MARCH 2019 HOSPITAL NEWS 21
Wound care By Rosemary Kohr hronic wounds have never had the same level of attention as cancer care, or treatments of heart disease, yet they quietly affect a significant share of our patients; and are responsible for longer hospital stays, sepsis and amputations. What are the numbers, you might ask – and the embarrassing answer is “we don’t really know”. Consistent, accurate data collection of chronic wounds (bedsores, diabetic foot ulcers, venous leg ulcers and stalled/infected surgical wounds) has been spotty at best – the last cross-Canada estimate was in 2004. However, we can make some reasonable assumptions, based on US figures, where at any point in time, 15 per cent of the acute care population is estimated to have a pressure injury (Institute for Healthcare Improvement, 2012). Now well into the 21st Century, patients admitted to hospital are older, sicker and often with multiple issues related to mental health, family stress, poverty, etc. What might have once been a fairly simple “throughput” experience, has become the unfortunate-
Stop Chronic Wounds Today! WOUND CARE has changed, with new dressings and technologies, yet many wound care practices remain outdated. Do you have up-to-date knowledge to provide the best in safe, evidenceinformed wound prevention and care? The Wound Care Certificate at York University will provide you with current, clinically relevant information about preventing and managing chronic wounds, such as pressure injuries, venous/ arterial, diabetic foot ulcers and infected wounds. This practical 4-day course, offered through the Health Leadership and Learning Network at York University, is custom-designed for nurses and other health professionals. Experience education that you can apply directly to the workplace through interactive case discussions and hands-on opportunities to try various dressings. The focus is on understanding the generic principles of each dressing type, and developing confidence to prevent, assess, treat and document wounds. Currently in its fifth year at York University in Toronto, the course will be on the road for first time with sessions in Ottawa, Sudbury, Windsor (ON), and Halifax (NS) for 2019. Please contact us at firstname.lastname@example.org or 416-736-2100 x 22170 for more information. Inquire also about our special wound care course for chiropodists.
22 HOSPITAL NEWS MARCH 2019
ly common scenario for many patients. Take for example, Mrs. Ida Jackson. She’s an 86-year-old widow, living in her own home. On Saturday, she trips over a scatter rug and falls. She’s brought to the emergency department (ED) where X-rays confirm a hip fracture. Admitted for surgery, she still has to wait 24 hours in the ED for an apropriate bed to become available. The ED is busy; Mrs. Jackson is in a continence brief (adult diaper). She’s NPO (“Nothing by mouth”), with an IV running. Her surgery goes well on Tuesday, but discharge is put on hold, due to her slow recovery. Her mobility and activity have both been limited; due to pain, she has been reluctant to get out of bed or follow the deep coughing instructions from the respiratory tech. She only picks at her food. Family visits have been sporadic, since her grown children are busy with work and other responsibilities. The nurses have documented a Stage 2 Pressure Ulcer on her coccyx, and have notified the team. After a quick look, the doctor writes the orwww.hospitalnews.com
COVER STORY der, Daily dressing and reposition q 2 h. The nurses use foam dressings, reinforced with a transparent film over top, but the whole dressing is often found in the continence brief. The nurses encourage Mrs. Jackson to change her position to decrease the pressure on her coccyx, but they note that she now appears to be developing a reddened spot on her “good” hip. By Friday, Mrs. Jackson is transferred to the General Medicine Unit. There is a smell in the room, and one of the nurses suggests using an open box of kitty litter under the bed to deal with the odour. The doctor orders Betadine-soaked gauze b.i.d. By the time her daughter asks to see Mrs. Jackson’s backside on Saturday, the bedsore has oozing yellowish- gray fibrous tissue as well as a strong odour. The daughter hits the roof. We know that elderly individuals are at higher risk of skin breakdown and slower healing, and that incontinence and poor nutritional intake are major culprits. But we also should know that appropriate prevention and treatment are available.
So why do situations like this one, which unfortunately happens to be a true story, occur with such alarming frequency? One of the basic reasons is that medical and nursing students have virtually no education regarding upto-date, evidence informed knowledge relating to chronic wound prevention and management. Until they are in the work-force, nurses and doctors, along with other healthcare professionals, often don’t realize the magnitude and complexity of skin tears, pressure injuries, diabetic foot ulcers, venous leg ulcers and stalled surgical wounds. And, poised over the patient’s wound, who has the time to stop and learn? It’s no surprise, then, to fall back on an out-of-date and usually inappropriate approach. If you don’t know that wounds change over time, and the order from last week is likely no longer what the wound needs, why would you question what you are doing? And if you do happen to ask, the response is likely to be, “Because that’s the way we’ve always done it”. In
over 15 years of teaching wound care to nurses and doctors, and consulting on more wounds than I can remember, this is the most common situation I have seen. The sad thing is, it is far costlier and time-consuming than to actually do the right thing. It’s time to change this paradigm. If we can’t change the academic programs to increase curriculum content on chronic wounds, at least in the clinical world, this shift can happen. The first step is to ensure all staff, physicians and students have up-todate training in preventing and managing chronic wounds. This education (on-site, webinars, etc) must include a hands-on component to be able to confidently and quickly select appropriate treatments, particularly dressings. Everyone, from management to Personal Support Workers, needs to be on board with evidence-informed, practical and relevant education with a focus on how to work as a team to optimize patient outcomes. Zero tolerance for hospital-acquired pressure injuries can be a realistic goal, for example. Continued on page 24
In Canada approximately
1 in 8 patients
in acute care hospitals,
1 in 11
nursing home residents, and
1 in 50
a leader in health continuing professional education Learn everything you need to know about preventing and managing wounds such as: • pressure injuries • venous/arterial ulcers • diabetic foot ulcers Inquiry today about our practical Nfle[:Xi\:\ik`ÔZXk\gif^iXd[\j`^e\fi nurses and other health professionals Upcoming Locations and Dates: • Toronto (May 1-4, 13-16, Oct 28-31, OR Nov 6-9 ) • Sudbury (June 5-8) • Windsor (June 11-14) • Halifax (June 17-20) 416-736-2100 ext 22170 | email@example.com hlln.info.yorku.ca/open-programs www.hospitalnews.com
MARCH 2019 HOSPITAL NEWS 23
COVER STORY Continued from page 23
Hospital Acquired Wound care Pressure Injuries tend to stay Patients with
4 days longer in hospitals, are7% more likely to die,
and, on average, cost the health care system an additional $13,500. Although its financial burden to the health systems is not as well known as those of other diseases,
pressure ulcers are expensive, costing the health care system as much as diabetes
and about a third as much as cardiovascular disease.
PROMOGRAN PRISMA ™
WOUND BALANCING MATRIX
Did you know... 90% of wounds with elevated protease activity will not heal without proper interventions.
The second solution is the implementation of a consistent electronic documentation and data collection tool, that includes wound photo and measurement (apps to automatically do this are currently available), as well as tracking product utilization. I know this is a challenge. But what is needed is the recognition that this MUST happen, and the will, at the senior levels of management, to make it so. Costs to implement the technology (already developed and commercialized) will be off-set through the savings directly related to patient outcomes. The third aspect of this change is to recognize the need for a team approach. Wounds heal from the inside out, so the patient must be an integral part of the treatment plan as much as possible. Depending on the issue, different members of the team may be key players. The team also extends to staff where the patient will be going – home, long-term care, etc. Communication is critical. In our example of the unfortunate Mrs. Jackson, the dietitian, pharmacist (re: pain medica-
tion) and occupational therapist would have been involved from the start; the home care social worker would have been connecting with the family re: home supports. So, in summary, the “big three” components of this change are knowledge, documentation and collaboration. From this month’s special focus on wound care, you can see that information abounds regarding treatment approaches to improve wound closure/ healing. As well, there are educational programs at a variety of levels, described and advertised – all designed for the needs of healthcare professionals across the continuum of care. Consider the quiet frequency of stories like Mrs. Jackson’s. These can be avoided with a clear commitment to those values we all hold so dear: safe, effective and efficient care, with excellent outcomes for our patients, our organizations and our communities. Leaders at all levels need to be fully engaged as champions to support this sustainable approach to skin breakdown and chronic wound prevention H and management. That’s you. ■
The five-year mortality rate for someone with
a healable, diabetes-related foot wound is similar to or higher than that of the most common types of cancer except for lung and pancreatic cancer.
Up to two-thirds of people with diabetes who have had an amputation die within the following year, 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)
24 HOSPITAL NEWS MARCH 2019
and up to
80% die within 5 years.
Rosemary Kohr RN, BScN, MScN, PhD, is a wound specialist with over 20 years providing clinical care and consultation in Acute Care (London Health Sciences Centre), long-term care and the community. She is currently Program Director, Health Leadership & Learning Network, York University and Instructor, Graduate Program, Faculty of Health Disciplines, Athabasca University. www.hospitalnews.com
Did you know... ...the 5 year mortality risk of Diabetic Foot Ulcers and Amputations is higher than breast cancer. How are you managing DFUs
V.A.C. VERAFLO CLEANSE CHOICE™ DRESSING
WOUND BALANCING MATRIX
Reference: Armstrong DG. Wrobel J. Robbins JM. Are diabetes-related wounds and amputations worse than cancer? Int Wound J. 2007:4(4):286-7. 5.
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. Copyright 2018 KCI Licensing, Inc. Unless otherwise designated, all trademarks are proprietary to KCI Licensing, Inc., its afﬁliates and/or licensors. PRA-PM-CA-00031 (06/18).
2/27/2019 8:41:58 AM
Wound care revolution:
Put away your rulers and reach for your phone By Julie Robert onitoring a wound is critical, especially in diabetic patients, whose lack of sensation due to nerve damage can lead to infection of a lesion and, ultimately, amputation. Clinicians and healthcare professionals at the McGill University Health Centre (MUHC) and other hospitals believe that the use of a new app, Swift Skin and Wound™, which accurately measures and charts the progression of skin wounds, could potentially have a significant impact on clinical management and patient outcomes. “Many of my patients are diabetic and are dealing with slow-healing foot ulcers; this app offers a way to clearly document and quantify the size of the ulcer to ensure it is actually healing, and if it is not healing, I can change strategies,” says Dr. Greg Berry, Chief of Orthopaedic Surgery at the Montreal General Hospital of the MUHC and Chief and Mueller Chair of the Division of Orthopaedic Surgery at McGill University. “I can concretely show them that what we are doing is working. They get on board and are more devoted to the treatment plan because they see it is successful,” he adds. The app was the idea of Dr. Sheila Wang, a resident in dermatology in the Department of Medicine at McGill University and a scientist at the Research Institute of the McGill University Health Centre (RIMUHC). Early in her medical career, she saw that there was a problem with the way that wounds were measured and went on to co-found the company, Swift Medical, which developed the smartphone software. “When I was in medical school in Toronto in 2013, I noticed doctors and nurses relied on rulers to measure patients’ wounds,” she says, “resulting in widely varied descriptions, depend-
NEW APP P PILOTED IN MONTRE EAL HOSPITALS S GIVES ACCU URATE, TOUCHLESS WOUND MEASUREMENTS
Photos courtesy MUCH newsroom.
Dr. Sheila Wang and Dr. Greg Berry ing on who was doing the measuring. It didn’t seem very exact, so I decided to do something about it.” Dr. Wang was first author on a paper, published in the scientific journal PLoS ONE, which shows that the app
provides measurements of wounds that are more consistently accurate than those taken by using a ruler. They are as accurate as another measuring tool known as a digital planimeter, but using the app allows medical personnel to share and track wound information. She also recently published an article in the JMIR Dermatology that focused on understanding the type and location of skin and wound lesions found in longterm care facilities and mapping these on the body. Swift Skin and Wound can be used remotely. Dr. Wang and her colleagues expect the app will play an important
role in telehealth monitoring in the future. “The app allows different health care workers to collect images and data from each patient and to follow the wound over time, something which is very important in the Northern regions, where there is a high turnover of staff,” adds Dr. David Dannenbaum, Faculty Lecturer in the Department of Family Medicine at McGill University. “This is one of the first wound measurement apps to be developed,” says Dr. Wang. “Swift Skin and Wound is now used to monitor over 100,000 patients in over 1,000 healthcare facilities across Canada and the USA. Its ability to transform wound care, even when used by those with little experience, will make it an invaluable tool H for health care workers.” ■
Julie Robert is the Communications Coordinator – Research at McGill University Health Centre. 26 HOSPITAL NEWS MARCH 2019
Challenging the process for changing a dressing By James Scarfone he problems and challenges confronting us in healthcare today are too big and too complex for top-down solutions. We need the collective wisdom of our large workforce to find solutions. At Hamilton Health Sciences (HHS), we’re empowering and equipping our frontline staff to make improvements to their work environment and to patient care on a daily basis. This is occurring with our Continuous Quality Improvement (CQI) model. CQI has created a culture change within HHS that allows staff and physicians to see opportunities to improve the way a hospital unit works. People are more receptive to changes in process and embrace fixing even seemingly minor issues if it will make the job easier and more effective. Staff in pediatric oncology unit at HHS’ McMaster Children’s Hospital identified that the adhesive remover they regularly used for IVs and dress-
PEOPLE ARE MORE RECEPTIVE TO CHANGES IN PROCESS AND EMBRACE FIXING EVEN SEEMINGLY MINOR ISSUES IF IT WILL MAKE THE JOB EASIER AND MORE EFFECTIVE.
ing changes was not overly effective. It also was supposed to reduce pain for patients but that was not always the case due to it being ineffective. Nurses had to sometimes re-apply the remover or spend extra time cleaning the area multiple times in order for the next dressing to be applied properly. The product also emitted a strong scent that bothered several members of the team and violated HHS’ fragrance-free policy. The team also found there was a different process in practice on the inpatient and outpatient pediatric oncology units. Therefore, they iden-
tified it as a process improvement to go through CQI. A small group was formed to tackle finding a solution. As part of the CQI process, the group met with several other units that were high users of this brand of adhesive remover. They created a list of pros and cons of continuing with the product. Then the group met with other areas in the hospital, namely housekeeping staff. Here they discovered the use of a similar product, as part of the cleaning routine, which was more effective. This other product was actually safer for patients, didn’t smell as much,
and was already available within the hospital. Due to this, switching to the other adhesive remover turned out to be a relatively simple solution that could be implemented in a short period of time with few resources. After implementing the solution, staff within the unit provided positive feedback on the new product. It’s now being used all throughout McMaster Children’s Hospital. “We knew a better way existed, we just needed the tools to find it,” says Stephanie Furtado, a skin, wound and ostomy nurse clinician at HHS and the person who identified the problem and led finding the solution. Switching products was not only safer for patients and easier for staff, but it also saved HHS money. Though a small amount, the savings add up quickly with a large workforce working together to create positive change. “Even something trivial can have a H big impact,” says Stephanie. ■
James Scarfone is a Public Relations Specialist at Hamilton Health Sciences. www.hospitalnews.com
MARCH 2019 HOSPITAL NEWS 27
The care team at Providence Healthcare (from L to R): Susan Chandler, clinical nurse specialist in wound care & prevention, Kimberly Mackenzie, relationships and partnerships manager, Chiara Campitelli-Thompson, patient care manager, and Kelly Tough, patient flow manager.
A new wound-care initiative is
tackling painful wait times By Selma Al-Samarrai and Michael Oliveira revor Kampen marvels at the number of people he’s met during his journey from St. Michael’s Hospital to Providence Healthcare to treat his debilitating pressure wound, a condition caused by his spina bifida. “There’s a lot of people involved in this,” the 30-year-old says with a chuckle as he tries to list off the names of all the doctors, nurses, occupational therapists, physiotherapists, his dietician and others who have had a part in his care. “If I forget somebody, I’m sorry, but there’s a lot of names and faces to remember.” Kampen is the first patient to take part in the new St. Michael’s-Providence clinical collaboration that could eventually help double the number of
28 HOSPITAL NEWS MARCH 2019
pressure wound surgeries performed at St. Michael’s each year. Pressure wounds are caused by prolonged or intense pressure to a localized area, and often develop in individuals with impairments in sensation or motor function. Providence staff have enhanced knowledge to provide rehabilitation for patients who undergo the surgery. “To be a part of this new initiative and be able to provide a service in such a meaningful and important surgery is very exciting,” says Providence patient care manager Chiara Campitelli-Thompson. “It may sound a little cliché but this has been the true definition of collaboration.” Previously, it was a struggle to find facilities that could take on a patient
for the typical six-to-eight weeks of post-operative recovery time, says Dr. James Mahoney, chief of Plastic Surgery, who performs the surgeries along with Dr. Karen Cross. “I had actually stopped doing the surgery for more than a year because I did not have the rehab space to provide patients the support I thought they required,” Dr. Mahoney says. “The surgery is only one little part,” he adds, stressing how important the collaborative nature of the initiative is. “My surgery can be undone in one episode if something is not done correctly in the rehab process.” Collaborating with Providence as the rehabilitation site means patients have access to the interdisciplinary care needed for a healthy recovery, explained Janeth Velandia, nurse prac-
titioner for the Wound Care Team at St. Michael’s Hospital, and one of three project leads for this clinical collaboration along with Cecilia (TingTing) Wan, occupational therapist for the Wound Care Team, and Kimberly Mackenzie, relationships and partnerships manager at Providence. “Providence has the full range of health care providers who are needed for rehabilitation for surgery to be successful, such as doctors, pharmacists, occupational therapists, physiotherapists, registered nurses, and registered dietitians,” explained Velandia. Kampen’s spina bifida – which limits the sensation in his lower body – led to his first pressure wound issue almost a decade ago. Continued on page 30 www.hospitalnews.com
helps ease the pain for wound care patients By Blain Fairbairn n a Canadian first, patients undergoing wound care procedures at Calgary’s Rockyview General Hospital are now using a virtual-reality program to help ease pain and anxiety. Using one of two Samsung Gear headsets funded by an anonymous donor, wound care patients are transported to an immersive, three-dimensional environment that includes a virtual lakeside campground, a pre-
historic landscape with dinosaurs and a tranquil ocean to swim with dolphins. Graydon Cuthbertson used the therapy three times after having multiple surgeries involving his calves. “It’s a godsend,” says the 47-year-old Calgary man. “Even with painkillers, the first time I had wound care after my surgery, the pain was excruciating. But with virtual reality, I got through the next treatment with flying colours.
VIRTUAL REALITY’S VISUAL AND AUDITORY EXPERIENCE HAS BEEN CLINICALLY PROVEN TO BE EFFECTIVE IN REDUCING PAIN AND ANXIETY REPORTED BY PATIENTS. “I was focused on what I was seeing and hearing, and not thinking at all about how painful it might be. All of the sudden, one-and-a-half
Continued from page 28
wound-care initiative “It involves an excessive load or direct pressure, typically over a bony prominence, and it overpowers our normal circulation leading to a wound,” says Dr. Mahoney in explaining how pressure wounds develop. It can be shocking for patients and their family members to see how severe a pressure wound can worsen. “These go all the way through your skin down to the underlying bone,” Dr. Mahoney says. “These are very significant and deep and often associated with complications.” Kampen was referred to Dr. Mahoney after years of struggles and setbacks with managing his wound, including misdiagnoses. He then had to go through an extensive assessment process to ensure he was a good candidate for surgery which was performed by Dr. Mahoney, Velandia and Wan, and included input from experts in infectious disease and imaging. Kampen also had to commit to giving up smoking, eating properly, and following a regiment of care after surgery to prevent complications and to improve wound healing.
The care team at St. Michael’s Hospital (from L to R): Janeth Velandia, nurse practitioner, Wound Care Team, Dr. Karen Cross, plastic, reconstructive and aesthetic surgeon, Dr. James Mahoney, chief division of Plastic and Reconstructive Surgery, Elizabeth Butorac, program director, Trauma/Neurosurgery and Mobility programs, and Cecilia (TingTing) Wan, occupational therapist, Wound Care Team He was then booked for so-called skin flap surgery, which involves removing compromised tissue related to the wound and filling the cavity with flaps, or rearrangements of local tissue. In Kampen’s case, hip and lower leg muscle was used. After a few days of recovery at St. Michael’s, Kampen was transferred to Providence for eight weeks of rehabilitation. Care teams at both sites
kept in close contact as his treatment progressed, often sharing images and updates electronically so Kampen wouldn’t have to be transferred back to St. Michael’s for follow up assessments by Dr. Mahoney. “My health has been a lot better and my walking has improved greatly since the surgery. I’m now able to return back to work slowly and to enjoy H the outdoors more,” says Kampen. ■
Selma Al-Samarrai and Michael Oliveira work in communications at Unity Health Network.
30 HOSPITAL NEWS MARCH 2019
hours go by and it’s all over. It was awesome.” Virtual reality’s visual and auditory experience has been clinically proven to be effective in reducing pain and anxiety reported by patients. The team leading the initiative at the hospital was inspired to investigate the therapeutic benefits of virtual reality after reviewing studies on its effectiveness from a pilot program conducted by Cedars-Sinai Medical Center in Los Angeles. While virtual reality has been used in clinical settings around the world for a variety of therapeutic and relaxation purposes, Rockyview General Hospital is the first hospital in Canada to employ the technology for wound care patients. During the research phase at the hospital, patients receiving wound care were asked to rate their level of discomfort and overall experience using surveys administered before and after virtual-reality therapy. Patient discomfort included ratings of pain, nausea and anxiety while measures of patient experience included feelings about future treatments and overall impression. The results were impressive: All patients who used virtual reality found it helpful. Patients reported a 75 per cent reduction in patient discomfort with a 31 per cent improvement in overall patient experience. Unlike conventional pain and anxiety-reduction therapies, such as painkillers or sedatives, no side effects were reported by patients who used virtual-reality therapy. While the program is not intended to replace pharmaceutical interventions, it’s anticipated virtual reality can be widely used as a complementary therapy that may reduce dependency upon drugs to enhance patient care. “Rockyview’s virtual reality program www.hospitalnews.com
illustrates how AHS employs innovative technology to improve patient care,” says Christopher Burnie, allied health manager at the hospital. “Technology has always played an important role in healthcare but this is particularly exciting in that we can make a really positive impact on a patient’s experience without having to invest in something costly or complex. Interestingly, we’ve also seen how the therapy benefits staff. When surveyed, wound care staff described lower levels of distress while they delivered treatment because they know their patients are much more comfortable.” In addition to wound care patients, the virtual-reality program is also being tested on patients in the hospital’s intensive care and cardiac care units. Comprehensive criteria have been developed by the researchers and clinicians to ensure patients are suitable candidates for the therapy. Those who qualify can choose from 12 curated
Physiotherapists Jaclyn Frank, left, and Jane Crosley, right, help patient Graydon Cuthbertson take his mind off a painful wound care procedure thanks to virtual reality. Photo credit: Blain Fairbairn. spired to give because, as a cancer patient, she can relate to living in pain and she wants to help ease discomfort for other patients if possible. Results from the virtual-reality study are being shared with other Alberta Health Services sites in the hopes the
virtual reality experiences currently offered by the hospital. Rockyview recently announced a second donor has come forward with a gift to fund the purchase of two addition virtual-reality headsets and phones. This newest donor was in-
program may benefit patients across Alberta. Foothills Medical Centre’s burn unit is investigating the therapy for its patients and the program has received interest from the Royal Columbian Hospital in New Westminster, H B.C. ■
Blain Fairbairn is a Senior Communications Advisor at Alberta Health Services.
Diabetic foot infection he estimated lifetime risk of a person with diabetes mellitus developing a foot ulcer is 15–25 per cent. It is estimated that just over half of diabetic foot ulcers are infected at the time of presentation, and ulcers remain the most frequent complication of diabetes requiring hospitalization. A foot ulcer precedes 85 per cent of all lower-extremity amputations in patients with diabetes. Risk factors for developing diabetic foot ulcers include peripheral neuropathy, peripheral arterial disease, foot deformity and impaired immunity related to metabolic factors. Ulcers are often caused by trauma to the extremity – usually as the result of pressure – but can also develop as a result of chemical, thermal or mechanical factors. Well-recognized risk factors for infection in a diabetic foot ulcer are:
Classify Infection IWGDF, IDSA, CDA IV Antibiotic
Oral/IV Oral Mild
2 signs of classic inflammation, <2cm erythema, involves skin and subcutaneous tissue
Moderate Signs of local infection, erythema >2cm or involving deeper structures
Severe Local Infection +systemic toxicity
Classic signs of infection/inflammation – swelling, induration, erythema, tenderness, warmth, purulent discharge Reprinted with permission from Wounds Canada
• Ulceration present greater than 30 days • Previous or recurrent foot ulcers • Renal insufficiency • History of walking barefoot
• Positive probe-to-bone test Infection can advance quickly and requires careful clinical follow up. Early identification and treatment of these wounds is key in preventing the
cascade of human and economic burden to the healthcare system.
PREVENTATIVE CARE Preventing ulceration and infection should always be the goal of patients and healthcare professionals. Measures that can help prevent diabetic foot infection include: • Patient education on proper foot care • Glycemic control • Blood pressure control • Smoking cessation • Use of prescription footwear • Professional foot care to examine the feet at regular intervals defined by patient risk factors For more information on prevention, visit woundscanada.ca for a downloadable brochure, available in sixteen languages. Continued on page 32 MARCH 2019 HOSPITAL NEWS 31
WOUND CARE Continued from page 31
Surgical Management if:
Medical Management if:
• Substantial bone necrosis
• No need for surgery
• Non-salvageable foot
• Small and contained foot infection
In individuals with diabetes, signs of inflammation may be concealed by several factors, meaning an infection may go unnoticed until it has progressed to a limb-threatening stage. The underlying immune disturbance and perfusion issues that are common in individuals with diabetes make it more difficult to detect inflammatory signs of infection. Diabetic sensory neuropathy might mean a patient doesn’t feel pain (and therefore will not complain about pain), while a reduced inflammatory response may decrease redness. Other signs of infection, such as presence of necrotic tissue, friable granulation tissue, increased pain, exudate and odour, can be helpful when inflammatory signs are diminished.
• No available active antibiotic
• Patient too unstable for surgery
• Non-correctable foot ischemia
• Patient preference
Diabetic foot infections
DIAGNOSING AND ASSESSING INFECTION Clinicians should exercise a high degree of suspicion to identify infec-
• Patient preference Table 1. Surgical vs. Medical Management tion in its early stages, thus enabling efficient treatment and a minimized risk of limb loss. Clinicians should assess the patient, the wound and the environment to determine risk of infection; consider using Inlow’s 60-Second Diabetic Foot Screen as a tool to aid in assessment. Obtaining a culture is recommended if infection is suspected. The ulcer should be cleansed prior to the culture. Ideally, culture should be obtained by biopsy of tissue or bone, however this is not always practical. A diabetic foot infection, once diagnosed, can be classified as mild, mod-
erate or severe (see Figure 1). This requires careful evaluation of the patient (systemic symptoms), the affected limb (vascular status) and the ulcer. The severity of infection depends on the extent of the erythema, the depth of the wound and the presence of systemic symptoms (see Figure 1).
WOUND BALANCING MATRIX
Did you know... 90% of wounds with elevated protease activity will not heal without proper interventions.
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)
32 HOSPITAL NEWS MARCH 2019
Treatment of a diabetic foot infection is based on the extent and severity of the infection and co-morbid conditions (see Table 1)(figure 1). Mild infections are treated with oral antibiotics, local wound care and pressure offloading. Patients with moderate or
CLINICIANS SHOULD EXERCISE A HIGH DEGREE OF SUSPICION TO IDENTIFY INFECTION IN ITS EARLY STAGES, THUS ENABLING EFFICIENT TREATMENT AND A MINIMIZED RISK OF LIMB LOSS. OSTEOMYELITIS
An infection can advance from the soft tissue by contiguous spread to the underlying bone. Osteomyelitis complicates about 20 per cent of infections. The probe-to-bone test involves using a sterile blunt probe to assess the depth of the ulcer. If gritty, hard bone is felt at the base of the ulcer in highrisk patients, there is a high likelihood of osteomyelitis. Healthcare professionals should also consider laboratory testing and imaging to aid in assessment and diagnosis. The types of laboratory tests ordered depend on the presenting factors of the patient, co-morbid conditions and medications. X-ray imaging is a readily available test and can give information on the status of the bone or the possibility of a radio-opaque foreign body. X-ray changes related to osteomyelitis may take 2–3 weeks to develop, so serial x-ray may be required. Advanced imaging such as magnetic resonance imaging is considered the best test for diagnosing osteomyelitis.
severe infections can be considered for intravenous antibiotics and evaluated for possible surgical intervention. Antibiotics should only be used to treat the infection and not until closure of the ulcer. A guideline for antibiotic choices for the treatment of diabetic foot infection can be found in the Canadian Diabetes Association Clinical Practice Guidelines. Debridement of devitalized tissue is also an important part of managing these infections. This, however, is contraindicated if significant peripheral arterial disease is present. Ideally, the management of these complex infections is best coordinated at a multidisciplinary clinic, however it is essential that front-line clinicians are able to recognize the significance of the infection and to utilize early management principles. When a multidisciplinary foot clinic is not available, appropriate referrals may include infectious disease specialists, vascular surgeons, orthopedic surgeons, endocriH nologists, chiropodists or podiatrists. ■
Robyn Evans BSc MD CCFP is Medical Director at Women’s College Wound Healing Clinic and Medical Lead at Wounds Canada. Mariam Botros DCh DE IIWCC is CEO of Wounds Canada and a Chiropodist at Women’s College Wound Healing Clinic. www.hospitalnews.com
THE V.A.C. VERAFLO™ DRESSING THAT IS MAKING A BIG SPLASH! V.A.C. VERAFLO CLEANSE CHOICE™ Dressing • When used in conjunction with V.A.C. VERAFLO™ Therapy, the V.A.C. VERAFLO CLEANSE CHOICE™ Dressing can help facilitate the removal of wound exudate and infectious material such as thick ﬁbrinous exudate and slough.
• 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)