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 chronic wound. The themes of the speakers were broadly the history of wound healing, collaboration, the use of standards/guidelines and wound management, including reasons for dressing choices. History of Wound Healing The evolution of wound care was covered by both Professor Donald MacLellan, Director of Surgery 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 Egyptians and the Ebers papyrus (circa 1534 BC) which talked of internal medicine 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 Hippocrates (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 Galen 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 Joseph Lister (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 bleeding; for cleansing there has been milk, wine, salt water and vinegar; wounds have been dressed with honey, 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.