individual objectives of care with the available resources. ‘We cannot always provide services that meet all the client’s expectations, but we can provide client-centred care if we plan care individually based on the client’s living habits, issues related to wound healing, and financial resources.’ 

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Table 2. The nurses´ perception on issues that promote and impede client-centred wound care.

MAIN CATEGORY

PROMOTE CLIENT-CENTRED CARE

IMPEDE CLIENT-CENTRED CARE

Client

- is adherent during wound care as well as care of comorbidities - has open communication with professionals - is willing to take part in decision-making related to wound care - understands wound diagnosis and issues that affect wound healing - is committed to objectives of wound treatment - has abilities to implement self-care - has living habits that promote wound healing - has family member support

- is non-adherent during wound care - does not take an active role in decision-making for care - does not take responsibility for self-care - has many comorbidities that are difficult to manage - is not motivated to care - is unwilling to change living habits - expresses pain - has lack of social network - has low income for cost of wound care - is not heard and feels rejected in decision-making of wound care - expresses that wound care is complicated and time consuming - expresses that dressing changes are done too often

Professional

- good know-how of wound healing and treatment - experience in wound care - trusted relationship with a client - positive and respectful attitude toward client - empathy - ability to listen to the client

- lack of knowledge and skills of wound care - none or very limited experience in wound care - uncertainty - feeling of being in a hurry - frustration; especially if the client is not adherent to care - client is not supported to participate in decision making for wound care

Care organisation

- implements holistic assessment of client´s situation - allocates enough time for client´s care in clinical appointments or visits at home - uses individual care plan - provides 1–2 named nurses/clients - implements nurse-physician working pair - has organised cooperation between primary health care and specialised care - implements evidence-based care in practice - has flexible consultation model - uses multidisciplinary care team

- has shortages of resources - allocates too short of a time for client appointments - has too few professionals who are experts in wound care - often has changes in staff - has limited selection of wound care products - has too small rooms, too little space for wound treatment

The nurses stressed that interdisciplinary cooperation enables personalise care according to the client´s needs because of the combination of multi-professional knowledge. Interdisciplinary cooperation includes the nursephysician working pair, flexible consultation model, and evidence-based practice. The nurse-physician working pair supports competences needed for assessing wound healing and client-initiated factors related to healing and defining delayed healing and complications. The flexible consultation model enables obtaining expert opinions for a client´s situation without the waiting time for a specialist appointment. Evidence-based practice integrates the best available knowledge into the client´s personalised care by shared interpretations of different professionals. 16

Continuance of care for the wound patient includes shared objectives of care, the same professional’s involvement in the client´s wound care, and shared documentation with professionals. The nurses stressed the importance of shared objectives of care as premises for client-centred wound care. The objectives of care need to be shared. If possible, the objectives of wound care are shared with all who participate in the client´s wound care.’ The shared objectives of care are needed between the client, relatives, and all the professionals who participate in wound care to enabled reliable and trusting client-

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professional relationships and assessment of wound care. The problematic issue in continuance of wound care was found when a client was shifted from specialised care to primary health care and vice versa. In continuance of care in wound patients, the nurses stressed that when the same professionals care for a client and implement the wound treatment, the client-professional relationship is more personal and trusting when a client and professional know each other. The client´s individual needs can be better recognised and taken into consideration during care, and the assessment of wound healing is more reliable if the same professionals do the assessment. ‘When the nurse and physician are changing all the time, the assessment of wound healing is not reliable.’ Nurse appraisal of issues to promote and impede client-centred wound care In the survey, two questions asked nurses to describe issues that promote and impede client-centred wound care. The nurses´ description of issues to promote and impede clientcentred wound care are presented in Table 2 according to the main categories. The client´s adherence to and motivation for wound care were recognised to be key issues in client-centred wound care. Open communication and the client´s willingness to change living habits as well as abilities for self-care were stressed to promote client-centred wound care. The impeding issues were the client´s comorbidities, pain, lack of a social network, and low income and the feeling of not having a role in the decision-making for wound care. ‘It is hard to implement client-centred wound care when a patient is non-adherent, not responding to any information, and not willing to change living habits.’ ‘When a patient is a so-called difficult patient, not cooperative and not interested in care, a nurse gives up and just performs the routines.’ The professional´s know-how in wound healing and treatment as well as experience in wound care was described to promote client-centred wound care. ‘The staffs´ know-how in wound care is important. The nurse must know a lot be able to supervise a patient and treat the wound. Also, physicians need to be familiarised with wound care.’ The professional´s feelings of being in a hurry, uncertainty,

and frustration were described to impede client-centred wound care. In care organisations, holistic assessment, individual care plans, named nurses (1-2) per client, a flexible consultation model, multidisciplinary teams, and cooperation between primary and specialised care was reported to promote client-centred wound care. ‘The possibility to have a named nurse for each patient. The trust between the nurse and patient increases when the care relationship is longer and a patient´s situation is better understood.’ ‘When you know a patient, it is easier to stick to the problems or patient´s neglect of care.’ The impeding factors were shortage of resources, like too limited a selection of wound care products and too little space for wound treatment, continuous changes in staff, and too short a time for the client´s appointment and treatment of the wound. According to the nurses, time was essential for clientcentred wound care. The appropriate time for meeting a client, especially the first time, was mentioned as crucial to be able to create a good relationship with a client and have a holistic view of the client´s situation. The nurses reported that the time allocated for appointments with a wound patient is often too short for discussions with a client and a nurse feels forced just to concentrate on local treatment of the wound. There is no time for shared assessment of wound healing together with client. ‘The nurse does not have enough time for a patient and thus the only thing the nurse does is treat the wound and hurry forward.’ The time was related to the client´s possibility for decisionmaking. The nurses stressed that feelings of being in a hurry should not be present so that a client has enough time to compare different treatment possibilities and ask questions. Developing client-centred wound care The nurses´ ideas for the development of client-centred wound care are presented in the main categories. In the client´s perspective, nurses stressed that the development of client-centred wound care should focus on the client´s active role in decision-making. ‘A client should always participate in decision-making and planning of treatment.’ 

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‘Patients should be more involved in decision-making as well as implementation of wound care. Not that way that nurse and physician order everything in wound care.’

Interdisciplinary cooperation is needed to develop cooperation between professionals in different specialities to ensure ongoing and flexible consultation.

This requires that a client has enough knowledge of wound healing and the factors related to it. The client needs to understand the meaning of living habits for wound healing to be adherent to care.

‘The nurse should have the possibility to consult a specialist if there are problems in wound healing.’

‘Clients are not always realistic with wound care. They might think that the wound will heal, and they need to do nothing for it, they do not understand how their living habits and choices impact wound healing.’ The professionals´ attitude toward the client was suggested to be developed as more supportive so that professional´s facilitate the client to have an active role in the decisionmaking for wound care. ‘A nurse tells the facts to a patient, not makes the decisions for a patient.’ The client´s supervision and counselling by professionals needs to be developed further toward responsiveness. ‘The same model for client information and supervision that we have in starting new medication should be adapted to wound care and treatment selection.’ In the professional´s point of view, the most important issues were increasing and strengthening the professional´s know-how in wound care. The nurses stressed that wound care education is needed in working places and the amount of specialised wound care nurses need to be increased in practice. ‘Regular wound care education in the working place.’ ‘Increase the number of staff with wound specialisation education.’ The nurses stressed the need to increase competences in wound care in pre-register education. ‘More wound care in pre-register nurse-education is required.’ In care organisations, the development of client-centred wound care highlighted the need to enhance time allocated for appointments with clients. The feeling of being in a hurry impeded the implementation of client-centred wound care. ‘The nurse should have enough time for the wound patients. If you are in hurry, you do not implement holistic care.’ 18

Evidence-based wound care practice challenges the discussion between the professions. ‘Too often we do as usual. The routines are guiding wound care practice - not the evidence.’ CONCLUSIONS Client-centred wound care includes three main categories: client, professional, and care organisation, which are integrated with each other. The implementation of clientcentred wound care demands that the client, professionals, and care organisation are committed to client-centredness. In the client´ perspective, the premises for client-centred wound care are the client´s active role in planning, implementation, and evaluation of wound care and the client´s adherence to wound care. The autonomy of the client was stressed by nurses. The client´s role as an actor was also defined as one of the main areas in the development of client-centred wound care. To enable a client to be an actor in wound care, the client must have the possibility to affect the care by decision-making and evaluation of wound care. The care organisation thus needs to develop care processes so that a client´s role and involvement is defined in the different phases of wound care. In the professional´s perspective, a positive and respectful attitude toward the client, know-how in wound care, and a mutual relationship with a client were the key components in client-centred wound care. The professionals need the ability to define individual client´s needs and resources as well as preferences and values. The professional´s main challenge was to motivate, supervise, and support the client in the decision-making process and increase the client´s adherence to care. The professional informs the client of medical facts, treatment options, and gets the client interested to assess personal living habits related to wound healing. The professional’s knowledge and experience in wound care promotes implementation of client-centred wound care in practice. The development of client-centred wound care from a professional´s perspective highlights the need to focus a professional´s positive and respectful attitude toward the client and his or her significant others as well as the professional´s know-how in wound care. Client-centred wound care in a care organisation included holistic care philosophy, interdisciplinary cooperation, and continuance of care. Personalised, tailored care requires a

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holistic assessment of the client´s situation including needs of care and information as well as existing resources. To be able to implement a holistic assessment and personalised care, the time for a professional´s appointments with a client needs to be sufficiently long. The interdisciplinary cooperation with a nurse-physician working pair, flexible consulting model, and implementation of evidence-based practices ensure that the best available knowledge is provided for the client as the basis of care decisions. The continuity of care highlights the importance of shared objectives of client´s care. This challenges the care process and especially the documentation of care among the professionals involved in the wound care as well as the client. The objectives of care should be defined with a client and documented, so that the client can understand and adhere to objectives. DISCUSSION The study focused on client-centred wound care. The core for client-centred wound care is holistic care, which focuses on a client´s active role in the care process, a care professional´s positive and respectful attitude toward the client, competences in wound care, as well as organising wound care so that care is personalised. In a care organisation, client-centred care based on holistic care is a philosophy rather than a set of rules.2 The results of this study are similar to the systematic reviews of client- or patient-centred care focusing on holistic, collaborative, and responsive care.9 The client´s active role in wound management is based on an understanding of medical facts and possibilities as well as demands of treatment options that need to be presented by professionals. The professionals’ competences in wound care can be strengthen by education, mentoring, and pair working. The implementation of client-centred wound care shows the need to organise wound care in the context where knowledge of wounds, healing, and treatment is available for the professionals as well as for the clients and their significant others. Modern technology can help by providing information, easy consulting, and sharing the knowledge. In Finland, a Virtual Health Village has been developed, which provides digital information and support for citizens, care for patients, and tools for professionals. In the Virtual Health Village, evidence-based information and instructions related to medical problems and diseases, like diabetes, mental health disorders, and wounds, are collected in virtual houses, like Virtual Wound House (https://www.terveyskyla.fi/haavatalo). The digital material is available to all Finns regardless of their place of residence and income level (https:// www.terveyskyla.fi).14 Recommendations for development of practice In this study, client-centred wound care was defined us journal of the european wound management association 

ing a survey for RNs who studied in the Finnish National Wound Management Specialisation programme, because they were supposed to have an interest in and experience of wound care, and thus their perspective on client-centred care for wound patients was specified. It is important to be aware that the results are not presenting Finnish nurses perception of client-centred care for wound patients in general. The results present a subset of nurses´ perceptions of client-centred wound care in Finland. It would be interesting to implement the same surveys in another country and compare the results between the countries. It also would be interesting to study the physician perception of client-centred care among wound patients. Gachoud et al. (2012)15 showed there are differences between professions regarding how patient-centeredness is defined. Nurses considered themselves more patient-centred than physicians. For the assessment of client-centred care, a Client-Centred Care Questionnaire (CCCQ), which focuses on the client´s perspective as an outcome of client-centred care, has been developed.16 Based on the results of this study, it is possible to develop tools for assessment of clientcentred wound care with the dimensions of client, professional, and care organisation. The dimension of client focuses on the role of the client in the decision-making and implementation of wound care and the client´s adherence to care. The dimension of professional focuses on a professional´s attitude, relationship with client, and competence in wound care. The dimension of organisation focuses on holistic care with assessment, planning, and evaluation of care including time allocation for wound patients, interdisciplinary cooperation with a nurse-physician working pair model, flexible consultation, evidence-based practice, and continuity of care including the assessment of a client´s path and documentation of care. IMPLICATIONS FOR CLINICAL PRACTICE Client-centred care in wound care focuses on the dimensions of client, professional, and care organisation. A client is an actor in the wound care process: decisionmaking, self-care, and evaluation. A professional facilitates a client to be an actor in wound care by providing information regarding the diagnosis, medical facts, and treatment options. By holistic assessment, the professional together with the client assess the client´s need of care and possibilities that may affect wound healing. A professional supports the client´s adherence to wound care.

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Holistic care is a philosophy of the care organisation, which is implemented using holistic assessment and personalised wound care. Interdisciplinary cooperation and continuity of care enable implementation of client-centred wound care. There is a need to develop a client’s ability to be involved in decision-making for wound care, professional positive and respectful attitudes toward the client, and know-how in wound care.

develop a consultation model between primary and specialised care. Named nurse model and nurse-physician pair support implementation of client-centred wound care. FURTHER RESEARCH n Physician´s perception of client-centred wound care. n Cross

cultural studies of client-centred wound care.

n Develop

To promote client-centred wound care, the care organisation needs to allocate enough time for wound care and

self-assessment tool of client-centred care in wound care with dimensions of client, professional, and care organisation. m

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12. Elo S, Kyngäs H. The qualitative content analysis process. JAN. Research methodology 2007; 107-115. Doi:10.1111/j.1365-2648.2007.04569.x. Read 05.03.2019.

8. Haggerty J, Fortin M, Beaulieu M, Hudon C, Loignon C, Préville M et al. At the interface of community and health care systems: A longitudinal cohort study on evolving health and impact of primary healthcare from the patient´s perspective. BMC Health Service research 2010: 10; 1-10.

14. Terveyskylä.fi. https://www.terveyskyla.fi/tietoaterveyskyl%C3%A4st%C3%A4/virtuaalisairaala2-0-hanke/the-virtual-hospital-2-0. Read 05.03.2019.

9. Sidani S, Fox M. Patient-centered care: clarification of its specific elements to facilitate interprofessional care. Journal of Interprofessional Care 2014: 28 (2); 134-141. 10. Terveyden ja hyvinvoinnin laitos. Sote uudistus. https:// thl.fi/en/web/sote-uudistus/palvelujen-tuottaminen/ asiakkaat-ja-osallisuus. https://thl.fi/en/web/ social-welfare-and-health-care-reform Read 05.03.2019.

13. Erlingsson C, Brysiewics P. A hands-on guide to doing content analysis. African Journal of Emergency Medicine 2017: 7; 93-99.

15. Gachoud D, Albert M, Kuper A, Strpund L, Reeves S. Meaning and perception of patient-centeredness in social work, nursing and medicine: A comparative study. Journal of Interprofessional Care 2012: 26; 484-490. 16. Witte L, Schoot T, Proot I. Development of ClientCentered Care Questionnaire. Journal of Advanced Nursing. 2006: 56 (1); 62-8.

11. Valli, R. Creating a questionnaire for a scientific study. International Journal of Research Studies in Education 2017: 6 (4); 15-27. Doi 10.5861/ ijrse.2016.1584

journal of the european wound management association 

2019 vol 20 no 1


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Science, Practice and Education DOI: 10.35279/jewma201905.02

Optimising Wellbeing in Patients with Diabetic Foot Ulcers Living with diabetic foot ulceration can have a significant impact on a person’s physical and psychological health. All members of the multidisciplinary team have a responsibility to consider the importance of wellbeing assessment and to be mindful of a number of suggested approaches.

ABSTRACT Background Living with diabetic foot ulceration (DFU) can have a significant impact on a person’s physical and psychological health. Clinicians involved in the treatment of DFU patients should possess sufficient knowledge and understanding of the total impact of living with a DFU, including an awareness of an individual’s wellbeing.

Aim To provide an overview of the current literature with regard to wellbeing in patients affected by DFU by considering current outcome measures used to assess domains of wellbeing in this population.

Findings The psychological, physical, spiritual, and cultural domains of wellbeing all impact an individual’s overall wellbeing. There is no one standardised tool available that assesses all four domains of wellbeing specific to those with DFU. It is important for clinicians to be aware that all members of the multidisciplinary team have a responsibility to consider the importance of wellbeing assessment and to be mindful of suggested approaches.

Conclusions There is a need for a reliable and valid measurement tool to assess overall wellbeing in people living with DFU.

Implications for clinical practice This review highlights the importance of the inclusion of wellbeing assessment in optimising wound care for individuals with DFU. journal of the european wound management association 

John D. Ivory, MSc2

INTRODUCTION In recent decades, the prevalence of diabetes has increased in virtually all regions across the globe.1 The increased prevalence of diabetes and the fact that diabetic patients are living longer with the disease will undoubtedly give rise to a higher incidence of diabetes-specific complications, including cardiovascular disease, renal failure, and diabetic foot disease.1 The impact of living with diabetes and diabetic foot disease is complex and multifactorial. Diabetic foot disease can be defined as the presence of several characteristic diabetic foot complications that may be comprised of neuropathies, ischaemia, infection, and Charcot’s neuroarthropathy.2 Diabetic foot disease is associated with devastating outcomes such as diabetic foot ulceration (DFU), amputation, and premature death. A DFU is a pivotal event in the life of a person with diabetes and is a marker of serious disease.3 Patients with DFU are likely to have a reduced health-related quality of life (HRQoL) and are likely to experience symptoms of neuropathic pain, reduced mobility, sleep disturbances, leakage, and malodour from the wound.4 The psychological impact of living with DFU must be addressed within patient-centred management plans. Patients living with DFU are at greater risk of depression, anxiety, mood disorders, embarrassment, stigma, and issues associated with low self-esteem.4 Psychosocial factors, such as anxiety and depression, are associated with de

2019 vol 20 no 1

Caroline McIntosh, PhD1

Georgina Gethin, PhD, RGN3

Claire MacGilchrist, PhD4 1.

Professor of Podiatric Medicine, Discipline of Podiatric Medicine and the Alliance for Research and Innovation in Wounds, National University of Ireland Galway, Galway, Ireland.

2. Research Assistant (Wound Care), School of Nursing and Midwifery and the Alliance for Research and Innovation in Wounds, National University of Ireland Galway, Galway, Ireland. 3.

Head of the School of Nursing and Midwifery and the Alliance for Research and Innovation in Wounds, National University of Ireland, Galway, Ireland.

4.

Lecturer in Podiatric Medicine, Discipline of Podiatric Medicine and the Alliance for Research and Innovation in Wounds, National University of Ireland Galway, Galway, Ireland.

Correspondence: caroline.mcintosh@ nuigalway.ie Conflicts of interest: None

23


layed healing, while poor symptom management can cause patients to become non-concordant.5 Evidence shows that when individual patients are actively involved in their care, outcomes improve.5 Treatment goals should, therefore, aim to optimise wellbeing and fully engage patients in their treatment. However, while the physical aspects of diabetes and DFU can be easily measured, the concept of ‘wellbeing’ for those living with DFU is more difficult to capture.5 For example, in those with DFU, wellbeing may be adversely affected by nonhealing wounds, while patients with healed ulcers may have a poorer HRQoL due to fear of recurrence, amputation, and/or the need for lifelong treatment.5,6 HRQOL AND WELLBEING HRQoL is a health concept that represents the ultimate goal of health promotion interventions.7 The Center for Disease Control and Prevention (2011) defines HRQoL as an “individual’s cognitive appraisal of their standard of living in relation to their health”, and wellbeing specifically relates to “the existence of positive emotions and contentment, alongside the absence of persistent negative emotions”8. Chadwick and Rastogi (2016) argue that patient wellbeing should be considered as a separate, but linked, concept to HRQoL.4 DFU management should aim to achieve rapid wound closure and minimise complications and adverse outcomes, while restoring a patient’s HRQoL to “pre-ulcer” status.9 However, a dearth of literature exists with regard to DFU and wellbeing and there is a distinct lack of tools to measure wellbeing in this population. Yet, failure to address patient wellbeing can adversely affect clinical and patient outcomes and have negative impacts on health behaviours. DEFINING WELLBEING Wellbeing has been defined as: “a dynamic matrix of factors, including physical, social, psychological and spiritual. The concept of wellbeing is inherently individual, will vary over time, is influenced by culture and context, and is independent of wound type, duration or care setting”.5 DOMAINS OF WELLBEING An individual’s wellbeing encompasses physical, social, psychological, and spiritual domains that can all vary over time.5 The physical, social, and psychological factors associated with wellbeing are considered interrelated. Physical Wellbeing Physical wellbeing relates to an individual’s ability to partake in normal activities of daily living, such as self-hygiene and dressing and feeding oneself. Specific physical parameters of a wound that impact wellbeing can include size, 24

location, depth, and duration of the wound.10 Pain is considered one of the most distressing symptoms associated with living with a wound.11 Other commonly reported physical symptoms include wound exudate, malodour, and reduced mobility that, in isolation or collectively, may result in reduced social contact and sleep disturbances.12 Psychological Wellbeing The psychological impact of living with a chronic wound can be difficult to measure and less tangible than the physical challenges that are associated with the wound. Despite this, the psychological impact of living with a chronic wound is suggested to be of equal importance to and interrelated with the physical symptoms.13 The aforementioned physical parameters can result in negative emotional states, such as anxiety and depression, impacting an individual’s body image and self-esteem, ultimately affecting their overall psychological wellbeing.14 This negative emotional state may perpetuate further negative health behaviours such as poor nutritional choices, excessive alcohol consumption, and cigarette smoking.15 There is also evidence to suggest that in turn, this psychological stress can impair wound healing and, although further research is warranted, current evidence suggests that psychological interventions may play a role in the wound healing arena.16 Social Wellbeing Living with a chronic wound can significantly affect social wellbeing. Limited mobility associated with a wound may prevent social interactions with some individuals rendered bed/house bound. Physical and psychological parameters can impact social interactions. For example, pain, malodour, excess exudate production, anxiety, and depression can all impact social wellbeing.13 Remaining in the work force may also be a significant challenge for individuals due to altered mobility and frequent hospital/clinical appointments associated with a wound management regime. This can result in a loss of independence and reduced quality of life.17 Spiritual/Cultural Wellbeing An individual’s perception of their wound and their expectations for healing can be largely impacted by their spiritual and cultural influences.5 Clinicians should be mindful of religious/cultural implications and involve the patient in the management plan to ensure a holistic approach. An individual’s cultural and spiritual beliefs can have a powerful influence on a patient’s involvement and their interaction with the care provider.5 It is important that the clinician recognises this and works with the patient accordingly. To achieve optimal patient care, the clinician must be aware of the complex interactions between the physical,

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psychological, social, and spiritual/cultural domains of wellbeing. BARRIERS TO ASSESSING PATIENT WELLBEING Improving health and wellbeing is associated with economic and social benefits.5 Yet there is a lack of research that specifically focuses on the assessment of wellbeing for

patients living with DFU. Therefore, assessment of patient wellbeing in this population is frequently overlooked in clinical practice. Indeed, there may be many barriers that prevent clinicians from assessing wellbeing in this cohort that may include: a lack of time in busy clinical services, lack of privacy, lack of standardised documentation, no standardised tool to capture or measure wellbeing, different professionals involved in the care of the DFU patient,

Table 1. Summary of outcome measures associated with aspects of wellbeing in diabetic foot ulceration (DFU) patients.

OUTCOME MEASURE

PUBLICATION

DOMAIN OF WELLBEING

KEY FINDINGS

Herth Hope Index (HHI) Salomé et al 201719 Spiritual DFU patients presented Salomé et al 201320 low senses of hope and spirituality. DFU patients presented less hope of recovery than those with VLUs. Spirituality Self-rating Salomé et al 201719 Spiritual DFU patients presented Scale (SSRS), Salomé et al 201321 low senses of hope and spirituality. DFU patients presented poorer spirituality. Beck Depression Salomé et al 201122 Psychological (Depression) DFU patients presented Inventory (BDI) varying degrees of depressive symptoms. Powerlessness Assessment De Almeida et al 201424 Psychological Tool (PAT) (Powerlessness) Salomé et al 201320

Stronger feelings of powerlessness in patients with DFUs than with VLUs. DFU patients presented stronger feelings of powerlessness and less hope of recovery than those with VLUs.

The Pittsburgh Sleep Salomé et al 201325 Physical (Sleep) DFU patients have Quality Index (PSQI) poor sleep quality. Rosenberg Self- Salomé et al 201123 Psychological (Self-Esteem) Foot ulcers have a Esteem Scale negative impact on the self-esteem of patients with diabetes. Cardiff Wound Ogrin et al 201527 Overall wellbeing A statistically significant Impact Schedule (CWIS) improvement in well being followed closure of DFUs compared to base line. DFU - Diabetic foot ulcers VLU - venous leg ulcers journal of the european wound management association 

2019 vol 20 no 1

25


or individuals may not want to discuss such issues for fear of “bothering” the clinician or worrying that the clinician may judge them.5

For clinicians: “Knowing who their patients are and developing a partnership that facilitates a transparency of information for both parties”.28

OUTCOME MEASURES Published research in this area, specifically with regard to DFU, has primarily focused on HRQoL rather than on the specific domains of wellbeing. A recent position paper highlighted the importance of and the need for wellbeing to be included in future wound care research.18 HRQoL tools typically focus on limitations caused by physical functioning, rather than assessing positive emotions associated with wellbeing, such as optimism, life satisfaction, possession of coping skills, and hope for the future.18

NOVEL STRATEGIES TO ADDRESS DFU PATIENT WELLBEING

Several studies have investigated individual aspects of wellbeing in patients with DFUs (Table 1). The spiritual domain can be measured by considering an individual’s sense of hope.19, 20 Often the idea of ‘loss of independence’ emerges during the assessment of this domain.21 The psychological domain is associated with symptoms such as anxiety, depression22, grief, body image distortion, and self-esteem issues23 that can all contribute to an overall feeling of ‘powerlessness’.24 Most frequently reported in the literature are elements of the physical domain as various outcome measures can be used to report physical symptoms such as lack of sleep25, pain, exudate, and mobility issues. The aforementioned domains can influence the social domain, where individuals may be less likely to integrate into society due to the implication of living with a wound. Several domains of wellbeing have been previously assessed with regard to DFU (Table 1). However, there is no one standardised tool that takes a holistic approach to assess the overall wellbeing of patients with DFUs. The Wellbeing in Wounds Inventory is considered among the first to holistically assess wellbeing and has been demonstrated to be a valid and reliable measure of wellbeing for patients living with chronic wounds.26,27 However, this is a generic outcome measure for use in patients with chronic wounds. The lack of a diabetes-specific wellbeing assessment tool should be an area for further research. CURRENT STRATEGIES TO OPTIMISE PATIENT WELLBEING Involving patients in their own care is an increasingly recognised concept. Patient involvement can be defined as follows: For patients: “Being active in the management of their own health and health care, and in any decisions made about available treatment options”.28 26

Build a Therapeutic Relationship Effective communication is central to optimum patientcentred care. Developing an environment that is caring, competent, and compassionate is paramount to establishing an equitable relationship between patient and clinician. Clinicians can begin to establish effective therapeutic relationships by establishing their patients’ trust, recognising the patient ‘as a person,’ and being a true advocate for optimum patient-centred care.5 Ask Trigger Questions The following trigger questions have been suggested to assess wellbeing in those living with chronic wounds:5 1. Has your wound improved or worsened? Please describe. If new, how did it happen? 2. Has your wound stopped you from doing things in the last week? If so, what? 3. What causes you the most disturbance/distress and when does this occur? 4. Do you have anyone to help you cope with your wound? 5. What would help to ease/improve your daily experience of living with a wound? Patient Empowerment and Choice There is evidence to suggest that the more control one has over a situation the less likely one is to suffer from stress and pain. Thus, if patients have control of or influence over their condition, they will more likely engage in self-care of their DFU.29 Thus, healthcare practitioners must empower patients to take control of their condition, wounds, and treatment.30 Patients should be encouraged to openly discuss treatment options or concerns as this can improve self-management strategies and increase concordance with treatment regimes. It is important to consider that the effect of an individuals’ wound on wellbeing can be time dependant; thus, on-going, frequent assessment is key to accurately capture the domains of wellbeing. The clinician should ensure that when asking questions, the questions are individualised with a specific focus on the patients’ specific concerns in relation to the impact of living with their wound.5 It may

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be that generic approaches used to capture wellbeing are appropriate for other types of chronic wounds, but do not sufficiently address the diabetes-specific challenges faced by those living with DFU. Team Approach All members of the multi-disciplinary team should actively be involved in assessing patient wellbeing. There is a need for a standardised approach to allow for an effective evaluation of patient wellbeing, while ensuring that the clinician creates an appropriate environment to encourage this dialogue. Suitable occasions for this may be during home visits or routine clinical appointments to provide an opportunity for these more relaxed, informal conversations.5

address patient wellbeing adversely affects clinical and patient outcomes and has the potential to negatively impact health behaviours. Future research should further explore the concept of wellbeing in patients living with DFUs. There is a need through novel methodological approaches, including patient and public involvement in research, to develop a meaningful, specific, patient-centred wellbeing assessment tool to effectively measure wellbeing in those living with DFU. m î‚Š

IMPLICATIONS FOR CLINICAL PRACTICE n DFUs can impact all domains of patient wellbeing (physical, psychological, social, and spiritual/cultural). n People living with DFUs are at greater risk of depression, anxiety, mood disorders, embarrassment, stigma, and low self-esteem. n Negative emotional states may perpetuate negative health behaviours in this population, resulting in poor clinical and patient outcomes. n Patient

wellbeing should be assessed and measured as part of a patient-centred, holistic, wound management plan. n Current assessment tools are mainly generic for chronic wounds and only address certain parameters of well being. There are currently no assessment tools specific for measuring wellbeing in DFU patients.

FUTURE RESEARCH n There is a need to develop a valid and reliable assess ment tool to measure the various domains of wellbeing in patients with DFU. n Public and patient involvement in research would be an ideal methodological approach to explore wellbeing in patients with DFU. n A

valid and reliable measure of wellbeing in patients with DFU would aid clinicians in optimising health care and improving patient outcomes in those affected with DFU. CONCLUSIONS A dearth of literature exists with regard to wellbeing in patients with DFU, and there is a distinct lack of tools to measure overall wellbeing in this population. Failure to journal of the european wound management association 

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Science, Practice and Education

REFERENCES 1. Harding, JL. Pavkov, ME. Magliano, DJ. Shaw, JE. Gregg, EW. Global trends in diabetes complications: a review of current evidence, Diabetologia, 2019, 62: 3-16. 2. McIntosh, C. Impaired Wound Healing in the Diabetic Foot Wound Essentials, 2017, 12 (1); 52-56. 3. International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers, Wounds International, 2013. 4. World Union of Wound Healing Societies (WUWHS), Florence Congress, Position Document, Local management of diabetic foot ulcers, Wounds International, 2016. 5. International Consensus, Optimising wellbeing in people living with a wound. An expert working group review. London. Wounds International. 2012. Available from: http://www.woundsinternational.com 6. Jeffcoate, WJ. Vileikyte, L. Boyko, EJ. Armstrong, DG. Boulton, AJM. Current Challenges in the Prevention and Management of Diabetic Foot Ulcers, Diabetes Care, 2018: 41: 645-652. 7. World Health Organisation (1997) WHOQOL: Measuring Quality of Life. Available at: https://www. whoint/healthinfo/survey/whoqol-qualityoflife/en (Accessed January 2019). 8. Centre for Disease Control and Prevention: Well-being Concepts (2011). Available at: https://www.cdc.gov/ hrqol/wellbeing.htm (Accessed January 2019).

12. Cole-King A, Harding KG. Psychological factors and delayed healing in chronic wounds. Psychosom Med 2001; 63 (2): 216-20 13. Upton D, South F. The psychological consequences of wounds – a vicious circle that should not be overlooked. Wounds UK 2011; 7 (4): 136-138. 14. Guo S, DiPietro LA. Factors affecting wound healing. J Dent Res 2010; 89(3): 219-29. 15. Gouin JP, Kiecolt-Glaser JK. The impact of psychological stress on wound healing: methods and mechanisms. Immunol Allergy Clin North Am 2011; 31 (1): 81-93 16. Robinson H, Norton S, Jarret P, Broadbent E. The effects of psychological interventions on wound healing: A systematic review of randomized trials. Br J of Health Psychology 2017; 22: 805-835. 17. Goreki C, Brown J, Nelson EA et al. Impact of pressure ulcers on quality of life in older patients. J AM Geriatr Soc 2009; 57 (7): 1175-83. 18. Upton D, Andrews A, Upton P. Venous leg ulcers: What about well-being? J Wound Care 2014; 23 (1): 14-17. 19. Salomé GM, de Almeida SA, Mendes B, de Carvalho MR, Bueno JC, Massahud MR Jr, Ferreira LM. Association of Sociodemographic Factors with Spirituality and Hope in Patients with Diabetic Foot Ulcers. Adv Skin Wound Care 2017; 30(1): 34-39.

9. Guest, JF. Fuller, GW. Vowden, P. Diabetic foot ulcer management in clinical practice in the UK: costs and outcomes, International Wound Journal, 2017.

20. Salomé GM, Alves SG, Costa VF, Pereira VR, Ferreira LM. Feelings of powerlessness and hope for cure in patients with chronic lower-limb ulcers. J Wound Care 2013; 22(6): 300 -04.

10. European Wound Management Association. Position Document. Hard to heal wounds: a holistic approach. MEP Ltd, London 2008.

21. Salomé GM, Pereira VR, Ferreira LM. Spirituality and subjective wellbeing in patients with lower-limb ulceration. J Wound Care 2013 May; 22(5): 230-36.

11. Mudge E, Spanou C, Price P. A focus group study into patients’ perceptions of chronic wound pain. Wounds UK 2008; 4 (2): 21-28.

22. Salomé GM, Blanes L, Ferreira LM. Assessment of depressive symptoms in people with diabetes mellitus and foot ulcers. Rev Col Bras Cir 2011; 38(5):327-33.

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23. Salomé GM, Maria de Souza Pellegrino D, Blanes L, Ferreira LM. Self-esteem in patients with diabetes mellitus and foot ulcers. J Tissue Viability 2011; 20(3):100-6. 24. De Almeida SA, Salomé GM, Dutra RA, Ferreira LM. Feelings of powerlessness in individuals with either venous or diabetic foot ulcers. J Tissue Viability 2014; 23(3): 109-14. 25. Salomé GM, de Souza Pellegrino DM, Blanes L, Ferreira LM. Sleep Quality in Patients with Diabetic Foot Ulcers. Wounds. 2013;25(1): 20-7. 26. Upton D, Upton P, Alexander R. Well-being in wounds inventory (WOWI): development of a valid and reliable measure of well-being in patients with wounds. J Wound Care 2016; 25(3): 1-6. 27. Orgin R, Houghton PE, Thompson GW. Effective management of patients with diabetes foot ulcers: outcomes of an Interprofessional Diabetes Foot Ulcer Team. Int Wound J 2015; 12: 377-86. 28. International Best Practice Statement: Optimising patient involvement in wound management. Wounds International, 2016: 1-19. 29. Vedhara K, Dawe K, Wetherell MA, Miles JN, Cullum N, Dayan C, Drake N, Price P, Tarlton J, Weinman J, Day A, Campbell R. Illness beliefs predict self-care behaviours in patients with diabetic foot ulcers: a prospective study. Diabetes Res Clin Pract. 2014 Oct; 106(1):67-72. 30. Upton, D. Pain, wound Care and psychology: the missing link? Wounds UK, 2011, (7) 2: 119-122.

journal of the european wound management association 

2019 vol 20 no 1


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STAND B06:21 KCI is on the move to the future of wound healing. Through forward-thinking products and services, we are on our way to advancing the healing process. And we will not hesitate to ask for directions from those that know the journey best: YOU. Please join us as we evolve what’s possible from Here to Healed. Proceed to the KCI stand and visit our symposium to move healing FORWARD!

SYMPOSIUM Focusing Together on DFUs: Innovation, Treatments and Techniques WHEN: Thursday 6th June, 13:15 - 14:15 WHERE: Room G2-G3

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Science, Practice and Education DOI: 10.35279/jewma201905.03

Taking Care of an Individual’s Needs at Home: Experiences of a Community Care Nursing Group In Italy, home care is guaranteed in a variety of ways. This article reports community care experiences in Italy and documents how a group of professionals were able to adapt their roles as service providers to those of leaders, taking into account different patient needs.

ABSTRACT In Italy, home care is guaranteed in a variety of ways. This article reports community care experiences in the foothills of Bergamo (Lombardy) and documents how a group of professionals were able to adapt their roles as service providers to those of leaders, taking into account different patient needs.

BACKGROUND The reasons behind the constant increases in the use of health care services are found in four contexts that have changed the structure of care today (Fig. 1). Ageing increases the demand for health care and social services, and numerous pathologies require the involvement of different professionals and a complex, articulated approach to care. Chronic diseases (at least one chronic disease is present in 38% of the population) are partly related to age-

Manuela Noris2

ing, which obliges us to strengthen community care management for both their prevention and treatment that can be adapted to the demands of concomitant acute diseases and progressive disabilities. As 23 million people utilize 70% of the few family and NHS resources available , this contributes to the lack of self-sufficiency of fragile populations, further depleting the resources of the NHS, which in turn has suffered from the recent recession. Within this scenario, we reviewed the governance of the production and supply of community care services, with the objective to transfer services to teams to guarantee fair access and treatment, in line with established care objectives. The territory in which this improvement process originated is shown in Figure 2, in the foothills of Bergamo. 

Val di Scalue

Progressive ageing of the population

Val Brembana

Increases in numerous pathologies

Val Seriana

Increases in chronic diseases

Alessandra Negroni3

Battistino Paggi, RN4

Luisa Giunni5 1 Nurse

president of Bergamo Sanità, Italy

2 Vice president of Bergamo Sanità, Italy 3 Nurse coordinator of Community Care Services 4 Wound care and research consultant

Valle Imagna Valle Imagna Isola Bergamasca

Stefano Ghilardi1

Bergamo

Val Cavalina Val Calepio

5 Nurse coordinator in Bergamo Sanita

Reductions in resources Pianura Bergamasca

Figure 1. The four contexts of community care. journal of the european wound management association 

Figure 2. Regions of competency in Bergamo Santia. 2019 vol 20 no 1

Correspondence: battpaggi@gmail.com Conflicts of interest: None

31


In this context, it is increasingly necessary to underline the importance of a holistic approach that starts with “family medicine,” where the activities of individual professionals are focused on the patient and his or her needs (Fig. 3). This approach harmonizes the community with the hospital and favours the integration of primary care with both intermediate and hospital care, especially in the context of low-intensity care.

Nurse

Patient Care giver

Clinician

Other health professionals

Physiotherapist

Figure 3. Family medicine practitioners.

OBJECTIVES The primary objectives of this process were to identify the problem and possible solutions and to train operators to provide the best possible solution, considering the recommendations of specialists in the territory. The rule contained in Law No. 189 of 2012 suggests the following important goals: n Distribution n Care

of community care

of fragile patients

n Performance

guarantee in the presence of f inancial difficulties

We describe our community care experiences with particular attention to patients who have skin ulcers. The lack of homogeneity of approaches linked to individual professionals has led to the need for training courses that take into account the best knowledge, practices, and evidence regarding wound management considering the recommendations from third-level treatment centres for the care of difficult wounds, diabetic foot care management, and treatment of dermatological diseases.

32

1. Knowledge phase 2. In-depth training phase 3. Management change phase The first step, which involved the statistical analysis of the patients (Graph 1), nursing activities (Graph 2), and treatments for wounds (Graph 3) from 2014–2016, allowed an evaluation of the impact of the organizational and managerial structure of care on the treatment of patients with ulcers (Graphs 4–6).

Family physician Social worker

MATERIALS AND METHODS The process was divided into three phases:

This step led to an assessment of the most appropriate way to respond to the identified changes. The answer was to create an approach for the analysis of experiences obtained by individual nursing professionals, a direct comparison of the patients who were treated, and an in-depth study of the medical devices used. A training course was implemented to improve and consolidate knowledge about wound management issues, involving local providers. The course focused on diseases and complications for the generation and implementation of appropriate, shared treatment approaches. This process has also led to a review of the products in use and their more careful use. The last step involved the implementation of management changes, the drafting of a shared care protocol, and the execution of care approaches, considering that the health care and social needs are still in the implementation phase; thus, no results are available today. RESULTS The data, including 6,000 initial services that grew from 2014 to 2017 to more than 90,000 in the last year, show how wound care has become an important part of provider workload, exceeding 21,000 services among the different types of wounds treated (Graphs 7 and 8). In this scenario, although the absolute numbers differed, the percentages of workload dedicated to the treatment of skin wounds has remained stable, that is, 20 ± 4.5%. This means, in terms of working time for the nurse who goes to the home, 51.2% of the time available to him to carry out all the activities entrusted to him. The costs incurred for treatment and the results achieved after implementation of the approach have grown but are consistent when compared to the treatment plan applied, thanks to the use of a shared protocol and the availability of professionals in advanced levels of care.

journal of the european wound management association 

2019 vol 20 no 1


Science, Practice and Education

900

Wound Care

All treatment

2014 2015 2016

2014 2015 2016

30.000

800 25.000

700 600

20.000

500 15.000

400 300

10.000

200 5.000

100 0 2014

2015

0

2016

Graph 1. Number of patients treated in the 3-year period, 2014-2016.

Graph 4. Impact of wound care compared to all treatments provided.

30.000

24,50%

25.000

24,00% 23,50%

20.000

23,00% 15.000 22,50% 10.000

22,00%

5.000

21,50%

0 2014

2015

21,00%

2016

Graph 2. Number of nursing activities provided in the 3-year period.

7.000

2014

2015

2016

Graph 5. Wound care services as a percentage of total activities. PU

VLU

Others

2014 2015 2016

2014 2015 2016

2014 2015 2016

1.200

6.000 1.000 5.000 800

4.000

600

3.000 2.000

400

1.000

200

0 2014

2015

0

2016

Graph 3. Number of treatments for wounds of different aetiologies.

Graph 6a. Types of ulcers prevalent in men.

CONCLUSIONS The approach used to implement care plans has made it possible to offer a therapeutic response in line with good clinical practice. The comparison between the professionjournal of the european wound management association 

als and the clinical results achieved have improved the availability of medical devices, which ensures a significant

2019 vol 20 no 1

î‚Š

33


Science, Practice and Education

increase in both treatment times and satisfaction of users and professionals. The costs incurred for patient treatment have increased annually because of the complexity of available materials, even though they were partly borne by the providers. In fact, we found ourselves providing services at higher costs than what were reimbursed, allowing us to provide high quality care, which included patient comfort, in line with both quality standards recognised by the regional health system and best clinical practices. The effectiveness of the approaches undertaken remains unknown. The 2018 data are not yet available, particularly for changes linked to the shift in job function. Additionally, the clinical results demonstrated improved patient recovery related to the care objectives. m

PU

VLU

Others

2014 2015 2016

2014 2015 2016

2014 2015 2016

1.500

1.000

500

0

Graph 6b. Types of ulcers prevalent in women.

REFERENCES: 1. Bergamo SanitĂ s.c.s ONLUS: It consists of a multidisciplinary nursing team that deals with home care and provides social and health services on behalf of the NHS 2. Source Fondazione ISTUD, 2013

90.000 80.000 70.000 60.000 50.000 40.000 30.000 20.000 10.000 0 2014

2015

2016

2017

Graph 7. Treatments provided during the 4-year period, 2014-2017; total treatments/care activities (grey), treatment for ulcers (red) .

7.000 6.000 5.000 4.000 3.000

PU

VLU

Others

PU

VLU

2016

Others

PU

2015

VLU

PU

2014

VLU

0

Others

1.000

Others

2.000

2017

Graph 8. Types of ulcers and number of services provided during the 4-year period, 2014-2017.

34

journal of the european wound management association 

2019 vol 20 no 1


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Science, Practice and Education DOI: 10.35279/jewma201905.04

Post-surgical Pyoderma Gangrenosum: A Retrospective Analysis of four Clinical Cases Pyoderma gangrenosum is a rare neutrophilic, inflammatory disorder. A recent study from Finland has analysed patient records with postsurgical pyoderma gangrenosum with special focus on the diagnostic delay and treatment outcomes. ABSTRACT Background Pyoderma gangrenosum (PG) is a rare neutrophilic disease that is characterised by the pathergy phenomenon, as it worsens with trauma. Post-surgical PG (PSPG) occurs in surgical incisions and is typically first misdiagnosed as a surgical site infection. The diagnostic delay in PSPG is often considerable.

Hypothesis/Aim The aim of this study was to analyse patient records with PSPG that were diagnosed in our Department of Dermatology; with special focus on the diagnostic delay and treatment outcomes.

Methods The records of four patient cases that were diagnosed with PSPG in our Department of Dermatology from 2017 to 2018 were analysed retrospectively.

Results The average delay in diagnosis was 5 months, and the diagnosis could not rely on histological findings. Prednisolone treatment led to complete wound healing in three cases. In one case, switching from prednisolone to cyclosporine eventually healed the wound.

Conclusions The diagnostic delay was considerable, and prednisolone and cyclosporine were considered as effective treatments.

Implications for clinical practice This report emphasises the importance of early sus-

picion and recognition in PSPG cases, and early referral to dermatologist.

INTRODUCTION Pyoderma gangrenosum (PG) is a rare neutrophilic, inflammatory disorder. The typical presentation involves a papulo-pustule with violaceous inflamed borders evolving into enlarging, painful, undermined wounds.1 However, the clinical picture can vary greatly. Therefore, diagnosing these wounds can be challenging for the clinician. Recently, two reports on the diagnostic criteria have been published.2,3 It is important to keep in mind that PG is usually a diagnosis of exclusion. Often, a positive response to immunosuppressive treatment ultimately confirms the diagnosis.1,2 Several reports have also described post-surgical PG (PSPG).4,5 PSPG has been reported to occur most frequently after breast surgery, followed by cardiothoracic, abdominal, and obstetric surgeries.4 With PSPG, the association of typical PG comorbidities, such as inflammatory bowel disease (IBD), rheumatoid arthritis, and haematologic malignancies, may not be strong.6 The real challenge in PSPG for both the clinician and patient is the delay in diagnosis. Typically, it is first misdiagnosed as a surgical site infection (SSI), but the wounds continue to enlarge or remain unhealed despite revisions and antibiotic treatment.4 METHODS This retrospective study analysed four patient cases that were diagnosed with PSPG in our Department of Dermatology from 2017 to 2018 î‚Š

journal of the european wound management association 

Kirsi Isoherranen MD, PhD, Specialist in Dermatology and Allergology. Helsinki University Central Hospital and Helsinki University, Wound Healing Centre and Dermatosurgery Unit, Finland

2019 vol 20 no 1

Correspondence: kirsi.isoherranen@hus.fi Conflicts of Interest: None

37


(Table 1). Data from patient records were collected and included comorbidities, type of surgery, diagnostic delay (assessed from first symptoms to the diagnosis date), histological report, treatment, and time to complete wound healing after starting immunosuppressive therapy. This retrospective study protocol followed the ethical guidelines of the Declaration of Helsinki (2013). Photographs were included after permission from the patients was obtained. RESULTS Patient characteristics are shown in Table 1. One patient had IBD (colitis ulcerosa), and one patient had rheumatoid arthritis (Figures 1a and 1b). Histology was not specific in most of the cases. The diagnosis was mainly established by the following criteria: the clinical picture and wound history, lack of response to earlier treatments (e.g., revisions, antibiotics), and a positive response to immunosuppressive therapy. The average time from the onset of symptoms until diagnosis was 5 months. Initially, treatment relied on prednisolone in all patients. In one patient, prednisolone was switched to cyclosporine, after which the wound eventually healed (Figures 2 a,b,c and d). Local wound therapy was designed according to the TIME (T=tissue, I=infection/inflammation, M=moisture, E=edge) protocol.7 DISCUSSION PG was first described by a French dermatologist named Brocq in 1916.8 It is an uncommon neutrophilic disorder, which presents as inflamed pustules and ulcers similar to an infectious disease.1 This clinical picture and negative histology in many cases render the diagnosis challenging. However, holistic patient assessment is essential and aids the diagnosis in these patients. “It is not the hole in the patient but the whole patient”9 is a valid argument in PG patients. Different comorbidities, such as IBD, haematologic malignancies, and rheumatoid arthritis, can give

clues for PG diagnosis.9 Because IBD is such a common comorbidity, any wounds of interest in a patient with IBD can be considered a PG wound, until otherwise proven. Importantly, PG lesions occur in up to 50% of cases and are most commonly located at sites of cutaneous trauma, such as venepuncture, laparoscopy, and surgical incisions; this phenomenon is known as pathergy. PSPG refers to the development of PG at surgical sites in the immediate post-operative period, typically 1 week after surgery.5 The literature has described SSI as a frequent misdiagnosis, and mortality has been reported.4,5,11 However, the ulcers do not respond to antibiotic therapy and continue to enlarge after revisions, due to the pathergy phenomenon.4 From the patient’s perspective, there is a substantial delay in diagnosis time and decreased health-related quality of life due to pain, continuous wound management, and unnecessary surgical treatments. The aim of this study was to retrospectively analyse PSPG patients who were diagnosed and treated in our Dermatology Unit. The average delay in diagnosis was 5 months, which was the time from first symptoms to first dermatologic consultation. We believe this to be quite a long time, as PG ulcers usually heal very slowly after exact diagnosis and optimal treatment. The treatment relies on immunosuppressive therapy, and the first-line treatment option is high-dose prednisolone. After the suppression of inflammatory activity, a steroid-sparing agent is often combined to avoid the adverse reactions of high-dose steroids.12 However, in a randomised multicentre trial with 112 participants, cyclosporin and prednisolone did not differ across a range of objectives and patient-reported outcomes. Thus, it was concluded that the first-line drug should be decided based on each patient’s characteristics.13 In hard-to-heal PG wounds, biologic treatment is also an option.14 When the inflammatory reaction has been reduced by immunosuppressive therapy, negative-pressure

Figures 1 a and 1b. Post-surgical pyoderma gangrenosum in a 16-year-old girl after knee arthroplasty. Figure 1a shows the wound before treatment. Figure 1b shows complete wound healing after 2 months of prednisolone treatment. 38

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Science, Practice and Education

Table 1. Analysis of four post-surgical pyoderma gangrenosum patient cases. PATIENT OPERATION DELAY IN HISTOLOGY TREATMENT DIAGNOSIS

TIME FOR COMPLETE WOUND HEALING

Male 59 years Liberation of 5 months Granulation the ulnar nerve tissue and mixed in the left arm inflammatory cell infiltrate with neutrophils

1. Prednisolone 20 mg/day + mycophenolate mofetil 2000 mg/ day for 9 months 2. Ciclosporine 100 mg x 2

After starting cyclosporine, 5 months

Female 16 years Rotation 4 months Comorbidities: osteotomy Rheumatoid due to arthritis femoral fracture Female 33 years Mastectomy 11 months due to BRCA1- mutation

Prednisolone 30 mg/day

2 months

Granulation tissue with a lymphocytic infiltrate

Biopsy not Prednisolone taken, clinical 40 mg/day diagnosis

Female 31 years Knee 1 month Neutrophilic Prednisolone Comorbidities: arthroplasty inflammation 30 mg/day Colitis ulcerosa

wound therapy and skin grafting are recommended options for reducing healing time.15 In our patients, prednisolone treatment led to complete wound healing in three cases during a period of 1–2 months. This prompt response to immunosuppressive therapy ultimately confirmed the diagnosis of PSPG. In one case, prednisolone 20 mg/day for 9 months was ineffective, but cyclosporine eventually led to wound healing during a period of 5 months. The ineffectiveness of prednisolone in this case could potentially be influenced by the relatively low dose (20 mg/day) that was used, as the patient weighed 101 kg. Usually, the recommended dose of prednisolone ranges from 0.5–0.75 mg/kg/day.13 It is important to note that histology was not specific for PG in any of our cases. Typical histological findings were hypergranulation and mixed inflammatory infiltrate. Therefore, it is important that PG is not excluded by histological findings alone. In addition, the value of histology depends strongly on the site of biopsy. Optimally, surgeons and surgical nurses should be aware of this entity and recognise “danger” signs that highlight the need for dermatologic consultation. These signs include a previous history of PG, familial history of PG, IBD, haematologic malignancy, rheumatoid arthritis, negative wound swabs or unresponsiveness to antibiotic therapy, journal of the european wound management association 

1 month

2 months

violaceous wound borders, and enlargement of wounds by revisions.4,5 Indeed, PG is a diagnosis that clinicians “wish you had never operated on”.16 Finally, PG and PSPG are part of the family of atypical wounds, which deserve better recognition and treatment among health care professionals. The European Wound Management Association (EWMA) has established a working group to gather the best available knowledge on atypical wounds, and the EWMA Document on Atypical Wounds will be published in spring 2019. This document is targeted at increasing awareness of the clinical picture, diagnosis, and treatment of these wounds. It also aims to provide practical advice on some of the challenges that typically arise in the diagnosis or treatment of inflammatory and vasculopathy wounds, such as PG, malignant wounds, and cutaneous vasculitis.17 CONCLUSIONS PSPG is an important differential diagnosis for SSI. Prompt suspicion and recognition, as well as a dermatologic consultation, are necessary for favourable outcomes in these cases. The disease can also be fatal. Despite a considerable delay in diagnosis, our study showed favourable outcomes after exact diagnosis and immunosuppressive treatment. m 

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Figures 2a,b,c and d. Post-surgical pyoderma gangrenosum in the surgical scar of an ulnar nerve liberation. Figure 2a shows the wound before treatment. Figure 2b shows 9 months after prednisolone treatment. Figure 2c shows 1 month after the starting of cyclosporine. Figure 2d shows complete wound healing after 5 months of cyclosporine treatment.

REFERENCES 1. Hadi A and Lebwohl M. Clinical features of pyoderma gangrenosum and current diagnostic trends. J Am Acad Dermatol 2011; 64:950-954. 2. Jockenhöfer F, Wollina U, Salva KA, Benson S, Dissemond J. The PARACELSUS score: a novel diagnostic tool for pyoderma gangrenosum. Br J Dermatol 2018; doi:10.1111/bjd.16401 3. Maverakis E, Ma C, Shinkai K, Florentino D, Callen JP, Wollina U et al. Diagnostic criteria of ulcerative pyoderma gangrenosum: A Delphi Consensus of International Experts. JAMA Dermatol 2018; 154: 461-466. 4. Zuo KJ, Fung E, Tredget EE, Lin AN. A systematic review of post-surgical pyoderma gangrenosum: identification of risk factors and proposed management strategy. J Plast Reconstr Aestehtic Surg 2015;68 (3):295.303. 5. Larcher L, Schwaiger K, Eisendle K, Ensat F, Heinrich K, di Summa P et al. Aesthetic breast augmentation mastopexy followed by post-surgical pyoderma gangrenosum (PSPG): Clinic, treatment, and review of the literature. Aesthetic Plast Surg 2015; 39:506513. 6. Tolkachjov SN, Fahy AS, Cerci FB, Wetter DA, Cha SS, Camilleri MJ. Postoperative pyoderma gangrenosum: a clinical review of published cases. Mayo Clin Proc 2016;91(9): 1267-79.

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7. Schultz GS, Sibbald RG, Falanga V, Ayello EA, Dowsett C, Harding K et al. Wound bed preparation: a systematic approach to wound management. Wound Rep Reg 2003;11:1:1-28. 8. Farhi D. The clinical and histopathological description of geometric phagedenism (Pyoderma Gangrenosum) by Louis Brocq one century ago. JAMA Dermatol 2008; 144(6): 755. 9. International Consensus (2012) Optimising Wellbeing in People Living with a Wound. Available at: www. woundsinternational. com/media/issues/554/files/ content_10309.pdf 10. Su WP, Davis MD, Weening RH, Powell FC, Perry HO. Pyoderma gangrenosum; clinicopathologic correlation and proposed diagnostic criteria. Int J Dermatol 2004;43:790-800. 11. Tanini S, Calugi G, Lo Russo G. Combination of negative pressure wound therapy and systemic steroid therapy in postsurgical pyoderma gangrenosum after reduction mammoplasty; a case of proven efficacy and safety. Dermatology Reports 2017; (9):7209. 12. Herberger K et al. Treatment of pyoderma gangrenosum: retrospective multicenter analysisof 121 patients. Br J Dermatol 2016; 175 :1070-1072.

13. Ormerod AD, Thomas KS, Graig FE, Mitchell E, Greenlaw N, Norrie J et al. Comparison of the two most commonly used treatments for pyoderma gangrenosum: results of the STOP GAP randomized controlled trial. BMJ 2015;Jun12;350:h2958. 14. Brooklyn TN, Dunnill MG, Shetty A, Bowden JJ, Williams JD, Griffiths CE, et al. Infliximab for the treatment of pyoderma gangrenosum: a randomized, double blind, placebo controlled trial. Gut 2006;55(4):505-509. 15. Pichler M, Thuile T, Gatscher B, Tappeiner L, Deluca J, Larcher L et al. Systematic review of surgical treatment of pyoderma gangrenosum with negative pressure wound therapy or skin grafting. JEADV 2017;31(2): e61-e67. 16. Hradil E, Jeppsson C, Hamnerius N, Svensson Å. The diagnosis you wish you had never operated on: pyoderma gangrenosum misdiagnosed as necrotizing fascitis- a case report. Acta Orthopaedica 2017; 88:231-233. 17. EWMA Document. Atypical wounds: Best Clinical Practice and Challenges. Document submitted for publication.

journal of the european wound management association 

2019 vol 20 no 1


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Science, Practice and Education DOI: 10.35279/jewma201905.05

A Case Report: Toxic Epidermal Necrolysis in Children

Juliana C Ferreira PhD in Health Sciences2

Toxic epidermal necrolysis is a rare and severe skin reaction with a high mortality rate. This case report describes a case of toxic epidermal necrolysis in a 7-year-old patient caused by an adverse drug reaction. ABSTRACT Introduction Toxic epidermal necrolysis (TEN) is a rare condition associated with high morbidity and mortality, which is characterised by severe acute mucous-cutaneous eruptions that lead to necrosis and detachment of the epidermis and mucous membranes over 30% of the body. In Europe and the USA, 1 to 3 people per million suffer from the disease. Early diagnosis of the signs and symptoms are key to a good prognosis.

Method Case report.

Results A previously healthy 7-year-old patient, 28 kg, fever (38–40ºC), with exanthematous lesions all over his body. He was prescribed trihydrate amoxicillin/clavulanic acid and ketoprofen supplemented with loratadine for 5 days at the end of September 2017. One day after the last dose, the patient started showing signs of bullous lesions on the trunk. Diagnostic hypothesis: TEN. Lesions significantly worsened, with blisters on his face, limbs, genitalia, and trunk; lesions on the oral mucosa and epidermal detachment on over 30% of his body.

Discussion TEN is a rare, severe skin reaction associated with high mortality often triggered by the use of medications. Essential fatty acids are the first line of treatment in patients with epidermal detachment. The patient was discharged after 23 days (5 days in the paediatric intensive care unit and 18 days in the plastic surgery unit). Treatment employed is in line with other reports described in the literature.

Conclusion

adverse drug reaction, had a good progression and no sequelae because of adequate treatment.

Implication for clinical practice Given that TEN is a rare and severe skin reaction with high mortality and we have little data in the literature about children with TEN, it is important to disseminate experiences of children who suffered from this disease to the scientific community to contribute to the collective knowledge.

INTRODUCTION Toxic epidermal necrolysis (TEN) is characterised by rare and severe acute mucous-cutaneous eruptions that affect the oral, ocular, and genital mucosae. The condition is associated with a high mortality rate and leads to necrosis and epidermal detachment on over 30% of the body. Adverse drug reactions are responsible for 80% of cases, although it has also been linked to infection and sepsis.1-3 Early symptoms are usually nonspecific, like sore throat, fever, and ocular irritation, and manifest one to three days before any cutaneous lesions, which are characterised by erythematous macules of undefined borders and purple centres. The lesions are initially located on the face and upper trunk causing pain and a burning sensation. The lesions then expand to include the back and thorax, covering the entire body in one week.1-3 TEN affects 1 to 3 people per million in Europe and the United States of America (USA), regardless of age, gender, and race. Only 20% of the affected population are children and adolescents. In the USA, cases tend to be more frequent dur-

This rare and severe case of TEN, caused by an

journal of european wound management association 

Maria Lucia B Santos Attending Master´s Degree in Health Sciences1

2019 vol 20 no 1

Marcia A Souza Hospital Administration Specialist1

Gisele M Silva Stomatherapist1

Ana Cristina S Monteiro Stomatherapist1

Hilda Yogui Hospital Administration Specialist1

Authors to be continued:

43


ing spring and winter.1-3 The incidence of this disease in Brazil is still mostly unknown. However, it is believed that 0.4 to 1.2 people per million are affected each year. Mortality rates vary from 25 to 70%. Furthermore, multiple comorbidities, use of treatment medication, and advanced age seem to be risk factors for the disease.1-5 The most common medications linked to TEN onset are sulphas, phenobarbital, carbamazepine, dipyrone, piroxicam, phenylbutazone, aminopenicillins, and allopurinol.1-3 The main clinical difference between TEN and StevensJohnson syndrome (SJS) is the percentage body surface covered by cutaneous lesion and a positive or negative Nikolsky sign (NS). NS represents the detachment of the upper layer of the epidermis due to friction or light trauma. Patients with TEN show a positive NS over large areas of skin.4 By definition, lesions affect less than 10% of body surface area in SJS, 10 to 30% in SJS/TEN overlap, and over 30% in TEN.4-5 Prognosis and risk of death in patients with TEN is evaluated using the SCORTEN (SCORe of Toxic Epidermal Necrosis), a severity score developed by Bastuji-Garin et al. The tool considers seven parameters: Age > 40 years, malignancy, heart rate (HR) > 120 bpm, epidermal detachment > 10%, serum urea > 28 mg/dL, serum glucose > 252 mg/dL, and serum bicarbonate > 20 mg/dL.6 OBJECTIVE Case report of a case of TEN and the treatment employed to manage the skin lesions caused by this severe skin reaction. CASE REPORT A previously healthy 7-year-old patient, 28 kg, sought medical care on 10/14/2018, complaining of fever (38– 40ºC) since 10/12/2018 and exanthematous lesions all over his body. Initial diagnosis was ‘scarlet fever and he was prescribed amoxicillin. Personal history: the patient’s mother reported that the patient was prescribed trihydrate amoxicillin/clavulanic acid and ketoprofen, supplemented with loratadine and paracetamol, which he finished taking one day before the symptoms manifested. His condition worsened and on 10/15/2018 the patient’s mother brought him back to the emergency room, reporting additional symptoms of sleepiness and lesions on his hands and eyes. The new diagnostic hypothesis was ‘Kawasaki disease’ and the patient was hospitalised. The lesions evolved to bullous eruptions on the trunk, effectively disproving Kawasaki disease diagnosis and suggesting SJS. The lesions worsened, with blisters affecting the face, limbs, genitalia, trunk, and oral mucosa. He was prescribed antibiotic ther44

apy with ceftriaxone (10/14/2018), supplemented with oxacillin (10/15/2018 to 10/19/2018), and finally replaced by clarithromycin (10/18/2018). On 10/21/2018, a dermatologist evaluated the patient and diagnosed him with TEN, based on 30% epidermal detachment, areas with epithelial ulceration, fine brownish scales on upper and lower limbs, trunk, and face, necrotic crusts on upper and lower lips, and negative NS. Following a skin biopsy, he was prescribed immunoglobulin (4 g/kg) for 3 days. Laboratory tests were normal, including negative cultures, Glasgow Coma Scale (GCS) = 15, and body mass index = overweight (with medium risk for malnutrition). Patient was fed a complete polymeric diet through an enteral catheter. After ophthalmologic evaluation, he was prescribed methylcellulose ophthalmic at 0.5% 4/4 h and occlusive dressing with Epitezan ointment 6/6 h. An evaluation from a plastic surgeon and stomatotherapist indicated the use of rayon gauze bandages and essential fatty acids (EFA). Odontology orientation: oral hygiene with hexamidine mouthwash and laser treatment were used. The combination of prescribed treatment, bandages, and warm saline solution to clean the lesions proved beneficial and the patient showed improvement of the bullous lesions with hematic crusts. Morphine (0.05 mg/kg) was administered every 4 hours to manage moderate pain.

Figure 1. Bulbous lesions covering 80% of the thorax and abdomen, showing signs of healing.

Figure 2. Generalised erythematous and bullous lesions covering over 90% of the back and area of epidermal detachment, showing signs of healing.

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Science, Practice and Education

Treatment: Nonadherent gauze dressing and EFA, associated with warm saline solution to clean the lesions. Patient was discharged after 5 days in the paediatric intensive care unit and 18 days in the plastic surgery unit. Figures 3 and 4. Thorax and back 12 months after the onset of the disease.

DISCUSSION TEN is a rare and severe skin reaction with a high mortality rate, frequently triggered by an adverse drug reaction or infection that closely resembles a second-degree burn. This condition may affect the renal, respiratory, and digestive systems, among others. The acute prodromal phase of the disease lasts 1 to 4 days, during which patients may experience fever, malaise, cough, rhinorrhoea, photophobia, and diffuse erythema.7 Then, patients begin to develop mucosal and cutaneous lesions that are easily denuded with lateral shearing pressure applied by a clinician.7-8 A 20-year study performed in a tertiary referral hospital of Thailand reviewed all children diagnosed with SJS/TEN/SJS-TEN overlap and 12/36 cases had TEN (33.3%). The patients presented with morbilliform rash (83.3%), blisters (38.9%), targetoid lesions (25.0%), and purpuric macules (2.8%), and the most common mucosal involvements were oral (97.2%) and eye mucosae journal of european wound management association 

(83.3%).9 Lesions in this patient’s mucosae followed the same order as those reported in the literature, starting at the oropharynx, and spreading to the ocular, genital, and anal mucosae.10 In 2000 was published an article with a toxic epidermal necrolysis-specific severity-of-illness score for adults le to predict prognosis for the epidermal necrolytic disorders, called SCORTEN.6 However, this score includes criteria that are not applicable to children, such as age 40 years and older and ranges for laboratory values and vital signs that are relevant for adults. A study published in 2017 compared the adult SCORTEN tool with that of two modifications tailored to children for predicting disease outcome and revealed that the predictive power of the new paediatric SCORTENs for SJS/TEN in children was similar to that of the original SCORTEN developed for adults.11 This patient’s SCORTEN6 was 2, with an associated mortality rate of 12.1%, epidermal detachment > 30%, and HR > 120 bpm.

Ivana R Santana Pediatric Specialist1

1 Nursing Departament, Children’s Institute, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo 2

Clinical Research Center, Children´s Institute, Hospital das Clínicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo

The most common cause of TEN (70 to 90%) is medication,9,12-15 including antiepileptics, sulphonamides, antibiotics, NSAIDs, allopurinol, and paracetamol. A recent article recording adverse events (AE) reports for ‘paracetamol’ from 2007 to 2018 identified 24.2% of AE reports concerned children, 9/58 (15.5%) AE reports with fatal outcomes were SJS/TEN, and 286/4589 (6.2%) reports presented prodromes and symptoms of potentially life-threating SJS/TEN.16 Another study reviewed case reports of patients with SJS/TEN from 2006 to 2016 and found 94/166 cases of TEN, 29.5% of which were caused by antibiotics.17 No current consensus exists on how this disease should be treated. There are only health care protocols established by local hospitals. The literature has few clinical trials about specific treatment in children and it is controversial, with the few observational studies hindered by a low number of patients.13 The most commonly studied therapy is the use of intravenous immunoglobulins (IVIG) in doses of 2–7 mg/kg, until 2–4 g/kg, followed by corticosteroid treatment.9,18-21 Nonetheless, TEN is usually treated by closely and intensely monitoring the patient for possible multisystemic complications and employing a multidisciplinary team to provide the patient with the best care and follow-up. The supportive care for TEN resembles

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Correspondence: juliana.caires@hc.fm.usp.br Conflicts of interest: None

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that of a high-grade burn patient for adult and paediatric populations, and includes attenuation of the catabolic state, application of nonadherent protective barriers, and maintenance of appropriate urine output and other organ systems representing the focus of initial care.22 This patient received supportive care well within the recommendations contained in the current literature, including immediate suspension of the triggering drug and all non-essential medications; transfer to a burn unit as soon as possible; isolation in a warm environment (30 to 32°C); maintenance of sterile conditions; avoidance of skin trauma; monitoring of vital signs, weight, urine output, and hydration; monitoring of epidermal detachment extent (“rule of 9”); administration of IV fluids and nutritional support in the first 24 hours; debridement of devitalized tissue; application of eye drops to lubricate the eyes; and pain assessment and management.1-6,23 Nutrition is another important aspect of treatment. Because children have lower reserves of lean body mass, nutrition tends to be more of a problem compared to adults. Paediatric patients with SJS/TEN have an increased energy requirement. Therefore, a 30% factor should be applied to the resting energy requirements when calculating nutritional support.24 Moreover, enteral nutrition should be established early on, using a high protein-caloric content based on the patient’s baseline nutritional status, which tends to differ from country to country due to, among other factors, the patient’s economic status. Local therapy also needs special attention. Some experts recommend that the detached skin be debrided to remove all the potentially infected materials before covering with a biosynthetic dressings. However, others propose leaving the detached skin in situ as a biological dressing to protect the underlying dermis.25

administration of dipyrone for mild pain and morphine for moderate pain. The treatment we employed showed good results and the patient was released with no physical sequelae, confirming the effectiveness of using EFA as the first line of topical treatment in patients with epidermal detachment. IMPLICATION FOR CLINICAL PRATICE Given that TEN is a rare and severe skin reaction with a high mortality rate and that we have little data in the literature about children with TEN, it is important to disseminate experiences of children who suffered from this disease to the scientific community to contribute to the collective knowledge. CONCLUSION This rare and severe case of TEN triggered by an adverse drug reaction and characterised by lesions on the patient’s face, limbs, genitalia, trunk, oral mucosa, and eyes, had a good resolution and no sequelae because of adequate treatment. Early diagnosis of this clinical condition and treatment spearheaded by a multidisciplinary medical team are key factors for a good prognosis in children. The lack of substantial publications about TEN in children calls for specific health care protocols to guide intensive care teams regarding available treatments, in addition to immediate transfer to specialised units, and multicentre studies to help improve prognosis, reduce length of hospital stay, and improve quality of life. ETHICAL CONSIDERATION The patient’s parents signed an informed consent form, allowing this case and its associated images to be published in this journal. m

The application of gels containing polyhexanide and bland gauze bandages with reverse isolation is suggested26, even while using nonadherent gauze containing either petrolatum or paraffin to facilitate wound healing and prevent infection.27 Finally, the pain control must to be managed according to the degree of pain. Some articles suggest that analgosedation beginning initially in bolus and switching to continuous application can be used26 and the use of either opioid or non-opioid analgesics as a sub-dissociative dose of ketamine.28 In this case report, for evaluation and management of pain, the Face, Legs, Activity, Cry, Consolability (FLACC) pain scale was used, followed by the

46

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REFERENCES 1.

Bulisani ACP, Sanches GD, Guimarães HP, Lopes RD, Vendrame LS, Lopes AC. Síndrome de StevensJohnson e necrólise epidérmica tóxica em medicina intensiva. Rev Bras Ter Intensiva 2006;18(3):292297.

2.

Carneiro TM, Silva IAS. Diagnósticos de enfermagem para o paciente com necrólise epidérmica tóxica: estudo de caso. Rev Bras Enferm 2012;65(1):72-76.

3.

Neto FC, Piccinini PS, Andary JM, Sartori LDP, Cancian LT, Uebel CO, et al. Abordagem cutânea na necrólise epidérmica tóxica. Rev Bras Cir Plást 2017;32(1):128-134.

4.

Emerick MFB, Rodrigues MMT, Pedrosa DMAS, Novaes MRCG, Gottems LBD. Síndrome de Stevens-Johnson e Necrólise Epidérmica Tóxica em um hospital do Distrito Federal. Rev Bras Enferm 2014;67(6):898-904.

5.

Cabral L, Diogo C, Riobom F, Teles L, Cruzeiro C. Necrólise Epidérmica Tóxica (Síndrome de Lyell): uma patologia para as Unidades de Queimados. Acta Med Port 2004;17:129-40.

6.

Bastuji-garin S, Fouchard N, Bertocchi M, Roujeau JC, Revuz J, Wolkenstein P. SCORTEN: a severity-ofillness score for toxic epidermal necrolysis. J Invest Dermatol 2000;115(2):149-53.

7.

Eginli A, Shah K, Watkins C, Krishnaswamy G. Stevens–Johnson syndrome and toxic epidermal necrolysis. Annals of Allergy, Asthma & Immunology. 2017; 118(2):43–147.

8.

Gerull R, Nelle M, Schaible T. Toxic epidermal necrolysis and Stevens–Johnson syndrome: A review. Critical Care Medicine. 2011;39(6):1521–1532.

9.

Chatproedprai S.et al. Clinical features and treatment outcomes among children with Stevens-Johnson syndrome and toxic epidermal necrolysis: a 20-year study in a tertiary referral hospital. Dermatol Res Pract. 2018;2018:3061084. May 7.

10. Lissia M, Mulas P, Bulla A, Rubino C. Toxic epidermal necrolysis (Lyell’s disease). Burns 2010;36(2):152-63. 11. Sorrell et al: SCORTEN in Pediatrics. Pediatric Dermatology. 2017;34(4):433–437.

12. Ferrandiz-Pulido C, Garcia-Patos V. A review of causes of Stevens–Johnson syndrome and toxic epidermal necrolysis in children. Archives of Disease in Childhood. 2013;98(12):998–1003. 13. Pan RY, Dao RL, Hung SI, Chung WH. Pharmacogenomic advances in the prediction and prevention of cutaneous idiosyncratic drug reactions. Clinical Pharmacology and Therapeutics. 2017;102(1):86– 97. 14. Rotunda A, Hirsch RJ, Scheinfeld N, Weinberg J. Severe cutaneous reactions associated with the use of human immunodeficiency virus med- ications. Acta Dermato-Venereologica. 2003;83(1):1–9. 15. Rodríguez-Martín S et al. Incidence of Stevens-Johnson syndrome/toxic epidermal necrolysis among new users of different individual drugs in a European population: a case-population study. Eur J Clin Pharmacol. 2019;75:237–246. 16. Popiołek I, Piotrowicz-Wójcik K, Porebski G. Hypersensitivity Reactions in Serious Adverse Events Reported for Paracetamol in the EudraVigilance Database, 2007-2018. Pharmacy (Basel). 2019 Jan 17;7(1). pii: E12. 17. Yang SC et al. The Epidemiology of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in China. J Immunol Res. 2018;Jun(28):4154507. 18. Belver MaT et al. Severe delayed skin reactions related to drugs in the paediatric age group: A review of the subject by way of three cases (Stevens-Johnson syndrome, toxic epidermal necrolysis and DRESS). Allergol Immunopathol (Madr). 2016. JanFeb;44(1):83-95. 19. Viard I, Wehrli P, Bullani R, Schneider P, Holler N, Salomon D, et al. Inhibition of toxic epidermal necrolysis by blockade of CD95 with human intravenous immunoglobulin. Science. 1998;282:490-3.

21. Mangla K, Rastogi S, Goyal P, Solansky RB, Rawal RC. Effi- cacy of low dose intravenous immunoglobulins in children with toxic epidermal necrolysis: an open uncontrolled study. Indian J Dermatol Venereol Leprol. 2005;71:398-400. 22. Woolum JA, Bailey AM, Baum RA, Metts EL. A Review of the Management of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis. Advanced Emergency Nursing Journal. 2019;41(1):56–64. 23. Oliveira FL, Silveira LK, Morais TS, Serra MCVF. Necrólise epidérmica tóxica e síndrome de StevensJohnson. Rev Bras Queimaduras. 2012;11(1):26-30. 24. Mayes T, Gottschlich M, Khoury J, et al. Energy requirements of pediatric patients with StevensJohnson syndrome and toxic epidermal necrolysis. Nutr Clin Pract. 2008;23:547–50. 25. Schneider JA, Cohen PR. Stevens-Johnson syndrome and toxic epidermal necrolysis: a concise review with a com- prehensive summary of therapeutic interventions emphasizing supportive measures. Advances in Therapy. 2017; 34(6):1235–1244. 26. Wallenborn J, Fischer M. Intensive Care in a Patient with Toxic Epidermal Necrolysis. Case Rep Crit Care. 2017;2017:3246196. 27. de Prost N, Ingen-Housz-Oro S, Duong Ta, ValeyrieAllanore L, Legrand P, Wolkenstein P, Roujeau JC. Bacteremia in Stevens– Johnson syndrome and toxic epidermal necrolysis: Epidemiology, risk factors, and predictive value of skin cultures. Medicine (Baltimore). 2010;89(1):28–36. 28. Valeyrie-Allanore L, Ingen-Housz-Oro S, Colin A, Thuillot D, Sigal ML, Binhas M. Pain management in Stevens–Johnson syndrome, toxic epidermal necrolysis and other blistering diseases. Annales de Dermatologie et de Venereologie. 2011;138(10):694–697.

20. Stella M, Clemente A, Bollero D, Risso D, Dalmaso P. Toxic epidermal necrolysis and Stevens-Johnson syndrome experience with high-dose intravenous immunoglobulins and topical conservative approach. A retrospective analysis. Burns. 2007;33:452-9.

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1. Münter KC, Meaume S, Augustin M, Senet P, Kérihuel J.C. The reality of routine practice: a pooled data analysis on chronic wounds treated with TLC-NOSF wound dressings. J Wound Care. 2017 Feb; 26 (Sup2): S4-S15. Erratum in: J Wound Care. 2017 Mar 2; 26(3): 153 2. French Health Insurance Report to the Ministry of Health for 2014. July 2013.


Science, Practice and Education DOI: 10.35279/jewma201905.06

Factors that create Obstacles and Opportunity for Patient Participation in Orthopaedic Nursing Care The nurse plays an essential role in enabling the patient’s sense of participation, but patient’s involvement is essential and wound healing often requires patient involvement. The aim of this study was to highlight factors that hinder patient care and provide opportunities for patientcentred care from a nursing perspective. ABSTRACT Background The nurse plays an essential role in enabling the patient’s sense of participation. Although it has been several years since patient law was enacted, the patient’s involvement in their own care is still poorly understood in several areas. In many areas, wounds occur in various forms. Wound healing often requires patient involvement.

Aim The aim of this study was to highlight factors that hinder patient care and provide opportunities for patient participation in orthopaedic care from a nursing perspective.

Methods Electronic databases, such as PubMed and Cinahl, were searched using keywords from 2007-2017. Fifteen articles were reviewed, both qualitatively and quantitatively, and included in the content analysis.

Results Our results show the importance of open communication between nurses and patients, the routine and working methods used in healthcare facilities, as well as the fact that an organisation which supports a working person-centred approach is needed. Nurses and all members of the team need time for reflection and guidance to accomplish the personcentred approach.

Conclusions Person-centred care needs a new mindset to allow the patient to play a more active role. Skills and injournal of the european wound management association 

dividual training in groups are needed. To increase patient participation through person-centred care, organisational change and the resultant development of new routines are also important. This approach to healthcare can also reduce stress.

Susanne Stålenhag RN, BSc, Trauma and Reparative Medicine Theme, Karolinska University Hospital. Stockholm, Sweden.

Eila Sterner RN, PhD, Head of nursing development, Inst. Molecular medicine and surgery, Trauma and Reparative Medicine Theme, Karolinska University Hospital. Stockholm, Sweden.

Implications for Clinical Practice A participating patient can lead to faster recovery, higher quality of life, lower cost, and higher quality for health care. To achieve this, active leadership, a positive attitude from staff, encouragement, and support are needed for the patient. The work environment should be reviewed because it affects everyone in the healthcare sector.

BACKGROUND Today patients have higher demands to participation in and influence healthcare. Access to information and the opportunity to express their expectations before a scheduled operation have been shown to produce a more realistic expectation of patient experience and self-reported health.1,2 As we live longer, the cost of healthcare increases. Complicated operations can now be performed on ill, elderly, or physically weak patients. The care period in the hospital is short and day surgery is often possible. For example, five to ten years ago in Sweden, it was standard for patients undergoing knee replacement surgery to stay in the hospital for seven to ten days. Today, some patients can recover at home starting the day after this type of surgery. These developments place greater demands on the nurses and the multidisciplinary 

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team. Once home the patient’s task is to watch over the wound. They need to know when to contact their healthcare team if something is not right, such as when they have a fever, the wound dressing leaks, they notice a smell, or when other problems related to the wound occur. Nursing involves both surgical and non-surgical care. Excellent nursing requires theoretical knowledge and an ability to perform with an ethical approach.3 The patient is a specialist in his/herself and a valuable resource, but they do not always feel like an equal partner in their own healthcare.4 They are entitled to, and responsible for, decisions that concern their own lives. The nurse can both facilitate the healing process and support the patient in increasing the feeling of well-being that can lead to an improved quality of life.5-8 For patients to become more involved in their wellness, they need information, support, and knowledge about medical treatments. Laws and regulations shape healthcare in Sweden just as in other countries. Swedish law states that health and medical care must be conducted in such a way that it meets the requirements for good care and that it must be based on respect for the patient’s self-determination and integrity.9-11 Systematic quality work must also be performed in parallel12 to continuously develop and secure the quality of care. However, the goal of achieving high quality patient-centred care has proven difficult. Participation Patient participation is a vague and ambiguous concept. The nurse plays a crucial role in encouraging and engaging the patient, which in turn increases his or her self-esteem. 13 To achieve this goal, collaboration based on communication and understanding of the situation is required.14 Health and medical care have evolved from being traditional and paternalistic to starting from the patient’s personal preferences.15 If the nurse has a positive attitude plus gives encouragement and support to the patient, it is of great importance for participation and patient safety. 2 Being seen is of great importance to the patient’s sense of participation.16 Patients are often satisfied with the treatment, but less satisfied with information and participation. A well-informed and engaged patient is more likely to follow treatment plans and experience increased well-being.13 A person-centred approach requires participation from the whole healthcare team. Person-centred care also requires becoming familiar with another person’s perspective, and the ability to adapt working methods based on the patient’s needs and wishes. For the nurse, this means having a holistic perspective, being honest and committed, and willing to show respect for the individual patient’s story.3

50

It is important to ask patients open-ended questions, listen carefully, and allow time for the patient to express himself.2,15,17 Improved communication, individualised care, shared decision-making, and patient education are other factors that lead to increased patient involvement and independence.15 In one of the first literature reviews on person-centred care, person-centring is defined as an approach with four central concepts: being in a relationship, being in a social world, being in a place, and being yourself.18 Within personcentred care, the perspective is shifted from describing “what” a patient is about to telling “who” a person is based on three parts: the patient’s story, forming a partnership (i.e., the team’s collective knowledge of the patient), and having a documented planned agreement.19 Placing the patient as the focal point, which is based on relationships and the need for a patient story, is actually not a new concept; one can read it already in Travelbee’s interaction theory.20 Communication between nurse and patient is fundamental to good care. There are several touch points between Travelbee’s theory and person-centred care. She describes it as essential that all people have equal value, and that one should see each patient as a human being and not someone who is “sick.” With person-centred care, nurses are aware that suffering is subjective. Regardless of the disease or diagnosis, the patient may experience illness differently, and the experience of health-related illness is therefore unique. The patient is always at the centre and it is important to build a relationship from the beginning to meet the patient’s needs. Travelbee and person-centred care are thus aligned on the need for the patient story. The nurse must be committed to taking the time to understand the needs of the patient. An important part of nursing care is effective communication to increase the interaction between nurse and patient.20 The key to following and finding meaning in the patient’s story is understanding both verbal and non-verbal communication.21 All people are unique and have the right to good health regardless of their abilities and resources. Therefore, it is essential to study the obstacles and opportunities that can affect the patient’s involvement from a nursing perspective in the field of orthopaedics. METHODS Student papers can make differences and contribute to the implementation of more in-depth research within the chosen area. To cover the current research field, online databases such as PubMed and Cinahl were used. Both qualitative and quantitative research were included in the content analysis22 to help answer the research question. Research articles in languages other than English

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and Swedish were excluded due to translation issues. The search strategy did not impose any language limitations. Data Gathering The literature research began with a manual search strategy to obtain an understanding of the current area. The review question was identified using keywords and a combination of keywords with AND, OR, and NOT. The keywords Patient participation, Patient-centred care, Nurse-patient relations, Nurse’s role, and Orthopaedics were combined with Communication barriers and obstacles. The search was conducted with the consultation of an expert librarian, and papers published from 2007 to 2017 were collected. The search strategy and results of different phases and combinations of the systematic review are presented in Tables 1 and 2. Inclusion criteria were focused on articles where the survey group consisted of people over 18 years of age and when patient engagement was combined with orthopaedic care and nursing involvement. Unfortunately, orthopaedic care did not give any relevant results, so the search was broad-

ened to acute care. Each phase of the systematic review was conducted by the author. The first step involved selecting the papers to include in the review. The second step was appraising the methodological quality of the included papers followed by extracting data from the papers. Finally, a synthesis of the papers was prepared for presenting the findings. These different steps were described in the literature by Caldwell.22 The articles were checked for quality using criteria developed on a scorecard as published previously.23,24 Fifteen papers met the quality criteria and were included in the final analysis. ANALYSIS To create the summary, the selected articles were tabulated to facilitate overview and formulate conclusions.22, 25 Data were classified, and significant information was marked in color to organise the data into groups. Then the similarities and differences were identified and grouped into different themes, categories, and codes.22,25 Two themes were identified: obstacles and opportunities for patient participation. Three categories were identified: communication between the nurse and patient, working methods 

Table I. Summary of search strategies used in this review. Search strategies using databases such as PubMed and CIHNAL, keywords and their combinations are listed. DATABASE DATE

KEYWORDS AND COMBINATIONS

HITS

ABSTRACTS READ

ARTICLE(S) INCLUDED

PubMed 171129

Patient Participation and Patient-Centred Care AND Nurse-Patient Relations AND/OR Nurse’s Role

99

20

7

PubMed 171129

Patient Participation AND Patient-Centred Care AND Nurse’s Role

88

10

0

PubMed 171129

Patient Participation and Patient-Centred Care AND Nurse-Patient Relations AND/OR Nurse’s Role AND/OR Communication Barriers AND/ OR Hinders

25

4

1

CIHNAL 171205

Participation and Orthopaedics and Patient

127 (126 unique)

10

(1 – same as in Pubmed)

CIHNAL 171205

Participation and Person-Centred and Patient

82 (80 unique)

10 i

(2 – same as n PubMed)

CIHNAL 171206

Participation or Person-Centred or Nurse

26 (24 unique)

5

(2 – same as in PubMed)

Manual Search and Articles from Supervisor and Colleagues

7

Total

454 (449)

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7

66

15


Table 2. Strategy employed to select the 15 articles reviewed for this study. Articles based on the titles (n=449) Rejected because abstract did not confirm the inclusion criteria (n=380) Articles based on the abstract (n=70) Rejected because abstract did not confirm the aim (n=55) Articles based on full-texts (n=15)

Qualitative articles full-text (n=12)

Qualitative articles full-text (n=3)

and routines in the healthcare unit, as well as obstacles and opportunities for patient participation from an organisational perspective. (See Table 3).

more convenient way for them to relate.29 This response might be due to a lack of understanding of how to invite them into the conversation and increase their confidence.29

RESULTS Obstacles - Communication Between the Nurse and Patient

Obstacles - Routine The nurse usually worked routinely, especially on days with higher stress.26 Furthermore, today’s system of rounds does not encourage teamwork or interprofessional communication, which leads to frustration and reduced nursing quality.31 For example, even though nurses wanted to invite patients to take care of their usual medication, the nurses felt bound to rules and regulations for fear that something would go wrong and affect patient safety.26, 27 Documentation was rarely collected together with the patient, which resulted in incomplete recordkeeping that did not describe the patient’s desires and needs.32

There was less communication with the patient when nurses did their work without involving the patient. The nurses wish to have more control over how the work should be performed with no interference, and thus, would rather provide care themselves instead of involving, instructing, or educating the patient.26 This way of working depends on the professional judgment and confidence of the nurse who is responsible for the patient’s health and safety. Thus, patient safety must be the top priority if rules are overridden so that patients can participate more actively in their own care.26,27 Other factors that affect communication include the patient’s cognition, cultural background, and language barriers.28 Lack of teamwork, large workload, and stress also reduced the patient’s ability to participate. Speaking above the patient’s comprehension can make the patient feel invisible.28 The same feeling of invisibility can arise if there is a computer screen located between the patient and nurse.29 Being informed is not the same as being involved. However, some patients see themselves as passive listeners.30 and may adopt a more traditional, compliant role as it may be a 52

Obstacles - Organisation The advantage of person-centred care is perceived differently by different occupational categories. The physician observed little value in the need to implement a personcentred approach compared to other healthcare staff. They considered person-centred care as belonging to nursing and not medical care.33,34 The culture of an organisation has a significant impact on the implementation of personcentred care. The care is often controlled by production agreements, which can be affected when working toward person-centred care because it takes time to listen to the patient’s story.35 Implementation of person-centred care in a workplace is also affected by high staff turnover, the

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Table. 3. Description of the data analysis themes, categories, and codes based on the 15 papers reviewed. THEME

CATEGORY

CODE

Obstacles to patient participation

Obstacles to communication between the nurse and the patient – for patient participation

The relationship between nurse and patient The importance of communication Passivity of the patient Attitudes Cultural factors for nurses and patients

Obstacles to working methods and routines in the healthcare unit – for patient participation

Routines Standardisation Patient safety Secrecy Documentation

Obstacles from an organisational perspective – for patient participation

Skills shortage (knowledge) Difficulties with implementation Lack of team work Jargon Leadership Hierarchical structures Stress High workload High staff turnover Inexperienced nurses

Communication between the nurse and the patient that can support

Commitment Communication Attitudes Autonomy Empowerment

Working methods and routines in the healthcare unit – that can support patient participation

Partnerships Person-centred care Rounds Reports (between shifts, patient records) Documentation

From an organisational perspective – to support patient participation

Teamwork Interprofessional work Leadership Organisation Reflection Learn from each other Training

Opportunities for patient participation

hiring of nurses without person-centred care experience, lack of experience in the staff overall, as well as a stressful work environment.36 The existing paternalistic healthcare system requires educational skills when implementing a patient-centred care approach where patients are seen as partners.35 Possibilities - Communication The nurse plays a crucial role in promoting the patient’s opportunity to participate in their care.36 At the same journal of the european wound management association 

time, this is a challenging task. The nurse must identify each patient’s specific needs and a find balance between assessing the patient’s condition and the need for nursing. Studies show that when the nurse asks open-ended questions and inquires about the current situation, the patient’s ability to participate actively in their care is encouraged and strengthened.37 By deliberately handing over responsibilities in various nursing activities, the patient feels encouraged to understand, participate in, and increase their

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commitment to healing.28,29 When professionals listened to the patient and focused on them as a person rather than on their disease, they felt secure.29 Listening to the patient is also an attribute that demonstrates empathy by the nurse. Patients experienced something more than just being taken care of; they experienced hope, which, in turn, created a catalyst for empowerment and participation.38 Listening and encouraging participation without the patient feeling pressure to take a decision is a winning concept.39 When the patient’s role is strengthened with increased participation, improved patient safety is observed, leading to independence and confidence.36 Possibilities - Routine The interaction between a patient and their nurse increases the patient’s sense of participation and leads to safer care. Patients who felt they were treated respectfully were more willing to speak up and felt that they could correct any inaccuracies, leading to increased patient safety.27,30 Having time for reflection and supervision also plays an important role in the nurses’ ability to implement person-centred.34 Patient-centred rounds have a positive impact on the nurses’ work situation and have contributed to better teamwork and reduced hierarchy between different healthcare professionals.31 When working in a person-centred environment, documentation is performed together with the patient and their relatives, which prevents misunderstandings and clarifies communication.32 Possibilities - Organisation The development of nursing skills in communication strategies and person-centred care as a measure of patient safety would promote patient participation.26 However, attention should be paid to nurses’ concerns about maintaining confidentiality in connection with the patient.30 The workplace culture, (i.e., the employees’ perception of methods, procedures, and behaviours) affects patient participation. The need for a strong relationship between the work environment and person-centred care has been presented.40 A positive workplace culture is a prerequisite for person-centred care and, thus, patient participation. Nurses should have opportunities to continue their education, so that they can further develop their skills. The work environment affects both the nurses’ commitment and motivation, especially in times when a full workload is carried.40 DISCUSSION Open communication between everyone on the patient’s team (including the patient themselves) is an essential suc-

54

cess factor in achieving a person-centred approach. The review of work routines is required to increase active participation by the patient. The nurses felt bound to rules and regulations. Nurses should not fear scrutiny if rules are overridden or routines changed when the patient participates more actively.26,27 Orthopaedics was a criterion included in our database searches. Unfortunately, this term did not provide any relevant hits together with or without the wound healing process. This finding reveals that patient involvement in orthopaedic nursing care could be interesting to study. The literature review method was chosen for this bachelor’s thesis to obtain more knowledge about the field of patient-centred care and to facilitate planning of follow-up studies at a later stage. Literature review with a systematic approach gives readers the opportunity to decide whether the conclusions are credible. This literature review has both strengths and weaknesses. One of the strengths was that nine of the 15 selected articles were written after 2013, which should increase the reliability of the results obtained. A possible weakness is that this review was written by only one author which, due to a lack of collaboration, may limit processing of the collected material and the opportunity to include all papers in the review. One’s understanding can also affect and shape the outcome. It is difficult to generalise the results presented in this paper, but it can be used as a basis for discussion in one’s healthcare unit. Writing a review also requires different biases to be considered. For example, the studies discussed in these articles were performed in different countries, six from Sweden, five from Australia, one from Canada, USA, and Ireland, and one from Israel. Thus, further discussion could be conducted about whether the healthcare systems in these countries differs and how any differences may affect the results. The concept of person-centred care is based on the patient being an equal partner. This partnership is only achieved if the patient is invited to participate and is given the opportunity to influence their own care. The intention is not for the staff to create something for the patient. Instead the staff should identify and strengthen the resources that exist in the patient.19 Participation, the patient’s autonomy, communication, and the role of the nurse are the basis for person-centred care, which in turn leads to patient involvement. There may be different perceptions between the patient and the nurse regarding the extent of participation, and this may be the reason why the patient sometimes feels dissatisfied with the nursing care received.4

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The department’s routines and the nurse’s attitude, communication, and sometimes controlling function reduce the patient’s ability to participate.26,41 Existing routines and the absence of them can both impede a patient’s willingness to participate.26,41,42 Short care times and a shortage of experienced staff can make it difficult to provide individualized care as it is easier to follow standard routines. Today’s rounds system can also prevent patient participation.31 The difficulty of nurses handling confidentiality and sharing confidential information during bedside conversation was highlighted in several articles.28, 30,41 At the same time, conducting bedside conversation provides opportunity to amend any inaccuracies in the patient information.30 This could be remedied by providing more private rooms in the healthcare units and changing work methods. Lack of experienced staff, continuity, and a large workload can lead to less patient participation.36,39 One study also observed that time restrictions limit the possibility of patient participation, which ultimately affects patient safety.42 The same study also showed that the patient’s respect for authority can serve as an obstacle to many patients’ involvement in their care and treatment. Involving the patient at a round creates opportunities for improved communication, teamwork, and reduced hierarchy.31 Creating opportunities within the healthcare organisation for professionals to work toward a person-centred approach by educating nurses in communication strategies will promote participation.26 Discussing person-centred care at all levels of the organisation as a measure of patient safety30 can be a winning concept for increased participation and opportunities. The importance of partnership and competent staff in creating security, and therefore patient participation, is important.39 An educational, supportive working model with reflection and supervision is a

prerequisite for nurses to implement new approaches for increased patient participation.37 CONCLUSION Person-centred care requires a new mindset to let the patient play a more active role. There are many factors that influence the opportunity for patient participation in daily care, from the healthcare organisation in the ward and its leadership to the work environment for nurses in the healthcare sector. Both verbal and non-verbal communication between patients and nurses are as important as communication between all healthcare professionals. However, the fear that nurses feel when overriding rules or adjusting routines to allow patients to participate can hinder person-centred care from being fully implemented. This student essay can make a difference by helping to elucidate the fact that in-depth research is needed within a specific area of orthopaedic patient care. It also shows the importance of taking a critical approach when evaluating published studies. Equally important is the fact that care must rest on the best scientific research available. Wounds are treated in all fields of healthcare, especially in orthopaedic care. It is not only surgical wounds but also hardto-heal wounds after trauma and infections. Diabetic foot ulcers also occur. Those in need of wound healing are both young and old. Because wounds and people vary greatly, it is even more important to find working methods that involve the patient in an optimal and natural way. The wound healing process often requires patient involvement. They need to know when to contact their healthcare team if something is not right with the healing process. m 

Table 4/1. Framework for the review, including quality control. AUTHORS YEAR COUNTRY Tobiano, Bucknall, Marshall, Guinane, Chaboyer 2015 Australia

AIM

TITLE

METHODS

RESULTS

QUALITY/ TYPE OF STUDY

To explore nurses’ views on patient participation in nursing care. The objectives of this study were to investigate nurses’ understanding of patient participation, and the barriers and facilitators to it.

Nurses’ view of patient participating in nursing care

Interpretive study In-depth semistructured interviews were conducted and analysed using content analysis.

Five categories emerged from the nurses’ views. Nurses play a crucial role in promoting patient participation. Nurses felt limited by rules, perceptions of maintaining safety, and patient characteristics when attempting to enact participation.

I/K

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Table 4/1. Framework for the review, including quality control. AUTHORS AIM TITLE METHODS RESULTS YEAR COUNTRY

QUALITY/ TYPE OF STUDY

Svanström, Andersson, Rosén, Berglund 2016 Sverige

To describe experiences of implementing a process based on a learning support model designed to increase patient involvement and autonomy in care.

Moving from theory to practice: experience of implementing a learning support model designed to increase patient involvement and autonomy in care

Data were collected through interviews, notes, and written stories, and then analysed using hermeneutic analysis with a focus on meanings.

The participants described challenges when patients became involved in their care and took charge of their lives. The participants’ experience led to increased self-confidence and feelings of improved competence in dialogue with patients.

I/K

Sharp, McAllister, Broadbent 2016 Australia

To examine and understand the unique and particular experiences of a group of former patients’ participating in personcentred care.

The vital blend of clinical competence and compassion: how patients experience person-centred care

Semi-structured interviews with patients were examined via thematic analysis to understand how patients identify ways to enhance and support compassionate person-centred care in everyday nursing practice.

Clinically competent care, delivered compassionately through a positive nursepatient relationship, resulted in personal, emotional, or spiritual responses that were the catalyst for patient empowerment and participation in care, and a positive outlook toward recovery.

II/K

Abdelhadi, DrachZahavy 2011 Israel

To test a model that suggests the ward’s climate of service facilitates nurses’ patient-centred care behaviours through its effect on nurses’ engagement.

Promoting patient care: work engagement as a mediator between ward service climate and patientcentred care

A nested crosssectional research design was adopted, with three parameters to measure the behaviour of nurses by questionnaires: work engagement, ward’s climate for service, and control variables. Patient-centred care behaviours were assessed by structured observations.

The findings: service climate proved to be a link to nurses’ work engagement and patient-centred care behaviours. Nurses’ work engagement mediated the service climate patient-centred care behaviours.

II/RCT

Alharbi, Carlström, Ekman, Jarneborn, Olsson 2014 Sweden

To investigate whether patients did in fact perceive the intentions of partnership in the new care model 1 year after its implementation.

Experiences of person-centred carepatients´ perceptions: qualitative study

Sixteen participants were interviewed.

Patients felt listened to and that their own perception of the situation had been noted. Patients expressed that they felt the staff saw them as persons and did not solely focus on their disease.

I/K

Bolster, Manias 2010 Australia

To examine how nurses and patients interact with each other during medication activities in an acute care environment with an underlying philosophy of person-centred care.

Person-centred interactions between nurses and patients during medication activities in an acute hospital setting: qualitative observation and interview study

A qualitative approach was used comprising naturalistic observations and semi-structured interviews.

The results of the study generated insights into the nature of interactions between nurses and patients where person-centred care is the underlying philosophy of care. Three major themes were found: provision of individualised care, patient participation, and contextual barriers to providing personcentred care.

I/K

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Table 4/2. Framework for the review, including quality control. AUTHORS AIM TITLE METHODS RESULTS YEAR COUNTRY

QUALITY/ TYPE OF STUDY

Jangland, Gunningberg 2017 Sweden

To evaluate the implementation of a project on patient participation, using two specific research questions for patients and nurses.

Improving patient participation in a challenging context: a 2-year evaluation study of an implementation project

Study is a descriptive design using quantitative and qualitative methods.

Improving patient participation in a busy environment is challenging. Although the long-term implementation project did not improve patient participation in the units, the nurse managers described a changing culture in which staff grew to accept patients’ involvement in their own care. Several barriers to change and sustainability were acknowledged.

I/RTC

Tobiano, Marshall, Bucknall 2016 Australia

To describe and understand the activities that patients and nurses undertake to enact patient participation in nursing care.

Activities Patient and Nurses Undertake to Promote Patient Participation

Field notes were collected and were analysed both inductively and deductively.

Nurse–patient interactions promoted patient participation through dialogue and knowledge sharing. Less evident was patient involvement in planning or self-care. Nurses exerted control over patient care, which influenced the extent of patient participation.

II/K

Oxelmark, Ulin, Chaboyer, Bucknall, Ringdal 2017 Sweden

To describe registered nurses’ experiences with patient participation in nursing care, including their barriers and facilitators for participation.

Registered Nurses‘ experiences of patient participation in hospital care: supporting and hindering factors patient participation in care

Interviews were conducted with 20 registered nurses. Thematic data analysis was used to analyse the transcribed interview data.

Five themes emerged: listening to the patient, engaging the patient, relinquishing some responsibility, sharing power, and partnering with patients. In addition, hindering and facilitating factors to participation were identified, including patient desire to take on a passive role and lack of teamwork, which participants understood would enhance patient safety. Patient participation was hindered by medical jargon during the ward round; there was a risk of staff talking above patient comprehension, which was sometimes inevitable at the patient’s bedside.

I/K

Sharma, Klocke 2014 USA

To study and improve the perceived communication and interprofessional care provided by medical providers and nursing staff.

Attitudes of nursing staff toward interprofessional in-patientcentred rounding

We surveyed attitudes of nursing staff before and after four-month implementation of a patient-centred physician–nurse rounding process for in-patients.

Compared with baseline prerounding data, nursing staff satisfaction related to the communication and rounding by hospitalist providers significantly improved after the patient-centred in-patient rounding model was implemented. Nursing workflow, nurses’ perceptions of value as a team member, and their job satisfaction were also positively impacted.

II/K

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Table 4/3. Framework for the review, including quality control. AUTHORS AIM TITLE METHODS RESULTS YEAR COUNTRY

QUALITY/ TYPE OF STUDY

Wolf, Moore, Lydahl, Naldemirci, Elam, Britten 2017 Sweden

To explore the realities of partnership as perceived by patients and health professionals in everyday PCC practice.

The realities of partnership in person-centred care: a qualitative interview study with patients and professionals

Qualitative study employing a thematic analysis of semi-structured interviews with professionals and patients.

Our findings identified both informal and formal aspects of partnership that patients felt listened to and informed. They were content to ask questions and felt less involved in care planning, documentation, or exploring lifestyle goals.

I/K

Alharbi, Olsson, Ekman, Carlström 2014 Sweden

To measure the effect of organisational culture on health outcomes of patients 3 months after discharge.

The impact of organisational culture on the outcome of hospital care: after the implementation of person-centred care

A quantitative study using Organisational Values Questionnaire (OVQ) and a healthrelated quality of life instrument (EQ-5D).

The results tentatively indicated an association between an organisational culture and patients’ health-related quality of life. Our results showed that it could be hindering instead of helping the new health care model achieve its objectives.

II/P

Gachoud, Albert, Kuper, Stroud, Reeves 2012 Canada

To explore how “patient-centredness” is operationalised in the work life of those professionals.

Meanings and perception of patient-centredness in social work, nursing and medicine: a comparative study

Semi-structured interviews were employed because they generate understanding of the meanings different individuals have of their real-life world.

The analysis generated three main themes: “Definition of PCP”; “Value given to PCP”; and “PCP and collaboration”. All the themes gave a specific perspective on patient-centred in practice (PCP) and are presented below.

II/K

McMurray, Chaboyer, Wallis, Johnson, Gehrke 2011 Australia

To examine patients’ perspectives of participation in shift-toshift bedside nursing handover.

Patients´perspec-tives of bedside nursing handover

A descriptive case study was conducted. Data were analysed using thematic content analysis.

Four themes emerged from the analysis: patients appreciated being acknowledged as partners in their care; they viewed bedside handover as an opportunity to amend any inaccuracies in the information being communicated; some preferred passive engagement rather than being fully engaged in the handover; most patients appreciated the inclusive approach of handover as nurse-patient interaction.

I/K

Broderick, Coffey 2012 Ireland

To explore nursing documentation in long-term care, to determine whether it reflected a personcentred approach to care, and to describe aspects of PCC as they appeared in nursing records.

Person-centred care in nursing documentation.

A qualitative descriptive study using the PCN framework as the context through which nursing assessments and care plans were explored.

Findings indicated that many nursing records were incomplete, and documentation of information regarding psychosocial aspects of care was infrequent. There was evidence that nurses engaged with residents and worked with their beliefs and values. Nursing documentation was not completed in consultation with the patient, and there was little to suggest that patients were involved in decisions related to their care.

I/K

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Smith MA. The Role of Shared Decision Making in Patient-Centred Care and Orthopaedics. Orthopedic nursing. 2016;35(3):144-9.

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Vaismoradi M, Jordan S, Kangasniemi M. Patient participation in patient safety and nursing input - a systematic review. Journal of clinical nursing. 2015;24(5-6):627-39.

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Edberg A-K. Omvårdnadens grunder : en specialutgåva för sjuksköterskor. Lund: Studentlitteratur; 2010.

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Papastavrou E, Efstathiou G, Tsangari H, Karlou C, Patiraki E, Jarosova D, et al. Patients’ decisional control over care: a cross-national comparison from both the patients’ and nurses’ points of view. Scandinavian journal of caring sciences. 2016;30(1):26-36.

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14. Suter E, Arndt J, Arthur N, Parboosingh J, Taylor E, Deutschlander S. Role understanding and effective communication as core competencies for collaborative practice. Journal of interprofessional care. 2009;23(1):41-51. 15. Robinson JH, Callister LC, Berry JA, Dearing KA. Patient-centred care and adherence: definitions and applications to improve outcomes. Journal of the American Academy of Nurse Practitioners. 2008;20(12):600-7. 16. Kim HS. The nature of theoretical thinking in nursing. New York: Springer Pub. Co.; 2010. 17. Berwick DM. What ‘patient-centred’ should mean: confessions of an extremist. Health affairs (Project Hope). 2009;28(4):w555-65.

Arvidsdotter T, Marklund B, Taft C. Effects of an integrative treatment, therapeutic acupuncture and conventional treatment in alleviating psychological distress in primary care patients--a pragmatic randomized controlled trial. BMC complementary and alternative medicine. 2013;13:308.

18. McCormack B. Person-centredness in gerontological nursing: an overview of the literature. Journal of clinical nursing. 2004;13(3a):31-8.

Dudas K, Olsson LE, Wolf A, Swedberg K, Taft C, Schaufelberger M, et al. Uncertainty in illness among patients with chronic heart failure is less in personcentred care than in usual care. European journal of cardiovascular nursing : journal of the Working Group on Cardiovascular Nursing of the European Society of Cardiology. 2013;12(6):521-8.

20. Travelbee J. Interpersonal aspects of nursing1971.

Feldthusen C, Dean E, Forsblad-d’Elia H, Mannerkorpi K. Effects of Person-Centred Physical Therapy on Fatigue-Related Variables in Persons With Rheumatoid Arthritis: A Randomized Controlled Trial. Archives of physical medicine and rehabilitation. 2016;97(1):26-36. Hansson E, Carlstrom E, Olsson LE, Nyman J, Koinberg I. Can a person-centred-care intervention improve health-related quality of life in patients with head and neck cancer? A randomized, controlled study. BMC nursing. 2017;16:9. Socialdepartementet. Hälso- och sjukvårdslag (2017:30) Stockholm: Sveriges riksdag; 2017 [Available from: https://www.riksdagen.se/sv/ dokument-lagar/dokument/svensk-forfattningssamling/halso--och-sjukvardslag_sfs-2017-30.]

10. Socialdepartementet. Patientlag (2014:821) Stockholm: Sveriges Riksdag; 2014 [Available from: https://www.riksdagen.se/sv/dokument-lagar/ dokument/svensk-forfattningssamling/patientlag-2014821_sfs-2014-821.] 11. Socialdepartementet. Socialtjänstlag (2001:453) Stockholm: Sveriges Riksdag; 2001 [Available from: https://www.riksdagen.se/sv/dokument-lagar/ dokument/svensk-forfattningssamling/socialtjanstlag-2001453_sfs-2001-453.] 12. Socialstyrelsen. SOSFS 2011:9 Ledningssystem för systematiskt kvalitetsarbete, 2011 Stockholm: Socialstyrelsen; [Available from: https://www. socialstyrelsen.se/publikationer2011/2011-6-38.] 13. Wilson J. Breaking down barriers to patient engagement. British journal of nursing (Mark Allen Publishing). 2010;19(8):473.

19. Ekman I. Personcentrering inom hälso- och sjukvård : från filosofi till praktik [ ccccc] Stockholm: Liber; 2014. 21. Dahlberg K, Ekman I. Vägen till patientens värld och personcentrerad vård : att bli lyssnad på och förstådd. Stockholm: Liber; 2017. 22. Caldwell K, Henshaw L, Taylor G. Developing a framework for critiquing health research: an early evaluation. Nurse education today. 2011;31(8):e1-7. 23. Berg A. Evidensbaserad omvårdnad vid behandling av personer med depressionssjukdomar. Stockholm: SBU; 1999. 24. Willman A, Stoltz P, Bahtsevani C. Evidensbaserad omvårdnad : en bro mellan forskning & klinisk verksamhet. Lund: Studentlitteratur; 2011. 25. Bettany-Saltikov J, McSherry R. How to do a systematic literature review in nursing : a step-by-step guide. London: McGraw-Hill Education/Open University Press; 2016. 26. Tobiano G, Marshall A, Bucknall T, Chaboyer W. Activities Patients and Nurses Undertake to Promote Patient Participation. Journal of nursing scholarship : an official publication of Sigma Theta Tau International Honor Society of Nursing. 2016;48(4):362-70. 27. Bolster D, Manias E. Person-centred interactions between nurses and patients during medication activities in an acute hospital setting: qualitative observation and interview study. International journal of nursing studies. 2010;47(2):154-65. 28. Oxelmark L, Ulin K, Chaboyer W, Bucknall T, Ringdal M. Registered Nurses’ experiences of patient participation in hospital care: supporting and hindering factors patient participation in care. Scandinavian journal of caring sciences. 2017.

31. Sharma U, Klocke D. Attitudes of nursing staff toward interprofessional in-patient-centred rounding. Journal of interprofessional care. 2014;28(5):475-7. 32. Broderick MC, Coffey A. Person-centred care in nursing documentation. International journal of older people nursing. 2013;8(4):309-18. 33. Gachoud D, Albert M, Kuper A, Stroud L, Reeves S. Meanings and perceptions of patient-centredness in social work, nursing and medicine: a comparative study. Journal of interprofessional care. 2012;26(6):484-90. 34. Jangland E, Gunningberg L. Improving patient participation in a challenging context: a 2-year evaluation study of an implementation project. Journal of nursing management. 2017;25(4):266-75. 35. Alharbi TS, Olsson LE, Ekman I, Carlstrom E. The impact of organisational culture on the outcome of hospital care: after the implementation of personcentred care. Scandinavian journal of public health. 2014;42(1):104-10. 36. Tobiano G, Bucknall T, Marshall A, Guinane J, Chaboyer W. Nurses’ views of patient participation in nursing care. Journal of advanced nursing. 2015;71(12):2741-52. 37. Svanstrom R, Andersson S, Rosen H, Berglund M. Moving from theory to practice: experience of implementing a learning supporting model designed to increase patient involvement and autonomy in care. BMC research notes. 2016;9:361. 38. Sharp S, McAllister M, Broadbent M. The vital blend of clinical competence and compassion: How patients experience person-centred care. Contemporary nurse. 2016;52(2-3):300-12. 39. Wolf A, Moore L, Lydahl D, Naldemirci O, Elam M, Britten N. The realities of partnership in personcentred care: a qualitative interview study with patients and professionals. BMJ open. 2017;7(7):e016491. 40. Abdelhadi N, Drach-Zahavy A. Promoting patient care: work engagement as a mediator between ward service climate and patient-centred care. Journal of advanced nursing. 2012;68(6):1276-87. 41. Tobiano G, Bucknall T, Sladdin I, Whitty JA, Chaboyer W. Patient participation in nursing bedside handover: A systematic mixed-methods review. International journal of nursing studies. 2018;77:24358. 42. Nilsen P, Skagerstrom J, Ericsson C, Schildmeijer K. [Patient participation for safer health care - interviews with physicians and nurses]. Lakartidningen. 2017;114.

29. Alharbi TS, Carlstrom E, Ekman I, Jarneborn A, Olsson LE. Experiences of person-centred care - patients’ perceptions: qualitative study. BMC nursing. 2014;13:28. 30. McMurray A, Chaboyer W, Wallis M, Johnson J, Gehrke T. Patients’ perspectives of bedside nursing handover. Collegian (Royal College of Nursing, Australia). 2011;18(1):19-26.

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Science, Practice and Education DOI: 10.35279/jewma201905.07

Effectiveness and Safety of Patientcentred Care Compared to Usual Care for Patients with Pressure Ulcers in Inpatient Facilities: A Rapid Review Pressure ulcers are serious, costly and common adverse events that develop as a result of a combination of physiological factors and external conditions. This rapid review compares the clinical effectiveness, safety and cost-effectiveness of patient-centred care versus the usual care in pressure ulcer management.

ABSTRACT Background Pressure ulcers (PUs) are serious, costly and common adverse events that develop as a result of a combination of physiological factors and external conditions. In many cases they are avoidable.

Hypothesis/Aim The aim of this rapid review was to compare the clinical effectiveness, safety and cost-effectiveness of patient-centred care versus the usual care in PU management.

Miloslav Klugar PhD, Adjunct Associate Professor

randomisation. The second study showed that the patient-centred care was not as cost-effective for PU management. Zuzana Kelnarová Dr

Conclusions The results of these two high quality papers did not show the higher clinical effectiveness, safety or cost-effectiveness of patient-centred care when compared to usual care. Further research in countries other than Australia is necessary for a more detailed analysis of the clinical effectiveness, costeffectiveness and safety of patient-centred care for the prevention of PUs.

Methods A systematic search was undertaken using four databases. The paper selection, critical appraisal and data extraction were completed independently by two reviewers using standardised instruments. A meta-analysis was not possible, so the data were presented in a narrative format and by using a table summary based on the Grading of Recommendations, Assessment, Development and Evaluations approach.

Results/Findings In this search, 417 studies were identified, and two relevant high-quality papers were included: one randomised controlled trial (RCT) and one costeffectiveness study. Although the RCT showed approximately twice the PU incidence in the control group when compared to the intervention group (patient-centred care) and an even higher incidence of stage 1 PUs, the differences were not statistically significant after making adjustments to the cluster journal of the european wound management association 

Andrea Pokorná PhD, Professor

INTRODUCTION Pressure ulcers (PUs) are serious, mostly avoidable, costly and common adverse events that develop as a result of a combination of physiological factors and external conditions.1,2 Some of the factors influencing the PU incidence are the aging population and the increase in the number of elderly individuals living with disabilities. Learning how to manage PUs appropriately has become increasingly important for all wound care professionals.1 The time required to develop a PU depends on many factors, including the patient’s physiology, the degree of pressure and the shear force placed on the tissue.3 It also depends on the healthcare professionals’ ability to provide appropriate preventive measures. However, it has been reported that only 10.8% of the patients with PU development risks fully receive adequate prevention in bed and while sitting.4 More than 70% of the patients 

2019 vol 20 no 1

Jitka Klugarová PhD, Adjunct Associate Professor

Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech Evidence-Based Healthcare Centre: Joanna Briggs Institute Centre of Excellence, Masaryk University GRADE Centre), Institute of Biostatistics and Analyses, Faculty of Medicine, Masaryk University, Brno, Czech Republic

Correspondence: klugar@med.muni.cz Conflicts of Interest: None

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who are not at risk receive some PU prevention while lying or sitting.4 So, for many patients, the basic standard of preventive care is provided (including positioning, skin care and nutrition support). However, the PU development risk level is not taken into account in every case, and the management is not always sufficiently individualised. In the 2017 Organisation for Economic Cooperation and Development Health Ministerial Statement, the health ministers agreed on the importance of addressing health literacy barriers in order to help healthcare systems become more ‘person’-centred.5 Although there is no universally agreed upon definition of patient/person centred care (PCC), it is embedded within the paradigm of holism that views an individual as a biopsychosocial and physiological whole.6 The major objective of PCC is to achieve a working partnership between patients and their families in relation to the delivery of healthcare services.7 Health literacy is an important element of PCC because it supports individuals becoming partners in the co-production of their own health, and it optimises the quality of the interactions between individuals and healthcare systems. The literature shows that health literacy is positively associated with a better patient experience, improved selfcare practices and, at times, better health outcomes.7 For the management of PUs, health literacy is the degree to which individuals have the capacity to obtain, process and understand the basic health information about PU prevention, symptomatology and services that is needed to make appropriate health decisions. In this case, the patient’s involvement is crucial. PUs are considered to be some of the most preventable adverse events, but there is still a lack of information about comprehensive and appropriate prevention strategies, especially in relation to the PCC concept (individualised level). Several PU consequences for patients as well as healthcare systems in terms of costs have been described internationally. While focusing on the healthcare costs, various countries have included hospital acquired PU (HAPU) rates as a hospital performance indicator with subsequent financial penalties8, which assumes that staffing with skilled nurses can improve the healing rate with a reduced medical cost.810 However, none of the authors performed systematic/ rapid reviews in order to identify the value of PCC in PU management (both prevention and treatment). Thus, there is a need to perform a rapid review of this topic because systematic and rapid reviews are two types of studies that speed up evidence translation into practice.11,12 This review was approved as a rapid review, and it is registered in the PROSPERO International Prospective Register of Systematic Reviews. The record is published

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on PROSPERO websites under registration number CRD42019120926. The preliminary search was conducted using the MEDLINE, PROSPERO and Epistemonikos databases and platforms in order to establish whether any systematic or rapid reviews on this topic had been conducted. The search was performed in December of 2018, and no rapid or systematic reviews related to this issue were found. This review was conducted according to an a priori protocol that was published/registered in the PROSPERO database. METHODS This rapid review was developed with the following review question: What is the clinical effectiveness and safety of patient-centred care when compared to usual care for patients with PUs in inpatient facilities? This rapid review was developed based on the Joanna Briggs Institute (JBI) guidelines11, Cochrane Collaboration methodology12 and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.13 Inclusion and exclusion criteria (PICO format) Population: This review included adult patients at risk for PUs or with existing PUs in inpatient settings. Intervention and Comparison: This review included any type of PCC when compared to usual care for the management of PUs. Outcome: The outcomes of this review were the clinical effectiveness, cost-effectiveness and safety of the PU/injury management, which was mainly measured as the incidence of newly developed PUs and the direct costs of prevention and treatment. Study designs This review included experimental study designs [randomized controlled trials (RCTs) and quasi-RCTs] and cost-effectiveness studies. However, we also searched for observational analytical study designs (cohort, case-control and cross-sectional studies). Search strategy A three-step search strategy was used. Initial and limited searches of the Web of Science and Scopus were undertaken, followed by analyses of the keywords contained in the titles, abstracts and index terms used to describe an article. A second search using all of the identified keywords and index terms was undertaken across the Web of Science, Scopus, Ovid MEDLINE (R) and Cumulative

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Index to Nursing and Allied Health Literature (CINAHL) Complete databases (Appendix 1). Thirdly, the reference lists from the newly identified reports and articles were searched for additional studies. All of the studies with titles and abstracts in English were considered for inclusion, regardless of the language used in the body of the manuscript, and studies published between January 2014 and January 2019 were sought out. The PCC concept was first introduced by the European Pressure Ulcer Advisory Panel guidelines in 2014.14 Afterwards it was partially used in connection with a PU prevention and treatment wound care team review by the Cochrane Library that was published in 2014; however, that review had a different review question and different inclusion criteria than our review.15 Study records The literature search results were uploaded to EndNote X7 (Clarivate Analytics, Philadelphia, PA, USA). The titles and abstracts of the studies retrieved using the search strategy were screened independently by two review authors (AP and ZK) to identify the studies that potentially met the inclusion criteria outlined above. The full texts of these potentially eligible studies were retrieved and independently assessed for eligibility by two review team members (AP and ZK). Any disagreements between them over the eligibility of a particular study were resolved through discussion with a third reviewer (MK). Risk of bias The papers selected for retrieval were assessed by two independent reviewers (MK and JK) for their methodological quality prior to their inclusion in the rapid review. The assessments were conducted using standardised critical appraisal instruments from the JBI System for the Unified Management, Assessment and Review of Information (SUMARI).16 Any disagreements were resolved by discussion and through the consultation of a third reviewer (AP). Data extraction The data were independently extracted by two reviewers (AP and JK) from the studies included in the review using the standardised data extraction tools from the JBISUMARI. The extracted data included the following: the study setting, study population, participant demographics and baseline characteristics, details of the intervention and comparison, study methodology and outcomes relevant to the rapid review objectives. Any disagreements were resolved during the team discussions.

included, so a meta-analysis was not possible. The findings were presented in a narrative form, including tables and figures to aid in the data presentation where appropriate. Confidence in the evidence Based on the results and quality of the evidence, the Grading of Recommendations, Assessment, Development and Evaluations (GRADE).17,18 approach was used. The evidence quality was assessed across the risk of bias, consistency, directness, precision and publication bias domains. The quality was assessed as high (further research is very unlikely to change our confidence in the estimate of the effect), moderate (further research is likely to have an important impact on our confidence in the estimate of the effect, and it may change the estimate), low (further research is very likely to have an impact on our confidence in the estimate of the effect, and it is likely to change the estimate) or very low (very uncertain about the estimate of the effect). RESULTS The literature search was performed using four electronic databases, and a total of 417 studies were found. In the Scopus database, 136 studies were found, 129 were found in the Web of Science database, 54 were found in the Ovid Medline database and 101 were found in the CINAHL database (Fig. 1). There were 87 duplicates that were identified and removed. Two independent reviewers excluded 326 studies after the analyses of the titles and abstracts. Four full texts were independently reviewed, and two of them were excluded with reasons (Appendix 2). Finally, two relevant papers2,19 were critically appraised, and both were included in the review. Methodological quality The methodological quality was determined using the JBI Critical Appraisal Checklists for RCTs and Economic Evaluation. Two authors (MK and JK) independently appraised each paper, and there were no disagreements regarding the appraisal (Tables 1 and 2). The overall quality of both papers was high, and the risk of bias was low. Review findings Only one relevant RCT paper19 and one cost effectiveness paper2 were included in the review; however, both papers were based on one study with the same population sample (the RCT focused on the clinical perspective, while the cost effectiveness paper focused on the costs). The findings are presented in a narrative form, including tables and figures to aid in the data presentation where appropriate (Tables 3 and 5).

Data synthesis Only one RCT and one cost-effectiveness study were  journal of the european wound management association 

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Citations identified through systematic searching (n = 417) Duplicate citations removed (n = 87)

Articles excluded (n = 326)

Full text assessed for eligibility according to inclusion criteria (n = 4)

Articles excluded (n = 2)

CRITICAL APPRAISAL

Titles and abstracts screened (n = 330)

Studies included in critical appraisal (n = 2)

INCLUDED

PAPER RETRIEVAL

IDENTIFICATION

Figure 1. Study selection and inclusion process.20

Studies included in meta-analysis and narrative synthesis (n = 2)

Clinical effectiveness and PCC compared to usual care Only one RCT19 compared PCC with usual care by assessing the clinical effectiveness and safety of patients with PUs. Chaboyer et al.19 reported that the HAPU incidence in the control group was significantly higher when compared to the patient-centred PU prevention care bundle (PUPCB) group (Table 4). The PUPCB was theoretically and empirically based on patient participation and the clinical practice guidelines. There were multiple components, with three messages presented to the patients for PU prevention: keep moving, look after your skin and eat a healthy diet. The training aids for the patients included a DVD, brochure and poster. The nurses in the intervention hospitals were trained to partner with their patients in their PU prevention care. As part of the PUPCB, there were no special interventions used when compared to the standard preventive strategies. The main difference was in 64

the implementation of the preventive measures according to the patient’s degree of PU risk formation. Therefore, the precise risk stratification of the patients was the most important factor that influenced the preventive measures (positioning frequency, skin inspection frequency and healthy diet). A PUPCB consisting of multicomponent nurse training and patient education was mentioned above. However, the development of a HAPU did not differ statistically significantly between the intervention group, consisting of 49 patients (6.1%), and the control group, consisting of 84 patients (10.5%), after adjusting for clustering, but the control group had approximately twice the HAPU incidence of the PUPCB group (unadjusted hospital level data). There was no statistically significant effect of the PUPCB on the PU incidence at the participant level once the prognostic factors and clustering were accounted for.

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Table 1. Critical appraisal of the economic evaluation paper. Citation

Q1

Q2

Q3

Q4

Q5

Q6

Q7

Q8

Q9

Q10

Q11

TOTAL

Whitty et al.2 Y Y Y Y Y Y Y Y Y U Y 90

%

100 100 100 100 100 100 100 100 100 0 100

Y: yes, U: unclear

Q7 – Are the costs and outcomes adjusted for differential timing?

Q1 – Is there a well-defined question?

Q8 – Is there an incremental analysis of the costs and consequences?

Q2 – Is there a comprehensive description of alternatives?

Q9 – Were sensitivity analyses conducted to investigate uncertainty in the

Q3 – Are all of the important and relevant costs and outcomes for each

Q10 – Do the study results include all of the issues of concern to the

alternative identified?

estimates of the costs or consequences?

Q4 – Has clinical effectiveness been established?

users?

Q5 – Are the costs and outcomes measured accurately?

Q11 – Are the results generalizable to the setting of interest in the

Q6 – Are the costs and outcomes valued credibly?

review?

Table 2. Critical appraisal of the randomised controlled trial. Citation

Q1

Q2

Q3

Q4

Q5

Q6

Q7

Q8

Q9

Q10 Q11

Q12 Q13

TOTAL

Whitty et al.2 Y Y Y Y N/A Y Y Y Y Y Y Y Y 90 % 100

100 100 100 100 0 100 100 100 100 100 100 100 100

Y: yes, N/A: not applicable

Q1 – Was true randomization used for the assignment of the participants

analysed?

Q9 – Were the participants analysed in the groups to which they were

to treatment groups?

the groups in terms of their follow up adequately described and

Q2 – Was the allocation to the treatment groups concealed?

randomized?

Q3 – Were the treatment groups similar at the baseline?

Q10 – Were the outcomes measured in the same way for the treatment

Q4 – Were the participants blind to their treatment assignments?

groups?

Q5 – Were those delivering the treatments blind to the treatment

Q11 – Were the outcomes measured in a reliable way?

assignments?

Q12 – Was the appropriate statistical analysis used?

Q6 – Were the outcomes assessors blind to the treatment assignments?

Q13 – Was the trial design appropriate, and were any deviations from the

Q7 – Were the treatment groups treated identically other than in the

standard randomised controlled trial design (individual randomi-

zation, parallel groups) accounted for in the conduct and analysis

of the trial?

intervention of interest?

Q8 – Was the follow up complete; if not, were the differences between

The authors also reported a 52% reduction in the HAPU risk associated with the intervention when compared with usual care; however, this difference was not statistically significant. In addition, this trial showed a significantly higher incidence of stage 1 HAPUs in the PUPCB group (28 patients, 3.5%) when compared to the control group (60 patients, 7.5%) (Table 4). However, after adjusting for clustering, there was no significant difference between the intervention and control groups in the new PU severity. Moreover, the stage 2 incidence was almost the same between the intervention group (16 patients, 2.0%) and the control group (19 patients, 2.4%). With regard to unstageable HAPUs, 5 patients (0.6%) were identified in each group. journal of the european wound management association 

Cost-effectiveness of PCC compared to usual care Only one paper2 analysed the cost-effectiveness and cost benefits of PCC compared to usual care in patients with PU risks. This cost-effectiveness paper2 used the same population as the abovementioned RCT.19 The largest contributor to the prevention costs was related to the clinical nurses’ time required to reposition the patients or to inspect their skin. The intervention costs also contributed substantially in the PUPCB group. Whitty et al.2 found a significant difference between the groups in the costs associated with skin inspection, which were a

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Table 3. Data extraction from the included papers.

STUDY

CHABOYER ET AL.19

WHITTY ET AL.2

Type of paper

Randomised controlled trial (a cluster randomised trial)

Cost-effectiveness and cost-benefit study

Country

Australia

Australia

Participant characteristics

1,600 adults > 18 years old; medical and surgical patients at risk of pressure ulcers due to limited mobility; expected to stay in the hospital > 48 h; across eight tertiary hospital sites in Australia

1,600 adults >18 years old; medical and surgical patients at risk of pressure ulcer due to limited mobility; expected to stay in the hospital > 48 h; across eight tertiary hospital sites in Australia

Group descriptions and samples

Four clusters were randomised to each group, and 799 patients per group were analysed (intervention/control). Random number generating software was used to randomise the hospitals (clusters) within the strata with a random 1:1 block allocation of hospitals to the intervention or control groups. Pressure ulcers present at the baseline in 60 (7.7%) patients in the intervention group and 95 (12.0%) patients in the control group.

Four clusters were randomised to each group, and 799 patients per group were analysed. Random number generating software was used to randomise the hospitals (clusters) within strata with a random 1:1 block allocation of hospitals to the intervention or control groups. Pressure ulcers present at the baseline in 60 (7.7%) patients in the intervention group and 95 (12.0%) patients in the control group.

Outcomes measured

Primary outcomes were the incidence of hospital-acquired pressure ulcers measured in the cluster and the individual participant level by the daily skin inspection. Secondary outcomes were the severity of the hospital-acquired pressure ulcers classified according to the International Pressure Ulcer Classification System and the patient participation in the pressure ulcer prevention.

Cost-effectiveness analyses: Primary outcomes were the incremental costs of prevention per additional hospital-acquired pressure ulcer/incidence of a hospital acquired pressure ulcer of any stage versus the hospital-acquired pressure ulcer cases prevented, delay in developing a hospital-acquired pressure ulcer and the days free from hospital-acquired pressure ulcers versus the costs associated with the length of stay. Cost-benefit analyses: Primary outcomes were the costs of prevention and any difference in the length of stay and any day reduction in the length of stay with an Australian – Diagnosis Related Group.

Description of main results

The pressure ulcer prevention care bundle was associated with a large reduction in the hazard of ulceration (the difference was not statistically significant).

A pressure ulcer prevention care bundle consisting of multicomponent nurse training and patient education may promote best practice nursing care, but it may not be cost-effective for preventing hospital acquired pressure ulcers.

CHARACTERISTIC

mean of $44.27 more costly in the PUPCB group than the usual care group (p=0.014). The other PUPCB strategy products (keep moving and a healthy diet) contributed relatively little to the costs, but the time spent positioning the patient was higher in the intervention group (p=0.343). This paper2 also showed that the PUPCB was associated with an increased number of days free from PUs per participant (mean difference of 1.12 days per patient, 95% confidence interval of 0.34 to 1.82) (Table 5). However, 66

the PUPCB may be cost-effective when making reasonable assumptions about the willingness to pay thresholds for a PU prevented ($3.786). Based on the cost-benefit analysis, the PUPCB was significantly costlier for a significantly less benefit than usual care, suggesting that the PUPCB was not a cost-effective use of resources. In addition, the comparison of the lengths of stay (LOSs) confirmed that the PUPCB (mean LOS of 6 days) was not cost-effective when compared to the control group (mean LOS of 5

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Table 4. Summary of Findings. Clinical effectiveness and safety of patient/person-centred care compared to usual care. Patient/person-centred care compared to usual care (management of PUs) for adult patients with PU formation risks or with existing PUs in inpatient settings. Patient or population: adult patients with PU formation risks or with existing PUs in inpatient settings Setting: hospital/inpatient Intervention: patient/person-centred care Comparison: usual care (management of PU)

Anticipated absolute effects* (95% CI)

Explanations a. one grade down due to impressions b. one grade down due to publication bias

Relative effect (95%CI)

No of participants (studies)

Certainty of the evidence (GRADE)

61 per 1,000 (44 to 86)

RR 0.58 (0.42 to 0.82)

1,598 (1 RCT)

LOW ab

75 per 1,000

61 per 1,000 (44 to 86)

RR 0.45 (0.28 to 0.71)

1,598 (1 RCT)

LOW ab

Incidence of STAGE 2 HAPUs

24 per 1,000

61 per 1,000 (44 to 86)

RR 0.84 (0.44 to 1.63)

1,598 (1 RCT)

LOW ab

Incidence of unstageable HAPUs

6 per 1,000

6 per 1,000 (2 to 22)

RR 1.00 (0.29 to 3.44)

1,598 (1 RCT)

LOW ab

Outcomes

Risk with usual care (management of PU)

Risk with patient/ personcentred care

Incidence of new HAPUs

105 per 1,000

Incidence of STAGE 1 HAPUs

Comments

*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). PU: pressure ulcer, CI: confidence interval, RR: risk ratio, GRADE: Grading of Recommendations, Assessment, Development and Evaluations, HAPU: hospital-acquired pressure ulcer, RCT: randomized controlled trial

GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low certainty: We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of the effect.

days); even the exclusion of the outliers did not change the results (Table 5). DISCUSSION This rapid review identified only two relevant papers that conducted research using the same population. One paper described an RCT19 dealing with clinical effectiveness and one described cost-effectiveness and cost-benefit analyses.2 The RCT compared PCC with usual care, and the HAPU incidence was measured using the clinical standard skin inspection methods.19 The limitation of relying on the medical record documentation for the presence of a PU was overcome by the prospective and daily outcome assessments. Although the control group had almost twice the HAPU incidence when compared to the intervention group based on the analyses of the unadjusted data, if the data were adjusted to a hospital level, there was no statistically signifi-

cant effect of the intervention on the PU incidence at the participant level, once the prognostic factors and clustering were accounted for. However, as shown in Tables 4 and 5, due to the low level of events (respectively, participants in clusters), we used the GRADE approach to move one grade down due to the imprecision of the results. We also used the GRADE approach to move one more grade down due to the risk of publication bias of this rapid review; therefore, the level of evidence of this review was graded with low certainty in the outcomes. There were some differences in the baseline characteristics between the groups; for example, a lower number of patients were admitted from assisted living facilities in the intervention group. These patients were more likely to have neurological comorbidities, less likely to have cancer and less likely to have PUs at the baseline than the control group. Although the authors adjusted for these differences, they might have limited the results. î‚Š

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Table 5. Summary of Findings. Cost-effectiveness of patient/person-centred care compared to usual care. Patient/person-centred care compared to usual care (management of PUs) for adult patients with PU formation risks or with existing PUs in inpatient settings. Patient or population: adult patients with PU formation risks or with existing PUs in inpatient settings Setting: hospital/inpatient Intervention: patient/person-centred care Comparison: usual care (management of PU)

Anticipated absolute effects* (95% CI)

Explanations a. one grade down due to impressions b. one grade down due to publication bias

Relative effect (95%CI)

No of participants (studies)

Certainty of the evidence (GRADE)

The mean LOS in the intervention group was 2.67 days higher (1.22 higher to 4.7 higher)

-

1,598 (1 RCT)

LOW ab

The mean LOS (excluding outliers) was 7.41 days

The mean LOS (excluding outliers) in the intervention group was 1.12 days higher (0.39 higher to 4.7 higher)

-

1,598 (1 RCT)

LOW ab

Probability of avoiding a PU

The mean probability of avoiding a PU was 0.89

The mean probability of avoiding a PU in the intervention group was 0.04 higher (0.03 lower to 0.12 higher)

-

1,598 (1 RCT)

LOW ab

Days free of a PU

The mean days free of a PU was 5.23 days

The mean days free of a PU in the intervention group was 1.12 days higher (1.34 higher to 1.82 higher)

-

1,598 (1 RCT)

LOW ab

Outcomes

Risk with usual care (management of PU)

Risk with patient/ personcentred care

LOS

The mean LOS was 7.78 days

LOS (excluding outliers)

Comments

*The risk in the intervention group (and its 95% CI) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). PU: pressure ulcer, CI: confidence interval, RR: risk ratio, GRADE: Grading of Recommendations, Assessment, Development and Evaluations, HAPU: hospital-acquired pressure ulcer, RCT: randomized controlled trial

GRADE Working Group grades of evidence High certainty: We are very confident that the true effect lies close to that of the estimate of the effect. Moderate certainty: We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. Low certainty: Our confidence in the effect estimate is limited: The true effect may be substantially different from the estimate of the effect Very low certainty: We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of the effect.

This paper2 also showed that the intervention was associated with an increased number of days free from PUs per participant. The intervention may be cost-effective when making reasonable assumptions around the willingness to pay thresholds for a PU prevented; however, based on the cost-benefit analysis, the intervention was significantly costlier for significantly less benefit than usual care, suggesting that the care bundle was not a cost-effective use of resources. It is clear from this that it is very important to choose the patients on whom the PUPCB is used. The PUPCB is expensive for patients without PU risks; however, it is beneficial for patients with high PU risks.2,19 68

Although the findings were inconclusive, the PUPCB was based on the current best evidence, suggesting that it may be a tool that nurses can use to assist them in providing PCC. The main PUPCB roles should be seen in the nurse’s education as well as in patient training to help them better understand PUs or help them to participate in PU prevention. Study limitations This study was a rapid review designed to show the best available evidence in a rapid way. This was not as robust of a study design as a systematic review, which is the biggest

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Appendix 1. Search Strategy Web of Science 2.1.2019 8:01–8:27 in Title (last 5 years) #

SEARCH

Ovid MEDLIN(R) 1946 to January 02, 2018 2.1.2019 8:40–8:58 in Title (last 5 years) RESULTS

#

SEARCH

RESULTS

1. Patient-centered care

2.399

1. Patient-centered care

676

2. Patient-centred care

2.399

2. Patient-centred care

236

3. Person-centered care

459

3. Person-centered care

135

4. Person-centred care

459

4. Person-centred care

151

5. Wound*

14.049

5. Wound*

50.518

6. 1 OR 2 OR 3 OR 4 OR 5

16.824

6. 1 OR 2 OR 3 OR 4 OR 5

51.714

7. Pressure ulcer*

1.226

7. Pressure ulcer*

3.643

8. Pressure sore *

81

8. Pressure sore *

1.324

9. Pressure injur*

955

9. Pressure injur*

222

10. 5 OR 6 OR 7

2.142

11. 4 AND 8

129

10. 5 OR 6 OR 7 11. 4 AND 8 12. Poslednich 5 let

SEARCH

188 54

CINAHL Complete 3.1.2019 9:11–9:18 in Title (last 5 years)

Scopus 2.1.2019 8:28–8:48 in Title (last 5 years) #

5.176

RESULTS

#

SEARCH

RESULTS

1. Patient-centered care

2.421

1. Patient-centered care

1.440

2. Patient-centred care

2.421

2. Patient-centred care

454

3. Person-centered care

718

3. Person-centered care

361

4. Person-centred care

718

4. Person-centred care

449

5. Wound*

77.354

5. Wound*

20.181

6. 1 OR 2 OR 3 OR 4 OR 5

80.404

6. 1 OR 2 OR 3 OR 4 OR 5

22.831

7. Pressure ulcer*

5.358

7. Pressure ulcer*

5.219

8. Pressure sore *

1.800

8. Pressure sore *

865

9. Pressure injur*

3.322

9. Pressure injur*

1.429

10. 5 OR 6 OR 7

10.020

10. 5 OR 6 OR 7

7.155

11. 4 AND 8 12. Poslednich 5 let

381

11. 4 AND 8

535

136

12. Poslednich 5 let

101

limitation of this study, especially from the viewpoint of publication bias. Moreover, although they were the most relevant databases, only four databases of published studies were searched, while the databases of unpublished studies were not searched, so there is a small risk that some important studies could have been missed. CONCLUSION This rapid review identified only two relevant papers performed on the same population. One dealt with clinical effectiveness and one dealt with the cost-effectiveness and safety of PCC when compared to usual care in adults with PU development risks. The results of these two high quality papers did not prove the better clinical effectiveness, journal of the european wound management association 

safety and cost-effectiveness of PCC when compared to usual care. Therefore, further research performed in countries other than Australia is necessary for a more detailed analysis of the clinical effectiveness, cost-effectiveness and safety of PCC for PU prevention. IMPLICATIONS FOR CLINICAL PRACTICE In PCC, an individual’s specific health needs and desired health outcomes are the driving force behind all of the healthcare decisions and quality measurements. As with other forms of value-based healthcare, PCC for PU prevention and management requires shifts in the way that provider practices and healthcare systems are designed, managed and reimbursed. 

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FURTHER RESEARCH Future research from different healthcare systems (different standards of care provided by the nurses) should investigate the patient reported outcomes and PCC satisfaction with regard to PU and injury management, especially in high risk patients.

Acknowledgements This study was supported by the Ministry of Health of the Czech Republic, grant no. 15–29111A entitled “The register of Decubitus Ulcers – Integration Strategy for Monitoring and Preventive Interventions on the National Level. m

Moreover, there is a need to explore objective and valid tools for determining patient outcomes and evaluating their satisfaction with PU management.

REFERENCES 1. Boyko TV, Longaker MT, Yang GP. Review of the current management of pressure ulcers. Advances in Wound Care 2018; 7(2):57-67. Available from: PubMed 2. Whitty JA, McInnes E, Bucknall T, Webster J, Gillespie BM, Banks M, et al. The cost-effectiveness of a patient centred pressure ulcer prevention care bundle: Findings from the INTACT cluster randomised trial. International Journal of Nursing Studies 2017; 75:35-42. Available from: c8h 3. Gould L, Abadir P, Brem H, Carter M, Conner-Kerr T, Davidson J, et al. Chronic wound repair and healing in older adults: current status and future research. Wound Repair and Regeneration: Official Publication of the Wound Healing Society [and] the European Tissue Repair Society 2015; 23(1):1-13. Available from: PubMed 4. Vanderwee K, Defloor T, Beeckman D, Demarré L, Verhaeghe S, Van Durme T, et al. Assessing the adequacy of pressure ulcer prevention in hospitals: A nationwide prevalence survey. BMJ Quality & Safety 2011; 20(3):260-7. 5. Moreira L. Health literacy for people-centred care: Where do OECD countries stand? OECD Health Working Papers 2018; 107. 6. Ekman I, Wolf A, Olsson L, Taft C, Dudas K, Schaufelberger M, et al. Effects of person-centred care in patients with chronic heart failure: The PCC-HF study. European Heart Journal 2012; 33(9):1112-9. 7. Delaney JL. Patient-centred care as an approach to improving health care in Australia. Collegian 2018; 25(1):119-23.

8. Sanada H, Nakagami G, Mizokami Y, Minami Y, Yamamoto A, Oe M, et al. Evaluating the effect of the new incentive system for high-risk pressure ulcer patients on wound healing and cost-effectiveness: A cohort study. Int J Nurs Stud 2010 Mar; 47(3):27986.

16. Munn Z, Aromataris E, Tufanaru C, Stern C, Porritt K, Farrow J, et al. The development of software to support multiple systematic review types: The Joanna Briggs Institute System for the Unified Management, Assessment and Review of Information (JBI SUMARI). Int J Evid Based Healthc 2018;17(1):e36-43.

9. Beeckman D, Defloor T, Schoonhoven L, Vanderwee K. Knowledge and attitudes of nurses on pressure ulcer prevention: A cross-sectional multicenter study in Belgian hospitals. Worldviews Evid Based Nurs 2011 Sep; 8(3):166-76.

17. Munn Z, Porritt K, Aromataris E, Lockwood C, Peters M. Summary of findings tables for Joanna Briggs Institute systematic reviews. Adelaide: Joanna Briggs Institute 2014.

10. Pieper B, Zulkowski K. The Pieper-Zulkowski pressure ulcer knowledge test. Adv Skin Wound Care 2014 Sep; 27(9):413-9. 11. Joanna Briggs Institute. Joanna Briggs Institute reviewer’s manual. Adelaide: The Joanna Briggs Institute; 2017. 12. Higgins J, Thomas J, Cumpston M, Chandler J, Li T, Page M, et al. Cochrane handbook for systematic reviews of interventions version 6: DRAFT. London: The Cochrane Collaboration; 2019. 13. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. Open Med 2009; 3(3):e123-30. 14. National Pressure Ulcer Advisory Panel. Prevention and treatment of pressure ulcers: Quick reference guide. Osborne Park, Western Australia: Media C; 2014. 15. Moore ZEH, Webster J, Samuriwo R. Wound-care teams for preventing and treating pressure ulcers. Cochrane Database of Systematic Reviews 2014; 2014(3). Available from: Scopus C7 - CD011011

18. Schünemann H, Brożek J, Guyatt G, Oxman A. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. Hamilton: Updated October 2013. 19. 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 Studies 2016 Dec; 64:63-71. 20. Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement. PLoS Med 2009 Jul 21; 6(7):e1000097. 21. Kaitani T, Nakagami G, Sugama J, Tachi M, Matsuyama Y, Miyachi Y, et al. Evaluation of an advanced pressure ulcer management protocol followed by trained wound, ostomy, and continence nurses: A non-randomized controlled trial. Chronic Wound Care Management and Research 2015; 2:39-51.

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References: 1. Dowsett C, Hampton J, Myers D, Styche T. Use of PICO to improve clinical and economic outcomes in hard-to-heal wounds. Wounds International. 2017;8, p53–58 2. Kirsner R, Dove C, Reyzelman A, Vayser D, Jaimes H. Randomized controlled trial on the efficacy and acceptance of a single-use negative pressure wound therapy system versus traditional negative pressure wound therapy in the treatment of lower limb chronic ulcers (VLU and DFU). Poster 8 presented at Wild on Wounds National Wound Conference. September 12–15, 2018, Las Vegas, USA. 3. Sharpe A, Myers D, Searle R. Using single use negative pressure wound therapy for patients with complicated diabetic foot ulcers: an economic perspective. Wounds UK. 2018;14:80-84. Available at: Wounds  UK. *n=52 **n=161 ***n=4. ™Trademark of Smith & Nephew ©February 2019 Smith & Nephew. PICO 14 sNPWT is pending CE mark. 17411 GMC0775.


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Science, Practice and Education DOI: 10.35279/jewma201905.08

A Case Report: Pilonidal Sinus Management with Medical-Grade Honey

Renée Hermanns MR Bsc. Triticum Exploitatie BV

Due to its antimicrobial properties, medical-grade honey has shown to be effective in management of pilonidal sinus disease. This case report describes the potential therapeutic options of medical-grade honey for preventing infection and inducing wound healing.

ABSTRACT Background

Byron Rodrigues Nurse at Hospital da Luz – Clínica da Amadora, Portugal

Conclusions

Pilonidal sinus disease arises from folliculitis and is commonly resolved by surgery. The subsequent management of recovery is difficult and often a chronic state ensues, negatively affecting patient health. Conventional therapies are limited to providing antibiotics, which can impair the healing process. Medical-grade honey (MGH) addresses infection while improving wound healing.

The application of MGH has been shown to be highly effective, even in difficult area treatment that is at risk of infection.

Implication for clinical practice MGH should be considered as a first-line therapy for the management of pilonidal sinus wounds that show no signs of healing to prevent further delay in healing and to reduce impact on a patient’s life.

Aim We observed the use of MGH to determine its effectiveness in the management of chronic wound recovery following surgical excision.

Method A 23-year-old male received excisional surgery of a pilonidal sinus followed by primary closure. The wound dehisced 1 week later, and conventional treatment remained ineffective for 4 months. Healing stagnated as the wound continued to bleed, which adversely impacted the patient’s health and day-to-day activities. Hence, the treatment strategy was changed to monotherapy with daily application of MGH and standard dressing.

Results Wound depth was reduced by 93% within 16 weeks and infection was prevented successfully, without administration of antibiotics. The patient was able to resume day-to-day activities as the wound was tended on a self-care basis, visiting the hospital every other week for a follow-up examination until complete healing.

INTRODUCTION Pilonidal sinus disease (PSD1) refers to an inflammatory condition of the natal or inter-gluteal cleft. The prevalence of PSD is approximately 25–28 of every 100,000 individuals.1,2 It predominantly affects adolescent and young adult males between 15 and 30 years of age. Although the exact aetiology is yet to be elucidated, folliculitis is considered the cause of abscess and sinus formation and risk factors include familial history, hirsutism, a sedentary lifestyle, obesity, and local irritation.3,4 The introduction of loose hair to the sinus can also trigger a foreign body reaction, further reinforcing the inflammatory response and leading to the pathology of PSD.2,5 Studies have reported that patients with PSD generally experience pain, with an average lapse of 3–5 years from the time the first symptoms arise until the diagnosis.5 Whilst a single occurrence of a cyst can be easily managed via drainage and surgical incision, standardised guidelines for surgical techniques and post-surgical wound management are lack

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Correspondence: renee@mesitran.com Conflicts of Interest: The first author, Renée Hermanns, is an employee of Triticum Exploitatie BV which provided the medical grade honey formulation L-Mesitran that was used in this study free of charge. The author declares that there is no further conflict of interest.

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ing, complicating the successful treatment of chronic conditions.6-8 It is widely accepted that the ideal treatment method should lead to a low recurrence rate with minimum excision followed by a short hospitalisation time to allow the patient to return promptly to a normal lifestyle.6 Due to its location, however, the wound is at an increased risk for infection.7 Compared to other complications, infections are most frequently reported to interfere with the healing process and contribute to longer hospitalisation time and more frequent hospital visits.7,9 To control infection and reduce the risk of sepsis, conventional treatment includes the administration of systemic antibiotics to limit the bacterial load in the sinus.5 The presentation of clinical signs of a pilonidal abscess requires the excision of the infected cyst, which results in a wound that often presents drainage problems.10 This can cause the patient to experience an altered body image, low self-esteem, and embarrassment.11 Postoperative anxiety and depression are common outcomes, and studies have suggested that these might worsen in patients with prolonged recovery periods, which are frequently observed in PSD.1,4,12-14 Additionally, frequent hospital visits can result in a loss of work time, and day-to-day activities are often restricted, either due to pain and discomfort or the psychological toll the wound has on the patient and effect that this has on his relationships.5 Hence, the patient’s quality of health, comfort, and long-term psychological status following the surgical procedure are factors that should be considered when deciding on treatment aims. The lack of a clinical consensus or gold standard for a treatment strategy has led to the use of new modalities, including medical-grade honey (MGH)2 which has demonstrated particular potential both for the prevention and control of infection, as well as stimulation of the healing process.11 Within the medical community, the ongoing demand to employ effective healing agents in a setting where conventional methods such as common antimicrobials begin to fail, has led to a resurgence of this ancient natural substance.15-19 Honey harbours multiple essential modes of action that facilitate wound healing, such as promoting a moist wound environment and reducing inflammation and oedema. Furthermore, it exerts an antimicrobial effect because of its physicochemical properties and has previously been integrated in the management strategies of PSD and a diverse range of other wounds, from burns to chronic ulcers.2,20-22 This case report describes the use of MGH as a mode of treatment for PSD. Case Presentation A 23-year-old male patient was admitted for surgical excision and primary closure of a pilonidal sinus in August 74

2017. This was the first time the patient was diagnosed with PSD. Otherwise, he was in general good health but did have a history of asthma, which was controlled with budesonide (160 mcg) and formoterol fumarate dehydrate (4.5 mcg) per inhalation. The patient reported being allergic to azithromycin and denied smoking or alcoholic habits. On 4 September 2017, the patient returned for suture removal where wound dehiscence of approximately twothirds of the wound was observed. Daily lavage with saline was commenced, followed by application of a sterile compress dressing on the open wound. Progression was markedly slow, and the wound opened and bled easily throughout a timeframe of nearly four months. During this period, systemic antibiotic therapy was administered on two different occasions, consisting of amoxicillin and clavulanic acid. The prolonged unaltered state of the wound had a negative impact on the patient, who was further restricted in his daily activities because he had to visit the hospital daily. The negative experience stemming from the wound’s condition led to a change in the treatment strategy to include MGH products starting from 8 January 2018. From this point, data were collected in the form of wound measurements and photographs for which the patient consented. METHOD The wound was initially cleansed with saline, followed by the application of an MGH gel3 containing 40% honey and vitamin C and E along the length of the wound, covered with a hydrogel net dressing4 containing the same honey formulation rolled into the cavity. This was covered with a secondary compress and repeated daily. During the examination at week 6 post implementation of the new treatment regimen, the wound edges were gently mechanically debrided, and dressings were applied after cleansing. The same protocol was followed, and daily changes were maintained for 9 weeks. At week 15, the 40% honey gel was substituted for a 48% honey ointment5 from the same manufacturer. The regimen of daily dressing changes was changed to every other day which was maintained until the end of the six-month observation period. From week 22, the patient performed self care of the wound at home, and the wound was examined in the clinic once per week. RESULTS At the start of treatment, the wound measured 7.5 cm in length with a depth of 1.5 cm, and bled at the slightest manipulation (Figure 1 – A). At 6 weeks of treatment, the wound maintained a length of 7.5 cm but the depth was reduced by more than onehalf, to 0.6 cm (Fig. 1 – B). During the examination at 10

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weeks, the wound maintained the same length and became slightly more superficial, at 0.4 cm in depth, and less bleeding was observed on manipulation (Fig. 1 – C). After a full 14 weeks, clear improvement was visible (Fig. 1 – D) and the wound showed additional healthy granulation tissue

in week 15 (Fig. 1 – E); it was decided to apply a higher concentration of the MGH product. Following the change to 48% MGH at week 15, the wound presented closed areas along its length and measured 0.1 cm in depth at the examination at week 16 (Fig. 1 – F). This improvement 

Figure 1. Progression of the wound during the 6-month treatment at A) 1 week, B) 6 weeks, C) 10 weeks, D) 14 weeks, E) 15 weeks, F) 16 weeks, G) 19 weeks, and, finally, almost complete closure at H) 22 weeks.

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translated into a 93% decrease, as shown in Figure 2 below. At week 19, the wound presented with additional areas of closure along its length. A 1-cm opening remained at the cranial end and a 2-cm opening at the caudal end, both with granulation tissue and progressing towards closure

Effect of MGH on wound depth

Figure 3. Closed wound at 24 weeks on 20 June 2018.

Wounds deepth (cm)

2

1,5

1 60% 73%

0,5

93% 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Weeks Figure 2. Reduction of the wound depth following the initiation of medical-grade honey treatment, displaying a 60% reduction, 73% reduction, and 93% reduction when measured at 6, 10, and 16 weeks, respectively.

(Fig. 1 – G). Finally, at 22 weeks of treatment, the length of the wound was closed except for the 2-cm opening at the caudal end, which still presented with granulation tissue (Fig. 1 – H). From here, the patient was on a self-care routine at home, under careful instructions to maintain the dressing changes following personal hygiene. Due to the favourable evolution of the wound, from then onwards, the follow ups at the hospital were conducted once per week. During the last follow up 2 weeks later, the wound still presented as closed, except for the caudal end opening which continued to decrease in size (Fig. 3). DISCUSSION In the present case, the chronic pilonidal sinus wound responded very well to the MGH treatment employed when all other forms of management failed, including the initial attempt at surgical resolution. This result agrees well with existing literature on applying honey for the same condition, as well as for various other wound types.2,21 Due to the necessity for the wound to heal by second intention, it was crucial to prevent infection throughout the prolonged recovery process. Whereas the patient received antibiotics on multiple occasions before the honey treatment was ap76

plied, no systemic antibiotics were administered during the honey-based treatment and no signs of infection were observed throughout the 6-month documented time frame. This can be accredited to several potential mechanisms. Due its hygroscopic properties, honey provides an osmotic effect that stimulates autolytic debridement of the wound whilst maintaining an outward flow of wound exudate, thus preventing pathogens from entering the wound environment.23,24 Furthermore, the osmotic effect also applies to the content of bacterial cells, which dehydrate and die when honey is applied to the wound.25,26 Furthermore, honey possesses the enzyme glucose oxidase, which produces gradually increasing amounts of hydrogen peroxide as the honey is diluted with wound exudate. The production rate of this potent antimicrobial agent occurs disproportionally, depending on the dilution factor over time. It has been reported that the production of H2O2 varies among different types of honey and is not cytotoxic because the H2O2 concentration is roughly one thousand times lower than the 3% solution generally used as an antiseptic.24,27 Hydrogen peroxide has been found to stimulate fibroblasts and epithelial cells alike, as well as promote healing.28,29 Moreover, the continuous production of H2O2 from glucose oxidase has been found to be more effective than H2O2 added as a bolus.30 Likewise, the amount of endogenous H2O2 has been correlated with antibacterial activity.31,32 Frequent dressing changes might aid in the constant supply of hydrogen peroxide to the wound, which clinically translates into faster healing times witnessed in wounds treated with honey. 27,33-36 In addition to its antimicrobial properties, honey can exert immunomodulatory action on different immune cells, and its components influence the formation of reactive oxygen species (ROS6) produced by these cells. Honey’s anti-inflammatory actions can be explained by several mechanisms, including: 1) inhibition of the classical complement pathway; 2) inhibition of ROS formation; 3) inhibition of leukocyte infiltration; and 4) inhibition of cyclooxygenase-2 (COX-27) and inducible NO synthase expression.37-39

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Furthermore, several studies have described honey’s effect on epithelial growth because honey stimulates cell migration, proliferation, and collagen matrix production.24,36, 40 By changing to a higher concentration of MGH, the wound in this case presents rapid closure towards the end of the treatment that can be accredited to the augmentation of epithelialisation, as shown from April 26, 2018 onwards (Figure 1 – F-H). Another likely important contributor to the success of the treatment was the unique composition of the specific MGH product used for the patient presented in this case. L-Mesitran contains additional pro-healing elements, such as the antioxidant vitamins C and E. In many biological systems, vitamin C functions as the major protector of aqueous environments and vitamin E protects lipid membranes from free radical attack by providing electrons for oxidation.41 Studies have shown that vitamin E prevents ultraviolet (UV) irradiation-induced damage to the skin because it is depleted by UV irradiation.42 Upon oxidation by free radicals, vitamin E is regenerated in the membrane by vitamin C, which is present in a 200-fold greater concentration than vitamin E.43-47 Topical application of vitamins C and E protects the skin against UV-induced erythema and immunosuppression, photoaging changes and photocarcinogenesis in mice, inhibits melanogenesis and maintains epidermal barrier function.22,48-56 The photoprotective effects exerted by these two antioxidants have been found to increase four fold when applied together.57 In wound healing, this synergy is of equal value because it has been shown to enhance wound healing.53 Furthermore, vitamin C is essential in proper wound healing because it plays a critical role in collagen synthesis and maintenance of the collagen network by being an essential cofactor for enzymes crucial in collagen structure and cross-linking, improving the tensile strength of the skin.58-60 The effectiveness of the

L-Mesitran formulation has been documented in a range of diverse patient populations.23,61 CONCLUSION Due to its antimicrobial properties, MGH has been shown to be effective in preventing infection and inducing healing. Concerning wound healing, MGH should be considered a potential therapeutic option to reduce the prolonged or repeated use of antibiotics. Based on this case, it is suggested that MGH should be considered as a first-line modality when a wound is showing signs of delayed healing. IMPLICATIONS FOR CLINICAL PRACTICE - Infection remained absent during MGH treatment, suggesting that MGH might control and prevent infections effectively during pilonidal sinus management, which is further supported by the literature. - The immediate initiation of MGH treatment might aid in preventing chronic conditions and can result in a speedy recovery with minimal impact on the patient’s life. FURTHER RESEARCH Further research could investigate the management of surgical excision of a pilonidal sinus using MGH in a cohort of patients. m FOOTNOTES 1 PSD: pilonidal sinus disease 2 MGH: medical-grade honey 3 L-Mesitran Soft, Triticum Exploitatie BV, The Netherlands 4 L-Mesitran Net, Triticum Exploitatie BV, The Netherlands 5 L-Mesitran Ointment, Triticum Exploitatie BV, The Netherlands 6 ROS: reactive oxygen species 7 COX-2: cyclooxygenase-2

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6. Mustafi N, Engels P. Post-surgical wound management of pilonidal cysts with a haemoglobin spray: a case series. J Wound Care. 2016;25(4):191-2, 4-8.

11. Grant T. Treating pilonidal sinus wounds with an antibacterial wound gel after incision and drainage. Wounds UK. 2009;5(1):3.

7. Bascom J, Bascom T. Failed pilonidal surgery: new paradigm and new operation leading to cures. Arch Surg. 2002;137(10):1146-50.

12. Duman K, Ozdemir Y, Yucel E, Akin ML. Comparison of depression, anxiety and long-term quality of health in patients with a history of either primary closure or Limberg flap reconstruction for pilonidal sinus. Clinics (Sao Paulo). 2014;69(6):384-7.

8. Iesalnieks I, Ommer A, Petersen S, Doll D, Herold A. German national guideline on the management of pilonidal disease. Langenbecks Arch Surg. 2016;401(5):599-609. 9. Stauffer VK, Luedi MM, Kauf P, Schmid M, Diekmann M, Wieferich K, et al. Common surgical procedures in pilonidal sinus disease: A meta-analysis, merged data analysis, and comprehensive study on recurrence. Sci Rep. 2018;8(1):3058. 10. Berry DP, Harding KG. Treatment of natal cleft sinus. BMJ (Clinical research ed). 1992;305(6848):311-2.

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13. Khanna A, Rombeau JL. Pilonidal disease. Clin Colon Rectal Surg. 2011;24(1):46-53. 14. Marks J. HKG, Hughes L.E., Ribeiro C.D. Pilonidal sinus excision – healing by open granulation. Br J Surg. 2005;72(8):4. 15. Boekema BK, Pool L, Ulrich MM. The effect of a honey based gel and silver sulphadiazine on bacterial infections of in vitro burn wounds. Burns. 2013;39(4):754-9.

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Science, Practice and Education 16. Cooper RA, Halas E, Molan PC. The efficacy of honey in inhibiting strains of Pseudomonas aeruginosa from infected burns. J Burn Care Res. 2002;23(6):366-70. 17. Cooper RA, Molan PC, Harding KG. The sensitivity to honey of Gram-positive cocci of clinical significance isolated from wounds. J Appl Microbiol. 2002;93(5):857-63. 18. Cooper RA, Wigley P, Burton NF. Susceptibility of multiresistant strains of Burkholderia cepacia to honey. Lett Appl Microbiol. 2000;31(1):20-4. 19. Alam F, Islam MA, Gan SH, Khalil MI. Honey: a potential therapeutic agent for managing diabetic wounds. Evid Based Complement Alternat Med. 2014;2014:169130. 20. Stephen Haynes J, Callaghan R. Properties of honey: its mode of action and clinical outcomes. Wounds UK. 2011;7(1). 21. Molan P, Rhodes T. Honey: A Biologic Wound Dressing. Wounds. 2015;27(6):141-51. 22. Gensler HL, Magdaleno M. Topical vitamin E inhibition of immunosuppression and tumorigenesis induced by ultraviolet irradiation. Nutr Cancer. 1991;15(2):97-106. 23. Stephen Haynes J, Callaghan R. Properties of honey: its mode of action and clinical outcomes. Wounds UK. 2011;7(1). 24. White R, Molan P. A Summary of Published Clinical Research on Honey in Wound Management. In: White RJ, Cooper RA, Molan PC (eds.) Honey: A Modern Wound Management Product. Aberdeen, SCT: Wounds UK Publishing; 2005. p. 130-142. 25. Israili ZH. Antimicrobial properties of honey. Am J Ther. 2014;21(4):304-23. 26. Oryan A, Alemzadeh E, Moshiri A. Biological properties and therapeutic activities of honey in wound healing: A narrative review and meta-analysis. J Tissue Viability. 2016;25(2):98-118. 27. Dunford C. The use of honey-derived dressings to promote effective wound management. Prof Nurse (London, England). 2005;20(8):35-8. 28. Lusby PE, Coombes A, Wilkinson JM. Honey: a potent agent for wound healing? J Wound Ostomy Continence Nurs. 2002;29(6):295-300. 29. Tur E, Bolton L, Constantine BE. Topical hydrogen peroxide treatment of ischemic ulcers in the guinea pig: blood recruitment in multiple skin sites. J Am Acad Dermatol. 1995;33(2 Pt 1):217-21. 30. Pruitt KM, Tenovuo JO. The Lactoperoxidase System. New York, NY, USA: CRC Press; 1985. 31. White JW, Jr., Subers MH, Schepartz AI. The identification of inhibine, the antibacterial factor in honey, as hydrogen peroxide and its origin in a honey glucose-oxidase system. Biochim Biophys Acta Bioenerg. 1963;73:57-70. 32. Brudzynski K. Effect of hydrogen peroxide on antibacterial activities of Canadian honeys. Can J Microbiol. 2006;52(12):1228-37.

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33. Kamaratos AV, Tzirogiannis KN, Iraklianou SA, Panoutsopoulos GI, Kanellos IE, Melidonis AI. Manuka honey-impregnated dressings in the treatment of neuropathic diabetic foot ulcers. Int Wound J. 2014;11(3):259-63. 34. Postmes TJ, Bosch MMC, Dutrieux R, van Baare J, Hoekstra MJ. Speeding Up the Healing of Burns with Honey. In: Mizrahi A, Lensky Y, editors. Bee Products: Properties, Applications, and Apitherapy. Boston, MA: Springer US; 1997. p. 57-63. 35. Subrahmanyam M. Topical application of honey in treatment of burns. Br J Surg. 1991;78(4):497-8. 36. Molan PC. Re-introducing honey in the management of wounds and ulcers - theory and practice. Ostomy Wound Manage. 2002;48(11):28-40. 37. van den Berg AJ, van den Worm E, van Ufford HC, Halkes SB, Hoekstra MJ, Beukelman CJ. An in vitro examination of the antioxidant and anti-inflammatory properties of buckwheat honey. J Wound Care. 2008;17(4):172-4, 6-8. 38. Leong AG, Herst PM, Harper JL. Indigenous New Zealand honeys exhibit multiple anti-inflammatory activities. Innate Immun. 2012;18(3):459-66. 39. Hussein SZ, Mohd Yusoff K, Makpol S, Mohd Yusof YA. Gelam Honey Inhibits the Production of Proinflammatory, Mediators NO, , TNF-α, and IL-6 in Carrageenan-Induced Acute Paw Edema in Rats. J Evid Based Integr Med. 2012;2012:13. 40. Majtan J. Honey: an immunomodulator in wound healing. Wound Repair Regen. 2014;22(2):187-92. 41. Shindo Y, Witt E, Han D, Epstein W, Packer L. Enzymic and non-enzymic antioxidants in epidermis and dermis of human skin. J Invest Dermatol. 1994;102(1):122-4. 42. Thiele JJ, Traber MG, Packer L. Depletion of human stratum corneum vitamin E: an early and sensitive in vivo marker of UV induced photo-oxidation. J Invest Dermatol. 1998;110(5):756-61. 43. Chan AC. Partners in defense, vitamin E and vitamin C. Can J Physiol Pharmacol. 1993;71(9):725-31. 44. Halpner AD, Handelman GJ, Harris JM, Belmont CA, Blumberg JB. Protection by vitamin C of loss of vitamin E in cultured rat hepatocytes. Arch Biochem Biophys. 1998;359(2):305-9. 45. Hamilton IM, Gilmore WS, Benzie IF, Mulholland CW, Strain JJ. Interactions between vitamins C and E in human subjects. Br J Nutr. 2000;84(3):261-7. 46. Shindo Y, Witt E, Han D, Tzeng B, Aziz T, Nguyen L, et al. Recovery of antioxidants and reduction in lipid hydroperoxides in murine epidermis and dermis after acute ultraviolet radiation exposure. Photodermatol Photoimmunol Photomed. 1994;10(5):183-91. 47. Njus D, Kelley PM. Vitamins C and E donate single hydrogen atoms in vivo. FEBS Lett. 1991;284(2):14751.

ultraviolet radiation-induced damage. Br J Dermatol. 1992;127(3):247-53. 49. Nakamura T, Pinnell SR, Darr D, Kurimoto I, Itami S, Yoshikawa K, et al. Vitamin C abrogates the deleterious effects of UVB radiation on cutaneous immunity by a mechanism that does not depend on TNF-alpha. J Invest Dermatol. 1997;109(1):20-4. 50. Pasonen-Seppanen S, Suhonen TM, Kirjavainen M, Suihko E, Urtti A, Miettinen M, et al. Vitamin C enhances differentiation of a continuous keratinocyte cell line (REK) into epidermis with normal stratum corneum ultrastructure and functional permeability barrier. Histochem Cell Biol. 2001;116(4):287-97. 51. Ponec M, Weerheim A, Kempenaar J, Mulder A, Gooris GS, Bouwstra J, et al. The formation of competent barrier lipids in reconstructed human epidermis requires the presence of vitamin C. J Invest Dermatol. 1997;109(3):348-55. 52. Uchida Y, Behne M, Quiec D, Elias PM, Holleran WM. Vitamin C stimulates sphingolipid production and markers of barrier formation in submerged human keratinocyte cultures. J Invest Dermatol. 2001;117(5):1307-13. 53. Burke KE. Photodamage of the skin: protection and reversal with topical antioxidants. J Cosmet Dermatol. 2004;3(3):149-55. 54. Jurkiewicz BA, Bissett DL, Buettner GR. Effect of topically applied tocopherol on ultraviolet radiationmediated free radical damage in skin. J Invest Dermatol. 1995;104(4):484-8. 55. Record IR, Dreosti IE, Konstantinopoulos M, Buckley RA. The influence of topical and systemic vitamin E on ultraviolet light-induced skin damage in hairless mice. Nutr Cancer. 1991;16(3-4):219-25. 56. Roshchupkin DI, Pistsov MY, Potapenko AY. Inhibition of ultraviolet light-induced erythema by antioxidants. Arch Dermatol Res. 1979;266(1):91-4. 57. Lin JY, Selim MA, Shea CR, Grichnik JM, Omar MM, Monteiro-Riviere NA, et al. UV photoprotection by combination topical antioxidants vitamin C and vitamin E. J Am Acad Dermatol. 2003;48(6):866-74. 58. Vaxman F, Olender S, Lambert A, Nisand G, Grenier JF. Can the wound healing process be improved by vitamin supplementation? Experimental study on humans. Eur Surg Res. 1996;28(4):306-14. 59. Taylor TV, Rimmer S, Day B, Butcher J, Dymock IW. Ascorbic acid supplementation in the treatment of pressure-sores. Lancet. 1974;2(7880):544-6. 60. Kivirikko KI, Myllyla R. Post-translational processing of procollagens. Ann N Y Acad Sci. 1985;460:187201. 61. Smaropoulos E. PE, Netskos D., Gkikas O. Open Amputation in Preterm Neonatal Digits With Post-Operative Management Using Medical Grade Honey. J Pediatr Neonatal Care. 2017;3(125).

48. Darr D, Combs S, Dunston S, Manning T, Pinnell S. Topical vitamin C protects porcine skin from

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Cochrane Reviews

ABSTRACTS OF RECENT ­COCHRANE REVIEWS Publication in The Cochrane Library Issue 9, 2018

Protease activity as a prognostic factor for wound healing in venous leg ulcers Maggie J Westby, Jo C Dumville, Nikki Stubbs, Gill Norman, Jason KF Wong, Nicky Cullum, Richard D Riley Citation example: Westby MJ, Dumville JC, Stubbs N, Norman G, Wong JKF, Cullum N, Riley RD. Protease activity as a prognostic factor for wound healing in venous leg ulcers. Cochrane Database of Systematic Reviews 2018, Issue 8 . Art. No.: CD012841. DOI: 10.1002/14651858.CD012841.pub2. ABSTRACT Background: Venous leg ulcers (VLUs) are a common type of complex wound that have a negative impact on people’s lives and incur high costs for health services and society. It has been suggested that prolonged high levels of protease activity in the later stages of the healing of chronic wounds may be associated with delayed healing. Protease modulating treatments have been developed which seek to modulate protease activity and thereby promote healing in chronic wounds. Objectives: To determine whether protease activity is an independent prognostic factor for the healing of venous leg ulcers. Search methods: In February 2018, we searched the following databases: Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE, Ovid Embase and CINAHL. Selection criteria: We included prospective and retrospective longitudinal studies with any follow-up period that recruited people with VLUs and investigated whether protease activity in wound fluid was associated with future healing of VLUs. We included randomised controlled trials (RCTs) analysed as cohort studies, provided interventions were taken into account in the analysis, and case-control studies if there were no available cohort studies. We also included prediction model studies provided they reported separately associations of individual prognostic factors (protease activity) with healing. Studies of any type of protease or combination of proteases were eligible, including proteases from bacteria, and the prognostic factor could journal of the european wound management association 

be examined as a continuous or categorical variable; any cut-off point was permitted. The primary outcomes were time to healing (survival analysis) and the proportion of people with ulcers completely healed; the secondary outcome was change in ulcer size/rate of wound closure. We extracted unadjusted (simple) and adjusted (multivariable) associations between the prognostic factor and healing. Data collection and analysis: Two review authors independently assessed studies for inclusion at each stage, and undertook data extraction, assessment of risk of bias and GRADE assessment. We collected association statistics where available. No study reported adjusted analyses: instead we collected unadjusted results or calculated association measures from raw data. We calculated risk ratios when both outcome and prognostic factor were dichotomous variables. When the prognostic factor was reported as continuous data and healing outcomes were dichotomous, we either performed regression analysis or analysed the impact of healing on protease levels, analysing as the standardised mean difference. When both prognostic factor and outcome were continuous data, we reported correlation coefficients or calculated them from individual participant data.

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

We displayed all results on forest plots to give an overall visual representation. We planned to conduct metaanalyses where this was appropriate, otherwise we summarised narratively. Main results: We included 19 studies comprising 21 cohorts involving 646 participants. Only 11 studies (13 cohorts, 522 participants) had data available for analysis. Of these, five were prospective cohort studies, four were RCTs and two had a type of case-control design. Follow-up time ranged from four to 36 weeks. Studies covered 10 different matrix metalloproteases (MMPs) and two serine proteases (human neutrophil elastase and urokinase-type plasminogen activators). Two studies recorded complete healing as an outcome; other studies recorded partial healing measures. There was clinical and methodological heterogeneity across studies; for example, in the definition of healing, the type of protease and its measurement, the distribution of active and bound protease species, the types of treatment and the reporting of results. Therefore, metaanalysis was not performed. No study had conducted multivariable analyses and all included evidence was of 

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Correspondence: gill.rizzello@ manchester.ac.uk More information: www.wounds.cochrane.org Conflicts of interest: None

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very low certainty because of the lack of adjustment for confounders, the high risk of bias for all studies except one, imprecision around the measures of association and inconsistency in the direction of association. Collectively the research indicated complete uncertainty as to the association between protease activity and VLU healing. Authors’ conclusions: This review identified very low validity evidence regarding any association between protease activity and VLU healing and there is complete uncertainty regarding the relationship. The review offers information for both future research and systematic review methodology.

Plain language summary Protease activity and its association with future healing of venous leg ulcers What is the aim of this review?: The aim of this Cochrane Review was to find out if there is a link between different levels of protease in venous leg ulcers (open skin wounds on the lower leg caused by problems with the way blood flows through the veins) now and the healing of wounds at some time in the future. Protease is an enzyme, a chemical naturally produced by the body that breaks down proteins and which may affect wound healing. We wanted to know whether having higher protease levels meant that wounds were less likely to heal or to heal more slowly. If so, this could help find the most useful treatments for each person with a leg ulcer. Review authors from Cochrane collected and analysed all relevant studies to answer this question and found 19 studies. Key messages: At the moment, there is complete uncertainty about any association between protease activity and venous leg ulcer healing, but this review did give pointers on what may be important for future research on natural chemicals present in wounds and their effect on healing. What was studied in the review?: Venous leg ulcers can last weeks, months or years. Leg ulcers can be painful, may become infected, and may affect mobility and quality of life. The usual treatment for venous leg ulcers is compression therapy (e.g. compression (elastic) bandages), but even this does not work for everyone (about a third of people still have wounds that have not healed after six months). We wanted to find out why these wounds often do not heal, and whether there are factors in the wound (called biomarkers) that can indicate which wounds are unlikely to heal. It has been suggested that wounds are slow to heal when there are high levels of protease. In this review, we investigated whether there was any evidence that higher protease levels at the start of a study were associated with slower healing leg ulcers or less healing at a future time point (such as six months). In February 2018, we searched for relevant studies that had a reliable design and that investigated links between protease levels and future healing of venous leg ulcers. We found 19 studies involving 646 people. Not all studies reported the age and sex of participants. In those that did, the average age of the participants varied from 51 to 75 years. Eleven studies gave results we could use, involving 13 groups of people. Most people had wounds that had been there for at least three months. 80

What were the main results of the review?: There were many differences among the included studies: for example, how they defined healing, the type of proteases and how they measured them, the types of treatment and how they reported results. This lack of consistency meant we could not combine and compare the results, so we summarised the findings in a general way. A bigger problem was that none of the studies had analysed the data appropriately as they did not take into account the impact of age or infection or treatments, and so we could not be sure that it was the protease levels that were important for healing, rather than age or other factors. Most studies were small and could have been better conducted, so it was difficult to be sure how meaningful the results were. Overall, the certainty of the evidence was very low. Further studies are needed to explore the importance of biomarkers for wound healing. How up to date is this review?: We searched for studies that had been published up to February 2018.

Publication in The Cochrane Library Issue 10, 2018

Support surfaces for treating pressure ulcers Elizabeth McInnes, Asmara Jammali-Blasi, Sally EM Bell-Syer, Vannessa Leung Citation example: McInnes E, Jammali-Blasi A, Bell-Syer SEM, Leung V. Support surfaces for treating pressure ulcers. Cochrane Database of Systematic Reviews 2018, Issue 10 . Art. No.: CD009490. DOI: 10.1002/14651858.CD009490.pub2. ABSTRACT Background: Pressure ulcers are treated by reducing pressure on the areas of damaged skin. Special support surfaces (including beds, mattresses and cushions) designed to redistribute pressure, are widely used as treatments. The relative effects of different support surfaces are unclear. This is an update of an existing review. Objectives: To assess the effects of pressure-relieving support surfaces in the treatment of pressure ulcers. Search methods: In September 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 and EBSCO CINAHL Plus. 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: We included published or unpublished randomised controlled trials (RCTs), that assessed the effects of support surfaces for treating pressure ulcers, in any participant group or setting. Data collection and analysis: Data extraction, assessment of ‘Risk of bias’ and GRADE assessments were performed indepen-

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dently by two review authors. Trials with similar participants, comparisons and outcomes were considered for meta-analysis. Where meta-analysis was inappropriate, we reported the results of the trials narratively. Where possible, we planned to report data as either risk ratio or mean difference as appropriate. Main results: For this update we identified one new trial of support surfaces for pressure ulcer treatment, bringing the total to 19 trials involving 3241 participants. Most trials were small, with sample sizes ranging from 20 to 1971, and were generally at high or unclear risk of bias. Primary outcome: healing of existing pressure ulcers Low-tech constant pressure support surfaces It is uncertain whether profiling beds increase the proportion of pressure ulcer which heal compared with standard hospital beds as the evidence is of very low certainty: (RR 3.96, 95% CI 1.28 to 12.24), downgraded for serious risk of bias, serious imprecision and indirectness (1 study; 70 participants). There is currently no clear difference in ulcer healing between water-filled support surfaces and foam replacement mattresses: (RR 0.93, 95% CI 0.63 to 1.37); low-certainty evidence downgraded for serious risk of bias and serious imprecision (1 study; 120 participants). Further analysis could not be performed for polyester overlays versus gel overlays (1 study; 72 participants), non-powered mattresses versus low-air-loss mattresses (1 study; 20 participants) or standard hospital mattresses with sheepskin overlays versus standard hospital mattresses (1 study; 36 participants). High-tech pressure support surfaces: It is currently unclear whether high-tech pressure support surfaces (such as low-airloss beds, air suspension beds, and alternating pressure surfaces) improve the healing of pressure ulcers (14 studies; 2923 participants) or which intervention may be more effective. The certainty of the evidence is generally low, downgraded mostly for risk of bias, indirectness and imprecision. Secondary outcomes: No analyses were undertaken with respect to secondary outcomes including participant comfort and surface reliability and acceptability as reporting of these within the included trials was very limited. Overall, the evidence is of low to very low certainty and was primarily downgraded due to risk of bias and imprecision with some indirectness.

designed beds, mattresses or cushions can help to treat pressure ulcers. Researchers from Cochrane collected and analysed all relevant studies (randomised controlled trials) to answer this question, and found 19 relevant studies. Key messages: We cannot be certain which support surfaces are most effective for pressure ulcer treatment as the studies comparing them did not involve enough people and were not well designed. What was studied in the review?: Pressure ulcers (also called pressure sores, decubitus ulcers and bed sores) are wounds to the skin and underlying tissue caused by pressure or rubbing. They typically form at points on the body which are bony or which bear weight or pressure, such as the hips, buttocks, heels and elbows. People who have mobility problems or who lie in bed for long periods are at risk of developing pressure ulcers. A range of treatments, including wound dressings and support surfaces like special mattresses and cushions, are used to treat pressure ulcers. Support surfaces for pressure ulcer treatment can include specially-designed beds, mattresses, mattress overlays and cushions that are used to protect vulnerable parts of the body and distribute the surface pressure more evenly. Low-tech support surfaces include mattresses filled with foam, fluid, beads or air; and alternative foam mattresses and overlays. High-tech support surfaces include mattresses and overlays that are electrically powered to alternate the pressure within the surface, beds that are powered to have air mechanically circulated within them and low-air-loss beds that contain warm air moving within pockets inside the bed. Other support surfaces include sheepskins, cushions and operating table overlays. We wanted to find out which support surfaces were most effective in helping pressure ulcers to heal. We also wanted to compare different support surfaces in terms of cost, reliability, durability, and the benefits or harms for patients using them. What are the main results of the review?: In September 2017, we searched for trials looking at support surfaces for treating pressure ulcers and which reported their effects on wound healing. We found 19 trials involving 3241 participants, all adults, the majority of whom were older people and bed-bound in hospitals or nursing homes. In studies where participants’ sex was reported, the majority were women. Not all studies reported their funding sources, but two of those who did were funded by device manufacturers.

Support surfaces for treating pressure ulcers

Five studies involving 318 participants compared low-tech constant low-pressure (CLP) support surfaces such as foam mattresses. We cannot be certain how these different support surfaces affect pressure ulcer healing as the evidence is mainly of low certainty. Fourteen studies involving 2923 participants compared different high-tech support surfaces such as air-fluidised beds. Again, we cannot be certain how these different support surfaces affect ulcer healing rates as the certainty of the evidence is mainly low.

What is the aim of this review?: The aim of this review was to find out whether different support surfaces such as specially-

We are not able to draw firm conclusions about the effects of different support surfaces for treating pressure ulcers because

Authors’ conclusions: Based on the current evidence, it is unclear whether any particular type of low- or high-tech support surface is more effective at healing pressure ulcers than standard support surfaces.

Plain language summary

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the overall quality of the evidence is low to very low. Many of the studies included only small numbers of people, did not provide adequate information on their results, or were not well designed. Further, better conducted trials are necessary to determine which support surfaces are most effective in treating pressure ulcers.

Data collection and analysis: Two review authors independently performed study selection, risk of bias assessment and data extraction. Initial disagreements were resolved by discussion, or by including a third review author when necessary. We presented and analysed data separately for foot ulcers and postoperative wounds.

How up to date is this review?: We searched for studies that had been published up to September 2017.

Main results: Eleven RCTs (972 participants) met the inclusion criteria. Study sample sizes ranged from 15 to 341 participants. One study had three arms, which were all included in the review. The remaining 10 studies had two arms. Two studies focused on postamputation wounds and all other studies included foot ulcers in people with DM. Ten studies compared NPWT with dressings; and one study compared NPWT delivered at 75 mmHg with NPWT delivered at 125 mmHg. Our primary outcome measures were the number of wounds healed and time to wound healing.

Publication in The Cochrane Library Issue 10, 2018

Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus Zhenmi Liu, Jo C Dumville, Robert J Hinchliffe, Nicky Cullum, Fran Game, Nikki Stubbs, Michael Sweeting, Frank Peinemann Citation example: Liu Z, Dumville JC, Hinchliffe RJ, Cullum N, Game F, Stubbs N, Sweeting M, Peinemann F. Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus. Cochrane Database of Systematic Reviews 2018, Issue 10 . Art. No.: CD010318. DOI: 10.1002/14651858. CD010318.pub3. ABSTRACT Background: Foot wounds in people with diabetes mellitus (DM) are a common and serious global health issue. People with DM are prone to developing foot ulcers and, if these do not heal, they may also undergo foot amputation surgery resulting in postoperative wounds. Negative pressure wound therapy (NPWT) is a technology that is currently used widely in wound care. NPWT involves the application of a wound dressing attached to a vacuum suction machine. A carefully controlled negative pressure (or vacuum) sucks wound and tissue fluid away from the treated area into a canister. A clear and current overview of current evidence is required to facilitate decision-making regarding its use. Objectives: To assess the effects of negative pressure wound therapy compared with standard care or other therapies in the treatment of foot wounds in people with DM in any care setting. Search methods: In January 2018, for this first update of this review, 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 and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies, 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. We identified six additional studies for inclusion in the review. Selection criteria: Published or unpublished randomised controlled trials (RCTs) that evaluated the effects of any brand of NPWT in the treatment of foot wounds in people with DM, irrespective of date or language of publication. Particular effort was made to identify unpublished studies.

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NPWT compared with dressings for postoperative wounds Two studies (292 participants) compared NPWT with moist wound dressings in postoperative wounds (postamputation wounds). Only one study specified a follow-up time, which was 16 weeks. This study (162 participants) reported an increased number of healed wounds in the NPWT group compared with the dressings group (risk ratio (RR) 1.44, 95% confidence interval (CI) 1.03 to 2.01; low-certainty evidence, downgraded for risk of bias and imprecision). This study also reported that median time to healing was 21 days shorter with NPWT compared with moist dressings (hazard ratio (HR) calculated by review authors 1.91, 95% CI 1.21 to 2.99; low-certainty evidence, downgraded for risk of bias and imprecision). Data from the two studies suggest that it is uncertain whether there is a difference between groups in amputation risk (RR 0.38, 95% CI 0.14 to 1.02; 292 participants; very low-certainty evidence, downgraded once for risk of bias and twice for imprecision). NPWT compared with dressings for foot ulcers: There were eight studies (640 participants) in this analysis and follow-up times varied between studies. Six studies (513 participants) reported the proportion of wounds healed and data could be pooled for five studies. Pooled data (486 participants) suggest that NPWT may increase the number of healed wounds compared with dressings (RR 1.40, 95% CI 1.14 to 1.72; I² = 0%; low-certainty evidence, downgraded once for risk of bias and once for imprecision). Three studies assessed time to healing, but only one study reported usable data. This study reported that NPWT reduced the time to healing compared with dressings (hazard ratio (HR) calculated by review authors 1.82, 95% CI 1.27 to 2.60; 341 participants; low-certainty evidence, downgraded once for risk of bias and once for imprecision). Data from three studies (441 participants) suggest that people allocated to NPWT may be at reduced risk of amputation compared with people allocated to dressings (RR 0.33, 95% CI 0.15 to 0.70; I² = 0%; low-certainty evidence; downgraded once for risk of bias and once for imprecision). Low-pressure compared with high-pressure NPWT for foot ulcers One study (40 participants) compared NPWT 75 mmHg and NPWT 125 mmHg. Follow-up time was four weeks. There were no data on primary outcomes. There was no clear difference in

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the number of wounds closed or covered with surgery between groups (RR 0.83, 95% CI 0.47 to 1.47; very low-certainty evidence, downgraded once for risk of bias and twice for serious imprecision) and adverse events (RR 1.50, 95% CI 0.28 to 8.04; very low-certainty evidence, downgraded once for risk of bias and twice for serious imprecision). Authors’ conclusions: There is low-certainty evidence to suggest that NPWT, when compared with wound dressings, may increase the proportion of wounds healed and reduce the time to healing for postoperative foot wounds and ulcers of the foot in people with DM. For the comparisons of different pressures of NPWT for treating foot ulcers in people with DM, it is uncertain whether there is a difference in the number of wounds closed or covered with surgery, and adverse events. None of the included studies provided evidence on time to closure or coverage surgery, health-related quality of life or cost-effectiveness. The limitations in current RCT evidence suggest that further trials are required to reduce uncertainty around decision-making regarding the use of NPWT to treat foot wounds in people with DM.

Plain language summary Negative pressure wound therapy for treating foot wounds in people with diabetes mellitus What was the aim of this review?: We reviewed the evidence about whether or not negative pressure wound therapy (NPWT) is effective in treating foot wounds in people with diabetes. Researchers from Cochrane collected and analysed all relevant studies (randomised controlled trials; clinical studies where people are randomly put into one of two or more treatment groups) to answer this question and found 11 relevant studies. Key messages: We cannot be certain whether NPWT is effective for treating foot wounds in people with diabetes. There is some low-certainty evidence that NPWT increases the number of wounds healed compared with dressings, and may reduce the time it takes wounds to heal. We are uncertain about the effectiveness of different pressures of NPWT on wound healing. Overall, the reliability of the evidence provided by the trials is too low for us to be certain of the benefits and harms of NPWT for treating foot wounds in people with diabetes. What did the review study?: Diabetes mellitus is a common condition that leads to high blood glucose (blood sugar) concentrations, with around 2.8 million people affected in the UK (approximately 4.3% of the population). Some people with diabetes can develop ulcers on their feet. These wounds can take a long time to heal, they can be painful and become infected. Ulceration of the foot in people with diabetes can also lead to a higher risk of amputation of parts of the foot or leg. Generally, people with diabetes are at a higher risk of lower-limb amputation than people without diabetes. NPWT is a treatment currently being used for wounds including leg ulcers. NPWT involves the application of a wound dressing attached to a vacuum suction machine which sucks any wound and tissue fluid away from the treated area into a canister. Worldwide, the use of NPWT is increasing. However, it is expensive compared with wound treatments such as dressings.

We wanted to find out if NPWT could help foot wounds in people with diabetes to heal more quickly and effectively. We wanted to know if people treated with NPWT experienced any side effects. We were also interested in the impact of NPWT on people’s quality of life. What were the main results of the review?: In January 2018, we searched for randomised controlled trials that compared NPWT with other treatments for foot ulcers or other open wounds of the foot in people with diabetes. We found 11 trials involving 972 adults. Participant numbers in each trial ranged from 15 to 341 and trial follow-up (observation) times ranged from four weeks to 16 weeks where specified. Not all the studies stated how they were funded. Two were funded by an NPWT manufacturer. There is low-certainty evidence to suggest that NPWT may be effective in healing postoperative foot wounds and ulcers of the foot in people with diabetes compared with wound dressings, in terms of the proportion of wounds healed and time to healing. For the comparison of different pressures of NPWT for foot ulcers in people with diabetes, we are uncertain whether there is a difference in the number of wounds closed or covered with surgery, and side effects. There was no evidence available on time to closure or coverage surgery, health-related quality of life and cost-effectiveness. How up to date was this review?: We searched for studies that had been published up to January 2018.

Publication in The Cochrane Library Issue 12, 2018

Dressings and topical agents for preventing pressure ulcers Zena EH Moore, Joan Webster Citation example: Moore ZEH, Webster J. Dressings and topical agents for preventing pressure ulcers. Cochrane Database of Systematic Reviews 2018, Issue 12. Art. No.: CD009362. DOI: 10.1002/14651858.CD009362.pub3 ABSTRACT Background: Pressure ulcers, localised injuries to the skin or underlying tissue, or both, occur when people cannot reposition themselves to relieve pressure on bony prominences. These wounds are difficult to heal, painful, expensive to manage and have a negative impact on quality of life. Prevention strategies include nutritional support and pressure redistribution. Dressing and topical agents aimed at prevention are also widely used, however, it remains unclear which, if any, are most effective. This is the first update of this review, which was originally published in 2013. Objectives: To evaluate the effects of dressings and topical agents on pressure ulcer prevention, in people of any age, without existing pressure ulcers, but considered to be at risk of developing one, in any healthcare setting. 

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Search methods: In March 2017 we searched the Cochrane Wounds Group Specialised Register, CENTRAL, MEDLINE, MEDLINE (In-Process & Other Non-Indexed Citations), Embase, and EBSCO CINAHL Plus. We searched clinical trials registries for ongoing trials, and bibliographies of relevant publications to identify further eligible trials. There was no restriction on language, date of trial or setting. In May 2018 we updated this search; as a result several trials are awaiting classification. Selection criteria: We included randomised controlled trials that enrolled people at risk of pressure ulcers. Data collection and analysis: Two review authors independently selected trials, assessed risk of bias and extracted data. Main results: The original search identified nine trials; the updated searches identified a further nine trials meeting our inclusion criteria. Of the 18 trials (3629 participants), nine involved dressings; eight involved topical agents; and one included dressings and topical agents. All trials reported the primary outcome of pressure ulcer incidence. Topical agents : There were five trials comparing fatty acid interventions to different treatments. Two trials compared fatty acid to olive oil. Pooled evidence shows that there is no clear difference in pressure ulcer incidence between groups, fatty acid versus olive oil (2 trials, n=1060; RR 1.28, 95% CI 0.76 to 2.17; low-certainty evidence, downgraded for very serious imprecision; or fatty acid versus standard care (2 trials, n=187; RR 0.70, 95% CI 0.41 to 1.18; low-certainty evidence, downgraded for serious risk of bias and serious imprecision). Trials reported that pressure ulcer incidence was lower with fatty acid-containingtreatment compared with a control compound of trisostearin and perfume (1 trial, n=331; RR 0.42, 95% CI 0.22 to 0.80; low-certainty evidence, downgraded for serious risk of bias and serious imprecision). Pooled evidence shows that there is no clear difference in incidence of adverse events between fatty acids and olive oil (1 trial, n=831; RR 2.22 95% CI 0.20 to 24.37; low-certainty evidence, downgraded for very serious imprecision). Four trials compared further different topical agents with placebo. Dimethyl sulfoxide (DMSO) cream may increase the risk of pressure ulcer incidence compared with placebo (1 trial, n=61; RR 1.99, 95% CI 1.10 to 3.57; low-certainty evidence; downgraded for serious risk of bias and serious imprecision). The other three trials reported no clear difference in pressure ulcer incidence between active topical agents and control/placebo; active lotion (1 trial, n=167; RR 0.73, 95% CI 0.45 to 1.19), Conotrane (1 trial, n=258; RR 0.74, 95% CI 0.52 to 1.07), Prevasore (1 trial, n=120; RR 0.33, 95% CI 0.04 to 3.11) (very low-certainty evidence, downgraded for very serious risk of bias and very serious imprecision). There was limited evidence from one trial to determine whether the application of a topical agent may delay or prevent the development of a pressure ulcer (DermalexTM 9.8 days vs placebo 8.7 days). Further, two out of 76 reactions occurred in the DermalexTM group compared with none out of 91 in the placebo group (RR 6.14, 95% CI 0.29 to 129.89; very low-certainty evidence; downgraded for very serious risk of bias and very serious imprecision).

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Dressings: Six trials (n = 1247) compared a silicone dressing with no dressing. Silicone dressings may reduce pressure ulcer incidence (any stage) (RR 0.25, 95% CI 0.16 to 0.41; low-certainty evidence; downgraded for very serious risk of bias). In the one trial (n=77) we rated as being at low risk of bias, there was no clear difference in pressure ulcer incidence between silicone dressing and placebo-treated groups (RR 1.95, 95% CI 0.18 to 20.61; low-certainty evidence, downgraded for very serious imprecision). One trial (n=74) reported no clear difference in pressure ulcer incidence when a thin polyurethane dressing was compared with no dressing (RR 1.31, 95% CI 0.83 to 2.07). In the same trial pressure ulcer incidence was reported to be higher in an adhesive foam dressing compared with no dressing (RR 1.65, 95% CI 1.10 to 2.48). We rated evidence from this trial as very low certainty (downgraded for very serious risk of bias and serious imprecision). Four trials compared other dressings with different controls. Trials reported that there was no clear difference in pressure ulcer incidence between the following comparisons: polyurethane film and hydrocolloid dressing (n=160, RR 0.58, 95% CI 0.24 to 1.41); Kang’ huier versus routine care n=100; RR 0.42, 95% CI 0.08 to 2.05); ‘pressure ulcer preventive dressing’ (PPD) versus no dressing (n=74; RR 0.18, 95% CI 0.04 to 0.76) We rated the evidence as very low certainty (downgraded for very serious risk of bias and serious or very serious imprecision). Authors’ conclusions: Most of the trials exploring the impact of topical applications on pressure ulcer incidence showed no clear benefit or harm. Use of fatty acid versus a control compound (a cream that does not include fatty acid) may reduce the incidence of pressure ulcers. Silicone dressings may reduce pressure ulcer incidence (any stage). However the low level of evidence certainty means that additional research is required to confirm these results.

Plain language summary Dressings and topical agents (creams or lotions) for preventing pressure ulcers Review question: We reviewed the evidence about whether dressings and topical agents, like creams, can prevent pressure ulcers. Background: Pressure ulcers, also known as bed sores or pressure sores, are injuries to the skin or tissue underneath, or both. They develop as a result of sustained pressure on bony parts of the body. They are common among elderly people and those with mobility problems. They are often difficult to heal, expensive to treat and have a negative impact on people’s quality of life, so it is important to prevent them. Special mattresses, cushions, and regular changes of position are used for prevention. Dressings and creams are also widely used. We wanted to compare different dressings and topical agents and find out which were best at preventing pressure ulcers in people at risk of developing them. We also wanted to consider other outcomes, like pain, quality of life, and the cost to healthcare systems of the different treatments.

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Trial characteristics: In order to ensure that the information contained within this review is up to date, in March 2017 we searched for any new randomised controlled trials (RCTs) that compared dressings and/or topical agents with other methods for preventing pressure ulcers. RCTs are medical studies where patients are chosen at random to receive different treatments. This type of trial provides the most reliable evidence. This is the first time we have updated this review. We found nine RCTs, giving us a total of 18 relevant trials. These trials included 3629 adults, mainly elderly people, though some included younger adults with mobility-limiting injuries. Products tested included fatty acid (fatty acids come from animal and vegetable fats and oils and are used to moisten the skin), creams and dressings made with silicone or foam.

Objectives: To assess the effects of different provider-orientated interventions targeted at the organisation of health services, on the prevention and treatment of pressure ulcers.

Key results: The results of six trials suggest that silicone dressings may reduce the likelihood of people developing pressure ulcers . However, we were uncertain about the evidence from five of these trials because they used poor methods, so we cannot be confident about these results. We also found that use of fatty acid versus a control compound (a cream that does not include fatty acid) may reduce the incidence of pressure ulcers, but results from this trial were uncertain. None of the other comparisons involving topical agents provided conclusive evidence that they make it less likely that people will develop a pressure ulcer.

Selection criteria: Randomised controlled trials (RCTs), clusterRCTs, non-RCTs, controlled before-and-after studies and interrupted time series, which enrolled people at risk of, or people with existing pressure ulcers, were eligible for inclusion in the review.

Quality of the evidence: The certainty of the evidence in the trials was low to very low. Additional trials at low risk of bias are needed to clarify the effect of dressings and topical agents in preventing pressure ulcers. We searched for trials that had been published up to March 2017.

Publication in The Cochrane Library Issue 12, 2018

Organisation of health services for preventing and treating pressure ulcers Pauline Joyce, Zena EH Moore, Janice Christie Citation example: Joyce P, Moore ZEH, Christie J. Organisation of health services for preventing and treating pressure ulcers. Cochrane Database of Systematic Reviews 2018, Issue 12. Art. No.: CD012132. DOI: 10.1002/14651858.CD012132.pub2. ABSTRACT Background: Pressure ulcers, which are a localised injury to the skin, or underlying tissue, or both, occur when people are unable to reposition themselves to relieve pressure on bony prominences. Pressure ulcers are often difficult to heal, painful, expensive to manage and have a negative impact on quality of life. While individual patient safety and quality care stem largely from direct healthcare practitioner-patient interactions, each practitioner-patient wound-care contact may be constrained or enhanced by healthcare organisation of services. Research is needed to demonstrate clearly the effect of different provider-orientated approaches to pressure ulcer prevention and treatment.

Search methods: In April 2018 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 and EBSCO CINAHL Plus. We also searched three 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.

Data collection and analysis: Two review authors independently performed study selection, risk of bias assessment, data extraction and GRADE assessment of the certainty of evidence. Main results: The search yielded a total of 3172 citations and, following screening and application of the inclusion and exclusion criteria, we deemed four studies eligible for inclusion. These studies reported the primary outcome of pressure ulcer incidence or pressure ulcer healing, or both. One controlled before-and-after study explored the impact of transmural care (a care model that provided activities to support patients and their family/partners and activities to promote continuity of care), among 62 participants with spinal cord injury. It is unclear whether transmural care leads to a difference in pressure ulcer incidence compared with usual care (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.53 to 1.64; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). One RCT explored the impact of hospital-in-the-home care, among 100 older adults. It is unclear whether hospital-in-thehome care leads to a difference in pressure ulcer incidence risk compared with hospital admission (RR 0.32, 95% CI 0.03 to 2.98; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). A third study (cluster-randomised stepped-wedge trial), explored the impact of being cared for by enhanced multidisciplinary teams (EMDT), among 161 long-term-care residents. The analyses of the primary outcome used measurements of 201 pressure ulcers from 119 residents. It is unclear if EMDT reduces the pressure ulcer incidence rate compared with usual care (hazard ratio (HR) 1.12, 95% CI 0.74 to 1.68; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear whether there is a difference in the number of wounds healed (RR 1.69, 95% CI 1.00 to 2.87; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear whether there is a difference in the reduction in surface area, with and without EMDT, (healing rate 1.006; î‚Š

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95% CI 0.99 to 1.03; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear if EMDT leads to a difference in time to complete healing (HR 1.48, 95% CI 0.79 to 2.78, very lowcertainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). The final study (quasi-experimental cluster trial), explored the impact of multidisciplinary wound care among 176 nursing home residents. It is unclear whether there is a difference in the number of pressure ulcers healed between multidisciplinary care, or usual care (RR 1.18, 95% CI 0.98 to 1.42; very low-certainty evidence, downgraded twice for very serious study limitations and twice for very serious imprecision). It is unclear if this type of care leads to a difference in time to complete healing compared with usual care (HR 1.73, 95% CI 1.20 to 2.50; very low-certainty evidence; downgraded twice for very serious study limitations and twice for very serious imprecision). In all studies the certainty of the evidence is very low due to high risk of bias and imprecision. We downgraded the evidence due to study limitations, which included selection and attrition bias, and sample size. Secondary outcomes, such as adverse events were not reported in all studies. Where they were reported it was unclear if there was a difference as the certainty of evidence was very low. Authors’ conclusions: Evidence for the impact of organisation of health services for preventing and treating pressure ulcers remains unclear. Overall, GRADE assessments of the evidence resulted in judgements of very low-certainty evidence. The studies were at high risk of bias, and outcome measures were imprecise due to wide confidence intervals and small sample sizes, meaning that additional research is required to confirm these results. The secondary outcomes reported varied across the studies and some were not reported. We judged the evidence from those that were reported (including adverse events), to be of very low certainty.

Plain language summary Organisation of health services for preventing and treating pressure ulcers What is the aim of this review? The aim of this review was to find out whether the way in which health services are organised can affect prevention and treatment of pressure ulcers. Cochrane researchers collected and analysed all relevant studies to answer this question and found four relevant studies. Key messages: We cannot be certain whether transmural care (a way of providing care that delivers activities to support patients and their family/partners, and activities to promote continuity of care), hospital-in-the-home care, care provided by a team of different disciplines or care that is usually provided, make any difference to whether people develop pressure ulcers, how fast existing ulcers heal, or whether people with ulcers are admitted or readmitted to hospital. What was studied in the review?: Pressure ulcers, sometimes known as bedsores or pressure sores, are injuries that develop as

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a result of continued pressure on bony parts of the body such as the hips, heels or lower back. It is thought that the way health services are organised can influence the development of pressure ulcers among people at risk, and may also influence the healing of these wounds. Care can be delivered to people with pressure ulcers in various ways. We wanted to find out whether different types of care delivery affected the number of people developing pressure ulcers and how fast existing ulcers healed. What are the main results of the review?: We found four studies dating from 1999 to 2014, that compared alternative types of care delivery to the way care is usually provided. The mean number of participants in the studies was 140, and the ages of participants ranged from 36.5 years to 83 years. In the studies 198 participants were men and 301 were women. All studies were funded by government agencies. Two studies focused on prevention of pressure ulcers, one on prevention and treatment, and one on treatment only. It is unclear whether any alternative type of care delivery is better than care that is usually provided at reducing risk of pressure ulcers, or improving pressure ulcer healing. It is also unclear whether the way healthcare services are organised improves quality of life, patient and staff satisfaction, reduces hospital admissions, emergency room visits, or death at 28 days. This is because we are very uncertain about the evidence in all studies. This Plain language summary is up to date as of 18 April 2018.

Publication in The Cochrane Library Issue 1, 2019

Risk assessment tools for the prevention of pressure ulcers Zena EH Moore, Declan Patton Citation example: Moore ZEH, Patton D. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database of Systematic Reviews 2019 , Issue 1 . Art. No.: CD006471. DOI: 10.1002/14651858.CD006471.pub4. Abstract Background: Use of pressure ulcer risk assessment tools or scales is a component of the assessment process used to identify individuals at risk of developing a pressure ulcer. Use of a risk assessment tool is recommended by many international pressure ulcer prevention guidelines, however it is not known whether using a risk assessment tool makes a difference to patient outcomes. We conducted a review to provide a summary of the evidence pertaining to pressure ulcer risk assessment in clinical practice, and this is the third update of this review. Objectives: To assess whether using structured and systematic pressure ulcer risk assessment tools, in any healthcare setting, reduces the incidence of pressure ulcers. Search methods: In February 2018 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of

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Cochrane Reviews

Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase; and EBSCO CINAHL Plus. 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: Randomised controlled trials (RCTs) comparing the use of structured and systematic pressure ulcer risk assessment tools with no structured pressure ulcer risk assessment, or with unaided clinical judgement, or RCTs comparing the use of different structured pressure ulcer risk assessment tools. Data collection and analysis. Two review authors independently performed study selection, data extraction, ‘Risk of bias’ assessment and GRADE assessment of the certainty of evidence. Main results: We included two studies in this review (1,487 participants). We identified no new trials for this latest update. Both studies were undertaken in acute-care hospitals. In one study, patients were eligible if they had a Braden score of 18 or less. In the second study all admitted patients were eligible for inclusion, once they were expected to have a hospital stay of more than three days and they had been in hospital for no more than 24 hours before baseline assessment took place. In the first study, most of the participants were medical patients; no information on age or gender distribution was provided. In the second study, 50.3% (619) of the participants were male, with a mean age of 62.6 years (standard deviation (SD): 19.3), and 15.4% (190) were admitted to oncology wards.

to 1.90; 821 participants; stage 2 pressure ulcers: RR 1.25, 95% CI 0.50 to 3.13; 821 participants), or risk assessment using the Ramstadius tool (pressure ulcers of all stages: RR 1.41, 95% CI 0.83 to 2.39; 821 participants; stage 1 pressure ulcers: RR 1.16, 95% CI 0.63 to 2.15; 821 participants; stage 2 pressure ulcers: RR 2.49, 95% CI 0.79 to 7.89; 821 participants). Similarily, risk assessment using the Ramstadius tool may make little or no difference to pressure ulcer incidence, or to pressure ulcer severity, when compared to risk assessment using clinical judgement (pressure ulcers of all stages: RR 0.79, 95% CI 0.46 to 1.35; 820 participants; stage 1 pressure ulcers: RR 0.90, 95% CI 0.48 to 1.68; 820 participants; stage 2 pressure ulcers: RR 0.50, 95% CI 0.15 to 1.65; 820 participants). We assessed the certainty of the evidence as low (downgraded once for study limitations and once for imprecision). The studies did not report the secondary outcomes of time to ulcer development, or pressure ulcer prevalence. Authors’ conclusions: We identified two studies which evaluated the effect of risk assessment on pressure ulcer incidence. Based on evidence from one study, we are uncertain whether risk assessment using the Braden tool makes any difference to pressure ulcer incidence, compared with training and risk assessment using clinical judgement, or risk assessment using clinical judgement alone. Risk assessment using the Waterlow tool, or the Ramstadius tool may make little or no difference to pressure ulcer incidence, or severity, compared with clinical judgement. The low, or very low certainty of evidence available from the included studies is not reliable enough to suggest that the use of structured and systematic pressure ulcer risk assessment tools reduces the incidence, or severity of pressure ulcers.

Plain language summary Risk assessment tools used for preventing pressure ulcers

The two included studies were three-armed studies. In the first study the three groups were: Braden risk assessment tool and training (n = 74), clinical judgement and training (n = 76) and clinical judgement alone (n = 106); follow-up was eight weeks. In the second study the three groups were: Waterlow risk assessment tool (n = 411), clinical judgement (n = 410) and Ramstadius risk assessment tool (n = 410); follow-up was four days. Both studies reported the primary outcome of pressure ulcer incidence and one study also reported the secondary outcome, severity of new pressure ulcers. We are uncertain whether use of the Braden risk assessment tool and training makes any difference to pressure ulcer incidence, compared to risk assessment using clinical judgement and training (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.53 to 1.77; 150 participants), or compared to risk assessment using clinical judgement alone (RR 1.43, 95% CI 0.77 to 2.68; 180 participants). We assessed the certainty of the evidence as very low (downgraded twice for study limitations and twice for imprecision). Risk assessment using the Waterlow tool may make little or no difference to pressure ulcer incidence, or to pressure ulcer severity, when compared to risk assessment using clinical judgement (pressure ulcers of all stages: RR 1.10, 95% CI 0.68 to 1.81; 821 participants; stage 1 pressure ulcers: RR 1.05, 95% CI 0.58

What is the aim of this review?: The aim of this review was to find out what effect the use of risk assessment tools has on the development of new pressure ulcers, among people at risk of pressure ulcer development. Many different pressure ulcer risk assessment tools are used in clinical practice and it is not known which one is the best. Researchers from Cochrane collected and analysed all relevant studies (randomised controlled trials) to answer this question and found two relevant studies. Key messages: We cannot be certain whether the use of a risk assessment tool makes any difference to the number of new pressure ulcers that develop among people who are at risk. The certainty of evidence ranged from low to very low. What was studied in the review?: Pressure ulcers (also known as bed sores, pressure sores, pressure injuries and decubitus ulcers) are areas of localised injury to the skin and underlying tissue, usually over a bony part of the body such as the hip or heel. These ulcers develop as a result of pressure, or pressure in combination with shear forces (squeezing and stretching soft tissues between bony structures and the skin). Pressure ulcers mainly occur in people who have limited mobility or nerve damage, such as older people, people with spinal injuries, or long-term hospital patients. Pressure ulcer risk assessment is part of the process used to identify individuals at risk of developing a pres

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Cochrane Reviews

sure ulcer. Use of a risk assessment tool is recommended by many international guidelines on pressure ulcer prevention. Different tools are used for pressure ulcer risk assessment. We wanted to find out which is the most effective in preventing pressure ulcers from developing. We also wanted to find out which risk assessment tools reduced the time for a pressure ulcer to develop and the severity of the pressure ulcer. What are the main results of the review?: We found two relevant studies, dating from 2009 and 2011. Both of the included studies had three arms. One study compared Braden risk assessment and training, to training and risk assessment using clinical judgement, or risk assessment using clinical judgement alone. The second study compared Waterlow risk assessment to Ramstadius risk assessment, or risk assessment using clinical judgement. The studies involved 1,487 people at risk of developing pressure ulcers. In the first study, no information was provided on age or gender distribution. In the second study, 50.3% (619) of the participants were male, with an average age of 62.6 years. The first study did not state any source of funding. The second study was funded by research grants from the Queensland Nursing Council, the Royal Brisbane and Women’s Hospital Private Practice Fund, the Royal Brisbane and Women’s Hospital Research Foundation and a Queensland Health Nursing

Research Grant: We cannot be certain whether use of a risk assessment tool makes any difference to the prevention of pressure ulcers, compared with the use of clinical judgement. The results of the studies did not show differences in the number of pressure ulcers that developed among the participants and one study did not show a difference in the severity of pressure ulcers that developed. We assessed the certainty of the evidence as low, or very low, because not all the people completed one of the studies, and in both studies the results varied widely, and the staff knew which study group the patient was in. The outcomes for time to pressure ulcer development, and pressure ulcer prevalence, were not reported on by either study. How up to date is this review? We searched for studies that had been published up to February 2018. m

www.a-dfs.org

ADFS Cadaver Course 2019

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1 July 2019 .org n deadline: o ti a tr n www.a-dfs is g re Early formation o in re o m d n a Registration

Anatomical and Surgical Dissection of the Foot The Reconstruction of the Diabetic Foot

14-15 November 2019 Padua, Italy


Antimicrobial resistance might result in 10 million deaths each year by 20501

Can a small change in perception have a big impact in the fight against antimicrobial resistance? Find out how effective wound management could help us combat antimicrobial resistance at:

OUR BOOTH

70553-00005-00

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1) Tackling drug-resistant infections globally: Final Report and Recommendations – The Review on Antimicrobial Resistance chaired By Jim O’Neill, May 2016


Book Reviews

Book Review Antiseptic Stewardship GĂźnter Kampf Springer 2018

Rose Cooper BSc, PhD, PGCE

This book is comprised of 694 pages, organised into 22 chapters. It concerns 15 antiseptics used in human medicine, veterinary medicine, food production and food handling. Each antimicrobial agent (or biocide) has been used in at least two types of antiseptic product, by at least two manufacturers.

Correspondence: cooper139@gmail.com

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The book includes an introductory chapter in which the background and diversity of antiseptic stewardship is explained. There is a chapter for each selected antiseptic, where information on chemical characteristics and types of application is provided, together with regulatory status within the European Union and USA. The spectrum of antimicrobial activity against bacteria, fungi and mycobacteria is presented using data collated from microbiostatic tests (MIC tests) and microbiocidal tests (suspension tests), as well as antibiofilm activity. Information on the adaptive responses of microorganisms to low-level exposure to each biocide allows the risk of microbial adaptation and the emergence of resistance to be determined. Importantly, changes following exposure to that agent alone or in combination with other antimicrobial agents (including antibiotics) as a marker of cross-resistance are described. Resistance mechanisms (such as biofilm formation, horizontal gene flow and efflux pump activity) are also catalogued. Where appropriate, examples of microbes isolated from contaminated products or involved in outbreaks of infection are given; these indicate the probable frequency of resistance. For each antiseptic, the principal antimicrobial activity and key findings of acquired resistance and cross-resistance are summarised at the end of each chapter.

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This is how life feels to people with EB. Their skin is as fragile as a butterfly’s wing. They have Epidermolysis Bullosa, a painful and currently incurable skin blistering condition. www.debra-international.org There are also six chapters concerning antiseptic stewardship in different contexts: alcohol-based hand rubs, skin antiseptics, surface disinfectants, instrumental disinfection, antimicrobial soaps and wound and mucous membrane antiseptics. These chapters contain valuable information on the composition and intended use of formulations, risks of resistance, health benefits and implications for antimicrobial stewardship. Bar charts clearly demonstrate the frequency of adaptive responses to each agent. This book contains helpful information on 15 antiseptics that are commonly used in healthcare. Although the content is very detailed, it is accessible. A long abbreviations list removes ambiguity in microbial names; the presentation of laboratory data in tables allows easy assimilation, and charts and figures provide useful illustrations. For those wishing to verify observations, comprehensive references are available throughout the book. At a time when the overuse and misuse of antimicrobial agents has facilitated the emergence of widespread antimicrobial resistance, it is evident that the future success of medical procedures is threatened. Antimicrobial stewardship is essential for continued health, but for many practitioners it is foreign territory. Although much has been published about the need to control the use of antibiotics, the importance of limiting the use of other antimicrobial agents to safeguard their role in controlling the spread of infectious agents has received less attention. The importance of non-antibiotic antimicrobial agents is likely to become more important as antibiotics become less effective, and the need to use the former agents wisely is already paramount. The information contained in this book is pertinent to everyone involved in healthcare and will guide many future antiseptic stewardship initiatives. It contains impartial reviews of reported antimicrobial efficacy, resistance and crossresistance that will allow informed decisions to be taken by responsible staff. I recommend this book on antiseptic stewardship to all healthcare practitioners unreservedly. m

International.


Book Reviews

Book Review Infermieri

Enzo Cei è un fotografo italiano indipendente; ha pubblicato 14 libri, frutto di suoi progetti fotografici ed editoriali, sui temi del lavoro, della salute pubblica, della medicina, della ricerca in campo medico e in quello della scienza.

Photos by Enzo Cei Edited by Prof. Franco Mosca, MD, PhD, FRCS, FACS Pacini Editore 2018

Questa opera vuole documentare, con la forza dell’infermiere nella sua autonomia professiona volti, mani, gesti, sorrisi, pianti, con asciutta na

ENZO CEI

INFERMIERI

Il suo libro autobiografico Ai piedi dei miei anni ha vinto il premio letterario Edizione straordinaria 2012.

Con un finanziamento del Ministero dei Beni Culturali, ha girato il documentario Nato prematuro, selezionato al Festival Internazionale del Film di Roma 2013. Per la Fondazione Arpa ha pubblicato Trapianti, Federico Motta Editore, 2008. www.enzocei.com

Enzo Cei is an independent Italian photographer; he has published 14 books, the results of his photographic and publishing projects, on the themes of labour, public health, medicine, research in the medical field and in science.

Il Pronto soccorso, la Psichiatria, la Neonatolog l’Assistenza domiciliare, la Prima accoglienza ai duecento scatti gli oltre trenta contesti che cos operano i nostri 460.000 infermieri.

Un tempo l’infermiere si trovava in posizione su ma anche agli occhi della società, anche se, fin essere complementare a quello del medico. Ent ognuno vede da prospettive diverse ma ben int

I giovani che scelgono oggi la professione di inf speciali. Consapevoli che li aspetterà un lavoro anche scomodo e faticoso. Orari festivi e turni Chi si avvicina a questa professione sa di dover è altrettanto consapevole che tutto è ben affro conferirà identità e riconoscimento.

His autobiographical book Ai piedi dei miei anni was awarded the Edizione straordinaria literary prize of 2012.

For the Arpa Foundation he published Trapianti, Federico Motta Editore, 2008. www.enzocei.com

Professore Emerito di Chirurgia Generale, Università di Pisa.

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Ha introdotto e sviluppato a Pisa la Chirurgia Vascolare, i trapianti renali, pancreatici ed epatici, le nuove tecnologie in Medicina e Chirurgia (Centro di Eccellenza dell’Università di Pisa ENDOCAS, http://www.endocas.org). Medaglia d’oro della Repubblica Italiana al merito della Sanità Pubblica. Fellow Royal College Of Surgeon Edimburgh (Hon.), American Surgical Association (Hon.), Association of Polish Surgeons (Hon.)

Alberto Piaggesi MD Director, Diabetic Foot Section, Department of Medicine, University of Pisa, Italy

Past Presidente della Scuola per Infermiere Professionale dell’Università di Pisa.

INFERMIERI

With funding from Ministry of Cultural Heritage, he shot the documentary Nato prematuro, selected for the Rome International Film Festival 2013.

Questo libro dunque, e le splendide fotografie che, scegliendo questa professione, entrano i acquisito un patrimonio consolidato di nuovi ma anche nei percorsi sanitari ove dimostran cultura della multidisciplinarità.

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The Emergency Room, the Psychiatric Ward, Ne Unit, Home Care, and First Line Reception for re that make up the daily settings within which ou two hundred photographs.

Fondatore e Presidente della Fondazione Arpa Onlus (http://fondazionearpa.it). Promotore e organizzatore del Festival Internazionale della Robotica a Pisa 2017 e 2018 (www.festivalintenazionaledellarobotica.it).

Not so long ago this professional figure held a s and in the eyes of society. It has always been c complement the doctor’s role. In fact, both are and although different, they strictly integrate w

Professor Emeritus of General Surgery, University of Pisa. He introduced and developed Vascular Surgery in Pisa, renal, pancreatic and hepatic transplants, new technologies in Medicine and Surgery (Center of Excellence of the University of Pisa ENDOCAS, http://www.endocas.org). Gold medal of the Italian Republic to the merit of Public Health. Fellow Royal College Of Surgeon Edimburgh (Hon.), American Surgical Association (Hon), Association of Polish Surgeons (Hon.). Past President of the School for Professional Nurse at the University of Pisa. Founder and President of the Arpa Onlus Foundation (http://fondazionearpa.it)

a cura di

FRANCO MOSCA

Promoter and organizer of the International Robotics Festival in Pisa 2017 and 2018 (www.festivalintenazionaledellarobotica.it).

It is with great pleasure that we welcome this photographic book on nursing as depicted inside a complex entity like the University Hospital of Pisa, a centre of excellence in Italy for many different surgical and medical specialities.

Dacci le tue parole, t’ascolteremo in coro.

This book joins the exquisite artistic quality of the photographs of Enzo Cei, a renowned international photographer with vast experience in documenting life’s healthrelated aspects, with the profound knowledge of hospital settings possessed by Franco Mosca, a professor of general surgery who spent his professional life in Pisa, where he contributed greatly to improving the quality and services of its hospital. It gives a unique picture of the role of the nurses and their essential contributions to the wellbeing of their patients. The photographs catch the nurses in all aspects of their lives and jobs, and transmits the emotions that this demanding job creates, producing a narration that is in itself a journey through the life of the profession.

Correspondence: alberto.piaggesi@ med.unipi.it

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Through the power of images, this work aims to go about their daily work. Here the photo shoot gestures, smiles and tears, all with a straightfo

From paediatrics to surgery, from intensive care to psychiatry, the everyday lives and tasks of the nurses are captured at different moments of the day and the night: from frustration at a failed procedure to joy at the recovery of a patient with serious complications, from the concentration of a briefing before an operation to the personal involvement in the difficulties faced by the patients’ families, the central figure of the nurse is focused on all the technical and human aspects.

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Today, the young people who choose to becom special people. They are aware that a secure, ap but also a job that is uncomfortable and tiring. family sacrifices: those who go into this profess are involved, but they are equally aware that ev and that studying will give them identity and re

This book is dedicated to all of those who, by c a world where nurses have acquired a consolid the relationship with the patient, but also in he transversal collaborative skills and a multidisci


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IRCCS Fondazione Stella Maris. Esperienza e pazienza degli infermieri aiutano a interagire con i piccoli degenti in un reparto che richiede grande professionalità e doti umane.

Through the vision of this photographic book, the concept of medical humanities, which now informs all aspects of the modern approach to medicine and surgery, comes to life in front of your eyes. With a focus on the patient and his/her world, medical humanities arouse emotions, particularly empathy, and brings you closer to the essence of nursing: the healing relationship between the nurse and the patient. IRCCS Stella Maris Foundation. Experience and patience help the nurses interact with young patients in a unit that requires great professionalism and human skills.

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Terapia Intensiva Neonatale. Nell’incubatrice l’infermiera ripristina la nutrizione interrotta dal parto prematuro.

Neonatal Intensive Therapy. In the incubator, the nurse continues the infant’s nutrition, interrupted by the premature birth.

Linfa e madre a flebili rivoli di vita.

its 208 coloured pages, fully displays the art of nursing in all its complexity and richness.

Accorrete, un pianto è una cometa.

The book, which contains additional prefaces by the authors Andrea Bocelli and Oliviero Toscani, is bilingual (Italian/English) and is published by Pacini Editore, Pisa. More information at www.pacinieditore.it. or to be obtained from Mrs. Marcella Finotti mfinotti@ pacinieditore.it. m

As Andrea Bocelli states in his preface to the book, ‘nursing is an art, and requires devotion and hard preparation’. This book, through the art of photography, in

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EWMA

Journal of EWMA

Other journals

Previous Issues

EWMA wishes to facilitate the exchange of information on wound healing in a broad perspective with this section on international journals.

Volume 19, no 2, October 2018 The future of pressure ulcer prevention is here: Detecting and targeting inflammation early Gefen A Need for an international consensus conference on heel pressure injuries: A preliminary literature review Rivolo M, Marcadelli S Using technology to advance pressure ulcer risk assessment and self-care: Challenges and potential benefits Patton D, Moore Z, O’Connor T, Shanley E, De Oliveira A L, Vitoriano A, Walsh S G, Nugent L E Prevalence of pressure injuries and other dependence-related skin lesions among paediatric patients in hospitals in Spain Pancorbo-Hidalgo P L, Torra-Bou J E, Garcia-Fernandez F P, Soldevilla-Agreda J J Survey of wound prevalence in a long-term care facility Peckford S

Advances in Skin & Wound Care. March 2019 www.aswcjournal.com

English Advances in

SKIN& WOUND CARE ®

The International Journal for Prevention and Healing

www.woundcarejournal.com

C M E

Volume 32 Number 3 March 2019

CLINICAL MANAGEMENT EXTRA

Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries ORIGINAL INVESTIGATION

Pressure Ulcer Prevalence by Level of Paralysis in Patients with Spinal Cord Injury in Long-term Care Survey Results from the Gulf Region: NPUAP Changes in Pressure Injury Terminology and Definitions Silicone Foam Dressing for Prevention of Sacral Deep Tissue Injuries Among Cardiac Surgery Patients PLUS

Editorial • Commentary • Payment Strategies

Finnish

Reexamining the Literature on Terminal Ulcers, SCALE, Skin Failure, and Unavoidable Pressure Injuries Ayello EA, Levine JM, Langemo D, et al. Pressure Ulcer Prevalence by Level of Paralysis in Patients with Spinal Cord Injury in Long-term Care Cowan LJ, Ahn H, Flores M, et al. Silicone Foam Dressing for Prevention of Sacral Deep Tissue Injuries Among Cardiac Surgery Patients Strauss R, Preston A, Zalman D, et al.

Haava, no 4, 2018 www.shhy.fi Celebration of Journal Haava 20 year publication Treatment of Diabetes is Progressed – does it decrease the amount of diabetic wounds? Pirjo Ilanne-Parikka Toxic epidermal necrolysis: Literature Review and Research Results Anthony Papp Specialization Programme of Wound Management and Competences Salla Seppänen

Volume 19, no 1, April 2018 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 Skin tears in the aging population: Remember the 5 Ws Vanzi V, LeBlanc K Recommendations to improve health care for people with chronic diseases Maggini M, Zaletel J Bioburden levels of spools of surgical tape in different healthcare settings Yu V, Deing V, Nehrdich T, Struensee B Specific risk factors for pressure ulcer development in adult critical care patients – a retrospective cohort study Ahtiala M, Soppi E, Tallgren M Prevalence of chronic wound in different modalities of care in Germany Kröger K, Jöster M

Helcos, vol. 29, no. 4, 2018

Spanish CONTENTS GEROKOMOS Volume 29, Number 4, December 2018

EDITORIAL 155 About Conferences and Symposia J. Javier Soldevilla Agreda

NOTEBOOK ORIGINAL ARTICLES 156 Old age as a disease: a topic closed in Classical Antiquity Alfonso López-Pulido

160 Nursing role in assessing geriatric syndromes and functional status in a Geriatric consultation Ana Isabel Jordán Agud and Dolors Estrada Reventos

REVIEW ARTICLE

165 Is the presence of episodes of delirium in the elderly a risk factor for the subsequent appearance of a demential syndrome? Josep Deví Bastida, Jonathan Repiso Solana, Susanna Jofre Font, Albert Fetscher Eickhoff and Enric Arroyo Cardona

171 Parkinson’s disease: Nursing approach from primary health care

M.ª Concepción García Manzanares, M.ª Lourdes Jiménez Navascués, Esther Blanco Tobar, María Navarro Martínez and María de Perosanz Calleja

CASE REPORT 178 Purple urine syndrome: Care planning

Eva Vilaplana-Morillo, Emili Marco-Segarra, Alicia Baltasar-Bagué, Mónica Pons-Roca, Moisés Costa-Bosch and Carmen Malagón-Aguilera

Grupo Nacional para el Estudio y Asesoramiento en Úlceras por Presión y Heridas Crónicas PHOTOGRAPHY: “Friction”. J. Javier Soldevilla Agreda

ORIGINAL ARTICLES

181 Health workers’ knowledge regarding the use of Topical Negative Pressure Therapy in the treatment of wounds Patricia Cerezo-Millán, Pablo López-Casanova, José Verdú-Soriano and Miriam Berenguer-Pérez

192 Pressure ulcers, one more step in the care and safety of our patients Fernando Talens Belén and Nuria Martínez Duce

REVIEW ARTICLE

Volume 18, no 2, October 2017

Health workers´knowledge regarding the use of Topical Negative Pressure Therapy in the treatment of wound P Cerezo-Millán; P López-Casanova; J Verdú-Soriano; Pressure ulcer, one more step in the care and safety of our patients F Talens; N Martinez Diabetic foot Classifications II. The problem remainse H Gonzalez-De la Torre, M Berenguer-Pérez; A Mosquera

197 Diabetic foot Classifications II. The problem remains

Héctor González de la Torre, Miriam Berenguer Pérez, Abián Mosquera Fernández, María Luana Quintana Lorenzo, Raquel Sarabia Lavín and José Verdú Soriano

CASE REPORT 210 Usage of dressings with gelifying alveolar technology for pressure ulcer healing B

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 Debridement method optimisation for treatment of deep dermal burns of the forearm and hand Zacharevskij E, Baranauskas G, Varkalys K, Kubilius D, Rimdeika R Lived experiences of life with a leg ulcer - a life in hell Lernevall LSD, Fogh K, Nielsen CB, Dam W, Dreyer PS Illness, Normality, and Self-management: Diabetic Foot Ulcers and the Logic of Choice Andersen SL, Pedersen M, Steffen V Essential microbiology for wound care Pina E

Sònia Farran Farré

Italian Journal of Wound Care, Vol 2, 2018 www.woundcarejournal.it

Italian

IJW JWC JW C Italian Journal of

WOUND CARE

www.aiuc.it

Insertion of the podiatrist and implementation of the diagnostic and therapeutic care path for the diabetic foot in the area of Cesena Giulia Casadei, Costanza Santini, Giovanni Calbucci Vol. 02, n.3 – (sept 2018) The L-PRF membrane and its derivatives useful in wound care surgery Alessandro Crisci, Carmela Rescigno, Michela Crisci V.03, n.1 (febb 2019) The management of procedural pain in the fungating malignant wounds of the cervical and facial area Antonino Lombardo, Francesco Stivala, Loredana Reina, et all. V.03, n.1 (febb 2019)

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

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English VOLUME 28 ISSUE 1 FEBRUARY 2019 ISSN 0965-206X

JOURNALOF

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In this issue: • Investigating the influence of intermittent and continuous mechanical loading on skin through non-invasive sampling of IL-1ι • Detection and classification methodology for movements in the bed that supports continuous pressure injury risk assessment and repositioning compliance • Oral mucosa pressure ulcers in intensive care unit patients: A preliminary observational study of incidence and risk factors • MDRPU - an uncommonly recognized common problem in ICU: A point prevalence study Official Journal of the

rt on your institution’s research strengths, rch-intelligence/ace

Spanish R E V I S TA D E L A S O C I E D A D E S PA Ă‘ O L A D E H E R I D A S

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DICIEMBRE 2018 VOLUMEN 8 Trimestral Incluida en el catĂĄlogo de Latindex desde enero de 2017

Heridas y CicatrizaciĂłn

Phlebologie, vol. 6, 2018 www.schattauer.de

German

Investigating the influence of intermittent and continuous mechanical loading on skin through non-invasive sampling of IL-1Îą J.F.J. Soetens, P.R. Worsley, D.L. Bader et al. Detection and classification methodology for movements in the bed that supports continuous pressure injury risk assessment and repositioning compliance Jonathan Duvall, Patricia Karg, David Brienza et al. Oral mucosa pressure ulcers in intensive care unit patients: A preliminary observational study of incidence and risk factors Chul-Hoon Kim, Myoung Soo Kim, Myung Ja Kang et al.

Heridas y CicatrizaciĂłn, no 8 - 2019 Calciphylaxis: importance of prevention, early diagnosis, combined treatment and multidisciplinar approach. Juan Carlos PeĂąa MartĂ­nez Burns Edgar Mauricio Avellaneda Oviedo Dermic fistula due to cerebrospinal fluid fistula secondary to sacrum teratoma. MarĂ­a DueĂąas Carretero, Carlos SĂĄnchez FernĂĄndez, EstefanĂ­a Uriel MonsĂĄlvez, et al.

Extended secondary prophylaxis after venous thrombosis Schimmelpfennig, Bauersachs Novel clinical trial data on the treatment of cancer-associated venous thromboembolism with DOACs Voigtlaender, Yamamura, Langer The lower leg vein thrombosis – a disease for specialists Herold, Bauersachs

SÅRmagasinet no 1, 2019 www.swenurse.se Person-centered teamwork is the key- Role of the occupational therapist in prevention and treatment of pressure ulcers Sandra Strand ISAP.s Classification system for skin tears Källman U. et al Hard-to-heal wounds in home care Patrik Peterman and BjÜrn Malmros

Scandinavian En tidskrift frĂĽn SĂĽrsjukskĂśterskor i Sverige

nr 1 • 2019

TEMA:

Sue Bale

PORTRĂ„TT:

SĂĽr i hemsjukvĂĽrden TrycksĂĽr InfĂśr EWMA konferensen

Scandinavian Marts 2019

Ă…RGANG 28 NR 1

Editorial: Bromelaína, una nueva revolución en el arsenal terapÊutico para el paciente quemado • Revisión: Calcifilaxis: importancia de su prevención, diagnóstico precoz, tratamiento combinado y enfoque multidisciplinar • Quemaduras • Caso Clínico: • Fístula dÊrmica como complicación de fístula de líquido cefalorraquídeo secundaria a teratoma sacro • Revista de prensa: • Imagen del mes: Reconstrucción de cicatriz pretibial atrófica secundaria a biopsia • Normas de publicación

Journal of Tissue Viability, vol. 28, no 1, 2019 www.journaloftissueviability.com

MEDLEMSBLAD FOR DANSK SELSKAB FOR SĂ…RHELING OG FOR NORSK INTERESSEFAGGRUPPE FOR SĂ…RHELING

Wound Practice and Research, Vol. 26 Nr 4 2018

Australian

familien plejehjemmet hospitalet

Wound Practice and Research Jour nal of Wounds Australia

Volume 26 Number 4 December 2018

Innovative approaches for the development of the next generation of wound dressings.

Featuring Editorial: Wound Innovation: now and in the future A descriptive exploratory survey of incontinenceassociated dermatitis in the intensive care setting: The ADDrESS study Collaboration across the care continuum to improve the patient experience Exploring the impact of incontinence-associated dermatitis on wellbeing Necrotising fasciitis after removing the intrauterine device Surfaces to enhance matrix deposition for wound healing

Collaboration across the care continuum to improve the patient experience Therese Jepson, Tanya O’Hara and Sue Monaro Exploring the impact of incontinence-associated dermatitus on wellbeing Alicia Spacek, Ann Marie Dunk and Dominic Upton Necrotising fasciitis after removing the intrauterine device Birgul Ozkaya, Asiye Gul and Hale Tosun

arbejdsmarkedet (relatiomner)' lĂŚger

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TILMELDING –TEMADAG. FRIST DEN 1. MARTS! 3C PATCH – DET VIRKER NYT FRA NIFS SLAGELSE SÅRCENTER – ENERGISK OG MÅLRETTET BAKTERIER I SÅRET – FREMTIDENS SÅRBEHANDLING

Wounds, vol. 31, no. 2, 2019 www.woundsresearch.com Preclinical and Clinical Studies of Hyaluronic Acid in Wound Care: A Case Series and Literature Review Schneider HP, Landsman A Exercise and Chronic Wound Healing Bolton L Use of Negative Pressure Wound Therapy With Instillation and a Novel Reticulated. Open-cell Foam Dressing With Through Holes at a Level 2 Trauma Center Blalock L

English

Lietuvos chirurgija, vol. 17 no 3-4, 2018 www.chirurgija.lt

Lithuanian

Methods of adipose tissue distribution measurement by ultrasound: systematic review Buckus B, Brimas G Laryngeal palpation in thyroid surgery: practical recommendations for method integration into daily clinical practice according to comprehensive literature review and prospective cohort study results Rybakovas A, Matulevicius A, Belogorceva V, et al. Ovarian Dysgerminoma with Metastases in Supraclavicular Lymph Nodes Diagnosed in a 16-year-old Girl: Clinical Case and Literature Review Maldziute D, Rukauskaite V, Trainavicius K

Wund Management, no 1, 2019

German ISSN 1864-1121 Fachzeitschrift fĂźr das interprofessionelle Wundteam

13. Jahrgang

1/2019

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T H E O F F I C I A L P U B L I C AT I O N O F W O U N D S C A N A D A

Saving Health-care Dollars:

Two Stories from LTC The Impact of Spinal Cord Injuries

The Importance of Hydration for Wound Healing

Embracing

Social Media in Health Care

n mit chronische von Menschen aus Sicht der Versorgung nd: Status quo Wunden in Deutschla Experten versorgenden

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Wound Care

Feature:

Session Summaries from the 2018 Fall Conference

Wound Sleuth: Recurrent Ulcers on the Site of Previous Trauma and Multiple Surgical Procedures R. Gary Sibbald BSc, MD, MEd, DSc (Hon), FRCPC (Med) (Derm), FAAD, MAPWCA, JM; Patricia M. Coutts RN, IIWCC Wounds Canada Fall Conference: Exploring Integrated Wound. Management: Session Summaries Kathryn Bassett BMus; Sue Rosenthal BA, MA Healing with Hydration Ellen Mackay MSc, RD, CDE

journal of the european wound management association 

Sür (Wounds), no. 1 - 2019 www.saar.dk 3C Patch – It works Jens Fonnesbech Slagelse Wound Centre – Energetic and goal oriented Jens Fonnesbech Bacteria in the wound, bacteria in the intestine – The wound treatment of the future Adam Bencard

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Actual state of care of people with chronic wounds in Germany K. Protz, M. Augustin, K. HagenstrĂśm Treatment of people with chronic wounds in Germany: Status quo from the point of view of the treating experts M. Augustin, K. Protz, V. Gerber et al Recommendations for improving the care of chronic wounds in Germany K. HagenstrĂśm, M. Augustin, K. Protz

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EWMA

EWMA 2019 GOTHENBURG ¡ SWEDEN

5-7 JUNE 2019

EWMA 2019 Conference in Gothenburg, Sweden 5-7 June 2019 Experience high-level scientific presentations, great networking and an excellent opportunity to exchange knowledge and experiences with international colleagues and industry representatives at the 29th Conference of the European Wound Management Association in Gothenburg, Sweden.

OTHER COLLABORATORS:

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THE EWMA 2019 CONFERENCE PROGRAMME IN NUMBERS:

n 740

submitted abstracts from 57 countries.

n More

than 100 invited speakers from Europe, USA and Asia.

n More

than 1000 presentations given in key sessions, focus sessions, workshops, free paper sessions and poster presentations.

n 25

industry sponsored satellite symposia and company sponsored workshops.

In June 2019, the EWMA Conference will be held in the heart of Gothenburg, one of the world’s most sustainable cities located at the Swedish harbour front. It is well-known as a “smart city” that is going green and open to the world.

THE CONFERENCE THEME IS

Person-centred Wound Care. Who is in Charge of the Wound? A wound is always part of someone’s body; a person has to live with it. The patient therefore qualifies as being an important member of the team focusing on wound healing. When all professionals, with their specific competences, work together with the patient, progress can be made and clinical knowledge and competences can be developed and shared. A multidisciplinary interprofessional team and person-centred wound care approach will support the wound healing process, increase patients’ quality of life and be more cost effective. The scientific programme will consist of various key sesjournal of the european wound management association 

sions, workshops, focus sessions, full-day streams, and satellite symposia. The conference offers a wide variety of sessions ranging from prevention and management of wounds to epidemiology, pathology, and diagnosis. This makes it easy for delegates to tailor their own programme based on their interests and professional background. During the 3-days there will be several streams, focusing on a specific topic. One of the streams will concentrate on Diabetic Foot Ulcers which has been an essential topic for the EWMA programme for many years. The stream will include sessions on Rehabilitation following Amputation, Peripheral Arterial Disease, IWGDF Guidance and workshops on casting and offloading. Many well-known, international experts have been invited to speak in these sessions. 

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EWMA

PROGRAMME HIGHLIGHTS

KEY SESSIONS

FOCUS SESSIONS

n Opening

session: Person-centred Wound Care n Atypical Wounds (EWMA document) n Burns n Catastrophe & War Wounds n Economy of Wound Management n Multidisciplinarity & Organisation n Patient Involvement & Patient Safety n Pressure Ulcer Prevention n Surgical Site Infection (EWMA document) n Surgical Treatment of Chronic Wounds n Translational Science & Clinical Opportunities

The focus sessions foster more in-depth discussions than the workshops allow.

WORKSHOPS

GUEST SESSIONS

The interactive workshops will give the participants an opportunity to address and elaborate on particular aspects of the session themes.

The programme offers guest sessions from several organisations that are active in thematic issues related to wound healing and management.

The workshops include: n After Debridement n Debridement n Diabetic Foot – Assessments, Offloading and Footwear n Eczema in Leg Ulcer Patients n How to apply TCC or CCO with NPWT n How to Read a Paper n Is this wound infected or not? n Managing Wounds after Discharge n Patient Repositioning and Support n Regulatory workshop

Join @ewmawound

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The focus sessions include: n Skin Necrosis in Wounds n Malignant & Fungating Wounds n Wound Care, Exploring the Pain Dimension n Wound Care in Fragile Populations n Regenerative Medicine in the Treatment of Chronic Wounds n The use of Biologics in the Management of Complex Inflammatory Wounds n Surgical Management of Chronic Lymphoedema and Venous Insufficiency n Living with Chronic Wounds

The organisations include: n Association of Diabetic Foot Surgeons (ADFS) n Cardiovascular and Interventional Radiological Society of Europe (CIRSE) n Dystrophic Epidermolysis Bullosa Research Association (DEBRA) n European Council of Enterostomal Therapy (ECET) n European Pressure Ulcer Advisory Panel (EPUAP) n European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) n European Tissue Repair Society (ETRS) n International Lymphoedema Framework (ILF)

Find more information about the updated programme on the conference website, ewma2019.org. You can also find updates on EWMA’s social media platforms.

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18 – 20 Septem ber 2019

Lyon, Fr

ance

www.e puap20 19.org Meeting 21st Annual e ean Pressur p o r u E e th f o or y Panel! Ulcer Advis

cer Pressure ul prevention tiers n without fro

Abstract submission deadline

30 April 2019

Early registration deadline

20 June 2019

EPUAP 2019 CHAIRS Dominique Sigaudo-Roussel | Benoît Nicolas

EPUAP 2019 JOINT ORGANISING COMMITTEE EPUAP representatives Jane Nixon | Dimitri Beeckman | Zena Moore | Yohan Payan | Carina Bååth | Cees Oomens | Susanne Coleman

Société Française de l’Escarre representatives Bérengère Fromy | Martine Barateau | Denis Colin | Jean Marc Michel | Yann Groc | Sandrine Robineau | Anthony Gélis | Brigitte Barrois

EPUAP Business Office

Codan Consulting; Provaznicka 11, Prague 1 office@epuap.org, Tel.: +420 251 019 379


EWMA

New EWMA Document AL WO

ATY

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Kirsi Isoherranen MD, PhD, Helsinki University Central Hospital, Helsinki Wound Healing Centre, Finland

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I C Practice U Atypical Wounds - Best Clinical and Challenges P

ATYPICAL WOUNDS

Learn more about the document at the EWMA 2019 Conference Key Session: EWMA Document Presentation: Atypical Wounds - Best Clinical Practices and Challenges

BEST CLINICAL PRACTICES AND CHALLENGES

Date and time: Wednesday 5 June, 13.45 – 15.00 Room: Session Room F4-F5 Speakers: Kirsi Isoherranen, Joachim Dissemond, Jürg Hafner, Stephan Nobbe. Julie Jordan O’Brien RNP, MSc Nursing, Advanced Nurse Practitioner Plastic Surgery, Beaumont Hospital, Dublin, Ireland 268x200_EWMA_Atypical Wounds_221218.indd 1

The EWMA Document ‘Atypical Wounds: Best Practices and Challenges’ will be published as an online supplement to the Journal of Wound Care during spring 2019 and available for free download from the JWC website https://www. magonlinelibrary.com/ journal/jowc

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Background and aims Atypical wounds comprise approximately 20% of all chronic wounds. With an aging population and increasing rates of comorbidity, these numbers are expected to rise. Atypical wounds are those wounds that do not fall into a typical wound category (i.e., venous, arterial, mixed venous and arterial, pressure or diabetic foot ulcers). They are a broad spectrum of conditions or diseases caused by inflammation, infection, malignancy, chronic illnesses or genetic disorders. An atypical wound can be suspected if the wound has an abnormal presentation or location, pain out of proportion to the size of the wound and does not heal within 4 to 12 weeks following a good treatment plan. Unfortunately, the diagnostic delays associated with these wounds can be considerable, which leads to higher mortality rates. With the above in mind, it is important that every healthcare professional treating these wounds is familiar with this concept, or at least has the knowledge to suspect an atypical wound and knows when to refer the patient to an expert. A multidisciplinary team is needed to manage this group of patients, but it is mainly community healthcare practitioners who manage these patients on a day-to-day basis. Early diagnoses and referrals to dermatologists are important, as they are experts in diagnosing and treating these wounds. After an exact diagnosis is made, a holistic assessment and interdisciplinary plan of care is essential for cost-effective management and to prevent recurrence. From the patient perspective, atypical wounds can be very painful and have prolonged healing times, which lead to impaired quality of life. Many patients suffer daily with physical challenges such as odour, exudate, pain and reduced mobility, and psychologically with negative emotions, loneliness and depression. Mortality rates are higher not only due to their comorbidities, but also due to lower socio-economic circumstances, which lead to higher rates of suicide. Still, there is a dearth of literature reporting on quality of life or health economy in this patient population. In response to this lack of uniform data, EWMA has established a working group to gather the best available knowledge on atypical wounds.

Correspondence: ewma@ewma.org

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This document is targeted at increasing awareness of the clinical picture, diagnosis and treatment of

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these wounds among healthcare professionals and to provide practical advice on some of the challenges that typically arise, such as delays in diagnosis of inflammatory and vasculopathy wounds (such as pyoderma gangrenosum (PG), an inflammatory neutrophilic disorder, and cutaneous vasculitis). We hope that a systematic approach will improve the care and quality of life for this patient group. Lastly, it is also hoped that this document will act as a catalyst in the management of atypical wounds and fill the void that currently exists in clinical decision making. The document focuses on atypical wounds caused by inflammation, malignancy and chronic illnesses. The aim of the document is to: n Present the diagnostic criteria, comorbidities and diagnostic tools for wounds defined as ‘atypical’, including practical hints for healthcare professionals. n Present the best available documented current treatment options. High-quality evidence is sparse, but there are retrospective and observational studies and some randomised prospective studies upon which we may draw. n Present some newer treatment options for atypical wounds. n Reduce the diagnostic delays of these wounds by providing up to date, evidence-based literature on atypical wounds and an algorithm to aid clinicians in assessing these wounds in a systematic way.

Document content The document contains different chapters for the following atypical wounds: Pyoderma gangrenosum (Figures 1a and b), Vasculitides (Figure 2), Occlusive vasculopathy, Martorell HYTILU (Figure 3) and calciphylaxis, Hidradenitis suppurativa, malignant wounds, artefactal ulcers, Ecthyma and ecthyma gangrenosum. For these atypical wounds, pathophysiology, clinical presentation, diagnosis and treatment are described. In addition, several clinical pictures are presented, in order to make these wounds more recognisable. Other types of atypical wounds are covered briefly in one chapter. There are also separate chapters for the histology of atypical wounds, the topical treatment of atypical wounds, the patient perspective and health economy and organisation. As atypical wounds consist of heterogeneous diseases, the author group considered it important to have one chapter that summarises the most important aspects related to suspecting, diagnosing and treating these challenging wounds. Therefore, one chapter is titled ‘Practical aspects of diagnosing and treating atypical wounds’. The chapter highlights the importance of a patient’s history in diagnosing these wounds; a table for important comorbidities and medications is included. In addition, important clinical signs, such as hypergranulation, pathergy, violaceous and undermined borders, necrosis, atypical location, severe pain (out of proportion which is normally associated with wounds), livedo racemosa and reticularis and rapidly progressive ulceration are described. An algorithm of different types of atypical wounds is introduced. It is also stressed that, if the wound does not show signs of healing after 4–12 weeks despite optimal treatment (topical treatment, offloading, compression therapy), a biopsy should be taken from the wound edge. Drawings to show this are provided. However, it is important to remember that a negative histology does not exclude an atypical wound. A clinical assessment is required, and the patient should be referred to a dermatologist. Once a diagnosis has been established, an interdisciplinary approach should be adopted to reach a successful outcome. This might include one or more of the following healthcare professionals: dermatologist, vascular and plastic surgeon, nephrologist, rheumatologist, tissue viability nurse or podiatrist. The exact nature of the treatment relies on the specific type of the atypical wound and will be presented in the individual chapters of this document. Where patients with a wound are being treated by immunosuppressive agents, negative pressure wound therapy (NPWT) and skin grafting can also be considered, but only after the inflammation has been reduced by immunosuppressive therapy. Also, topical corticosteroids may help to reduce excessive inflammation that impairs wound healing in atypical wounds, such as Pyoderma gangrenosum, vasculitides and Martorell HYTILU. As the immunosuppressive agents can cause delayed wound healing, advanced therapies, epidermal grafting and surgical procedures are also important in terms of reducing healing time, it is possible to perform punch grafting, a traditional method for obtaining thin split-thickness skin grafts containing epidermis and papillary dermis. journal of the european wound management association 

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Compression therapy (as provided by bandages, hosiery or compression wraps) can be beneficial for most leg ulcers with oedema, even if the cause of the wound is not venous. After exclusion of advanced peripheral arterial occlusive insufficiency, compression therapy should be used in all patients with lower leg ulcers. However, compression therapy may be painful in patients with inflammatory PG or vasculitides, therefore lower pressures of 20 mmHg should be used initially.

Conclusions and future perspectives The key observations and recommendations of the document are presented in the final combined ‘Conclusions and future perspectives’ chapter, which addresses, among other topics: n The need for prospective multicentre clinical trials with well-defined outcomes. n The need for more precise understanding of the inflammatory and occlusive mechanisms of atypical wounds. n The need for further studies of the benefits of traditional treatments, such as topical corticosteroids and tacrolimus. n That the time of recurrence for ulcers, as well as their frequency, should also be taken into consideration when examining the effectiveness of treatments. n That studies on diagnostic delays are important both from the patient`s and the organisational point of view. n There is evidence of a positive outcome to early skin grafting in ulcers in the context of arteriolo pathy, with a breakdown in the vicious cycle necrosis–inflammation and consequent pain reduction and epithelialisation promotion. n That organised multidisciplinary teams consisting of dermatologists, vascular and plastic surgeons, rheumatologists, diabetologists, infectious disease specialists, psychiatrists, tissue viability nurses, psychologists, nutritionists, physiotherapists and social care workers should be included in care pathways for these wounds. n The importance of early suspicion and expert consultation with these wounds; a ‘wait and see’ attitude can lead to devastating outcomes. n The proposal for an algorithm, presented in the chapter ‘Practical aspects of diagnosing and treating atypical wounds’ that will hopefully help with the daily practice, systematic assessment of these wounds.

We hope that the document will be disseminated and used among all healthcare professionals treating chronic wounds. We also hope that the document stimulates practitioners and scientists to adopt a translational research approach in the future.

List of Authors Kirsi Isoherranen (Editor) MD, PhD Helsinki University Central Hospital and Helsinki University, Wound Healing Centre and Dermatology Clinic, Helsinki, Finland Julie Jordan O’Brien (Co-Editor), RNP, MSc Nursing Advanced Nurse Practitioner Plastic Surgery, Beaumont Hospital, Dublin, Ireland Judith Barker, Nurse Practitioner Wound Management, Rehabilitation, Aged and Community Care Adjunct Associate Professor, University of Canberra, Canberra, Australia Joachim Dissemond (JD), Professor, MD University Hospital of Essen, Department of Dermatology, Venerology and Allergology, Hufelandstraße 55, Essen, Germany

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EWMA

Jürg Hafner, Professor, MD Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, Zurich, Switzerland Gregor B. E. Jemec (GJ), Professor, MD Department of Dermatology, Zealand University Hospital, Roskilde, Denmark Jivko Kamarachev (JK), MD, PhD Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, Zurich, Switzerland Severin Läuchli, MD, PhD Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, Zurich, Switzerland Elena Conde Montero, MD, PhD Hospital Universitario Infanta Leonor, Dept. of Dermatology, Madrid, Spain Stephan Nobbe (SN), MD Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, Zurich, Switzerland Department of Dermatology, Cantonal Hospital of Frauenfeld, Switzerland Cord Sunderkötter (CS), Professor, MD and chair Department of Dermatology and Venerology University and University Hospital of Halle, Ernst-Grube-Strasse 40, Halle, Germany Mar Llamas Velasco, MD, PhD Department of Dermatology, Hospital Universitario De La Princesa, Madrid, Spain

The document is supported by unrestricted educational grants from: Essity and PolyMem.

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EWMA

New EWMA Document Surgical Site Infections – Preventing and Managing Surgical Site Infections across Health Care Sectors On behalf of the author group, we are pleased to introduce the new EWMA Document on surgical site infections, which will be published during the summer of 2019 in the Journal of Wound Care. In the drafting of this publication, we have focussed on making the vast pool of published resources and guidelines available to readers in a more condensed and easily accessible format. Surgical site infections (SSI) are undeniably connected to the hospital setting, the patient, site of surgery and the surgical procedure itself. However, an often-overlooked aspect of SSI is its occurrence upon discharge from hospital to the home. This is why we have dedicated a special focus to the home care setting and the multidisciplinary approach needed to prevent SSI and secure treatment pathways outside the hospital setting.

Date and time: Thursday 6 June, 11.15 –12.15 Room: Session Room G2-G3

A

PREVENTING AND MANAGING SURGICAL SITE INFECTION ACROSS HEALTH CARE SECTORS

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SITE INF TIONS

The EWMA Document Surgical site Infections will be published as an online supplement to the Journal of Wound Care during spring 2019 and available for free download from the JWC website https://www. magonlinelibrary.com/ journal/jowc

Key Session: EWMA Document Presentation: Surgical Site Infection - Preventing and Managing Surgical Site Infection Across Health Care Sectors

EC

Kylie Sandy-Hodgetts BSc, MBA, PhD, Senior Research Associate. Faculty of Medicine, School of Biomedical Sciences, University of Western Australia.

SURGICAL SITE INFECTIONS RGIC

Learn more about the document at the EWMA 2019 Conference

SU

Jan Stryja MD, PhD, Vacular surgeon. Centre of Vascular and Miniinvasive Surgery, Hospital Podlesi, Trinec, The Czech Republic.

Speakers: Jan Stryja, Kylie Sandy-Hodgetts, Jennie Wilson and Karen Ousey.

A JOINT DOCUMENT

Aims, objectives and scope of document

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SSI is an unfortunate post-operative complication that affects many surgical patients worldwide, and the treatment of this type of wound is most likely to occur following discharge from an acute care setting. Whilst there are several guidelines for preventing and managing SSI in hospitals, there is an absence of guidelines for the optimum postoperative management in the home care setting. Furthermore, a set of recommendations on this topic covering primary and community health care professionals’ roles remains absent from clinical resources. The overall aims of this document are to: n Highlight present knowledge with regard to the prevention and management of SSI in the primary and community health care sectors. n Present a set of recommendations to guide clinical practice in the community setting for maximum patient healing outcomes following surgery.

More specifically, the main objectives of the document are to: n Map SSI incidence, prevalence and high-risk areas, based on published information and data available from SSI registries. n Present the principles of management of surgical wounds and the available modern techniques for the prevention and treatment of SSI across sectors. Correspondence: ewma@ewma.org

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n Provide a summary of evidence-based best perioperative practice recommendation to prevent SSI.

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Structure and content This document is presented in 10 chapters. Chapter 1 is the introduction to the document and describes the aim and objectives of the work. Chapter 2 presents the methodology and terminology used in the document. Chapter 3 describes the epidemiology of SSI, while Chapter 4 discusses principles of the management of surgical wounds. Chapter 5 presents a summary of best practices for the pre-, intra- and post-operative phases. Chapter 6 discusses principles of post-operative care, and Chapter 7 presents contemporary methods of wound assessment and discusses the diagnosis of infection. Chapter 8 reports on current treatments for the clinical management of SSI. Chapter 9 summarises the main conclusions of the document, with Chapter 10 providing a brief look at new developments and highlighting areas that require further research.

Author group Jan Stryja, (editor) MD, PhD, Vascular surgeon. Centre of Vascular and Miniinvasive Surgery, Hospital Podlesi, Trinec, The Czech Republic. Salvatella Ltd., Centre of Non-healing Wounds Treatment, Podiatric outpatients’ department, Trinec, The Czech Republic. Kylie Sandy-Hodgetts, (co-editor), BSc MBA PhD, Senior Research Associate. Faculty of Medicine, School of Biomedical Sciences, University of Western Australia. Mark Collier, RGN, ONC, RCNT, RNT, BA (Hons), Nurse Consultant and Associate Lecturer - Tissue Viability. Independent – formerly at the United Lincolnshire Hospitals NHS Trust, c/o Pilgrim Hospital, Sibsey Road, Boston, Lincolnshire, PE21 9QS Claus Moser, MD, Clinical microbiologist. Rigshospitalet, Department of Clinical Microbiology, Copenhagen, Denmark Karen Ousey, PhD, MA, PGDE, BA, RN, ONC, Professor of Skin Integrity. University of Huddersfield. Institute of Skin Integrity and Infection Prevention, Huddersfield, UK Sebastian Probst, RN, DClinPrac, Professor of tissue viability and wound care. HES-SO University of Applied Sciences and Arts Western Switzerland, School of Health Sciences, Geneva, Switzerland Jennie Wilson, Professor of Healthcare Epidemiology. University of West London, College of Nursing, Midwifery and Healthcare, London, UK Deborah Xuereb, RN, Senior Infection Prevention &infection Control Nurse. Mater Dei Hospital, Msida, Malta

The document is supported by unrestricted educational grants from: Abigo, Argentum Medical, BBraun, Essity, Mölnlycke Health Care, Ferris (Polymen) and Vancive Medical Technologies.

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EWMA

EWMA Publications

New and coming soon: Publications in 2019 New EWMA Document:

SURGICAL SITE INFECTIONS A

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TIONS

RGIC

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PREVENTING AND MANAGING SURGICAL SITE INFECTION ACROSS HEALTH CARE SECTORS

SURGICAL SITE INFECTIONS – PREVENTING AND MANAGING SURGICAL SITE INFECTIONS ACROSS HEALTH CARE SECTORS

SITE INF

This document will provide guidance on how to deal with SSI management and prevention in hospitals and community care. The document is developed in collaboration with Wounds Australia and the Association for the Advancement of Wound Care (USA). The document will be published as an online supplement to the Journal of Wound Care in spring 2019

A JOINT DOCUMENT

The topic will be covered in a key session during the EWMA 2019 Conference:

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Date and time: Thursday 6 June, 11.15 -12.15 Room: Session Room G2-3

ATYPICAL WOUNDS

New EWMA Document:

ATYPICAL WOUNDS - BEST CLINICAL PRACTICES AND CHALLENGES

BEST CLINICAL PRACTICES AND CHALLENGES

This document provides an overview of recent knowledge and evidence about atypical wounds, defined as wounds that cannot be placed in the primary categories of non-healing wounds. The document will be published as an online supplement to the Journal of Wound Care in May 2019 The topic will be covered in a key session during the EWMA 2019 Conference:

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Date and time: Wednesday 5 June, 13.45 -15.00 Room: Session Room F4-5

New EWMA Curriculum:

WOUND CURRICULUM FOR NURSES:

WOUND CURRICULUM FOR NURSES: POST-REGISTRATION QUALIFICATION WOUND MANAGEMENT – EUROPEAN QUALIFICATION FRAMEWORK LEVEL 6

POST-REGISTRATION QUALIFICATION WOUND MANAGEMENT EUROPEAN QUALIFICATION FRAMEWORK LEVEL 6

EWMA has finalised the second curriculum (EQF Level 6) in a series of curricula developed for education covering 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. The EQF Level 6 curriculum was published as an online supplement to the Journal of Wound Care in February 2019.

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The implementation of standardised wound management curricula are discussed in the EWMA Education session during the EWMA 2019 Conference: Date and time: Wednesday 5 June, 13.45 -15.00 Room: Session Room G1

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New E-Learning Course BASIC WOUND MANAGEMENT

In January 2019, EWMA published a set of e-learning modules on the basics of wound management, targeting health care professionals and medical students with no specialisation in wound management. The aim of the course is to support a high level of care in organisations with wound patients (hospitals, nursing homes and home care units) and provide materials that may be used in education. The course is free of charge and can be accessed via EWMA’s e-learning platform. For more information about the course and the content of each module, please visit e-learning.ewma.org.

New E-Learning Module:

EWMA & BSAC E-LEARNING COURSE ON ANTIMICROBIAL STEWARDSHIP IN WOUND CARE This course will be available on FutureLearn.com in the summer of 2019.

Coming up: EWMA Projects and Publications in 2020 EWMA Document:

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BIRTH-RELATED WOUNDS

The objective of this project is to develop resources targeting health care professionals who provide care to women who have undergone childbirth (vaginally or by caesarean section). The objective will be to enhance the wound management skills of these professionals, thereby supporting the prevention and treatment of birth-related wounds and post-caesarean section infections. Expected publication: Spring 2020.

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EWMA Project:

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PERSON-CENTRED CARE - PATIENT EMPOWERMENT IN WOUND MANAGEMENT With this project, EWMA aims to develop resources supporting best practice approaches to patientcentred care in wound management. The project places the patient ‘at the heart of decision making’ by helping caregivers to identify effective strategies for supporting patients in taking co-ownership in the treatment process and engaging in self-care. Expected publication: Spring 2020.

For download or more information about the above publications and initiatives, please visit www.ewma.org or contact the EWMA Secretariat: ewma@ewma.org

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Adipose tissue is potential autologous cell and extracellular matrix (ECM) source that can be used as an engineered skin equivalent material. ROKIT HEALTHCARE developed a procedural technology that easily separates MA-ECM (minimally manipulated autologous-extracellular matrix)-Stromal Vascular Fraction (SVF) micro-cluster from lipoaspirate and turns those into a custom shaped tissue engineered dermis using 3D bio-printer ‘INVIVO’ (ROKIT HEALTHCARE, Inc, Korea) within 1hr after liposuction. Stromal vascular fraction (SVF) is a multi-cell complex containing ADSCs (adipose-derived stem cells), fibroblasts, endothelial cells, epithelial cells, and macrophages. As a whole ECM, adipose derived ECM consists of more than 300 proteins and associated cytokines, provides an optimal 3D biomechanical environment and promotes cellcell and cell-ECM interaction to stimulate ECM production and vascularization for skin regeneration. INVIVO 3D bio-printing enables three dimensional cell printing with uniform density and reproducible cellular arrangement, and suture free lamination and customized wound shape and depth. Our global clinical trials (Korea, US, Turkey, Slovakia, Italy, and India) are showing excellent wound healing for scar revision, burn treatment and diabetic foot ulcer indications. ROKIT HEALTHCARE present some of the ongoing clinical trial progress at EWMA 2019. Detailed information for the special symposium will be announced by e-Blast email.

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EWMA

EWMA Wound Curriculum for Nurses EQF Level 6

Sebastian Probst RN, DClinPrac, Professor of tissue viability and wound care. HES-SO University of Applied Sciences and Arts Western Switzerland, School of Health Sciences, Geneva, Switzerland

Taking care of patients with an acute, chronic or palliative wound is complex. To recognise this complexity and to maximise patients’ and their families’ outcomes, clinicians should acquire appropriate evidence-based and best practice WOUND skills and knowledge. LUM

CURRICU S: FOR NURSE

Samantha Holloway RN, MSc. Reader. Centre for Medical Education. School of Medicine. Cardiff University Wales, UK

TRATION POST-REGIS N WOUND O TI A QUALIFIC NT E M E G A N MA N A E EUROP ON QUALIFICATI K R O W E FRAM LEVEL 6

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Sara Rowan RN PgDip, MPhil. Lecturer. C3S – Clinical Scientific Support Services CRA for NAMSA Ltd, Selby UK

To achieve this goal, the European Wound Management Association (EWMA) has developed curricula for nurses that are in line with the curriculum on wound healing for physicians that has been approved by the European Union of Medical Specialists (UEMS) (European Union of Medical Specialists, 2017). In 2017, EWMA published the Level 5 curriculum (Pokorna, Holloway, Strohal, & VerheyenCronau, 2017), with the goal of equipping nurses with the responsibility and autonomy to obtain skills and knowledge for exercise management and supervision in wound care activities where there is an unpredictable change. Nurses are also trained to review and develop their own and others’ performance. With the new curriculum Level 6 (Probst, Holloway, Rowan, & Pokorna, 2019), journal of the european wound management association 

nurses will acquire advanced skills, demonstrating the mastery and innovation required to solve complex and unpredictable problems in wound care. They will also acquire advanced knowledge of wound care involving a critical understanding of its theories and principles. With these skills and knowledge, nurses should be able to manage complex technical or professional activities or projects, taking responsibility for decision-making in unpredictable work or study contexts and taking responsibility for managing the professional development of individuals and groups. The Level 6 curriculum is designed in a modular structure and includes 19 units (see table 1) of study with a minimum of 116 learning units of 45 minutes’ duration and 59 hours of self-directed 

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Andrea Pokorná RN, PhD, Professor, Senior Lecturer, Medical Faculty, Masaryk University, Dept. of Nursing. Brno, Czech Republic. Institute of Health Information and Statistics of the Czech Republic, Department of quality of care assessment, Head of Department Prague, Czech Republic

Correspondence: ewma@ewma.org

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learning, 50 hours of clinical practice and 50 hours of exam preparation. The educational level and learning outcomes are aligned with the European Qualifications Framework (EQF) (European Commission, 2019) according to competence Level 6. After successful completion,

11 ECTS credits (European Credit Transfer and Accumulation System) in wound management can be achieved. This curriculum can be downloaded free of charge from the EWMA homepage. m

Table 1. Units of the Level 6 curriculum for nurses.

Unit Number

Title

1

Role of prevention in wound care

2

Evidence-based nursing/evidence-based practice

3

Patient education and promoting self-care

4

Case management (patient-centred care)

5

Wounds and wound healing

6

Nutrition and wound healing

7

Moist wound healing

8

Microbiology and wounds

9

Antimicrobial agents, hygiene and wounds

10

Acute wounds

11

Debridement and wounds

12

Alternative treatment options for wounds

13

Pressure ulcers

14

Diabetic foot syndrome

15

Lower leg ulcers

16

Skin tears

17

Palliative wound care

18

Healthcare delivery and health economics

19 Documentation

EWMA Wound curricula will be discussed at EWMA 2019 Conference Education Session: Date and time: Wednesday 5 June, 13.45 - 15.00 Room: Session Room G1

REFERENCES European Commission. (2019). How does the European Qualifications Framework (EQF). Retrieved from https://tinyurl.com/hkca4mg European Union of Medical Specialists. (2017). Training Requirements Wound Healing for all Medical Specialties, which include Wound Healing in their Curricula. Retrieved from https://tinyurl.com/ yaa23uy9

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Pokorna, A., Holloway, S., Strohal, R., & Verheyen-Cronau, I. (2017). Wound Curriculum for Nurses. J Wound Care, 26(Sup12), S1-S27. doi:10.12968/ jowc.2017.28.Sup12.S1

Probst, S., Holloway, S., Rowan, S., & Pokorna, A. (2019). Wound Curriculum for Nurses: Post-registration qualification wound management - European qualification framework level 6. J Wound Care, 28(Sup2a), S1-S33. doi:10.12968/jowc.2019.28. Sup2a.S1

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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

The joint Pressure Ulcer Prevention and Patient Safety Advocacy Project of the European Pressure Ulcer Advisory Panel (EPUAP) and EWMA is now in its third and final year.

Andrea Pokorna2 Professor, Department of Nursing, Faculty of Medicine, Masaryk University, Brno

The project is continuing some activities from the previous years, including the publishing of joint statements and articles, of which the most recent is included below this box, and a collaboration with the OECD Health Care Quality Outcomes project. The project team is currently working on the finalisation of a generic patient case study to exemplify the patient and health economic value of preventing pressure ulcers from occurring. Case studies are a recognised way of highlighting complex problems from patients’ and lay carers’ perspectives. In terms of following up on the earlier organised activities with members of the European Parliament and the European Commission, EPUAP and EWMA are working to organise a roundtable session at the European Parliament during late autumn 2019.

Lisette Schoonhoven2 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

During the EWMA 2019 conference, the joint project will host the following session. More details are available at ewma2019.org.

1 Chair

of the Joint EPUAP & EWMA Pressure Ulcer Prevention & Patient Safety Advocacy Project

Thursday 6 June, 8.30 – 9.30: The joint EPUAP-EWMA Pressure Ulcer Prevention and Patient Safety Advocacy Project Session The article below, as well as earlier articles and updates about the project, are available from the EWMA.org and EPUAP.org websites.

2 Member of the Joint EPUAP & EWMA Pressure Ulcer Prevention & Patient Safety Advocacy Project

Disability in Europe: The invisible burden of pressure ulcers Over a billion people, about 15% of the world’s population, have some form of disability, with 80 million of these people living in Europe.1 People with disabilities have the potential to make an enormous contribution to our society, culture and economy. However, they often face barriers that prevent them from participating in society and commonly do not receive adequate care. At an international level, through the EU institutions’ actions and the Convention on the Rights of Peoples with Disabilities (CRPD), EU member states committed to cooperating to ensure the rights of journal of the european wound management association 

EU citizens with disabilities. These include the right to participation in society on an equal basis, as well as the rights to good quality of life and health. Despite this commitment, there are still many unaddressed challenges to meet the health needs of people with disability. Depending on the group and setting, people with disabilities encounter greater risks of comorbidities, age-related and secondary conditions, compared to their counterparts without disability. 

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Correspondence: ewma@ewma.org Conflicts of interest: None

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As a result, they have a higher rate of premature death. Furthermore, these people are particularly vulnerable to the deficiencies in healthcare delivery, yet these deficiencies can be addressed to avoid morbidity and premature mortality. Secondary conditions commonly occur in addition to (and related to) the primary health condition, thus, they are predictable and often preventable. In the case of people with disabilities, these conditions include urinary tract infections, osteoporosis, avoidable pain, and pressure ulcers. Pressure ulcers, also known as bed sores, pressure sores, or decubitus ulcers are wounds caused by constant pressure on the skin and underlying tissues, arising because the person sits or lies in one position for too long, not being able to change the position actively. They usually develop on body parts such as the elbow, heel, hip, shoulder, back, and back of the head. People with disabilities who are bedridden, or use a wheelchair, have a high risk of developing this secondary condition which can lead to further disability, decreases in mobility, loss of independence, increased isolation, the need for surgical interventions, and even fatal infections. The risks factors for pressure ulcers in people with disabilities are multiple: reduced mobility or paralysis, injury completeness, moisture from bowel or bladder incontinence, loss of feeling, muscle atrophy and being underweight. A constant monitoring of those at risk is essential to enable prompt action and to avoid leaving symptoms unnoticed (when the person has sensory issues, they may not feel the intense pressure being placed on an area of the body). People with Spinal cord injuries (SCI) often develop pressure ulcers, and in this population, pressure ulcers are a serious complication, which often lead to regular hospitalisations, multiple surgeries, and other devastating complications. Although preventable in most situations, pressure ulcers may disrupt rehabilitation, prevent people with SCI from working, or participating in society, and therefore interfere with their community reintegration. Data from the United States revealed that people with SCI are among the highest risk population for developing pressure ulcers; the incidence in SCI population is up to 66%.2 Furthermore, the lifetime risk of developing a pressure ulcer among those with SCI is up to 90%.3 Acting to improve quality of care of those in need is not only possible, but also necessary. For those who use a wheelchair, or are bedridden, preventing secondary conditions, or comorbidities is a life-long commitment which requires understanding, cooperation and initiative. Col-

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laboration within healthcare team is essential to develop a prevention plan that includes effective strategies and all possible actions – from position changes to use of special cushions and mattresses, ensuring adequate nutrition and hydration, and daily skin care. Also, pressure ulcer care requires constant monitoring, thus rehabilitation nurses should use a consistent framework with accurate quantification to assess, document, and monitor changes in the individual and the pressure ulcer over time. EPUAP and EWMA are at the forefront of raising the awareness at EU level about pressure ulcers, wound care and patient safety. The commitment and expertise of these groups have been instrumental in building support for a consistent epidemiology measurement and methodology in Europe. Looking at the challenges of disabilities and health outcomes, EPUAP and EWMA believe that the EU has a role to play in guiding and supporting its’ member states to increase awareness of the needs of people with disability and include related secondary conditions as a component of national health policies and programmes. It is also essential to promote strategies to ensure that people with disabilities are knowledgeable about their own health conditions and risks. Informal carers should also be educated. Building on the current European Disability Strategy 2010-2020, a follow-up strategy shall look into creating synergies amongst member states on better health services for people with disabilities and the prevention of costly secondary conditions. In this sense, the Academic Network of Disability Experts (ANED), supported by the European Commission and the EU countries, might be instrumental in providing new analysis and information on national disability policies and the impact of secondary conditions, such as pressure ulcers. Join EWMA and EPUAP campaign on pressure ulcers’ prevention and help to spread our message #Europe4PUprevention. m

REFERENCES 1. World Health Organization, Disability and Health: key facts, available at: https://www. who.int/news-room/fact-sheets/detail/disability-and-health 2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3831318/ 3. Kruger E A, Pires M, Ngann Y, Sterling M & Rubayi S, Comprehensive management of pressure ulcers in spinal cord injury: current concepts and future trends, J Spinal Cord Med 2013, 36, 572-85.

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EWMA

A Storytelling Journey:

Living With Chronic Wounds In 2018 EWMA promoted a project revolving around the patient’s perspective on wound care. To realise the project, filmmaker and storyteller Aurora Piaggesi visited six wound care centres across Europe, interviewing and filming patients with chronic wounds and their relatives and caregivers, focusing on the experience of what “living with chronic wounds” means. The following is the story of this experience, from Aurora Piaggesi’s point of view.

Aurora Piaggesi Storyteller and filmmaker

Swiss patient tells his story to Aurora Piaggesi.

It was back in 2016 when I first heard the story of a patient living with a chronic wound. Surrounded by spinning fans while seated in a comfortable and well-furnished kitchen during an extremely hot summer in Florence, I met with L.N., a 62-year-old gentleman with diabetic foot, at the time in the process of healing from a surgery that had cut away three of his toes. He could not leave the house to reach for a fresher environment, nor stay barefoot. Yet, what a nice host he journal of european wound management association 

was! He offered me coffee and started telling the story of his disease in front of my camera, like he had done nothing different in his whole life. He told me how he had found out that he had type 2 diabetes, how he faced the struggle of not being able to work and provide for his family, how, at some point, he had been left behind by the professionals who were supposed to help him heal, and, finally, how he met those who were leading him to comprehension of his condition and, therefore,

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More information: www.aurorapiaggesi.com www.ewma.org Correspondence: ewma@ewma.org

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Lead nurse and consulant Mark Collier at Pilgrim Hospital in Lincolnshire during the LWCW tour.

safety. Some days later, I joined him during his appointment at the DF Clinic, where his doctor and podologist took care of his wound and, soon after, told me the same story from their perspective. This was the first step of what was to become an international storytelling project that would involve more than six countries and dozens of people across Europe. How it all began Being the daughter of two doctors, I have always been surrounded by medical terminology and practices but, having chosen a different - more literary - field, I was never actually able to fully grasp the meaning of what I heard and saw. I could not help but to think: What would I have done if I suffered from the conditions my parents’ patients were suffering? Would I be able to understand what was happening and deal with it in the most proper way? How would those diseases would affect my lifestyle? Could a better communication between the patients and the caregivers improve the quality of the experience of suffering from a chronic pathology? These considerations, which I shared with some wound management specialists, led to the embryo of a project: What if we analysed a clinical case from multiple points of view? What if we created a showcase of different diseases that could be approached by people from different cultural backgrounds and medical knowledge? What if, at the same time, we could create a way for clinicians and patients to better understand each other? With these questions in mind, I edited the footage I had as 116

a pilot for a project, initially called The Patient’s Perspective, creating three different videos with the same footage. One was focused more on the patient’s perspective and language, a short video of 5 minutes. The second was targeted to doctors, and the language changed accordingly. But I kept some extracts from the interview of L.N. to create a composition between the knowledge of the doctor on the subject and what impact this knowledge had had on the patient’s life. The third segment, short as the other two, focused on how the institutions and the regulation system could affect the practice and, consequently, the patient’s life and care. One could choose whether to watch these three short videos one after another, or just the perspective they were interested in. This pilot is now uploaded on the EWMA website. The project was then submitted to the EWMA Council as a strategic initiative for 2018/2019: more clinical cases from different countries had to be involved. The Living with Chronic Wounds Tour The EWMA Council endorsed the project Living With Chronic Wounds on January 2018. On 9 July, I took the first of the six flights I was going to take that summer. Six centres from six countries in Europe joined the project and selected one or more clinical cases for me to focus on. Together with the scientific responsible, I wrote four lists of questions to give to each group of participants. One was for the patients, one for their family and caregivers, one for the health-care professionals and, lastly, one for the representatives of the local health institutions. The

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questions, varied in language and structure, focused all on how the chronicity of the wound may affect peoples’ lives and communication between healthcare professionals, the patients and their families. Finland The first city I visited was Helsinki, in Finland. I was extremely impressed both by the temperature and light I encountered as by the local team, led by EWMA Council member Kirsi Isoherranen, MD, Specialist in Dermatology at Skin and Allergy Hospital. The morning after my arrival, I was accompanied to a patient’s house for my first interview. I.L. lives in a lovely and cosy apartment with her two daughters. When I visited her, I followed the practice of getting my shoes off, and admired her long dress. She offered us cake and coffee, and sat on a comfy sofa to tell the story of a 20-years-long condition that profoundly affected her life. When she was 18, she was diagnosed with a stomatitis. Beside all the pain and surgeries during those 20 years, she had to face the impossibility of having a normal life since, as she said, her day used to “revolve around the toilet”. Her big, white and comfortable bathroom was the playground where her children used to spend their time, if they wanted to be together with their mother. I also interviewed the children and I.L.’s mother to have their perspective on what I.L. had experienced during the course of her life. It was a moving and tear-jerking moment for all the people in the room. During my three days in Helsinki, I managed also to pay a visit to the Dermatology Unit and interview Dr. Isoherranen and her team. After that, it was time to leave for the Czech Republic. Czech Republic I took a train from Prague to Trinec, in the eastern part of Czech Republic, close to the Polish border, where I spent one day in the clinic managed by EWMA Council member Jan Stryja, MD, vascular surgeon at the Cardiovascular Centre of Hospital Podlesi. There, I met with P., one of Dr. Stryja’s patients, affected by venous leg ulcer. She impressed me as an extremely strong and positive woman, despite the difficult condition she was experiencing. She had to take care not only of her wound, but also of her 28-year-old disabled son and her elderly parents. Like I.L., P. mentioned a breakup due to her disease. And yet there she was, sitting on the sofa at her lovely house in the countryside, serving biscuits and aromatised water, or joking with the nurse while being treated in Dr. Stryja’s office. She told me that with that team, she finally felt accepted as a human being and treated respectfully. In the past, she had encountered physicians that didn’t even want her to sit on their chair because she was “too fat”. She said that at those times, she didn’t feel the motivation to heal, journal of the european wound management association 

because she had no one that could understand her pain and discomfort. Now, with Dr. Stryja, she was finally at peace, and her wound was better than ever. Before heading back to Prague, where I would catch my plane for Montpellier, France, I also paid a visit to EWMA Council member Andrea Pokorná, Associate Professor at Masaryk University in Brno. Inside the modern and functional building, she shared with me a cup of coffee and some impressions on the relationship between the Czech Health System and the professionals’ capability of applying the good practises developed on a European level. France When I landed in the south of France, summer got to me abruptly. The citizens of Montpellier were waiting with great excitement and anticipation the final match of the Football World Cup. On an extremely hot Sunday, I walked my way, camera equipment on my back, to Hòpital Lapeyronie, where I had my appointment with the next chronic wound patient. I knew that he was going to be admitted that evening for a surgery that he had planned for the following day. I wanted to be there to record his arrival. Forty sweaty minutes later, I reached a building surrounded by a nice pine park, where families of the inpatients had set for picnics to watch the game on portable TVs and laptops. I wandered through the silent corridors of the hospital until I reached the section I was looking for. There, in an interesting mix of English and French, I had a short conversation with a kind nurse who informed me that monsieur M. decided to stay at home for the night in order to see the match. He was going to be hospitalised the next day. I took a cab back to my hotel. France had won. The next morning, I arrived at the hospital very early, and yet I managed to miss M.’s arrival. When I entered his room, he was lying on his bed, the national team T-shirt still on, while he was watching commentaries on the previous night’s game. If I had felt a little mistreated the day before, I could not help but forgive him. To be hospitalised, he had to travel from Perpignan, almost two hours of driving. He would have surely missed the match, and one could immediately tell that M. loved sports. He had a bad incident 17 years ago, while riding his motorcycle. Since that day, he had been paralysed from the torso down. His surgery, that afternoon, was to heal a decubitus lesion on his lower back. I sat down to talk to him about his experience and I was there when two nurses entered the room to prepare him for his surgery. I watched the look in his eyes as he was being washed. I expected to find embarrassment, and there was some, in a minor part. I was not sure why, exactly, until he turned on his right side and I saw what he had tattooed on his back: a leopard. A fierce, proud feline.

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And there, I saw all the powerless rage, the hurt pride of a strong, passionate man in his 40s, dealing with a condition that put him constantly in a submissive status, in the hands of strangers, his nakedness exposed. I left the room. While I waited for him to come back from the operating room, I sat in the corridor thinking about the fables of the mouse that takes out a spike from the lion’s paw. Switzerland I spent the next five days in Geneva, enjoying the charming company of EWMA Journal Editor Sebastian Probst, Professor in Wound Care at the University of Applied Sciences Western Switzerland, and his colleague, Chantal Rosset. They showed me the clinic that they manage, which specialises in chronic wounds. I met with a variegated group of patients, some older, some younger. I filmed them as they were treated by Chantal and her colleagues or at home. One of them, an elderly gentleman, struck my heart by criticising all the questions I had meticulously prepared for our interview. The small but modern and comfortable clinic appeared to be like a little paradise in green and purple. The patients I met expressed their trust toward those who were taking care of them. They felt heard, accepted. Understood. A subject that caught my interest, as a young woman, was how women described their relationship with their femininity and their wounds. A woman in her 30s told me that she felt embarrassed to go out with men, as she was afraid that her wound would leak or smell. Another lady got my attention as she was treated for a wound on her breast. She laid with her palms resting on her stomach. I could not help but notice how nice her manicure was, how sparkling her jewellery was. She had a surgical knife working in her infected breast wound and still she looked extremely feminine and composed. I felt the urge to film those hands. United Kingdom My last stop was in an unusual sunny and hot Britain. I took a train from London to Lincoln, where I was joined by former EWMA Council Member Mark Collier, Lead Nurse and Consultant on Tissue Viability at the United Lincolnshire Hospitals. We drove through the English countryside to reach S. at her lovely cottage, quite in the middle of nowhere. S. is in her 60s, has type 2 diabetes and her venous leg ulcer is just starting to get better. Still, she is not able to leave her house for more than a few hours. She cannot climb the stairs to the bedroom she shares with her husband. Therefore, now, she sleep in a small room at the entrance of the house, so that every morning, when the home nurse arrives to change her bandage, she can easily reach for the door and open it. There were four of us in that tiny room. S. sat on the bed while the nurse treated her. I kept walking in and out the house. I had

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never felt so hot in the UK before in my life. I could not imagine how S. would have felt. When I turned the camera on to interview her, she wasn’t shy at all. She spoke for a very long time, telling anecdotes and personal stories so interesting that I had repeatedly to ask Mark not to react loudly, because that would have ruined the recording. S. described very vividly the frustration she was experiencing in that hot summer day. She would not find any workplace that would have accepted her. She could not travel. She could not have intimacy with her husband anymore. Again, there were tears in the room, and she was not the only one slipping them. When I left the UK to come back to my country, I had my mind full of thoughts and my heart full of emotions. As I catalogued the many clips of video I had collected, I could not help but notice how unique every story and environment was, and yet how similar some situations might have been. I travelled across seven countries, visited hospitals, clinics and houses. I interviewed doctors, nurses, academics and, more importantly, patients. I heard and recorded their firsthand experiences. I encountered men and women, old and young people, patients on their way to heal from their chronic condition and patients who have just started the journey. Nevertheless, no matter who they were, where they lived and what they were suffering from, all shared a perception of their wounds as a strange presence on their body, something that made them change how they perceived themselves and affected deeply their lifestyle and, in particular, their ability of intimacy with another person. Many of them experienced a breakup from very important relationships because of their disease. Many of them felt that their condition had been mistreated and not understood at some point of their life. They had felt ashamed, guilty and alone. But all of them felt relief in finding someone who would listen to them and in being in the care of professionals who would understand what they were going through. And, most of all, all of them wanted to tell their stories. m

The interviews and the films will be used to produce educational movies and tutorials, which will be available on the EWMA website. The entire project will be presented at the EWMA 2019 Conference: Living with Chronic Wounds Focus Session Date and time: Friday 6 June, 11.15 - 12.15 Room: Session Room F1-2

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Expose wounds to a physiological moist environment to enhance natural healing processes. Provide optimal moist environment. Protect exposed ner ve endings thereby produce analgesic effect. Assist in autolytic debridement by liquefying and discharging necrotic tissues. Create antimicrobial environment. Prevent scar formation & improve scar quality. Promote skin regeneration in situ.

Indications Mild, Moderate & Severe Burn

Venous Ulcers

Donor Site

Traumatic Wounds

Diabetic Foot Ulcers

Dermatological Disease

Pressure Sores

Surgical Wounds

MEBO International F31, Building A, The Spaces International Center, 8 Dongdaqiao St, Chaoyang District, Beijing, China, 100020 www.mebo.com Contact: wuyun@mebo.com


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

Hypertension

Chronic Metabolic Disturbance

Cardiomyopathy

Diabetes

Atherosclerosis

Cardiac Failure

Vasculopathy

Neuropathy

Trauma

Visual Impairment

Nephropathy

Alberto Piaggesi Jan Apelqvist

Ulcer Progressive Retinopathy

Infection

Dyslipidemia

Amputation

Dialysis

Depression

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 w.karger.com/f id Karger – Medical and Scientific Publishers CH–4009 Basel, Switzerland orders@karger.com, f: +41 61 306 12 34 www.karger.com

KI17454_EWMA

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


EWMA

New Project of the EWMA Patient Outcome Group:

New EU Medical Device Regulation (MDR): Challenges and Opportunities The EWMA Patient Outcome Group The EWMA Patient Outcome Group (EWMA POG) was created in 2008. Members of the group have a clinical scientific background and include both clinicians and representatives from companies working within wound healing. The overall objective of the group is to address topics such as the structure of treatment and the quality of traditional clinical trials and evidence in wound care. The group is concerned with the approval and reimbursement of wound care services, including the regulation of patient access to high quality wound management. This article describes a recent initiative of the EWMA POG, addressing new EU regulations for medical devices. Challenges and opportunities related to the new medical device regulations In 2018, the EWMA POG focused on the effects of the implementation of two new EU regulations for medical devices (MDR), from both the industry perspective and that of health care professionals and researchers. These new regulations entered into force on 25 May 2017 and entail increased requirements and documentation for advanced wound care, leading up to the full implementation of the regulations in May 2020. With this initiative, the EWMA POG aims to explore the possibilities for a joint dialogue (led by industry and health care professionals) with the regulatory authorities concerning the MDRrelated challenges and opportunities defined by

Jan Apelqvist Chair of the EWMA Patient Outcome Group

wound care health professionals and the industry. The EWMA POG has prioritised this initiative and emphasised its importance in light of the farreaching consequences that the MDR changes may prompt in terms of optimal patient care. For EWMA, the availability of effective wound care therapies is of the highest priority. An optimal regulatory environment should guarantee healthcare professionals and their patients a full spectrum of wound care diagnostics and therapeutic solutions that have proved their value in everyday clinical practice. Furthermore, regulations should neither hamper nor stop the development of, or access to, new wound care therapies, as these are likely to have a significant impact on improving patients’ burdens and quality of life in a positive direction. EWMA hopes that this focus on MDR will facilitate continued market access and the development of innovative wound care portfolios by the companies and support high quality research in wound management. With the increased need for data related to the MDR requirements for product approval and post-market surveillance, EWMA would like to discuss the related opportunity to establish Pan-European databases for wound management data collection. If you are interested in learning more about the ongoing transition from previous directives to MDR and discussing the related challenges and opportunities for the industry and health care professionals, you should attend the EWMA-hosted workshop on the topic. It will be held during the 

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EWMA

Medical Device Regulation workshop Thursday 6 June, 14.15 Session room F3 Dr Edwin den Braber

Presentation and Q&A with - Dr Edwin den Braber, PhD, Managing Partner, GR Consulting LLC

Dr Bernhard Weber

Marcia Nusgart

- Dr Bernhard Weber, Associate Director Quality Management & Regulatory Affairs Healthcare products at Diapharm GmbH & Co. KG - Marcia Nusgart, Executive Director, Alliance of Wound Care Stakeholders (US) Topics: n

Current status; what is changing with MDR?

n

Transition into MDR; how will wound care products be influenced?

n

Looking forward; what can industry and health care professionals do?

n

Perspectives on the new European MDR as seen from the US

n

Open discussion

EWMA 2019 conference in Gothenburg, where two regulatory experts will introduce the MDR requirements and procedures and lead the discussion.

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To learn more about the EWMA POG initiative and workshop, please contact the EWMA secretariat at ewma@ewma.org.

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EWMA 2019

THE EWMA UNIVERSITY CONFERENCE MODEL (UCM) IN GOTHENBURG

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.

PARTICIPATING INSTITUTIONS:

The UCM programme at the EWMA 2019 Conference in Gothenburg 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. Yours sincerely Christian MĂźnter Chair of the Education Committee

EWMA

Knowledge Centre Access EWMA webcasts, e-Posters, documents and abstracts www.ewma.org

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


EWMA

Post-caesarean Section Surgical Site Infections:

Anna Rose MD, Adademic FY2, Queen Elizabeth University Hospital,Glasgow, Scotland

A retrospective Audit and Case-note Review at a large Ethiopian Referral Hospital Anna Rose was awarded a travel grant by EWMA in 2016 for her project in Ethiopia exploring the incidence of surgical site infections following caesarean delivery. This is Rose’s report on the risk of infections during childbirth in low-income settings. Anna Rose with one of the obstetrics and gynaecology surgical residents.

EWMA provides travel grants to young practitioners who wish to develop their skills within wound care and wound management abroad. The travel grants will primarily be given for educational purposes or clinical experiences outside the applicants’ own countries. Next deadline for applications: 15 February 2020 More information www.ewma.org

Correspondence: ewma@ewma.org

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I am currently a fifth-year medical student at the University of Aberdeen, Scotland. During our final year of study, we have the opportunity to undertake a two-month period of research at an institution of our choice. I have a keen interest in academic surgery, particularly in a global health context, so I travelled to Ethiopia to investigate the management of surgical site infections after caesarean delivery. In low-income settings, infection acquired during childbirth is a leading cause of death amongst women of reproductive-age, and delivery by caesarean section (CS) is one of the most significant risk factors, largely due to complications arising from surgical site infections (SSIs).1,2 The risk of postCS wound infection depends on many factors, including the timing and use of prophylactic antibiotics.3 Improved outcome is possible through continuous quality improvement of service provision.2 Numerous studies have demonstrated that many SSIs can be prevented if evidence-based interventions are implemented.4-6 The suggested three-step “bundle” for preventing SSIs includes the appropriate selection and timing of prophy-

lactic antibiotics, avoiding razor shaving and optimising pre-operative skin hygiene and skin preparation.4 In January 2017, thanks to the generous support of the European Wound Management Association, I travelled to the city of Bahir Dar, Northern Ethiopia, to spend seven weeks at Felege Hiwot Referral Hospital. With only 400 beds, it provides medical and surgical care for the surrounding population of between 7 and 9 million people. The aim of my visit was to undertake a retrospective audit and case-note review of surgical site infections (SSIs) occurring after caesarean section during a two-month period. For women who developed a SSI, additional details on preand post-operative management were recorded. Potential associations between SSI and risk factors (including maternal, delivery and operative characteristics) were explored using binary logistic regression. Significant results were indicated by 95% confidence intervals. Patient education regarding wound infection prevention was indirectly evaluated through reading case notes.

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EWMA

Felege Hiwot Referral Hospital.

The operating theatres within the maternity department.

Between 1 October and 31 November 2016 there were 1,043 deliveries. Of these, 718 were vaginal deliveries (68.9%) and 325 were CS (31.2%). Out of 325 CS, medical records of 247 (76%) were analysed. The leading indication for CS was previous CS. The overall incidence of SSI was 8.6% of all CS (21 cases), including 14 incisional SSI (14/21, 66.6%) and 7 organ/space infections (7/21, 33.3%). Only three cases were detected prior to discharge. Of all SSIs, only one woman received blood cultures and, despite many cases presenting with wound discharge, no wound swab analysis was performed. Undertaking microscopy, culture and sensitivity testing is a critical step in the management of infections to improve the chances of successful eradication and minimise the risk of antimicrobial resistance.

watch for (wound discharge, headache, fever, increasing pain), yet no specific advice on personal hygiene or wound management was given. With post-CS infection, prevention is better than cure and the appropriate use of antibiotic prophylaxis can prevent the onset of SSIs. I was surprised by the number of women who did not receive appropriate surgical antimicrobial prophylaxis as a result of poor documentation and prescribing. Practice should be changed to improve documentation and antibiotic prescribing both before and after surgery.

From this audit, factors associated with a significantly reduced risk of SSI included attending antenatal care, a normal pre-operative haemoglobin, the absence of pregnancy complications and intact membranes before CS. Nonsignificant associations with an increased risk included younger maternal age, having a first delivery, a positive maternal HIV status, unplanned CS, increased duration of membrane rupture before CS, a midline surgical incision and not receiving pre-operative antibiotics. A large number of women did not receive appropriate antibiotic prophylaxis, either before or after surgery, largely due to poor documentation. Regarding patient education, general advice was provided on when to have stitches removed and danger signs to

My experience has demonstrated the importance of basic wound principles in preventing infection, namely surgical antimicrobial prophylaxis and basic wound management. In order to reduce the incidence of post-CS SSIs, efforts should be made at both an institutional and individual level. In a low-resource setting such as Ethiopia, the large majority of people live in the rural area without access to running water. Bathing and washing is often performed using water from the local well or lake. A great deal of attention is paid to pre-operative skin preparation and sterile dressing, yet once the patient is discharged this is neglected. In the community, the level of patient education regarding wound management is minimal. On numerous occasions, I witnessed wounds dressed with pieces of material and not kept clean and dry. These basic principles of wound management are relatively simple to implement, but often neglected. Patients should be properly counselled regarding immediate wound management, with an emphasis on personal hygiene. m

REFERENCES 1. Leth RA, Møller JK, Thomsen RW, Uldbjerg N, Nørgaard M. Risk of selected postpartum infections after cesarean section compared with vaginal birth: a five-year cohort study of 32,468 women. Acta Obstetricia et Gynecologica Scandinavica 2009;88(9). 2.

van Dillen J, Zwart J, Schutte J, van Roosmalen J. Maternal sepsis: epidemiology, etiology and outcome. Curr Opin Infect Dis. 2010.

3. Weinberg M, Fuentes JM, Ruiz AI, Lozano FW, Angel E, Gaitan H, et al. Reducing Infections Among Women Undergoing Cesarean Section in Colombia by Means of Continuous Quality Improvement Methods. JAMA Internal Medicine 2001;161(19).

5. Horan TC, Andrus M, Dudeck MA. CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting. Am J Infect Control 2008;36(5).

4. Corcoran S, Jackson V, Coulter-Smith S, Loughrey J, McKenna P, Cafferkey M. Surgical site infection after cesarean section: Implementing 3 changes to improve the quality of patient care. Am J Infect Control 2013 12;41(12):1258-1263.

6. Fehr J, Hatz C, Soka I, Kibatala P, Urassa H, Smith T, et al. Risk Factors for Surgical Site Infection in a Tanzanian District Hospital: A Challenge for the Traditional National Nosocomial Infections. Infection Control Hospital Epidemiology 2006.

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EWMA

‘Time is not on our side. We need urgent action’ Jan Stryja EWMA Antimicrobial Stewardship Chair.

EWMA participated in the European Joint Action on Antimicrobial Resistance and Healthcare Associated Infections (EU-JAMRAI) first Annual Meeting and Stakeholder Forum in Vienna, Austria on 8 - 9 November 2018.

EWMA – BSAC initiative acknowledged by the EU-JAMRAI The joint EWMA – BSAC position paper ‘Antimicrobial stewardship in wound care’ (2016) has been adopted in the EU-JAMRAI repository as part of their libraries of highquality stewardship guidance which is a delivery under Work Package 7. The paper is included under the following categories: - All Levels Of Care - Hospital Care - Long Term Care Read more at www.eujamrai.eu/wp7-result1/ The paper can be downloaded free of charge at www. ewma.org/what-we-do/ antimicrobial-stewardship/ Learn more at the EWMA 2019 Conference Joint EWMA/BSAC Key Session: Antimicrobial Stewardship in Wound Care Date and time: Thursday 6 June, 11.15 – 15.15 Room: Session Room G2-G3

Martin Seychell speaking at EU-JAMRAI.

A problem for patients, health systems and society ‘Time is not on our side. We need urgent action’, said Martin Seychell, Health Deputy General Director of the European Commission, in his keynote outlining a sinister outlook for the preservation of the antibiotic reserve. But antimicrobial resistance (AMR) is not only a future problem. Mr Seychell continued, ‘Today, 33,000 people die each year from multiresistant infections in the European countries. By 2050, annual global GDP could be reduced by 3,8% amounting to 1 trillion euros’. That is €1,000,000,000,000,000,000, or one billion billion, making AMR a problem for all levels of society. The challenge of implementation One of the frequently discussed matters in this forum was the implementation of guidelines for appropriate hospital procedures. As Mr Seychell stated, ‘It is the action on the wards that makes change possible’.

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As an umbrella organisation, EWMA is proud

to represent over 25.000 wound care professionals healing wounds and improving patients’ lives every day, and we believe that we have a role to play in implementing antimicrobial stewardship measures in the wound care arena. As such, EWMA was invited take part in the Swedish-led Work Package 6.2 (WP6.2). ‘Policies for prevention of Healthcare-Associated Infection (HCAI) and their implementation’. WP Leader Lotta Edman, from the Public Health Agency of Sweden (FOHM), was in charge of the workshop in which country leaders from pilot hospitals in Lithuania, Estonia and Georgia presented their measures implemented to improve prevention, diagnosis and surveillance of catheter-associated urinary tract infections (CAUTI). While wound management is not in the specific interest of the WP, it is believed that we can learn from the implementation strategy applied. Let’s talk about AMR WP8 is dedicated to establishing campaigns to raise awareness about the problem of AMR and

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Antimicrobial stewardship programmes (ASPs) are increasingly advocated as a means of decreasing the misuse of antimicrobial agents. Along with infection prevention and control, hand hygiene and surveillance, AMS is considered a key strategy in local and national programmes to prevent the emergence of antimicrobial resistance and decrease preventable healthcare-associated infections. Discussions taking place in Vienna in November 2018.

health care-associated infections. As stakeholders in this massive joint action, EWMA is also asked to support the communication efforts. The Spanish-led WP recently published a series of videos to raise awareness about the importance of following through with an antibiotic course once prescribed by a doctor. The campaign uses the hashtag #Don’tLeaveItHalfway, and the humorous videos can be viewed here: https://eu-jamrai.eu/campaigns/. About Antimicrobial Stewardship in Wound Management Given the growing global problem of antibiotic resistance, it is crucial that clinicians use antibiotics wisely, which largely means following the principles of antimicrobial stewardship (AMS). Treatment of various types of wounds is one of the more common reasons for prescribing antibiotics.

EWMA is continuously contributing to the EU’s commitment to face the challenges of antimicrobial resistance; however, the overall aim of EWMA’s ASP is to reduce the inappropriate use and overuse of antimicrobials in wound care by promoting, facilitating and teaching good antimicrobial practice in clinical practice. With a focus on the health professional’s role in the area of appropriate use of antimicrobials across health care settings, the programme is not only targeting health professionals involved with wound care - doctors, nurses, pharmacists and microbiologists - but also reaching out to policy makers, such as clinical administrators or managers at the local, regional or national levels. More information on EWMA’s Antimicrobial Stewardship programme is available here: https://ewma.org/what-wedo/antimicrobial-stewardship/ m

Diabetic Foot Global Conference October 17 - 19, 2019 · Los Angeles · CA

19th edition Back in LA Submit your abstract, register and find general information about DFCon19 on the website dfcon.com Abstract submission deadline Early bird registration deadline

JOIN US

June 15, 2019 July 31, 2019

@DFCon #DFCon19

JOIN US dfcon.com · dfcon@cap-partner.eu


www.ecet2019.org

Management of the Diabetic Foot Pisa International Diabetic Foot Course 11th Course · 2-5 October 2019 · Pisa · Italy

2-5

October 2019

Save the date for the Pisa International Diabetic Foot Course 2019

14TH CONFERENCE OF THE Theory & Practice 4-day theoretical course and practical training Date & Place 11th Course 2-5 October 2019 Hotel San Ranieri & Pisa University Hospital Pisa · Italy

Programme includes · Neuropathy · Charcot · Infection · Ischaemia · Surgery Including a live transmission from the operating room of the Diabetic Foot Clinic

European Council of Enterostomal Therapists

· Hands-on workshops

Members of EWMA receive a 10 % discount for the course.

www.diabeticfootcourses.org

The course is endorsed by EWMA

ECET 2019 23-26 June 2019 · Rome · Italy


EWMA

Report from the 10th anniversary edition of the Pisa International Diabetic Foot Course:

Management of the Diabetic Foot - Theory and Practice Alberto Piaggesi Responsible for the Scientific programme Professor, Endocrinologist Director of the Diabetic Foot Section of the Pisa University Hospital. University of Pisa, Italy More information: www.diabeticfootcourses.org

The 10th anniversary edition of the International Diabetic Foot Course was held in Pisa, Italy, 19-22 September 2018. 44 participants from 22 different countries, 12 international faculty members and 11 national faculty members took part in the 2018 course. The Diabetic Foot Courses combine theory and practical training, with multidisciplinary and clinical aspects as the leading themes through the whole programme, with the aim of giving a more realistic picture of such a complex pathology. The course programme was divided into five main topics: neuropathy, charcot foot, infection, ischemia and surgery. Theoretical lectures on these topics were held in the mornings and practical workshops with smaller groups took place in the afternoons in the specialised diabetic foot clinic at the Pisa University Hospital. The individual training covered all the areas related to the modern clinical approach to the diabetic foot, including instrumental diagnosis, revascularization, surgery and rehabilitation. The course finished with a 2-hour long direct transmission with interactive audiovisual connection from the operating room, where prof. Alberto Piaggesi and his staff performed two operations. It was possible for the participants to comment and ask questions during the operation. The networking part of the course – not to forget – also reflected the spirit of the anniversary, among others, during the course dinner held “au plein air” in the stunning surroundings of the Golf Club Tirrenia. The event was a beautiful evening in good company, with nice food and wine. The next course will take place on 2-5 October 2019 in Pisa. This year, there will be two additional hands-on workshops, focusing on the biomechanical lab and thermal imaging. The course is officially endorsed by EWMA, and members of EWMA receive a 10% discount. Please note that there is a limited number of seats available at the course. Additional information is available at: www.diabeticfootcourses.org.

Endorsed by EWMA

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NEW SPONSORS

MEBO International MEBO International is a global life science enterprise specialising in the development and application of regenerative life science.

MEBO International was established in 1987 by Professor Rongxiang Xu who invented Moist Exposed Burn Ointment (MEBO)/ Moist Exposed Burn Therapy (MEBT).

MEBO International is not just a company, but a missionoriented enterprise striving for human life.

Over the past decades, we have developed comprehensive product portfolios including medicines, medical devices, nutritional supplements and cosmetics. All products provide premium solutions to the market with unique positioning and strong science behind the claims. MEBO International possesses a wealth of intellectual property across the world and has obtained over 40 international patents in countries and regions such as China, America and Europe.

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Regenerative medical technology is the cornerstone of the development of MEBO International. Today, over 200,000 doctors from 77 countries have been applying our technology and products in over 20 medical fields, and over 40 million patients afflicted with burns, wounds and ulcers have been cured.

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ROKIT Healthcare The world’s first global biotechnology and healthcare company combines 3D bioprinting technology to autologous stem cell therapy for customised organ regeneration.

3D BIOPRINTING Evolution from 2D Cell Culture to 3D Tissue Analogs. 3D bioprinting is an innovative technology reliably producing layer-by-layer depositions of bio-materials, cells, and growth factors to create a functional human tissues or organs AN ALTERNATIVE TO ORGAN TRANSPLANT 3D bioprinting technology and autologous cell therapy have been used separately in many different field of studies. In ROKIT’s organ regeneration platform technology, 3D bioprinting is met with autologous stem cell therapy in a synergetic way for regenerative medicine to provide an alternative solution to organ transplant. WHO WE ARE Made by Nature. Healthcare Innovation by INVIVO. We, ROKIT Healthcare, endeavor and strive to bring changes to the world with our customised organ regeneration platforms. We are committed to develop the safest

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and effective customized organ regeneration technologies with our expertise in regenerative medicine and tissue engineering. We believe global paradigm shift in healthcare economics has already begun, and there are urgent needs in new therapeutic methods reachable to those who otherwise their lives are at risk. ROKIT HEALTHCARE is a pioneer in this new paradigm of utilizing autologous cell, cell sheet technology, and 3D biofabrication technology. INNOVATIONS IN SKIN WOUND HEALING Adipose tissue is a rich source of mesenchymal and hematopoietic stem cells as well as whole extracellularmatrix (ECM) that could serve as a biocompatible scaffold building block. In ROKIT’s autologous skin regeneration platform technology, autologous keratinocytes and micronised adipose tissue particles containing adipose derived stem cells and ECM are uniquely structured throughout 3D bioprinting to create a customised full thickness living skin equivalent that could be quickly taken while minimizing unwanted scar formation.

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Organisations

SAfW Swiss Association for Wound Care

Doris von Siebenthal Co-President SAfW D-CH

MD Ulf Benecke Co-President SAfW D-CH

Patient Safety - State of Play in Switzerland As the Federal Office of Public Health states on its web page, there are currently shortcomings in patient safety—international studies show that, on average, one in ten patients experiences an adverse event while in hospital. These studies, examining incidents documented in medical records, indicate that around half of those events could be prevented. If the findings from a study conducted by the Institute of Medicine1 are extrapolated to Switzerland, the number of deaths due to poor patient safety would be around 2,000 to 3,000 per year. As yet, no national adverse event study has been conducted in Switzerland.”2

tions of service providers and health insurers to conclude nationwide quality development agreements that are binding for service providers–for example, doctors–and specifies sanctions.

According to estimates by Swissnoso (2017)3, depending on the type of operation, about 1% to more than 20% of patients in Switzerland suffer from a wound infection after surgery. These numbers are high. Nevertheless, it cannot be said that nothing is being done in the country to develop quality and patient safety.

The Advisory Board of the federal Council4 points to hindrance factors to proceed:

As wound care specialists, we are aware that patient safety and patient-centred treatments are essential for ethically correct and high quality treatment in wound care. However, at present, we do not know if or to what degree these requirements are recognised in wound care centres across Switzerland, or whether appropriate procedures have been implemented to achieve them.

n Clinical training programmes in Switzerland

To answer these questions in depth, the Swiss government has commissioned the Swiss National Report on Quality and Patient Safety, which will be published in the second half of 2019. The SAfW is looking forward to the results of the report, which will enable us to discuss patient safety for wound patients in Switzerland in an objective way.

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The impetus for the so-called ‘quality bill’ was provided by a parliamentary initiative back in 2006. On 5 March 2019, the Swiss Parliament decided that patient safety and quality development should be anchored in the revised Health Insurance Act. Parliament obliges the associa-

At the same time, the cantons, associations of service providers and insurers should, according to the will of the parliamentary commission majority, set up a joint organisation in which patient organisations and experts are also represented. This organisation is charged with developing quality indicators, conducting studies and national quality programmes and ensuring that patient safety is promoted.

n Quality assurance is demanding and often

underestimated in terms of the resources and competencies required.

do not yet cover safety and quality sufficiently.

n There is also a need to raise awareness of

patient safety and to train healthcare personnel in safety and quality improvement.

For the years 2021 to 2024, the joint organisation will have 50 million Swiss francs at its disposal to overcome these factors. For now, we refer to the recommendations of the Swiss foundation ‘Patientensicherheit’ (www.patientensicherheit.ch). Working with health stakeholders, the foundation develops solutions for the promotion of patient safety and the necessary frameworks, and promotes their dissemination. This information is freely accessible on the internet. Though we have currently no binding procedures in Switzerland regarding the treatment of patients with wounds, as for patient-centred treatment and safety, the SAfW D-CH has been certifying wound care centres in the German-speaking part of Switzerland since 2009. These centres are obliged to provide an interdisciplinary setting al-

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lowing patient-centred treatment. Furthermore, they are required to fill in an online survey listing data related to their investigations into the care and treatment of their wound patients. In the first year of the full survey, 111 cases of wound care patients were recorded. Four years later, there were already 1,711 cases documented, and by December 2018, 2,139 cases had been registered. In total, 12,360 cases have been documented. Over all the years of data collection, for example, it appears that the most common type of wound is postoperative wound healing disorder, with the most frequent location (with 37%) being the trunk.5 In 2006, the Council of Ministers of Europe made their recommendations, ‘Management of patient safety and prevention of adverse events in health care’, and made clear that ‘education for patient safety should be introduced at all levels within healthcare systems, including

individual public and private health-care organisations’.6 In Switzerland, the Zukunft Medizin Schweiz’ project, under the leadership of the Swiss Academies of Sciences and Art (SAMW) makes recommendations on how to integrate education for patient safety into the education of health care professionals.7 As seen with the just finalised current innovation in the Swiss Health Insurance Act (KVG in Switzerland),8 political processes take some time, so changes will not be immediate, but they are well underway. For now, the SAFW will continue to certify wound care centres with a view to promoting interdisciplinary and interprofessional patient-centred treatment. We will endeavour to stay in conversation with all stakeholders concerned to improve patient safety. m

REFERENCES 1. Kohn K., Corrigan F., Donaldson M. (editors), To err is human: building a safer health system, Institute of Medicine, 2000 2. https://www.bag.admin.ch/bag/en/home/versicherungen/krankenversicherung/krankenversicherung-qualitaetssicherung.html 3. Swissnoso/ANQ (2017) Nationaler Vergleichsbericht, Programm zur Überwachung postoperativer Wundinfektionen, 2015/2016, https://www.swissnoso. ch/fileadmin/module/ssi_surveillance/ Dokumente_D/9_Resultate/20170904_SSI_Nationaler_Vergleichsbericht_2015_2016_Swissnoso.pdf

4. Allegranzi B. et al. (2017) Recommendations and proposals for the fedaeral strategy (Report of the Scientific Advisory Board https://www.bag.admin.ch/ dam/bag/en/dokumente/kuv-leistungen/qualitaetssicherung/second-report-advisory-board-30-06-2017. pdf.download.pdf/second-report-advisory-board30-06-2017-en.pdf 5.Signer M. (2019) Nationales Datenregister, Wundmanagement, 1(13)342.

6. Ministerrat des Europarates: Empfehlungen /Management of patient safety and prevention of adverse events in health care’, 2006. 7. https://www.samw.ch/de/Projekte/Archiv/Zukunft-Medizin-Schweiz.html 8. https://www.parlament.ch/de/ratsbetrieb/suche-curiavista/geschaeft?AffairId=20150083

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Organisations

Skin Wounds, and Trauma (SWaT) Research Centre Ms. Simone G. Walsh1a

The new Skin Wounds, and Trauma (SWaT) Research Centre at the Royal College of Surgeons in Ireland specialises in cutting-edge research in the field of wound healing and tissue repair, with a specific emphasis on pressure ulcer prevention and management. As a nurse-led centre, the team behind the SWaT Research Centre has a wealth of experience in both clinical practice and academia. This experience spans the continuum of evidence generation, to the critical appraisal and synthesis of existing evidence, through to the development of solutions and guidelines for important challenges within clinical practice today and into the future. This enables the translation of evidence into contemporary clinical decision-making, providing a platform for outcome-focused healthcare practice.

Dr Declan Patton2a Professor Tom O’Connor3a Professor Zena E. Moore4a 1 Senior Research Projects Manager, Skin Wounds, and Trauma (SWaT) Research Centre 2 Deputy Director, Skin Wounds, and Trauma (SWaT) Research Centre, Senior Lecturer and Director of Nursing and Midwifery Research

“Leaders in research and innovation in the field of wound care”

3 Lead Researcher, Skin Wounds, and Trauma (SWaT) Research Centre, Senior Lecturer and Director of Academic Affairs 4 Director, Skin Wounds, and Trauma (SWaT) Research Centre, Professor of Nursing and Head of the School of Nursing and Midwifery Authors’ affiliation: a

Skin Wounds and Trauma (SWaT) Research Center, School of Nursing and Midwifery, Royal College of Surgeons in Ireland

The SWaT Team, left to right, Professor Tom O’Connor, Professor Zena Moore, Simone Walsh, Dr Declan Patton.

Centre Director, Professor Zena Moore, is Professor of Nursing and Head of the RSCI School of Nursing and Midwifery. Prof Moore is an eminent wound care expert and former President of the European Wound Management Association. Her renowned clinical expertise was marked by her being the first appointed clinical nurse specialist in tissue viability in Ireland, pioneering the growth of this clinical speciality throughout the country. Deputy Director, Dr Declan Patton is Senior Lecturer and Director of Nursing and Midwifery Research at the RCSI School of Nursing. Over the past four years, Dr Patton has secured a number of high-level grants relating to wound care and in journal of the european wound management association 

particular pressure ulcer prevention and the prevention and management of diabetic foot ulceration. Senior Research Projects Manager, Simone Walsh is clinical research nurse and population health researcher, with extensive experience in epidemiological surveillance and management of national health information systems. Lead Researcher, Professor Tom O’Connor is Deputy to the Head of School, Senior Lecture and Director of Academic Affairs at the RCSI School of Nursing and Midwifery. Prof O’Connor has worked alongside the SWaT director and the deputy direc

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More information: www.rcsi.ie/swat Twitter: SWaTRCSI Facebook: SWaTRCSI Instagram: swatrcsi Correspondence: simonewalsh@rcsi.com

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tor in completing high-quality, patient-centred wound care research projects. Prof O’Connor has a particular interest in venous leg ulcers. GLOBAL LANDSCAPE Wound management is a significant issue within healthcare today, with figures suggesting that almost 5% of the population is affected by a wound at any given time.1,2 Further, up to 6% of healthcare budgets are spent on the management of these often-preventable wounds.1,2 With our rapidly ageing population, it is reasonable to predict that the burden of global wound care will increase unless current prevention and management strategies are challenged. The majority of patients with wounds are managed in the community care setting. Given the desire for increased capacity within primary healthcare and for people to remain in their own homes for as long as possible, coupled with the ever-increasing reduction in available trained health professionals, it is now more important than ever that effective and efficient wound prevention and management strategies are developed and evaluated. The SWaT Centre houses the skills, expertise, education, clinical and academic partners to lead and meet the demands of wound care research.

researchers in wound care and tissue viability. Students have opportunities to take part in a taught Post Graduate Diploma in Wound Management and Tissue Viability and a taught MSc programme, as well as MSc by Research and PhD programmes. The courses are delivered in a challenging and nurturing environment, supporting students to develop advanced research skills and to ultimately work as independent practitioners. INDUSTRY, CLINICAL, PATIENTS AND ACADEMIC PARTNERS Strong partnerships with patients, industry, clinical and academic institutes establishes the SWaT Centre as a centre for multi-faceted research. n The SWaT centre is a hub for industry partners seeking

to evolve and bring to the market wound care prevention and treatment devices through clinical investigations. n Clinical partners are the cornerstone in the provision of

care for patients, and by working together with the SWaT centre, these key stakeholders will have an equal partner ship in the drive for solutions to their problems. Clinical partners and patients are our facilitators for transferring evidence into practice - a core goal of SWaT Director Professor Zena Moore. n National and international academic partnerships

broaden the scope of expertise in wound care and tissue viability research, enhancing the SWaT Centre’s research prowess.

Industry Laboratory

Student

Patient Evaluation

Clinical Partners Policy

FOR PATIENTS AND THE PUBLIC The SWaT Centre is primarily interested in examining patient outcomes through the completion of large-scale clinical studies. Those at risk of wound care issues will ultimately benefit from this approach, with SWaT Centre research improving the quality of life of at-risk people and saving services money. STUDENTS The SWaT Centre cultivates the education of leading 136

FUNDING AND RESEARCH CAPABILITIES Professor Zena Moore has been awarded €3,257,995 for pressure ulcer and wound care research from the Irish Research Council, Enterprise Ireland, Health Research Board of Ireland and industry. The studies range from evaluation of assessment tools, to movement studies, to large-scale randomised control trials. The SWaT Centre specialises in regulated clinical investigations of novel medical devices. LABORATORY The SWaT Team works closely with biomedical scientists in RCSI laboratories, providing capabilities to validate clinical findings with laboratory analysis. The RSCI houses state of the art simulation laboratories and was awarded the Education Building of the Year 2018. In addition, the RCSI Institute of Research is an advanced multi-site biomedical research facility (5,800 sq metres) supporting some 400 researchers. POLICY The development of wound care policy in Ireland and internationally is a foundation stone in the SWaT Centre strategy. The Centre won the tender for, and led, the development

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Organisations

Members of the academic team pictured with PhD and MSc students.

of the 2018 Irish National Wound Care Guidelines. SWaT Director, Professor Zena Moore is an international expert advisor on European policy, serving as an Executive Board Member (2017-present), co-chair of the Scientific Committee (2017-present), and Guideline Governance Group Member (2017-present) for the European Pressure Ulcer Advisory Panel. She is a European Advisory Board Member for Bruin Biometrics (2015-present), is on the Pan European OUTPUT Methodological Advisory Panel (2015-present), Médecins Sans Frontières (MSF) Wound Management Guideline Development Group, European Pressure Ulcer Advisory Panel Trustee/Board Member (2015-present) and the Cochrane Wounds Group (2004-present). Speaking at the launch of the centre, on November 12, 2018, Professor Moore said: “The launch of this research

centre marks an important step forward in encouraging partnerships that will develop better practices for skin wound and trauma care, ultimately saving lives. It is expected that by 2025, more than 20% of Europeans will be aged 65 years or over, with a particularly rapid increase in numbers of over-80s. The prevalence of wounds increases with ageing; therefore, it is reasonable to predict that the burden of global wound care will increase unless current prevention and management strategies are challenged. Fundamentally, our goal is to enhance the lives of those who access the health service, through the promotion of active and healthy ageing and the avoidance of unnecessary complications such as pressure ulcers. Together as a team, the SWaT Centre looks forward to embracing the many opportunities to ensure success for all involved.” m

REFERENCES 1. Guest J. F, Ayoub N, McIlwraith T, Uchegbu I, Gerrish A, Weidlich D, et al. Health economic burden that different wound types impose on the UK’s National Health Service. Int Wound J 2017 14, 322-330.

2. Gillespie, P., Carter, L., McIntosh, C. & Gethin, G. 2016. Estimating the Healthcare Costs of Wound Care in Ireland. Poster Presentation at the European Wound Management Association. Bremen, Germany.

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Organisations

ISTAP NEWS ISTAP The International Skin Tear Advisory Panel

Karen Cambell ISTAP President More information: www.skintears.org Twitter: @SkinTears LinkedIn: www.linkedin.com/company/international-skin-tearadvisory-panel-istap

The International Skin Tear Advisory Panel has recently joined EWMA as new International Partner Organisation.

Skin tears affect people of all ages and continue to be a common problem in all health care settings. They are often painful, acute wounds resulting from trauma to the skin and are largely preventable. The International Skin Tear Advisory Panel (ISTAP) was formed to raise international awareness of the prediction, assessment, prevention and management of skin tears. ISTAP comprises a panel of multidisciplinary healthcare professionals representing Africa, Asia, Australia, Europe, the Middle East, North America and South America. The ISTAP now includes 15 global expert members from 10 countries. Our vision is ‘A WORLD WITHOUT SKIN TEARS’, and our core values include: n Collaboration n Innovation n Transparency n Passion n Research base n Creativity n Leadership n Respect n Inspiration

One of ISTAP’s official partners is the Nurses Specialized in Wound, Ostomy and Continence Canada (NSWOCC); in December 2018, ISTAP became a partner of the European Wound Management Association (EWMA). ISTAP has published numerous articles pertaining to skin tears, including: ‘2018 Best Practice Recommendations for the Prevention and Management of Skin Tears in Aged Skin’; ‘Skin Tears: The Art of Dressing Selection’; ‘International Skin Tear Advisory Panel: Putting it all together, a Tool Kit to aid in the Prevention, Assessment and Treatment of Skin Tears’; ‘Validation of a New Classification System for Skin Tears’; and ‘Skin Tears - State of the Science: Consensus Statements for the Prevention, Prediction, Assessment, and Treatment of Skin Tears’ (Table 1). The ISTAP Classification System has been translated into English, Arabic, Chinese, Czech, Danish, Dutch, French, French-Canadian, Italian, Portuguese, Spanish and Swedish. Publications are pending in several other languages. Currently, ISTAP is working collaboratively with the Skin Integrity Research Group (SKINT) at Ghent University on the global evaluation of the psychometric properties of the ISTAP classification system for skin tears. Presently, a two-phase international psychometric evaluation study of the ISTAP Classification System is taking place in 15 languages worldwide. EWMA International Partner Organisation

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Karen Campbell is ISTAP’s current president. She is an adjunct faculty member for the Masters of Clinical Science in Wound Healing at Western University in London, Ontario, Canada. In addition, she is an associate scientist at the Lawson Health Research Institute. She has functioned as an advanced practice nurse in wound and continence care and is currently a student in the ostomy portion of the WOCEP Program with NSWOCC (Nurses Specialized in Wound, Ostomy, and Continence Canada, formerly CAET). Dimitri Beeckman is ISTAP’s President-Elect and works as a Professor of Skin Integrity and Clinical Nursing at the University Centre of Nursing and Midwifery at Ghent University, in Belgium. He is the scientific coordinator of the Skin Integrity Research Group (www.SKINTGhent.be) at the University Centre for Nursing and Midwifery.

ISTAP Publications LeBlanc K., Campbell K., Beeckman D., Dunk A., Harley C., Hevia H., Holloway S., Idensohn P., Langemo D., Ousey K., Romanelli M., Vuagnat H., Woo K. (2018). Best practice recommendations for the prevention and management of skin tears in aged skin. Wounds International. LeBlanc, K, Baranoski, S, Christensen, D., Langemo, D., Edwards, K., Holloway, S., Gloeckner, M., Williams, A., Woo, K., Campbell, K., & Regan, M. (2016). The art of dressing selection: A consensus statement on skin tears and best practice. Advances in Skin & Wound Care, 29(1), 32–46. LeBlanc, K, Baranoski, S, Christensen, D., Langemo, D., Sammon, M., Edwards, K., Holloway, S., Gloeckner, M., Williams, A., Sibbald, G., Campbell, K., & Regan, M. (2013). International Skin Tear Advisory Panel: Putting it all together, a tool kit to aid in the prevention, assessment and treatment of skin tears. Advances in Skin & Wound Care, 26(10), 459–476. LeBlanc, K., Baranoski, S., Christensen, D., Langemo, D., Sammon, M., Edwards, K., Holloway, S., Gloeckner, M., Williams, A., Sibbald, G., Campbell, K., & Regan, M. (2013). International Skin Tear Advisory Panel (ISTAP) – Validation of a new classification system for skin tears. Advances in Skin & Wound Care, 26(6), 263–265. LeBlanc, K, Baranoski, S, Christensen, D., Langemo, D., Sammon, M., Edwards, K., Holloway, S., Gloeckner, M., Williams, A., Carville, K., Campbell, K., Madori, A., & Regan, M. (2011). Skin tears – State of the science: Consensus statements for the prevention, prediction, assessment, and treatment of skin tears. Advances in Skin & Wound Care, 24(9), 2–15.

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Organisations

MSWCP NEWS MSWCP Malaysian Society of Wound Care Professionals

Malaysian Society of Wound Care Professionals has recently joined EWMA as new International Partner Organisation. The Malaysian Society of Wound Care Professionals (MSWCP) was formed in 2011 to further enhance wound management in Malaysia, a country of 30 million people. The incidence of diabetes mellitus in Malaysia is 17.5% (National Health Morbidity Study 2015, Ministry of Health, Malaysia); therefore, there is also a high incidence of diabetic foot complications, making multidisciplinary wound management important for preventing amputations. The MSWCP’s guiding principle is ‘Wound Healing with Passion’, as one needs passion to manage these chronic and complex wounds. There has been an increase in the number of interested stakeholders over the years, and we hope their numbers will continue to increase.

Harikrishna K. R. Nair MD, FRCPI, FCWCS, FMSWCP, CMIA President More information: https://www.mswcp.org/

The MSWCP’s motto is ‘Learn, Help and Heal’. This shows that much of the organisation’s emphasis is based on learning, as we need to empower our wound care professionals in terms of knowledge and clinical experience. We also publish two books per year to help educate wound care professionals and train different groups that involve doctors, nurses, paramedics and pharmacists. We have also begun offering a Certificate in Clinical Wound Care, a six-month-long programme in wound management with online modules, case studies, attachment and exams. The programme’s sixth cohort began work in March 2019. Trainings and workshops are also organised frequently to give hands-on training to the various participants from different backgrounds. Finally, we are involved in trainings and programmes offered by several institutions and countries, such as post-graduate orthopaedics, diabetes and endocrinology, enterostomal nursing and rehabilitation medicine trainings. Help is our next mission, and we have introduced our own wound care kits that have been distributed to all wound care teams in Malaysia’s health clinics and hospitals, and in some other parts of Asia. These kits have also been sent to areas hit by disaster, such as the Philippines (during typhoons Yolanda and Tacloban), Thailand (after the bomb blast in Erawan), the Maldives, Laos (following a dam collapse), Indonesia (in light of incidents in Lombok, Palu and Donggala), the Solomon Islands and India (for the wound ward at Banares Hindu University). This is a very important programme, as we need to help the region during its darkest hours. We also help patients by giving advice through our online portals on the MSWCP website. Healing is important, as wound healing with minimal or no complications is the outcome that we strive for. We have been instrumental in forming the ASEAN Wound Council, comprised of 10 countries under the ASEAN framework. This will further enhance the collaboration and cooperation among member nations. We are also a part of the Asian Wound Care Association (AWCA), with members from 17 countries, including China and India. These involvements are important for further strengthening cooperation and fostering good friendships among Asian countries. Finally, we are grateful to be working with the European Wound Management Association as one of its International Partner Organisations. m

EWMA International Partner Organisation

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Organisations

SSiS NEWS Swedish Wound Care Nurses Association is the organisation partner of the EWMA 2019 Conference. Enthusiasts are needed in health care. In November 2005, the Swedish Wound Care Nurses Association (SSiS) was founded for nurses and nurse students with an interest in healing wounds from a professional nursing science perspective. Today, the organisation has 472 members. Since 2005, SSiS has helped with the advancement of wound management. The organisation grows more influential each year, which shows the value of the work it has accomplished. SSiS is a section of the Swedish National Nurses Association (SSF). Prof Christina Lindholm served as the first president and chair of SSiS, and today the SSiS board consists of 11 members led by president and chair Susanne Dufva, a specialist in malignant tumor wounds. Many of the board members have earned doctorates in a diverse range of specialties that provide support and knowledge of healing wounds. Every member is passionate about increasing understanding of wound care and developing higher education of wound management on all levels. All members of the board are also active in wound management within different networks. SSiS actively collaborates with the Swedish Association of Local Authorities and Regions (SKL), the National Board of Health and Welfare (Socialstyrelsen), and the Swedish Agency for Health Technology Assessment and Assessment of Social Services (SBU) to keep wounds on the

agenda. SSiS is also a referral resource for various issues connected to wound prevention and treatment. SSiS has an international collaboration with EWMA and the European Pressure Ulcer Advisory Panel (EPUAP). Lack of education and experience is one of the reasons wound treatments today are not always evidence-based or performed according to current guidelines. The knowledge of new woundcare products is also less than optimal. For example, wound dressings could easily be replaced with another type of dressing, which not have the same characteristic, and sometimes is completely different but will be cheaper. Upgrading wound care supplies will help as a catalysator for patient-safety and person-centred care.

SSiS

Swedish Wound Care Nurses Association

Eila Sterner RN, PhD, Head of nursing development, Trauma department, Karolinska University Hospital and cashier SSiS during 2005-2017 More information: www.swenurse.se

As one of several goals, SSiS wishes to continue to grow and engage with healthcare professionals, as well as build bridges between industries within health care and research. SSiS is also developing and improving the procedure together with procurement department in different regions in Sweden. This includes analysing health economics and cost of treatment with different wound dressings, so the focus is on the function of the wound dressing and support of the healing process, rather than merely looking at the price per product. m The EWMA 2019 Conference is organised in collaboration with SSiS.

Activities: n Annual conferences n Homepage where documents from EWMA, EPUAP and WUWHS and other important

documents can be downloaded.

n The Journal SårMagasinet, edited by a committee of the board, is distributed to 4,700

nurses, doctors and other health care workers interested in wounds throughout Sweden in five issues annually.

n Several scholarships for nursing students, nurses with projects in wound management,

membership for nurses who will participate in SSiS conferences, as well as the award for “Wound Nurse of the Year. EWMA Cooperating Organisation

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Conference Calendar 2019

For web addresses please visit www.ewma.org

Conferences 2019

Theme

Month

Days

City

Country

Tissue Viability Society (TVS)

Gain Knowledge, Develop Skills, May Improve Care

1-2

Southampton

United Kingdom

SAWC Spring

Connect, Learn & Grow May 7-10 – At an all new SAWC Spring

San Antonio, TX USA

34th Nordic Congress of Dermatology and Venereology

May

8-10

Gothenburg

Sweden

German Wound Congress 2019 (ICW)

May

8 - 10

Bremen

Germany

9-10

Vendryně

Czech Republic

Rande Congress 2019

Occupation of Chronic Ranks, May Skin Defects and Repair

SaWf French Section Congress 2019

May

16

Morges

Switzerland

Australasian Lymphology Association (ALA)

May

17 - 19

Sydney

Australia

May

22-25

The Hauge

The Netherlands

The Hauge

The Netherlands

Dunedin

New Zealand

Innovations in Practice

ADFS Symposium

8th International Symposium on May 22-25 the Diabetic Foot (ISDF) 9th National Conference of NZWCS Biennial Conference May 23 - 25

Spanish Association Vascular Nurse The Fortune of Caring May 30-31 Las Palmas and Wounds (AEEVH) 29th Conference of the European Wound Person-centered Wound Care. June 5-7 Gothenburg Management Association 2019 (EWMA) Who is in Charge of the Wound? 20th congress of The European Federation of National Associations of Orthopaedics and Traumatology (EFORT)

Sweden

June

5 - 7

Lisbon

Portugal

9th

International Conference of the International Lymphoedema Framework (ILF)

June

13-15

Chicago

USA

14th Conference of European Council of Enterostomal Therapy (ECET)

June

23 - 26

Rome

Italy

51st Conference of Wound Ostomy and Continence Nurses Society (WOCN)

June

23 - 26

Nashville, TN

USA

19th Congress of DGfW

June

27 - 29

Giessen

Germany

ETRS Annual Meeting

September

11-13

Munich

Germany

38th Annual meeting of the European Bone and Joint Infection Society (EBJIS)

September

12 – 14

Antwerp

Belgium

SAfW (German Section)

September

12

Zürich

Switzerland

55th Annual Meeting of the European September 16 - 20 Association for the Study of Diabetes (EASD) Annual Meeting of European Pressure Ulcer Pressure ulcer prevention September 18 – 20 Advisory Panel (EPUAP) without frontiers

Barcelona

Spain

Lyon

France

19th Annual Conference of The Lindsay Leg Club Foundation

Person Centered Care A Question of Balance

September

25-26

Worcester

England

AWA National congress

The right thing at the right time

September

27-29

Salzburg

Austria

15th National AIUC Congress

October

2-5

Napoli

Italy

11th

Pisa International Diabetic Foot Course

October

2-5

Pisa

Italy

2019 Fall Conference of Wounds Canada

October

3-6

Niagara Falls

Canada

28th

October

9-13

Madrid

Spain

Diabetic Foot Global Conference 2019 (DfCon)

October

17-19

Los Angeles

USA

6th

October

24-25

Copenhagen

Denmark

EADV Congress

Registries & Impact On Practice

Gran Canaria Spain

Infection prevention in the age of antibiotic resistance

International Biofilm Course 2019

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Conference Calendar 2019/2020

For web addresses please visit www.ewma.org

Conferences 2019

Theme

Month

Days

City

Country

Wounds UK

November

4-6

London

United Kingdom

ADFS Cadaver Course

November

14-15

Padua

Italy

Portuguese Association for the Treatment of Wounds (APTFeridas)

November

21-22

TBA

Portugal

Dutch Knowledge Centre for Wound Care (WCS) in collaboration with V&VN Wound Expertise

November

26 - 27

Utrecht

The Netherlands

2nd Conference of Wound Management in Nuremberg

December

5-7

Nuremberg

Germany

Wound Management Association of Turkey

December

13-16

Antalya

Turkey

Conferences 2020

Month

Days

City

Country

Conference of the French Society for Wound Care (SFFPC)

January

26-28

Paris

France

Conference of Finnish Wound Care Society

Jan/Feb

31-1

Helsinki

Finland

WUWHS 2020

March

8-12

Abu Dhabi

UAE

18th Malvern Diabetic Foot Conference

May

13-15

Malvern

United Kingdom

30th

Conference of the European Wound Management Association 2020 (EWMA)

May

13-15

London

United Kingdom

16th Conference of Diabetic Foot Study Group (DFSG)

September

18-20

TBA

Austria

Wound Care Congress

Theme

Global Healing Changing Lives

Submit your manuscript to the October 2019 issue of Journal of the European Wound Management Association

The October 2019 issue is dedicated to Palliative wound care Deadline for submission of scientific papers is 24 June 2019 Journal of the European Wound Management Association author guidelines at ewma.org ewma@ewma.org Published by EUROPEAN WOUND MANAGEMENT ASSOCIATION www.ewma.org

Editorial Board Sebastian Probst, Editor Sue Bale, Editor in Chief Vickie R Driver

Georgina Gethin Salla Seppänen Andrea Pokorná


Cooperating Organisations AEEVH

Spanish Association of Vascular Nursing and Wounds www.aeevh.es

AFIScep.be

French Nurses’ Association in Stoma Therapy, Wound Healing and Wounds www.afiscep.be

AISLeC

Italian Nurses’ Cutaneous Wounds ­Association www.aislec.it

AIUC

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

AMP Romania

Wound Management Association Romania www.ampromania.ro

APTFeridas

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

AWA

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

AWTVNF

All Wales Tissue Viability Nurse Forum www.welshwoundnetwork.org

ELCOS

Portuguese Wound Society www.sociedadeferidas.pt

FWCS

Finnish Wound Care Society www.shhy.fi

GAIF

Associated Group of Research in Wounds www.gaif.net

GNEAUPP

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

HSWH

Hellenic Society of Wound Healing and Chronic Ulcers www.hswh.gr

ICW

Chronic Wounds Initiative www.ic-wunden.de

LBAA

Latvian Wound Treating ­Organisation

LUF

BWA

MASC

Maltese Association of Skin and Wound Care

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

Macedonian Wound Management Association

National Association of Tissue Viability Nurses, S ­ cotland

NIFS

Norwegian Wound Healing Association www.nifs-saar.no

NOVW

Croatian Wound Association www.huzr.hr

Dutch Organisation of Wound Care Nurses www.novw.org

DGfW

PWMA

German Wound Healing Society www.dgfw.de

Polish Wound Management Association www.ptlr.org.pl

DSFS

SAfW

Danish Wound Healing Society www.saar.dk

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MSKT

NATVNS

CWA

SAWMA

Serbian Advanced Wound Management Association www.lecenjerana.com

SEBINKO

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

SEHER

The Spanish Society of Wounds www.sociedadespanolaheridas. es

SFFPC

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

SSiS

SSOOR

Lithuanian Wound Management Association www.lzga.lt

CNC

Czech Wound Management Society www.cslr.cz

Swiss Association for Wound Care (Holding Association) www.safw.ch

LWMA

MWMA

CSLR

SAfW

Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

Bulgarian Wound Association www.woundbulgaria.org

Clinical Nursing Consulting – Wondzorg www.wondzorg.be

Swiss Association for Wound Care (French section) www.safw-romande.ch

The Leg Ulcer Forum www.legulcerforum.org

BEFEWO

Belgian Federation of Woundcare www.befewo.org

SAfW

Slovak Wound Care Association www.ssoor.sk

SSPLR

The Slovak Wound Healing Society www.ssplr.sk/en

STW Belarus

Society for the Treatment of Wounds (Gomel, Belarus) www.burnplast.gomel.by

SUMS

Icelandic Wound Healing ­Society www.sums.is

SWHS

Serbian Wound Healing Society www.lecenjerana.com

TVS

Tissue Viability Society www.tvs.org.uk

URuBiH

Association for Wound Management of Bosnia and Herzegovina www.urubih.ba

UWTO

Ukrainian Wound Treatment Organisation www.uwto.org.ua

Swiss Association for Wound Care (German section) www.safw.ch

journal of european wound management association 

2019 vol 20 no 1


Organisations

Cooperating Organisations (cont.) V&VN

ETRS

European Tissue Repair Society www.etrs.org

FIP-IFP

Decubitus and Wound Consultants, ­Netherlands www.venvn.nl

International Federation of Podiatrists - Fédération Internationale des Podologues www.fip-ifp.org

WCS

ILF

Knowledge Center Woundcare www.wcs.nl

WMAI

Wound Management ­Association of Ireland www.wmai.ie

WMAK

Wound Management Association of Kosova

WMAS

Wound Management Association Slovenia www.dors.si

WMAT

Wound Management ­Association Turkey www.yaradernegi.net

International Lymphoedema ­Framework www.lympho.org

ISTAP

International Skin Tear Advisory Panel www.skintears.org

IWII

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

KWMS

Korean Wound Management Society www.woundcare.or.kr/eng

MSWCP

Malaysian Society of Wound Care Professionals www.mswcp.org

NZWCS

International Partner Organisations Alliance of Wound Care Stakeholders www.woundcarestakeholders. org

AAWC

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

CTRS

Chinese Tissue Repair Society www.chinese-trs.com/en

Debra International

Dystrophic Epidermolysis Bullosa Research Association www.debra.org.uk

ECET

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

SILAUHE

Iberolatinoamerican Society of Ulcers and Wounds www.silauhe.org

Other Collaborators DFSG

Diabetic Foot Study Group www.dfsg.org

EADV

European Academy of Dermatology and Venereology www.eadv.org

EBA

European Burns Association www.euroburn.org

ESNO

European Specialist Nurses Organisation www.esno.org

ESPEN

The European Society for Clinical Nutrition and Metabolism www.espen.org

ESPRAS

The European Society of Plastic, Reconstructive and Aesthetic Surgery www.espras.org

ESVS

European Society for Vascular Surgery www.esvs.org

IWGDF

The International Working Group on the Diabetic Foot www.iwgdf.org

ICC

International Compression Club www.icc-compressionclub.com

SOBENFeE

Brazilian Wound M ­ anagement ­Association www.sobenfee.org.br

WAWLC

World Alliance for Wound and Lymphedema Care www.wawlc.org

Wounds Australia

Wounds Australia www.awma.com.au

Wounds Canada

Wounds Canadia www.woundscanada.net

European Council of Enterostomal Therapy www.ecet-stomacare.eu

Associated Organisations Leg Club

Lindsay Leg Club Foundation www.legclub.org

LSN

The Lymphoedema Support Network www.lymphoedema.org/lsn

Media Partner

EFORT

JWC

European Federation of National Associations of ­Orthopaedics and Traumatology www.efort.org

Journal of Wound Care www.magonlinelibrary.com

PPC

Practical Patient Care www.practical-patient-care.com

EPUAP

European Pressure Ulcer Advisory Panel www.epuap.org

For more information about EWMA’s Cooperating and International Partner Organisations please visit www.ewma.org journal of european wound management association 

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Organisations

Corporate Sponsors Corporate A

Coloplast

www.coloplast.com

ConvaTec Europe www.convatec.com

Essity www.essity.com

KCI an Acelity company www.acelity.com

Lohmann & Rauscher www.lohmann-rauscher.com

URGO Medical

www.urgomedical.com

Wacker Chemie AG www.wacker.com

Mรถlnlycke Health Care AB www.molnlycke.com

Ferris Mfg. Corp. www.polymem.com

Smith & Nephew Advanced wound management www.smith-nephew.com/wound

Corporate B 3M Health Care www.mmm.com

ABIGO Medical AB www.abigo.com

FB Wound www.fbwound.com

Fidia farmaceutici S.p.A. www.fidiapharma.com

Juzo Julius Zorn GmbH www.juzo.com

MEBO International www.mebo.com Pharma Care www.pharmacare.sk

Flen Health SA www.flenhealth.com

Medela AG www.medelahealthcare.com Rokit Health Care www.rokithealthcare.com

Aurealis Pharma, Itd www.aurealispharma.com

B. Braun Medical www.bbraun.com

Nutricia Advanced Medical Nutrition www.nutricia.com

Freudenberg Performance Materials SE & Co. KG www.freudenberg-pm.com

Frontier Medical Group www.frontier-group.co.uk Chemviron www.zorflex.com Paul Hartmann AG www.hartmann.info

Medi GmbH & Co. KG www.medi.de SOFAR S.p.A. www.sofarfarm.it MESI, development of medical devices, Ltd www.mesimedical.com

Mimedx Group, Inc. www.mimedx.co

Stryker www.stryker.com

Welcare Industries Spa www.welcaremedical.com


O F T H E E U R O P E A N W O U N D M A N A G E M E N T A S S O C I AT I O N

5 Editorial. Probst S

Science, Practice and Education 7 Letter to Editor. Piaggesi A, Apelqvist J 11 Finnish Nurses’ Perception of Client-centred Wound Care. Seppänen S 23 Optimising Wellbeing in Patients with Diabetic Foot Ulcers. McIntosh C, Ivory J D, Gethin G, MacGilchrist C 31 Taking Care of an Individual’s Needs at Home: Experiences of a Community Care Nursing Group. Ghilardi S, Noris M, Negroni A, Paggi B, Giunni L 37 Post-surgical Pyoderma Gangrenosum: A Retrospective Analysis of four Clinical Cases. Isoherranen K 43 A Case Report: Toxic Edipermal Necrolysis in Children. Ferreira J, Santos M, Souza M, Silva G, Monteiro A, Yogui H, Santana I 49 Factors that create Obstacles and Opportunity for Patient Participation in Orthopaedic Nursing Care. Stålenhag S, Sterner E 61 Effectiveness and Safety of Patient-centred Care Compared to Usual Care for Patients with Pressure Ulcers in Inpatient Facilities. Pokorná A, Klugar M, Kelnarová Z, Klugarová J 73 A Case Report: Pilonidal Sinus Management with Medical-Grade Honey. Hermanns R, Rodrigues B

Cochrane Reviews 79 Abstracts of Recent Cochrane Reviews. Rizzello G

Book Reviews 90 Antiseptic Stewardship. Cooper R 92 Infermieri. Piagessi A

EWMA 94 EWMA Journal Previous Issues and Other Journals 96 EWMA 2019 Conference in Gothenburg, Sweden 100 New EWMA Document: Atypical Wounds. Isoherranen K, O’Brien J 104 New EWMA Document: Surgical Site Infections. Stryja J, Sandy-Hodgetts K 106 EWMA Publications 109 EWMA Wound Curriculum for Nurses EQF Level 6. Probst S, Holloway S, Rowan S, Pokorná A 115 A Storytelling Journey: Living With Chronic Wounds. Piaggesi A 121 New EU Medical Device Regulation: Challenges and Opportunities. Apelqvist J 124 A retrospective Audit and Case-note Review at a large Ethiopian Referral Hospital. Rose A 126 Time is not on our side. We need urgent action. Stryja J 129 Management of the Diabetic Foot – Theory and Practice. Piagessi A 130 New Corporate Sponsors

Organisations 132 Swiss Association for Wound Care. Siebenthal D, Benecke U 135 Skin Wounds, and Trauma (SWaT) Research Centre. Walsh S, Patton D, O’Connor T, Moore Z 138 The International Skin Tear Advisory Panel. Cambell K 140 Malaysian Society of Wound Care Professionals. Nair H 141 Swedish Wound Care Nurses Association. Sterner E 142 Conference Calendar 144 Cooperating Organisations, International Partner Organisations and Corporate Sponsors

Profile for EWMA European Wound Management Association

Journal of the European Wound Management Association_May 2019  

Journal of the European Wound Management Association May 2019 issue Volume 20 (1)

Journal of the European Wound Management Association_May 2019  

Journal of the European Wound Management Association May 2019 issue Volume 20 (1)