The significance of MRSA and VRE in chronic wounds

Gosbell IB FRACP, FRCPA

Summary
Methicillin resistant Staphylococcus aureus (MRSA) and Vancomycin resistant enterococci (VRE) are important nosocomial bacteria which are highly resistant to antibiotics and readily transmitted patient to patient. They are significant in chronic wounds in terms of causing infection, especially MRSA, and by constituting an infection control risk.
It is important to distinguish colonisation from infection of chronic wounds, as infection requires specific treatment whereas colonisation does not. If signs of infection (increased purulence, pain, swelling, redness, warmth) are present, local measures to control infection should be instituted and, if these fail, antibiotics should be used. Local measures are more important with these bacteria as the drugs to treat them are not readily available or have to be given parenterally. In terms of infection control, handwashing before and after patient contact is the most important measure. Cleaning of the environment is also important.

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The use of molecular biology in evaluating human wound healing

Wysocki S BSc (Hons), PhD

Abstract
Proteins fulfil the majority of structural and functional requirements in living cells -medicinal drugs act directly or indirectly through proteins in the cell membrane or proteins located within the cell. The unique properties of a protein are determined by the sequence of amino acids within this macromolecule. The unit of deoxyribonucleic acid (DNA) that codes for a protein is known as a gene and is copied or transcribed to generate a gene transcript which specifies the sequence of amino acids in the protein.
The study of genomic DNA, gene transcripts and proteins at the molecular level is encompassed by the term molecular biology. This article will address the application of a recent advance in molecular biology, namely DNA microarray technology. to the evaluation of wound healing.

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Issues in clinical practice: Dressings

Duncan G • Andrews S • McCulloch W

Abstract
This is a summary of the dressings workshop held at the first World Wound Healing Congress in 2000. The objectives of the dressings workshops were to review the variety of dressing classes available on the Australian market and consider the general properties of each class, including structure, function, form and use.
Modern interactive/bioactive dressings were discussed in the workshops, with only brief mention made of the inert products. The first dressings classes explored were the film dressings, foams hydrogels and hydrocolloids. Each dressing class is addressed in terms of general description and physical properties, indications, method of application and removal, effective use, limitations and brand name products available.

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The use of Dermagraft® in neuropathic foot ulcers in people with diabetes: an economic analysis for Australia

Segal L PhD, MEcon • John S MBus, Cert in Health Econ

Summary
The purpose of this study was to establish the costs of conventional management of neuropathic foot ulcers in people with diabetes and evaluate the cost effectiveness of Dermagraft®, a living human dermal replacement, as an adjunct therapy. The cost of conventional management of foot ulcers was established by surveying specialist clinics for typical resource use and applying published unit costs. A Markov model was used to estimate expected cost per ulcer healed, with and without Dermagraft, drawing on effectiveness data from the pivotal clinical trial. The expected use of Dermagraft in Australian specialist clinics was based on an observational case study of 27 hard to heal ulcers. The data from this study was also used to establish an alternative cost-effectiveness estimate, using a pre-post own control study design.
Using the Markov model, the mean cost per ulcer healed is estimated at $10,906 using conventional management and $12,128 using Dermagraft as an adjunct or $9,393 if Dermagraft is cut and used to treat two ulcers. In the case studies, a mean 7.6 applications of Dermagraft were used per ulcer, with healing achieved in 85 per cent of ulcers. Based on the case studies, the mean cost of managing an ulcer after commencement with Dermagraft -until healing was achieved or to 24 weeks -was $4,682, compared with an estimated $12,500 incurred under conventional management prior to Dermagraft use.
The use of Dermagraft as an adjunct to conventional management in the specialist clinic setting for hard to heal ulcers results in a similar average cost per ulcer healed and a lower cost per week in a healed state to conventional management alone. A shorter treatment period, fewer complications and fewer inpatient episodes will, in some cases, offset the cost of Dermagraft making the treatment cost saving.

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Implementation of a preventative pressure management framework

B McErlean BN • J Prendergast • S Sandison • LJeffers • A Milne J Cotton • W Humphreys

Summary
This article describes the quality improvement and audit processes used by one hospital to: examine pressure prevention practices and rates of pressure ulcer development; develop and implement an organisational pressure prevention framework in response to the audit results found; and evaluate the outcomes. The developed framework supports the principle:" of clinical governance. The early identification of risk is then communicated to all subsequent health care workers, resulting in the implementation of appropriate preventative interventions.
Point prevalence monitoring is the main organisational evaluation mechanism used and, whilst methodological differences existed between the first and subsequent audits, there still remains enough evidence to support the notion that the framework has been successful in achieving its goal. The hospital has seen an increase in the identification of the patient at risk on admission and the implementation of appropriate preventative interventions; this has led to a reduction in the incidence and severity of pressure ulcers. However, the brief of the working party is not complete. The working party plans to undertake a piece of research in 2002 to validate the risk assessment tool developed and also to develop a mechanism to link the identified risk with the casemix profile of the patient.

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Wound management by aged care specialists

Dr M Woodward MB BS FRACP

Abstract
As the population ages, wound management increasingly requires the expertise and resources of specialists in aged care. This paper presents a survey of the wound management practices and knowledge of Australian geriatricians. Seventy five per cent felt they had sufficient knowledge to manage a lower limb ulcer, but only 41 per cent were comfortable advising on the management of more complex ulcers. Twenty four per cent were unaware of any specialist wound clinic available to see their patients. For 39 per cent of the doctors, more than 10 per cent of their patients had lower limb ulcers although it was not usually the patients' primary problem. These aged care doctors used a range of wound management products but 6.5 per cent indicated that they used gauze dressings and only 42 per cent always, or nearly always, recommended compression for an uncomplicated venous ulcer. Some 65 per cent always or nearly always had access to a nurse to assist them with dressings. Fifty six per cent never or almost never used a written protocol when managing wounds and only 22 per cent always or nearly always used a risk assessment tool to estimate pressure ulcer risk. Thus, it is important that geriatricians and other aged care specialists have adequate knowledge of wound management, and that there are sufficient specialists in aged care with It is concluded that comprehensive wound management education would be valuable for these aged care specialists, and that there is a need for more wound clinics staffed by geriatricians.

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Vasculitic leg ulcers -a review

Assoc Prof SN Sinha MBBS FRACS FACS • P Luk MBBS student

Summary
Vasculitic leg ulcers, although forming a small proportion of all leg ulcers seen at the specialised wound clinics, pose a significant challenge in terms of diagnosis and treatment. Cutaneous vasculitis may be associated with systemic involvement and occur as a result of hypersensitivity reaction with formation of immune complexes.
Obtaining a deep biopsy from the margin of the ulcer assists with making a definitive diagnosis of a vasculitic leg ulcer. The essential elements of treatment of vasculitic leg ulcers include treatment of the primary cause, providing moist occlusive dressings, protection from further trauma and, most importantly, relieving pain.

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Issues in clinical practice: Dressings 2
 
Duncan G • Andrews S • McCulloch W

Abstract
This article is the second part of the practice review of modern wound dressings. The abstract at the beginning of part one covers both articles. Part one described the nature of the article as well as the objectives of the workshops from which the article was derived. It also discussed some broader wound management concepts that facilitate the selection of a particular dressing.
This second part will consider dressings that fall in to the classes of hydroactive, alginate, hydrocolloid, hydrofibre, cadexomer iodine and zinc paste bandages.

Designing the future in wound care: the role of the nurse practitioner

MacLellan L • Gardner G • Gardner A

Abstract
The nurse practitioner is emerging as a new level and type of health care. Increasing specialisation and advanced educational opportunities in nursing and the inequality in access to health care for sectors of the community have established the conditions under which the nurse practitioner movement has strengthened both nationally and internationally. The boundaries of responsibility for nurses are changing, not only because of increased demands but also because nurses have demonstrated their competence in varied extended and expanded practice roles. The nurse practitioner role reflects the continuing development of the nursing profession and substantially extends the career path for clinical nurses.
This paper describes an aspect of a large-scale investigation into the feasibility of the role of the nurse practitioner in the Australian Capital Territory (ACT) health care system. The paper reports on the trial of practice for a wound care nurse practitioner model in a tertiary institution. In the trial the wound care nurse practitioner worked in an extended practice role for 10 months. The nurse practitioner practice was supported, monitored and mentored by a clinical support team. Data were collected relating to a range of outcomes including definition of the scope of practice for the model, description of patient demographics and outcomes and the efficacy of the nurse practitioner service.
The findings informed the development of clinical protocols that define the scope of practice and the parameters of the wound care nurse practitioner model and provided information on the efficacy of this model of health care for the tertiary care environment. The findings further suggest that this model brings expert wound care and case management to an at-risk patient population. Recommendations are made relating to ongoing research into the role of the wound care nurse practitioner model in the ACT health care system.

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Healing of wounds created in the nasal mucosa following endoscopic sinus surgery can be affected by different nasal packing materials

Cowin A • McIntosh D • Wormald PJ

Abstract
Chronic sinusitis is a very common condition requiring surgery if medical treatment fails. In fact, diseases relating to the nose and paranasal sinuses are one of the most common health care complaints in Australia and the USA (18 per cent). Although a proportion of these infections respond well to medical treatment, there remain a significant number of patients who develop chronic sinusitis requiring surgery.
After endoscopic sinus surgery (ESS) it is common practice to place nasal packing material in the operated area to prevent adhesions from forming. Although many different packs have been used clinically, there is little evidence of their effects on the repair of the nasal mucosa or on the formation of adhesions. This paper examines a sheep model developed for ESS which shows that different packing materials can affect the re-epithelialisation of wounds created in the nasal mucosa. The incorporation of bioactive agents into these packing materials could offer significant advantages in the healing of the nasal mucosa and may also help to reduce adhesions from forming. Improved healing would lead to reduced numbers of patients with recurrent chronic sinusitis.

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A multi-site clinical evaluation trial of the Alfredl Medseed Wound Imaging System prototype

Santamaria N • Austin D • Clayton L

Abstract
This paper describes a multi-site evaluation of the Alfred/Medseed Wound Imaging System (AMWIS). The evaluation comprised laboratory testing followed by trials at 34 clinical sites in five Australian states over a 12 month period. The aim was to determine its planimetric accuracy and clinical utility. AMWIS was developed to improve the precision of measurement and documentation of wounds through the use of digital still imaging and processing techniques. AMWIS allows the clinician to measure a wound and its component areas at the millimetre level as well as calculating wound volume, and document a range of wound characteristics and treatment.
A total of 79 patients had wound measurements performed and tracked on 100 wounds, generating data on 440 wound images. This enabled the determination of the system's accuracy and efficacy in wound surface area measurement and clinical utility. Results of laboratory planimetric testing produced a measurement error rate of +1.28 per cent in repeated measures of standard geometric two dimensional objects (n=360, p<0.01). Planimetric accuracy in clinical use was 94.9 per cent (n=440). Clinician evaluations indicated that AMWIS provided more accurate wound measurements, improved documentation, decreased the time required for wound assessment and increased the capability for conducting wound care research.

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Handy hints when treating venous leg ulcers and using compression therapy

Rice J

Abstract
This article has been drawn from a workshop presentation of the same name given at the First World Wound Healing Congress in Melbourne, September 2000. The thoughts and concepts presented within this article are offered as a means of assisting clinicians who work primarily within the community to marry the theoretical management of venous leg ulceration (VLU) with the reality of clinical practice. When it comes to assessing each individual patient, adjustments to clinical practice guidelines sometimes need to be made in order to provide individualised patient care. This article is a selection of handy hints gained from clinical experience that may be useful for other clinicians to consider in the management and education of patients with VLU.
In this article, the causes of lower leg ulceration, venous ulceration and the principles of VLU management and compression therapy will be discussed. Handy hints related to the use of moisturisers, padding under bandages, itchy skin, zinc impregnated bandages and ways to facilitate easy donning of compression stockings will also be discussed.

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Chronic wound healing with hyperbaric oxygen

May K • Hodgson M

Abstract
The clinical podiatrist, along with other wound management specialists, provides chronic wound management to the patient with diabetes. In this challenging patient group, clinicians need to consider the use of appropriate and available wound management therapies. Many modalities are available to the wound management practitioner to facilitate wound healing. Options available include wound dressings and pressure relief strategies, as well as the 'newer' technologies such as human dermal replacement and hyperbaric oxygen.
Hyperbaric oxygen therapy (HB02) essentially reverses tissue hypoxia and may facilitate wound healing in the patient with a compromised vascular supply. Background information on lower limb wounds in people with diabetes and HB02 is discussed, followed by three case studies on the use of HB02 as part of a holistic wound management strategy.

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A unique case of ulceration secondary to heel pad dystrophy

Maddaford L • Foley L

Abstract
This case study presents a unique cause of dystrophy of the plantar heel pad and its associated ulceration. The heel pad is a specialised structure, designed to shock absorb ground reactive forces during normal gait. Reduction or loss of shock absorption results in abnormal and destructive forces being applied to the plantar surface of the calcaneus, namely the medial calcaneal tubercle. Consequently. lack of tissue resilience over bony prominences, coupled with repetitive constant pressure, and underlying neuropathy, inevitably leads to ulceration. Wound management and providing the patient with functional gait whilst minimising pressure to the heel pad is the therapeutic goal.

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The use of Opsite, Fixomull and LYCRA ® in the management of diabetic neuropathic pain of the foot

TroyT

Abstract
Peripheral neuropathy is the most common, early and often painful manifestation of diabetic neuropathy. There are a multitude of treatments, mainly drug based, which have a variable result in reducing the pain being experienced by the patient. Opsite Flexifix™, LYCRA® and FixomullTM Stretch have been found to be useful adjuncts to these treatments. They each seem to work best in treating pain associated with touch allodynia and superficial hyperalgesia. Patients using these products have experienced less pain within the foot, making neuropathic pain more bearable. The need for oral pain relief has been reduced and some patients' sleep patterns have improved. This article will describe the use of Opsite Flexifix TM, LYCRA ® and Fixomull Stretch TM in the management of neuropathic pain of the foot secondary to diabetes only; and not other forms of peripheral neuropathy as described in Appendix 1.

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