A comparative trial of long stretch compression bandaging versus multi-layer compression
bandaging in the treatment of chronic venous ulcers

Harley J • Harcourt D • Hutchinson B • McLean M • Long M

Abstract
Venous ulcers are a common problem associated with venous incompetence, chronic venous hypertension and venous stasis, leading to oedema, skin necrosis and ulceration. Compression therapy has been found to be the most efficient means of treatment but remains expensive due to the chronic nature of this problem.
The major aims of this study were to compare the effectiveness in terms of time to healing, complications experienced and patient comfort of the long stretch compression therapy bandaging system (LSB) to the multi-layer compression bandaging therapy (MLB) in patients with chronic venous ulcers. Secondary aims were to compare the cost of different forms of bandaging and to assess the ease of application by nurses trained in the technique of both bandaging types. Within our study, a total of 30 patients, randomly divided into two treatment groups, participated in the experimental trial conducted over a 30 month period commencing in 1999. Group 1 comprised 16 patients – they were treated using MLB; Group 2 comprised 14 patients – they were treated using LSB. Although the results were not conclusive with regards to superiority between systems when examining the issue of time to healing, MLB does appear to be superior in other ways to LSB, as revealed by the following findings:
• The MLB group experienced significantly fewer complications, on average, than the LSB group.
• The MLB group experienced significantly fewer incidences of evidence of inappropriate pressure, on average, than the LSB group.
• The MLB group received significantly fewer non-routine bandage changes, on average, than the LSB group.
• A significantly higher number of the MLB group experienced greater comfort levels with their treatment than the LSB group.
• A significantly higher number of the LSB group had their treatment discontinued than the MLB group.
• The healing duration did not vary significantly between the treatment groups.
Harley J, Harcourt D, Hutchinson B, McLean M & Long M. A comparative trial of long stretch compression bandaging verus multi-layer compression bandaging in the treatment of chronic venous ulcers. Primary Intention 2004; 12(1); 6, 7, 9-13.

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Raising PUPPS: establishing the prevalence of pressure ulcers in the acute and subacute health sectors in Victoria – a State-wide methodology model

Strachan V • Balding C

Abstract
In 2003 the Victorian Quality Council (VQC) undertook a pressure ulcer point prevalence survey; a project that affectionately became known State-wide as PUPPS. Pressure ulcers are an internationally recognised patient safety problem and, as such, a reduction in pressure ulcer prevalence in Victoria is a key outcome of the VQC strategic plan 1. This paper describes the PUPPS methodology used by the VQC to ascertain the prevalence of pressure ulcers in the acute and subacute sectors of Victorian public health services. Building on the model advocated by Prentice 2, PUPPS proved a manageable and successful approach to conducting a State-wide pressure ulcer point prevalence survey. It also served as a useful guide to those wishing to conduct pressure ulcer prevalence surveys locally. Several elements critical to success were identified – the importance of thorough planning and project management; the preparation and provision of information materials for health services to enable them to make an informed decision to participate; the piloting and refinement of the methodology; the testing of and support for surveyors; and the importance of and flow-on effects of the surveyor education programme.
These elements are discussed in detail, along with the many practical lessons learned throughout the course of the survey. Results of the prevalence survey will be presented in a forthcoming article.
Strachan V & Balding C. Raising PUPPS: establishing the prevalence of pressure ulcers in the acute and subacute health sectors in Victoria– a State-wide methodology model. Primary Intention 2004; 12(1); 14, 16-20, 22, 24-26, 30-33.

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Postoperative pressure ulcers in vascular patients after epidural analgesia: case reports

Angel D • Sieunarine K • Hunduma N • Clayton M • Abbas M • Ponosh S

Abstract
Epidural analgesia is widely recognised as one form of postoperative pain relief. However, several authors have expressed concerns that there is an increased incidence of pressure ulcer development in patients with epidural analgesia. Patients with peripheral arterial occlusive diseases (PAODs) are already at risk of pressure ulcer development due to reduced peripheral blood supply, and the use of epidural analgesia will increase their risk unless appropriate preventative measures are taken at all levels of care. This case series demonstrates the potential complications associated with epidural analgesia in three postoperative patients with PAODs. Recommendations are made to try and reduce these complications. In addition, as there is limited low level evidence linking the development of pressure ulcers and epidural analgesia, further well-conducted research is needed.
Angel D, Sieunarine K, Hunduma N, Clayton M, Abbas M & Ponosh S. Postoperative pressure ulcers in vascular patients after epidural analgesia: case reports. Primary Intention 2004; 12(1); 35-38.

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A report on the effectiveness of comprehensive wound assessment and documentation in the community

Carville K • Smith J

Abstract
The most important practical lesson that can be given to nurses is to teach them how to observe (assess) – how to observe (assess) what symptoms indicate improvement – what the reverse – which are of importance – which are evidence of neglect, and what kind of neglect– Florence Nightingale, 1859 1.
This paper highlights the wisdom expressed here by Miss Nightingale in regard to the care of aged wounded war veterans in the domiciliary setting. Silver Chain Nursing Association is the largest provider of home care in Western Australia. In 2000 a wound survey was carried out on all Department of Veterans’ Affairs (DVA) clients who were receiving wound management from Silver Chain. The aim of the survey was to review the prevalence, type and source of wounds on DVA clients referred, and to evaluate the nursing assessment and resources used to manage their wounds. A process was also established to review the times and costs involved in healing these wounds. In addition, when the findings of this study were compared with the findings of a wound prevalence survey that was conducted in 1996 amongst all Silver Chain clients who received nursing care, it was found that clients in the DVA study were 30% more likely to heal than those all-aged clients in the 1996 study. The significant reduction in healing rates and associated reduction in costs of wound healing were thought to be achieved when comprehensive nursing assessment and documentation were employed in the management of clients with wounds in the community.
Carville K & Smith J. A report on the effectiveness of comprehensive wound assessment and documentation in the community. Primary Intention 2004; 12(1); 41-44, 46-48.

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The effectiveness of digital imaging and remote expert wound consultation on healing rates in chronic lower leg ulcers in the Kimberley region of Western Australia

Santamaria N • Carville K • Ellis I • Prentice J

Abstract
The incidence of chronic lower limb ulcers in remote regions of Australia is high and results in significant morbidity, decreased quality of life and high cost. These wounds present challenges to clinicians due to their complex nature, high levels of comorbidity and the difficulty of gaining expert wound consultation due to distance. A 12 month prospective randomised controlled trial was conducted at four sites in the Kimberley region of Western Australia (WA). The aim was to examine the effect on clinical outcomes and costs of providing remote expert wound consultation using the Alfred/Medseed Wound Imaging System (AMWIS) for patients with chronic leg and foot ulcers. All patients (n=93) had sequential wound assessments conducted using AMWIS at each clinic attendance. Control patients (n=43) received standard wound care, whereas intervention group patients (n=50) had their digital records transmitted to Perth every 2 weeks for remote review by a wound care consultant; these were then returned to their treating clinician with wound management advice. Results indicate that intervention group patients had a positive healing rate of 6.8% per week, whereas controls had a negative rate of -4.9% per week (p=0.012). There were six amputations in the control group and one in the intervention group. The estimated treatment cost difference between the groups at 12 months was $191,935 lower in the intervention group. We believe that our findings provide early evidence of the clinical and cost effectiveness of remote expert wound consultation using a digital wound imaging system in geographically remote regions.
Santamaria N, Carville K, Ellis I & Prentice J. The effectiveness of digital imaging and remote expert wound consultation on healing rates in chronic lower leg ulcers in the Kimberley region of Western Australia. Primary Intention 2004; 12(2): 62-64, 66-68, 70.

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The incidence of percutaneous gastrostomy infection and variation in wound care practices

Davis JP • Entrop M • Read SJ

Abstract
The aim of this study was to assess the incidence of percutaneous gastrostomy site infections and to describe current wound care practices in response to this problem at our hospital. A retrospective audit of medical records and hospital databases was performed. Patient demographics, indication for gastrostomy, insertion technique, prophylactic antibiotic use, pathology results and wound care practices, including the use of cleansing agents, topical antiseptics and dressings, were recorded. Compliance with the hospital protocol for gastrostomy wound care was determined. Gastrostomy site infection was determined by reviewing clinical assessments recorded in the medical record. Gastrostomy site infection was found in 19 (32%) of 60 patients. The infection rate was not associated with demographics, indication for gastrostomy, insertion technique or antibiotic prophylaxis. Wound care documentation was poor, with 61% of non-infected wounds and 21% of infected wounds not documented. Variation in practice was high, with three types of cleansing agent, three types of topical antiseptic, six types of dressing and dressing frequency ranging from daily to every 2 hours. Documented practices tended to be inconsistent with hospital protocol. Gastrostomy site infection occurred in almost one third of cases. Wound care practices appear to be a significant contributor to this infection rate. The diversity and variability in wound care practices, combined with non-adherence to hospital protocol, supports this view. Given the paucity of research evidence to support current wound care strategies, further research is needed in the form of randomised controlled trials.
Davis JP, Entrop M & Read SJ. The incidence of percutaneous gastrostomy infection and variation in wound care practices. Primary Intention 2004; 12(2): 73-75, 77, 80-81.

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Skin tear prevalence and management at one hospital

McErlean B • Sandison S • Muir D • Hutchinson B • Humphreys W

Abstract
One organisation undertook a hospital-wide audit of skin tears to determine the type, location and current wound management practices in place. Prevalence varied greatly between wards, ranging from 0-3.8% in surgical wards to 27% in the palliative care ward. Using the Payne-Martin skin tear classification system, the majority of skin tears were categorised as 2A, partial thickness skin tears with less than 25% tissue loss. The audit discovered various management practices in places, some at variance with recommended wound care practices. To support consistency of practice, organisational practice guidelines were developed and are in the process of being disseminated to staff. Evaluation measures will consist of regular auditing practices, noting prevalence, location, causation factors and wound management practices, as well as staff knowledge.
McErlean B, Sandison S, Muir D, Hutchinson B & Humphreys W. Skin tear prevalence and management at one hospital. Primary Intention 2004; 12(2): 83-86, 88.

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The use of honey in chronic leg ulcers: a literature review

Mwipatayi BP • Angel D • Norrish J • Hamilton MJ • Scott A • Sieunarine K

Abstract
The purpose of this study was to investigate the clinical effects of topical honey on chronic leg ulcers, through a systematic review of published trials – randomised (RCTs) and non-RCTs – and to clarify its role in our daily practice. The Pubmed, MEDLINE, EMBASE, CINAHL database and the Cochrane Library were searched for relevant publications on the efficacy of honey as an antibacterial agent and in the promotion of wound healing in chronic leg ulcers 1980-2004. We found 13 publications concerning the use of honey in chronic leg ulcers, but only two were clinical trials of relevance to our study. The studies analysed were influenced by different sources of bias, especially lack of blinding, poor reporting quality and poor sample size. None of those studies was a RCT. In order to elucidate the evidence for the use of honey as a first line treatment in chronic leg ulcers, RCTs and laboratory studies on cellular effects are urgently needed.
Mwipatayi BP, Angel D, Norrish J, Hamilton MJ, Scott A & Sieunarine K. The use of honey in chronic leg ulcers: a literature review. Primary Intention 2004; 12(3): 107-108, 110-112.

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Using a foam silver dressing to promote healing of a mixed aetiology leg ulcer

Templeton S

Abstract
Chronic leg ulceration is a problem that affects a significant number of people and costs the health care system millions of dollars per year 1. To achieve optimal outcomes for the person with a chronic wound, the treatment must identify and address local and systemic factors that can impair healing.
Wound bed preparation is recognised as the foundation for effective management of the chronic wound. Wound bed preparation considers the elements of the chronic wound environment that contribute to delayed healing. One component of wound bed preparation is reduction of high wound bioburden. Silver has been used in various forms for centuries as an anti-microbial agent. In recent years, the delivery of silver for wound management has been refined and improved and ionic silver released in a controlled manner onto the wound has been found to be an efficacious treatment for high wound bioburden.
This case study illustrates the need to address systemic and local factors to achieve optimal wound healing outcomes. In particular, the efficacy of a foam dressing which releases silver (ContreetTM foam) is evaluated as part of a leg ulcer management regime.
Templeton S. Using a foam silver dressing to promote healing of a mixed aetiology leg ulcer. Primary Intention 2004; 12(3): 115-116, 118-120.

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Breaking down the barrier from multidisciplinary to interdisciplinary care
A case study in a high risk foot clinic

Tennant J • McClelland M • Miller J

Abstract
This case study examines the importance of an interdisciplinary team approach to wound management in the particular case of a 63 year old man with a high risk foot ulcer. Treatment options and the perceived traditional professional boundaries of the individual health care providers are discussed alongside interdisciplinary approaches to working as a complementary team.
Tennant J, McClelland M & Miller J. Breaking down the barrier from multidisciplinary to interdisciplinary care. A case study in a high risk foot clinic. Primary Intention 2004; 12(3): 127-130.

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Conference report
5th Biennial Australian Wound Management Conference 2004
Hobart, 18-20 March 2004

Quarmby S • Young C

Abstract
The Tasmanian Wound Care Association (TWCA) hosted the 5th Biennial Australian Wound Management Association (AWMA) Conference on behalf of AWMA from 18-20 March 2004. The Wrest Point Convention & Conference Centre was an ideal location for this event as it is situated on Hobart’s beautiful waterfront, enabling the 450 national and international conference delegates to access Hobart’s magnificent scenery in between conference activity. The weather also facilitated this as it was quite moderate– much to the surprise of some of our interstate colleagues!
Quarmby S & Young C. Conference report: 5th Biennial Australian Wound Management Conference 2004. Hobart, 18-20 March 2004. Primary Intention 2004; 12(3): 132-133.

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Conference report
World Union of Wound Healing Societies Meeting
Paris, 8-13 July 2004

Woodward M

Abstract
Over 5,500 delegates attended this, the largest ever meeting of wound healing professionals. Australia was well represented with approximately 100 representatives from all professional areas. Whilst the weather was mediocre, the scientific content was unsurpassable with the stars including Falanga, Sibbald, Debure, Stacey, Sussman, Margolis, Harding (of course!), Moffatt, Briggs and numerous others. With Mike Stacey and Geoff Sussman on the organising committee, we were assured of a great meeting, and the content (if not the organisation at all times) lived fully up to expectations. We all look forward to Toronto in 2008.
Further reports on other sessions at the Congress will be presented at a later date. For this participant, whilst there were several highlights, the following presentations stood out.
Woodward M. Conference report: World Union of Wound Healing Societies Meeting 2004. Primary Intention 2004; 12(3): 135-138.

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Preventing chronic diabetic foot pathology from progressing to amputation: a podiatric case study

Peters J

Abstract
Diabetes is one of the most potentially destructive and deforming disease processes in the human foot. The complications associated with diabetes are the primary cause of morbidity seen in hospital-based podiatry practice. Damage occurs at random in large and small blood vessels, sensory, motor and autonomic nerve fibres, often progressing to ulceration, Charcot joint disease, gangrene and limb loss. This paper takes a snapshot of one man’s disease process, examining his foot complications over a 3 year period and describing the way they were managed in a hospital-based podiatry practice setting. The emphasis of the article centres on management of the mechanical causes of ulceration and the utilisation of a simple and safe procedure (a percutaneous tendo Achilles lengthening – TAL) 1, 2 to address those complications.
Peters J. Preventing chronic diabetic foot pathology from progressing to amputation: a podiatric case study. Primary Intention 2004; 12(4):155-160.

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The application of TIME (wound bed preparation principles) in the management of a chronic heel ulcer

Foley L

Summary
A review of the treatment of a difficult to heal chronic heel ulcer using TIME (wound bed preparation principles).
Foley L. The application of TIME (wound bed preparation principles) in the management of a chronic heel ulcer. Primary Intention 2004; 12(4):163-164, 166.

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Indecent exposure: a descriptive study of wound exposure times associated with dressing changes

Page T • McCutcheon H

Abstract
The purpose of this descriptive study was to describe the duration of wound exposure during dressing changes and to document variables such as type of dressing, aetiology, or presence of infection that may influence the time the wound was exposed during the dressing change. In particular, the study explored how wound assessment procedures influenced the exposure time of the wound.
The setting was a surgical unit of a 650 acute care bed tertiary hospital – 47 patients with open wounds were recruited; three of these were not included in data analyses as they did not undergo a wound dressing change in the clinical setting. A total of 281 dressing changes were timed for 44 participants.
Of the 281 dressing changes, exposure for an extended amount of time was documented in 126 cases. A statistically significant correlation between wound assessment by medical officers and wound exposure was demonstrated (p<0.004). Comparisons between aetiologies, dressing products and infectious status also demonstrated statistically significant results for length of wound exposure.
This descriptive study found that long periods of wound exposure were associated with wound dressing changes. There is no evidence as yet that wound exposure is harmful to wound healing; however, the literature states that moist, warm environments are beneficial to healing, which suggests that current practice could have detrimental effects.
Page T & McCutcheon H. Indecent exposure: a descriptive study of wound exposure times associated with dressing changes. Primary Intention 2004; 12(4):170-172, 174-176, 178-179.

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