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Focus on Resource-Limited Settings Wound and Lymphoedema Management 2ND EDITION Focus on Resource-limited Settings Editor, David H. Keast, BSc, MSc, MD, CCFP, FCFP(LM) Wound and Lymphoedema Management 2ND EDITION Focus on Resource-limited Settings Editor, David H. Keast, BSc, MSc, MD, CCFP, FCFP(LM) Wound and Lymphoedema Management 2nd Edition Focus on Resource-limited Settings World Alliance for Wound and Lymphedema Care Editor, David H. Keast, BSc, MSc, MD, CCFP, FCFP(LM) Acknowledgement Thanks are extended to all the authors for their contributions to this publication. Special thanks are extended to Sue Rosenthal (Canada) for her editorial skill and patience, and to Robert Ketchen (Canada) for a masterful layout. This publication would not be possible without the support and guidance of Hubert Vuagnat (Switzerland) and Jan Kristensen (Denmark) on behalf of the World Alliance for Wounds and Lymphedema Care. This book was published with partial support of ASCRES – Association de Soutien aux Centres de Recherche, Enseignement et Soins en Milieux à Ressources Réduites (Association for the Support of Research, Teaching and Care Centers in Resource‑Limited Settings) Foreword This is not intended to be an academic text but rather practical information for those working in resource‑limited settings. The focus of each chapter follows four key ideas: 1. Background/Introduction – What is the extent of this problem? Why is it important? 2. Diagnosis – How is this problem diagnosed in settings that may have limited investigative resources available? 3. Management – How is this problem managed? How are barriers to implementing best practice overcome with limited resources? 4. Key tips Dedication This publication is dedicated to the vision and commitment of John Macdonald (USA) and Terry Treadwell (USA) to improving wound and lymphoedema care in resource‑limited settings and key founders of the World Alliance for Wound and Lymphedema Care. Publisher World Alliance for Wound and Lymphedema Care c/o CAP partner Nordre Fasanvej 113, 2 2000 Frederiksberg, Denmark Editor David H. Keast, BSc, MSc, MD, CCFP, FCFP(LM) Chronic Wound and Lymphedema Care Parkwood Institute St. Joseph’s Healthcare London, Canada Cover photo Taken in Mbarara, Uganda. © 2020 World Alliance for Wound and Lymphedema Care · www.wawlc.org All rights reserved. No part of this book may be reproduced in any manner without written permission from the copyright owner except for brief excerpts in a book review. First printing November 2020. ISBN 978‑87‑971974‑0‑0 (paperback) ISBN 978‑87‑971974‑1‑7 (PDF) ii World Alliance for Wound and Lymphedema Care · Wound and Lymphoedema Management TABLE OF CONTENTS Chapter 1: Introduction: What is best practice in resource‑limited settings? . 1 Chapter 2: Global Impact of Chronic Wounds and Lymphoedema. 4 Chapter 3: Wound Healing in Limited‑resource Settings. 11 Chapter 4: The Wound Prevention and Management Cycle: An Approach to Wound Care . 16 Chapter 5: Chronic Wound Assessment and Treatment System (CWATS) . 23 Chapter 6: Integrating the Concept of Wound Care, the Importance of Wound Treatment, Wound Treatment Education, and the Wound Care “Team” in Resource‑limited Areas Around the World . 33 Chapter 7: Wound Healing: The Role of Compression Therapy . 39 Chapter 8: Wound Infection: Diagnosis and Management. 47 Chapter 9: Pressure Injuries. 54 Chapter 10: Chronic Venous Insufficiency, Venous Hypertension, and Venous (Stasis) Ulcers . 64 Chapter 11: Neuropathic Diabetic Foot Ulcers . 70 Chapter 12: Lymphatic Filariasis. 80 Chapter 13: Podoconiosis . 86 Chapter 14: Buruli Ulcer . 96 Chapter 15: Burns . 105 Chapter 16: Hansen’s Disease (Leprosy). 112 Chapter 17: Using Local Resources for Wound Care. 131 Chapter 18: The WAWLC Wound Care Kit: A Tool for Modern Wound Care in Limited‑resource Settings. 138 Chapter 19: Case Studies. 149 World Alliance for Wound and Lymphedema Care · Wound and Lymphoedema Management iii CHAPTER 1 Introduction: What is best practice in resource-limited settings? David H. Keast, BSc, MSc, MD, CCFP, FCFP(LM) Associate Scientist, Parkwood Institute Research, London, Canada Evidence-based Medicine As evidence accumulates regarding healthcare practices, doing things “the way we have always done them” is no longer acceptable. In the past, part of the art and necessity of practice in healthcare was making decisions on the basis of tradition and, in many cases, inadequate evidence. This often led to variances in practice, inappropriate care and uncontrolled costs. (1) In 2000 Sackett et al. described the concept of evidence‑based medicine as “The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients and involves integrating indi‑ vidual clinical expertise with the best available external evidence from systemic research”. (2) The Centre for Evidence‑based Medicine in Oxford, England, pro‑ motes evidence‑based healthcare and provides resources for clinicians interested in learning more about evidenced‑based practice (available at http://www.cebm. net/index.aspx?o=1001). Multiple organisations have developed and maintained clinical practice guidelines for the prevention and management of various medical conditions. These clinical practice guidelines undergo a rigorous process in their develop‑ ment, including a thorough review of the literature, accessing clinical practice norms and compiling expert opinion. These guidelines are readily available on the Internet through such agencies as the National Guideline Clearinghouse™ (NGC), a publicly available database of evidence‑based clinical practice guide‑ lines, available at http://www.guideline.gov, or the National Institute Health and Care Excellence (NICE) in the UK, available at www.nice.org.uk. Many wound care organisations such as the European Wound Management Association (www. ewma.org) maintain wound‑specific guidelines. Implementation of Evidence-based Medicine Guideline documents are often very large and implementation can be chal‑ lenging, depending on the environment. Barriers may include lack of financial and other resources, inadequate or contradictory knowledge of evidence‑based practice and an environment that does not support the implementation or sustainability of the guidelines. In resource‑limited settings, implementation will require adapting guidelines to account for resources available, local cultural norms and availability of ongoing support. Many models for implementation of evidence‑based, or best, practice have been developed. Kitson et al. (3) have developed a simple model, which has three components required for successful implementation of best practice: World Alliance for Wound and Lymphedema Care · Wound and Lymphoedema Management 1 1. Robust Evidence: Best practice requires robust scientific evidence such as that developed in clinical practice guidelines. 2. Context: The environment where the evidence is to be implemented needs to be prepared to receive the change in practice. Change strategies, such as assessing readiness for change, need to be employed. Barriers and facilitators for change must be identified, and strategies to reduce barriers and enhance facilitators must be sought. 3. Facilitation: Change is difficult in any environment. For change to be sustain‑ able, ongoing facilitation is required. This is often the piece that is ignored. Ongoing facilitation includes the training and mentoring of local practice facilitators to avoid outsiders taking over the care and creating dependency. Figure 1 outlines a pathway that illustrates the foundations of implementing evidence‑based medicine. Figure 1: The pathway to best practice Evidence base in Clinical Expert the literature experience opinion Best Practice Guidelines Best Practice Recommendations Practice Enablers Patient preferences, Available risk, and readiness resources Target barriers: Enhance facilitation: • Education • Education • Communication • Communication • Clinical practice • Clinical practice • Finance • Finance Best Practice at the Bedside Adapted from Keast and Orsted (4) 2 World Alliance for Wound and Lymphedema Care · Wound and Lymphoedema Management This revision of Wound and Lymphoedema Management (5) is intended to take a practical approach to wound and lymphoedema care in resource‑limited settings. Each chapter will include key practice points intended to enable best practice. Key Practice Points: Implementation of best practice in limited‑resource settings must: • Take into account resources and skills available • Be culturally sensitive • Be facilitated References 1. Orsted HL, Keast DH, McConnell H, Ratliff C. Best practice guidelines, algo‑ rithms, and standards: tools to make the right thing easier to do. In: Krasner DL, ed. Chronic Wound Care: The Essentials. Malvern, HMP Communications, 2014:319–330. 2. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evi‑ dence‑based Medicine: How to Practice and Teach EBM, 2nd ed. New York, Churchill Livingstone; 2000:1. 3. Kitson A, Harvey G, McCormack B. Enabling the implementation of evidenced based practice: a conceptual framework. Qual Health Care. 1998;7(3):149– 158. 4. Keast DH, Orsted HL. The pathway to best practice. Wound Care Canada, 2006;4(1):10‑11. 5. MacDonald J, Geyer, MJ, eds. Wound and Lymphoedema Management. World Health Organization: 2010. Available from: http://whqlibdoc.who.int/ publications/2010/9789241599139_eng.pdf. World Alliance for Wound and Lymphedema Care · Wound and Lymphoedema Management 3 CHAPTER 2 Global Impact of Chronic Wounds and Lymphoedema
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