Absorption of blood by moist wound healing dressings

Terrill P • Sussman G • Bailey M

Abstract
An understanding of the various properties of the many dressings on the market enables the clinician to select the appropriate dressing product for the patient's wound. A comparative analysis of the ability of moist wound healing (MWH) products to absorb blood has not been previously reported. The aim of this study was to compare the rate and the maximal weight of blood absorbed, the ability of the dressings to retain blood within the dressing when under pressure, sheet integrity, and lateral wicking of the blood within the dressing. The MWH dressings tested included 12 'fibre' dressings (alginates and hydrofibre) and 15 'absorptive' (polyurethrane foams, hydroactive and combination products).
The most absorbent fibre dressings were Hydroheal Algin Firm, Sorbalgon, Cutinova Alginate, Kaltostat and Restore Calcicare, absorbing greater than 35g of blood per 100cm2 dressing. The least absorbent was Aquacel with 21.5g/100cm2 The integrity of the fibre dressings varied markedly from Sorbsan, which disintegrated, to Curasorb and Seasorb Alginates, which retained full strength. The rate of absorption of all fibre dressings was rapid (<18 seconds). Lateral wicking was least with Aquacel and greatest with Algoderm and Kaltostat.
The absorptive dressings showed a wide variation in absorptive capacity, from Flexipore which absorbed only 1.7g/100cm2 to Allevyn which absorbed 79.9g/100cm' and Hydrasorb 79.4 g/100cm2. Under pressure, Cutinova Foam retained the greatest amount of blood. Rate of absorption varied dramatically between products, with Polymem Alginate, Polymem, Exu-dry, Biatain and Hydrasorb all taking less than 1 minute to absorb 1ml of blood, whilst seven dressings showed incomplete absorption after 30 minutes.

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The cost of cost-savings

Quarmby C • Rode H

Abstract
Over the past decade there has been an explosion of scientific research and new products in the field of wound healing. Our primary care clinics in South Africa, however, make very little use of these new dressings, stating cost as the reason.
We undertook a study in the burns clinic of the Red Cross Children's Hospital in Cape Town to determine the cost implications of using a polyurethane film dressing (Omiderm®) for patients with small to intermediate-sized partial thickness burns in place of conventional daily silver sulfadiazine dressings. Twenty patients with partial thickness scald burns ranging from 1-15% total body surface area (TBSA) were included in the study. We demonstrated that by using Omiderm dressings we achieved an average saving of R260 (AU$47) per patient, a saving of over 60%. These results show not only the significant cost reduction that can be attained by using a new generation dressing such as Omiderm, but also demonstrate the considerable hidden costs of conventional dressings.

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The role of pressure in pressure ulcer aetiology: a review of the literature

Tweed C

Abstract
Pressure ulcers are localised areas of tissue breakdown affecting the skin and/or underlying tissues including subcutaneous fat and muscle. Applied pressure is a major factor in the aetiological process of pressure ulceration, although it is acknowledged that the exact mechanisms are complex and poorly understood. It is not known how external loads affect the tissues and how this eventually leads to tissue damage.
This paper reviews the key scientific literature with specific respect to how pressure affects different functional units of the tissues, namely though occlusion of blood vessels, impaired transport of nutrients through the interstitium and deformation of the cells.

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Acute lower limb ischaemia: the challenges of patient care

Angel D

Abstract
Acute limb ischaemia (ALI) can be described not only as limb-threatening but also as life threatening. This case study examines the many challenging aspects of caring for a patient with acute distal lower limb ischaemia which led to bilateral lower limb amputations. The specific issues that will be addressed in this case study are wound management, pressure ulcer prevention and pain management, and the importance of psychological support. In most instances, nurses like to be interactive with wound management, in this instance it is a case of wait and see!

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Determining the effectiveness of implementing the AWMA Guidelines for the Prediction and Prevention of Pressure Ulcers in Silver Chain, a large home care agency
Stage 1: baseline measurement

Lewin G • Carville K • Newall N • Phillipson M • Smith J• Prentice J

Abstract
Silver Chain is the largest aged and community care provider in Western Australia and assists the frail aged and disabled to remain in their own homes. Many of these individuals have compromised mobility and health status and without appropriate prevention are at significant risk of developing pressure ulcers.
Like many other community organisations, Silver Chain did not have any standardised work processes for predicting the risk and reporting of pressure ulcers. As part of its commitment to providing high quality care, Silver Chain is currently undertaking a project to introduce the Australian Wound Management Association's (AWMA) Clinical Practice Guidelines for the Prediction and Prevention of Pressure Ulcers. This will be achieved by incorporating the guidelines into everyday work processes and accompanying the introduction of the new processes by a comprehensive staff education and training programme.
The methodology and the tools developed by Prentice for the introduction and evaluation of the AWMA guidelines in Australian tertiary hospitals were adapted for use within a community setting. Baseline measurements of clinical and non-clinical staff knowledge and pressure ulcer prevalence were collected in December 2002. The results of the baseline study clearly demonstrated a need to improve staff knowledge of pressure ulcer prevention and the need to implement standardised quality processes to prevent pressure ulcers.

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The evolution of a hospital based leg ulcer clinic

Hewitt A • Flekser R • Harcourt D • Sinha S

Abstract
The objective was to determine whether there was a change over time in referral patterns, as well as clinical and demographic features, of patients attending a hospital based outpatient leg ulcer clinic based at a tertiary referral hospital servicing a total population of 473,500. This prospective clinical audit involved the collection of comprehensive clinical data of all patients referred to the ulcer clinic over an 8 year study period.
The referral source, patients' demographic and clinical features, as well as the type of management instituted were recorded. Six hundred and twenty seven patients attended the clinic. The mean age of patients at admission was 72.3 years. General practitioners (GPs) referred approximately 80% of these patients and there was no significant change in patients' demographic features.
Over time, there was a statistically significant increase in the number of patients who presented with an ulcer which had been present for less than 3 months and there was a significant decrease in the proportion of subjects who presented with multiple ulcers. The proportion of venous ulcers treated at the clinic decreased from 53.7% during the first two year period to 35.9% in the final two year period, whilst there was a 6% increase in the proportion of ulcers caused by combined arteriovenous insufficiency over this time. In conclusion, although there was only minimal change in patients' demographic features or referral source, there was a significant change in the clinical features of patients over time.

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An Australian model for conducting pressure ulcer prevalence surveys

Prentice JL • Stacey Me • Lewin G

Abstract
Pressure ulcers are recognised internationally as iatrogenic injuries of the skin and underlying tissues and, in most cases, are seen as avoidable adverse events. They are also seen as clinical indicators of the standard of care provided. Numerous researchers have examined pressure ulcer prevalence within a variety of clinical settings. Meaningful comparison of data is impaired by reoccurring anomalies relating to different methodological approaches used to collect and analyse data. Therefore the conclusions that can be drawn regarding pressure ulcer prevalence and the impact of pressure ulcers on both patients and health care systems are lessened.
This paper describes a subsection of the methodology used in a national multi-centre study which evaluated the efficacy of Australian guidelines for pressure ulcers in improving doctors' and nurses' knowledge of pressure ulcers, and in reducing pressure ulcer prevalence when implemented in conjunction with an education programme. The subsection presented here proposes a standardised model for surveillance of pressure ulcer point prevalence. It addresses discrepancies with data collection methods used in previous Australian studies assessing pressure ulcer prevalence and meets international standards for conducting multi-centre prevalence studies. Using a standardised approach, as this model proposes, ensures a common understanding of pressure ulcer terminology, improved inter-rater reliability (IRR) in classifying pressure ulcers, and less variance in the quality of data collected.
Only a brief summary of the prevalence found in this study will be discussed here. Detailed results of the study will be presented in a forthcoming article. This study, however, has found Australian guidelines for pressure ulcers to be effective in reducing pressure ulcer prevalence from 26.5% to 22% (p<0.002) when implemented in conjunction with an education programme.

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A review of the literature examining the relationship between temperature and infection in surgical wound healing

Tweed C

Abstract
Wound infection following surgery is a relatively common and serious complication. Perioperative hypothermia increases risk of surgical wound infection by several mechanisms including cutaneous vasoconstriction and a decrease in the activity of the immune system. This paper reviews these mechanisms and concludes that both prevention of hypothermia and application of local and systemic heat may assist in reducing the incidence of surgical wound infection.

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Comparing different ulcer measurement techniques: a pilot study

Brown D

Abstract
The aim of this pilot study was to compare interrater and intrarater reliability and to provide analysis of difference of common measurement tools used in podiatry. The tools used to measure the surface area in this study were ruler, tracings and photographic methods. Ten volunteers participated in the study. The surface area for the tracing was determined by counting the squares on graph paper and using a computerised program called UTHSCSA Image Tool program (version 2). The surface area for the two cameras was determined by using the UTHSCSA Image Tool program and the length and width measurements were calculated for the ruler method.
The one way ANOVA intraclass correlation coefficient ICC(1,1) indicated good reliability for both podiatrists with an ICC(1,1) >0.8. Wilcoxon signed rank test was used to compare tracing, counting of squares from tracing, ruler, digital camera and SLR camera. The p value for ruler measurements were statistically significant when compared to the other methods, while the comparison of the other methods was more varied. In addition, the ruler method had values that were consistently larger than all other methods. It was concluded that this study was unable to provide one statistically significant reliable measurement tool, therefore further investigations were required to strive for a gold standard in measurement techniques.

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Is pentoxifylline an underused drug? Review of the literature and a case study

Ogrin R, Duncan G, Warmington S, Darzins P and the Wound Management Service Team at Melbourne Extended Care and Rehabilitation Service, Victoria

Abstract
Research supports the use of pentoxifylline to improve symptoms in people with peripheral arterial disease. It acts at the microcirculatory level, essentially improving the movement of blood cells in the smaller vessels. These actions would be useful in wound healing where poor microcirculation plays a significant inhibitory role. Here we present a short literature review and case study introducing the use of pentoxifylline in wound healing. We believe further investigation of pentoxifylline to ascertain its usefulness in the treatment of ulcers is warranted.

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Principles of wound bed preparation and their application to the treatment of chronic wounds

Chin C • Schultz G • Stacey M • Contributions from the Wound Bed Advisory Board

Abstract
Optimal treatment of chronic wounds requires first identifying the molecular and cellular abnormalities that prevent a chronic wound from healing and then correcting them. The principles of wound bed preparation (WBP) embodied in TIME (tissue, infection, moisture and edge), provide a systemic approach to remove molecular and cellular barriers that prevent wounds from healing. This article is a concise overview of the molecular and cellular regulation of normal wound healing and practical applications of methods of WBP to promote healing.

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Pressure ulcers in Australia: patterns of litigation and risk management issues

Nelson T

Abstract
Unexpected outcomes or adverse events in the field of medicine have always existed and will continue to do so. Litigation for particular types of errors is increasing, perhaps not because health care professionals make more mistakes, but because consumers of health services are better informed and have come to expect outcomes which are reasonable and realistically achievable. However, it must be recognised that even state of the art medicine or faultless health care cannot cure all disease conditions nor save all lives. Delivering good health care involves not only the knowledge of science but the application of the art of good judgement. Despite this, there are still adverse outcomes or medical errors which should not occur. A medical error may be described as an unintended act (either of omission or commission) or an act that does not achieve its intended purpose.
This article examines some of these concepts and how they interface with the prediction and prevention of pressure ulcers. The article will examine, in particular, civil litigation patterns in this area, specific areas of legal exposure for practitioners and how the AWMA Standards for Wound Management ('the Standards'), provides clinicians with the opportunity to deliver sound risk management principles in the prevention and management of pressure ulcers.

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The multifactorial nature of leg ulcers and the necessity to address all aetiologies to ensure successful healing: a case study

Ogrin R • Khalil Z • Woodward M

Abstract
The aetiology of leg ulcers is multifactorial in nature and all of the factors need to be addressed so that appropriate management can be implemented. This article describes a case study of a female with diabetes that presented to the wound management service (WMS) with a chronic leg ulcer. This ulcer was complicated by infection, venous disease and impaired microcirculation. The management of this ulcer by the multidisciplinary team is outlined and the costs involved in the treatment are also discussed. Only when all of the aetiologies were addressed did healing rate increase, confirming the importance of correct diagnosis in managing leg ulcers.

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Skin tears: a case review

Morey P

Abstract
Skin tear occurrence is known to be a problem in the elderly, particularly in residential care. Within the acute care setting, the risk of elderly patients sustaining skin tears also presents challenges for care. The management of skin tears varies considerably and is best determined by assessment of the patient and skin tear itself. Two cases with different categories of skin tears treated in the acute care sector will be discussed and will highlight some of the risk factors and alternative options for wound management.

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