First aid treatment of burn injuries

Cuttle L & Kimble RM

Abstract
The recommendations for the first aid treatment of burn injuries have previously been based upon conflicting published studies and as a result the recommendations have been vague with respect to optimal first aid treatment modality, temperature, duration and delay after which treatment is still effective. The public have also continued to use treatments such as ice and alternative therapies, however there is little evidence to support their use. Recently there have been several studies conducted by burn researchers in Australia which have enabled the recommendations to be clarified. First aid should consist of cool running water (2-15°C), applied for 20 minutes duration, as soon as possible but for up to 3 hours after the burn injury has occurred. Ice should not be used and alternative therapies should only be used to relieve pain as an adjunct to cold water treatment. Optimal first aid treatment significantly reduces tissue damage, hastens wound re-epithelialisation and reduces scarring and should be promoted widely to the public.

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Evaluation of NovoSorb™ novel biodegradable polymer for the generation of a dermal matrix Part 1: In-vitro Studies

Greenwood JE, Li A, Dearman BL & Moore TG

Abstract
Dermal skin substitutes can be used to overcome the immediate problem of donor site shortage in the treatment of major skin loss conditions such as burn injury. In this study the biocompatibility, safety and potential of three variants of NovoSorb™ (a family of novel biodegradable polyurethanes) as dermal scaffolds were determined in-vitro. All three polymers exhibited minimal cytotoxic effects on skin cells allowing human keratinocytes, dermal fibroblasts and microvascular endothelial cells to grow normally in co-culture. Assessment of a three-dimensional polymer matrix followed. A rudimentary composite skin was created with the sequential culturing of dermal fibroblasts and keratinocytes within the matrix. Furthermore, the polymeric matrix provided a scaffold for the guided formation of a cultured microvasculature. These results prompt further investigation in-vivo to assess their safety in biological systems and to elucidate their interaction with the wound environment.

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Evaluation of NovoSorb™ novel biodegradable polymer for the generation of a dermal matrix Part 2: In-vivo Studies

Greenwood JE, Li A, Dearman BL & Moore TG

Abstract
In previous work, the biocompatibility, safety and potential of three variants of NovoSorb™ (a family of novel biodegradable polyurethanes) as dermal scaffolds were determined in-vitro. This paper documents the subsequent in-vivo work. Subcutaneous implantation of the three candidate NovoSorb™ polymers in rats demonstrated no systemic toxic effects of the materials or their degradation products. The anticipated local foreign body reaction compared favourably with commercially-available medical sutures. Assessment of a three-dimensional polymer matrix followed. When engrafted onto a surgically-created full-thickness sheep wound, the non-cellular matrix integrated, healed with an epidermis supported by a basement membrane and was capable of withstanding wound contraction. The resistance to contraction compared favourably to a commercially-available collagenbased dermal matrix (Integra™). These results suggest that the NovoSorb™ matrix could form the basis of an elegant 2-stage burn treatment strategy with an in tial non-cellular Biodegradable Temporising Matrix to stabilise the wound bed followed by the application of cultured composite skin.

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Burn wound management: a surgical perspective

Cameron AM, Ruzehaji N & Cowin AJ

Abstract
Any patient who survives a large burn injury will be left with some degree of scarring. As well as affecting the form and function of the skin, scarring can have severe psychological consequences such as post-traumatic stress disorder and depression 1. This is particularly the case for hypertrophic or keloid scars, which are common after serious burns. Despite this, the process underlying their formation is incompletely understood and limited effective options are available for their treatment. This paper reviews current understanding of the pathophysiology of the wound healing process in relation to burns and reviews the current management for burn wounds.

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A review on porcine burn and scar models and their relevance to humans

Wang X & Kimble RM

Abstract
Burns are common injuries worldwide and often heal with significant scarring when injury extends into the deep dermal layer. It can lead to hypertrophic scarring, scar contracture, impaired skin function, and disfigurement. Due to the heterogeneous nature of burns and subjective approaches in diagnosis and in outcome, many clinical studies cannot be compared and consensus can be hard to reach. Despite great effort, the mechanism of hypertrophic scarring is still poorly understood, partly due to the lack of animal models with scars similar to human hypertrophic scars. The porcine burn model is widely accepted as the best animal model. This article reviews porcine burn models from the literature and from our laboratory. It details the creation of burns from various methods, the determination of burn depth, the assessment of re-epithelialisation, and the evaluation of the subjective measurements of wound infection and clinical scar outcome. It describes that in our porcine model, burn of 40−50cm² with a pale appearance is deep dermal partial thickness, takes more than 3 weeks to completely re-epithelialise and heals with significant scarring that is similar to a human hypertrophic scar. It further draws attention to the relative quantitative approaches of most assessments conducted on our porcine burns/scars and verifies the subjective judgement of wound infection and clinical scar outcome. The information here not only provides essential elements for conducting porcine burn trials, but more importantly offers valuable knowledge for better burn care clinically and for improved clinical trials.

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Experience with Biobrane™; uses and caveats for success

Greenwood JE, Clausen J & Kavanagh S

Abstract
Objective: To present some of our experience with Biobrane™ (a total of 703 patients in 7 years) in a range of uses in burn practice and to illustrate the caveats which we have found applicable in maintaining our success with this versatile material.
Methods: Retrospective analysis of theatre records, medical notes and photography database to categorise our experience with Biobrane™. Thorough assessment of our surgical and nursing protocols (both literature and experience influenced) to identify caveats for successful use.
Results: Pivotal steps are revealed in wound selection, wound preparation, material application, dressing and subsequent nursing care which have led to overwhelming success in definitive management of superficial partial to mid-dermal burns (ensuring pain relief, allowing early mobilisation, tolerance of dressing changes and therapy, and earlier hospital discharge). Its many uses in a broad range of common burn situations are demonstrated and tips provided to achieve best outcome.
Conclusions: Biobrane™ is not a panacea but it is extremely versatile. The different potential uses have learning curves and suggestions are provided to flatten these.

Developing Clinical Practice Guidelines for the Prevention and Management of Venous Leg Ulcers

Barker J & Weller C

An inaugural Venous Leg Ulcer Consensus meeting was held in Perth, Western Australia, on 6 September 2005. It was attended by a large number of Australia’s wound care leaders who endorsed the need for, and support of, a proposal to develop Clinical Practice Guidelines for the Prevention and Management of Venous Leg Ulcers under the auspices of the Australian Wound Management Association (AWMA). The guidelines will not duplicate existing resources, but develop an innovative Australian framework for care. The key aim in developing the proposed guidelines is to improve health outcomes for the Australian community by preventing venous legs ulcers and their recurrence and provide an evidence-based framework for their management.

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Diagnosis and management of venous leg ulcers: a nurse's role?

Templeton S & Telford K

Abstract
Leg ulcers are a common, debilitating and chronic condition, more prevalent in older people. As with most chronic illnesses and conditions, leg ulcers have a significant impact on the health system and the individual. As most leg ulcers are managed in the community, it is imperative that community-based practitioners have specific clinical expertise, skill and professional judgement to inform decisions about the ulcer aetiology, appropriate management and optimal client outcomes. The Royal District Nursing Service (RDNS) SA Inc. undertook an integrative literature review to examine the role of the district nurse (DN) and general practitioner (GP) in management of leg ulcers. The review concluded that, whilst there is some uncertainty regarding roles, the competent district nurse can independently assess and manage venous leg ulcers to achieve optimal outcomes for clients and support the already overburdened healthcare system.

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The Leg Ulcer Prevention Program: effectiveness of a multimedia client education package for people with venous leg ulcers

Kapp S, Miller C, Sayers V & Donohue L

Abstract
The prolonged and recurrent nature of venous leg ulceration can be a source of great frustration to client and clinicians alike. Venous ulcers may have a significant effect on a person’s quality of life and treatment of this condition generates a burden on healthcare systems. It is a challenge to assist people with these ulcers to adhere to treatment and to generate and maintain positive lifestyle changes so as to reduce the risk of delayed healing, ulcer recurrence and poor health.

The Leg Ulcer Prevention Program (LUPP) was designed around key elements which influence ulcer healing, promote chronic disease management, optimise recurrence prevention and, more broadly, are conducive to better health and wellbeing. The program sought to empower clients to take ownership of their chronic disease and participate in self-management activities to augment their formal care.

LUPP led to statistically significant improvements in client knowledge for ulcer aetiology, compression bandaging treatment, activity and exercise, nutrition, skin care and the need for compression stockings following healing. Statistically significant improvements in client behaviours were demonstrated in the areas of activity and exercise, skin care and compression bandaging.

The results of this research are of interest to clinicians and organisations who deliver care to people with venous leg ulcers or indeed any chronic disease. LUPP is an evidence-based resource for providing effective client education to improve client knowledge and behaviours and, in turn, promote better health and wellbeing.

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The Leg Ulcer Prevention Program: nurse perspectives on a multimedia client education package for people with venous leg ulcers

Kapp S, Miller C & Donohue L

Abstract
The Leg Ulcer Prevention Program (LUPP) is an evidence-based, multimedia client education package for people receiving care for a venous leg ulcer. The program is delivered in the home via the nurse’s tablet personal computer. LUPP aims to assist people to understand and adopt clinically effective leg ulcer treatment and better manage chronic disease risk factors. The program engages clients in the ownership of their ulcer and self-care activities, promoting wound healing and recurrence prevention.

To complement the evaluation of client outcomes when participating in LUPP, the nurse perspective was investigated. A nurse survey and focus group was undertaken to describe and explore the nurse experience and satisfaction with LUPP. Satisfaction with LUPP was found to be high. LUPP demonstrated success in improving client education practices and nurses facilitated positive health outcomes for clients. LUPP was perceived by nurses as a valuable tool to engage clients and themselves in the education of people with venous leg ulcers.

The LUPP: nurse perspectives on a multimedia client education package for people with venous leg ulcers.

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Sub-bandage pressure difference of tubular form and short-stretch compression bandages: in-vivo randomised controlled trial

Weller CD, Jolley D & McNeil J

Abstract
This research report outlines the findings of a sub-bandage pressure randomised controlled trial (RCT). The aim of the subbandage study was to estimate the difference between mean interface sub-bandage pressures of two multi-layer compression bandage systems during supine position, standing, exercise and recovery. This open-label, prospective, single factor crossover, randomised within person RCT was designed to measure the sub-bandage pressure difference in two compression systems in vivo to inform a current pilot clinical RCT that is comparing the effectiveness of a three-layer straight tubular (elastic) bandaging system with a short-stretch (inelastic) compression bandaging system in the management of people with venous ulceration (3VSS2008). In the sub-bandage in-vivo study the inelastic and elastic compression bandages were randomised to opposite limbs of 42 healthy adult volunteers. Sub-bandage interface pressures for both bandages were compared within person. Interface sub-bandage pressures varied between different activities but the mean difference in interface pressures between inelastic and elastic bandages was consistently at least 13mmHg. Stiffness was 7.3mmHg higher in the inelastic group (95% CI: 5.1 to 9.5). The estimated difference in amplitude of sub-bandage pressure between the bandages during exercise was 15.5mmHg (95% CI 12.2 to 18.9). We found in-vivo interface sub-bandage pressures varied with the type of bandage and activity phase. These baseline results will be useful to inform future compression bandage studies that plan to measure venous ulcer healing rates.

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Guest editorial: The Pan-Pacific Pressure Ulcer Forum and the AWMA Venous Leg Ulcer Forum

Carville K & Barker J

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Pain and stress as contributors to delayed wound healing

Upton D & Solowiej K

Abstract
It is possible that patients who suffer from acute and chronic wounds can interpret wound pain as a stressor. It is known from previous research that stress can delay wound healing; however, little is known about the influence of pain in this relationship.
This review explores the literature surrounding the relationship between stress, pain and delayed healing of acute and chronic wounds. Many studies have demonstrated the impact of stress on the healing of biopsy, surgical and chronic wounds and there is a range of medical, psychological and social interventions that may reduce both pain and stress and consequently speed up wound healing.

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Client perceptions of two types of antimicrobial dressings and compression bandaging

Miller C, Karimi L, Kapp S, Newall N, Lewin G, Carville K & Santamaria N

Abstract
Client perceptions of wound treatments represent an important but often overlooked aspect of research which principally focuses on the clinical effectiveness of treatments. In a large multi-site randomised controlled trial (RCT) comparing a nanocrystalline silver dressing and cadexomer iodine dressing, which were used in conjunction with multi-layer compression bandaging, client perceptions about the acceptability of these antimicrobial products and compression bandaging were evaluated. Data from 207 participants were analysed, representing a 74% response rate of the 281 RCT recruits. Both antimicrobial dressings were rated highly, with the majority of respondents willing to use their randomised treatment in the future if the need should arise. There was no significant difference in ratings of the acceptability of the nanocrystalline silver dressing and cadexomer iodine dressing. The acceptability of compression bandaging was high as was willingness to use compression bandaging again. Though adherence to compression bandaging was significantly associated with higher satisfaction ratings, acceptability of the treatment remained high, even for those clients not adhering to compression bandaging regimes. This result challenges the perception that a lack of client willingness to use compression bandaging is a principal driver of non-adherence to this treatment. Clearly other factors influenced adherence and these require further investigation if the benefits of this best practice treatment are to be realised.

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Managing venous leg ulcers in the community: personal financial cost to sufferers

Smith E & McGuiness W

Abstract
Venous leg ulcers are chronic wounds which often persist for many years, despite active treatment, and occur predominantly in people over the age of 60. In recent times, the care of these wounds has shifted from the acute care sector into the community, where wound care services and products aren’t fully subsidised by the government. It is logical to assume that these costs are passed onto the client; however, within the Australian context there is currently no research concerning the magnitude of such costs, although anecdotal evidence suggests they can be substantial.
The purpose of this pilot study was to describe the average cost of managing a venous leg ulcer in the community. The study forms a pilot for future larger-scale studies within the Australian setting. A descriptive-correlational design was used to identify costs incurred by a convenience sample of 15 venous leg ulcer sufferers over a two-month period.
It was found that, on average, participants spent A$114 a month managing their ulcer. Total management cost was found to be related to the size of the wound and the amount of exudate produced, while residential location influenced the type of expenses incurred.
The results indicate that expenses incurred by sufferers in the process of managing their venous leg ulcer are concerning, especially in light of the financial situation of many elderly people. Larger, more rigorous studies are recommended in order to further investigate these issues.

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Working in partnership: holistic care for a diabetic patient with a heel wound

Manton H & Boogaerts M

Abstract
This case study describes the care and management of an Indigenous patient who sustained a pressure injury during surgery. After discharge from hospital community nurses worked in partnership with the patient and his family and, despite a history of diabetes and multiple comorbidities, wound healing was achieved. It demonstrates that a collaborative holistic approach, where health professionals, the patient and family work together, has the potential to achieve good health outcomes.

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Honey: the bees' knees for diabetic foot ulcers?

Freeman A, May K & Wraight P

Abstract
Aim: To trial medical-grade honey wound dressings on dry, clinically infected diabetic foot ulcers in an acute high-risk foot service (HRFS).
Method: Five clinicians trialled medical-grade honey wound gel and medical-grade honey alginate on appropriate diabetic foot wounds and completed a simple evaluation form for each application including patient tolerability.
Results: Clinician ease of use, Clinician overall satisfaction and Patient comfort was rated as “high” in the majority of applications (66–93%).
Conclusion: Honey wound dressings did not lead to deterioration in diabetic foot wounds and were rated highly by clinicians and patients with regards to ease of use, overall outcome and tolerability

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Telemedicine for wound care: Current practice and future potential

Gray LC, Armfield NR & Smith AC

Summary
Telemedicine offers the potential to improve access to specialist care for people in rural communities, and for those with chronic illness, disability and limited support of carers, including in metropolitan settings. Individuals with chronic ulcers and wounds will often meet these criteria. The declining cost of equipment and improving access to the internet will add to the attractiveness of the telemedicine option.
In this paper, the current status of telemedicine is reviewed, and the application of telemedicine techniques for wound care assessment and management explored. The store-andforward approach, where images are recorded remotely and transmitted to a wound specialist for diagnostic and management review, supported by a protocol-driven approach, appears suited to chronic wound care. The available evidence supporting diagnostic accuracy, patient acceptance, clinical outcomes and cost-effectiveness suggests this strategy to have considerable merit.
Current investment in the national broadband network, and policy and funding developments in healthcare in Australia, may open the door to more extensive use of telemedicine in wound care.

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Does the use of store-and-forward telehealth systems improve outcomes for clinicians managing diabetic foot ulcers? A pilot study

Lazzarini PA, Clark D, Mann RD, Perry VL, Thomas CJ & Kuys SS

Abstract

Diabetic foot ulcers are one of the most hospitalised diabetes complications and contribute to many leg amputations. Trained diabetic foot teams and specialists managing diabetic foot ulcers have demonstrated reductions in amputations and hospitalisation by up to 90%. Few such teams exist in Australia. Thus, access is limited for all geographical populations and may somewhat explain the high rates of hospitalisation.

Aim: This pilot study aims to analyse if local clinicians managing diabetic foot complications report improved access to diabetic foot specialists and outcomes with the introduction of a telehealth store-and-forward system.

Method: A store-and-forward telehealth system was implemented in six different Queensland locations between August 2009 and February 2010. Sites were offered ad hoc and/or fortnightly telehealth access to a diabetic foot speciality service. A survey was sent six months following commencement of the trial to the 14 eligible clinicians involved in the trial to gauge clinical perception of the telehealth system.

Results: Eight participants returned the surveys. The majority of responding clinicians reported that the telehealth system was easy to use (100%), improved their access to diabetic foot speciality services (75%), improved upskilling of local diabetes service staff (100%), and improved patient outcomes (100%).

Conclusion: This pilot study suggests that clinicians found the use of a telehealth store-and-forward system very useful in improving access to speciality services, clinical skills and patient outcomes. This study supports the recommendation that telehealth systems should be made available for diabetic foot ulcer management.

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The development of an electronic wound management system for Western Australia

Santamaria N, Glance DG, Prentice J & Fielder K

Abstract
The MMEx Wounds Management System (MMEx WMS) has been developed as a collaboration between the WoundsWest Advisory Service (WWAS) of the Department of Health WA (DoHWA) and the University of Western Australian Centre for Software Practice (UWA CSP). The system was designed as a comprehensive wound imaging and clinical management system that would support collaborative management of a patient’s wounds. Patients with chronic wounds are currently often treated by a number of clinicians at a number of sites during the course of the management of one wound; however, the transfer of clinical information between clinicians is compromised and rendered inefficient due to a multiplicity of factors including: paper-based systems, variation in wound assessment and time lags in sharing essential information between clinicians. The current problems are compounded in rural and remote locations in a state as large as Western Australia (WA). The design of the software was based on the extensive experience of the WoundsWest Service team together with research evidence-based best practice in the area of wounds management and collaborative healthcare. This design was coupled with an agile software development process that emphasises end-user participation, feedback and rapid, frequent iterations of software development. The entire first phase of the system was brought to a pilot implementation within a six-month period with high user acceptance. Ultimately, the MMEx WMS will improve wound management clinical outcomes and reduce costs associated with treatment and patient transfers due to the timely and accurate availability of wound treatment progress data and the increased availability of expert remote wound consultation.

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WoundsWest Advisory Service pilot: An innovative delivery of wound management

Edmondson M, Prentice J, Fielder K & Mulligan S

Abstract
The WoundsWest Advisory Service (WWAS) is a telephone-based service, utilising an electronic documentation system to provide evidence-based advice to Western Australian (WA) health professionals on wound prevention and management. A pilot of 10 months' duration was conducted in selected sites in remote and rural WA to test the application of a telephone-based advisory service utilising an electronic documentation system. A total of 61 patient referrals were received with chronic wounds being the most frequently referred wounds. Patient outcomes included healing in 71.5% of patients who continued with the WWAS input until wound healing was achieved. Staff and patient feedback on the service was positive, with benefits to both patients and staff identified.

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From the laboratory to the leg: Patients’ and nurses’ perceptions of product application using three different dressing formats

Hammond CE, Than M & Walker JW

Abstract
Leg ulcers (for example, venous, arterial or mixed aetiology ulcers) produce a significant burden for the patient, their family and health services because of slow healing and chronic recurrence requiring intensive wound products and nursing time. The mainstay of treatment for venous ulcers is compression therapy to address the underlying cause of chronic venous hypertension. Many wound products have been trialled to improve the efficacy of leg ulcer healing. A key part of product development is evaluation of product acceptability for patients and nurses. This study examined the user acceptability of three new types of keratin wound dressings during development. A convenience sample of 23 patients, with leg ulcers of differing aetiology, were recruited from a nurse-led, community-based Wound Management Clinic in New Zealand using inclusion/exclusion criteria. Patients and nurses were asked to complete a structured questionnaire at each dressing change and provide comments on each product. The results showed that both patients and nurses preferred all of the dressings over previous products. For the gel and the foam, the preference was virtually unanimous for both nurses and patients. For the matrix, the preference was still strong (82% for patients and 64% for nurses) and for those nurses who did not prefer the matrix, the main reasons were that it was more difficult and time-consuming to apply. Comments on usability have enabled the company to improve the matrix’s structure to address these issues. This study has highlighted the importance of patients and nurses being involved in product testing to ensure the product meets criteria of comfort, duration, timeliness, ease of use and overall preferability.

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