A survey of clinicians’ perceptions of, and product choices for, the infected wound

Dunk AM & Taylor J

Abstract
In today’s health system, nursing has broadened its considerable expertise, resulting in an increase in the number and variety of specialities within clinical practice. Two essential practices that have been affected by this need for increased specialist knowledge are wound management and infection prevention and control. In many facilities both speciality practices are managed by nurses and midwives who hold speciality qualifications and are considered experts in their practice areas. However, if this level of expertise is not available, it is the responsibility of the ward clinicians to assess and manage wounds and prevent and control infections.

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Reducing pressure ulcer prevalence in residential aged care: results from phase II of the PRIME trial

Santamaria N, Carville K, Prentice J, Ellis I, Ellis T, Lewin G, Newall N, Haslehurst P & Bremner A

Abstract
Pressure ulcers are a significant iatrogenic cause of morbidity and mortality in the aged care population, with prevalence reported to be as high as 43% in some aged care facilities. The PRIME trial was a 15-month pre- and post-intervention study designed to investigate the effectiveness of an integrated pressure ulcer management system consisting of pressure ulcer risk assessment tools, Australian Wound Management Association (AWMA) guidelines, digital imaging and clinical education in reducing pressure ulcer prevalence in residential aged care facilities. A total of 1228 residents from 23 residential aged care facilities were enrolled in this Commonwealth-funded study.

The findings suggest that the PRIME intervention significantly reduced pressure ulcer prevalence risk by 52% (p<0.001) and highlighted the association between cachexia, Braden sub-scales for activity, nutrition, friction/shear and pressure ulcer risk. The study also demonstrated that following the PRIME intervention, the use of appropriate pressure ulcer risk reducing equipment was significantly increased. Overall, the results suggest that an integrated approach combining the elements of the PRIME intervention is effective in reducing pressure ulcer prevalence in the frail elderly population in residential aged care facilities.

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Nurses’ experiences of participating in a randomised controlled trial (RCT) in the community

Newall N, Miller C, Lewin G, Kapp S, Gliddon T, Carville K & Santamaria N

Abstract
There is a dearth of experience and sharing of experiences by community nursing agencies in the conduct of clinical trials in the community. The objective of this research was to explore and identify the challenges and opportunities that arose when two community nursing services implemented a randomised controlled trial (RCT) in the community. An exploratory study was undertaken with the nurses responsible for implementing the trial at the operational level. Three focus group discussions were convened with the nurses. Key themes from the data were extracted and summarised. The eight key themes emerging from the analysis of the focus group data were – being part of a trial, expectations versus the real RCT experience, benefits associated with implementing the trial, responses to the trial of other nurses not directly involved in the RCT, clients’ responses to the trial experience, challenges, strategies to refine research processes and further involvement in research.

This study offers insights into the experiences of clinicians and researchers involved in implementing a clinical trial in community settings. These include what worked well, what the pitfalls were and how they might have been avoided, and strategies for organisations wishing to undertake a clinical trial or to refine their existing research processes. Additionally, some lessons for everyday practice were identified as requiring follow-up as impacting not only on the conduct of a RCT but clinical care at all times.

This paper provides guidance as to how to actively involve nurses in research not just to gather data and find study recruits, but as significant contributors to decisions about research design and implementation so that they are better equipped to inform and lead future research endeavours.

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Maggots down under

Geary MJ, Smith A & Russell RC

Abstract
Maggot debridement therapy (MDT) is an old form of wound care treatment that was used prior to the introduction of antibiotics. Maggots nurse a wound by the processes of debridement, disinfection, cleansing and healing. In the modern healthcare arena, new innovative methods that are being developed overseas for MDT are proving to be more acceptable to clinicians and patients – many wound care workers that have used MDT for the treatment of some chronic wounds in Australia have said they would recommend this therapy to their colleagues.

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Red frames: an introduction to pressure education and memory aids

Stirling M

Abstract
The prevention and management of pressure injuries (ulcers) is a major concern to those involved in healthcare. Improving knowledge about pressure injuries, including the correct use of a pressure risk tool, is one way to improve overall patient care and decrease the number of hospital-acquired injuries. A staff survey identified gaps in nursing staff knowledge and so an education programme incorporating a newly devised mnemonic ‘RED FRAMES‘ was introduced. RED FRAMES reminds the clinician of various risk factors associated with pressure injury and prompts appropriate action.

Education was designed as small informal sessions held on the wards which allowed for active interaction. Sessions were reinforced by an education board which was also accessible to patients and their carers. A lanyard was produced for staff which included RED FRAMES and a description of the different pressure ulcer stages. After the introduction of these initiatives a pressure ulcer point prevalence survey conducted by the hospital showed that the number of hospital-acquired pressure ulcers had dramatically decreased. These findings may be due to factors other than the intervention and so further research is needed, including the use of RED FRAMES at other health facilities. This article describes the events

 

Epidermolysis bullosa (EB) – diagnosis and therapy

McMillan JR, Long HA, Akiyama M, Shimizu H & Kimble RM

Abstract
The hemidesmosome (HD)-anchoring filament complex comprises a multiprotein complex that aids the attachment of epidermal keratinocytes to the underlying basal lamina and dermis. The importance of the HD and its components is highlighted by genetic defects that cause congenital blistering skin diseases that are categorised under the epidermolysis bullosa (EB) group of disorders. EB disorders can be subcategorised into three main subtypes by the level of epidermal separation – within the basal keratinocyte (EB simplex – EBS), between the keratinocyte and underlying basal lamina (junctional EB – JEB), and separation beneath the basal lamina (dystrophic EB – DEB). HD-anchoring filament-related components – including keratins 5 and 14, plectin, a6ß4 integrin, collagen XVII, laminin 332 and collagen VII – have been demonstrated to harbour defects leading to EB disease. We summarise here the current understanding of the biological function of these HD-components and their involvement in EB in light of their functions in keratinocyte adhesion and also describe putative future therapeutic avenues that hold promise to alleviate the morbidity suffered by EB patients over the coming decades.

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Management of epidermolysis bullosa (EB) skin lesions with a non-adherent dressing, Urgotul®

Stevens LJ

Abstract
Epidermolysis bullosa (EB) is defined as a rare group of inherited skin disorders involving blistering of the skin and sometimes mucous membranes. It is characterised by recurrent, chronic and painful skin lesions. The local management of lesions attempts to reduce the frequency of skin breakdown, reduce the size of the chronic wounds and minimalise pain. This requires a nonadhesive and non-adherent dressing to prevent pain and bleeding on removal.

The aim of this small case study was to assess the efficacy of the primary dressing Urgotul® in two patients suffering from non-Herlitz EB. The treatment was initiated on a primary visit by the clinical nurse consultant, and was then monitored for a maximum of 8 weeks. Assessment was based on the level of pain associated with the dressing change, ease of applying and removing the dressing, bleeding, trauma, adherence of the dressing to the wound and the effect on wound healing. The findings show that Urgotul® is an effective primary dressing for the treatment of EB wounds, demonstrating pain free removal and improved wound healing.

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Raising the roof on epidermolysis bullosa (EB): a focus on new therapies

Kopecki Z, Murrell DF & Cowin AJ

Abstract
Epidermolysis bullosa (EB) is a complex group of genetic disorders producing various degrees of recurrent skin blistering and epidermal detachment from the basement membrane. Patients with this disease experience the loss of intact epidermis, disruptions of basement membrane adhesion units and altered cellular adhesion, migration and integrin expression. Wound healing in patients suffering from EB remains a major challenge to their survival because of infection risk and fluid loss.

There are four main types of EB each characterised by different levels of blistering formation at the dermal-epidermal junction (DEJ) (basal layer, lamina lucida, sub-lamina densa and various respectively) and different clinical phenotypes. Advances in the understanding of the pathogenesis of EB in the last 15 years have led to the identification of several candidate genes and proteins; however, present management of these diseases is still supportive and therapy symptomatic. Different avenues of therapy options being investigated, some of which are in clinical trials, include bone marrow transplant, gene therapy, cell-based therapy and protein-based therapy. Further research focused on the development of novel therapies may lead to improved quality of life for patients suffering from EB.

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Comparison of the two leading approaches to attending wound care dressings

Gillespie BM & Fenwick C

Abstract
Many nurses practise wound dressing based upon knowledge of sequential procedural steps rather than understanding the principles underpinning the most effective approaches to wound dressing. Currently two leading dressing approaches, aseptic (clean hand/dirty hand) technique and wound field, are being taught to undergraduate nursing students. Collectively and comparatively, both techniques have evoked some controversy regarding the most appropriate and effective technique to apply. This paper clarifies the differences between these approaches and suggests that both techniques will have similar outcomes providing the principles of minimising or eliminating risks associated with contamination are practised.

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Nutrition therapy in the prevention and treatment of pressure ulcers

Crowe T & Brockbank C

Abstract
Pressure ulcers are serious problems within hospital and aged care settings and are associated with adverse health outcomes and high treatment costs. Because of a high incidence of pressure ulcers in the health system, attention is now being directed to not just preventing, but also more effectively treating them. Nutrition plays a fundamental part in wound healing, with malnutrition, dehydration and recent weight loss identified as independent risk factors for the development of pressure ulcers. While the optimal nutrient intake to promote wound healing is unknown, increased needs for energy, protein, zinc and vitamins A, C and E have been documented. There is reasonable evidence to show that nutritional support, mostly by high-protein oral nutritional supplements, is effective in significantly reducing the incidence of pressure ulcers in at-risk patients by 25%. Intervention studies using high-protein or specialised disease-specific nutritional supplements support a trend to increased healing of established pressure ulcers. Such specialised supplements are typically based on defined amounts of arginine, vitamin C and zinc. Mechanisms by which nutritional support can aid in pressure ulcer prevention and healing are likely related to addressing macro- and/or micro-nutrient deficiencies arising from either poor oral intake or increased nutrient requirements related to the wound healing process. With much more research still to be done in this area, nutrition support appears an efficacious and costeffective adjunct to current medical and nursing approaches in the prevention and treatment of pressure ulcers.

WoundsWest education: taking the evidence on wounds to the clinician

Carville K, Keaton J, Rayner R, Prentice JL L & Santamaria N N

Abstract
The WoundsWest (WW) education programme is an innovative and ambitious subproject of the WW project in Western Australia (WA). It involves the interdisciplinary development of online wound management education modules, which are designed to assist health professionals and health services to reduce preventable wounds and adverse wound management outcomes. The aims, objectives and processes that underpin this development are outlined in this paper, which is illustrated with examples from the WW online education programme.

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WoundsWest: Delivering comprehensive strategies to improve wound management in Western Australian Health Services

Prentice JL, Strachan V, Carville K, Santamaria N N, Elmes R & Della P

Abstract
It is well known that prudent, supported, early discharge of patients back to their home environment facilitates recuperation, rehabilitation or palliation. Patients with wounds are no exception to this.

The provision of effective ambulatory wound care is gaining increasing attention and importance worldwide as health services seek to provide efficient and effective services to growing numbers of patients with wounds, often under burgeoning fiscal constraints. The lack of, or poor utilisation of, evidence-based clinical practice guidelines and protocols for wound care and inequities in terms of access to resources, whether wound dressings or education, are causal factors leading to inconsistencies in the clinical management of wounds that contribute to less than optimal outcomes for patients with wounds.

Health services and health managers' ability to strategically plan and rationalise wound management services is often further hindered by a lack of data on the epidemiology and potential burden of acute or chronic wounds within and on local or state health services. Furthermore, where there is an absence of clinical governance in relation to wounds, these wounds are not subject to the same scrutiny as other medical conditions and, therefore, opportunities to improve service delivery in relation to wound management are missed.

This article describes a tripartite and multidimensional approach to providing West Australian public health services and employees with a sustainable system for the prediction, prevention and management of wounds. WoundsWest (WW), a partnership between WA Department of Health (WA Health), Silver Chain Nursing Association (Silver Chain) and Curtin University of Technology (Curtin University) is a novel, 6-year project and a first for Australia. WW aims to facilitate clinical governance of wounds within health services, enhance clinicians’ knowledge, skill and competence in wound management, improve clinical outcomes for patients with wounds and increase health services' ability to decrease the burden of wounds in Western Australian public hospitals.

In order to achieve these aims, WW established a number of subprojects to ascertain the prevalence of wounds within WA public hospitals, improve access to educational resources for wounds, improve access to expertise in wound management and provide a repository for wound-related data for the purpose of ongoing research.

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Pressure injury prevalence in a private health service: risks and recommendations

Gardner A A, M Millar L L, L Legg S, Gomez Y, M McGillion T, M McGillion T & M Mulcahy A

Summary
A pressure injury point prevalence was conducted by a private healthcare service (PHS) to determine the prevalence of pressure injuries in inpatients and to provide statistics for use in future comparison studies. The survey was conducted as part of the quality improvement programme of the PHS and the survey instrument was a modified version of a widely used existing tool. On the day of the survey, data collectors, working in pairs, performed skin inspections and completed the survey. Data were then collated and analysed. The overall pressure injury prevalence was 28.2% but with the exclusion of stage one injuries, decreased to 9.9%. Multivariate analysis revealed that the main risk factors for pressure injury development were the inability to reposition independently, older age and having a diagnosis of cancer. The major recommendations for practice change included the provision of pressure relieving devices to all patients unable to reposition independently, alteration of the Braden Scale risk score used on admission to identify older patients at risk from 16 to 18 in accordance with published literature and provision of further education to nurses about use of the Braden Scale and of pressure relieving devices. This study has also highlighted the need for further investigation into the reasons for patient non-participation in research and the direct and indirect relationships between surgery and acquisition of pressure injuries.

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The Dressing Bank™ – a system for providing access, equity and cost-effectiveness for advanced wound dressings in the acute care setting

McInnes WA

Abstract
At the Queen Elizabeth Hospital in South Australia, the cost of wound care products and the duplication of supplies in individual clinical areas was a growing problem. New technologies, the introduction of new products on the market as well as trends in clinical areas were contributing to spiralling costs. Other issues included inequity of resources, waste and a diverse range of advanced wound dressings that were often used inappropriately.

The solution, a sub-store using a banking system called “The Dressing Bank™”, that houses advanced wound care products. This system has been in place for 4 years, allowing equity in access, cost-effectiveness, quality control and ongoing evaluation of wound products to achieve a coordinated approach across the organisation.

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Chronic wound pain: a literature review

Duncan G & Brooks M

Abstract
Wound-related pain is an important consideration for patients, yet is an aspect of wound management that often seems to be given relatively little attention by clinicians. Wound-related pain may be discussed openly with patients, yet it seldom is well documented. To understand this better a comprehensive literature review was undertaken that examined how well wound-related pain is assessed, documented and researched.

Four key themes were identified in this process 1; assessment and management of pain related to chronic wounds 2, clinicians’ and patients’ perspectives relating to acute and chronic wounds 3, procedural pain associated with chronic wounds and 4 the effect of pain management on patients’ quality of life (QOL).

Leg ulcers: atypical presentations and associated comorbidities

Rayner R, Carville K, Keaton J, Prentice J & Santamaria N

Abstract
WoundsWest is an innovative Western Australian (WA) project under Ambulatory Care and Chronic Disease Management Reform undertaken in partnership with the Western Australian Department of Health, Curtin University of Technology and Silver Chain Nursing Association.

WoundsWest’s Online Wound Management Education Program is a core component of WoundsWest. It involves the interdisciplinary development of an anticipated 16 online wound management education modules, which are designed to assist health professionals and health services to deliver best practice in wound management and reduce preventable wounds and adverse wound management outcomes. The development of these modules involves an extensive search of the literature to ascertain the evidence for best practice. In preparation for the development of the forthcoming online Leg Ulcer Module a considerable number of atypical leg ulcer presentations and associated comorbidities were identified. This paper outlines some of these presentations and comorbidities and reminds health professionals of the need for further diagnostic investigations when leg ulcer signs and symptoms are atypical, or the ulcer fails to heal in an orderly and timely manner.

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From ‘minor ulcer’ to complex wound: management of a patient with a neuro-ischaemic foot ulcer complicated by verrucous hyperplasia

Erikson K

Abstract

Diabetic foot ulceration can present a major challenge to healthcare professionals. Even very small lesions have the potential for a disastrous outcome; particularly those overlying joints. This case study discusses the management of a 60-year-old male Maori with type 2 diabetes and a neuro-ischaemic foot ulcer, who underwent a 1st ray and 2nd toe amputation followed by a split skin graft. Friction to the graft site led to the development of verrucous hyperplasia; a hyperkeratotic, papillomatous verrucous lesion. Despite excision and regrafting, the lesion recurred. Structural changes to the foot caused a new foot ulcer to develop. In this paper the impact of the complications of diabetes on the patient’s feet and his mobility as well as the psychosocial factors related to his foot ulceration and foot deformity will be discussed.

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A pilot study evaluating topical negative pressure using V1STA® technology

Panicker VN

Abstract

A number of recent research articles have shown that negative pressure wound therapy (NPWT) is effective in healing a wide range of complex wounds. This form of therapy helps expedite wound healing mainly by the removal of wound exudate, bacterial reduction as well as encouraging wound contraction. A pilot study was conducted to evaluate the clinical efficacy and cost-effectiveness of NPWT using the V1STA® wound vacuum system (Smith & Nephew) across three surgical areas. This technology uses a special gauze-based wound interface instead of the medical grade sponge. This evaluation, which consisted of 20 patients with chronic or surgical wounds, included objective wound measurement at each dressing change to track wound healing rates. The complexity of wounds included compromised graft site (1), diabetic foot ulcers (8), dehisced surgical wounds (5), orthopaedic wounds (5) and necrotising fasciitis (1). This study has demonstrated that positive outcomes were obtained at cost savings of almost 30%, compared with the alternative NPWT. Furthermore, this mode of delivery not only was a lot easier to apply but was relatively pain-free to remove the old dressings.

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Is it time for a new descriptor 'pressure injury': a bibliometric analysis

Dunk AM & Arbon P

Abstract

Prediction, prevention and management of pressure injuries are areas that require specific attention from nurses in clinical practice. Moreover, increased awareness that these injuries are preventable is an important precursor to changing nurses’ practice and reducing the incidence of pressure injuries. The language and terminology that we use in daily practice can impact on the understanding and approach that nurses take to care delivery. In this area of wound care practice commonly used terminology that emphasises the nature of the wound, rather than its causation, may be a significant factor that limits the level of concern about prevention and responsibility taken by clinicians. This paper argues that the term ‘pressure injury’ promotes a better understanding of the fact that these wounds are preventable and may refocus the attention of nurses providing care to at-risk patients.

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Assessment of wound healing: validity, reliability and sensitivity of available instruments

Pillen H, Miller M, Thomas J, Puckridge P, Sandison S & Spark JI

Abstract
Objectives: If wound assessment instruments are to be used in the periodic assessment of wound healing, they must prove to be valid, reliable and sensitive measures of wound healing. Thus, this systematic literature review aims to examine available wound healing instruments in terms of these parameters.

Method: Only instruments able to measure changes in wound healing were included in this review and not those used to predict healing, classify wounds, or measure wound characteristics per se. All wound types were suitable for inclusion.

Results: A total of 20 articles were found, evaluating the validity of 10 instruments used to monitor wound healing. No instrument satisfied all criteria required for instrument validation. Instruments used to assess pressure ulcers, notably the Pressure Ulcer Scale for Healing (PUSH) and Pressure Sore Status Tool (PSST), had been validated to the greatest extent, whilst those describing healing in leg ulcers and general or surgical wounds tended to lack comprehensive and quality evaluation.

Conclusion: This review identified substantial gaps in the literature with regard to validation of existing wound healing instruments. Future studies are needed to comprehensively validate these instruments.

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