NZWCS Scholarships 2010

2010 Scholarship Recipient Report

Christine Cumming Local Conference Attendance

The New Zealand Wound Care Society Conference Dunedin, 2-4 November 2011

The author would like to congratulate the conference organising committee and the NZWCS for such a well facilitated, informative conference and thank them for the opportunity to attend via a scholarship. Please note that this report is based on the author’s conference notes supported by the website presentations. Recommendations by speakers and reported here should be used in conjunction with

local policies and procedures.

“Bringing the Pieces Together to Improve Patient Outcomes” was the title of the conference with the speakers all stressing that the patient is the focus and a team is required around them to get a good outcome, particularly from a . The themes of the speakers were broadly the history of , collaboration, the use of standards/guidelines and wound management, including reasons for choices.

History of Wound Healing The evolution of wound care was covered by both Professor Donald MacLellan, Director of from New South Wales and Sue Templeton. Clinical Practice Consultant and Advanced Wound Specialist with the Royal District Nursing Service in South Australia. Professor MacLellan began with a light-hearted look at the history of wound care beginning with the ancient and the (circa 1534 BC) which talked of internal and the Smith papyrus (circa 1600 BC) which mentioned wounds and fractures. The Egyptian Imhotep, widely considered to be the founder of medicine, was second only to the Egyptian gods. Doctors don’t like being second and in due course he became a God, thus restoring rightful order (according to Professor MacLellan)!

Although Imhotep was considered to be the founder of medicine, the Greek (460-377 BC), is said to be the father of medicine and his works mention early haemostasis and wound suppuration. He used vinegar to irrigate open wounds and wrapped dressings around wounds to prevent further injury. His teachings remained unchallenged for centuries until came along (130-200 AD). He claimed that four things were necessary for the treatment of a sore – God, the surgeon, medicine and the patient. Galen also recognised that pus from wounds heralded healing (laudable pus). Unfortunately, this observation was misinterpreted, and the concept of pus pre- empting wound healing persevered well into the 18th century. The link between pus formation and healing was emphasised so strongly that foreign material was introduced into wounds to promote pus formation. In the early 1800s Sir Charles Bell (as in Bell’s Palsy) and his contemporaries refined surgical techniques and made progress in debridement and controlling haemorrhage by ligation. Prior to that in the 1500s hot cautery was used - boiling oil or hot irons.

Louis Pasteur (1864) had the idea that micro-organisms infecting animals and humans cause disease. This led (1867) to develop antiseptic methods in surgery. He revolutionised care by advocating cleaning the operating area with carbolic spray prior to surgery – “let us spray” – and reduced that amputation mortality rate from 46% to 15%. Dry dressings were introduced in the 19th century by Joseph Gamgee followed by the moist wound healing theory of George Winter in the 1960s. 1

Sue Templeton described a long history of topical applications to wounds which varied according to culture, religious beliefs and availability of resources. For example leaves, sand and dung have all been used to stop ; for cleansing there has been milk, wine, salt water and vinegar; wounds have been dressed with , lard, beef and resins.

Collaboration Professor MacLellan talked about the three P approach to change – the politician, the practitioner and the patient – who need to work together to achieve change.

The need for collaboration was stressed by Katie Elkin, Chief Legal Advisor to the Health and Disability Commissioner, who spoke about the complaints process in relation to pressure sores. Trends in complaints relate to documentation, treatment and diagnosis, and coordination and continuity of care. Case studies were presented where information was not recorded in care plans and there was little evidence that assessment, care planning and evaluations took place. A quote Katie gave from Health and Disability Commissioner, Anthony Hill (2011) reminds us that communication needs to be documented.

“The communication in the clinical records should tell the whole story about the patient’s care, show the observations and how they were acted on, show continuity of care delivered following the observations including medications and other treatments, specify arrangements for review and follow up, and show how the patient responded to the care.”

Recurring themes in the case studies presented by Katie were - get the basics right, read the notes, ask the questions, talk to the patient, ensure continuity of care and take responsibility; patient safety is everyone’s job!

Pressure ulcers were also the focus for Rachel Taylor, Team Manager at ACC Treatment Injury Centre, in her talk on treatment injuries. Reasons that pressure ulcers are accepted as a treatment injury include risk assessment not done on admission, risk assessment high but no prevention put in place, no reassessment when the client’s condition changes, poor documentation of pressure areas when noticed, lack of a structured management plan and not using alternatives when equipment is not available. Case studies can be viewed on the ACC website.

Collaboration with a team in the management of a patient with a diabetic foot ulcer (DFU) using a total contact cast (TCC) was the topic for a presentation by Emil Schmidt, Wound Clinical Nurse Specialist, from Dunedin. The team included the orthopaedic surgeon, orthotic specialist, podiatrist, diabetes nurse specialist, vascular specialist, wound care specialist, registered nurse and endocrine specialist. Figures show that 85% of patients who have a lower limb amputation first of all have a foot ulcer and that 75% of the problems are caused by shoes. Shoes need to protect and support the feet as well as accommodate deformities and match the shape of the foot.

There are options for offloading which include bed rest, use of wheelchair, insoles, extra depth or custom shoes, felt and foam padding, ortho wedge shoe and removable cast walker, with pros and cons for each. But the TCC is the gold standard with healing rates of 88% and 90% of DFU. The TCC is a below knee cast that conforms to the patient’s anatomical contours with little padding. The close fit increases the weight bearing surface area of the foot and leg. The wound and the patient must have a thorough assessment as contraindications include severe arterial disease, deep foot ulcers with abscesses, osteomyelitis or gangrene, skin problems or cellulitis. There are many different application techniques for a TCC and it must be used with caution by an experienced technician. A cast was applied to a patient during the presentation.

Standards and Guidelines Cathy Hammond and Pip Rutherford introduced the brand new Australia & New Zealand Clinical Practice Guideline for Prevention and Management of Venous Leg Ulcers, 2011, developed by the Australian Wound Management Association and the New Zealand Wound Care Society. Copies of 2 this are available on the NZWCS Website and the New Zealand Guidelines Group website. There is a full text guideline, an abridged version and a flow chart. Cathy talked about the process of developing the guideline, literature reviews, the consultation process, and the levels of evidence.

Cathy also spoke about the Canterbury Initiative - “Health Pathways” – web based information which was launched in 2008. The pathways are localised to the Canterbury area and provide access to information that enables general practitioners to provide more effective care. Hospital specialists and general practitioners work together with managers and funders to ensure that funding is available to support clinical solutions. The pathways include information on assessment, management, referrals, patient information and education resources.

Sue Templeton also identified the need to use clinical pathways – for example for stage 3 and 4 pressure ulcers. She also uses a healing probability scale and while she admits that it is not truly validated, it is probably something that many health professionals can identify with. The scale is for wounds that are likely to heal in a timely way (less than three months), those that are likely to have delayed healing (three to twelve months) and those that are unlikely to heal. In the first category will be those with factors that aid healing such as good general health including nutritional status and fitness level and who can participate in their care. In the second are those who have factors that may impair healing such as older age (70+), cardiac disease, malignancy or systemic corticosteroids and are unable or unwilling to participate in care. Those whose wounds may never heal are likely to have uncontrolled diabetes, peripheral arterial disease or chronic heart disease. In this group, if there are multiple factors present, the likelihood of healing is further reduced. In the first two groups elimination or control of the factors impairing healing increases the healing probability.

Associate Professor Bill McGuiness, Head of the Nursing and Midwifery School, Head Director of Nursing Research at La Trobe Alfred Clinical School, Melbourne and President of the Australian Wound Management Association introduced the draft Pan Pacific Clinical Practice Guideline for the Prevention and Management of Pressure Injury and encouraged everyone to give feedback. The aims of the guideline are threefold. Firstly, to promote the prevention and optimal care of patients at risk of, or with, a pressure injury (PI). Secondly to assist health professionals to identify, assess and manage patients at risk of or with a PI. Finally it may be used as a source for education or the development of local practice policies and procedures. The guideline uses the term stage rather than category or grade and includes unstageable and suspected deep tissue injury.

Assoc. Professor McGuiness showed a slide of factors associated with pressure area risk and also a flow chart for management (see PDF on NZWCS website).

Wound Management Assoc. Professor McGuiness had an amusing, relaxed but very informative way of speaking. He also reminded us that it is necessary to focus on all the good things we, as health professionals, do and not only on that which is not done well. He spoke about the basic wound sessions he does for GPs. He commented that this session would not tell us anything we did not already know but that he had found that it was a succinct way of getting wound management across to GPs.

We dress wounds to: 1. Protect - from further trauma by using a non-adherent interface - from pain - from bacterial burden - patient self-image (ie don’t want leaking, smelly wounds) 2. Maintain moisture - cells will not move in dry areas; he likened a dry area to lying on the beach; and what do we do when we are lying on the beach? -nothing! - dressing that will donate moisture OR absorb exudate – he showed a

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cascade of moist interface dressings from most to least - use of compression 3. Cover sensory nerves - should never have to soak a dressing off 4. Maintain even temperature 5. Provide a delivery platform 6. Enhance aesthetics

Using the D.A.S.E. acronym for Determine aetiology, Assess wound status, Set management aims, and Establish outcome parameters, he covered the basics of traumatic wounds (abrasions, skin tears and burns), surgical wounds and ulcerations. A key point he made in relation to a necrotic heel was – if the eschar doesn’t move, keep it dry. If it moves and is starting to separate something needs to be done – ie take it off.

Wound dressings have been categorized in various ways over the years and Sue Templeton spoke about moving past the “ingredients based” way of thinking. She suggested that a dressing should be chosen based on the desired moisture level for the wound and divided dressings into categories as follows.  Traditional – eg Vaseline gauze and pad which do not independently change, improve or optimise the wound environment.  Basic contemporary – hydrate, retain moisture and manage exudates which independently achieve and maintain an optimal wound environment eg gels, hydrocolloids, foams and alginates.  Specialised – those which are used as a course to overcome a problem. T – high sodium I – antimicrobial M – compression, cavity dressings E – topical negative pressure, rapid capillary action

Sue described using the HEIDI acronym H istory E xaminations I nvestigations D iagnosis I nterventions (TIME) E valuation

Sue emphasized the need to always assess the old dressing for how it looks; eg whether it has remained intact, the exudate quantity and quality including which part of the dressing is the more saturated (most dressings should be 75% saturated before removal), any strike through or leakage, the wear time of the dressing and how easy it is to remove. The wound itself needs to be assessed and also the surrounding skin. The dressing regime is determined by a number of factors. Firstly the patient – their preferences, sensitivities, ability and/or willingness to participate in their care and their lifestyle. Secondly the wound – the diagnosis, objective, characteristics and progress. The third factor is the knowledge and skills of the practitioner (who should not use dressings they do not understand). The last two factors are the other health professionals involved and the ability to get patients seen (eg for sharp debridement, or a dietitian) and the service provider’s policies and procedures and their ability to provide the resources required. This is similar to Professor MacLellan’s comment about the patient, the practitioner and the politician having to work together to achieve change. Leg ulcers Natalie Scott from Capital and Coast DHB spoke of setting up a nurse led ulcer clinic following a review in 2009 which indicated that 60-70% of the district nurses’ work load was wound care. The Clinical Nurse Specialist role was redirected to have a focus on wounds and it was decided to make the clinic more accessible for Maori and Pacific Island people by running it in a low socio-

4 economic area). The average age of the patients was just over 60 with more than 50% being Maori or Pacific Islanders. Fifty five percent of patients had their ulcers healed within 12 weeks with no recurrence during the six month trial period. Natalie described a risk assessment tool for leg ulcer healing but unfortunately it was not available at the presentation.

A ten week study comparing the assessment and treatment of leg ulcers both in the community and in the outpatient clinic with the (old) NZ guidelines was carried out by first year house surgeon Laura Benoiton. Subjects were consecutive patients attending a Dunedin vascular clinic who agreed to take part. Only 9% of community patients had had an Ankle Brachial Pressure Index (ABPI) recorded compared with 67% of hospital based clinic patients; numbers of community patients in compression were correspondingly low. The conclusion was that district nurses (quite rightly) require an ABPI to commence compression therapy (hence the low number of patients in compression in the community). The ABPI was mostly done in the clinics, and compression was initiated there. Although clinic waiting times were mentioned there was no mention of whether DNs in Dunedin are trained in measuring the ABPI thus getting patients into compression in a more timely way.

The “Southland Snail” was introduced by Mandy Pagan, CNS, Wound for Southern DHB. It is an innovative pressure device used to try and get more pressure around a venous leg ulcer over the area above the malleolus where there is a bit if a dent and regular compression bandaging does not provide enough pressure on this area. The device is made of a tubular gauze (Tubinet) folded in half and half again and rolled like a snail. It keeps its shape under compression and does not cause any skin damage. The indurated skin of patients actually became softer and it also helped to flatten out rolled edges. There has been no associated pain and it has also been used above undermined wounds to try and force the underlying tissues together. The team in the Southland clinic were motivated to find a way to treat recalcitrant ulcers that were close to the malleolus. An article has been published and the easiest way to get to it is to google "Southland Snail”.

Skin Tears Skin function, particularly in relation to older people and skin tear risk was presented by Rachel White, a Wound Clinical Nurse Specialist in an Older Person’s Health Service. She spoke about prevention of skin tears by ensuring that the environment is safe, including padding to wheelchairs, and the use of appropriate clothing, including skin protectors, and slide sheets. The Skin Tear Audit Research (STAR) classification was demonstrated with the appropriate management for each category. One good tip was to always try and align the skin flap; if necessary use “truckloads” of saline to “float” the skin flap to enable it to be drawn over the exposed tissue.

Burns Margaret Conaglen, Nurse Educator in the Plastic Surgery Unit, Christchurch, gave an excellent presentation on burns starting with the fact that there is a three hour window for cooling a burn so if it is not done straight away (which of course is ideal) it is not too late to cool it within the next three hours. If there is a cool pad/gauze on a burn it needs changing every 10 minutes as the heat gets into the pad.

Burn assessment and treatment is on the Health Pathway website described earlier. Information is also available on www.nationalburnservice.co.nz.

There are regional burn services at Waikato, Hutt and Christchurch hospitals where patients with complex burns will be referred, and a national unit at Middlemore. Criteria for the national unit are burns to more than 30% total body square area (TBSA), full thickness burns to more than 15% TBSA in the very young or very old, those likely to require prolonged ventilation and those with significant chemical or electrical burns.

A burn assessment includes history and time of burn, estimated TBSA, estimated depth and past medical history. Margaret went into detail about the depth of burns – see website presentation. The aim of burn management after cooling and assessment is cleansing, debridement and dressing selection, bearing in mind patient comfort, bacterial burden and moist wound healing. 5

She said that burn wound exudate is very excoriating so the surrounding skin requires protection and the dressing needs to absorb the exudate well. Dressing options for the depth of the burn are given on her presentation on the NZWCS website. Margaret also stressed the need for adequate pain relief and to review the wound in 48 hours to check for infection and burn depth changes. She also highlighted the fact that Toxic Shock Syndrome may occur even in small burns.

At a second presentation Margaret covered skin grafts. There are three phases to a skin graft “take” - plasmatic imbibition, inosculation and capillary ingrowth. Plasmatic imbibition occurs in the first 48 hours and allows the graft to survive before circulation is established. The graft is fixed to the wound bed allowing exudate to provide nutrients, oxygen and disposal of waste products via the process of diffusion. Plasmatic imbibition is followed by inosculation from 48 - 72 hours. A vascular network forms between the old capillaries in the wound bed those in the graft. Angiogenesis continues and by five to seven days a robust vascular system has formed. Skin grafts require careful handling and need to avoid pressure or shearing. Adequate hydration, nutrition, oxygenation, analgesia and warmth are required as well as observation for complications such as bleeding, fever, increased pain, odour. The first dressing is done on Day 5. Grafts may fail for a number of reasons: haematoma, infection, seroma, shearing forces or a poorly vascularised wound bed.

Donor sites dressed with Mefix/Hypafix have the absorbent padding removed at 48 hours. Any collection of fluid under the Mefix should be expressed and any separated tape should be replaced with fresh sterile Mefix. The patient can shower and wet Mefix after 48 hours. Mefix should be left in place until it “falls off”. If there is odour or purulent ooze present at day 12 – the Mefix should be removed and the wound reviewed

Those dressed with an alginate dressing should have the entire dressing changed at 48 hours and replaced with a fresh alginate dressing and a light gauze dressing on the top. It should be kept dry and showered off at Day 12. If it is has adhered it should be covered with a hydrocolloid and removed the following day.

The Future Professor MacLellan concluded that wound care in the 21st century needs to be evidence based, patient centred and systems oriented. He said that biofilm control will be one of the main challenges of the future with options for treatment including appropriate debridement; new antibiotics and antiseptics that penetrate and kill the biofilm bacteria; disruptors - electric current and laser and Topical Negative Pressure Therapy with installation.

The requirements of the 21st century workforce include an organised approach to the patient presenting with a wound with a multidisciplinary assessment followed by a critical analysis of the information provided and obtained. Deductive reasoning will lead to an appropriate diagnosis and management plan. Good communication and teamwork are vital.

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