Helpful hints in neonatology wound care

Louise Forest-Lalande RN MEd ET

Summary
Wound care in paediatrics presents many challenges related to the particularities of this clientele which ranges from premature babies to adolescents. Wound aetiology in paediatrics may also be less well understood. This article will first review the skin physiology of premature infants. Those neonates represent a new clientele at risk and the characteristics of their skin should be considered when they present with wounds. Secondly, an overview of the most common wounds encountered in the paediatric setting will be discussed, including ulcerated haemangiomas, epidermolysis bullosa (EB) and pressure ulcers. Prevention and management strategies will also be considered.

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Prevalence, incidence and risk: a study of pressure ulcers at a rural base hospital

Corrine Charlier BN

Abstract
This project was conducted in an Australian rural base hospital. It compared the Norton and Waterlow pressure ulcer risk assessment scales with an informal nurse assessment via a prevalence and an incidence study of inpatients.
This study, more a pilot study due to the small sample size, suggests that the pressure ulcer prevalence and incidence within this Australian hospital was comparable to national and overseas studies. Statistical analysis of the incidence data using the Kappa and McNemar tests showed that the Waterlow risk assessment scale performed better than both the Norton scale and the informal nurse assessment when identifying patients at risk of developing pressure ulcers.

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The tissue trauma team: a multidisciplinary approach to wound and oedema management

Andrea M B Minnis

Summary
The Tissue Trauma Clinic (ITC) at the John Lindell Rehabilitation Unit (JLRU), Bendigo Health Care Group, offers a comprehensive multidisciplinary approach to wound and oedema management, including the management of leg ulcers, pressure ulcers, bums. lymphoedema and other chronic oedemas, for clients of all ages. This article will discuss the structure and function of the clinic, patient assessments, treatments, other services provided and outcomes.

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The social dimension in leg ulcer management

Ellie Lindsay BSc(Hons) RN dncERT dIPhe cpt

Summary
The correlation between social isolation, poor compliance to treatment and low healing rates for patients suffering from leg ulcers is well documented. Pain, odour, bandages etc. result in low self-esteem, depression and social stigma. Home visits by community nurses do not address the social and psychological needs of this client group. By providing leg ulcer management in a social, non-medical setting, where the emphasis is on social interaction, participation, empathy and peer support, Debenham Leg Club is an innovative approach to meeting the holistic needs of the patients. It is a unique partnership between the district nurses and the local community in which a sense of ownership empowers patients to become stakeholders in their own treatment. Clinics are held weekly in a community cottage on an informal 'drop in’ basis. Patient contacts average 1,000per annum, 70per cent for treatment, the balance for assessment, monitoring or advice. The value of the 'club’ concept is evident in the happy, welcoming, uninhibited atmosphere that characterises the clinic. Patients’  views have identified positive attitudes and a strong sense of ownership in 'their’ club. Many long-standing ulcers have healed or greatly improved as patients have attended the Leg Club. However, prospective quantitative studies need to be performed to confirm whether ulcers do heal better in this type of environment. This nurse-led social leg ulcer clinic provides holistic care and combats the effects of social isolation on compliance and wound healing.

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Wound cleansing: which solution, what technique?

Ritin S Fernandez RN MN
Rhonda D Griffiths BEd MSc(Hons)
Cheryl Ussia RN Cert Wound Management

Abstract
Cleansing is a vital component of wound management. However, there is limited research to inform protocols. Although research has focused on types of dressings, little attention has been given to the solutions and techniques to be used for cleansing purposes. The available evidence about the effectiveness of solutions and techniques in the prevention of wound infection and the promotion of healing has not been systematically quantified in a manner that would assist clinicians in choosing a solution and the appropriate technique. This study aimed to critically review the literature and present the best available evidence that investigates the effectiveness of solutions and techniques for wound cleansing.
A key word search of wound care journals was completed. At least two types of solutions and techniques had to be compared and the infection rate and/or healing rates analysed. Two independent reviewers extracted data on population, intervention, outcome and methodological quality. In the only study comparing tap water to normal saline, the infection rate in wounds cleansed with tap water was noted to be lower than wounds cleansed with normal saline. Studies that compared normal saline, boiled water, distilled water and povidone-iodine for wound cleansing demonstrated no difference in the infection rate of wounds. However, one study demonstrated a statistical difference in the infection rate in wounds that were not cleaned compared to those that were soaked in normal saline. No randomised controlled trials (RCTs) were identified that compared swabbing or scrubbing as techniques for cleansing wounds. In post-operative patients, showering the wound did not demonstrate a significant difference in the rate of infection and healing; however, it was reported to enhance a feeling of cleanliness and well-being amongst those patients. Insufficient data exists to determine the effect of tap water on chronic wounds. Considering the widespread use of tap water for wound cleansing in the community, more large high quality RCTs of the effectiveness of tap water and the techniques used for wound cleansing are warranted.

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Clinical pathways in foot ulcer management: a pilot study

Diana Brown B.App.Sc(Pod) Dip.App.Sc(Nsg)

Abstract
This is a pilot study to determine if podiatrists prefer to use a clinical pathway in ulcer management rather than their current documentation procedure. A clinical pathway was developed at The Queen Elizabeth Hospital (TQEH) podiatry department to decrease the amount of time spent documenting details of ulcer therapy. The podiatry department sees predominantly high-risk patients in an outpatient setting. These patients often suffer from diabetes and its complications resulting in foot ulceration(s). The clinical pathway was used as a tool to provide outcomes on ulcer therapy that could easily be monitored or evaluated.
Rural and metropolitan South Australian public sector podiatrists agreed to participate in this study. The podiatrists trialled the clinical pathway for approximately 3 months, after which a questionnaire was completed. The results from this pilot study indicated that the majority of the podiatrists agreed and supported the concept of clinical pathways. However, there was a more varied response as to whether they would implement it in their current workplace.

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A patient-centred wound management clinic: theory put into practice

Robins M, Warmington S, Duncan G, Jessup R, Nielsen C, Darzins P, Ricketts I, Sussman G & Martin C

Abstract
In 1996, lack of wound management services within the north and western suburbs of Melbourne was highlighted by the number of bed days devoted in one hospital to a single diagnostic related group (DRG); the then North West Hospital, a rehabilitation and aged care facility, funded 7,050 bed days to the treatment of leg ulcers alone. The mean average length of stay was 51 days. This observation formed the catalyst for the successful submission by the campus to develop and implement an age-specific wound management clinic at the North West Hospital -now known as Melbourne Extended Care and Rehabilitation Service Parkville Campus. This paper will discuss the aims and objectives of the clinic, analysis of clients referred to the service and
examples of how theory has been linked to the practical application of this clinic.

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Skin ulcer healing enhanced by brain-derived endothelial cell growth factors

Tang-De Zhang
 Xian-Wen Qiu
Hong-Bing He

Abstract
Endothelial cell growth factors (ECGFs) are potent mitogens of endothelial cells and fibroblasts which are important cells in the granulation tissue of wounds. The effects of bovine brain-derived ECGFs on skin ulcer healing were investigated in 14 patients with 42 skin ulcers using a self-control design. The skin ulcers were varicose, decubitus and vasculitis ulcers.
The mean time to reach a 50 per cent healing was significantly shorter with ECGFs than with the control. The healing rate was approximately 1cm2 per week in ECGFs treated ulcers. The skin ulcers treated with ECGFs also demonstrated a fast growth of granulation tissue. At the time of reaching 100 per cent healing, vasculitis ulcers had taken longer than non-vasculitis ulcers (varicose ulcer and decubitus ulcer). These results suggest that ECGFs can accelerate the healing of skin ulcers. It also suggests that the degree of vessel injury in skin ulcers has an impact on the effect of ECGFs on healing.

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Clinical practice guidelines for the prediction and prevention of pressure ulcers

Murray LD, MHA RN • Magazinovic N, BHSc RN • Stacey MC, DS FRACS
 
Abstract
The Pressure Ulcer Interest Subcommittee (PUISC) of the Australian Wound Management Association (AWMA) has prepared Guidelines for the Prediction and Prevention of Pressure Ulcers. The Subcommittee, a multidisciplinary panel of health professionals, reviewed available research on pressure ulcer prediction and prevention and developed recommendations based on the best evidence. When good evidence was not available, consensus statements were prepared.
The supporting evidence was rated using the levels of evidence as recommended by the National Health and Medical Research Council (NH&MRC). The major recommendations in the guidelines are:

Specific risk factors for the development of pressure ulcers have been documented in the guidelines with levels of supporting evidence. The guidelines have been prepared as a general guide to appropriate practice and should only be followed subject to the health practitioner's judgement in each individual case.

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Implementing the guidelines for the prediction and prevention of pressure ulcers

Prentice JL, BN STN • Stacey MC, DS FRACS

Abstract
Since the late 1960s, guidelines for clinical care of a large number of diseases have been promulgated under a variety of guises by health care institutions and medical or specialty societies. They offer evidenced based practical guidance in the management of a health problem to institutions, clinicians and patients. In addition, they reduce variations in clinical practice, they reduce costs and they improve patient, clinician and institutional outcomes.
Many clinicians, however, remain sceptical of the real-life value of clinical practice guidelines (CPGs). The processes used to develop, disseminate and implement CPGs are critical to their successful adoption. Key factors in this process relate to the identification of the need for the CPG, a multidisciplinary approach to their development, gaining institutional and clinical leader support for their implementation, consulting with and educating staff and patients and having a well planned implementation strategy.
Pressure ulcers are acknowledged as a significant health problem within Australian health care settings. The Australian Wound Management Association (AWMA) has developed CPGs for the prediction and prevention of pressure ulcers. This paper will discuss the general attributes and benefits of CPGs, barriers to their adoption and key factors to successful dissemination and implementation. A practical approach for introducing the AWMA CPGs for pressure ulcers will also be outlined.

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Pressure ulcers: the case for improving prevention and management in Australian health care settings

Prentice JL, BN STN • Stacey MC, DS FRACS
 
Abstract
The causes of pressure ulcer development have been the subject of investigation for centuries. It is commonly accepted that the majority of pressure related tissue injuries (pressure ulcers) which are caused by unrelieved external pressure are preventable. In spite of this knowledge, the prevalence of pressure ulcers worldwide remains unacceptably high. Lack of nursing care, in particular, is still seen as one of the primary causes for their development. Pressure ulcers are increasingly used as an indicator of the quality of care.

Whilst pressure ulcer research in Australia is in its infancy, accumulated data indicate that pressure ulcers and their sequelae are a significant problem, the extent of which is not fully appreciated by government, institutions or clinicians. This failure to acknowledge the problem may be because pressure ulcers are not viewed in the same context as other acute or chronic diseases such as heart disease.

Despite this, clinical practice guidelines for pressure ulcers are gaining prominence in Australia in an endeavour to reduce pressure ulcer prevalence, morbidity, cost and litigation. Institutional risk management strategies for pressure ulcers are believed to contribute to improved patient outcomes. Both of these measures need to be evaluated to ensure that they do meet the needs of the consumer.
This paper briefly highlights the history of pressure ulcers, the extent of the problem in Australia and the need for improvement through education, risk management strategies and adoption of Australian clinical practice guidelines for their prevention.

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Benefits to patients and practitioners in adopting the guidelines for the prediction and prevention of pressure ulcers

Bennett G, MB FRCP
 
Abstract
The aim of this article is to place the international array of clinical practice guidelines concerning the prediction and prevention of pressure ulcers into a patient and practitioner context. This requires a brief overview of the current major international pressure ulcer prevention guidelines, outlining the desirable attributes of these guidelines and discussing the weighing of research evidence used to develop guideline recommendations.
Further objectives include indicating the evidence for assessing guideline impact, guidelines in context - the benefits to patients and practitioners of clinical practice guidelines versus the role of litigation - and emphasising the role of education within a patient/practitioner environment.

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Skin tears: a descriptive study of the opinions, clinical practice and knowledge base of RNs caring for the aged in high care residential facilities

White W, BEd RN

Abstract
The purpose of this study was to gain an insight into the opinions, current clinical practice and knowledge base of registered nurses (RNs) responsible for the care of residents in high care (nursing home) residential aged care (HCRAC) facilities in relation to skin tears. In addition, the awareness and/or use of research findings in their practice, along with the identification of topics to be included in skin tear educational programmes were also explored. This descriptive study used questionnaires to collect data from the target population.
The main findings of the study were that skin tears are perceived by RNs to be a commonly occurring wound in aged residents, and that RNs are directly involved in the reporting, assessment and management of these wounds. There appeared to be no uniform language used by Australian clinicians relating to the description and classification of skin tears. RNs were also often unaware of published skin tear research. A wide range of treatment modalities was being used for skin tears, with little evidence available to support their use in these wounds. Specific skin tear topics identified for inclusion in future educational programmes were aging skin issues, resident risk assessment, skin tear classification skills, local wound management and preventative strategies. The non-response rate was high.
Further research is required to add to the small but growing skin tear knowledge base. National incidence and prevalence rates, along with uniformity in skin tear language, incident reporting, assessment, classification and management are required. Future prospective, randomised, controlled, clinical studies relating to skin tear type (classification) and treatment modality may guide clinicians in the provision of evidence based wound care. There is a need to raise clinicians' awareness and to disseminate both past and future research findings through exposure to the literature and formal educational programmes.

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Meningococcal septicaemia and purpura fulminans in children -surgical management and outcome: a 22 year review of 68 patients

Rode H, FCS (SA) FRCS(Ed) • Millar AJW, FRCS (Eng) (Ed) FRACS • Argent A, FCPAEDS (SA) MMed (Paed) • Hudson D, FCS (SA) FRCS(Eng) • Davies J, FC PATH (SA)

Abstract
Meningococcal septicaemia complicated by purpura fulminans remains a devastating illness with rapid onset, debilitating morbidity and high mortality. The clinical course of management of 68 children (average age 3.4 years) with purpura fulminans seen over a 22 year period is described. All patients received maximum systemic support. Standard surgical techniques were utilised for skin grafting and amputations.
Overall mortality was 10 per cent. Demarcation of necrotic areas was evident at 5.5 days and the average area of skin necrosis was 14 per cent body surface area. The lower limbs were predominantly affected. Purpura fulminans resolved in 13 children (19 per cent) without skin necrosis. Skin grafting was required in 39 children.
The following factors were associated with a poor outcome for peripheral extremity salvage; progressive irreversible skin changes, early disappearance of distal pulses, tense cold swollen extremities and intense pain on passive movement of the affected extremity. Amputations were performed proximal to the area of necrosis, on average 27 days post injury. Soft tissue releasing incisions were not performed.

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The role of growth factors, cytokines and proteases in wound management

Traversa B • Sussman G

Abstract
The wound healing process involves a series of cellular and biochemical events that ultimately lead to tissue repair and regeneration. These events are classically defined as haemostasis, inflammation, proliferation, epithelisation, maturation and remodelling of the scar tissue. Of particular importance to the healing process is the involvement of endogenous growth factors, cytokines and proteases at each of these events. Current knowledge of these at each stage of healing, as well as the biochemical nature of wounds, suggests that there is great potential for analogues of these agents to improve the quality and healing time of a wound, particularly a chronic wound, when they are applied exogenously.
However, many products containing growth factors, cytokines or protease inhibitors are yet to reach market availability. This is mainly due to formulation problems (such as stability), safety concerns, pharmacological aspects (such as effective doses and growth factor combinations) and difficulties with developing well-controlled clinical trials to prove their efficacy.
However, the concept of employing exogenous growth factors, cytokines and protease inhibitors to promote optimal wound healing is only in its infancy. And, while further research into the pharmacology, toxicology and formulation of design and development is still warranted, the American Food and Drug Administration's approval of the growth factor based product, Regranex®, should that indicate that the role of these substances in wound management seems promising.

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Venous thromboembolism: an insidious hazard Part III: role of graduated compression

MacLellan DG, BSc MD Grad.Dip.Bus.Admin FRACS

Abstract
Venous thromboembolism (VTE) continues to be a major cause of morbidity and mortality in hospitalised patients. Its long-term sequelae of post phlebitic syndrome and venous ulceration are significant burdens on the Australian health dollar. Prevention of VTE by appropriate prophylactic measures is unquestioningly the key to reducing acute and long-term consequences of deep venous thrombosis (DVT). Unfortunately, best practice guidelines for VTE prophylaxis are not optimally being followed in our hospitals.
In the first review article in this series, the incidence, prevalence and sequelae of VTE were discussed. The second article discussed the guidelines for prophylaxis and treatment of VTE. However, considerable confusion exists about the role of graduated compression stockings in VTE prophylaxis and the relevance of difference compression levels. Many clinicians are also unfamiliar with intermittent pneumatic compression devices. This final article in the series seeks to clarify the role of compression therapy in VTE prophylaxis.

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