The difficult leg ulcer
A case review illustrating the problems and difficulties associated with treatment

Angel D • Sieunarine K • Abbas M • Mwipatayi B

Through the vehicle of a case study, this paper illustrates the complexity associated with venous leg ulcerations. In order to be effective with treatment regimes, a comprehensive understanding of the pathophysiology of the lower leg venous system, the pathology of venous insufficiency and the pathology of venous leg ulcerations must be fully understood. Compression therapy is the cornerstone to treatment, however, this must only be applied after the patient has been thoroughly investigated to exclude other causes of the leg ulcer. Unlike the United Kingdom and Europe, Australia does not have national guidelines for the management of patients with venous leg ulcers. In view of the high costs associated with this condition, perhaps there may be better outcomes for patients if this approach were adopted in Australia.
Angel D, Sieunarine K, Abbas M & Mwipatayi B. The difficult leg ulcer: a case review illustrating the problems and difficulties associated with treatment. Primary Intention 2005; 13(1): 7-10, 12-14, 16.

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PUPPS 2
A short report on the model for conducting serial State-wide pressure ulcer prevalence surveys in the acute and sub-acute health sectors in Victoria

Strachan V • May K

Pressure ulcers are an internationally recognised patient safety problem, one of six being addressed by the Victorian Quality Council (VQC), which operates as an expert, strategic, ministerial advisory council with a primary role to improve safety and quality in health care 1. As a consequence of conducting PUPPS 1, the acronym given to the first State-wide pressure ulcer point prevalence survey, the VQC State-wide PUPPS report 2003 2 made a number of recommendations aimed at improving pressure ulcer prevention and management. These included suggestions for action in the areas of pressure reducing equipment resources, wound management staff resources, education for staff and patients, risk assessment, monitoring and ongoing reporting.
Action on the PUPPS 1 recommendations to date includes: support for several of the recommendations by their inclusion in the Victorian Department of Human Services (DHS) Policy and Funding Guidelines for 2004-2005; $2 million in funding for a State-wide mattress replacement programme; development of patient/consumer information on pressure ulcer prevention (also available in 10 alternative language versions), roll-out of a ‘pressure ulcer basics’ education programme State-wide; and a second State-wide recording of pressure ulcer prevalence – PUPPS 2.
This report outlines the methodology/model used by VQC for the collection of serial State-wide pressure ulcer prevalence of in the acute and subacute sectors of Victorian public health services.
Strachan V & May K. PUPPS 2: a short report on the model for conducting serial State-wide pressure ulcer prevalence surveys in the acute and sub-acute health sectors in Victoria. Primary Intention 2005; 13(1): 19-21.

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Turning the world upside down
Changes in wound care that resulted from the establishment of the West Australian Wound Care Association (WAWCA)

Williams A • Carville K • Morey P

In 1990 a group of nurses interested in wound care joined together to organise a study day to improve the quality of woundcare in Western Australia by highlighting recent changes in the management of wounds. Following the enormous success of that study day, and the expression of support and interest from practising nurses, the West Australian Wound Care Association (WAWCA) was established.
The philosophy of that association stated that all people with wounds were entitled to receive appropriate wound management that was supported by current, validated research. The association set out to: promote and increase awareness of wound management by establishing a network of persons with expertise in wound care; provide ongoing education into current prevention and management of wound care; and facilitate continued research into wound management. Following the establishment of WAWCA, wound management protocols in Western Australia underwent a rapid change. After 3 years, an international conference was organised which led to the formation of a national, multidisciplinary wound management association, and Primary Intention, The Australian Journal of Wound Management.
Difficulties are often expressed concerning the utilisation of research in nursing practice. This paper will identify and describe the strategies used by WAWCA that successfully altered practices and improved the management of wounds within Western Australia. The history of WAWCA provides insight and direction for the integration of practice, research and education.
Williams A, Carville K & Morey P. Turning the world upside down. Changes in wound care that resulted from the establishment of the West Australian Wound Care Association (WAWCA). Primary Intention 2005; 13(1): 24-26, 28-30.

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Using the web to facilitate successful wound care within a health service

Blanchfield D

This paper briefly describes how a clinical nurse consultant wound care (CNCWC) developed, implemented and marketed a website on wound care for a large Australian area health service. The purpose of the website was to provide an effective user friendly method of disseminating information on wound care practices, wound care products and educational resources available for use within the area health service.
Blanchfield D. Using the web to facilitate successful wound care within a health service. Primary Intention 2005; 13(1): 32-35.

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Course report
The Advanced Wound Care Course 2004: a challenging and fulfilling experience

Morey P • Hoskin S

Wound care education occurs in many arenas and at different levels. This article outlines the experience of two participants at an Advanced Wound Healing Course held over 4 days in Bowral, New South Wales in September 2004. The course was structured around current wound healing evidence and professional development. Participants were advanced wound care practitioners whose roles often involve educating others and initiating product evaluation and research. The intent was for participants to build on their knowledge in a safe environment, with maximum interaction in order to achieve learning outcomes.
The preceptors were experienced educators and clinicians involved directly and indirectly in wound care and wound management education for a number of years. They challenged participants to interact, question and develop or refine skills; these ranged from doppler assessment to literature critique and presentation skills. The course was sponsored by trade but was otherwise presented in generic terms without bias to product manufacturers. The value of courses such as these extends beyond 4 days.
Both formal and informal networks can evolve and serve to stimulate knowledge, research and practice changes in wound care.
Morey P & Hoskin S. Course report – The Advanced Wound Care Course 2004: a challenging and fulfilling experience. Primary Intention 2005; 13(1): 37-39.

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Course report
The 9th Oxford-European Wound Healing Summer School
St Anne’s College, Oxford, 23-26 June 2004

Rando T

The Ninth Oxford-European Summer School on Wound Healing was held at St Anne’s College, Oxford in June 2004. Over 100 delegates from around the world attended this prestigious course, including delegates from Russia, Croatia, United States, Ireland, Emirate States, Scandinavia and Australia. It conveniently preceded the 2nd World Union of Wound Healing Societies Conference held in Paris.
For this participant, there were many highlights across various professional, educative and networking levels. The calibre and diversity of international expert presenters were outstanding and the innovative key lessons that were gained were worth the long journey and subsequent inclusion in this report.
Rando T. Course report – The 9th Oxford-European Wound Healing Summer School. St Anne’s College, Oxford, 23-26 June 2004. Primary Intention 2005; 13(1): 40-42.

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Prevalence of mycoses in chronic lower limb wounds of people with onychomycosis and/or tinea pedis

Crutchfield L • Frescos N • Duncan GJ• Weller C • Woodward M

Chronic lower limb wounds are constantly exposed to bacterial and fungal organisms and are inevitably contaminated with several organisms. The aim of the pilot study was to investigate the prevalence of fungi in chronic lower limb wounds in people with onychomycosis and/or tinea pedis.

Consecutive, consenting patients with a chronic lower limb wound and a clinical diagnosis of onychomycosis and/or tinea pedis were recruited from two wound management clinics over a five-week period following ethics approval for the relevant institutions.

Wound swabs, toenail clippings and/or skin scrapings were collected from each participant and subjected to mycological examination. Wound swabs were analysed for fungal presence by culture, while both microscopy and culture techniques analysed toenail and skin samples.

In four participants, wound cultures tested positive for the opportunistic fungal Candida species. All four participants also had onychomycosis confirmed in their toenails by either a microscopy or culture analysis. Statistical analyses did not generate any significant (p>0.05) relationships between fungal presence in wounds and wound aetiology, wound duration or positive toenail and skin samples, however fungi-positive wounds and wound location were found to be statistically significantly related (p<0.05).

Crutchfield L, Frescos N, Duncan GJ, Weller C & Woodward M. Prevalence of mycoses in chronic lower limb wounds of people with onychmycosis and/or tinea pedis. Primary Intentions 2005; 13(2): 61-67.

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Clinical experiences with activated polyacrylate dressings (TenderWet 24®)

BP Mwipatayi • D Angel • P Dixon • S Higgins • G Gregory • K Sieunarine

The aim of this study was to report our experience with activated polyacrylate dressing ‘TenderWet24®’ dressing (Paul Hartmann AG) and to establish the effectiveness of the dressing in preparing the wound bed.

Methods : A prospective case series study was conducted from March to September 2004. Patients with wounds that were assessed as being amenable to the process of autolytic debridement as a method of wound bed preparation were recruited to the study. The wounds were assessed for infection and colonisation by wound fluid cultures and wound biopsy (punch biopsy at wound margin). The arterial blood supply was assessed as needed by clinical examination and with ankle brachial indices. The amount of tissue requiring debridement was assessed and the degree of wound debridement was followed from the first application of TenderWet 24® until the wound did not require further debridement or the treatment was judged to be a failure.

Results : Ten patients were recruited for the study. There were nine males and one female patient with an overall mean age of 62 years (range 33-92 years). Diabetes mellitus was previously diagnosed in three patients. Four wound types were recorded: venous ulcer (n=4); diabetic ulcer (n=3); arterial ulcer (n=5); and wounds due to various aetiologies not included in the other four types (n=1). Biopsy of the wound was performed in six patients.

A microbiological profile was obtained in all patients. In two patients, the dressing did not achieve debridement and an alternative agent was used. We show that the use of TenderWet 24® decreased the mean surface area wounds from 26.4 cm2 to 21.4 cm2 over a mean period of 6.5 days.

Conclusion: The results of this study suggest that activated TenderWet 24® therapy is safe and effective for the debridement of all types of wounds. However, to yield statistically significant results, larger studies must be performed.

Keywords: TenderWet 24®, wound bed preparation, leg ulcer, debridement.

BP Mwipatayi, D Angel, P Dixon, S Higgins, G Gregory & K Sieunarine. Clinical experiences with activated polyacrylate dressings (Tenderwet 24®). Primary Intentions 2005; 13(2): 69-74.

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Probing the literature: Recommended practice for the use of wound probes

Flowers C • Pilgrim J • Carville K

The traditional wound probes are long slender metal instruments, which are commonly used by nurses in the management of wounds to assess cavities or sinus tracts and as instruments to introduce wound packing agents. Indiscriminate use of wound probes can lead to pain and tissue trauma. A review of the published literature was instigated to inform the development of guidelines to regulate the use of wound probes within a community nursing service. The review located limited literature, and no research-based studies, which might aid the development of guidelines for the use of wound probes. The need to extend the investigation beyond published sources and to initiate dialogue with other agencies, clinicians, and manufacturers is recommended prior to the development of much needed guidelines.

Flowers C, Pilgrim J & Carville K. Probing the literature: Recommended practice for the use of wound probes. Primary Intentions 2005; 13(2): 75-80

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A case report on necrotising fasciitis

Wilkes A

This case report discusses the management of an elderly woman patient who presented with a provisional diagnosis of cellulitis of the right lower limb to a district hospital. Subsequent rapid deterioration of the limb and the development of clinical features suggestive of necrotising fasciitis led to immediate surgical intervention.

Wilkes A. Discovering an unusual wound. A case report on necrotising fasciitis. Primary Intentions 2005; 13(2): 83-88.

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Pressure ulcer prevalence and its relationship to comorbidity in nursing home residents: results from phase 1 of the PRIME Trial

A/ Professor Nick Santamaria • A/ Professor Keryln Carville • Jenny Prentice • Isabelle Ellis • Tal Ellis • Dr Gill Lewin • Nelly Newall RN

Abstract
Pressure ulcers are a significant cause of morbidity and mortality in the aged care population with prevalence rates reported to be as high as 43% in some aged care facilities. The PRIME Trial was designed to investigate the effectiveness of an integrated pressure ulcer management system in reducing pressure ulcer prevalence and incidence in nursing homes. A total of 1956 residents from 23 nursing homes in NSW, Vic, SA and WA were enrolled in this Commonwealth funded study.

This paper presents the results from phase 1 of the trial and indicates that the prevalence of pressure ulcers in the cohort of 1956 residents was 25.9%. Significant associations between the development of a pressure ulcer and comorbidity level (Charlson Index) (p=0.01), risk assessment level (Braden Scale) (p=0.00) and the lack of appropriate equipment (p=0.00) were detected. Residents who developed a pressure ulcer whilst in an acute hospital showed a trend to develop more than one ulcer and ulcers that were of higher severity than those developed in a nursing home.

The results from phase 1 of the PRIME Trial suggest that emphasis needs to be given to appropriate risk assessment of the elderly nursing home resident that should include comorbidity status and the provision of suitable pressure relieving equipment.

Key words: Pressure ulcer, prevalence, nursing home, comorbidity. Primary Intentions 2005: 13(3): 107, 109-110,112,114-115.

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New South Wales Pressure Ulcer Initiatives South Eastern Sydney Illawarra Area Health Service (Southern Sector): Taking the pressure off

Gaye Sykes • Debbie Blanchfield RN

Abstract
In Australia, the cost of treating patients with deep pressure ulcers, where muscle and bone are exposed, is estimated to cost between $61,230 and $100,000 per patient (Young, 1997). Overall annual estimated costs in treating patients with pressure ulcers in Australia reportedly reached up to $350 million in 1997 (Woolridge 1997).

Like many other improvement activities, diverse, disparate and well-intentioned efforts were being made in pressure ulcer prevention across the Area Health Service. However, the lack of a coordinated and strategic area-wide effort had weakened the potential for improved outcomes in all high-risk patients.

This project was initiated following a 2002 audit that identified 13% of patients transferred to Rehabilitation Aged and Extended Care (RAEC), had a pre-existing pressure ulcer. This, as well as other issues identified, were addressed through the Areawide implementation of standardised and evidence based strategies for the prediction and prevention of pressure injury and management supported by an innovative staff-training program.

Results of an Area-wide audit indicate the number of patients identified with a pressure ulcer within Illawarra Health, (IH) decreased from 17% in 1993, to 7.5% in 2003; and to 5.4% in 2004. Primary Intentions 2005: 13(3): 122-123.

Silver dressings in wound healing: what is the evidence?

Associate Professor Michael Woodward

Abstract
Silver has a long history of medicinal use based on its antimicrobial effects. Microbial burden can delay wound healing and makes silver an attractive local antiseptic for wounds affected this way, especially as antibiotics have limitations. Whilst there is good evidence in preclinical studies of the effects of silver on microbes and on processes that delay wound healing, evidence for the benefits of silver products on human wound healing is still far from robust. At this stage, silver products should be confined to adequately assessed wounds that are failing to heal with cheaper products, especially where microbial burden appears to be delaying healing.
There are a range of silver products currently available, with differing formulations and delivery of silver, and differing product bases. Current evidence does not clearly demonstrate that one product is more effective that another, and choice of an initial product will be based on wound and patient characteristics, product availability and practitioner familiarity and preferences.

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Nanocrystalline silver reduces the need for antibiotic therapy in burn wounds

Catherine Tonkin, Fiona Wood

Abstract
Wound infection is a serious consequence of burn injury. This study aims to compare the effectiveness of Acticoat™ and silver sulphadiazine (SSD) in relation to antibiotic use during a product trial at Royal Perth Hospital (RPH) in Western Australia (WA). This investigation consisted of four periodic clinical audits (n=72) comparing SSD and Acticoat wound dressing regimens for burn injury, with the primary outcome variable being antibiotic use.
Of the 72 patients audited, 81.9% were male and 18.1% female, with a mean age of 35.7 years. The most common burn agent was flame (58%); 36% had partial depth burns. The mean percentage total body surface area (%TBSA) of burn was 9.3%. Antibiotic use was prescribed for 24 (36.1%) of the 72 patients reviewed. There was a statistically significant (p=0.016) decrease (50%) of antibiotic usage with Acticoat dressings compared to SSD. The mean length of stay (LOS) for those patients receiving Acticoat showed a statistically significant decrease (p=0.045); 8.8 days compared with a LOS of 15.1 days in the SSD group. It was therefore concluded that Acticoat is a more effective dressing for reducing infection than SSD in burn wounds.

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Management of chronic wounds: the role of silver-containing dressings

Sue Templeton

Abstract
The last few years has seen an increasing interest in the area of topical antimicrobial dressings. In particular, dressings containing silver are being developed at a rapid rate. The use of silver-containing dressings is escalating and they are now widely utilised on many types of wounds. In particular, silver-containing dressings can be a valuable component of wound bed preparation and the management of chronic wounds.
This paper examines the current literature on silver-containing dressings. Implications for practice are discussed and two protocols for use of silver-containing dressings in practice are proposed. Many questions regarding the use of silver-containing dressings remain unanswered and this paper suggests directions for future research to assist clinicians to achieve optimal, economically sustainable client outcomes.

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A silver tale: pseudomonas vs Aquacel Ag

Denise Kolera

Abstract
The treatment of infected wounds often requires a multi-faceted and multi-disciplinary approach. The use of intravenous antibiotics in combination with effective antimicrobial silver dressings will have positive outcomes for the patient, management team and organisation. However, wound management practitioners often work within finite budgets and the use of expensive silver dressings must be both evidence-based and outcome driven. The following case study shows intravenous antibiotics alone were unsuccessful in managing a severe pseudomonas infection; however, in collaboration with Aquacel Ag®, desired wound healing was achieved. This outcome, and countless similar cases managed at Redcliffe Hospital, validates the use of expensive silver dressings in improving patient outcomes and facilitating early discharge.

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Reduced cellular toxicity of a new silver-containing antimicrobial dressing and its clinical performance in non-healing wounds

Holger Kapp, Hans Smola

Abstract
Normal wound healing may become disturbed by bacterial colonisation of the wound; this can give way to infection, which requires systemic intervention with antibiotics. As an antimicrobial agent, silver has a long tradition and has been used from the ancient past to today. In burn centres, topical silver preparations are used to prevent the entry of pathogenic micro-organisms into the burn wound and to reduce the risk of sepsis.
Silver-containing dressings were introduced in the 1970s and have received widespread attention recently regarding their use in wounds with impaired healing such as leg ulcers, decubitus and diabetic foot infections. Various silver dressings are available; however, cellular toxicity is a serious concern and the benefit of antimicrobial action needs to be carefully balanced against the cytotoxic harm silver can do.
With this rationale, we developed a new silver-containing tulle dressing, Atrauman Ag. Atrauman Ag effectively kills a panel of commensal and pathogenic bacterial strains while viability of HaCaT keratinocytes remained at 90%. In two separate studies, 86 and 624 patients with a variety of wounds with impaired healing were treated with Atrauman Ag in an office-based setting. After three dressing changes, evaluation scores improved in both studies. Physicians’ and patients’ rating also were very favourable, reporting that the dressing format was versatile and that dressings were easy to apply and less painful to remove. It can be concluded that Atrauman Ag has a superior profile of antimicrobial activity over cellular toxicity. The low silver ion release rate of Atrauman Ag may not cause harmful interference with wound healing mechanisms.

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Wounds with a silver lining

Rosalind Probert, Sarah Burston

Abstract
In our practice we have used wound management products that contain silver on pressure ulcers, donor sites, acute, chronic and malignant wounds. These initial applications have proved effective, providing positive anecdotal evidence. In this article four case studies are discussed; we will use these as a springboard to further explore the use of silver dressings and to collate evidence to support their use.
Luke sustained multiple fractures and friction burns as a result of a motorbike accident. Acticoat Ag® was used over the friction burns, resulting in complete re-epithelialisation in 5 days. Amanda, a wheelchair bound spina bifida patient, had Stage IV pressure ulceration on her buttocks and a complex care history. Aquacel Ag® and a VAC® were used to effectively manage Amanda. Daniel had spinal fusion and wound dehiscence following a fall in a mountain range and subsequent air retrieval. Daniel had a non-Methicillin-resistant Staphylococcus aureus (MRSA) infection in the wound. Aquacel Ag, foam and suction were applied to the wound to facilitate healing and allow transfer from the acute setting to the spinal rehabilitation programme. Betty had an isolated limb infusion of chemotherapy for treatment of melanoma. Subsequent to discharge there was necrosis at some digits and ongoing inflammatory reaction. Admission was required to treat the wounds. We used Aquacel Ag, Alione®, Contreet Foam®, Polymem Ag® and Acticoat® at various stages of the healing process. Medical impatience dictated a change to silver sulphadiazine® (SSD) cream. Five days of treatment with SSD demonstrated deterioration in the wound and the medical
decision at that time was to return to the previous dressing.

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The use of silver products in the management of burn wounds: change in practice for the burn unit at Royal Perth Hospital

Joy Fong

Abstract
The aim of this paper is to describe and discuss the properties and applications of silver in the management of burn wounds.
Recent renewed interest in silver has resulted in the development of new silver delivery systems. Silver is a broad spectrum antibiotic with antiseptic, antimicrobial, anti-inflammatory and pro-healing properties. Free silver cations released in a wound have a potent antimicrobial effect, destroying bacteria by the process of cell replication inhibition, blocking cellular respiration and cell functional structure. Research indicates that the effectiveness of the silver dressing is related to the bacterial burden in the wound and the delivery of silver must be at the right concentration over an appropriate time. Research into silver toxicity reveals low mammalian toxicity; ‘agyria’ is the most common side effect.
There is limited documentation on silver bacterial resistance. Burn wounds are susceptible to infection, often exacerbated by immuno-suppression associated with burn injury. Burn wound infections remain the main cause of mortality and morbidity for patients with burn injuries.
The common silver products used in burn wound management are silver sulphadiazine cream (SSD), Flammercerium, silver nitrate 0.5% solution, ActicoatTM, Acticoat Absorbent, Aquacel Ag and silver hydrocolloids such as ContreetH. Several investigations found that Acticoat is more effective than other silver dressings. The burn unit at Royal Perth Hospital, after conducting patient care audits to evaluate the effectiveness of Acticoat as compared to SilvazineTM, found Acticoat more effective and cost effective. The unit subsequently changed their practice of early burn wound management to Acticoat dressings for all partial to full thickness burn admissions.

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Flights of fancy: the use of silver dressings to treat a trauma wound in a wild cockatoo

Simone Vitali, Karen Payne, Paul Eden

Abstract
This case report illustrates the application of nanocrystalline silver dressings in the second intention healing of an open wound in a wild cockatoo. The challenges of managing these non-compliant patients are discussed.

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