Wounds cost the Canadian health system
cost of a diabetic foot ulcer is $21,371
If the wound becomes chronic, the cost over three years climbs to
The total direct-care cost of diabetic foot ulcers to the Canadian health-care system was determined to be
In Canada, the prevalence of pressure ulcers is estimated to be
25.1% in acute care hospitals and
in long-term care facilities
MARCH 2018 HOSPITAL NEWS 17
Taking the pressure off patients and hospital staff Wound care best practices minimize incidence and prevalence of pressure ulcers By Brenda Mundy and Michelle Lee Hoy ressure injuries, more commonly known as pressure ulcers or bedsores, have a significant impact on a person’s well-being. These hospital-acquired pressure injuries can affect several aspects of a patient’s life, from physical and social, to psychological and financial. Additionally, the impact it has on the healthcare sector means more costs involved and resources used. It is estimated that treatment costs of a single pressure injury can range from US$10,000 to US$86,000 and result in increased nursing time by up to 50 per cent.
ability to mobilize and maintain independence. Especially in the elderly who are hospitalized, quality of life is significantly impacted along with prolonged hospitalization. So, how do we address this issue to the best of our abilities? Proactive and routine assessments and diligent risk management are the best defenses against pressure wound development. According to Accreditation Canada, the prevention of pressure injuries is a required organizational practice. Additionally, the Canadian Patient Safety Institute have identified the development of stage three and greater
PROACTIVE AND ROUTINE ASSESSMENTS AND DILIGENT RISK MANAGEMENT ARE THE BEST DEFENSES AGAINST PRESSURE WOUND DEVELOPMENT
The senior population is a particularly vulnerable population with respect to risk of skin breakdown and the ability to recover from pressure injury. Aging of the skin coupled with reduced mobility and prolonged pressure on bony areas of the body such as the heels, coccyx, elbows, shoulders and the back of the head results in an increased likelihood for pressure injury development. Patients with pressure injuries are more prone to encountering serious complications such as infections of the bone or blood, known as sepsis, and once developed, these injuries can impact a person’s
pressure injuries acquired in hospital to be a never event. All patients admitted to hospital should be assessed for risk of skin breakdown that can occur while under acute care. In addition to demographic factors, some causes for pressure injuries include pressure from devices worn, prolonged stay in one position, poor nutrition, and moisture build up from bodily fluids. Evaluation tools such as the Braden Scale Risk Assessment guide nurses in their assessments by providing the criteria to determine the risk level each patient is at upon admission and throughout their acute care. Criteria
include sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score a patient receives indicates the level of risk the patient is at, but the individual scores inform the healthcare team on what strategies to focus on to prevent skin breakdown and development of pressure injuries. Routinely changing position in a chair or bed, utilizing cushioning devices such as pressure relieving heelboots to help reduce pressure caused from prolonged laying down or air beds to help increase air flow and promote dryness, and mobilizing the patient if possible are but a number of ways to help keep a pressure injury from forming. Brenda Mundy, Manager of the Skin and Wound Program at Southlake Regional Health Centre, stresses the importance of being proactive in skin assessments and interventions: “Upon admission, all of our patients are assessed for risk and then appropriate interventions are implemented to prevent pressure injury development. Daily checks are then performed to ensure we can be proactive should there become a risk for pressure injury development while the patient is in hospital.” Hospitals may conduct annual prevalence assessments for pressure wound incidences to inform them of adjustments in care necessary to reduce the rate of risk. Most organizations will also have a wound care specialist on-site to make the necessary recommendations for treatment once a pressure wound has developed. Southlake’s Skin and Wound Program aims to educate all nursing staff on the proper assessment,
prevention and treatment of hospital acquired pressure injuries. In 2013, Southlake developed a quarterly prevalence and incidence study tool for use at the bedside. Implementation of this tool resulted in a significant reduction of pressure injuries and provided the evidence needed to support the purchase for new pressure relieving mattresses throughout the hospital, including models specifically designed for high risk patients. This data also supported the case for pressure relieving heelboots, which help keep feet off the bed and prevent heel pressure injuries from developing. From 2011, Southlake’s pressure injury incidence rates went from 20 per cent down to as low as 2.1 per cent at the lowest by present day. “We found quarterly pressure injury incidence studies to be especially impactful, because they provided our staff with the data to inform their decisions around strategies for prevention more immediately,” added Mundy. “Factors including bath products used as well as environmental circumstances such as having patients in overcensed areas have been identified as contributing to an increased rate in pressure injuries – learning this has enabled us to implement changes to reduce avoidable risk factors in a shorter period of time.” Due diligence for assessing pressure injuries requires empowering the entire nursing staff with the knowledge and resources to confidently make clinical judgments on the course of action required to minimize risk and maximize patient quality of life while they are receiving acute care in the H hospital. ■
Brenda Mundy is the Manager of the Skin and Wound Program at Southlake Regional Health Centre. She is also the manager of Professional Practice and Student Placements. Michelle Lee Hoy is a Strategic Communications Consultant at Southlake Regional Health Centre. 18 HOSPITAL NEWS MARCH 2018
Novel muscle pump activator device
speeds wound healing By Diana Swift ecent studies and a compelling case report show how an innovative hemodynamic add-on device (originally developed to prevent deep vein thrombosis) can reduce the healing time of new leg ulcers before they become chronic. The wireless, wearable, wristwatch-size gekoTM Wound Therapy device marshals the bodyâ€™s own biomechanical mechanisms to boost blood flow and promote healing. Activating calf and foot muscle pumps through stimulation of the common peroneal nerve below the knee, the device boosts blood volume and velocity in the super-
ficial femoral vein and artery, and systemically when worn on both legs. â€œThat results in improved microcirculation to the skin and tissue, which is the wound bed,â€? explains Connie Harris, RN, a specialist in wound care and tissue repair since 1992 and a consultant for the muscle pump activatorâ€™s distributor. â€œIn the first study to look at using the device in new leg wound patients, we found an average weekly reduction in wound surface of 36.5 per cent in this group, which is really unbelievable,â€? Harris says. â€œIn a prior study of patients with chronic non-healing wounds we saw a reduction of roughly
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0591%% 6JG 'PVGTQUVQOCN 6JGTCR[ 0WTUG '60 YKNN DG MPQYP CU p0WTUG 5RGEKCNK\GFKP9QWPF1UVQO[%QPVKPGPEGq 0591% Enterostomal Therapy Nurses or Nurses Specialized in Wound, Ostomy & Continence, are the only registered nurses in Canada who have Canadian Nurses Association (C.N.A.)
iĂ€ĂŒÂˆwV>ĂŒÂˆÂœÂ˜ÂˆÂ˜ĂŒÂ…iĂŒĂ€ÂˆÂ‡ĂƒÂŤiVÂˆ>Â?ĂŒĂžÂœvĂœÂœĂ•Â˜`]ÂœĂƒĂŒÂœÂ“Ăž>Â˜`VÂœÂ˜ĂŒÂˆÂ˜iÂ˜ViV>Ă€iÂ° ÂœĂ€ vĂ•Ă€ĂŒÂ…iĂ€ ÂˆÂ˜vÂœĂ€Â“>ĂŒÂˆÂœÂ˜ ÂœÂ˜ ĂŒÂ…i Â˜>Â“i VÂ…>Â˜}i] ÂœĂ€ ĂŒÂœ Â?i>Ă€Â˜ >LÂœĂ•ĂŒ ĂŒÂ…i Ć‚ / Ć‚V>`iÂ“Ăž ĂŒĂ€ÂˆÂ‡ĂƒÂŤiVÂˆ>Â?ĂŒĂži`Ă•V>ĂŒÂˆÂœÂ˜ÂŤĂ€Âœ}Ă€>Â“vÂœĂ€Ă€i}ÂˆĂƒĂŒiĂ€i`Â˜Ă•Ă€ĂƒiĂƒÂˆÂ˜ĂœÂœĂ•Â˜`]ÂœĂƒĂŒÂœÂ“Ăž>Â˜`VÂœÂ˜ĂŒÂˆÂ˜iÂ˜Vi V>Ă€i]ÂŤÂ?i>Ăƒi}ÂœĂŒÂœĂœĂœĂœÂ°V>iĂŒÂ°V>ÂœĂ€iÂ“>ÂˆÂ?ÂœvwViJV>iĂŒÂ°V>
nine per cent per week, which was also pretty amazing.â€? The costs of treating chronic wounds are enormous: in 2016, wound care cost the Canadian healthcare system almost $4 billion and chronic non-healing wounds affect as many as 500,000 Canadians. Testifying to the deviceâ€™s applicability in wound healing is the 2017 case of a 74-year old woman from Cambridge, Ont., who sustained a deep laceration to her right lower leg when it was struck on the outer side by the pedal of an elliptical exercise machine at a seniorsâ€™ recreation centre. Continued on page 20
WOUND CARE Continued from page 19
Muscle pump activator A large flap of skin and tissue was torn away and blood and loss was significant. The flap was sutured in place in a hospital emergency room and the sutures were removed by her family doctor after 10 days. At that time, the patient received a topical antibiotic cream, but when the dressing was changed the next day, the wound edges had reopened, revealing several sutures still in place. An additional 12 sutures were removed in the ER and an antimicrobial silver dressing was applied and changed at seven and 14 days. At that time the woman entered the Waterloo Wellington Local Health Integration Network (LHIN) Home and Community Care Program. Her wound measured 6 cm long by 1.7 cm wide by 0.3 cm deep (3 cm3). After the wound was debrided of yellow slough for a second time, it measured 4.5 cm by 1.5 cm by 0.5 cm (3.375 cm3), representing a 9.7 per cent per week increase in size since entering the program. The patient was then fitted with the geko™ device and taught how to apply, properly set, and remove it after each six-hour treatment, given five days a week. A strong foot twitch in response to stimulation suggested she was a good candidate and would have an optimal hemodynamic response. She was advised to turn the device off while driving in order to prevent a potentially risky involuntary movement of her pedal foot. A single-layer tubular compression stockinette of 8-10 mmHg was added to her therapy to help reduce edema and provide some surface protection. Three weeks and four days later, the wound had closed, for a rapid 100 per cent reduction in wound size at a weekly rate of about 28 per cent. “A normally healing new leg ulcer would be expected to heal by 12 to 24 weeks,” Harris says. The patient was able to go on a planned vacation and even swim in the ocean. “If it weren’t for this device, I’d still have a big hole in my leg,” she says, crediting the muscle pump
Wound on appearance day of geko™ start; and then closed at 3.5 weeks with geko™ therapy. activator for the rapid resolution of her leg wound. Combined with best practices used for chronic non-healing venous leg ulcers, the device has shown benefit in other patients with new wounds. Last year, the Waterloo Wellington LIHN and Home and Community Care Program evaluated the device in 10 new wound patients, a largely elderly group that included the 74-year-old in the case study and had a total of 16 leg recent ulcers.
(range 2.29–100). In nine patients, the average time to complete wound closure was 3.03 weeks (range 5 days to 9 weeks). One obese patient with diabetes, who had developed multiple infections over time, failed to heal but did show improvement. “The device really sped up healing in people with comorbidities who looked as though they were not going to heal. One lady who was going out of the country healed in a week,” says Donna Radul, RN, wound care lead
THE WIRELESS, WEARABLE, WRISTWATCHSIZE GEKOTM WOUND THERAPY DEVICE MARSHALS THE BODY’S OWN BIOMECHANICAL MECHANISMS TO BOOST BLOOD FLOW AND PROMOTE HEALING. With a mean Home and Community Program stay of 23 days, the patients had experienced an average weekly increase in wound size of 79.29 per cent (range 618–27.7). After the addition of geko™, wound size decreased by a weekly average of 36.5 per cent
at the Cambridge LHIN clinic, adding that the device creates the same circulatory effect as walking three hours day. “And patients who were less mobile said their legs felt better. It gives them hope they’ll get better.” The adjunctive device also increased
urine output and reduced edema and lymphedema came down within a week. The device also helped another woman who had to postpone needed surgery because of wounds. “In situations where we need to heal wounds before patients can have needed surgery I think muscle pump activators really should be considered,” says Radul. In another setting, the device was recently evaluated in a randomized controlled trial in kidney and pancreas transplant patients at Ontario’s London Health Sciences Centre. Patients were randomized either to standard care with compression stockings plus intermittent pneumatic compression pump or to the geko™ applied on each side. The results were positive and will be published in two articles, one looking at the device’s impact on wound healing and the other on prevention of edema. For Harris, with her more than 25 years’ experience in wound care, the hemodynamic approach is “truly the most exciting thing I’ve seen in all that time. I believe it can be a life changer H for many patients.” ■
Diana Swift is a freelance writer in Toronto. 20 HOSPITAL NEWS MARCH 2018
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Wound Therapy Providing increased blood circulation to promote ZRXQGKHDOLQJQDWXUDOO\IURPWKHLQVLGH
The gekoâ„¢ Wound Therapy device action increases venous, arterial and microcirculatory blood volume Ã€RZE\DFWLYDWLQJORZHUOHJDQGIRRWPXVFOHSXPSVWKURXJKVWLPXODWLRQRIWKHFRPPRQSHURQHDOQHUYH1-4 7KHEORRGÃ€RZLQFUHDVHSUHYHQWVDQGUHGXFHVHGHPD4 and maintains TCpO2 â€“ promoting conditions IDYRUDEOHIRUZRXQGKHDOLQJ3,5 ,QHYDOXDWLRQVLQ+RPHDQG&RPPXQLW\&DUHVHWWLQJVLQ2QWDULRSDWLHQWVZLWKUHFDOFLWUDQWYHQRXV OHJXOFHUVLQOFXGLQJVRPHZLWKYHQRO\PSKHGHPDUHFHLYHGXVXDOEHVWSUDFWLFHVIRU9/8V3/86WKHJHNRÂŒ GHYLFHKRXUVSHUGD\GD\VSHUZHHN7KHSDWLHQWVZKRDGKHUHGWREHVWSUDFWLFHWUHDWPHQWDQGXVH RIWKHJHNRÂŒGHYLFHDFKLHYHGDQDYHUDJHUHGXFWLRQRI6XUIDFH$UHDOHQJWK[ZLGWK RISHUZHHN 7KLVZRXOGEHFRQVLGHUHGDÂ³1RUPDOÂ´KHDOLQJWUDMHFWRU\LQQHZO\DGPLWWHGSDWLHQWV )RUIXUWKHULQIRUPDWLRQRQWKHJHNRÂŒ:RXQG7KHUDS\GHYLFHDQGWKHFOLQLFDOHYLGHQFH SOHDVHYLVLWRXUZHEVLWHwww.gekowound.ca Demonstrations / Ordering: 7 (PDLORUGHUV#SHUIXVHPHGWHFFRP 7XFNHU$7HWDO,QW-$QJLRO6SULQJ HH :LOOLDPV.-HWDO3KOHERORJ\-XQ -DZDG+HWDO-RXUQDO9DVF6XUJ9RO :LOOLDPV.-HWDO3RVWHU9DVFXODU6RFLHW\$QQXDO6FLHQWLÂ¿F0HHWLQJ*ODVJRZ1RYHPEHU :DUZLFN'HWDO,QW-$QJLRO$SULO +DUULV&HWDO,QW:RXQG- $YDLODEOHDWKWWSRQOLQHOLEUDU\ZLOH\FRPGRLLZMHSGI +DUULV&HWDO,QW:RXQG- $YDLODEOHDWKWWSRQOLQHOLEUDU\ZLOH\FRPGRLLZMHSGI *HOIDQG-0HWDO-RXUQDORI,QYHVWLJDWLYH'HUPDWRORJ\
MARCH 2018 HOSPITAL NEWS 21
Preventing diabetic foot ulcers By Ann Besner n a spring day in Halifax in 2017, groups of physicians, chiropodists, educators, industry and government representatives, and advocates crowd around tables in a hotel meeting room. They have gathered for a policy roundtable, hosted by Diabetes Canada. The participants share stories and discuss their experiences working in the field of, and, in some cases, living with, diabetes. The conversation turns to amputation prevention, including best practices in screening, foot care, and education, and by the end of the session, a series of recommendations had been developed to guide Diabetes Canada in its future research and advocacy work. Fast forward to the fall of 2017, where conversations with similar stakeholders also took place at three
subsequent Diabetes Canada roundtables in Winnipeg, Edmonton and Victoria. Across the country, preventative foot care is a critical issue for diabetes practitioners, policy makers, health organizations and patients alike. This is because in Canada, diabetes is the leading cause of non-traumatic lower limb amputation, one of the most debilitating and feared complications among people with the disease. Approximately 85 per cent of amputations that occur in people with diabetes follow foot ulcers, which are often the result of neuropathy and/or peripheral vascular disease, known complications of sub-optimally controlled diabetes. A diabetic foot ulcer (DFU) is extremely costly to the healthcare system. In Nova Scotia, the overall annual cost of DFUs is around $30 million, while larger provinces like Ontario
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How are you managing them? To learn how PROMOGRAN PRISMA™ can help, please contact your KCI representative at 800-668-5403 or visit systagenix.ca NOTE: Speciﬁc indications, contraindications, warnings, precautions and safety information may exist for Systagenix and KCI (Acelity companies) products. Please consult a healthcare provider and product instructions for use prior to application. Reference: Serena T, Cullen B, Bayliff S et al. Protease activity levels associated with healing status of chronic wounds [abstract] Serena T, Cullen B, Bayliff S et al. Wounds UK 2011. Copyright 2018 KCI Licensing, Inc. All rights reserved. Unless otherwise designated,all trademarks are proprietary to KCI Licensing, Inc., its afﬁliates and/or licensors. PRA001634-R0-CA, EN (02/18)
22 HOSPITAL NEWS MARCH 2018
DIABETES IS THE LEADING CAUSE OF NON-TRAUMATIC LOWER LIMB AMPUTATION, ONE OF THE MOST DEBILITATING AND FEARED COMPLICATIONS AMONG PEOPLE WITH THE DISEASE cite costs that exceed $400 million per year. People with diabetes are over 20 times more likely to be hospitalized for non-traumatic lower limb amputation secondary to an ulcer compared to the general population. Moreover, DFUs pose a tremendous physical and emotional encumbrance to individuals and their families. They often cause great pain and discomfort, decrease mobility, and interfere with sleep and other activities. Research suggests an increased incidence of anxiety and depression, and feelings of powerlessness in people with a DFU. The overall impact of ulcers is significant and troubling. Proper treatment of foot ulcers can relieve some of the burden on the healthcare system and improve productivity and quality of life for people living with diabetes. From Diabetes Canada’s 2017 policy roundtables series, participants unanimously supported immediate public funding of offloading devices – specially fitted equipment that alleviates pressure from foot wounds, thereby allowing for better and faster healing – in each of their provinces for medically eligible people, to decrease risk of amputation. Fewer ulcers and amputations would save millions in direct and indirect healthcare costs, and represent less time for patients and healthcare providers spent on DFU treatment in clinics and emergency departments. In November 2017, the Government of Ontario announced that it would devote funding over the next
three years to cover specialized casts for those with a DFU, and to support wound care training and education for healthcare workers. This is the first, and only, province to date to take this action. Diabetes Canada is calling for other governments to follow suit. With respect to DFU care, best practice guidelines also recommend that “individuals who develop a foot ulcer should be managed by a multidisciplinary healthcare team with expertise in the management of foot ulcers to prevent recurrent foot ulcers and amputation”. Ideally, DFUs should be prevented. To this end, regular foot examinations for people living with diabetes, education on proper foot care and foot wear, and timely referrals to trained specialists are advised. One way to promote best practice is to embed evidence-based guidelines in electronic medical record systems to remind healthcare providers to perform regular foot assessments on their patients with diabetes. Access to education, medications, devices and services that help Canadians to achieve and maintain good diabetes control also goes a long way to preventing the complications that can lead to foot wounds. Finally, an interdisciplinary approach to diabetes treatment, including coordination of care and communication between healthcare professionals, is necessary to decrease the prevalence of DFUs and to support people living with diabetes to H reach their health potential. ■
Ann Besner MScA, RD, CDE is Manager, Research and Policy Analysis at Diabetes Canada.
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• Ideal for wound cleansing when surgical debridement must be delayed or is not possible or appropriate.
To learn more about V.A.C. VERAFLO CLEANSE CHOICE™ Dressing or about V.A.C VERAFLO™ Therapy and for an evaluation, please contact your local Acelity Representative at 800-668-5403 or visit VERAFLO.com NOTE: Speciﬁc indications, contraindications, warnings, precautions and safety information exist for KCI products and therapies. Please consult a clinician and product instructions for use prior to application. Copyright 2016, 2017 KCI Licensing, Inc. All trademarks designated herein are proprietary to KCI Licensing, Inc., its afﬁliates and/or licensors. PRA001633-R0-CA, EN (10/17)
The pressure’s on:
Seeking better options for bed sore prevention By Barbara Greenwood Dufour ost of us don’t have to worry about pressure ulcers, or “bed sores.” But for people who stay in the same position for long periods of time without shifting their weight or repositioning themselves — such as wheelchair users and those confined to bed due to an injury or surgery – they’re a very serious concern. In Canada, the prevalence of pressure ulcers is estimated to be 25.1 per cent in acute care hospitals and 29.9 per cent in long-term care facilities. Once pressure ulcers form, they can be hard to treat and can lead to severe medical complications, including infection, sepsis, and death. Therefore, healthcare providers try to prevent them from developing in the first place by regularly repositioning their patients, choosing support surfaces (beds and chairs) that might reduce or redistribute pressure on areas of the body most susceptible to skin and tissue damage, and inspecting skin regularly for signs of damage. However, despite these measures, pressure ulcers remain common in atrisk individuals, leading healthcare providers to seek better ways to prevent them. Over the years, CADTH has looked at what the evidence says about the effectiveness of some of the preventive technologies. CADTH is an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, and procedures to help Canadian healthcare decision-makers.
In 2015, CADTH looked for evidence specifically related to people who use wheelchairs. One review, focused on wheelchair selection, found evidence that points to the importance of a formal assessment of a patient’s unique physical attributes and lifestyle when choosing a wheelchair. The second review, which looked at evidence-based guidelines for pressure ulcer prevention, found that, in addition to individualized assessments, measures related to education and self-management; weight management and nutrition; pressure mapping; proper bed positioning and patient repositioning; and mobility, activity, and conditioning are recommended. For patients with limited mobility confined to beds, repositioning is an important aspect of pressure ulcer prevention. Repositioning can be performed manually, but special turning devices are available to help healthcare providers reposition patients more easily and more regularly. Similarly, “positioning chairs” are available that allow for frequent repositioning of seated patients and can be either designed as wheelchairs or, for more mobile individuals who sit for long periods of time, stationary chairs. CADTH looked for evidence of the effectiveness of turning devices in 2013 and of positioning chairs in 2017 but found that no studies had yet been published. Materials such as incontinence underpads (also called soaker pads)
and natural sheepskins are sometimes placed on top of a patient’s bed or other support surface in an attempt to prevent pressure ulcers. CADTH looked into both these interventions in 2017. No evidence was found on the effectiveness of incontinence underpads; however, if they are to be used, disposable underpads might result in significantly fewer pressure ulcers than the reusable variety, according to a CADTH review of the evidence comparing the two. CADTH’s review of natural sheepskins found low-quality evidence suggesting that they might reduce the risk of pressure ulcers although some patients might find the woolly sheepskins too warm. In addition to the established methods for preventing pressure ulcers, there are some newer interventions. Used in patients with spinal cord injuries, electrical muscle stimulation delivers periodic electrical pulses to the buttock muscles in an attempt to simulate the subconscious fidgeting and shifts in body position that those without mobility issues make. A 2016 CADTH review found that it isn’t yet clear if this technology is effective. Wound dressings are typically used to treat pressure ulcers after they’ve developed but are sometimes used to protect areas of the body vulnerable to pressure ulcers due to friction and shear, such as the base of the spine and the heels. In 2016, when CADTH looked at the effectiveness of newer
polyurethane film dressings, some evidence was found to suggest that they might be an effective for preventing pressure ulcers. Polyurethane foam dressings are another newer option. Like film dressings, they protect the skin from friction and shear; however, they also provide cushioning, which may help redistribute pressure and manage moisture levels to keep skin healthy. A 2017 CADTH review of found that, for at-risk adults in most settings, they may be an effective option for preventing pressure ulcers. Several other new innovations have come on the market, including advanced support surfaces that control skin temperature and moisture, sensors that monitor how often patients move, and smart textiles that can sense when pressure ulcers may be forming. Finding better ways to prevent pressure ulcers is and will continue to be important to improving patient care, and research is needed to determine what the best practices should be and which new technologies live up to their promise. If you’d like to read any of the CADTH reviews mentioned in this article – or those on a variety of drugs, devices, or procedures – they are freely available at www.cadth.ca/reports. To learn more about CADTH, visit www. cadth.ca, follow us on Twitter: @ CADTH_ACMTS, or talk to our Liaison Officer in your region: www.cadth. H ca/contact-us/liaison-officers. ■
Barbara Greenwood Dufour is a Knowledge Mobilization Officer at CADTH. 24 HOSPITAL NEWS MARCH 2018
Early-detection improves foot surveillance for patients with diabetes By Kelly O’Brien ore than three million Canadians have diabetes, a number that has nearly doubled since 2002 and continues to grow. They have tools to manage their glucose levels, but not to manage foot wounds that often lead to infection and amputation. MIMOSA (Multispectral Mobile Tissue Assessment Device) is an early-detection tool developed by Dr. Karen Cross, a surgeon-scientist at
St. Michael’s Hospital, and Dr. General Leung, a magnetic resonance physicist at St. Michael’s. The device detects poor blood circulation in the feet, which can lead to diabetic foot ulcers, by photographing the skin with near-infrared light. “It’s just beyond the range of human vision , so it’s safe, but also it has deep penetration into the skin, so it’s going to get below that top layer,” says Dr. Cross. Continued on page 26
Photo courtesy of St. Michael’s Hospital
Dr. General Leung with the MIMOSA device which detects poor blood circulation in the feet, which can lead to diabetic foot ulcers, by photographing the skin with near-infrared light.
a leader in health continuing professional education Find out more about our interactive wound care courses designed for health professionals to prevent and manage chronic wounds: • •
Specialty custom workshops are also available for • ED physicians and nurses - What to have in the ED wound care toolkit to reduce length of stay • Chiropodists or RPNs in chiropody care • Nurses in Medicine Units/Palliative Care/ Geriatric care Contact us for more information: 416-736-2100 ext 22170 | firstname.lastname@example.org hlln.info.yorku.ca/open-programs www.hospitalnews.com
MARCH 2018 HOSPITAL NEWS 25
WOUND CARE Continued from page 25
Early-detection “It can see things that we can’t.” Dr. Cross likened the light MIMOSA uses to the technology used to discover that Leonardo da Vinci was the artist behind The Adoration of the Magi, the painting most often attributed to Filippino Lippi. The light allowed art historians to view the different layers of the painting without damaging it. “We’re doing the same thing,” says Dr. Cross. “Before, to see how much hemoglobin you have, you’ve got to take blood. You’re damaging something by putting a needle in there. We can actually do it by not damaging anything.” Between 15 and 25 per cent of people with diabetes will have a foot ulcer at some point. These ulcers often become infected and as a result, diabetics are 23 times more likely than the general population to have a lower limb amputation. The technology MIMOSA uses to monitor wounds was originally developed as an early detector and triage tool for determining burn depth. But what has changed is the size of the tool. “Because of the way the technology’s changed, and because we have so much computing power in our pockets and our cell phones, we’re able to shrink it down,” says Dr. Leung. “So now it’s evolved from being 10 or 12 feet tall to being a little clip-on device.” The device is designed to work for all diabetics, no matter their age or level of mobility. “This is something you could put on a selfie stick and put it down below and take a picture,” says Dr. Cross. The team has already seen success using MIMOSA to monitor wound development in a recently completed pilot study, and will soon begin work on a two-year, multicentre randomized controlled trial. Evidence has also shown prevention strategies such as MIMOSA can result in a 20 to 40 per cent reduction in treatment costs. “Diabetes is a global tsunami,” she says. “More than 300 million people worldwide have diabetes, and that number is only growing. So something that can be made quite simply and can reduce those costs is an easy sell. H That’s what we want to do.” ■ 26 HOSPITAL NEWS MARCH 2018
Hyperbaric: A fresh approach for the non-healing wound By Dr. Anton Marinov here are few conditions more disturbing, demoralizing and debilitating than complex non-healing wounds that persist for months, and sometimes years. The toll on the patients’ quality of life and the costs to the healthcare system are significant. According to the Government of Canada, the annual cost of wound care exceeds 3.9 billion. Morbidity is high. Diabetic foot ulcer patients, for example, carry a three-year mortality rate of 26.4 per cent, and following amputation, the five-year mortality rate climbs to as high as 50 per cent. Traditionally, the treatment of infected, chronic, or re-opened surgical wounds has been the domain of surgical debridement, infection control and meticulous wound care with frequent dressing changes. Advances, such as
negative-pressure wound therapy and specialized wound dressings have had a positive impact, and are now among the most effective tools in wound treatment. Despite these gains, the most problematic wounds still fail to heal and it is here that hyperbaric oxygen therapy has gained popularity, as a treatment adjunct. When Karen Trace, a resident of Scarborough, Ontario, walked through the doors of Rouge Valley Hyperbaric Medical Centre, she had been told by her doctors that her only option was to have an amputation. “Understandably, I was scared,” she later confessed. Not ready to settle, she approached the recently-opened hyperbaric medical centre, located in the medical building of the Scarborough and Rouge Hospital’s Centenary Site. “My doctor was aware of the treat-
ment but cautious about how it would work for me. After consultations and several treatments, the wound completely healed and my foot was saved,” she went on. Karen is one of a growing number of patients who have benefited from hyperbaric oxygen.
SNAKE OIL There are few treatments less understood in the medical community than hyperbaric oxygen therapy. Having been in existence since the seventeenth century, it has been used for the treatment of a vast array of conditions. Today, the scientific evidence for many is lacking, but for a select few it is convincing enough to be approved by Health Canada and covered under the Ontario Health Insurance Plan. Complex wounds, diabetic foot ulcers, non-healing radiation damaged tissue, www.hospitalnews.com
and compromised flaps and grafts are all approved indications for treatment with hyperbaric oxygen. The body of knowledge regarding the effects of hyperbaric oxygen has steadily grown and today we find ourselves in what can be best described as a renaissance in the field. Numerous in vitro and animal experiments have revealed that hyperbaric oxygen works by promoting tissue growth factors, drives the formation of new blood vessels, mobilizes stem cells from the bone marrow, and diminishes the inflammatory response. At the same time, clinical studies have revealed that hyperbaric oxygen can prevent amputations in select diabetic patients and result in savings to the healthcare system.
HYPERBARIC PRACTICE TODAY Not long ago, perhaps 10 to 15 years, there were a handful of academic hospital-based hyperbaric centres
scattered across the country – Halifax, Quebec City, Ottawa, Toronto, Hamilton, Vancouver. In recent years however, driven by the accumulated knowledge base and renewed public interest, new hyperbaric treatment facilities, such as the Rouge Valley Hyperbaric Medical Centre where Karen received her treatment, have opened their doors. The typical treatment is conducted in individual acrylic-walled chambers, where the patient breathes 100 per cent oxygen at a pressure of 2 to 2.5 atmospheres for ninety minutes. The treatment regimen consists of a series of sessions, the number being determined by patient response and the indication for treatment. There are 14 conditions currently approved by Health Canada. In addition to problem wounds the list also includes osteomyelitis, sudden hearing loss, burns, severe anemia, carbon monoxide poisoning, decompression sickness, necrotizing soft tissue infections, crush
THERE ARE FEW TREATMENTS LESS UNDERSTOOD IN THE MEDICAL COMMUNITY THAN HYPERBARIC OXYGEN THERAPY injuries and arterial gas emboli. In the majority of these conditions, hyperbaric oxygen is utilized as an adjunct to mainstream treatment. In the case of chronic wounds, this includes debridement, infection control, specialized dressings and offloading.
FUTURE TRENDS Despite the advances in technology and science there is still much we do not know about this promising form of treatment. Dr. Rita Katznelson, a physician and researcher at the University Health Network is actively investigating the hyperbaric oxygen effects on patients suffering from stroke and those with spinal cord ischemia.
Research from around the world is contributing to a growing body of evidence that hyperbaric oxygen can be helpful in other conditions ranging from traumatic brain injury and avascular hip necrosis to interstitial cystitis. National meetings of the Canadian Undersea and Hyperbaric Medical Association, are fostering deeper collaboration in clinical research. Meanwhile, the front line hyperbaric physicians and technologists at the Rouge Valley Hyperbaric Medical Centre along with their colleagues across the country are laying the foundation of modern hyperbaric medicine by outreach, education and evidence-based H practice. ■
Dr. Anton Marinov is the Medical Director of the Rouge Valley Hyperbaric Medical Centre.
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WOUND CARE Valérie Chaplain an Enterostomal therapy (ET) Nurse at Hôpital Montfort in Ottawa often explains wounds to staff with the help of fruit.
A wound care hero By Gabrièle Caza-Levert rom fixing holes in walls, to fixing patients’ wounds, Valérie Chaplain, Enterostomal Therapy (ET) Nurse at Hôpital Montfort, in Ottawa, has a passion for helping others. It has been quite the journey for Valérie to become an ET Nurse. After high school, Valérie completed a bachelor’s degree in biology, thinking she would go on to do her Master’s and possibly teach biology. However, somehow, life had a different path for her. She decided to become a contractor and work in construction. For 12 years, she did everything from roofing, to changing windows, to installing hardwood and ceramic floors. Often having to lift objects that were heavier than she was, she even-
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tually felt the toll this line of work was having on her body. That’s when she decided to look into going back to school. Not sure what she would be interested in yet, she took a little while to explore her options. Around the same time, two of her close friends suffered from cancer. Valérie accompanied her friends and their families throughout this very difficult journey, offering comfort and support. After her second friend passed away, Valérie left on an adventure to Laos (South East Asia) with a group of tourists to explore on foot the most secluded areas of the country. Once, in an isolated village, a local mom came with her baby to seek help: her child had an enormous abscess. Valerie was carrying
a large first-aid kit and being a mom of four herself, she offered to help. Valérie remembers the scene like it was yesterday. “I sat on the ground, washed my hands thoroughly with hand sanitizer and told the mother to hold her baby tightly, as this would hurt. I pressed on the abscess and a fountain of pus came out. It was such a relief. I heard cheering from the villagers and my group, which was a great moment for me. I then proceeded to clean the wound and wash my hands. When I got up and turned around, what I saw shocked me. There was a long line of people who wanted me to care for them as well. I helped as much as I could.” When she came back to Canada, Valérie immediately started her education to become a specialized enterosto-
mal therapy nurse. After completing her nursing bachelor’s degree, she took a 13-month training offered by Nurses Specialized in Wound, Ostomy, and Continence Canada, then applied for the official certification in enterostomal specialization with the Canadian Nurses Association. What is enterostomal therapy? It’s three expertise combined in one speciality: wound, ostomy and continence care. An enterostomal therapy nurse takes care of people who eliminate through a stoma. They also take care of people with wounds that don’t heal well and those that have continence issues. Although not a large percentage of the population will have to be hospitalized because of a wound, the complexity of these cases and the impact www.hospitalnews.com
WOUND CARE on the healthcare system is important. Not only are the costs associated with wound care very high, the impact on the quality of life of affected patients is significant. Prevention is key, and that’s also where the enterostomal therapy nurse comes in. When there is a wound, early intervention will help reduce the risk of infection and delays in healing, and therefore, associated costs of complications. Enterostomal therapy nurses can also reduce the number of emergency department visits from the stoma clientele. For five years now, Valérie has been the only enterostomal therapy nurse at Montfort, offering care, information and education to her patients as well as training, advice and best practices to her colleagues. She started a clinic to follow up regularly with her stoma patients. Annually, she helps approximately 400 hospitalized patients and 150 patients in her clinic, amounting to over 1300 visits (including multiple visits with the same patients).
NOT ONLY ARE THE COSTS ASSOCIATED WITH WOUND CARE VERY HIGH, THE IMPACT ON THE QUALITY OF LIFE OF AFFECTED PATIENTS IS SIGNIFICANT “In wound care, there is no magical recipe. Every case is different. There is a plethora of factors that require you to evaluate each wound and each case individually,” explains Valérie. “The biggest challenge in wound care is that it is a dynamic speciality that is ever-changing, and therefore, you must constantly readjust your clinical judgment and re-evaluate the wound as it evolves. Knowing how to heal a wound and which bandage to use comes with experience and that is why every hospital can benefit from the expertise of an enterostomal nurse.” Working with ostomy patients in a hospital setting, ET nurses have a fleeting role in the lives of their patients. They make sure that everything
goes well during their stay and they know what to do with their stoma. However, they cannot offer long-term support with this condition and that is why Valérie opened an ostomy outpatient clinic at Montfort, shortly after her arrival. “It was essential to me to ensure patients, some of whom will have to live with a stoma this their entire life, had appropriate follow-ups and support.” What does it take to be a nurse specialized in wound, ostomy and continence? “It takes a lot of leadership skills. Everyone wants your opinion, from surgeons to fellow nurses, to patients and their families. You need to have confidence in yourself, your knowledge and your skills to offer ad-
vice and training. You need to be compassionate, considering you are working with a vulnerable clientele. Finally, you need to be curious and humble, knowing your field is constantly evolving and wanting to stay up-to-date with best practices,” she says. Valérie is passionate about research. She published an article in the Journal of Wound Ostomy & Continence Nursing, she validated the French translation of a skin tears classification tool with 92 nurses, and she will soon begin a research project, funded by the hospital’s knowledge institute, the Institut du Savoir Montfort, to validate a more efficient way to measure pH levels in wounds. Currently completing her Master’s in wound care, Valérie is also dedicated to education. Whether through her monthly educational e-newsletter, her yearly wound care fair or her regular classes to train wound care “champions,” Valérie is an inspiration for her peers and a shining star H at Montfort. ■
Gabrièle Caza-Levert is a Communications Advisor aat Hopital Monfort.
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