Skin safe. Implementing clinical guidelines to prevent pressure ulcers in home care clients

Lewin G, Carville K, Newall N, Phillipson M, Smith J & Prentice J

Summary
Silver Chain, the largest community care provider in Western Australia, assists older people and individuals living with a disability to remain living independently in the community. Many of these individuals are at risk of developing a pressure ulcer. This paper describes the results of a project that combined the introduction of the Australian Wound Management Association’s (AWMA) Clinical Guidelines for the Prediction and Prevention of Pressure Ulcers 1 into everyday work practices across the organisation with a systematic evaluation of the strategy’s effectiveness.
The project was originally designed to have the four discrete stages of: 1) baseline data collection, 2) guideline implementation, 3) repeat of baseline data collection, 4) ongoing evaluation. The main outcome measures were pressure ulcer prevalence and the adoption of prevention practices recommended by the guidelines. However, the lack of a significant reduction in prevalence when the baseline measures were repeated at one year, prompted the modification of the original design to include two further stages. These involved the implementation of strategies to reinforce the adoption of practice changes, followed by a third prevalence survey.
The project was then found to have been successful in significantly reducing the prevalence of pressure ulcers among our most at risk clients as well as having achieved practice change among our home care staff. However, ongoing monitoring indicates that the practice changes are not being sustained over time and that further research is needed to determine how the adoption of new practices may be better maintained so that a return to baseline levels of pressure ulcer prevalence may be avoided.

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To drain or not to drain? – That is the question

Taylor P

Abstract
With regard to the management of partial thickness burns blisters, confusion continues in the literature as to whether to drain the blister, drain and deroof the blister, or leave the blister intact. This in turn creates difference of opinion between medical and nursing colleagues with little in the way of evidence-based recommendations. This paper highlights some of the conflicting research in an attempt to assist in the development of policies of best practice.

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STAR: a consensus for skin tear classification

Carville K, Lewin G, Newall N, Haslehurst P, Michael R, Santamaria N & Roberts P

Abstract
Until now the Payne-Martin Classification System for Skin Tears has been the only skin tear classification system reported in the literature. Considering that the development of this taxonomy began over twenty years ago, it is rather puzzling that it has been poorly utilised in Australia. Especially in light of the fact that skin tears are perceived to be common wounds amongst frail older or disabled persons 1, 2, 3 and their prevalence can be expected to escalate in line with our ageing population. Stage one of the Skin Tear Audit Research (STAR) study aimed to gain a consensus from Australian nurse experts in wound management on a classification system for skin tears and to test the reliability of the resulting classification system. This paper reports on the processes undertaken to achieve a consensus, the STAR Skin Tear Classification System that resulted, and the reliability testing that it underwent.

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The use of ichthammol glycerin in burn wound care: a literature review

Rowe S, Hilmi S, Wood F

Introduction
The current concept in the clinical management of patients focuses on evidence-based quality use of medicines. In the area of wound management it has been purported that evidence-based practice has not kept pace with the numerous wound care products that are now available on the market. So, are wound care products that have been tested for efficacy by randomised controlled clinical trials the only ones that should be used in clinical practice? Is there still a place for those traditional ‘tried and true’ products in the management of wounds? One such product is ichthammol glycerin APF [Australian Pharmaceutical Formulary and Handbook], for which the question remains: Is its current use based on clinically supported evidence?
Ichthammol is derived from marine sediments in Mesozoic era rock formations. It has a high hydrogen/carbon ratio and is low in nitrogen. This is opposite to a tar with which it is often confused. Ichthammol is generated from low temperature carbonisation of shale oil. It is obtained by distillation from certain bituminous schists, sulphonation of the distillate and neutralisation of the product with ammonia to pharmacopeial specifications after which it is available for medical use [British Pharmacopoeia grade (BP)]. Ichthammol is also referred to as ammonium bituminosulphate, sulfonated shale oil and ichthyol although the latter usually refers to the pale version. Dark ichthammol is a result of strong acid treatment and pale ichthammol is the result of light acid treatment. Dark ichthammol is a dense, blackish-brown liquid which is miscible with glycerol (BP). Glycerol, a clear liquid possessing humectant and moisturising actions, therefore serves as a suitable vehicle for topical preparations containing ichthammol, and the resultant preparation is called ichthammol glycerin.
Believed to have been used in wound healing as early as the 1400s, with documented use in dermatology since the late 1880s, ichthammol has also been combined with a number of other ingredients, including mercury. Ichthammol is purported to have antibacterial, antiphlogistine, anti-inflammatory, antiseborrhoic, antieczematous, antimycetic, antiprurinous and blood flow stimulating effects. The literature claims that shale oils inhibit sebaceous secretion, migration of leucocytes and release of chemotactic factors by granulocytes 3. There are four anecdotal case reports of success in its clinical application, one clinical study supporting claims about its efficacy and one randomised control trial (RCT) identified through the Cochrane database. Ichthammol glycerin has been described as being used in combination but not in burn wounds. However, despite the paucity of information on both the mode of action and the antibacterial properties of these agents, they continue to be used in clinical practice in dermatology, vascular medicine and, the subject of this paper, burn wounds.

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Osteomyelitis in the diabetic foot: what lies beneath

Nubé V, Bolton T, Chua E, Yue D

Abstract

Osteomyelitis is an important cause of delayed healing of foot ulcers in diabetics, increasing the risk of amputation. There is limited evidence on which to base decisions regarding the role of surgical versus conservative treatment, the optimal duration of antibiotic therapy and the most effective agent. However, it is clear that early diagnosis provides the best chance of successful conservative treatment. This opportunity is frequently missed because patients with neuropathy do not seek treatment promptly and clinicians sometimes fail to recognise the signs of infection, which may be subtle in patients with diabetes. Even in severe, limb threatening infections, patients with diabetes can have little or no systemic symptoms. Thorough clinical evaluation of the patient and their wound is the first step to improving the detection of infection and osteomyelitis. This should be followed by baseline and follow-up X-rays for wounds that are large, deep, longstanding or recurrent. Investigation with nuclear scans or magnetic resonance imaging is useful when radiological signs are inconclusive. When conservative treatment is implemented too late or fails to result in resolution, timely amputation of a toe or distal aspect of the foot may reduce morbidity and preserve function. Determining the stage at which surgery or amputation is indicated is a challenging but important clinical decision based on the location and severity of the osteomyelitis, peripheral arterial disease and preference of the patient.

Primary Intention 2007: 15 (2): 49 – 57

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The diabetic foot: considerations for pressure reduction and off-loading

Mulder G & Alfieri D

Abstract

The development of foot ulcers in diabetics has been associated with numerous intrinsic and extrinsic risk factors leading to tissue compromise and deterioration 1. The primary contributing factors most frequently referenced are repetitive trauma and neuropathy 2. Decreased sensation in the diabetic foot and decreased ability to perceive injury allow for repetitive tissue trauma to proceed to ulceration that may go unnoticed by the diabetic until extensive and visibly obvious damage has occurred. Once present, the treatment of ulceration includes addressing the wound environment with appropriate treatment modalities, controlling the underlying disease, and reducing or eliminating trauma to the tissue by off-loading the foot. The focus of this manuscript is on the means of decreasing repetitive trauma through reducing or relieving pressure at either a site of previous injury and ulceration or preventing tissue injury to the high risk foot. The reader interested in learning about risk and mechanisms of diabetic foot injury, is referred to the extensive publications on risk factors for the development of ulcers. It is important to note that off-loading has the dual function of reducing risk of tissue damage and assisting with tissue repair, after damage has occurred, by the reduction or elimination of pressure.

Primary Intention 2007: 15 (2): 58 – 65

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Where to the diabetic foot ulcer?

Foley L

Abstract

The author contends that the use of the term ‘diabetic foot ulcer’ is misleading and may lead to confusion for clinicians or an assumption that all ulcers on the foot are homogeneous in their cause and treatment.

Primary Intention 2007: 15 (2): 66 – 76

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Case study: Left foot post-amputation site treated with AQUACEL® Ag

Ireland V

Abstract

The Clinical Challenge

• To heal the post-amputation wound site by debriding devitalised tissue and promoting granulation.
• To manage any infection in the wound to prevent further tissue destruction.
• To help the patient maintain optimal blood glucose, blood pressure and blood lipid control by way of multidisciplinary input.
• To regularly review vascular status to prevent further amputation in the future.
• To regularly review accommodative orthoses and custom footwear to enhance limb function, mobility and quality of life.

Primary Intention 2007: 15 (2): 77 – 79

 

Lessons to be learnt from data collection in a high risk foot clinic

Ogrin R, Miller J & Tennant J

Abstract
This study was undertaken to describe the patients treated by the Austin Health High Risk Foot Clinic for diabetes related foot ulcers and to illustrate the evolution of data collection within this service, highlighting specific data for inclusion. Prospective collection of data for all patients with diabetes and a foot ulcer attending the High Risk Foot Clinic between January 2000 and February 2005 were reviewed retrospectively. During this period 162 patients with a foot ulcer related to diabetes were seen and referral was predominantly from the outpatient clinic of the hospital. Over 70% of patients were aged >60 years and almost two thirds were men. Over 75% were diagnosed with diabetes for <25 years. In those where location of ulceration was noted, over 50% developed in the forefoot. Peripheral neuropathy was present in just over 75% of cases. The majority of management included pressure redistribution and wound treatment. Initial data captured basic demographic information. It has become clear that new data should include information about aetiology of ulceration and healing rates, to allow the practitioners to assess the efficacy of current management practices. The process of meaningful data collection requires ongoing evaluation and change in order to keep information relevant and up to date. Our experience reveals the clear need for objectives to be set prior to collecting data, with regular assessment of data to ensure that the targeted outcomes are being captured.

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Interface pressure measurement: Appropriate interpretation of this simple laboratory technique used in the design and assessment of pressure ulcer management devices

Phillips L

Abstract
Pressure redistributing support surfaces, designed to prevent and treat pressure ulceration, are generally based on one of two modalities; constant low pressure (foam, gel, low air loss etc) or alternating pressure. Despite appearing similar, these systems work in very different ways and require different techniques for measuring interface pressure. While such measurements are a useful and increasingly accessible adjunct to the design and evaluation of pressure redistributing support surfaces, when used alone they should not be considered a surrogate for clinical outcome studies. This review discusses why interface pressure measurements are undertaken, the methodologies, the factors that affect data reliability, and whether by making use of innovative Doppler techniques, interface pressure will be superseded by contemporary and perhaps more relevant performance indices such as tissue perfusion. The clinician who can critically appraise interface pressure data will be able to make informed decisions relevant to individual clinical practice.

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Risk assessment and anatomical foam heel dressings in emergency department contribute to reduced development of pressure ulcers

Sansom W & Flynn K

Abstract
Pressure ulcers affect large numbers of patients within health services. Preventive measures need to be implemented early in a patient hospital stay and at all levels of hospital care. A successful ulcer prevention program will address contributing factors such as pressure, shear forces, friction and moisture. This paper reports the results of a ‘quality activity’ undertaken to assess the role of an anatomical heel dressing, Allevyn Heel (Smith & Nephew), as part of a preventive pressure-area management strategy in at-risk patients in a hospital emergency department. Allevyn Heel dressings were applied to one hundred patients assessed as being at moderate to high risk of developing a pressure ulcer after presenting to Box Hill Hospital emergency department in Victoria, Australia. A random audit of twenty patient histories was performed at the end of the quality activity to determine how many patients, if any, developed a pressure ulcer. All twenty patient histories randomly audited at the end of the two-week period had no documentation of evidence of a pressure ulcer. Allevyn Heel was reported to be easy to use and comfortable for patients. This quality activity was successful in bringing pressure area management to the fore of emergency care consideration. The results of this activity show that emergency departments can successfully participate in the prevention of pressure ulcers by instituting preventive measures from the time a patient first presents to hospital, thereby helping to facilitate better long-term health outcomes.

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Skin tears: A literature review

Morey P

Abstract
Skin tears are reported to be a common occurrence in the elderly 1 because of age related skin changes and associated disease processes. The depth of literature with regard to skin tears is indeed limited, yet skin tears may cause pain and suffering to the individual as well as monetary cost to the individual, hospital and community. In some cases, skin tears may become infected and require surgical intervention, or become chronic wounds and the occurrence of skin tears may present as an indicator of the quality of care in healthcare facilities. However, there is no consensus for the prevention and management of skin tears, and evidence based protocols are limited, with many of the existing protocols generated by dressing product manufacturers.

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The Angior trial: community nurse perceptions of wound best practice initiatives

Flowers C, Kapp S, Lewin G, Newall N, Carville K, Gliddon T

Abstract
A survey of nurses from two community nursing services in two Australian States was undertaken to examine the experiences of being involved in a randomised controlled trial (RCT) using the trial intervention of two antimicrobial wound dressings – cadexomer iodine and nano-crystalline silver. The experience of using multi-layer compression bandaging as well as the impact of providing all these wound products at no cost to the client was also considered. Nurses rated the performance of the antimicrobials and compression bandaging for a number of dimensions and provided additional free text comments. Nurses at one study site answered additional questions regarding the impact of the provision of funding, sourced during the trial to provide wound products at no charge to participants who usually pay for their products.

The data were analysed using chi-square tests for independence. Both products were rated by nurses as performing well. Acticoat [Smith & Nephew] was rated as performing better than Iodosorb [Smith & Nephew] for maintaining the integrity of the periwound skin, the management of wound odour and obtaining bacterial balance. However, Acticoat was not as highly regarded by nurses compared to Iodosorb for its ability to manage wound exudate. Ratings of the acceptability of compression bandaging were high overall, particularly for its capacity to manage oedema and in avoiding trauma to the wound bed during removal. The findings also suggest that cost is a substantial barrier to the provision of best practice compression bandaging among persons who ordinarily pay for these products themselves.

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Client records: insights into clients and the services they are offered by a regional leg ulcer clinic in Queensland, Australia

Madsen W, de Lacy G, Alexander S & Fry H

Abstract
Clinicians collect much data on their clients that is not for the purposes of undertaking research. However, periodic investigation of such data provides an opportunity to not only review the completeness of the documentation, but also to consider what is being undertaken within the service and what could be strengthened.

This paper outlines the examination by two independent researchers of the client records of a small, private leg ulcer clinic in a regional Queensland city. The primary purpose of this examination was to establish an overall view of the clients attending the clinic and to identify aspects of the service that would benefit from future research.

The results presented here provide a client profile that mostly fits with that outlined in the published literature. The process of examining these results highlighted the conscientiousness of clinicians in collecting and recording physical data relating to the clients and their wounds. It also raised the issue of how well psychological and social aspects of the clients were being addressed in formulating treatment regimens.

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Wound debridement: doing and teaching

Sinha SN

Abstract
Wound debridement is an important aspect of wound management – removing dead tissue reduces bacterial burden and accelerates healing. Surgical debridement is the quickest and most efficient when compared to other methods of debridement. As described in this paper, the techniques of surgical debridement can be easily taught in the skills laboratory with simulation models prepared at minimum cost

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Unusual leg ulcers: a global phenomenon

Rice J

Abstract
In this age of evidence based medicine, clinicians are encouraged to identify the ulcer type and then follow well researched clinical practice guidelines. Most lower leg ulceration is venous or mixed venous/arterial aetiology 1, 2 but there are a few ulcers that have rarer aetiologies. This article discusses some of these more unusual ulcers that the author has seen in her years as a wound consultant – skin cancers, Necrobiosis Lipoidica Diabeticorum, Pyoderma Gangrenosum, vasculitis, mycotic skin infections, Leishmaniasis, Meliodosis, Mycobacterium Ulcerans/Buruli ulcer, medication induced/related ulceration and thalassaemia related ulcers.

Identification and treatment methods will be covered to assist clinicians with early diagnosis and aid a speedy recovery. As our communities become increasingly more global, aetiologies previously seen only in the developing world are being found in developed countries and clinicians in all areas will need to have some understanding of these other causes of lower leg ulcers.

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The use of honey in wound management following ENT surgery

Robson V, Cooper RA & Ehsan ME

Abstract
Wound breakdown following major ENT surgery is a concern to patients, medical and nursing staff because it can lead to additional surgery, prolonged hospital stay and increased patient morbidity. Holistic assessment of the patient and the surgical wound are vital for effective treatment, but a universal regime is not established. Four patients with wound breakdown following ENT surgery were treated with Medihoney™ medical grade, sterile honey. Rapid healing was observed in all the wounds; patient satisfaction was reported. In conclusion, honey is a suitable choice for treating wound breakdown in ENT patients following surgery for head and neck tumours.

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Headlice: a precursor to Group A Streptococcal infection in remote Indigenous children

Cook S, Ellis I, Knight S & Lenthall S

Abstract
A child is brought to a remote area nursing clinic by his mother. He appears acutely unwell, is crying and scratching his head through matted hair – he has impetigo as a result of head lice. This case report describes the comprehensive wound management considerations to reduce the risk of rheumatic heart disease or renal disease secondary to infection with Group A beta-haemolytic streptococci (GAS).

There is an extremely high incidence of impetigo secondary to scabies and head louse infestations in Northern Territory communities. Reducing the incidence of pyogenic skin disease and the more serious sequelae for children from remote Indigenous communities requires more than a course of antibiotics and educating the primary carers. It requires community wide action including promoting the importance of effective prevention and management of skin infections in infants and children and working with other sectors to address household overcrowding, a lack of health hardware, and a lack of ready access to affordable, effective topical head louse treatment.

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