EWMA Journal November 2016 (2) by EWMA European Wound Management Association

Volume 17 16 2 Number 1 November April 2016 2016 Published Published by by European Wound Wound Management Management Association

CHANGE, OPPORTUNITIES AND CHALLENGES

WOUND MANAGEMENT IN CHANGING HEALTHCARE SYSTEMS

The EWMA Journal ISSN number: 1609-2759 Volume 16, No 2, November, 2016 The Journal of the European Wound Management Association Published twice a year

EWMA Council Severin Läuchli

Sue Bale

Salla Seppänen

President

President Elect

Immediate Past President

Luc Gryson

Alberto Piaggesi

José Verdú Soriano

Editorial Board Sue Bale, UK, Editor Severin Läuchli, Switzerland Vickie R. Driver, USA Georgina Gethin, Ireland Martin Koschnick, Germany Rytis Rimdeika, Lithuania Salla Seppänen, Finland Hubert Vuagnat, Switzerland

Treasurer

Secretary

Scientific Recorder

EWMA web site www.ewma.org Editorial Office please contact: EWMA Secretariat Nordre Fasanvej 113 2000 Frederiksberg, Denmark Tel: (+45) 7020 0305 Fax: (+45) 7020 0315 ewma@ewma.org

Selcuk Baktiroglu

Gregory Bohn

Barbara den Boogert-Ruimschotel

Mark Collier

Georgina Gethin

Magdalena Annersten Gershater

Kirsi Isoherranen

Edward Jude

Christian Münther

Julie Jordan O’Brien

Andrea Pokorná

Sebastian Probst

Layout: Nils Hartmann, Open design/advertising Printed by: Kailow Graphic, Denmark Copies printed: 5.000 Prices: The EWMA Journal is distributed in hard copies to members as part of their EWMA membership. EWMA also shares the vision of an “open access” philosophy, which means that the journal is freely available online. Individual subscription per issue: 7.50€ Libraries and institutions per issue: 25€ The next issue will be published in April 2017. Prospective material for publication must be with the EWMA Secretariat as soon as possible and no later than January 15th 2017. The contents of articles and letters in EWMA Journal do not necessarily reflect the opinions of the Editors or the European Wound Management Association. All scientific articles are peer reviewed by EWMA Scientific Review Panel. Copyright of published material and illustrations is the property of the European Wound Management Association. However, provided prior written consent for their reproduction, including parallel publishing (e.g. via repository), obtained from EWMA via the Editorial Board of the Journal, and proper acknowledgement, such permission will normally be readily granted. Requests to reproduce material should state where material is to be published, and, if it is abstracted, summarised, or abbreviated, then the proposed new text should be sent to the EWMA Journal Editor for final approval. All issues of EWMA Journal are CINAHL listed.

Sara Rowan

Kylie SandyHodgetts

Robert Strohal

COOPERATING ORGANISATIONS’ BOARD Esther Armans Moreno, AEEVH Christian Thyse, AFISCeP.be Valentina Vanzi, AISLeC Corrado Maria Durante, AIUC Ana-Maria Iuonut, AMP Romania Aníbal Justiniano, APTFeridas Gilbert Hämmerle, AWA Kirsty Mahoney, AWTVNF Jan Vandeputte, BEFEWO Vladislav Hristov, BWA Els Jonckheere, CNC Lenka Veverková, CSLR Mirela Bulic, CWA Arne Buss, DGfW Susan Bermark, DSFS Heli Kallio, FWCS Rosa Nascimento, GAIF

J. Javier Soldevilla, GNEAUPP Georgios Vasilopoulos, HSWH Björn Jäger, ICW Aleksandra Kuspelo, LBAA Susan Knight, LUF Loreta Pilipaityte, LWMA Corinne Ward, MASC Hunyadi János, MSKT Suzana Nikolovska, MWMA Linda Primmer, NATVNS Øystein Karlsen, NIFS Louk van Doorn, NOVW Arkadiusz Jawie´n, PWMA Sebastian Probst, SAfW (DE) Maria Iakova, SAfW (FR) Goran D. Lazovic, SAWMA Tânia Santos, ELCOS

Jan Stryja

Hubert Vuagnat

Ján Koller, SSPLR Mária Hok, SEBINKO F. Xavier Santos Heredero, SEHER Sylvie Meaume, SFFPC Susanne Dufva, SSIS Jozefa Košková, SSOOR Leonid Rubanov, STW (Belarus) Guðbjörg Pálsdóttir, SUMS Cedomir Vucetic, SWHS Serbia Magnus Löndahl, SWHS Sweden Tina Chambers, TVS Jasmina Begi´c-Rahi´c, URuBiH Natalia Vasylenko, UWTO Barbara E. den Boogert-Ruimschotel, V&VN Caroline McIntosh, WMAI Skender Zatriqi, WMAK Dragica Tomc, WMAS Mustafa Deveci, WMAT

EWMA JOURNAL SCIENTIFIC REVIEW PANEL Paulo Jorge Pereira Alves, Portugal Caroline Amery, UK Jan Apelqvist, Sweden Sue Bale, UK Michelle Briggs, UK Stephen Britland, UK Mark Collier, UK Rose Cooper, UK Javorka Delic, Serbia Corrado Durante, Italy Bulent Erdogan, Turkey Ann-Mari Fagerdahl, Sweden Madeleine Flanagan, UK Milada Francu˚, Czech Republic Peter Franks, UK Francisco P. García-Fernández, Spain Magdalena Annersten Gershater, Sweden

Georgina Gethin, Ireland Luc Gryson, Belgium Marcus Gürgen, Norway Eskild W. Henneberg, Denmark Alison Hopkins, UK Gabriela Hösl, Austria Dubravko Huljev, Croatia Arkadiusz Jawien, Poland Gerrolt Jukema, Netherlands Nada Kecelj, Slovenia Klaus Kirketerp-Møller, Denmark Zoltán Kökény, Hungary Martin Koschnick, Germany Knut Kröger, Germany Severin Läuchli, Schwitzerland David Tequh, Netherlands Sylvie Meaume, France

Zena Moore, Ireland Christian Münter, Germany Andrea Nelson, UK Pedro L. Pancorbo-Hidalgo, Spain Hugo Partsch, Austria Elaine Pina, Portugal Patricia Price, UK Sebastian Probst, Schwitzerland Elia Ricci, Italy Rytis Rimdeika, Lithuania Zbigniew Rybak, Poland Salla Seppänen, Finland José Verdú Soriano, Spain Robert Strohal, Austria Richard White, UK Carolyn Wyndham-White, Switzerland Gerald Zöch, Austria

5 Editorial. Severin Läuchli, EWMA President

Science, Practice and Education 7 Efficiency in wound care: The impact of introducing a new foam dressing in community practice Krönert GT, Roth H, Searle RJ 15 Negative pressure wound therapy in the treatment of acute pyoinflammatory diseases of soft tissues Obolensky VN, Ermolov AA, Rodoman GV 23 The use of clinical guidelines during the treatment of diabetic foot ulcers in four Nordic countries Annersten M 27 The WAWLC Wound Care Kit for less resourced countries: a key tool for modern adapted wound care Vuagnat H, Comte E

Book Reviews 34 Essential microbiology for wound care. Pina E

Cochrane Reviews 37 Abstracts of Recent Cochrane Reviews. Rizello G

EWMA 46 EWMA Journal Previous Issues and Other Journals 48 EWMA 2017 Conference in Amsterdam, The Netherlands 52 WCS: Organisation of wound care in the Netherlands. Baljon R 55 EWMA 2016 Bremen: More than 6,000 participants from 84 countries took part in the conference. Soriano JV 60 New EWMA Council Members 61 Appreciations: leaving Council members. Läuchli S 63 Activities of the Cooperationg Organisations during the EWMA 2016 Conference in Bremen - Knowledge sharing across borders. Seppänen S 64 Antimicrobial stewardship in wound care: a Position Paper from BSAC and EWMA 67 Guest speaker at a U.S. Food & Drug Administration (FDA) panel meeting Washington DC 20 & 21 September 2016. Gottrup F 71 Parliamentary breakfast raises public awareness, Läuchli S, Augustin M 74 First EWMA Round Table and Lithuanian annual wound conference in Kaunas, Lithuania. Rimdeika R 78 New corporate sponsors 82 EWMA News 87 EWMA Publications

Organisations 88 AAWC News. Bohn G 91 Wounds Australia News. Sandy-Hodgetts K 92 WCS: Knowledge Centre Wound Care. Baljon R 94 Corporate Sponsors 96 Conference Calendar 98 Cooperating Organisations, International Partners and Other Collaborators; An Overview

ALLEVYN LIFE lasts 2x longer than other dressings

With its unique change indicator,2 ergonomic shape to fit the human body and ability to securely lock away fluid 3 and odour,3 ALLEVYN LIFE can reduce the number of dressing changes required 1 and save valuable nursing time.1,4,5 †

In clinical studies ALLEVYN LIFE has been shown to improve clinical outcomes,2 patient satisfaction,3 and help budgets look healthier.2

Try ALLEVYN LIFE dressings for free at www.allevynlife.com

™ Trademark of Smith & Nephew ©November 2015 Smith & Nephew 66503

* On average based on a reduction in frequency of dressing change visits in a UK product evaluation (N=37). † When used with appropriate training, education and effective promotion of practice change.

References 1. H. Joy et al. A collaborative project to enhance efficiency through dressing change practice (N=37). Journal of Wound Care Vol 24. No 7. July 2015. 2. D. Simon et al. A structured collaborative approach to appraise the clinical performance of a new product. Wounds UK. Vol 10. No 3. 2014. 3. A. Rossington et al. Clinical performance and positive impact on patient wellbeing of ALLEVYN LIFE. Wounds UK. Vol 9. No 4. 2013. 4. O’Keefe. Evaluation of a community based wound care programme in an urban area. Poster presented at EWMA Conference. 2006. 5. J. Stephen-Haynes et al. An appraisal of the clinical performance and economic benefits of a silicone foam in a large UK primary care organization. Journal of Community Nursing. 2013.

Supporting healthcare professionals for over 150 years

Designed for people who happen to be patients

EWMA Journal editorial

Change, opportunities and challenges - wound management in changing healthcare systems

t is well known and documented that the healthcare systems worldwide are challenged due to an increasing elderly population and the subsequent increase in chronic diseases such as diabetes.1-3 This creates an increased pressure on the health care budgets and an increased demand for documentation and cost effective care. These demands drive the health care systems to change and underline the need to implement evidence based guidelines. The 2017 EWMA Conference in Amsterdam, 3-5 May 2017, will focus on the various challenges and potential solutions to ensure high quality wound management in health care systems under pressure. Earlier discharge of hospitalised patients to home care or nursing homes is one of the ways to achieve cost savings. This leads to more patients with a complex pathological condition – including those with wounds –being treated at home.8 By these changes, new challenges are introduced with regards to diagnosis and management of acute and chronic wounds, as these patients risk never meeting the multidisciplinary team of wound care specialised staff that is able to diagnose and treat a non-healing wound appropriately.4,5 Telemedicine and telehealth services may be one of the solutions, but this still needs further investigation.14 Another focus area in these changing health care systems is the need to increase patient safety. EWMA is regularly investing in dedicated awareness activities aiming at the prevention of non-healing wounds, as well as ensuring that complications (such as surgical site infections) in the healing of acute wounds are recognised as important

focus areas in the European and national patient safety programmes.7 Pressure ulcers are well known to be largely preventable, but despite this, prevalence rates have been shown to vary from 8.8% to 53.2 %, and incidence rates to vary from 7 % to 71.6 %.8 Surgical site infections (SSIs) are generally reported to occur in less than 1% of low-risk patients, while SSIs may develop in up to 15% of high-risk patients undergoing contaminated procedures.9 Thus the prevention of pressure ulcers as well as SSIs is both an important patient safety issue and a potential driver of significant resource savings. Challenges related to the management of infections are also present in the prevailing debate about how to approach the urgent need to reduce use of antimicrobial agents, especially antibiotics, in health care in general.10,11 In conclusion, non-healing wounds require a systematic approach as well as the dedicated involvement of different medical specialties and professions, but internationally this remains a challenge to achieve. The current changes in the health care systems are not making this easier. However, the demand to change also presents opportunities and may, in the end, support the development of new services and procedures which will support better care for patients. We should aim to find out how the current demand for change may be used constructively to support the implementation of best practice wound treatment and care. n

Severin Läuchli, EWMA President

REFERENCES 1. Dale, J.J., et al., Chronic ulcers of the leg: a study of prevalence in a Scottish community. Health Bull (Edinb), 1983. 41(6): p. 310-4. 2. Posnett, J., et al., The resource impact of wounds on health-care providers in Europe. J Wound Care, 2009. 18(4): p. 154-161. 3. Hjort, A. and F. Gottrup, Cost of wound treatment to increase significantly in Denmark over the next decade. J Wound Care, 2010. 19(5): p. 173-84. 4. Gottrup, F., A specialized wound-healing center concepts: importance of a multidisciplinary department structure and surgical treatment facilities in the treatment of chronic wounds. Am J Surg, 2004. 187: p. 38-43.

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2016 vol 16 no 2

5. Moore, Z., Butcher, G., Corbett, L. Q., McGuiness, W., Snyder, R. J., van Acker, K. AAWC, AWMA, EWMA Position Paper: Managing Wounds as a Team. J Wound Care 2014; 23 (5 suppl.): S1-S38.

8. Moore Z, Cowman S and Conroy R M, A randomised controlled clinical trial of repositioning, using the 30° tilt, for the prevention of pressure ulcers. J Clin Nurs, 2011. 20(17-18): pp 2633-2644

6. Moore Z, eHealth in Wound Care – overview and key issues to consider before implementation, J Wound Care, 2015, 24, 5 S1-S44

9. Chauveaux D, Preventing surgical-site infections: measures other than antibiotics. Orthop Traumatol Surg Res, 2015, 101(1 Suppl): S77-83.

7. REPORT on the report from the Commission to the Council on the basis of Member States’ reports on the implementation of the Council Recommendation (2009/C 151/01) on patient safety, including the prevention and control of healthcare associated infections (2013/2022(INI))

10. Gottrup F, Wound certainties and Subtleties. Present problems in the use of local antimicrobial agents in non-healing wounds, European Medical Hygiene (EMH), February 2014 11. Gottrup, F., et al., EWMA Document: Antimicrobials and Non-healing Wounds - Evidence, Controversies and Suggestions. J Wound Care, 2013. 22((5 suppl.)): p. 1-92.

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Contact colactive@covalon.com for more information. CE Mark Pending. ColActive is a registered trademark of Covalon Technologies Ltd. ÂŠ 2016 Covalon Technologies Ltd. Mississauga, ON, Canada L4W 5S7.

Science, Practice and Education

Efficiency in wound care:

The impact of introducing a new foam dressing in community practice ABSTRACT An audit of resource use was undertaken in 35 patients treated by two ambulatory wound care providers in Germany (one medical practice and one outpatient wound clinic). A new wound dressingi was introduced with appropriate education and training in its use, and the frequency of dressing change and types of dressings used were recorded before and after adopting the new approach. Clinicians’ views on the performance of the dressing were also surveyed. After the introduction of the new wound dressing into routine community wound care practice, the mean frequency of dressing change was reduced by 1.3 times per week, from 4.6 to 3.3 times per week. The complexity and number of different dressing products decreased. The cost of dressings per change increased slightly, but the average cost of dressings per week was reduced by approximately 23%. Clinicians’ feedback on the new product was positive, with the overall performance rated as better than previous products for over 90% of wounds.

INTRODUCTION Wounds are a growing health issue in Europe, and their treatment consumes a considerable quantity of resource1. Surveys in the UK have reported the population prevalence of wounds to be 3 to 4 people with one or more wounds per 1000 population.1,2, It has been estimated that there are as many as 1.0-1.4 million diabetic foot ulcers (DFUs) and 0.5-1.3 million leg ulcers at any one time in Europe, with 400,000-600,000 new DFUs per year and almost one million new i ALLEVYNTM

LIFE, Smith & Nephew, Hull, UK

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2016 vol 16 no 2

venous leg ulcers (VLUs) presenting each year.3 The economic cost of managing these wounds is considerable, representing 2-4% of the total healthcare budget.4 As an example of the cost of treating individual wounds, the mean total cost of treating a chronic leg ulcer per year in Germany has been estimated to be over €9000.5,6 The demand for wound care will continue to grow because of an ageing European population and the growth of chronic long-term conditions, and as a consequence, the cost of treatment is likely to continue to rise.7 This is against a backdrop of competing resources from other areas of healthcare and increasing pressure on healthcare funding, and therefore efficiency gains will be necessary if providers are to continue to meet demand for wound care services. Much of the cost of wound care is driven by hospitalisation and nursing time, with materials and dressings making up a relatively small proportion.1,2 In the medical practice and outpatients setting, most of the resource utilisation is the time of healthcare professionals required to change wound dressings and undertake other activities such as cleansing, debridement and wound assessment.2 Hence one of the key ways to make wound care more efficient is to release some of this time. Previous studies have shown that the introduction of an advanced wound dressing combined with changes in practice can reduce unnecessary dressing changes and help to free up nurses’ time.8,9,10

G T Krönert1 H Roth2 R J Searle3 1 Thüringen-Kliniken

“Georgius Agricola” GmbH, 07318 Saalfeld/Saale. 2 Gemeinschaftspraxis Dr. Zollmann, Engelsplatz 8, 07743 Jena. 3 Smith

& Nephew, Hull, UK.

Correspondence to: Richard.Searle@ Smith-Nephew.com Conflicts of interest: This evaluation was funded by Smith & Nephew.



One of these studies also showed a reduction in dressing costs as a result of adopting this approach.10 The dressing used in these studies includes a change indicator that is designed to indicate when the dressing needs to be changed, and a discretion / masking layer that reduces the staining of the dressing surface with exudate. This article describes the results of an audit of resource use undertaken by two ambulatory operating wound care providers in Germany. With regard to the treatment of chronic wounds, the relevant medical practice in Jena treats ulcus cruris patients (both venous and arterial aetiologies), secondly decubitus cases and in some cases diabetic foot cases. The practice is part of the wound network of Thuringia, which is a network of ambulatory medical practices focused on wounds, hospitals, medical suppliers, nursing services etc, enabling well-organised treatment of patients with chronic wounds. The Saalfeld centre primarily treats peripheral arterial occlusive diseases (level 4) with peripheral lesions as well as diabetic foot ulcers. The newii wound dressingiii was introduced with appropriate education and training in its use, and the frequency of dressing change and types of dressings used were recorded before and after adopting the new approach. Clinicians’ views on the performance of the dressing were also surveyed as part of the audit. METHODS Firstly, prior to the introduction of the new dressing, there was a training and education phase, during which staff were made aware of the new dressing and trained in how to use it. Clinicians in one of the two sites had previously been aware of the dressing, whereas in the other they were not. Particular attention was paid to making use of the exudate masking and visual indicators, which help patients and clinicians to recognise the most appropriate time to change the dressing. Secondly, staff (wound care nurses and homecare providers) at the two sites used the new dressing routinely in their practice for suitable patients with chronic wounds, based on the product’s indications for use. These decisions were based on clinical judgment and clinicians were able to modify their practice where appropriate (particularly dressing change frequency) to make use of the features of the new dressing. Anonymised data were collected using a paper audit form for each wound where the dressing was used, for a maximum of four dressing changes during January 2015 to April 2015. The data collected included details ii The

term ‘new dressing’ refers to the newly-introduced dressing. ALLEVYN LIFE, Smith & Nephew, Hull, UK iv Area = length x width x ∏/4. iii

of wound characteristics, information about the dressings that were used and clinicians’ feedback on the performance of the new dressing. Wear times were recorded for previous dressings and for the new dressing (the latter being recorded for four dressing changes). These values were converted to frequency of dressing change for each wound using the equation: frequency (per week) = 7 / wear time (days). Dressing change frequency data were analysed on a per-patient basis, i.e. the frequency was first calculated for each patient and then the mean value was calculated across the group of patients. Wound area at the start of the evaluation was estimated from the maximum length and width of each wound using an ellipse formula.iv,11 Tables of results were prepared using SPSSTM v19.0. German national pharmacy prices were used to calculate the cost per dressing change and cost per week of the dressings that were used. In order to estimate costs where generic or non-specific dressing types were recorded, assumptions were made about which products were used. Details of dressing sizes were only recorded for the new dressing, so for previous dressings the nearest size which matched the size of the new dressing was assumed. In some cases, the secondary dressing or fixation was not recorded. In these cases, as a conservative approach, we did not assume any secondary dressing costs. RESULTS 35 patients with wounds who were being treated in the two different wound care providers in Germany (referred to above) were included in the audit. 34 patients had one wound and one patient had two wounds. For this latter patient, data relating to the larger of the two wounds were included. Therefore, in total, data from 35 wounds were included in the analysis. DEMOGRAPHICS AND WOUND CHARACTERISTICS Around three-quarters of patients were more than 60 years old, the most common age range being 71-80 years (Table 1). TABLE 1: PATIENT AGE Age category (years)

Number of patients

Percentage of patients

31-40

2.9%

41-50

0.0%

51-60

22.9%

61-70

14.3%

71-80

37.1%

81-90

22.9%

Total

100%

*Percentages may not add up to 100% due to rounding EWMA Journal

2016 vol 16 no 2

Science, Practice and Education

Of the 35 wounds included in the audit, 20.0% (7/35) were diabetic foot ulcers (DFUs), 31.4% (11/35) were venous leg ulcers (VLUs), 28.6% (10/35) were pressure ulcers and the remaining 20.0% (7/35) were other wound types. Nine of the ten pressure ulcers were Category 2 ulcers and one was a Category 3 ulcer. Of the seven DFUs, one was classified as a Stage 1 DFU, four were classified as Stage 2 and two were “malum perforans” ulcers. Wound area was calculated for 33 wounds where length and width were available. Of these wounds, more than 75% of the wounds had a wound area of less than 10cm2, with only 6.1% (2/33 wounds) having an area of more than 40cm2 (Figure 1).

FIGURE 1: WOUND AREA 80.0%

DRESSING PRACTICE 3 of the 35 wounds were newly-presenting and therefore had no previous dressing use. For the remaining 32 wounds, the previous dressing products used prior to the introduction of the new dressing were recorded. Four of these wounds had multiple products used, whereas 28 wounds had a single product used. Where there was a previous product used, 65.6% (21/32) of these wounds had been treated with a foam dressing. Other dressings used pre-implementation included alginates, hydrocolloids and absorbent dressings (Table 2). After the changes, the new dressing was used on all 35 wounds. In some cases, other products were used in conjunction with the new dressing (Table 3). TABLE 2: DRESSING PRODUCTS USED: PRE-IMPLEMENTATION

75.8%

70.0% 60.0%

Dressing 1 Dressing 2

Number Percentage of wounds of wounds*

Foam

21 65.6%

Hydrocolloid

50.0%

Alginate

2 6.3%

40.0%

Absorbent dressing

1 3.1%

30.0%

Gelling fibre Absorbent dressing dressing 1 3.1%

20.0%

12.1%

10.0% 0.0%

9.4%

6.1% 3.0%

3.0%

Less than 10-20cm2 20-30cm2 30-40cm2 40cm2 or 10cm2 greater Wound area (cm2)

The most common exudate level was Moderate (15/34 wounds, 44.1%), with 10 wounds recorded as Low (29.4%), 1 wound Moderate to high (2.9%) and 8 wounds with a high level of exudate (23.5%). Of the 33 wounds where the type of exudate was recorded, 23 (69.7%) were recorded as having Fluid exudate, and 10 (30.3%) had Viscous exudate. Respondents were also asked to record the condition of the wound bed at the start of the evaluation. These categories were not mutually exclusive and therefore selection of more than one category was permitted. 45.7% of wounds (16/35) were epithelialised, 68.6% (24/35) had granulation tissue present, 5.7% (2/35) had necrotic tissue and 68.6% (24/35) had slough. The condition of the surrounding skin at the start of the evaluation was recorded (again with multiple selection permitted). 48.6% (17/35) had healthy skin, 31.4% (11/35) had reddened skin, 5.7% (2/35) had moist skin and 8.6% (3/35) had dry skin.

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Foam Alginate 1 3.1% Foam Hydrogel 1 3.1% Foam Irrigation 1 3.1% Silver-containing gelling fibre dressing

1 3.1%

Total

32 100.0%

*Percentages may not add to 100% due to rounding

TABLE 3: DRESSINGS USED: POST-IMPLEMENTATION Dressings New dressing with no additional dressings

Number Percentage of wounds of wounds** 26*

74.3%

New dressing + hydrogel

14.3%

New dressing + alginate

5.7%

New dressing + silver-containing gelling fibre dressing

5.7%

Total

35 100%

* 18 recorded no additional dressing, 8 where additional dressing was blank. **Percentages may not sum to 100% due to rounding.



In the post-implementation phase, the most commonlyused size of the new dressing was 10.3 x 10.3cm (used on 62.9% of wounds, 22/35), followed by 12.9 x 12.9cm (14.3%, 5/35) and 15.4 x 15.4cm (11.4%, 4/35). The largest size used was 21 x 21cm (1 wound), and heel or sacrum dressings were used on 3 wounds. There were 140 dressing changes recorded. Four patients were excluded from this analysis because wear times were not available both before and after the new dressing. Table 5 shows that for these 31 patients the mean wear time increased by 0.46 days and the mean frequency of dressing change decreased by 1.25 changes per week. TABLE 4: FREQUENCY OF DRESSING CHANGE

Pre- Post-

implementation implementation Difference

Mean wear times (days)

1.73

2.19 0.46

Mean frequency of dressing change (times per week)

4.59

3.34

-1.25

For 100 of the 140 dressing changes (71.4%) the reason for changing the dressing was reported (from one provider only). The most common reason for dressing change (90.0% of changes, 90/100) was that the dressing was 75% saturated. This relates to the structure of the new dressing, which has four lobes that provide a visual indication of when to change the dressing. When three of the four lobes show exudate, a dressing change is required. For the remaining 10% of dressing changes, the reason was “Routine issues”. FEEDBACK FROM CLINICIANS ON THE PERFORMANCE OF THE NEW DRESSING As part of the evaluation clinicians were asked (for each wound included) “Would you recommend the new dressing for this kind of indication?” Responses were recorded for 82.9% of wounds (29/35), and of these, 27 (93.1%) replied that they would recommend the new dressing. Further feedback on how the dressing affected wound characteristics during its use is shown in Table 5. Feedback on the performance of the new dressing compared with previous dressings for ease of use, adhesion, wear time and overall performance is shown in Table 6.

TABLE 5: CLINICIAN FEEDBACK ON PRODUCT PERFORMANCE – WOUND CHARACTERISTICS Wound Number of wounds characteristic Decreased* Same* Increased* Wound size

26 (81.3%)

6 (18.8%)

Exudate level

24 (75.0%)

7 (21.9%)

Odour

21 (67.7%)

10 (32.3%)

Pain

21 (67.7%)

10 (32.3%)

1 (3.1%)

*Percentages may not sum to 100% due to rounding

TABLE 6: CLINICIAN FEEDBACK ON PRODUCT PERFORMANCE – COMPARED TO PREV. DRESSING Number of wounds Performance Better* Same* Ease of use

30 (96.8%)

1 (3.2%)

Adhesion

28 (90.3%)

3 (9.7%)

Wear time

28 (90.3%)

3 (9.7%)

Overall performance

30 (96.8%)

1 (3.2%)

*Percentages may not sum to 100% due to rounding

DRESSING COSTS Table 7 shows the estimated dressing costs for the 31 wounds where frequency of dressing change was available before and after the introduction of the new dressing. A 2.1% increase in the mean cost of dressings per change was observed, whereas the cost per week decreased by 22.6% after the introduction of the new dressing. TABLE 7: ESTIMATED DRESSING COSTS Mean cost of per dressing dressings per wound change

per week

Pre-implementation

€10.35 €45.81

Post-implementation

€10.57 €35.46

Reduction -€0.22 €10.35 % reduction

-2.1%

22.6%

DISCUSSION The age of patients and type of wound included in this audit are typical of those wounds encountered in routine practice in community healthcare.12 The majority of people living with wounds are in the older age groups, and other published surveys have shown that these patients often have underlying long-term conditions such as diabetes and cardiovascular disease.4 Wounds are often relatively small in surface area,12 and this is borne out by the results presented here. Further, wounds often produce exudate, the management of which is an important element of good 

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Science, Practice and Education

TABLE 8: AGGREGATED DRESSING CHANGE FREQUENCY RESULTS FROM FOUR EVALUATIONS Evaluation Frequency of dressing change (per week) Before After introduction introduction Difference

Number of wounds

Simon et al 20148

2.00 1.35 0.65

Stephen-Haynes et al 20139

4.52 2.88 1.64

3.60 1.80 1.80

This evaluation

4.59

Combined*

3.09 1.98 1.11

Joy et al

201410

3.34

1.25

193

*Mean weighted by the number of wounds

wound care.13 In this evaluation, the majority of wounds were moderately to highly exuding. Such wounds require dressings that are able to manage the exudate whilst providing a moist environment to aid healing, yet prevent maceration to the surrounding skin and trauma to the wound bed.13 The wound beds of the wounds in this audit were characterised by a mixture of tissue types, including over 60% of wounds with slough, and around a third of patients had reddened skin around the wound. For this group of patients, dressings that do not cause trauma to the skin are particularly important.14 Often patients with chronic wounds experience isolation, social exclusion, depression and other psychosocial effects, and dressings that can help to improve wellbeing are an important component of good wound care.15 The choice of dressings is therefore an important decision, and one that can have a profound impact on wellbeing. For wound care providers this choice may also have an impact on efficiency. Simplifying and rationalising wound care has been shown to have economic benefits,16 and this evaluation demonstrates a simplified picture of dressing usage after the introduction of the new dressing. Specifically, there were nine generic dressing combinations (e.g. foam + alginate) before and four combinations after the change. Previous evaluations have also demonstrated a reduction in the complexity of dressing usage. For example, one real-world evaluation of 37 wounds showed a reduction from eleven different generic dressing combinations to two, an 81.8% reduction.10 The complexity of care and the number of different dressing products has expanded markedly over the last two decades, and whilst the ability to choose may be seen as an advantage, a simpler pattern of usage may mean that efficiencies can be introduced. Frequency of dressing change is one of the most important determinants of cost in community wound care,1 and optimising frequency for a given patient may provide opportunities to free up resources. This evaluation demonstrated a marked reduction in frequency of change after

the introduction of the new dressing. This is in line with previously published real-world evaluations in community wound care similar in methodology to the work reported here.8,9,10 In total for these three previous reports combined, there were 186 wounds included, of which dressing change frequency information was reported for 162 (87.1% of the wounds). Combining data from this current evaluation provides a total of 221 wounds, of which 193 have dressing change frequency information both before and after the introduction of the new dressing. Table 1 shows the results of this current evaluation alongside the other previous reported projects. The combined results of the four evaluations demonstrate a reduction in dressing change frequency of just over one visit per week across 193 wounds. The mean reduction in visits per week ranges from 0.65 (Simon et al) to 1.80 (Joy et al). As discussed in previously published work, optimising dressing change frequency in this way could potentially free up a considerable quantity of time. For example, a provider covering a population of 500,000 people is likely to be treating 1,750 patients with wounds at any one time (assuming a population prevalence of 3.5 patients with a wound per 1000 population).1,2 Assuming that a reduction of one visit per week could be realised across this population, this could release 1,750 visits per week, or approximately 900 hours.17 Annually this would amount to 91,000 visits or over 46,000 hours. Two of the previous publications calculated the reduction in dressing change frequency for a subset of wounds that were previously having dressings changed 3 or more times per week, showing an even greater reduction in dressing change frequency for this group.8,9 Although clinical outcomes were not quantitatively assessed in this audit, clinicians’ views on the performance of the new dressing were sought. The results demonstrated that over the course of several dressing changes, positive changes in the wound size, exudate level, odour and pain 

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were observed. These results are not comparative with a control group, and the effect of the dressing itself cannot be separated from other aspects of the care that patients received. Nevertheless, they provide an important insight into the new product from the health care professionals’ perspective. Similarly, in terms of ease of use, adhesion, wear time and overall performance, clinicians reported a very positive view, with the new dressing being reported to be better than previous dressings in over 90% of wounds in each case. LIMITATIONS The number of patients included in the evaluation was relatively small, although when combined with results from other similar published evaluations the aggregated number of wounds included is substantial. Nevertheless, it would be beneficial to undertake further work in other localities and care settings to increase confidence in the

generalisability of the results. This evaluation represents real-world data and the authors recognise that other designs such as randomised controlled trials are valuable and would be useful to complement the data presented here. Finally it should be noted that the costs reported here apply specifically to Germany. CONCLUSIONS After the introduction of the new wound dressing into routine community wound care practice, the average frequency of dressing change was reduced by more than one change per week and the complexity and number of different dressing products decreased. The cost of dressings per change increased slightly, but the average cost of dressings per week was reduced by approximately 23%. Clinicians’ feedback on the new product was positive, with the overall performance rated as better than previous products for over 90% of wounds. n

REFERENCES 1. Drew P, Posnett J, Rusling L (2007). The cost of wound care for a local population in England. Int Wound Journal 4 (2):149-155.

8. Simon D, Bielby A (2014). A structured collaborative approach to appraise the clinical performance of a new product. Wounds UK 10(3):80-87.

15. Wounds International (2012). International consensus. Optimising wellbeing in people living with a wound. Wounds International, London.

2. Vowden K, Vowden P, Posnett J (2009). The resource costs of wound care in Bradford and Airedale Primary Care Trust in the UK. Journal of Wound Care 18 (3) 93-102.

9. Stephen-Haynes J, Bielby A, Searle R (2013). The clinical performance of a silicone foam in an NHS community trust. J Community Nurs 27(5), 50-59.

16. Henderson V (2013). Use of Lean methodology for the management of a total dressing scheme in primary care. Wounds UK 9(3):42-44.

10. Joy H, Bielby A, Searle, R (2015). A collaborative project to enhance efficiency through dressing change practice. J Wound Care 24(7):312, 314-7.

17. O’Keeffe M (2006). Evaluation of a community-based wound care programme in an urban area. Poster presented at EWMA Conference, 2006.

3. Posnett J, Gottrup F, Lundgren H, Saal G (2009). The resource impact of wounds on health-care providers in Europe. J Wound Care 18(4):154-161. 4. Probst S, Seppänen S, Gerber V, Hopkins A, Rimdeika R, Gethin G (2014). EWMA Document: Home care - wound care. J Wound Care 23 (5 Suppl.): S1–S44. 5. Purwins S, Herberger K, Debus ES, Rustenbach SJ, Pelzer P, Rabe E, Schäfer E, Stadler R, Augustin M (2010). Cost-of-illness of chronic leg ulcers in Germany. Int Wound J 7(2):97-102. 6. Augustin M, Brocatti LK, Rustenbach SJ, Schäfer I, Herberger K (2014). Cost-of-illness of leg ulcers in the community. Int Wound J 11(3):283-92. 7. Dowsett C, Bielby A, Searle R (2014). Reconciling increasing wound care demands with available resources. J Wound Care. Nov;23(11):552-62.

11. Shaw J, Hughes CM, Lagan KM, Bell PM, Stevenson MR (2007). An evaluation of three wound measurement techniques in diabetic foot wounds. Diabetes Care 30(10):2641-2642. 12. Ousey K, Stephenson J, Barrett S, King B, Morton N, Fenwick K, Carr C (2013). Wound care in five English NHS trusts: results of a survey. Wounds UK 9(4):2028. 13. Wounds UK Best Practice Statement. Effective exudate management. London: Wounds UK, 2013. Available at: www.wounds-uk.com. 14. Lawton S [Internet] Assessing and managing vulnerable periwound skin. World Wide Wounds. [2009] Available at: http://www.worldwidewounds. com/2009/October/Lawton-Langoen/vulnerableskin-2.html

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2016 vol 16 no 2

Granulox transports oxygen to the wound base. Studies show how effectively it helps. PubMed – Granulox clinical trial studies

ewMa 2015, Posters

Arenbergerova M, Engels P, Gkalpakiotis S, Dubská Z, Arenberger P. ToPicAl hEMoGlobin ProMoTES wounD hEAlinG of PATiEnTS wiTh vEnouS lEG ulcErS. hautarzt. 2013 Mar; 64(3):180-6. [Article in German]

[EP020] TrEATMEnT of chronicAl lowEr lEG ulcErS wiTh ToPicAl hEMoGlobin SPrAy. Danijela Semenic, Adrijana Debelak, irena Jovisic, Janja nikolic, Dragica Maja Smrke Slovenia , university Medical center ljubljana; Department of Surgical infections

Arenberger P, Engels P, Arenbergerova M, Gkalpakiotis S, García luna Martínez fJ, villarreal Anaya A, Jimenez fernandez l. clinicAl rESulTS of ThE APPlicATion of A hEMoGlobin SPrAy To ProMoTE hEAlinG of chronic wounDS. GMS Krankenhhyg interdiszip. 2011; 6(1): Doc 05.

[EP165] A ToPicAl hAEMoGlobin SPrAy for oxyGEnATinG chronic vEnouS lEG ulcErS: A PiloT STuDy. ray norris, Joy Tickle

PubMed – Granulox case rePorts & Pilot studies bateman SD. uSE of ToPicAl hAEMoGlobin on SlouGhy wounDS in ThE coMMuniTy SETTinG. br J community nurs. 2015 Sep; 20 Suppl 9: S. 32-9. Tickle J. A ToPicAl hAEMoGlobin SPrAy for oxyGEnATinG PrESSurE ulcErS: A PiloT STuDy. br J community nurs. 2015 Mar; Suppl wound care: S. 12, S. 14-8 norris r. A ToPicAl hAEMoGlobin SPrAy for oxyGEnATinG chronic vEnouS lEG ulcErS: A PiloT STuDy. br J nurs. 2014 nov; 23 Suppl 20: S. 48-53. babadagi-hardt Z, Engels P, Kanya S. wounD MAnAGEMEnT wiTh coMPrESSion ThErAPy AnD ToPicAl hEMoGlobin SoluTion in A PATiEnT wiTh buDD-chiAri SynDroME. J Dermatol case rep. 2014 Mar 31; 8(1). barnikol wK, Pötzschke h. coMPlETE hEAlinG of chronic wounDS of A lowEr lEG wiTh hAEMoGlobin SPrAy AnD rEGEnErATion of An AccoMPAnyinG SEvErE DErMAToliPoSclEroSiS wiTh inTEr-MiTTEnT norMobAric oxyGEn inhAlATion (inboi): A cASE rEPorT. Ger Med Sci. 2011 Mar 30; 9: Doc 08. Arenberger P, Elg f, Petyt J, cutting K. ExPEcTED ouTcoMES froM ToPicAl hAEMoGlobin SPrAy in nonhEAlinG AnD worSEninG vEnouS lEG ulcErS. J wound care. 2015 May; 24(5): 228-36.

[EP177] TrEATMEnT of infEcTED chronic lEG ulcErS coMbininG infEcTion conTrol, SurGicAl MoDAliTiES, hEMoGlobin SPrAy, wounD DrESSinG, AnD coMPrESSion ThErAPy. Peter Engels, nesat Mustafi [EP249] TrEATMEnT of burnS wiTh hAEMoGlobin SPrAy AS ADJuncTivE ThErAPy To STAnDArD cArE. nesat Mustafi & Peter Engels [EP417] fAST hEAlinG of vluS wiTh innovATivE AnD coMbinED TEchnoloGiES. florin Paraschiv, bucharest, romania [EP425] ThE SynErGy bETwEEn hEMoGlobin SPrAy AnD DAcc DrESSinGS. robert Tudoriu, bacau, romania, fan life-home care Services [EP430] AccElErATE TrEATMEnT of A vEry olD AnD infEcTED fiSTulA. Mitu roxana, bucharest, romania, bio hygiene-home care Services [EP441] ThE uSE of GrAnulox To hEAl A fooT ulcEr in A hiGh riSK PATiEnT wiTh DiAbETES: A clinicAl cASE STuDy. Alexandra whalley, uK, bolton Diabetes centre [EP443] uSinG hAEMoGlobin To iMProvE oxyGEn DiffuSion in coMPlEx chronic ulcErS lEADS To fASTEr hEAlinG AnD rEDucED coST of DrESSinG chAnGES AnD nurSinG cArE – 3 cASE STuDiES. luxmi Mohamud, london, uK, Guys and St Thomas community Services; Dulwich community hospital [EP451] hEAlinG A 14 yEAr-olD lEG ulcEr in four MonThS wiTh ToPic hEMoGlobin. Annemiek Mooij , Amsterdam, netherlands, Slotervaartziekenhuis [EP519] uSE of ToPicAl hAEMoGlobin in PoSTTrAuMATic wounD wiTh ExPoSED hArDwArE. Marin Marinovid, Josip Spanjol , Davor Primc, Stanislava laginja, nera fumid , bore bakota , branka Spehar, Eva Smokrovic, Aldo ivancic. university hospital rijeka; ogulin, Karlovac & home healthcare and rehabilitation [EP520] iS AMPuTATion ThE only SoluTion for ThE DiAbETic fooT? Stanislava laginja, Marin Marinovid, General hospital of ogulin & university hospital rijeka

wounds uK 2015

PubMed – Granulox review articles

AccElErATE wounD hEAlinG of AcuTE AnD chronic wounDS in PATiEnTS wiTh DiAbETES: ExPEriEncE froM MExico uSinG SuPPlEMEnTAry hAEMoGlobin SPrAy. obdulia lopez lopez, Peter Engels, fredrik Elg

Dissemond J, Kröger K, Storck M, risse A, Engels P. ToPicAl oxyGEn wounD ThErAPiES for chronic wounDS: A rEviEw. J wound care. 2015 feb; 24(2): 53-4, 56-60, 62-3.

ThE uSE of A novEl hAEMoGloblin SPrAy To ProMoTE hEAlinG in chronic wounDS. Eleanor wakenshaw, Tissue viability nurse, and ruth ropper, lead nurse Tissue viability, nhS lothian, Scotland

Marinović M, Spanjol J, fumić n, bakota b, Pin M, cukelj f. uSE of nEw MATEriAlS in ThE TrEATMEnT of chronic PoST-TrAuMATic wounDS. Acta Med croatica. 2014 oct; 68 Suppl 1: 75-80. [Article in croatian]

DiAbETic fooT ulcErATion – PoSiTivE ouTcoMES uTiliSinG ToPicAl hAEMoGlobin SPrAy. Sharon Dawn hunt, Advanced nurse Practitioner, South Tees nhS foundation Trusts

Prof. Dr. Dr. von Eiff w. focuSinG on QuAliTy, wEll-bEinG of PATiEnTS, AnD coSTS. hcM. 2013 nov; 4th vol.: 38-41.

other (non-PubMed) Granulox references ToPicAl oxyGEn-hAEMoGlobin uSE on SlouGhy wounDS: PoSiTivE PATiEnT ouTcoMES AnD ThE ProMoTion of SElf-cArE. Sharon Dawn hunt, wounds uk 2015 vol 11 issue 4 p. 90-95 APProPriATE uSE of ToPicAl hAEMoGlobin in chronic wounD MAnAGEMEnT: conSEnSuS rEcoMMEnDATionS. wounds uK, 11/05/15 Paul chadwick, Joanne Mccardle, luxmi Mohamud, Joy Tickle, Kath vowden, Peter vowden. PiloT STuDy: hAEMoGlobin SPrAy in ThE TrEATMEnT of chronic DiAbETic fooT ulcErS. chadwick, Paul; wounds uK; nov 2014, vol. 10 issue 4, p. 76

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Science, Practice and Education

C H E R WU

2006 – 2016

KO N G R E S S

EARS DE U

BREMEN · DE 1

Bremen

Negative pressure wound therapy in the treatment of acute pyo-inflammatory diseases of soft tissues

PATIENTS · WOUNDS · RIGHTS

EWMA n BREMEN 2016

Submitted to EWMA Journal, based on a presentation given in the E-poster session: Negative Pressure Wound Therapy.

ABSTRACT Aim To assess the effectiveness of negative pressure wound therapy (NPWT) for acute pyo-inflammatory diseases of soft tissues (APIDST). Methods Sixty-four patients with APIDST, consisting of abscesses and phlegmons at various locations, were included in this study. The patients underwent treatment in the Department of Wounds and Wound Infections of the City Clinical Hospital No. 13 in 2011−2014. The study group patients (n = 34; male, 20 [58.8%], female, 14 [41.2%]; mean age, 49.5 ± 3.0 years) were treated with NPWT. Patients in the comparison group (n = 30; male, 16 [53.3%], female, 14 [46.7%]; mean age, 49.6 ± 3.4 years) were treated with traditional locally applied remedies, including watersoluble polyethylene glycol-based ointments and povidone-iodine. Results The average duration of antimicrobial therapy was 6.7 ± 0.8 days in the study group and 10.0 ± 0.9 days in the comparison group (p < 0.02). On day 7, the average wound volume (estimated by the hydrometric method) in the study group was decreased by 50.9% and by 23.8% in the comparison group (p < 0.03), and was further reduced to 80.8% and 38.9%, respectively, by day 10 (p < 0.01). On average, 97.1% of patients in the study group had wounds that closed completely, whereas only 16.7% of patients in the comparison group had wounds that were completely closed before the hospital treatment phase ended (p < 0.01). The duration of the hospital stay averaged 13.1 ± 0.9 days in the study group and 18.1 ± 1.1 days EWMA Journal

2016 vol 16 no 2

V.N. Obolenskiy1,2

in the comparison group (p < 0.05). The average cost of treating one patient in the study group was €1762.70 and was €2160.25 in the comparison group. Conclusion NPWT is highly effective in the treatment of APIDST and improves the results and reduces the average duration of hospital stay.

A.A. Ermolov2

G.V. Rodoman2

INTRODUCTION In the 1980s, the application of negative pressure wound therapy (NPWT) was introduced for the treatment of complicated wounds. The first publication on the use of vacuum dressings in the treatment of wounds at the Yaroslavl Surgical Clinic in Russia was issued in 1987. Over the next four years, the same team performed nearly a dozen studies evaluating the methods that were issued by central scientific publishing houses.1−4 In 1989, Chariker et al.5 published a paper describing the use of gauze, incision film, and negative pressure of 60–80 mmHg in the treatment of postoperative wounds in the centralised hospital system. In 1993, Fleischmann et al.6 described their use of vacuum-assisted dressings, consisting of a polyvinyl sponge, silicone drainage, and transparent polyurethane film, in the treatment of 15 patients with open fractures. Later, Morykwas et al.7 described some of the major clinical effects of local negative pressure on the basis of their experimental and practical work in the treatment of complicated wounds of various aetiologies.

1State-Financed Health Institution, City Clinical Hospital No. 13, Moscow City Health Department, Velozavodskaya Str. 1/1, Moscow 115280, Russia

NPWT reduces the time involved in all stages of the wound process, including wound healing. NPWT also reduces the severity of the wound

Correspondence to: Vladimir N. Obolenskiy gkb13@mail.ru.



2State

Budget Educational Institution, Higher Professional Education, Pirogov Russian National Research Medical University, Ostrovitianov Str. 1, Moscow 117997½, Russia

Conflicts of interest: None

exudation, helping to maintain a moderately moist wound environment that is necessary for normal reparative and regenerative processes. All of these effects contribute to increasing the intensity of cell proliferation and enhancing the synthesis of the supportive matrices for connective tissue and proteins in the wound. NPWT elevates the levels of growth factors and stimulates angiogenesis in the wound and facilitates the formation of blood vessels, which provide optimal conditions for wound healing.8−14 In NPWT, disposable sterile supplies are used, including biocompatible polyurethane foam, adhesive film coatings, and specially designed drain ports that directly connect with a system of drains and containers for the collection of wound exudate. Aspirators are used as a source of vacuum to ensure the supply and maintenance of negative pressure in a broad range of from 0 to 250 mmHg. Currently, such devices maintain both permanent and intermittent modes of exposure of negative pressure to the wound by means of an electronic control system. In addition, these devices provide a high level of safety for treatment of both bedbound and active patients. Three-dimensional gauze may be used in place of polyurethane sponges.11,15,16 A negative pressure of -125 mmHg is typically used in the treatment of wounds in adults, whereas a constant suction at -90-125 mmHg is recommended for treatment in children.17,18 As an alternative to expensive commercial devices and consumables, use of sterilised urethane foam and incision film, with drainage installed between the foam layers and between the “petals” of film and the vacuum source, have been suggested.19 However, the use of a central vacuum line or vacuum suction, not intended to create permanent, preset negative pressure, or the use of mechanical bulbs do not provide optimal or controlled vacuum in a dressing. A multicentre randomised controlled trial by David Armstrong and colleagues20 found no difference in the effectiveness of local negative pressure with use of mechanical and electrical vacuum aspirators. Several authors have noted the clinical- and cost-effectiveness of NPWT for various types of wounds.21 Indeed, NPWT is recommended when surgical treatment, reconstructive surgery, or autodermoplasty under local or general anaesthesia is contraindicated.22 However, other authors point out the negative aspects of NPWT in some patients, such as the sense of dependence on the device, reduced mobility, sleep disturbances, and pain upon removal of film or sponge. Thus, an individualised approach to patient management, as well as additional training for both patient and staff is suggested.23−27 Nevertheless, the results of several meta-analyses demonstrate a higher efficiency of local negative pressure therapy compared with that of other methods in the treatment of various wounds, 16

TABLE 1: CRITERIA FOR INCLUSION AND EXCLUSION OF PATIENTS Criteria of inclusion

Criteria of exclusion

Existence of APIDST that requires surgical intervention

Dermatitis and eczema in the pathological area

Volume of pathological area > 50 cm3

Signs of malignant transformation

Presence of signs of systemic

Blood clotting

inflammatory reaction

abnormalities

Patient’s compliance

Dementia and other mental disorders

particularly with respect to preventing wound infections, improving perfusion of wound tissues, and shortening the wound-healing period.28, 29 The method can be tailored for an outpatient setting with the use of portable suction devices.30 In some countries (e.g., Germany and Japan), NPWT has been approved in the health insurance system and is funded by insurance companies.31 It is estimated that around 300 million acute wounds are treated globally each year. There is evidence of successful use of NPWT in the treatment of inflammatory diseases of soft tissues and extensive purulent wounds (class IV according to the criteria of the Centres for Disease Control and Prevention).32−36 The aim of this study was to assess the effectiveness of NPWT in the treatment of APIDST. METHODS This study included 64 patients with APIDST, including abscesses and phlegmons of different locations, who were treated in the Department of Purulent Surgery of City Hospital No. 13 in 2011−2014. Criteria for inclusion and exclusion of patients in the study are presented in Table 1. In the primary stage of diagnosis, all patients had laboratory tests and ultrasound examination of the pathological focus with the diagnostic device Voluson E8, equipped with annular and linear sensors (including broadband; 5−10 MHz). Surgery (incision of a purulent cavity) occurred on the first day of admission, and the wound was sanitised with antiseptic solutions and drained with gauze tampons. All patients received systemic antibiotic therapy beginning the first day, taking into account the possible causative agent of the disease, which was prolonged according to the severity of the systemic inflammatory response syndrome and the results of bacteriological research.

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Patients were randomly distributed into two groups. In the comparison group (n = 30 patients), wounds received topical therapy with water-soluble, glycol-based polyethylene ointments and povidone-iodine under the dressing, which were chosen according to the phase of wound process and species specificity of the pathogen of wound infection. In the NPWT group (n = 34 patients), a NPWT bandage was applied on the wound on the third day, consisting of sterile polyurethane foam with a pore size of 1066 microns and silicone drainage sealed by an incision film. A commercially available NPWT device was used as a negative-pressure sourcei . The target level of negative pressure was -125 mmHg. Dressings were changed once every 3−4 days, and the wound was checked and a decision was made regarding use of secondary sutures or reapplication of the vacuum-assisted dressing. Characteristics of the two groups according to sex, age, and nature of their pathology are presented in Table 2; differences between the groups were not statistically significant. TABLE 2. DISTRIBUTION OF PATIENTS ACCORDING TO SEX, AGE, AND NATURE OF THEIR PATHOLOGY Characteristic

NPWT group (n = 34)

Comparison group (n = 30)

Male

20 (58.8)

16 (53.3)

Female

14 (41.2)

14 (46.7)

49.5 ± 3.0

49.6 ± 3.4

Sex, n (%)

Average age, yr ± c

Nosological entity, n (%)

Hypothesis of no differences was rejected, if the value of the t-test exceeded the critical value. In the study of quantitative traits for comparison of 2 groups used the student’s t-test, and for a small number of groups, nonparametric Mann-Whitney test. For comparison of indicators within one group at different points in time - paired student’s t-test. In the study of qualitative signs for comparison of 2 groups was used Z-criterion and the Yates’ correction or the Fisher test for comparison of indicators within one group at different points in time - the criterion of Mak-Nimar. The pathological focus volume was determined using the original hydrometer method at the initial surgery after the incision of the purulent cavity and upon evacuation of its contents (Fig. 1, table 3), as well as on the 3rd, 7th, and 10th days from the start of treatment and prior to the application of secondary sutures. Biopsy specimens of soft tissues were taken during the dressing application from the bottom area and the edges of the wounds on the 3rd, 7th, and 10th (in the presence of wound defect) days for histological and bacteriological examinations. TABLE 3. VOLUME CHARACTERISTICS OF PATHOLOGICAL AREAS IN PATIENTS ON THE FIRST DAY OF TREATMENT Category

Minimum

1,400

1,500

319.6 ± 50.5

247.6 ± 53.2

13 (38.2)

11 (36.7)

Maximum

Phlegmon

21 (61.8)

19 (63.3)

Average

To organise clinical and laboratory data, a formalized map of the dynamic observations of the patient and considerations of remedial measures was developed. On its basis a database in Microsoft Excel 2007 was created, including 1182 records for 44 parameters. The statistical analysis was performed using the statistical analysis package for Microsoft Excel 2007 program Stat Soft Statistica 10.0 Enterprise 2011.

Comparison group (n = 30)

Volume, cm3

Abscess

Note: Group differences were not statistically significant.

NPWT group (n = 34)

Volume range (cm3), n 0–49

50–149

150–249

250–349

350–499

>500

Note: Group differences were not statistically significant.

To characterize the samples, we used average value, the average error of the average value. To compare the significance of differences between average values in different samples, we used the standard method of testing the hypothesis about the difference between two equal samples.

Bacteriological studies of biopsy specimens included qualitative (species) and quantitative analyses of the microflora in the soft tissue. The identification of isolated microorganisms was carried out on the basis of their morphological i S042 NPWT; VivanoTec, Germany

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characteristics. The level of bacterial contamination was determined from 1 g of wound tissue. The average baseline bacterial contamination of the wound tissues from both groups averaged 6.6 ± 0.4 CFU/ml on a logarithmic scale. A monoculture of Gram-positive microorganisms was prevalent in both groups: 76.6% in the NPWT study group and 63.3% in the comparison group. The microbial landscape in the wounds from patients included in this study is described in Table 4. TABLE 4. MICROBIOLOGICAL CHARACTERISTICS OF THE PATHOLOGICAL AREAS IN PATIENTS ON THE FIRST DAY OF TREATMENT Pathogen detected

NPWT group (n = 34)

Comparison group (n = 30)

Staphylococcus aureus Methicillin-susceptible

Coagulase-negative

Methicillin-resistant

Streptococcus spp.

Enterococcus spp.

Gram-positive organisms 26 (76.5%)

19 (63.3%)

Escherichia coli

Klebsiella pneumoniae

Pseudomonas aeruginosa 1

Enterobacter aerogenes

Gram-negative organisms 5 (14.7%) Microbiota

the research group, the number of required “traditional” dressings and other medical and non-medical costs in both groups. The calculation of the cost of one day of treatment (DCoT) using the commercially availably systemi was by the formula (Jürgen Hofstetter): DCoT = (SPkit х 0,25) + (SPkanister х 0,25) + SPunit (365 x 0.8) x 4 where SP (SellingPrice) – variables (according to pricelist) 0,25 – coefficient replacing disposable supplies system 365 – number of days in a year; 0,8 – coefficient of time of use of the apparatus, i.e. 80% of the time; 4 – estimated average life duration of the device. Calculation of the cost of treatment of patients of both groups were made based on the cost of consumables and the cost of medical labor, other non-medical expenses of City Hospital #13 for 2013. Secondary sutures were applied upon transition of wound processes into phase III, after bacterial contamination of the wound decreased below a critical level, with a significant reduction in the size of the wound cavity, and in the presence of pronounced granulation of tissue. In the case of a continuing tissue cavity defect, drainage was maintained through a counteropening with active aspiration.

2 (6.7%)

Microbial growth not detected 3

Note: Group differences were not statistically significant.

The calculation of economic parameters were made based on the known cost of a bed day of inpatient treatment in the Department of purulent surgery, the average value of daily consumption of dressings and preparations of local action, the cost of consumables dressings local negative pressure and depreciation of the used NPWT devices. With the aim of calculation of economic efficiency of used methods of treatment, we used analysis of economic costs as the most relevant aims, objectives and results obtained in the study. This made the calculation of the average cost of treating 1 patient of the study group and the comparison group on the basis of data on the average duration of treatment patients of both groups in the hospital, the average duration of application of the method LOD in

RESULTS Of the 34 patients in the study group, NPWT was used once in 29 patients, twice in 2 patients, and thrice in 3 patients. On average, 1.2 ± 0.1 bandages of local negative pressure were used per patient. The duration of NPWT ranged from 2 to 15 days, and averaged 5.8 ± 0.5 days. The average number of dressings per patient was 1.9 ± 0.2 in the NPWT group and 12.7 ± 0.9 in the comparison group (p < 0.01). With respect to haematological dynamics, no reliable differences were found between the groups; however, the patients in the NPWT group demonstrated an earlier normalisation of the white blood cell count (data not shown). The average level (logarithmic scale) of bacterial contamination of the wound tissues on the 3rd day was 5.29 ± 0.54 CFU/ml in the NPWT group and 5.17 ± 0.5 CFU/ ml in the comparison group (no difference). Bacterial contamination in the NPWT and control groups was 0.93 ± 0.3 and 3.83 ± 0.5 CFU/ml, respectively, on day 7 (p < i S042 NPWT; VivanoTec, Germany

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Science, Practice and Education Figure 1. Hydrometric method of determining the wound volume

Figure 1a. Original form of the wound.

Figure 1b. Sealing with incision film.

Figure 1c. Putting antiseptic into the isolated wound cavity.

Figure 1d. Estimation of wound defect volume.

0.01), and 0.2 ± 0.2 and 2.41 ± 0.5 CFU/ml, respectively, on day 10 (p < 0.01). In assessing the histological preparations, a positive effect of NPWT was noted on the dynamics of wound process in the study group, evidence by a shortening of the period

of transformation of degenerative and inflammatory processes in the wound tissues into inflammatory-regenerative ones.37 Comparisons between the NPWT and comparison groups are presented in Table 5. In general, in the NPWT group displayed improved results, with marked reduced time 

TABLE 5. RESULTS OF TREATMENT IN THE GROUPS STUDIED Characteristic

NPWT group Comparison group (n = 34) (n = 30)

p value

Relative reduction in average wound dimensions on the 7th day, %

50.9

23.8

< 0.03

Relative reduction in average wound dimension on the 10th day, %

80.8

38.9

< 0.01

Average duration of antibacterial therapy, d ± SEM

6.7 ± 0.8

10.0 ± 0.9

< 0.02

Proportion of patients with wound closure at the hospital stage, %

97.1

16.7

< 0.01

Average duration of treatment prior to application of secondary sutures, d ± SEM

8.1 ± 0.5

11.2 ± 2.4*

< 0.07

Average duration of treatment in hospital, d ± SEM

13.2 ± 0.9

17.9 ± 1.1

< 0.01

1678.76

2057.38

< 0.01

Average cost of treatment per patient, €

*Closure of the wound was possible in only 5 patients. EWMA Journal

2016 vol 16 no 2

and cost of treatment in comparison with those of the traditional local APIDST treatment. CASE REPORT The dynamic of the wound process when using NPWT (clinical example) is shown in Figure 2. DISCUSSION The active removal of excess wound exudate was noted during NPWT, including removal of substances that slow down the wound healing process. Moreover, a moist wound environment was maintained, which accelerated the elimination of bacterial contamination and wound contraction. With regard to the economic advantage of NPWT, it should be noted that vacuum dressings

were in place for a prolonged duration. This eliminates the need for frequent dressings in the first phase of the wound process, thus, reducing the number of dressings, topical medications, and time and efforts of medical personnel.38,39 Furthermore, this reduces exposure of the wound to hospital tools and air and hands of the medical staff, and thus reduces the risk of wound contamination with hospital strains of microorganisms40 and prevents healthcare-associated infections. In addition, the reduced duration of ongoing systemic antibacterial therapy results in significant cost savings. CONCLUSION The use of NPWT for patients with APIDST and extensive purulent wounds helps accelerate the cleansing and

Figure 2. Case report - patient P. 24 years, intra-muscular thigh phlegmon:

Figure 2a. View of wound on day 3 after phlegmon incision and drainage;

Figure 2b - the stages of application of vacuumassisted dressings on day 3;

Figure 2c - the stages of application of vacuumassisted dressings on day 3;

Figure 2d - view of wound day 7, suturing.

Figure 2e - view of wound on day 7, suturing.

Figure 2f - view of wound on day 7, suturing.

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decontamination of wounds, eliminates inflammation, reduces the size of wounds, and minimises the risk of secondary infection. This method reduces the duration

of hospital stay for patients, and reduces the duration and cost of treatment. n

REFERENCES 1. Davydov Yu. A., Usenko M.J., Larichev A.B. Vacuum therapy as an active treatment of acute purulent diseases of soft tissues and purulent wounds. Khirurgiya. 1987, 3:153-4 [Article in Russian]. 2. Davydov Yu. A., Larichev A.B., Smirnov A.P., Flegontov V.B. Vacuum therapy in treatment of acute purulent diseases of soft tissues and purulent wounds. Journal of Surgery. 1988, 9:4З-6 [Article in Russian]. 3. Davydov Yu. A., Larichev A.B., Menkov K.G. Bacteriological and cytological evaluation of vacuum therapy of purulent wounds. Journal of Surgery. 1988, 10:48-52 [Article in Russian]. 4. Davydov Yu. A., Larichev A.B., Kozlov A.G. Pathogenic mechanisms of vacuum therapy influence on the course of wound process. Khirurgiya. 1990, 6:42-7. 9-16,25-28 [Article in Russian]. 5. Chariker ME, Jeter KF, Tintle TE, Bottsford JE. Effective management of incisional and cutaneous fistulae with closed suction wound drainage. Contemp Surg. 1989;34:59-63. 6. Fleischmann W., Strecker W., Bombelli M., Kinzl L. Vacuum sealing as treatment of soft tissue damage in open fractures. Unfallchirurg. 1993 Sep;96(9):48892. [Article in German]. 7. Morykwas M., Argenta L.C., Shelton-Brown E.I., McGuirt W. Vacuum-assisted closure: A new method for wound control and treatment: Animal studies and basic foundation. Ann. Plastic. Surg. 1997; 38(6):553-62. 8. Davydov Yu. A., Larichev A.B. Vacuum therapy of wounds and wound process. M: Medicine. 1999; 160p. 9. Larichev A.B. Low-dose negative pressure in treatment of wounds and wound infections. Russian Medical Journal. 2005; 4:44-8 [Article in Russian]. 10. Larichev A.B. Vacuum-therapy of Wounds and Wound infections (negative Pressure Wound therapy). Carlsbad, CA (USA): BlueSky Publishing. 2005, 248p. 11. The Theory and Practice of Vacuum Therapy. / Edited by C. Willy, Germany, 2006; 405 p. 12. Larichev A.B., Antoniuk A.V., Kuzmin V.S. Vacuum therapy in the complex treatment of purulent wounds. Khirurgiya. 2008; 6:22-6 [Article in Russian]. 13. Erba P., Ogawa R., Ackermann M, Adini A., Miele L.F., Dastouri P., Helm D., Mentzer S.J., D’Amato R.J., Murphy G.F., Konerding M.A., Orgill D.P. Angiogenesis in wounds treated by microdeformational wound therapy. Ann Surg. 2011 February; 253(2): 402–9. doi: 10.1097/ SLA.0b013e31820563a8. 14. Schintler M.V. Negative pressure therapy: theory and practice. Diabetes Metab Res Rev. 2012; 28(1):72-7. doi: 10.1002/dmrr.2243.

15. Andros G., Armstrong D.G., Attinger C., Boulton A.J., Frykberg R.G., Joseph W.S., Lavery L.A., Morbach S., Niezgoda J.A., Toursarkissian B. Consensus statement on negative pressure wound therapy (V.A.C. therapy) for the management of diabetic foot wounds. Wounds. 2006; 18(6):1-32. 16. Tuncel U, Erkorkmaz U, Turan A. Clinical evaluation of gauze-based negative pressure wound therapy in challenging wounds. Int Wound J. 2012 Mar 15. doi: 10.1111/j.1742-481X.2012.00955.x. 17. Bütter A, Emran M, Al-Jazaeri A, Ouimet A. Vacuum-assisted closure for wound management in the pediatric population. J Pediatr Surg. 2006 May;41(5):940-2. 18. Budkevich LI, Zaitseva TV. State and prospects of the problem of treatment of children with wounds of various etiologies when using vacuum therapy. Detskaya khirurgiya. 2015, 3:44-47. [Article in Russian]. 19. Saraiya HA, Shah MN. Use of indigenously made negative-pressure wound therapy system for patients with diabetic foot. Adv Skin Wound Care. 2013 Feb; 26(2):74-7. doi: 10.1097/01. ASW.0000426716.51702.29. 20. Armstrong D.G., Marston W.A., Reyzelman A.M., Kirsner R.S. Comparative effectiveness of mechanically and electrically powered negative pressure wound therapy devices: a multicenter randomized controlled trial. Wound Repair Regen. 2012 May-Jun; 20(3):332-41. doi: 10.1111/j.1524-475X.2012.00780.x. 21. Antony S, Terrazas S. A retrospective study: clinical experience using vacuum-assisted closure in the treatment of wounds. J Natl Med Assoc. 2004 Aug; 96(8):1073-7. 22. Negosanti L, Sgarzani R, Nejad P, Pinto V, Tavaniello B, Palo S, Oranges CM, Fabbri E, Michelina VV, Zannetti G, Morselli PG, Cipriani R. VAC(®) therapy for wound management in patients with contraindications to surgical treatment. Dermatol Ther. 2012 May; 25(3):277-80. doi: 10.1111/j.1529-8019.2012.01451.x. 23. Keskin M, Karabekmez FE, Yilmaz E, Tosun Z, Savaci N. Vacuum-assisted closure of wounds and anxiety. Scand J Plast Reconstr Surg Hand Surg. 2008; 42(4):202-5. 24. Ottosen B, Pedersen BD. Patients’ experiences of NPWT in an outpatient setting in Denmark. J Wound Care. 2013 Apr; 22(4):197-8, 200-2, 204-6. 25. Upton D, Andrews A. Negative pressure wound therapy: improving the patient experience. Part 1 of 3. J Wound Care. 2013 Oct; 22(10):552-7. 26. Upton D, Andrews A. Negative pressure wound therapy: improving the patient experience. Part 2 of 3. J Wound Care. 2013 Nov; 22(11):582, 584-91. 27. Andrews A., Upton D. Negative pressure wound therapy: improving the patient experience. Part 3 of 3. J Wound Care. 2013 Dec 12; 22(12):671-80.

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28. Holle G, Germann G, Sauerbier M, Riedel K, von Gregory H, Pelzer M. Vacuum-assisted closure therapy and wound coverage in soft tissue injury. Clinical use. Unfallchirurg. 2007 Apr; 110(4):289300. [Article in German]. 29. Ubbink DT, Westerbos SJ, Nelson EA, Vermeulen H. A systematic review of topical negative pressure therapy for acute and chronic wounds. Br J Surg. 2008 Jun; 95(6):685-92. 30. Schintler M.V. Negative pressure therapy: theory and practice. Diabetes Metab Res Rev. 2012 Feb; 28(1):72-7. doi: 10.1002/dmrr.2243. 31. Bohn G. Mechanically powered ambulatory negative pressure wound therapy device for treatment of a colostomy takedown site. J Wound Ostomy Continence Nurs. 2013 May-Jun; 40(3):315-7. doi: 10.1097/WON.0b013e31828f478e. 32. Ogawa R. Treatment of surgical site infection and hypertrophic scars. Kyobu Geka. 2012 May; 65(5):409-17. [Article in Japanese]. 33. Kiliç A, Ozkaya U, Sökücü S, Basilgan S, Kabukçuoğlu Y. Use of vacuum-assisted closure in the topical treatment of surgical site infections. Acta Orthop Traumatol Turc. 2009 Aug-Oct; 43(4):336-42. [Article in Turkish]. 34. Damert HG, Altmann S, Schneider W. Soft-tissue defects following olecranon bursitis. Treatment options for closure. Chirurg. 2009 May; 80(5):448, 450-4. [Article in German]. 35. Beno M, Martin J, Sager P. Vacuum assisted closure in vascular surgery. Bratisl Lek Listy. 2011; 112(5):249-52. 36. Shweiki E, Gallagher KE. Negative pressure wound therapy in acute, contaminated wounds: documenting its safety and efficacy to support current global practice. Int Wound J. 2012 Mar 15. doi: 10.1111/j.1742-481X.2012.00940.x. 37. Obolenskiy V.N., Ermolov A.A., Aronov L.S., Rodoman G.V., Serov R.A. Application of the local negative treatment in the complex treatment of acute pyo-inflammatory diseases of the soft tissues. Khirurgiya. 2012; 12:50-5. [Article in Russian]. 38. Moffatt C.J., Mapplebeck L., Murray S., Morgan P.A. The experience of patients with complex wounds and the use of NPWT in a home-care setting. J Wound Care. 2011; 20(11):512,514,516. 39. Othman D. Negative Pressure Wound Therapy Literature Review of Efficacy, Cost Effectiveness, and Impact on Patients’ Quality of Life in Chronic Wound Management and Its Implementation in the United Kingdom. Plast Surg Int. 2012:374-98. 40. Steingrimsson S., Gottfredsson M., Gudmundsdottir I., Sjögren J., Gudbjartsson T. Negative-pressure wound therapy for deep sternal wound infections reduces the rate of surgical interventions for early re-infections. Interact Cardiovasc Thorac Surg. 2012 Sep.; 15(3):406-10.

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Science, Practice and Education

The use of clinical guidelines during the treatment of diabetic foot ulcers in four Nordic countries INTRODUCTION Since 2003 clinical guidelines disseminated aimed at the reduction of the rates of amputation and ulceration of the diabetic foot. A guideline has no value until after it has been implemented. This study aimed to explore this implementation in four Nordic countries. BACKGROUND Limb amputation is a common complication of diabetes mellitus. Every 30 seconds, a limb is lost due to diabetes somewhere in the world.1 To reduce the number of amputations, multidisciplinary teams have developed treatment strategies that have proven good results in healing and in reduced amputation rates.2,3 The first guidelines for the prevention and treatment of the diabetic foot were developed and published by the International Working Group of the Diabetic Foot in 1999. The guidelines were updated in 2003, 2007, and 2011.2,4,5 In the Nordic countries (Denmark, Finland, Iceland, Norway, and Sweden), the International Working group recommendations have been incorporated into different guidelines. In Sweden, the first National Guidelines of Diabetes Care was published in 1999,6 and was updated in 2010 and 2015;7,8 multi-disciplinary team management of the diabetic foot is included in this publication. After careful assessment, similar guidelines were published in 2009 in Norway and Finland,9,10 and in 2013 in Denmark.11 At the time of this survey, Iceland had no national diabetes care guidelines and was not included in this study. A guideline is of interest only when it is implemented in clinical practice. This study aimed to explore implementation of guidelines for the prevention and treatment of the diabetic foot in Denmark, Finland, Norway, and Sweden. METHODS During 2014, a web-based questionnaire was de-

veloped on behalf of the Nordic Diabetic Foot Task Force that explored the use of guidelines for the treatment of diabetic foot ulcers. It consisted of a) general questions regarding the health care setting of the respondents, and b) specific questions regarding the use of guidelines (i.e., Does your work place use any guidelines when referring patients with diabetes and a foot ulcer? If yes, which guideline? Please comment). The questionnaire was distributed electronically to all of the members of national associations of diabetes specialist nurses, wound care nurses, diabetologists, and endocrinologists, and to all hospitals in the included countries.

Magdalena Annersten Gershater and Nordic Diabetic Foot Task Force (Chair Klaus Kirketerp-Møller, Denmark, Vesa Juutilainen, Finland, Tore Julsrud Berg, Norway, Magnus Löndahl, Sweden)

The questionnaire was sent to all known hospitals in Sweden via the Swedish Diabetes Nurses Association. In the other countries, it was distributed through the national wound organisations and the Nordic Task Force members.

Magdalena Annersten Gershater Senior Lecturer Malmö University Faculty of Health and Society Department of Care Science 206 05 Malmö, Sweden

The response rate was N=601 completed questionnaires (Denmark, n=119; Finland, n=76; Norway, n=192; Sweden, n=214). The results were not considered conclusive or representative because there were no data regarding which of the contacted clinics were actually treating diabetic food ulcer patients. Descriptive statistics were used for the analysis. Content analysis was used to analyse the free text answers. THE NORDIC DIABETIC FOOT TASK FORCE The Nordic Diabetic Foot Task Force is a multidisciplinary network of national and international wound-care clinicians. This unique collaboration promotes the systematic implementation of guidelines for diabetic foot care in the Nordic countries. The Task Force aims to initiate and support various activities at the national level that can improve the implementation of recommended guidelines and the treatment of patients in clinical practice (www.nordicdiabeticfoot.com). 

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Correspondence: magdalena.gershater@mah.se Conflicts of interest: None

RESULTS The current work place categories described by the respondents were hospitals/specialist care (n=311, 52%), primary care (n=155, 26%), home nursing settings (n= 66, 11%), other (n= 67, 11%), or no response (n=2). A total of 517 (86%) of the respondents worked with diabetes foot patients at the work place; 167 (33%) respondents worked at a specialist centre for diabetic foot ulcer treatment. The patients were referred to the respondents by general practitioners (n=393, 65%), nurses in home nursing organisations (n= 284, 47%), other departments in the same hospital (n=278, 46%), specialist physicians (n=200, 33%), other hospitals in the region (n= 196, 33%), private chiropodists (n=134, 22%), or other hospitals outside the region (n=60, 10%). This referral question was not answered by 107 (18%) respondents. Regular foot screening of diabetes patients was performed by 312 (52%) of the respondents; 144 (24%) did not perform screening and 145 (24%) respondents did not answer this question. The results for the list of professions that participated in the treatment of the diabetic foot are presented in Table 1. Does your work place use any guidelines when referring patients with diabetes and a foot ulcer? If yes, which guideline? Yes (n=233, 39%) No (n=209, 69%) No answer (n=159, 26%). International guidelines were mentioned by 8, national guidelines by 26, regional guidelines by 31, and local guidelines by 22, respondents.

Comments from Denmark: “New regional guidelines are under development.” “I don´t know if we have any guidelines.” Comments from Finland: “We use recommendations from the diabetes foot team.” “We follow the internal working group’s recommendations.” “It is my own professional responsibility.” Comments from Norway: “We have no guidelines.” “I don´t know if we have any guidelines.” “The guidelines have expired.” “New guidelines are under development.” “We have no foot team to refer to.” “No one is responsible for the patients.” “It works well! A good tool for guidance!” Comments from Sweden: “There is a need for individualised assessments.” “There is a need for simpler guideline following the patient´s care chain.” “The regional guidelines have expired, new guidelines are under development.” “We have no foot team to refer to.” “I don´t know if we have any guidelines.” “We have no guidelines.” “It works well!”

TABLE 1. PROFESSIONS PARTICIPATING IN THE TREATMENT OF THE DIABETIC FOOT (N=366 RESPONDENTS). PROFESSION

ALWAYS IN THE TEAM

AVAILABLE NEARBY

EXTERNAL CONSULTANT

NEVER

Endocrinologist/diabetologist 148 65 82 71 General Surgeon

Vascular Surgeon

53 78 188 47

Orthopaedic Surgeon

121 65 135 45

Podiatrician

25 9 63 269

Chiropodist

201 34 91 40

Diabetes Specialist Nurse

179

Orthopaedic Technician

165

Dermatologist

20 38 165 143

Infection medicine specialist

Microbiologist

12 61 159 134

Plastic surgeon

138

170

Wound care Nurse

188

Other

41 33 76 216

101

116

138

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DISCUSSION The results of this study indicated that guidelines for the treatment of the diabetic foot have not been implemented in clinical practice in the Nordic countries. Only 39% of the respondents used guidelines. After more than 15 years after the introduction of the first international guideline, not all of the hospitals in the four countries have organised diabetic foot clinics. Health care professionals who cared for persons with diabetes and foot did not know where to refer patients. This situation is unsatisfactory. These four countries have well-developed health care organisations. The responsibility for development of diabetes foot centres should be assumed by these organisations. A reduction in numbers of amputations in patients with diabetes can be achieved via structured treatment strategies implemented by multi-disciplinary teams.2,3 During the last 10 years, the Nordic health care organisations have used time and resources for other areas of the health care instead of implementing the international guidelines. This prioritisation of funding is questionable because the financial costs of a major amputation are many times greater than the costs of primary healing without amputation.12 The study revealed that there was an alarming lack of awareness of the existing guidelines. Evidence-based care is fundamental to all health care education. International and national guidelines have been developed to facilitate continuous updating of the care process for this vulnerable patient group, and for other patients. The individual health care professional has a responsibility to maintain and develop professional skills and follow developments in the area. However, the caregiver/employer should facilitate professional development and organise the work setting so that guidelines can be implemented. Previous studies of the implementation of evidence-based care in clinical practice have revealed that this complex process is affected by organisational- and individual-level factors.13 Properties of the new method to be implemented can present obstacles. In the guidelines to reduce ulceration and amputation of the diabetic foot, the “new” method is mainly to systematically apply current techniques and existing methods through collaboration of multidisciplinary teams. Characteristics of the health care professionals using the new method could also present other obstacles. Team members may have different levels of knowledge and of resistance to change. It is the manager’s responsibility to organise the work in teams and to motivate and educate reluctant team members. The context of the implementation is crucial. The guidelines must be adapted to different health care settings and organisations, and in different leadership climates and management cultures. Managers and leaders must have the knowledge, skills, and abilities necessary to create a workplace culture that uses

evidence-based knowledge. A good management has welldeveloped routines for communication with the health care professionals. Motivated staff also demand receipt of updated guidelines in their daily clinical practice. Leadership skills that promote successful implementation include giving feedback and emphasis on evidence-based work. A financial model that promotes care provided according to guidelines could be used as an incentive at the “floor level” in the clinic and at a higher level. Centres of excellence could be used as examples for other clinics to appreciate and imitate. Time, education, perception, and equipment resources should be prioritised and allocated, and outdated methods and routines should be removed. METHODOLOGICAL CONSIDERATIONS The survey was sent to all hospitals in the four countries because there were no national registries of diabetic foot clinics. The low response rate might have been due to a lack of specialist clinics for diabetic foot treatment and because hospitals without a foot clinic might have decided to not respond to the survey. The guidelines were not well-known among even one-half of the respondents who worked in hospital/specialist care. The free text responses indicated that the questions were difficult to understand. This result suggested that many of the respondents were not familiar with evidence-based guidelines. The results of previous studies have indicated that most patients with diabetes and a foot ulcer receive daily care from health care professionals in primary care practice or who are employed by home nursing organisations.14 These settings are seldom included in implementation of clinical guidelines because these individuals perform their work far from the hospitals. The implementation of evidence-based guidelines should occur in all health care settings that treat patients with diabetes and at risk for, or with, foot ulcers. Achievement of this goal requires updated evidence-based education for all health care professionals caring for these patients. Future studies should explore knowledge and strategies for implementation of guidelines for individuals with formal leadership responsibilities in settings where persons with diabetes and foot ulcers receive care. IMPLICATION FOR CLINICAL PRACTICE Clinical leaders should assume responsibility for the implementation of clinical guidelines for the treatment of the diabetic foot. The documents are available and systematic follow-up of the quality of care in this area via the use of local registers of treatment outcomes and of national amputation registers should be implemented.15 n 

REFERENCES 1. Boulton AJM, Vileikyte L, Ragnarson Tennvall G, Apelqvist J. The global burden of diabetic foot disease. The Lancet 2005; 366(9498):1719-1724.

6. Socialstyrelsen. Nationella riktlinjer för vård och behandling vid diabetes mellitus. Stockholm: Socialstyrelsen; 1999.

2. Bakker K, Apelqvist J, Schaper NC. International Working Group on the Diabetic Foot. International Consensus on the Diabetic Foot & Practical Guidelines on the Management and Prevention of the Diabetic Foot. Diabetes Metab Res Rev 2011;16 (Suppl 1):84-92

7. Socialstyrelsen. [Internet] Nationella riktlinjer för diabetesvården 2010 – Stöd för styrning och ledning. Stockholm: Socialstyrelsen; 2010. [September 2016] Available from: http://diabetes.se/PageFiles/1222/2010-2-2.pdf

3. Apelqvist J, Larsson J. What is the most effective way to reduce incidence of amputation in the diabetic foot? Diabetes Metab Res Rev 2000;16(1):75-83. 4. Apelqvist J, Bakker K, van Houtum WH, Schaper NC. Practical guidelines on the management and prevention of the diabetic foot: based upon the International Consensus on the Diabetic Foot (2007) Prepared by the International Working Group on the Diabetic Foot. Diabetes Metab Res Rev 2008;24 (Suppl 1):181-7 5. Apelqvist J, Bakker K, Houtum WH, Nabuurs-Franssen MH, Schaper NC International consensus and practical guidelines on the management and the prevention of the diabetic foot. Diabetes Metab Res Rev 2000;16 (suppl 1):84–S92

12. Prompers L, Huijberts M, Schaper N, Apelqvist J, Bakker K:E,M., Holstein P, et al. Resource utilisation and costs associated with the treatment of diabetic foot ulcers. Prospective data from the Eurodiale Study. Diabetologia 2008;51(10):1826-34. 13. Grol R, Grimshaw J. From best evidence to best practice: effective implementation of change in patients’ care. The Lancet 2003;362(9391):1225-30.

8. Socialstyrelsen. [Internet] Nationella riktlinjer för diabetesvård - Stöd för styrning och behandling. Stockholm: Socialstyrelsen; 2015. [September 2016] Available from: http://www.socialstyrelsen.se/Lists/ Artikelkatalog/Attachments/19689/2015-2-3.pdf

14. Gershater MA, Pilhammar E, Alm Roijer C. Documentation of diabetes care in home nursing service in a Swedish municipality: a cross-sectional study on nurses’ documentation. Scand J Caring Sci 2011;25(2):220-6.

9. Helsedirektoratet. Nasjonale faglige retningslinjer Diabetes Forebyggning, diagnostikk og behandling.; 2009.

15. Amputations- och protesregistret för nedre extremiteten [Internet] http://swedeamp.com/

10. Current care guidelines. [Internet] Diabeetikon jalkaongelmat. The Finnish Medical Society (Suomalainen Lääkäriseura Duodecim). Guideline ed.; 2009. Available from: http://www.kaypahoito.fi/ web/kh/suositukset/suositus?id=hoi50079#suositus; (11) Sundhedsstyrelsen. National klinisk retningslinje for udredning og behandling af diabetiske fodsår. ; 2013.

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Science, Practice and Education

The WAWLC Wound Care Kit for less resourced countries: a key tool for modern adapted wound care INTRODUCTION Throughout the world, chronic wounds are a public health problem that is often ignored.1 This is even more evident in reduced resources regions, such as Africa, Asia, and South America. In these regions, the main aetiologies of wounds are similar to those encountered in Europe (e.g., vascular or diabetic ulcers, traumatic wounds, and burns) with the addition of typical tropical pathologies of infectious origin (e.g., leprosy, Buruli ulcer, phagedenic ulcer, and sickle cell ulcers). Wounds resulting from physical trauma are one of the primary reasons for the demand for care in natural disasters, displacements of populations, or armed conflicts. The treatment required for these wounds can be long and expensive. The patient often needs to remain in the hospital, while some will require additional help if the wound limits their independence such as in the case of an elderly person or a child. Even if the care is provided free of charge, the indirect costs (purchase of food, loss of ability to work, interruption to schooling for a child, and social limitations) create a difficult financial burden. In these settings, basic wound treatments largely rely on poor use of antiseptics and drying of the wound, resulting in long, expensive, and painful care. Additionally for large wounds, serious physical consequences, such as limb contractures, articular fixation, and amputations, can occur. Additionally, dressing material is often not available and is often limited to various bandages and compresses.

It is interesting to remember that the World Health Organisation (WHO) has defined a list of essential medicines, including approximately 200 medicines that respond to the priority health needs of a population. These were selected according to the prevalence of diseases, safety, efficacy, and a comparison of the cost-efficiency ratios. These medicines should be permanently available in the context of operational health systems, in sufficient quantities, in a suitable galenic formulation, with assured quality, and at an affordable price at the community level.2 This essential medicines list, which is revised every two years, is an effective tool for rationalisation of the distribution of medicines; however, no similar list exists for wound care materials. Over the last decades, the approach to wound care has been profoundly transformed, as a result of better understanding of wound healing physiology. The principles that were traditionally based on frequent disinfection and drying of the wound are no longer in use. International consensus now favours healing in a moist environment and less disinfection. These principles have been adopted by the WHO as the basic approach for wound care.3 Although healing in a moist environment has largely benefitted from the arrival of new dressings on the market (e.g., hydrocolloid, hydrogel, hydrocellular, and alginate dressings), these items are far too expensive and rarely available in countries with reduced resources. It seemed important for the World Alliance for Wound and Lymphoedema Care (WAWLC) to establish new 

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Hubert Vuagnat WAWLC General Secretary and Treasurer University Hospitals of Geneva Centre for Wounds and Wound Healing Rue GabriellePerret-Gentil, 4 CH-1211 Genève 14 SWITZERLAND

Eric Comte Coordinator, Geneva Health Forum University Hospitals of Geneva Rue GabriellePerret-Gentil, 4 CH-1211 Genève 14 SWITZERLAND Former Medical Director Médecins sans Frontières Suisse www.wawlc.org Correspondence: Hubert.Vuagnat@hcuge.ch Conflicts of interest: None

Basic materials needed for a modern adapted wound dressing. All elements except tweezers and scissors are contained in the WAWLC Wound Care Kit.

standards in the form of a list of essential materials for wound dressings. Thus, the authors developed such a list and then a practical wound care kit. GENERAL PRINCIPLE BEHIND HUMANITARIAN KITS International organisations, such as ICRC, HCR, and UNICEF, and NGOs, such as MSF, MDM, CARE, and Oxfam, are often called to respond to emergency situations due to conflicts or natural disasters. In the 1980s, to become more rational and more effective, these organisations worked on solutions to standardise medical supplies. This approach led to standardised, prepackaged, immediately available, and easy to transport kits. These kits reflected the WHO principles for medicine administration.4 These kits are generally composed of a base unit and additional units that enable the response to be better adjusted to the variety of scenarios encountered in the field. These medical kits are the result of consensus from the major emergency organisations and the WHO and are regularly updated according to field feedback, development of new medical products, and protocols. The kits are considered to be reliable, standardised, inexpensive, and able to quickly provide essential medicines and medical devices (renewable supplies and equipment) necessary in an emergency. Among the most used kits are the cholera kit5, the interagency emergency health kit 20116, and the reproductive health kit from UNFPA.7 UPDATING THE WOUND CARE KIT The actual Dressing Kit for caregivers contains the supplies necessary for 50 dressings.8 Largely used by international organisations, this kit was created more than thirty years ago and does not take into account progress in wound healing knowledge. Mainly composed of dry gauze and iodine, this kit is based on the principle of disinfecting and drying and does not provide for a modern approach to wound care. It was thus necessary to update the wound care kit. 28

THIS WAWLC WOUND CARE KIT, MUST: n Provide basic equipment in an emergency situation as well as for primary health care n Enable distribution of standardised materials n Offer appropriate, well-known materials n Facilitate management of stocks and health programmes n Facilitate management by better controlling orders and budgets THIS UPDATED WAWLC WOUND CARE KIT MUST ALSO ENABLE CREATION OF A NEW DYNAMIC: n Wound care protocols standardisation by using the same materials n Modern wound care training harmonisation based on a standard material list n WHO facilitation in establishing a list of essential materials n Facilitating negotiations with industry to obtain better commercial conditions n Facilitating development of materials for wound care in regions with limited resources THIS KIT WILL MAINLY SERVE PATIENTS OF THE FOLLOWING ORGANISATIONS: n Emergency situation organisations (e.g., UNICEF, UNHCR, ICRC, MSF, MDM, CARE, Oxfam, and Save the Children) that provide care in the field n National health programmes related to wound care (Buruli ulcer, yaws, leprosy, and lymphatic filariasis) n Organisations acting in the domain of primary or secondary health care (health centres and district hospitals) The WAWLC Wound Care Kit, which is described here, should be the basis of the update to the kits provided by specialised distributers in humanitarian crises. The content of this kit can also provide a simple reference list to help NGOs or local authorities to organise their own pharmacy from local purchases. Most importantly, all of its main components can either be bought in the less resourced EWMA Journalâ&#x20AC;&#x201A;

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Main features The WAWLC Wound Care Kit is stocked in a cardboard box. The kit has a volume of 0.1 m3 and weighs approximately 16 kg. It is composed as a basic functional unit to which additional units, such as the Modern Dressing 01 (defined below), can be added. The basic unit contains classic materials that are known by most care providers and that can be found in most countries. This unit can be easily used but, if necessary, can also be constituted or replenished on site.

countries or replaced with equivalent local products (e.g., shea butter instead of Vaseline). Following the WAWLC and WHO initiative, consensus work was carried out via a modified DELFI approach to define the content of this new kit. This task force, which brought together experienced clinicians from the fields of wounds and emergency care in regions with limited resources, assembled via internet consultations and in workshops organised at conferences of the European Wound Management Association (EWMA, Copenhagen, May 2013 and Madrid, May 2014) and the Canadian Association of Wound Care (CAWC, October 2014). GENERAL DESCRIPTION OF THE WAWLC WOUND CARE KIT n Main specifications The main objective is to realise quality wound care in an emergency situation or in a situation with limited resources in health centres or district hospitals. Such a kit should: n Contain the necessary renewable materials to make up to 100 dressings (standard size set at 10 cm x 10 cm) n Be simple to use for nursing or medical staff n Enable providers to follow the basic principles of modern wound care n Be transportable by plane, ship, or road and, in case of emergency, as hand luggage n Be able to easily go through customs n Be easy to store and quick to identify (expiry date, origin of the materials, name of the kit, and list of contents) n Be stable enough to be stored in humid conditions and high temperatures (50°C) n Have a shelf life of more than 2 years n Respect the laws of medical materials, notably directives 93/42/EEC concerning medical equip ment9

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The additional unit Modern Dressing 01 comprises three so-called modern dressing components, which are far from readily available in such settings. In addition, their use, although very simple, necessitates specific training. According to the resources available in the health structure, the WAWLC Wound Care Kit can be supplemented with other available materials such as the disinfection kit or the MSF kit, designated as “dressing, three instruments” (KSURBDRE3). Part of the included materials may necessitate sterilisation. If the structure does not have the necessary means for sterilisation, it is recommended that a sterilisation kit be procured. With no narcotic or psychotropic substances, the medicines that are included are not subject to international inspection, and there is no requirement for extra formalities in order to transport them. What is not included The kit is directed at care of the wound itself; however, it is clear that one of the basic principles of modern wound care is to take a holistic approach to the patient, thus requiring some items outside the kit. Pain control is most important, and use of analgesics (minor or major) will need to be evaluated in each situation. Localised or general secondary infections must be diagnosed and can sometimes necessitate oral or enteral antibiotics. It should be pointed out that most wounds do not require antibiotics. Simply cleaning the wound with clear water or possibly using an antiseptic is often sufficient. Moreover, many cases of fibrinous wounds are mistaken for infection, and therefore, education has an important role to play for this situation. The kit does not contain items necessary for diagnosis and aetiological treatment of wounds, such as those in diabetes  or Buruli ulcers. 29

This kit contains neither anti-tetanus vaccine nor serum that can be recommended according to the state of the wound and its context. Nutrition is an important issue that should also be considered. A Post-Exposure Prophylaxis (PEP) kit for staff members that are accidentally exposed to blood or body fluids is also recommended. Item quantities The benchmark measurement is a wound that requires covering by a 10-cm Ă&#x2014; 10-cm secondary dressing. The estimation of the quantities of materials is based on the use of standard therapeutic directives and on the figures provided by individuals or organisations with experience in the domain. The quantities should be sufficient if the clinicians follow the standard therapeutic directives. However, it should be stated that the WAWLC Wound Care Kit was not conceived for the treatment of severe acutte wounds or wounds from major surgery, which require acute treatment at secondary or tertiary level hospitals. Kit contents As mentioned above, no WHO-based list for essential wound dressing materials exists. The first part of the project was to establish such a list of essential materials. The goal was to consider three major item groups: n The WAWLC Wound Care Kit, which is composed of 26 items to allow basic adapted modern wound care (Table 1) n The additional Modern Dressing 01 Kit, which is composed of three so-called modern wound dressing items (Table 2) n 13 additional useful items to improve both woundcare and hygiene (Table 3) The objective of this essential material is to be able to realise modern, adapted wound care that can be summarised schematically in six points: n Comprehensive patient evaluation and treatment n Avoidance of physical and chemical trauma to the wound n Debridement and peri wound skin and judicious infection control n Management of controlled humidity of the wound n Control of periwound oedema/lymphedema n Prevention of disability As described above, the basic unit of the WAWLC Wound

Care Kit has been reduced to 26 items. This limitation has been met principally for two reasons: n A pedagogic will to promote simple protocols n Ease of management. With respect to the kit currently used by humanitarian organisations, 19 new items have been introduced: n Non-sterile, non-woven gauze n Thick, sterile tulle n Transparent alimentary film n Cohesive bandage n Under-plaster bandage, wadding n Vaseline n Silver sulfadiazine n Sterile saline solution n Liquid soap n Hydro alcoholic solution for the hands n Scalpel blade n Disposable scalpel with sheath n Single-use drapes In addition, some items that enable the management of patient follow-up and waste have been added: n Basic, easy-to-use wound care procedures (therapeutic directives) n Patient follow-up charts n Pen n Paper rulers n Sharp-edged box n Plastic rubbish bag The additional modern dressings unit for the wound care kit comprises three items: n Alginate n Hydrogel n Polyurethane foam (hydrocellular) The basic WAWLC Wound Care Kit also contains a list of additional kits that are available and a list of addresses of kit suppliers. To understand the convenience of the new kit, in the following table we have noted the use of each item with respect to the six basic principles of wound care. WHAT IS THE COST FOR THE NEW KIT? The cost of the actual Dressing kit is approximately 200 euros for up to 100 dressings (2 euros per dressing). The cost of the new WAWLC Wound Care Kit is currently estimated to be between 220 and 240 euros, but this price should be reduced 300-350 following mass production. Even if in an emergency situation a cost of 4 euros per

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TABLE 1: COMPOSITION OF THE BASIC UNIT OF THE WAWLC WOUND CARE KIT Essential materials

Items Avoidance Debridement Management Management Control Other present of physical and of controlled of the of (Hygiene, in the and chemical judicious humidity infection oedema immobilisation, former trauma to infection of the when and analgesics, Dressings kit the wound control wound present lymphoedema etc.)

GAUZE AND DRESSING 1. Sterile, non-woven gauze

2. Non-sterile, non-woven gauze

3. Thick, sterile tulle

4. Cellophane transparent film

BANDAGE 5. Cohesive bandage

6. Under-plaster bandage, wadding

7. Crêpe bandage

CREAMS, OINTMENTS 8. Vaseline

9. Silver sulfadiazine

TAPE 10. Plaster, 2 cm

11. Plaster, roll, 10 cm

HYGIENE AND DISINFECTANT 12. Sterile saline solution

13. Liquid soap

14. Povidone iodine, 10%, solution

15. Hydroalcoholic solution for the hands

MATERIALS 16. Single-use, non-sterile gloves

17. Scalpel blade X X 18. Disposable scalpel with sheath

19 Syringe, 20 ml

X X

20. Single-use drapes X STATIONERY 21. Marker X 22. Easy-to-follow procedure X 23. Patient follow-up card

24. Ruled paper X WASTE MANAGEMENT 25. Sharp-edged box X 26 Plastic rubbish bag X

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TABLE 2: ADDITIONAL UNIT MODERN DRESSINGS 01 Essential materials

GAUZE AND DRESSING Alginate X X X Hydrogel X X X Polyurethane foam (hydrocellular)

TABLE 3: COMPLEMENTARY ITEMS LISTED AS ESSENTIAL MATERIALS FOR WOUND CARE BUT NOT CONTAINED IN THE WAWLC WOUND CARE KIT Essential materials

GAUZE AND DRESSING Non-adherent dressing X Super-absorbent dressing X X Charcoal dressing

Dressing with PHMB

BANDAGE Light cotton bandages

Bandage with short extension

Tubular bandage

CREAMS, OINTMENTS Corticosteroid cream X HYGIENE AND DISINFECTANT 5% aqueous chlorhexidine solution

Povidone iodine ointment

Surface disinfectant X MATERIALS Xylocaine injectable X Xylocaine spray X

dressing is acceptable, a lower cost is desirable for everyday use in the context of limited resources. A maximum cost of 1 or 2 euros per dressing will have to be achieved.

packaging, n fostering competition between producers, and n procurement from producers in emerging countries.

Several mechanisms of cost reduction can be envisioned: n agreement with producers of differentiated price policies for countries with limited resources, n purchase of kits with money subsided by specific funds, n work with pharmaceutical companies to have cheaper

FURTHER DEVELOPMENT OF THE WAWLC WOUND CARE KIT After production of the very first prototype in April 2016, work, within WALWC, is underway to test the WAWLC Wound Care Kit. Eighteen preseries kits will be produced

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and sent to three reference hospitals. Once tested, the users will provide their opinions on a form. Based on these observations, necessary adaptation of the kit will be made before a dialogue with the medical device and/or pharmaceutical industry takes place for industrial production. Distributers and users will be invited to give their comments and recommendations for the next generation. To optimise both diffusion and use of the kit as well as a modern approach to wound care suited to the context of limited resources, various actions are underway: n both face-to-face and over the Internet training sessions, n use of the kit in training sessions, n guidelines currently under publication, notably within MSF, n validation request regarding the list of essential materials for wound care with the WHO, and n definition of quality criteria for materials for wound care in order to facilitate choice of procurement sources.

International Lymphoedema Framework Conference Co-hosted by the Italian Lymphoedema Framework

21-24 June 2017 Siracusa · Italy www.2017ILFconference.org

CONCLUSIONS Development of the WAWLC Wound Care Kit will greatly enhance the quality of wound care in less resourced countries. This will be accomplished by not only the materials contained in the kit but also through the training provided for the kit to clinicians. Of course, both the kits and related training have associated costs, and sponsors are welcome to contact the authors of this humanitarian endeavour that is undertaken under WAWLC auspices. n

REFERENCES 1. Sen CK, Gordillo GM, Roy S, Kirsner R, Lambert L, Hunt TK, Gottrup F, Gurtner GC, Longaker MT. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen. 2009; 17(6): 763-71. 2. WHO [Internet]. Listes modèles OMS des médicaments essentiels. [15 September 2016] Available from: www.who.int/medicines/publications/essentialmedicines/fr/ 3. WHO [Internet]. Wound and lymphoedema management, WHO Geneva 2010. [September 2016]. Available from: http://apps.who.int/iris/bitstre am/10665/44279/1/9789241599139_eng.pdf 4. WHO [Internet]. Guidelines for medicine donations revised 2010. Geneva. 2011. [September 2016] Available from: http://apps.who.int/iris/bitstre am/10665/44647/1/9789241501989_eng.pdf 5. WHO [Internet]. Interagency diarrhoeal disease kits - information note. [February 2009;September 2016]Available from: www.who.int/topics/cholera/materials/en/ 6. WHO [Internet]. Kit sanitaire d’urgence interinstitutions 2011, Médicaments et dispositifs médicaux pour une population de 10 000 personnes pendant environ 3 mois. [15 September 2016] Available from: www.who.int/medicines/publications/ kitsanitaire_urgence2011/fr/# 7. United nations population fund humitarian response branch [Internet]. Manuel, Kits de Santé, Reproductive Inter-organisations à Utiliser en Situations de Crise. 2011. [September 2016] .Available from: http://www.iawg.net/resources/184151_UNFPA_ FR.pdf 8. IMRES [Internet]. Dressing kit, 50 dressings. [15 September 2016]. Available from: http://www.imres.nl/media/sheets/en/42136.pdf 9. European commission [Internet]. Medical devices. [15 September 2016]. Available from: http://ec.europa.eu/growth/single-market/european-standards/harmonisedstandards/medical-devices/index_en.htm

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Book Reviews

Book Review ESSENTIAL MICROBIOLOGY FOR WOUND CARE Edited by Valerie Edwards-Jones. Oxford University Press 2016

Elaine Pina Independent researcher Portugal

Correspondence: elainesousapina@ gmail.com Conflicts of interest: None

Wound healing is dynamic and complex with numerous host-specific variables, and where the role of microorganisms is not always clearly understood. This book attempts to clarify this by addressing all aspects related to the role of microorganisms in a practical and objective way. The authors are well known experts from the United Kingdom but the content is applicable to other countries. The chapters follow a logical sequence and are of a reasonable size, the content is clearly stated by the objectives outlined at the beginning of each chapter. Key points, definitions and facts are highlighted in appropriate boxes. This makes the book easy to read. The book covers the basics of microbiology and pathogenesis, diagnosis and treatment with a final chapter on areas where there is ongoing research and where new research is needed. The issue of resistance and problem organisms is highlighted throughout the book and the important distinction between acute and chronic wounds is taken into account with indication of specific techniques for treatment and management for each type. The chapter describing laboratory diagnosis is very well presented with focus on the collection, transport and processing of appropriate samples with practical tips related to types of samples and the need to supply clinical information such as antibiotic usage, cause of trauma, medical conditions. The microbiological differences between acute and chronic wounds and the pathogenesis, manifestations and treatment of most common and several rarer wound pathogens are described in the following chapters. The chapter on biofilms presents

a subject which is still evolving, showing the difficulties in detection in practice at the present time as well as the possible strategies to treat and prevent biofilms in wounds. It has a wide list of references for those who would like to explore the topic in more detail. The role of antimicrobials is described next, stressing important aspects related to topical agents including honey, maggots and plant-derived products. The difficult topic of dressings is presented in a practical and useful way, especially focusing on the indications for their use and symptom-based criteria for their selection. A full chapter is dedicated to healthcare-associated infections and infection control policies. It presents the risk of cross transmission and the need to adopt standard precautions at all times. This is a subject that is often disregarded in practice and it is good to see it addressed since it is very important that infection control and, more specifically, standard precautions be integrated into daily practice. The next chapter emphasises the need for multifactorial management strategies with due importance given to cleansing and debridement. The small print on some of the figures in this chapter limits their usefulness. In conclusion, this is a very useful and timely book, which has acheived its goals very well throughout. Because of its format - small chapters and clear, practical contents - it is accessible also to those for whom English is not the first language. I would recommend it for all professionals involved in wound care in any care setting as a resource for clinical and scientific information for best practice. n

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www.wunddach-kongress-2017.org

2. WundD·A·CH Dreiländerkongress 2017 St. Gallen, Schweiz 28. - 30. September 2017 Abstract Deadline

Early Bird Registrierung

17. Mai 2017 15. Juli 2017 Vorläufige Themen Plenarsitzungen ■

Venöses Ulcus cruris - aus verschiedenen Blickwinkeln

■

Wunden in der Palliativmedizin

■

Diabetischer Fuß

■

Antimikrobielle Therapie

■

Amputation

■

Interprofessionelles Team in der Wundbehandlung

■

Lokaltherapie jenseits von Wundauflagen

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Wundbehandlung in der DACH Region

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Neues aus der Grundlagenforschung

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Allergien in der Wundbehandlung

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Inflammation in der chronischen Wunde

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Psychosoziale Aspekte beim chron. Wundpatienten

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Sicherheit in der Wundbehandlung

■

Ko-Morbiditäten

■

Ethik in der Wundbehandlung

■

Narben

WISSEN SICHERHEIT

QURACTIV ®. Experience wound healing. Quractiv® Derm. The evidence-based therapy for healing stagnating wounds.

Study results demonstrate the effectiveness

Available in three sizes– 20 ml, 12 ml and 7ml

Easy to use

Protect wounds.

Reduce pain.

Heal wounds.

Safely and reliably.

Delight patients.

Do not just manage them.

Rests gently against the wound and

Soothes the wounds

Activates and accelerates

protects it from external influences. –

Prevents germs from forming.

and eases pain.

self-healing powers.

Cochrane Reviews

ABSTRACTS OF RECENT COCHRANE REVIEWS Publication in The Cochrane Library Issue 3, 2016

Interventions for helping people adhere to compression treatments for venous leg ulceration Carolina D Weller, Rachelle Buchbinder, Renea V Johnston Citation example: Weller CD, Buchbinder R, Johnston RV. Interventions for helping people adhere to compression treatments for venous leg ulceration. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD008378. DOI: 10.1002/14651858. CD008378.pub3. ABSTRACT Background: Chronic venous ulcer healing is a complex clinical problem that requires intervention from skilled, costly, multidisciplinary wound-care teams. Compression therapy has been shown to help heal venous ulcers and to reduce recurrence. It is not known which interventions help people adhere to compression treatments. This review is an update of a previous Cochrane review. Objectives: To assess the benefits and harms of interventions designed to help people adhere to venous leg ulcer compression therapy, to improve healing and prevent recurrence after healing. Search methods: In June 2015, for this first update, we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE and EBSCO CINAHL. We also searched trial registries, and reference lists of relevant publications for published and ongoing trials. There were no language or publication date restrictions. Selection criteria: We included randomised controlled trials (RCTs) of interventions that aim to help people with venous leg ulcers adhere to compression treatments compared with usual care, or no intervention, or another active intervention. Our main outcomes were ulcer healing, ulcer recurrence, quality of life, pain,

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adherence to compression therapy and number of people with adverse events. Data collection and analysis: Two review authors independently selected studies for inclusion, extracted data, assessed the risk of bias of each included trial, and assessed overall quality of evidence for the main outcomes in ‘Summary of findings’ tables. Main results: One randomised controlled trial was added to this update making a total of three. One ongoing study was also identified. One trial (67 participants) compared a communitybased Leg Club® that provided mechanisms for peersupport, assistance with goal setting and social interaction with home-based care. There was no clear difference in healing rates at three months (12/28 people healed in Leg Club group versus 7/28 in homebased care group; risk ratio (RR) 1.71, 95% confidence interval (CI) 0.79 to 3.71); or six months (15/33 healed in Leg Club group versus 10/34 in home-based care group; RR 1.55, 95% CI 0.81 to 2.93); or in quality of life outcomes at six months (MD 0.85 points, 95% CI -0.13 to 1.83; 0 to 10 point scale). The Leg Club may lead to a small reduction in pain at six months, that may not be clinically significant (MD -12.75 points, 95% CI -24.79, -0.71; 0 to 100 point scale, 15 point reduction is usually considered the minimal clinically important difference) (low quality evidence downgraded for risk of selection bias and imprecision). Another trial (184 participants) compared a community-based, nurse-led self-management programme of six months’ duration promoting physical activity (walking and leg exercises) and adherence to compression therapy via counselling and behaviour modification (Lively Legs®) with usual care in a wound clinic. At 18 months follow-up, there were no clear differences in healing rates (51/92 healed in Lively Legs group versus 41/92 in usual care group; RR 1.24 (95% CI 0.93 to 1.67)); rates of recurrence of venous leg ulcers (32/69 with recurrence in Lively Legs group versus 38/67 in usual care group; RR 0.82 (95% CI 0.59 to 1.14)); or adherence to compression therapy (42/92 people fully adherent in Lively Legs group versus 41/92 in usual care group; RR 1.02 (95% CI 0.74 to 1.41)). The evidence from this trial was also downgraded to low quality due to risk of selection bias and imprecision. 

Gill Rizzello Managing editor Cochrane Wounds, School of Nursing, Midwifery and Social Work, University of Manchester.

Correspondence: gill.rizzello@ manchester.ac.uk More information: www.wounds.cochrane.org Conflicts of interest: None

A single study compared patient education delivered via video with education delivered by text (pamphlet). However, no outcomes relevant to this review were reported. We found no studies that investigated other interventions to promote adherence to compression therapy. Authors’ conclusions: It is unclear whether interventions designed to help people adhere to compression therapy improve venous ulcer healing and reduce recurrence. There is a lack of trials of interventions that promote adherence to compression therapy for venous ulcers.

Plain language summary Interventions for helping people adhere to compression treatments to aid healing of venous leg ulcers Background: Venous leg ulcers take weeks or months to heal, cause distress, and are very costly for health services. Although compression using bandages or stockings helps healing and prevents recurrence, many people do not adhere to compression therapy. Therefore, interventions that promote the wearing of compression should improve healing and prevent recurrence of venous ulcers. Study characteristics: This updated review (current to 22 June 2015) included three randomised controlled trials. One study conducted in Australia compared standard wound care (venous ulcer treatment, advice and support, follow-up management and preventive care) in a community clinic called ‘Leg Club’ (34 participants) with the same wound care in the home by a nurse (33 participants). Another study (184 participants) compared a community-based exercise and behaviour modification programme called ‘Lively Legs’ for promoting adherence with compression therapy and physical exercise plus usual care (wound care, compression bandages at an outpatient clinic) with ‘usual care’ alone in 11 outpatient dermatology clinics in the Netherlands. A third small study (20 participants) compared a patient educational intervention to improve knowledge of venous disease and ulcer management. The intervention was delivered via video or via written pamphlet for people attending a wound healing research clinic in Miami, USA. Participants in all studies were aged 60 or more, with a venous leg ulcer. Key results: The Leg Club®, a community-based clinic, did not improve healing of venous leg ulcers or quality of life any more than nurse home-visit care, but may result in less pain after six months. Seventeen more people out of 100 were healed after participating in Leg Club (46/100 people in Leg Club healed compared with 29/100 people having usual home care); this difference was not statistically significant and could have occurred by chance. Leg Club participants rated their quality of life 0.85 points better than those receiving home care, assessed on a 10 point scale. Leg Club participants rated their pain at six months 12.75 points lower than the home care group, assessed on a 100 point scale. This trial did not report whether Leg Club clinics improve adherence to compression, time to healing, or prevent recurrence more than home care. It is not clear whether Lively Legs®, a community-based selfmanagement programme, improves ulcer healing or recurrence after 18 months compared with usual care. It is not clear whether Lively Legs® influences adherence to compression ther38

apy. The trial did not report whether the Lively Legs self-management programme clinics improve time to healing of ulcers, reduce pain, or improve quality of life any more than usual care in a wound clinic. It is unclear if patient education delivered by video or via a pamphlet improves healing or recurrence, as the study did not measure any outcomes relevant to this review. No other interventions were identified. Quality of the evidence: It is unclear whether community-based clinics to promote adherence to compression therapy either promote adherence or improve ulcer healing or recurrence. The available evidence is low quality due to the risk of bias in the included studies and their small sample sizes which lead to great imprecision and uncertainty. One single small trial that evaluated an education intervention failed to measure the outcomes we considered important for this review such as ulcer healing and recurrence, and adherence. Further high quality studies are likely to change the outcome of this review. We know that compression therapy is effective, but do not know which interventions improve adherence to compression therapy. Up-to-date June 2015.

Antibiotics and antiseptics for surgical wounds healing by secondary intention Gill Norman, Jo C Dumville, Devi Prasad Mohapatra, Gemma L Owens, Emma J Crosbie Citation example: Norman G, Dumville JC, Mohapatra DP, Owens GL, Crosbie EJ. Antibiotics and antiseptics for surgical wounds healing by secondary intention. Cochrane Database of Systematic Reviews 2015 , Issue 6. Art. No.: CD011712. DOI: 10.1002/14651858.CD011712. ABSTRACT Background: Following surgery, incisions are usually closed by fixing the edges together with sutures (stitches), staples, adhesives (glue) or clips. This process helps the cut edges heal together and is called ‘healing by primary intention’. However, a minority of surgical wounds are not closed in this way. Where the risk of infection is high or there has been significant loss of tissue, wounds may be left open to heal by the growth of new tissue rather than by primary closure; this is known as ‘healing by secondary intention’. There is a risk of infection in open wounds, which may impact on wound healing, and antiseptic or antibiotic treatments may be used with the aim of preventing or treating such infections. This review is one of a suite of Cochrane reviews investigating the evidence on antiseptics and antibiotics in different types of wounds. It aims to present current evidence related to the use of antiseptics and antibiotics for surgical wounds healing by secondary intention (SWHSI). Objectives: To assess the effects of systemic and topical antibiotics, and topical antiseptics for the treatment of surgical wounds healing by secondary intention.

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Cochrane Reviews

Search methods: In November 2015 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other NonIndexed Citations); Ovid EMBASE and EBSCO CINAHL. We also searched three clinical trials registries and the references of included studies and relevant systematic reviews. There were no restrictions with respect to language, date of publication or study setting. Selection criteria: Randomised controlled trials which enrolled adults with a surgical wound healing by secondary intention and assessed treatment with an antiseptic or antibiotic treatment. Studies enrolling people with skin graft donor sites were not included, neither were studies of wounds with a non-surgical origin which had subsequently undergone sharp or surgical debridement or other surgical treatments or wounds within the oral or aural cavities. Data collection and analysis: Two review authors independently performed study selection, risk of bias assessment and data extraction. Main results: Eleven studies with a total of 886 participants were included in the review. These evaluated a range of comparisons in a range of surgical wounds healing by secondary intention. In general studies were small and some did not present data or analyses that could be easily interpreted or related to clinical outcomes. These factors reduced the quality of the evidence. Two comparisons compared different iodine preparations with no antiseptic treatment and found no clear evidence of effects for these treatments. The outcome data available were limited and the evidence was low quality. One study compared a zinc oxide mesh dressing with a plain mesh dressing. There was no clear evidence of a difference in time to wound healing between groups. There was some evidence of a difference in measures used to assess wound infection (wound with foul smell and number of participants prescribed antibiotics) which favoured the zinc oxide group. This was low quality evidence. One study reported that sucralfate cream increased the likelihood of healing open wounds following haemorrhoidectomy compared to a petrolatum cream (RR: 1.50, 95% CI 1.13 to 1.99) over a three week period. This evidence was graded as being of moderate quality. The study also reported lower wound pain scores in the sucralfate group. There was a reduction in time to healing of open wounds following haemorrhoidectomy when treated with Triclosan postoperatively compared with a standard sodium hypochlorite solution (mean difference -1.70 days, 95% CI -3.41 to 0.01). This was classed as low quality evidence. There was moderate quality evidence that more open wounds resulting from excision of pyomyositis abscesses healed when treated with a honey-soaked gauze compared with a EUSOLsoaked gauze over three weeks’ follow-up (RR: 1.58, 95% CI 1.03 to 2.42). There was also some evidence of a reduction in

the mean length of hospital stay in the honey group. Evidence was taken from one small study that only had 43 participants. There was moderate quality evidence that more Dermacym®treated post-operative foot wounds in people with diabetes healed compared to those treated with iodine (RR 0.61, 95% CI 0.40 to 0.93). Again estimates came from one small study with 40 participants. Authors’ conclusions: There is no robust evidence on the relative effectiveness of any antiseptic/antibiotic/anti-bacterial preparation evaluated to date for use on SWHSI. Where some evidence for possible treatment effects was reported, it stemmed from single studies with small participant numbers and was classed as moderate or low quality evidence. This means it is likely or very likely that further research will have an important impact on our confidence in the estimate of effect, and may change this estimate.

Plain language summary Antibiotics and antiseptics for surgical wounds healing by secondary intention What are surgical wounds healing by secondary intention? These are surgical wounds which are left open to heal through the growth of new tissue, rather than being closed in the usual way with stitches or other methods which bring the wound edges together. This is usually done when there is a high risk of infection or a large amount of tissue has been lost from the wound. Wounds which are often treated in this way include chronic wounds in the cleft between the buttocks (pilonidal sinuses) and some types of abscesses. Why use antibiotics and antiseptics to treat surgical wounds healing by secondary intention? One reason for allowing a wound to heal by secondary intention after surgery is that the risk of infection in that wound is thought to be high. If a wound has already become infected, then antibiotics or antiseptics are used to kill or slow the growth of the micro-organisms causing the infection and prevent it from getting worse or spreading. This may also help the wound to heal. Even where wounds are not clearly infected, they usually have populations of micro-organisms present. It is thought that they may heal better if these populations are reduced by antibacterial agents. However, the relationship between infection and micro-organism populations in wounds and wound healing is not very clear. What we found: In November 2015 we searched for as many studies as possible that both had a randomised controlled design and looked at the use of an antibiotic or antiseptic in participants with surgical wounds healing by secondary intention. We found 11 studies which included a total of 886 participants. These all looked at different comparisons. Several different types of wounds were included. Studies looked at wounds after diabetic foot amputation, pilonidal sinus surgery, treatment of various types of abscess, surgery for haemorrhoids, complications after caesarean section and healing of openings created by operations such as colostomy. Most studies compared a range of different types of antibacterial treatments to treatments without antibacterial activity, but four 

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compared different antibacterial treatments. Although some of the trials suggested that one treatment may be better than another, this evidence was limited by the size of the studies and the ways they were carried out and reported. All of the studies had low numbers of participants and in some cases these numbers were very small. Many of the studies did not report important information about how they were carried out, so it was difficult to tell whether the results presented were likely to be true. More, better quality, research is needed to find out the effects of antimicrobial treatments on surgical wounds which are healing by secondary intention. Assessed as up to date November 2015.

Publication in The Cochrane Library Issue 4, 2016

Antibiotics and antiseptics for pressure ulcers Gill Norman, Jo C Dumville, Zena EH Moore, Judith Tanner, Janice Christie, Saori Goto Citation example: Norman G, Dumville JC, Moore ZEH, Tanner J, Christie J, Goto S. Antibiotics and antiseptics for pressure ulcers. Cochrane Database of Systematic Reviews 2016, Issue 4. Art. No.: CD011586. DOI: 10.1002/14651858.CD011586. pub2. ABSTRACT Background: Pressure ulcers, also known as bedsores, decubitus ulcers and pressure injuries, are localised areas of injury to the skin or the underlying tissue, or both. A range of treatments with antimicrobial properties, including impregnated dressings, are widely used in the treatment of pressure ulcers. A clear and current overview is required to facilitate decision making regarding use of antiseptic or antibiotic therapies in the treatment of pressure ulcers. This review is one of a suite of Cochrane reviews investigating the use of antiseptics and antibiotics in different types of wounds. It also forms part of a suite of reviews investigating the use of different types of dressings and topical treatments in the treatment of pressure ulcers. Objectives: To assess the effects of systemic and topical antibiotics, and topical antiseptics on the healing of infected and uninfected pressure ulcers being treated in any clinical setting. Search methods: In October 2015 we searched: the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library), Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations), Ovid EMBASE, and EBSCO CINAHL Plus. We also searched three clinical trials registries and the references of included studies and relevant systematic reviews. There were no restrictions based on language or date of publication or study setting. Selection criteria: Randomised controlled trials which enrolled adults with pressure ulcers of stage II or above were included in the review.

performed study selection, risk of bias assessment and data extraction. Main results: We included 12 trials (576 participants); 11 had two arms and one had three arms. All assessed topical agents, none looked at systemic antibiotics. The included trials assessed the following antimicrobial agents: povidone iodine, cadexomer iodine, gentian violet, lysozyme, silver dressings, honey, pine resin, polyhexanide, silver sulfadiazine, and nitrofurazone with ethoxy-diaminoacridine. Comparators included a range of other dressings and ointments without antimicrobial properties and alternative antimicrobials. Each comparison had only one trial, participant numbers were low and follow-up times short. The evidence varied from moderate to very low quality. Six trials reported the primary outcome of wound healing. All except one compared an antiseptic with a non-antimicrobial comparator. There was some moderate and low quality evidence that fewer ulcers may heal in the short term when treated with povidone iodine compared with non-antimicrobial alternatives (protease-modulating dressings (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.98) and hydrogel (RR 0.64, 95% CI 0.43 to 0.97)); and no clear difference between povidone iodine and a third non-antimicrobial treatment (hydrocolloid) (low quality evidence). Pine resin salve may heal more pressure ulcers than hydrocolloid (RR 2.83, 95% CI 1.14 to 7.05) (low quality evidence). There is no clear difference between cadexomer iodine and standard care, and between honey a combined antiseptic and antibiotic treatment (very low quality evidence). Six trials reported adverse events (primary safety outcome). Four reported no adverse events; there was very low quality evidence from one showing no clear evidence of a difference between cadexomer iodine and standard care; in one trial it was not clear whether data were appropriately reported. There was limited reporting of secondary outcomes. The five trials that reported change in wound size as a continuous outcome did not report any clear evidence favouring any particular antiseptic/anti-microbial treatments. For bacterial resistance, one trial found some evidence of more MRSA eradication in participants with ulcer treated with a polyhexanide dressing compared with a polyhexanide swab (RR 1.48, 95% CI 1.02 to 2.13); patients in the dressing group also reported less pain (MD −2.03, 95% CI −2.66 to −1.40). There was no clear evidence of a difference between interventions in infection resolution in three other comparisons. Evidence for secondary outcomes varied from moderate to very low quality; where no GRADE assessment was possible we identified substantial limitations which an assessment would have taken into account. Authors’ conclusions: The relative effects of systemic and topical antimicrobial treatments on pressure ulcers are not clear. Where differences in wound healing were found, these sometimes favoured the comparator treatment without antimicrobial properties. The trials are small, clinically heterogenous, generally of short duration, and at high or unclear risk of bias. The quality of the evidence ranges from moderate to very low; evidence on all comparisons was subject to some limitations.

Data collection and analysis: Two review authors independently

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Cochrane Reviews

Plain language summary Antibiotics and antiseptics for pressure ulcers What are pressure ulcers and who is at risk? Pressure ulcers, also known as bedsores, decubitus ulcers and pressure injuries, are wounds involving the skin and often the tissue that lies underneath. Pressure ulcers can be painful, may become infected, and affect people’s quality of life. People at risk of developing pressure ulcers include those with spinal cord injuries, and those who are immobile or have limited mobility, such as elderly people and people who are ill. Why use antiseptics and antibiotics to treat pressure ulcers? Where pressure ulcers are infected, antibiotics or antiseptics are used to kill or slow the growth of the micro-organisms causing the infection and may prevent an infection from getting worse or spreading. This may also help the ulcer to heal. Where ulcers are not infected they usually still have populations of microorganisms present. It is thought that they may heal better if these are reduced by antimicrobial agents. However, the relationship between infection and micro-organism populations in wounds and wound healing is not very clear. What we found: In October 2015 we searched for as many studies as we could find that were randomised controlled trials and compared the use of an antibiotic or antiseptic with other treatments for pressure ulcers. We found 12 trials involving a total of 576 participants. Most study participants were older people in hospital. Most ulcers were not infected at the start of the trials. The different treatments assessed included povidone iodine, cadexomer iodine, gentian violet, lysozyme, silver dressings, honey, pine resin, silver sulfadiazine, polyhexanide and a combination of nitrofurazone and ethoxy-diaminoacridine. Silver sulfadiazine and nitrofurazone are topical (locally acting) antibiotics while the other treatments are antiseptics. No trials looked at systemic (acting across the whole body) antibiotics. The treatments were compared with each other or to treatments without antimicrobial qualities. Most evidence on wound healing came from trials comparing antiseptics to treatments without antimicrobial qualities. There was no consistent evidence of a benefit to using any particular antimicrobial treatment for pressure ulcers. However, there was some limited evidence that more ulcers healed when treated with some types of alternative dressings without antimicrobial properties than when treated with povidone iodine. All the studies had low numbers of participants, and in some cases these numbers were very small. Many studies did not report important information about how they were carried out so it was difficult to tell whether the results presented were likely to be true. More, better quality, research is needed to determine the effects of antimicrobial treatments on pressure ulcers.

Autologous platelet-rich plasma for treating chronic wounds [UPDATE] Maria José Martinez-Zapata, Arturo J Martí-Carvajal, Ivan Solà, José Angel Expósito, Ignasi Bolíbar, Luciano Rodríguez, Joan Garcia, Carlos Zaror

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Citation example: Martinez-Zapata MJ, Martí-Carvajal AJ, Solà I, Expósito JA, Bolíbar I, Rodríguez L, Garcia J, Zaror C. Autologous platelet-rich plasma for treating chronic wounds. Cochrane Database of Systematic Reviews 2016, Issue 5. Art. No.: CD006899. DOI: 10.1002/14651858.CD006899.pub3. ABSTRACT Background: Autologous platelet-rich plasma (PRP) is a treatment that contains fibrin and high concentrations of growth factors with the potential to improve the healing of chronic wounds. This is the first update of a review first published in 2012. Objectives: To determine whether autologous PRP promotes the healing of chronic wounds. Search methods: In June 2015, for this first update, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library): Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; and EBSCO CINAHL. We also searched for ongoing and unpublished clinical trials in the WHO International Clinical Trials Registry Platform (ICTRP) (searched January 2015). We did not impose any restrictions with respect to language, date of publication, or study setting. Selection criteria: We included randomised controlled trials (RCTs) that compared autologous PRP with placebo or alternative treatments for any type of chronic wound in adults. We did not apply any date or language restrictions. Data collection and analysis: We used standard Cochrane methodology, including two reviewers independently selecting studies for inclusion, extracting data, and assessing risk of bias. Main results: The search identified one new RCT, making a total of 10 included RCTs (442 participants, 42% women). The median number of participants per RCT was 29 (range 10 to 117). Four RCTs recruited people with a range of chronic wounds; three RCTs recruited people with venous leg ulcers, and three RCTs considered foot ulcers in people with diabetes. The median length of treatment was 12 weeks (range 8 to 40 weeks). It is unclear whether autologous PRP improves the healing of chronic wounds generally compared with standard treatment (with or without placebo) (risk ratio (RR) 1.19, 95% confidence interval (CI) 0.95 to 1.50; I2 = 27%, low quality evidence, 8 RCTs, 391 participants). Autologous PRP may increase the healing of foot ulcers in people with diabetes compared with standard care (with or without placebo) (RR 1.22, 95% CI 1.01 to 1.49; I2 = 0%, low quality evidence, 2 RCTs, 189 participants). It is unclear if autologous PRP affects the healing of venous leg ulcers (RR 1.02, 95% CI 0.81 to 1.27; I2 = 0% ). It is unclear if there is a difference in the risk of adverse events in people treated with PRP or standard care (RR 1.05, 95% CI 0.29 to 3.88; I2 = 0%, low quality evidence from 3 trials, 102 participants). Authors’ conclusions: PRP may improve the healing of foot 

ulcers associated with diabetes, but this conclusion is based on low quality evidence from two small RCTs. It is unclear whether PRP influences the healing of other chronic wounds. The overall quality of evidence of autologous PRP for treating chronic wounds is low. There are very few RCTs evaluating PRP, they are underpowered to detect treatment effects, if they exist, and are generally at high or unclear risk of bias. Well designed and adequately powered clinical trials are needed.

Plain language summary Autologous platelet-rich plasma (PRP) for chronic wounds Review question: What is autologous platelet-rich plasma and is it useful for treating chronic wounds? Background: Chronic wounds (or ulcers) are breaks in the skin that do not heal, or require a long time to heal, and frequently recur. Chronic wounds include pressure ulcers, venous leg ulcers, arterial ulcers, neurotrophic ulcers, and foot ulcers in people with diabetes. Autologous platelet-rich plasma (PRP) is a potential wound healing treatment because it has components such as fibrin (a substance produced in the liver that makes the blood clot) and high concentrations of growth factors that are thought to help healing. We reviewed the evidence on the effect of autologous PRP on wound healing in people aged 18 years or older with chronic wounds from any cause (such as pressure ulcers, arterial ulcers, venous ulcers). We also included patients with wounds of mixed aetiology e.g. mixed arterial-venous ulcers. What we found: We included 10 randomised clinical trials, with a total of 442 participants (mean age 61 years and 42% women). Four included studies recruited people with a range of chronic wounds; three studies enrolled people with venous leg ulcers; and the other three studies included people with diabetes who had foot ulcers. The median length of treatment was 12 weeks. All but three trials reported the sources of funding. Four of the studies received financial support from companies manufacturing PRP devices. The results were non-conclusive as to whether autologous PRP improves the healing of chronic wounds generally compared with standard treatment. Autologous PRP may increase the healing of foot ulcers in people with diabetes compared with standard care, but it is unclear if autologous PRP has an effect on other types of chronic wound. Three studies reported wound complications such as infection or dermatitis, but results showed no difference in the risk of adverse events in people treated with PRP or standard care. These findings are based on low quality evidence due to the small number of studies and patients included, and their poor methodological quality. This Plain Language Summary is up to date as of 16 June 2015.

Publication in The Cochrane Library Issue 6, 2016

Sulodexide for treating venous leg ulcers Bin Wu, Jing Lu, Ming Yang, Ting Xu

Citation example: Wu B, Lu J, Yang M, Xu T. Sulodexide for treating venous leg ulcers. Cochrane Database of Systematic Reviews 2016, Issue 5. Art. No.: CD010694. DOI: 10.1002/14651858.CD010694.pub2 ABSTRACT Background: Venous leg ulcers are common, chronic wounds caused by venous diseases, with a high recurrence rate and heavy disease burden. Compression therapy (bandages or stockings) is the first choice treatment for venous leg ulcers. However, when ulcers remain unhealed, medication can also be used with or without compression therapy. Sulodexide, a highly purified glycosaminoglycan (a naturally occurring molecule) has antithrombotic and profibrinolytic properties (it reduces the formation of blood clots) as well as anti-inflammatory effects. Sulodexide has been studied as a potential treatment for venous leg ulcers. Objectives: To assess the efficacy and safety of sulodexide for treating venous leg ulcers. Search methods: In July 2015 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE; EBSCO CINAHL; Chinese Biomedical Literature Database (CBM); China National Knowledge Infrastructure Database (CNKI); Wan Fang and VIP. We also searched clinical trials registries to identify ongoing studies, as well as references listed in relevant publications. There were no restrictions based on date of publication, language or study setting. Selection criteria: Randomised controlled trials (RCTs) involving people with a diagnosis of venous leg ulcers which compared sulodexide with placebo or any other drug therapy (such as pentoxifylline, flavonoids, aspirin), with or without compression therapy. Data collection and analysis: We used standard Cochrane methodological procedures. The authors independently selected studies, extracted data and assessed risk of bias. We pooled data to present the risk ratio (RR) with 95% confidence interval (CI), or presented a narrative summary. We assessed overall evidence quality according to the GRADE approach. Main results: We included four RCTs with a total of 463 participants (aged 42 years to 93 years); one report was only available as a published abstract. Meta-analysis of three RCTs suggests an increase in the proportion of ulcers completely healed with sulodexide as an adjuvant to local treatment (including wound care and compression therapy) compared with local treatment alone (rate of complete healing with sulodexide 49.4% compared with 29.8% with local treatment alone; RR 1.66; 95% CI 1.30 to 2.12). This evidence for sulodexide increasing the rate of complete healing is low quality due to risk of bias. It is unclear whether sulodexide is associated with any increase in adverse events (4.4% with sulodexide versus 3.1% with no sulodexide; RR 1.44; 95% CI 0.48 to

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4.34). The evidence for adverse events is very low quality, downgraded twice for risk of bias and once for imprecision. Authors’ conclusions: Sulodexide may increase the healing of venous ulcers, when used alongside local wound care, however the evidence is only low quality and the conclusion is likely to be affected by new research. It is not clear whether sulodexide is associated with adverse effects. The standard dosage, route and frequency of sulodexide reported in the trials were unclear. Further rigorous, adequately powered RCTs examining the effects of sulodexide on healing, ulcer recurrence, quality of life and costs are necessary.

Plain language summary Sulodexide for venous leg ulcers Review question: We reviewed the evidence about the effect of sulodexide on people with venous leg ulcers. Background: Venous leg ulcers are a common, chronic and recurring wound on people’s legs. Venous leg ulcers are caused by venous disease, particularly in the elderly. Compression therapy (usually using bandages or stockings) is the first choice of treatment for venous leg ulcers. However, compression therapy is not suitable for some people, and some ulcers remain unhealed with compression. Sulodexide (a medicine which reduces blood clotting) has been studied as a treatment for venous leg ulcers. We wanted to find out if there is good evidence for sulodexide improving venous ulcer healing. Study characteristics: The review includes four studies involving 463 people with venous leg ulcers aged between 42 and 93 years old. The studies compared sulodexide used in combination with local treatment (including wound care and compression therapy) with local treatment alone. The duration of the four studies ranged from one month to three months. Key results: Three studies (438 participants) indicated that sulodexide might help to improve ulcer healing, as the proportion of ulcers that were completely healed was increased from 29.8% with local treatment to 49.4% when the participants also received sulodexide. It is unclear whether sulodexide results in more adverse effects (4.4% with sulodexide versus 3.1% without sulodexide). Quality of the evidence: The overall quality of evidence for each outcome varied between low and very low, due to risk of bias, and imprecision (that is, for some outcomes, results from only one, small study were available). This plain language summary is up to date as of 1 July 2015.

Publication in The Cochrane Library Issue 7, 2016

Skin antisepsis for reducing central venous catheter-related infections Nai Ming Lai, Nai An Lai, Elizabeth O’Riordan, Nathorn Chaiyakunapruk, Jacqueline E Taylor, Kenneth Tan

Citation example: Lai NM, Lai NA, O’Riordan E, Chaiyakunapruk N, Taylor JE, Tan K. Skin antisepsis for reducing central venous catheter-related infections. Cochrane Database of Systematic Reviews 2016, Issue 7. Art. No.: CD010140. DOI: 10.1002/14651858.CD010140.pub2. ABSTRACT Background: The central venous catheter (CVC) is a device used for many functions, including monitoring haemodynamic indicators and administering intravenous medications, fluids, blood products and parenteral nutrition. However, as a foreign object, it is susceptible to colonisation by micro-organisms, which may lead to catheter-related blood stream infection (BSI) and in turn, increased mortality, morbidities and health care costs. Objectives: To assess the effects of skin antisepsis as part of CVC care for reducing catheter-related BSIs, catheter colonisation, and patient mortality and morbidities. Search methods: In May 2016 we searched: The Cochrane Wounds Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations and Epub Ahead of Print); Ovid EMBASE and EBSCO CINAHL Plus. We also searched clinical trial registries for ongoing and unpublished studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria: We included randomised controlled trials (RCTs) that assessed any type of skin antiseptic agent used either alone or in combination, compared with one or more other skin antiseptic agent(s), placebo or no skin antisepsis in patients with a CVC in place. Data collection and analysis: Two authors independently assessed the studies for their eligibility, extracted data and assessed risk of bias. We expressed our results in terms of risk ratio (RR), absolute risk reduction (ARR) and number need to treat for an additional beneficial outcome (NNTB) for dichotomous data, and mean difference (MD) for continuous data, with 95% confidence intervals (CIs). Main results: Thirteen studies were eligible for inclusion, but only 12 studies contributed data, with a total of 3446 CVCs assessed. The total number of participants enrolled was unclear as some studies did not provide such information. The participants were mainly adults admitted to intensive care units, haematology oncology units or general wards. Most studies assessed skin antisepsis prior to insertion and regularly thereafter during the in-dwelling period of the CVC, ranging from every 24 h to every 72 h. The methodological quality of the included studies was mixed due to wide variation in their risk of bias. Most trials did not adequately blind the participants or personnel, and four of the 12 studies had a high risk of bias for incomplete outcome data. Three studies compared different antisepsis regimens with no antisepsis. There was no clear evidence of a difference in all outcomes examined, including catheter-related BSI, septicaemia, catheter colonisation and number of patients who 

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required systemic antibiotics for any of the three comparisons involving three different antisepsis regimens (aqueous povidoneiodine, aqueous chlorhexidine and alcohol compared with no skin antisepsis). However, there were great uncertainties in all estimates due to underpowered analyses and the overall very low quality of evidence presented.There were multiple head-to-head comparisons between different skin antiseptic agents, with different combinations of active substance and base solutions. The most frequent comparison was chlorhexidine solution versus povidone-iodine solution (any base). There was very low quality evidence (downgraded for risk of bias and imprecision) that chlorhexidine may reduce catheter-related BSI compared with povidone-iodine (RR of 0.64, 95% CI 0.41 to 0.99; ARR 2.30%, 95% CI 0.06 to 3.70%). This evidence came from four studies involving 1436 catheters. None of the individual subgroup comparisons of aqueous chlorhexidine versus aqueous povidoneiodine, alcoholic chlorhexidine versus aqueous povidone-iodine and alcoholic chlorhexidine versus alcoholic povidone-iodine showed clear differences for catheter-related BSI or mortality (and were generally underpowered). Mortality was only reported in a single study. There was very low quality evidence that skin antisepsis with chlorhexidine may also reduce catheter colonisation relative to povidone-iodine (RR of 0.68, 95% CI 0.56 to 0.84; ARR 8%, 95% CI 3% to 12%; ; five studies, 1533 catheters, downgraded for risk of bias, indirectness and inconsistency). Evaluations of other skin antiseptic agents were generally in single, small studies, many of which did not report the primary outcome of catheter-related BSI. Trials also poorly reported other outcomes, such as skin infections and adverse events. Authors’ conclusions: It is not clear whether cleaning the skin around CVC insertion sites with antiseptic reduces catheter related blood stream infection compared with no skin cleansing. Skin cleansing with chlorhexidine solution may reduce rates of CRBSI and catheter colonisation compared with cleaning with povidone iodine. These results are based on very low quality evidence, which means the true effects may be very different. Moreover these results may be influenced by the nature of the antiseptic solution (i.e. aqueous or alcohol-based). Further RCTs are needed to assess the effectiveness and safety of different skin antisepsis regimens in CVC care; these should measure and report critical clinical outcomes such as sepsis, catheter-related BSI and mortality.

Plain language summary Skin antisepsis for reducing central venous catheter-related infections Review Question: We reviewed the evidence about whether using antiseptic treatments on people’s skin helps reduce infections related to central venous catheters (CVCs). Background: Central venous catheters (CVCs) are thin, flexible tubes that are inserted through the skin into a large vein, often in the arm or chest. The tube can then be used to give fluids, medicine and nutrition to chronically and critically ill patients. However, CVCs pose a significant risk of infection by providing a way for micro-organisms (germs) to spread into the body at the point where the catheter is inserted. In order to try to reduce 44

catheter-related infections, healthcare staff frequently use antiseptic solutions to clean the skin around the catheter insertion site, both prior to insertion and whilst the catheter is in place. In this review, we summarise the evidence of the benefits and harms of using antiseptics on the skin, and the effects of different antiseptic solutions. Search date: We searched multiple medical databases in May 2016. Study characteristics: In May 2016 we searched medical databases to find randomised controlled trials looking at the use of skin antiseptics in people with CVCs. We included 13 studies in this review, although only 12 studies contributed data for a total of 3446 CVCs. The study participants were mainly adults in intensive care units or other specialist hospital units. We reported our findings in terms of the number of catheters, as some studies did not provide the number of patients assessed, and some patients had more than one CVC.One study was funded by a national research body, five studies were funded in whole or in part by at least a pharmaceutical company, and in the remaining seven studies funding sources were not stated. Key results: Three studies examined the effect of cleansing versus no cleansing, and found no clear evidence of differences in blood infections, infections in the catheter and need for antibiotics between patients who received cleansing compared to those who did not. Chlorhexidine solution may reduce blood infections associated with the catheter compared with povidone-iodine solution (reducing the infection rate from 64 cases per 1000 patients with a CVC with povidone iodine to 41 cases of infection per 1000 with chlorhexidine). This translates into the need to treat 44 people to avoid one additional bloodstream infection. Chlorhexidine solution may (compared with povidone iodine solution) also reduce the presence of infectious organisms within the catheter (reduced from 240 infected catheters per 1000 people to 189 infected catheters per 1000 people). It is unclear whether antiseptic skin cleansing influences mortality rates as only one study reported this and although similar death rates were observed with povidone iodine and chlorhexidine, small numbers mean a difference cannot be ruled out. Quality of evidence: The overall quality of evidence was poor due to flaws in the way the studies were designed, small study sizes, inconsistency of the results between the included studies and the nature of the outcomes reported. These flaws have reduced our confidence in the results of the studies. This means we cannot be certain whether cleaning the skin around CVC insertion sites with antiseptic reduces catheter-related blood stream infection and other harmful effects, such as overall blood infections and mortality compared with no skin cleansing. Cleansing with chlorhexidine solution may be more effective than povidone iodine but the quality of the evidence was very low. This plain language summary is up to date as of May 2016. n

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Previous Issues

Volume 16, no 1, April 2016 Development of an Evidence-Based Global Consensus for Diabetic Van Netten JJ, Bakker K, Apelqvist J, Lipsky BA, Schaper NC, Clinical challenges of differentiating skin tears from pressure ulcers LeBlanc K, Alam T, Langemo D, Baranoski S, Campbell K, Woo K Primary Care Patient Safety (PISA) Research Group Samuriwo R, Evans HP, Carson-Stevens A, Rees P, Hibbert P,

Other journals EWMA wishes to facilitate the exchange of information on wound healing in a broad perspective with this section on International Journals. Acta Vulnologica, vol. 14, no 1, 2016 www.vulnologia.it

Italian

Application of Ortodermina ointment (lidocaine 5%) when preparing ulcers for ultrasonic debridement Giacinto F., Germano M., Giacinto E., et al Retrospective study on the use of negative pressure wound therapy in the treatment of pilonidal cysts (sinus pilonidalis) opera-ted on using an open technique or complicated by dehiscence of the surgery site through sepsis Carnali M., Ronchi R., Finocchi L., et al Epidemiology of antibiotic resistance and MBL genes among Pseudomonas aeruginosa and Acinetobacter baumannii clinical strains isolated from burnt patients in Iran: a systematic review Hashemi A., Tarashi S., Erfanimanesh S.

V OL . 14 - N O . 1 - MARCH 2016

Challenges faced by healthcare professionals in the provision of compression hosiery to enhance compliance in the prevention of venous leg ulceration Tandler SF Pressure Ulcer Incidence: Do patients retain information? Vowden K, Warner V, Collins J.

Volume 15, no 2, October 2015 Of youth and Age - What are the Differences regarding skin structure and function ? Kottner J The Development and Benefits of 10 year ́s Experience with an Electronic Monitoring Tool (PUNT) in a UK Hospital Trust. Collier M Preparing student Nurses for the future of Wound Management: Telemedicine in a simulated Learning Environment. Christiansen S, Rethmeier A The Psychological Effect of Malignant fungating Wounds on the Patient. Reynolds H, Gethin G The Pressure Ulcer Guidance (PUG) Tool. Barnard J, Copson D

English Open Access!

Authors have the option to set their articles for free access. See the author guidelines on our website: www.woundcarejournal.com.

SKIN& WOUND CARE ®

The International Journal for Prevention and Healing

www.woundcarejournal.com

C M E

Volume 29 Number 4 April 2016

CLINICAL MANAGEMENT EXTRA Risk Factors for Pressure Ulcers Including Suspected Deep Tissue Injury in Nursing Home Facility Residents: Analysis of National Minimum Data Set 3.0 Hyochol Ahn, PhD, ARNP, ANP-BC; Linda Cowan, PhD, ARNP, FNP-BC, CWS; Cynthia Garvan, PhD; Debra Lyon, PhD, RN, FAAN; and Joyce Stechmiller, PhD, ACNP-BC, FAAN

ORIGINAL INVESTIGATIONS A Multimodality Imaging and Software System for Combining an Anatomical and Physiological Assessment of Skin and Underlying Tissue Conditions Diane Langemo, PhD, RN, FAAN, and James G. Spahn, MD, FACS

The Use of a Novel Canister-free Negative-Pressure Device in Chronic Wounds: A Retrospective Analysis Thomas E. Serena, MD, and John S. Buan, PhD

Effects of Lidocaine, Bupivacaine, and Ropivacaine on Calcitonin Gene-Related Peptide and Substance P Levels in the Incised Rat Skin Guilherme A. F. Lapin, MD; Bernardo Hochman, MD, PhD; Jessica R. Maximino, PhD; Gerson Chadi, MD, PhD; and Lydia M. Ferreira, MD, PhD

PLUS Payment Strategies • Practice Points

Endorsed by

Lippincott Williams & Wilkins

Volume 15, no 1, April 2015 Efficacy of magnetic resonance imaging in deciding the appropriate surgical margin in diabetic foot osteomyelitis. Fujii M, Armstrong DG, Terashi H Ex vivo platelet activation with extended duration pulse electric fields for autologous platelet gel applications - A new, potential clinical standard for platelet activation and perspectives for a more widespread adoption and improved wound healing with platelet gels. Neculaes VB, Torres A, Morton C, Larriera A, Klopman S, Conway K, Garner AL Pressure ulcer reduction: the role of unregistered healthcare support workers in validation and prevention. Ellis MB, Price J Measuring change in limb volume to evaluate lymphoedema treatment outcome. Williams AF, Whitaker J

Finnish 2  2016 Suomen Haavanhoitoyhdistyksen ammattijulkaisu | 19. vuosikerta

Valtakunnalliset Haavapäivät

Spanish Volume 14 Number 2 October 2014 Published by European Wound Management Association

WOUND CARE – SHAPING THE FUTURE

Rf dC

A PATIENT, PROFESSIONAL, PROVIDER AND PAYER PERSPECTIVE

Advances in

Advances in Skin & Wound Care, vol. 29, no 4, 2016 www.aswcjournal.com A Multimodality Imaging and Software System for Combining an Anatomical and Physiological Assessment of Skin and Underlying Tissue Conditions Diane Langemo, and James G. Spahn The Use of a Novel Canister-free Negative-Pressure Device in Chronic Wounds: A Retrospective Analysis Thomas E. Serena, and John S. Buan Effects of Lidocaine, Bupivacaine, and Ropivacaine on Calcitonin Gene-Related Peptide and Substance P Levels in the Incised Rat Skin Guilherme A. F. Lapin, Bernardo Hochman, Jessica R. Maximino et al Risk Factors for Pressure Ulcers Including Suspected Deep Tissue Injury in Nursing Home Facility Residents: Analysis of National Minimum Data Set 3.0 Hyochol Ahn, Linda Cowan, Cynthia Garvan, et al

Haava, no. 2, 2016 www.shhy.fi Problematic wounds in pediatric Heli Kavola Treatment of periwound and surrounding skin Kirsi Isoherranen, Ulla Dunder Cancer and metastasis wounds and their treatment Arja Korhonen Diabetic foot ulcer Vesa Juutilainen

Helcos, vol. 26, no. 1, 2016

Volume 14, no 2, October 2014 Economic outcomes of a new chronic wound treatment system in Poland Grzegorz Krasowski, Robert Wajda, Małgorzata Olejniczak-Nowakowska Dressings for split thickness skin graft donor sites Dorte P. Barrit, Hanne Birke-Sorensen The utility of pulse volume waveforms in the identification of lower limb arterial insufficiency Jane H Davies, Jane E A Lewis, E Mark Williams The importance of using a nutritional risk analysis scale in patients admitted to continued care Jose M Corrales, Nuria P Gayo, Mª del Carmen P Águila, Almudena M Martín, Ana Ribeiro Neonatal facial pressure ulcers related to non-invasive ventilation Laura Bonell-Pons, Pablo García-Molina, Evelin Balaguer-López, Mª Ángeles Montal, María C Rodríguez

Validity of Braden and EMINA’s scales for patients at home, include in the immobilized patients programme FJ García-Díaz, R.Cabello-Jaime, M.Muñoz-Conde et al Prevalence of infection with Staphylococcus aureus methicillin resistent in chronic wounds in primary care of Lleida. Retrospective study C. Marquilles Bonet, S. Alexandre Lozano, J. Real Gatius Strategic and inductive wound care training for homecare nurses A. Jaqueline Leites, P. Diego Nieto, J Eduardo Padin et al

The EWMA Journals can be downloaded free of charge from www.ewma.org

EWMA Journal

2016 vol 16 no 2

Journal of Tissue Viability, vol. 25, no 3, 2016 www.journaloftissueviability.com

English

Scandinavian

Wounds (SÅR) no 2, 2016 www.saar.dk The Compression Stocking” - filled with challenges Else Sværke Henriksen New Mobilization System For Pressure Ulcers Åse Fremmelevholm Clinical Assessment Of Product: New foam dressing of silicone Ann-Mari Fagerdahl Feet Can Reveal Cancer Tina Rønhøj

Scandinavian

SÅRmagasinet no 2, 2016

The effect of topical anti blister products on the risk of friction blister formation on the foot Farina Hashmi, Suzanne Kirkham, Christopher Nester, et al Development of a Sitting MicroEnvironment Simulator for wheelchair cushion assessment Tyler Freeto, Allissa Cypress, Sarah Amalraj, et al Pain prevalence, socio-demographic and clinical features in patients with chronic ulcers Elaine Aparecida Rocha Domingues, Marianna Carvalho e Souza Leão Cavalcanti, Paula Cristina Pereira da Costa, et al Journal of Wound Care, vol. 25, no 4, 2016 www.journalofwoundcare.com

English

Negative pressure wound therapy Christina Monsen Negative pressure of infected sternum wounds Richard Ingemansson Hard-to-heal wounds- health economic strategies for the future Christina Lindholm Do pressure ulcers increase suffering? Linn Åkerblom

volume 25. number 8. august 2016

Official journal of the World Union of Wound Healing Societies

MEDLINE LISTED

IMPACT FACTOR

Comparative effect of superabsorbent dressings on exudate management Antiseptic with modern wound dressings in the treatment of venous leg ulcers Exploring nurses’ and patients’ feelings of disgust with malodorous wounds Peripheral nerve crushing to treat chronic pain of diabetic and ischaemic foot ulcers NPWT with and without instillation of saline on wound healing

Polish

Exploring nurses’ and patients’ feelings of disgust associated with malodorous wounds: a rapid review K. Ousey, D. Roberts Antiseptic with modern wound dressings in the treatment of venous leg ulcers: clinical and microbiological aspects M. Sopata, M. Kucharzewski, E. Tomaszewska Quality of wound dressings: a first step in establishing shared criteria and objective procedures to evaluate their performance N. Mennini, A. Greco, A. Bellingeri et al. Antimicrobial resistance among aerobic biofilm producing bacteria isolated from chronic wounds in the tertiary care hospitals of Peshawar, Pakistan K. Rahim, M. Qasim, H. Rahman, et al.

Scandinavian

LEUCOPATCH – A patch of the patient’s own blood Jens Fonnesbech SKIN TEARS - Skin lesions with flap Jette Skiveren & Susan Bermark REAL WOUNDS - A journey of discovery into the clinic Ole E. Sørensen LEUCOPATCH 34 - A medico-technical stroke of genius Jens Fonnesbech

Leczenie Ran vol. 12, no 4, 2015 www.journalofwoundcare.com

Number 4 Pages 607-752 July-August 2016

Lietuvos chirurgija, vol. 15, no 1, 2016 www.chirurgija.lt

mtfwoundcare.org

JSWH Meeting Abstracts

Antibiotic-Loaded Keratin Hydrogel for Burn Wound Infection Control

WOUND REPAIR AND REGENERATION THE INTERNATIONAL JOURNAL OF TISSUE REPAIR AND REGENERATION

The Wound Healing Society

The European Tissue Repair Society

The Japanese Society for Wound Healing

The Australian Wound Management Association

14/07/16 8:48 AM

German

2016 vol 16 no 2

Diabetic Foot: difficulties in addressing and referencing in Braga USF Ferreira, Marta; Afonso, Cristina Characterization of people with bowel elimination ostomy in Portugal Alves, Paulo et al TIME concept: Relevance in the healing of Chronic wounds Leão, Maria et al Treatment of a radiogen injury in primary health care: a case study Ramos, Paulo et al

Wund Management, no 4, 2016 Scenarios for evaluating electronic wound documentation systems: The AOK Bundesverband study U. Hübner, K. Krämer, S. Milde, J. Thye und N. Egbert The electronic wound summary – the basis for interprofessional communication across care settings U. Hübner, G. Schulte, D. Flemming Practical experience with the application of IT-based wound documentation in the context of nursing documentation – A report from the Augusta Hospital Anholt T. Goedecke, K. Güttler

Phlebologie, vol. 4, 2016 www.schattauer.de Venous thromboembolism in the elderly C. Ploenes Practical aspects of compression therapy - Update 2016 K. Protz, K. Heyer Diagnosis and treatment of lipoedema S. Reich-Schupke Off-label use of tumescent local anaesthesia in endovascular and surgical techniques N. Frings et al

EWMA Journal

In this issue:

WRR_C1-C4.indd 1

Rectal prolapse: surgical perineal treatment Ir Fretes, D. Muñoz Complication of ostomies R. Escalante, L. Siso, S. Mendoza Surgical Management of Ischemic Colitis Kyu Joo Park Successful nonintubated uniportal video- -assisted thoracoscopic left upper lobectomy: a case report L. Pankratjevaitė, D. Samiatina-Morkūnienė

German

Volume 24 Number 4 July-August 2016

ISSN 1067-1927

Volume 24

Wound Repair and Regeneration, vol. 24, no. 4, 2016

English

WOUND REPAIR AND REGENERATION

The role of angiopoetic factors in wound healing among patients with diabetes treated with negative-pressure wound therapy Mrozikiewicz-Rakowska B, Kania J, Bucior E et al. Prevention and treatment of decubitus ulcers in the practice of neurology nurses in relation to the recommendations issued by the Polish Wound Management Association. Preliminary report INTRODUCING Bazalinski D, Fafara A, Zabek P et al. Effect of silver-releasing foam dressing in hydrofiber® technology on healing of diabetic foot ulcers Kucharzewski M, Wilemska-Kucharzewska K, Sopata Mwoundetcare better, Making for everyone. al.

Lithuanian

Sår (Wounds), no. 3 September 2016

Hungary

Sebkezelés Sebgyógyulás, no 2, 2015 No English translation available.

EWMA 2017 AMSTERDAM, THE NETHERLANDS

3-5 MAY 2017

EWMA 2017 Conference in Amsterdam, The Netherlands It is a great pleasure to announce the 27th conference of the European Wound Management Association, EWMA 2017 which will take place in Amsterdam, The Netherlands 3-5 May 2017. EWMA 2017 is organised in cooperation with WCS Knowledge Centre Wound Care.

EWMA Journalâ&#x20AC;&#x201A;

2016 vol 16 no 2

EWMA

CONFERENCE THEME The conference theme is:

CHANGE, OPPORTUNITIES AND CHALLENGES -WOUND MANAGEMENT IN CHANGING HEALTHCARE SYSTEMS National healthcare systems in Europe are continuously changing, reorganising and adapting to respond to changing demographics and budget restrictions. This sets the context in which wound healing and wound carers must navigate to provide the best possible treatment for the individual patient. At the same time technology is rapidly developing, providing new methods and means of treatment and organisation.

PROGRAMME EWMA 2017 includes a mixture of new topics which are important to the European wound community, in addition to topics that have had enormous appeal during previous EWMA conferences. The sessions deal with advancement of education and research in relation to epidemiology, pathology, diagnosis, prevention and management of wounds.

The 27th EWMA conference will have its focus on the changes, opportunities and challenges provided by these continuous processes for wound management across Europe and beyond.

ABSTRACT SUBMISSION FOR FREE PAPER AND E-POSTER PRESENTATIONS Abstracts for oral presentations and electronic poster presentations can be submitted for any topic in wound healing and wound management. î&#x201A;Š

EWMA Journalâ&#x20AC;&#x201A;

2016 vol 16 no 2

EWMA

PRIMARY CATEGORIES ARE: n

Acute Wounds

Antimicrobials

Basic Science

Burns

Devices & Intervention

Diabetic Foot

Dressings

Education

e-Health

Health Economics & Outcome

Home Care

Infection

Leg Ulcer

Negative Pressure Wound Therapy

Nutrition

Pain

Pressure Ulcer

Prevention

Quality of Life

Wound Assessment

Case Studies (e-posters only)

n Professional Communication (e-posters only)

All abstracts should be submitted online at www.ewma2017.org Abstract submission deadline: 1 December 2016 See a list of sessions as well as the detailed programme of 2016 here: www.ewma2016.org/scientific

PROGRAMME HIGHLIGHTS KEY SESSIONS The key sessions this year cover EWMA focus areas including: n Surgical site infections across sectors â&#x20AC;&#x201C; what can be done to improve prevention? n Advanced therapies n Use of oxygen therapies in wound care - EWMA document release n Scar tissue n Healing wounds, saving limbs - management of arterial ulcers n Economy and standards n Diabetic foot n Microbiology of wounds. From basic to clinical science n Chronic wounds in the fragile aging patient n Psychological impact of chronic illness or chronic wounds? EWMA STREAMS The full-day streams are particularly popular among EWMA conference delegates, as they foster more in-depth discussions. Planned streams for EWMA 2017 are: n Basic science n Diabetic foot / podiatry n Antimicrobials WORKSHOPS A number of workshops will be offered at EWMA 2017. The workshops are typically held in a smaller setting than key sessions and free paper sessions. THE WORKSHOPS ARE: n Oncological wounds - focus on breast cancer n Wound debridement n Care of burn patients who are not hospitalised n Advanced wound care n Eczema in leg ulcer patients n Offloading n Maggot therapy n Infection and wound care n Positioning patients with pressure ulcers n Compression n Diabetic foot screening n How to read a paper - critics and feedback Stay updated on the latest programme on www.ewma2017.org

EWMA Journalâ&#x20AC;&#x201A;

2016 vol 16 no 2

REGISTRATI

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registration: rating

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European Bone and Joint Infection Society

REGISTRATION Register for the conference on www.ewma.org/ewma-conference/2017/registration/ WHY ATTEND THE CONFERENCE? Attend EWMA 2017 to: n Gain new knowledge and best practice about the most recent research and treatment in wound management. 91% of the participants at EWMA 2016 said that they could use the knowledge gained in their daily practice. n Meet peer researchers and clinicians from all over the world. 96% of the participants at EWMA 2016 net worked professionally with the other participants. n Attend high level key sessions, free paper sessions, hands-on workshops, focus sessions and guest sessions hosted by other medical societies offering new know ledge. 89% of participants stated that the programme offered new knowledge. n Meet with suppliers and exchange experiences about wound care products and technology. 95% of partici pants felt that attending the exhibition was relevant to their work.

Save the date

7 - 9 September 2017 Nantes · France · La Cité, Nantes Events Center

We look forward to welcoming you to Amsterdam! MORE INFORMATION Stay updated by visiting the conference website, www. ewma2017.org, where information about registration and programme is available. You can also get your updates on EWMA’s social media platforms.

IMPORTANT DATES: n

Conference dates: 3-5 May 2017 n

Registration opens: November 2016 n

Deadline for abstract submission: 1 December 2016 (23:59 CET)

Find more information on www.ebjis2017.org

Early registration deadline: 1 March 2017

EWMA Journal

2016 vol 16 no 2

EWMA

WCS Wound care Consultant Society

René Baljon, chairman of WCS Knowledge Center Wound Care More information: www.wcs.nl

Organisation of wound care in the Netherlands In 2012 the Health Care Insurance Board commissioned a survey about wound care in the Netherlands. That survey caused a considerable stir throughout the country, developing a focus on wound care. One of the recommendations of the research report was to develop an umbrella organisation, in which every organisation related to wound care would participate. That resulted in founding the Dutch Wound Platform (WPN) in 2012; earlier it already existed, but wasn’t founded yet. The WPN has all professional associations related to wound care (as nurses, surgeons, dermatologists, plastic surgeons, geriatric specialists) and patients as its members. Associated members are from industry, for example the suppliers of wound care products, and interest organisation for example EWMA. Members of the advisory board are the Ministry of Public Health, Welfare and Sport, Health Insurances of the Netherlands and the Dutch Knowledge Institute. The quality standard mentioned earlier will be ready as the EWMA conference takes places in 2017. Hopefully it will be presented to you at this event. It gives an overview of developed guidelines already in place and fills in the blank spots of what isn’t developed yet. Thereby it will focus on the organisation of wound care: which caregiver is responsible for what kind of care; how can we manage to organise local care for the patient, as that is a governmental policy. Wound care is a basic need and therefore reimbursed by the health care insurer. But evidence is a requirement and, as we know, evidence is not always that clear in wound care. Therefore we need to registrate our care, preferably all in the same way, so we can provide data. Because digital registration isn’t common in this country, data collection is still a problem. Still a lot to do, but also a lot has done in the last few years.

EWMA Cooperating Organisation

EWMA Journal

2016 vol 16 no 2

13th Conference of the European Council of Enterostomal Therapists (ECET 2017)

JOIN US

for the 13th Conference of the European Council of Enterostomal Therapists (ECET 2017) 18 - 21 June 2017 Berlin · Germany Building bridges – from west to east, from south to north Ostomy – Continence – Wound European Nurses with academic nature and good clinical experience for ostomy, incontinence and wound care

www.ecet2017.org

New HydroTac® accelerates epithelial wound closure.[2] This innovation is the ideal supplement to the cleansing effect of HydroClean® plus.

• • • •

Fast epithelial wound closure Dressing change is safe and atraumatic Active moisture release Optimal absorption

www.hydrotherapy.info

Humbert P., Faivre B., Véran Y., et al.: Protease-modulating polyacrylate-based hydrogel stimulates wound bed preparation in venous leg ulcers--a randomized controlled trial. J Eur Acad Dermatol Venereol. 28:1742-50 (2014) / Zöllner et al., Biometric report on HydroTac (comfort) dated 6th June 2010 Smola H., Maier G., Junginger M., Kettel K., Smola S.: Hydrated polyurethane polymers to increase growth factor bioavailability in wound healing. Presented at the EORS Congress, 2014, Nantes / Smola H.: Stimulation of epithelial migration – novel material based approaches. Presented at EWMA Congress, 2015, London

What if ... we could speed up wound healing!

[2]

Fast and active epithelialization

[1]

HydroTac ®

NEW!

EWMA

EWMA 2016 IN BREMEN, GERMANY:

MORE THAN 6,000 PARTICIPANTS FROM 84 COUNTRIES TOOK PART IN THE CONFERENCE

The 26th Conference of the European Wound Management Association (EWMA) was held in Bremen, Germany, between 11-13 May 2016. The conference was organised in cooperation with the Initiative Chronische Wunden e.V. (ICW) and the collaboration of German-speaking wound associations WundD·A·CH. More than 6,000 participants from 84 countries took part in the conference, including a large number of international key opinion leaders and senior industry executives. There was a significant influence and participation from the host country Germany as well as a substantial international representation.

all the speakers, presenters, and organisers who actively participated in the sessions.

The conference provided an energetic environment in which colleagues within the field of wound management came together from all over the world for more than 900 high-level scientific presentations and great networking opportunities. It was encouraging to see the high standard of these presentations and to reflect upon the continued strong interest in wound healing across Europe. Our heartfelt appreciation goes out to

The theme focused on the patient as more than a person with a wound. He/she is a human being with needs and requirements - and rights! According to the international declaration of human rights, everyone has the right to health, implying that prevention and treatment of nonhealing wounds must be available to everyone. Thus, securing patients’ Quality of Life is a po-

EWMA Journal

2016 vol 16 no 2

CONFERENCE THEME The conference theme of EWMA 2016 was

PATIENTS · WOUNDS · RIGHTS

José Verdú Soriano EWMA Scientific Recorder

Correspondence: ewma@ewma.org



litical responsibility as well as a clinical one. Patients’ access to wound care requires the collaboration of patients, professionals and policy makers. It is a cornerstone of good practice in wound management and a fundamental objective of the interdisciplinary team approach. THE SESSIONS The conference included many interesting sessions prepared by EWMA, ICW and WundD.A.CH. in collaboration with EWMA’s cooperating organisations and international partners. The key sessions included a variety of topics that are important to the European wound community in general and dealt with the advancement of education and research in epidemiology, pathology, diagnosis and prevention. Among the topics were Biofilm, New Technologies in Wound Care, Tissue Engineering in Wound Care, Management of patients with venous leg ulcers, Debridement, Electro Stimulation, Evidence and Outcome, Migration, culture and ethnic skins and much more in a number of key sessions, free paper sessions, streams and workshops. The conference programme included guest sessions from many wound care related organisations, including the Dystrophic Epidermolysis Bullosa Research Association (DEBRA), European Burns Association (EBA), The European Council of Enterostomal Therapy (ECET), European Federation of National Associations of Orthopaedics and Traumatology (EFORT), European Pressure Ulcer Advisory Panel (EPUAP), European Society for Clinical Nutrition and Metabolism (ESPEN), European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS), European Society for Vascular Surgery (ESVS), European Tissue Repair Society (ETRS), International Compression Club (ICC), International Lymphoedema Framework (ILF) and World Alliance for Wound & Lymphedema Care (WAWLC). In addition, EWMA was happy to welcome our international partner association from Australia, Wounds Australia who organised a session on Australia – State of Play. The scientific programme would not have been complete without the many submitted abstracts, that contributed to 22 free paper sessions and more than 400 e-Posters. EWMA greatly appreciates the interest from all clinicians and researchers who submitted abstracts for the conference! Abstracts presented at the conference as oral or e-poster presentations are available at EWMA Conference Knowledge on www.ewma.conference2web.com.

EWMA Journal

2016 vol 16 no 2

EWMA

E-POSTER PRIZE E-poster prizes are awarded to e-posters that: n Are visually appealing n Are well laid out in a logical manner n Contain relevant and interesting content n Have clear conclusions

THE PRIZES WERE AWARDED TO THE FOLLOWING FIVE E-POSTERS: n Stephen Young, UK: EP216, Basic Science. An

Evaluation of a long fibre carbon and the effect on healing in chronic wounds

n Kristina Nesporova, Czech Republic: EP212,

FIRST TIME INTERNATIONAL PRESENTER AWARD 2016 During the conference, chairs evaluated first time international presenters and selected the following speaker for the First Time International Presenter Award based on the high quality of his presentation, which was particularly outstanding: Elena Komelyagina, Russia Abstract No. OP044: The rationality of growth factor therapy in hard to heal diabetic foot ulcers Free paper session: Diabetic Foot 1

Of the many abstracts chosen for presentation at the conference, one was awarded the First Time International Presenter Prize and five were awarded e-Poster prizes for especially great presentations. A number of symposia were also included in the programme: EWMA symposium: Exploring the Potential of Phage Therapy in Wound Care addressing the great therapeutic potential of phages in wound care. The symposium took place Wednesday 11th May, 16.45-18.00. Webcasts are available at www.ewma.conference2web.com. The Antimicrobial stewardship in wound management. Joint Symposium of BSAC and EWMA addressed use of antimicrobials. The WHO has identified the following as key factors contributing to general misuse of antimicrobials: diagnostic uncertainty, lack of skills, failure to properly utilise clinical guidelines, and insuffi-cient implementation EWMA Journalâ&#x20AC;&#x201A;

2016 vol 16 no 2

Basic Science. Age-related changes in gene expression and cell behav-iour relevant to wound healing studies in vitro

n Mireille Boink, Netherlands: EP192, Pressure

Ulcer Prevalence of local oedema surrounding pressure ulcers of the lower limb

n Giorgia Ciliberti, Italy: EP125, NPWT. The effect

of a bacteria and fungi binding mesh dressing on the bacterial load of pressure ulcers treated with negative pressure wound therapy (NPWT), a pilot study n Jodie Lovett, UK: EP112, Quality of Life.

Assessing the potential for cross-contamination following wound bed preparation

of basic policies to promote rational use. EWMA is dedicated to facing this challenge. To strengthen the knowledge base and educational power of the meeting, EWMA joined forces with the British Society for Antimicrobial Chemotherapy in the symposium held Wednesday 11th May. 13.45-16.40. Webcasts are available at www.ewma.conference2web.com. Furthermore the International Conference of the Veterinary Wound Healing Association (VWHA) was held during EWMA 2016. The conference provided a unique platform where scientists and other experts within veterinary and human wound management, as well as in public health, could meet. The symposium offered an opportunity to share new knowledge, to identify interfaces between veterinary and human wound research and management, and to create a basis for achieving synergies. The symposium took place Thursday 12th May during EWMA 2016. î&#x201A;Š

EWMA

THE CONFERENCE THEME WILL BE: CHANGE, OPPORTUNITIES AND CHALLENGES - WOUND MANAGEMENT IN CHANGING HEALTHCARE SYSTEMS

Participants looking at e-Posters in the e-Poster area.

When speaking of the great success of EWMA 2016 conference, it is also important to stress the large contribution of industry. The exhibition hosted 229 companies, organisations, and associations for EWMA participants to visit. The industry-sponsored scientific symposia were of great value, and the Scientific Committee is thankful to all of the industry partners whose cooperation contributed to the success of EWMA 2016. EWMA 2016 was undoubtedly an enjoyable and informative experience for all participants. EWMAâ&#x20AC;&#x2122;s highest priorities are bringing together the European wound healing community and, perhaps most importantly, creating and strengthening links among national associations that strive to raise the profile of wound management within their respective countries.

National healthcare systems in Europe are continuously changing, reorganising and adapting to respond to changing demographics and budget restrictions. This sets the context in which wound healing and wound carers must navigate to provide the best possible treatment for the individual patient. At the same time technology is rapidly developing, providing new methods and means of treatment and organisation. The EWMA 2017 conference will focus on the changes, opportunities and challenges provided by these continuous processes for wound management across Europe and beyond. The 27th Conference of the European Wound Management Association is being organised in cooperation with Knowledge Centre Wound Care (WCS). Thank you for joining us at EWMA 2016 in Bremen; please come and join us for the next conference in Amsterdam, Netherlands! n

In addition to the scientific part of the conference, a get-together event for all participants took place on the evening of Thursday 12th May at Messe Bremen, which provided a great opportunity for informal networking and simply having a great time with other conference attendees. This year EWMA is celebrating its 25th anniversary. On this occasion a number of events and activities took place and will take place during 2016 to highlight important milestones in the history of EWMA and modern wound management in general. Follow events, activities and news on www.ewma.org

SEE YOU 3-5 MAY 2017 FOR EWMA 2017! www.ewma2017.org

EWMA 2016 IN NUMBERS n 900 scientific and clinical practice presentations n More than 6000 participants from 84 different

countries n 440 invited speakers; including 340 international

speakers and 100 German speakers

n 13 organisations hosted 17 guest sessions and

SEE YOU NEXT YEAR! We will build on the success of this conference and make the next one even better. Therefore, come join us in Amsterdam for EWMA 2017, 3-5 May. As the conference continues to grow, there will be sessions describing new wound care solutions, and sessions that deal with the problems you face in your day-to-day work.

international partner sessions

n ICW and WundD.A.CH offered 45 sessions in

German, some with simultaneous translation into English n 20 satellite symposia organised by the industry

offered the participants new knowledge about wound care technologies

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Debrisoft® An integrated part of wound management.

Learn more about the mode of action!

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New EWMA Council Members

Selcuk Baktiroglu

Kirsi Isoherranen

Julie Jordan O’Brien

Sara Rowan

The individual members and the Cooperating Organisations Board elected four EWMA Council members during the EWMA 2016 Conference in Bremen. Selcuk Baktiroglu (Turkey), elected by the Cooperating Organisations Board n Kirsi Isoherranen (Finland), elected by the Cooperating Organisations Board n

Julie Jordan O’Brien (Ireland) n Sara Rowan (Italy) n

During the EWMA 2016 Conference, the EWMA Council also elected Sue Bale (UK) as the President Elect of the Association. Sue Bale will replace Severin Läuchli (Switzerland) as the President of EWMA from May 2017. Sue Bale New EWMA President Elect

The EWMA Council welcomes all new members of the EWMA Council and looks forward to a fruitful collaboration.

AAWC and Wounds Australia representation on the EWMA Council In 2015 EWMA welcomed representatives of the Association for the Advancement of Wound Care (AAWC) in the USA and Wounds Australia as official members of the EWMA Council. The aim of this extension of the EWMA Council is to further formalise and strengthen the long-standing collaboration and knowledge sharing with these international partner organisations. In 2016 these partner organisations are represented by:

Dr. Gregory Bohn, Medical Director of Wound Care and Hyperbaric Medicine, Westshore Center for Wound Care and Hyperbaric Medicine, USA, AAWC President

Kylie Sandy-Hodgetts, Research Associate, Curtin University, Australia, Wounds Australia Deputy Chair

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EWMA

Appreciations: leaving Council members By Severin Läuchli, EWMA President

In May 2016 two members ended their 3 year term on the Council. Both were members of the EWMA Council in the period 2013-2016 and were elected by the Cooperating Organisations. Knut Kröger (Germany) joined the EWMA Council with both enthusiasm and engagement from the very beginning. His first action as a council member was to initiate a point prevalence survey on the cost of wound care in his home region in Germany, based on the methodology used by EWMA in similar surveys. This was finalised and presented a few years later. Knut Kröger maintained this high level of engagement throughout the term and will continue his involvement in EWMA as a member of the author group responsible for developing a document on Oxygen Therapies, which is scheduled for publication in May 2017. During his time on Council, Knut Kröger was also a member of the EWMA Scientific Committee and the EWMA Patient Outcome Group. He also contributed to the document ‘eHealth in wound care – from conception to implementation’, which was published in 2015 as part of the EU support project United4Health that EWMA was engaged in. Knut Kröger is also Vice President of the German cooperating organisation (ICW) which co-hosted the joint EWMA Conference in Bremen in 2016, and has as such contributed further to the development of the collaboration with this important cooperating organisation of EWMA. Knut Kröger: MD, Director of the Department of Angiology, HELIOS Klinikum Krefeld, Germany

Arkadiusz Jawien (Poland) has a real networking personality. During his time on the EWMA Council, he has contributed significantly to the strengthening of the collaboration between EWMA and the Polish Wound Management Association (PWMA), as well as national and international specialist societies such as the Polish Society of Phlebology and the European Society for Vascular Surgery (ESVS), of which he was the President in 2015. Arkadiusz has also been an active member of several working groups during his time on Council. As a member of the Scientific Committee he has delivered important contributions to the development of EWMA Conference programmes. In particular, he has worked to raise the profile of vascular surgery in the programme to increase the interest of this group of professionals in wound management. Arkadiusz Jawien is also a member of the EWMA Patient Panel and contributed to the development of EWMA information material targeting patients with non-healing wounds. Lately he contributed to a section of the joint EWMA-Wounds Australia document on ‘Management of patients with venous leg ulcers’, which was published in May 2016. The author group responsible for this document benefitted from Arkadiusz’ substantial knowledge about invasive treatment of venous leg ulcers. We look forward to continuing the collaboration with Arkadiusz in relation to the EWMA 2018 Conference in Krakow, which will be co-hosted by PWMA. Arkadiusz Jawien, MD, PhD, Head of Angiology Department, Collegiujm Medicum, University of Nicolaus Copernicus, Bydgoszcz, Poland

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FOR ANY TYPE OF WOUND AND ALL PHASES OF WOUND HEALING

A NEW CLASS OF WOUND HEALING AGENT

ONE POWERFUL PRODUCT

WITH FOUR BENEFITS CONTINUOUS DEBRIDEMENT ANTIBACTERIAL ACTIVITY

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2,3,4

EWMA

By : Salla Seppänen, Chair of the Cooperating Organisations Board EWMA Immediate past president

Activities of the Cooperating Organisations during the EWMA 2016 Conference in Bremen - Knowledge sharing across borders Collaboration with the Cooperating Organisations is a key component of the European Wound Management Association activities. The annual EWMA conference is a significant opportunity to gather representatives from our partnering organisations, European as well as international, to bridge, bond and - most importantly – share knowledge. Every year during the conference in May, EWMA hosts two events to strengthen ties and touch base with our Cooperating Organisation representatives, and international partner organisations. COOPERATING ORGANISATIONS BOARD MEETING In the middle of the buzzing conference vibe on Thursday afternoon, I had the pleasure of welcoming 46 participants, including Cooperating Organisation representatives, international partners and council members for the Cooperating Organisations Board meeting, for inspiring presentations, discussion and networking. The first focus topic of the meeting this year was “Challenges and current best practices in the management of patients with venous leg ulcers”. National and international representatives gave presentations on the current guideline status in their respective home countries, and thereafter discussed barriers and challenges related to the development and implementation of best practice and guidelines. The second topic of debate was concerning the structure of future Cooperating Organisations Board meetings. It has been proposed to change the structure of the Board meeting next year, and there was general interest in having the Board representatives more central to the meeting activities. Going forward, this format will be implemented by incorporating presentations from national representatives to an even larger extent.

More information: www.ewma.org

EWMA Journal

the Board meeting is integral in maintaining the meeting as a valuable occasion for reaching out, touching base and knowledge sharing for Cooperating Organisations, as well as international collaborators. COOPERATING ORGANISATIONS WORKSHOP Our other annually recurring event is the Cooperating Organisations Workshop. Leading up to the workshop, all Cooperating Organisations are encouraged to submit an abstract about a national wound care-related theme. One of the notable features about the workshop is that it presents the possibility for our Cooperating Organisations to present and debate best practices as well as local initiatives and issues, and thus draw on the experience of peers across the continent. To ensure that the topics reflect the widest possible field of interest, all Cooperating Organisations are invited to vote on the presentations they are most interested in seeing presented prior to the workshop. This year, the topics presented included compression therapy, advanced educational programmes, as well as the issue of getting policymakers engaged with wound care. The contributions were submitted by both doctors and nurses from Germany, Portugal, Norway and Switzerland, and the attending participants revealed an even wider representation of different nationalities. I would like to take this opportunity to thank all of the participating and contributing representatives for their engagement and tremendous efforts in ensuring a successful Cooperating Organisations Board meeting and Workshop. Further, I also encourage all of our Cooperating Organisations partners to consider contributing an abstract for next year’s Workshop, so that we can continue to share challenges and broaden our horizons! n

The continuous evaluation and development of

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Antimicrobial stewardship in wound care: a Position Paper from BSAC and EWMA The EWMA BSAC Partnership This is the third collaboration between the two organisations, which was kick-started at the 2015 EWMA conference and followed up in 2016 with the Joint Symposiums on Antimicrobial Stewardship in Wound Management. The relationship is considered mutually beneficial for both organisations. BSAC is entirely dedicated to the issues concerning antimicrobial use, and has been spearheading the agenda by advocating the need for the effective use of antimicrobials. However, collaborating with practitioners’ associations like EWMA allows for the message of the stewardship concept to be brought directly to the clinicians who are acting at the centre of the resistance problem.

We are proud to announce that EWMA, together with the British Society for Antimicrobial Chemotherapy (BSAC), have published a joint position paper on antimicrobial stewardship in wound care. The paper was published in the Journal of Antimicrobial Chemotherapy in July 2016. It is authored by renowned experts in infectious diseases/ clinical microbiology (from the British Society for Antimicrobial Chemotherapy) and wound management (from the European Wound Management Association); namely Benjamin A. Lipsky, Matthew Dryden, Finn Gottrup, Dilip Nathwani, Ronald Andrew Seaton and Jan Stryja. Antibiotic resistance is one of the most pressing public health issues and there is a general overuse of antibiotics worldwide. In fact, up to 50% of in and outpatient treatments with antibiotics are unnecessary or inappropriate. The problem of inappropriate use of antibiotics amplifies the risk of development of resistant microorganisms. Infections with these organisms are directly responsible for increases in morbidity, length of hospitalisation, mortality and cost of healthcare.

With the growing global problem of antibiotic resistance it is crucial that clinicians use antibiotics wisely, which largely means following the principles of antimicrobial stewardship (AMS). Treatment of various types of wounds is one of the more common reasons for prescribing antibiotics, which is why this guidance document is aimed at providing clinicians an understanding of: n the basic principles of why AMS is important in caring for patients with infected wounds n

who should be involved in AMS

n and how to conduct AMS for patients with infected wounds.

Download the document free of charge at www.jac.oxfordjournals.org/

EWMA ANTIMICROBIAL STEWARDSHIP PROGRAMME

More information: www.bsac.org.uk and www.ewma.org

Antimicrobial stewardship programmes are increasingly advocated as a means to decrease misuse of antimicrobial agents. Along with infection prevention and control, hand hygiene and surveillance, antimicrobial stewardship is considered a key strategy in local and national programmes to prevent the emergence of antimicrobial resistance and decrease preventable healthcare associated infection. The overall aim of EWMA’s antimicrobial stewardship programme is to reduce inappropriate use and overuse of antimicrobials in wound care by promoting, facilitating and teaching good antimicrobial practice. With a focus on the health professional’s role in the area of appropriate use of antimicrobials across health care settings, the programme is targeting health professionals involved with wound care - doctors, nurses, pharmacists, microbiologistsbut also reaching out to policy makers, such as clinical administrators or managers at local, regional or national level.

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Superior absorption. Faster healing Let’s make every day count Biatain® Silicone combines superior absorption and a gentle & secure fit · Biatain Silicone is a flexible foam dressing with a gentle silicone adhesive · The unique Biatain foam conforms closely to wound bed ensuring superior absorption and an optimal moist wound healing environment1-4 · Easy and aseptic application due to 3-piece non-touch opening1,4,5 · The gentle fixation ensures high patient comfort and minimal pain at removal6,7 · Biatain Silicone can be used for non-to-high exuding chronic and acute wounds when patients need increased mobility

Biatain® Silicone Lite - superior absorption with soft adhesion for increased mobility

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Follow us at facebook.com/ColoplastWoundCare References: 1. Cartier H et al. Wound management with the Biatain® Silicone foam dressing: A multicentre product evaluation. Wounds International 2014;10(4), 2. Andersen MB & Marburger M. Comparison of 24 hours fluid handling and absorption under pressure between ten wound dressings with silicone adhesive. Presented at EWMA 2015 3. Data on file, Coloplast 2015 (0100485). 4. Wounds UK Best Practice Statement. Effective exudate management. London, Wounds UK, 2013 5. Data on file. Coloplast 2015 (0095768). 6. Chadwick P et al. Biatain® Silicone dressings: A case series evaluation. Wounds International 2014;5(1) 7. Data on file, Coloplast 2012 (0011444).

Now it’s time to confront the biofilm villain The dressing that gives you the weapons you need to attack the key local barriers to wound healing. AQUACEL® Ag+ Dressing doesn’t just manage exudate and infection*1-5. It helps destroy biofilm too*6-8.

Find out more about AQUACEL® Ag+ Dressings at www.convatec.co.uk

O BI EXUD AT

M FIL

*As demonstrated in vitro 1. Newman GR, Walker M, Hobot JA, Bowler PG, 2006. Visualisation of bacterial sequestration and bacterial activity within hydrating Hydrober™ wound dressings. Biomaterials; 27: 1129-1139. 2. Walker M, Hobot JA, Newman GR, Bowler PG, 2003. Scanning electron microscopic examination of bacterial immobilization in a carboxymethyl cellulose (AQUACEL™) and alginate dressing. Biomaterials; 24: 883-890. 3. Bowler PG, Jones SA, Davies BJ, Coyle E, 1999. Infection control properties of some wound dressings. J. Wound Care; 8: 499-502. 4. Walker M, Bowler PG, Cochrane CA, 2007. In vitro studies to show sequestration of matrix metalloproteinases by silver-containing wound care products. Ostomy/Wound Management. 2007; 53: 18-25. 5. Assessment of the in vitro Physical Properties of AQUACEL EXTRA, AQUACEL Ag EXTRA and AQUACEL Ag+ EXTRA dressings. Scientific background report. WHRIA3817 TA297, 2013, Data on file, ConvaTec Inc. 6. Antimicrobial activity and prevention of biofilm reformation by AQUACEL™ Ag+ EXTRA dressing. Scientific Background Report. WHRI3857 MA236, 2013, Data on file, ConvaTec Inc. 7. Antimicrobial activity against CA-MRSA and prevention of biofilm reformation by AQUACEL™ Ag+ EXTRA dressing. Scientific Background Report. WHRI3875 MA239, 2013, Data on file, ConvaTec Inc. 8. Physical Disruption of Biofilm by AQUACEL™ Ag+ Wound Dressing. Scientific Background Report. WHRI3850 MA232, 2013, Data on file, ConvaTec Inc. AQUACEL, AQUACEL Extra, ConvaTec, the ConvaTec logo, Hydrofiber and the Hydrofiber logo are trademarks of ConvaTec Inc. All other trademarks are the property of their respective owners. © 2016 ConvaTec Inc. AP-016136-GB

EWMA

Guest speaker at a U.S. Food & Drug Administration (FDA) panel meeting Washington DC 20 & 21 September 2016 FDA is well known by many people in the wound area, especially by the wound care companies that need FDA approval of their products before they can be sold and used in the USA – one of the most important markets worldwide. Also, many countries around the world follow the FDA guidelines. The structure, decision-making and working procedures of this organisation have been an unknown area for most wound management specialists in Europe. For these reasons the author of this article has been asked to describe his participation in an FDA meeting, where he was invited to give a presentation as a guest speaker.

The meeting was related to the General and Plastic Surgery Devices Panel of the Medical Devices Advisory Committee which had a Panel meeting on 20-21 September 2016. I was invited to present at the meeting based on my professional expertise, especially within wound management outcome measures, evidence and use of antimicrobials. Primarily I was invited to serve as a consultant at this and future panel meetings for a four-year term. However, as this position cannot be held by a non-American citizen, I was invited as guest speaker instead. The General and Plastic Surgery Devices Panel consist of 17 persons with different backgrounds, including ten doctors, one nurse, one statistician, one industry representative, one patient representative, and one consumer representative. The group of doctors included representatives of different specialties (dermatology, plastic surgery, general surgery, oncology, internal medicine, etc.). Some of the doctors worked regularly with EWMA Journal

2016 vol 16 no 2

wounds, for example, some of the surgeons were linked with burn units offering wound treatment. The purpose of the meeting was to formulate recommendations concerning the classification of devices that can be defined as wound dressings combined with drugs (“wound dressings containing drugs”). These products include solid wound dressings, gels, creams, ointments, and liquid wound washes. THE MEETING AGENDA – NEW CLASSIFICATION OF WOUND DRESSINGS COMBINED WITH DRUGS The panel was asked to recommend a classification of these wound dressings combined with drugs, based on their respective risk/benefit profiles. The final outcome of this classification was recommendation to the FDA on whether to classify wound dressings combined with drugs as Class III (subject to Premarket Approval), Class II (subject to General and Special Controls), or Class I (subject only to General Controls).

Finn Gottrup Professor of Surgery, University of Southern Denmark. Copenhagen Wound Healing Center, Department of Dermatology, D42, Bispebjerg University Hospital, Copenhagen, Denmark.

The primary focus of this meeting was wound devices containing a substance especially related to antimicrobials. The latest FDA classification was performed in 2005. Thus, the outcome of this meeting is especially interesting for the companies producing this type of products. Today most of the products on the market are placed in Class II, which means that they can be on the market with only limited documentation about security and effectiveness. If the new evaluation results in a changed classification of these products to Class III, much more detailed 

Correspondence: fgottrup@post4.tele.dk Conflicts of interest: None

EWMA

The author in front of screen announcing meeting.

FDA General and Plastic Surgery Devices Panel. The panel is placed in U-shaped set up.

documentation from the companies will be required and may have the consequence that some products must be removed from the market in the USA until the required documentation has been developed.

and study outcome/endpoints”. As mentioned, the primary focus of this meeting was use of antimicrobials in a wound dressing device. My presentation was structured as a clinical survey covering the relevant topics related to this focus area:

MEETING STRUCTURE The first day of the panel meeting was focused on current clinical practice for wound care and a discussion about the available scientific evidence regarding clinical practice. The second day of the panel meeting was dedicated to specific sub-categories of wound dressing products and recommendations concerning their classification. FDA had prepared presentations covering all relevant topics related to safety and effectiveness of the products. These presentations were followed up by questions to the panel members. These questions generated a discussion and ended up with a final set of recommendations from the panel to the FDA. Based on this, a decision will be made on how to categorise the different products. Both meeting days included an “Open Public Hearing” where companies, patient organisations, medical societies and other relevant stakeholders were allowed to give a 5 minute presentation related to, for example, product classification, guidelines, and recommendations. At the end of both meeting days some FDA questions were discussed and preliminary panel recommendations were prepared. The definitive FDA recommendations will be made at a later stage. MY PRESENTATION As a guest speaker, my presentation was placed as the final input in the series of FDA presentations on the first day. I was given 45 minutes for my presentation, followed by 15 minutes “clarifying questions from the Panel”. The title of my presentation was “Clinical Wound Management with focus on infection, development of AMR, evidence

1. Risk of infection and development of resistance; 2. Available evidence and use of outcome measures/ endpoints. EWMA played a central role in my presentation, due to EWMA’s focus on evidence in wound care and the current antimicrobial stewardship programme. Previous EWMA publications on antimicrobials in wound management and outcome measures in wound management were included in the presentation and shared with the panel. In addition, EWMA’s role as an umbrella organisation for wound management associations in Europe was described. Based on the reactions from the panel, the clinical point of view on these topics in my presentation was well received. This is supported by the fact that most of the FDA material made available to the panel was relatively theoretical. Many questions were raised by the panel after my presentation as well as later in the meeting, where I was called upon a number of times to discuss topics from my presentation. IN CONCLUSION The invitation from the FDA to participate in one of their meetings has been an inspiring opportunity for me to learn more about the structure of the FDA and how topics are evaluated and finally decided on. This has increased my understanding of the FDA as a closed organisation with an enormous influence on which products and procedures can be used in wound management. n

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It’s time for

27 TH CONFERENCE OF THE EUROPEAN WOUND MANAGEMENT ASSOCIATION – EWMA – IN COOPER ATION WITH WCS KNOWLEDGE CENTRE WOUND CARE

EWMA 2017

A M S T E R DA M , T H E N E T H E R L A N D S 3 - 5 M AY 2017

VISIT EUROPE'S LEADING CONFERENCE ON WOUND MANAGEMENT

W W W.EWM A 2017.ORG W W W.EWM A .ORG W W W.WCS.NL

EWMA

Parliamentary breakfast raises public awareness

Severin Läuchli EWMA President

In the wake of the EWMA 2016 conference in Bremen, EWMA organised, in collaboration with the German Chronic Wounds Initiative, Initiative Chronische Wunden (ICW), the German-Austrian-Swiss wound care umbrella organisation WundD-A-CH, and the German Wound Council (DWR) a breakfast meeting on the 10 May for specially invited German members of Parliament and health care decision-makers in Berlin.

Matthias Augustin Director of the Institute for Health Care Research in Dermatology and Nursing, Hamburg

From left to right: Dr Severin Läuchli (EWMA President), Mr Erwin Rüddel (Member of the German Parliament), Mr Henrik Nielsen (EWMA Director), Prof. Dr Matthias Augustin (Director of the Institute for Health Care Research in Dermatology and Nursing, Hamburg) and Dr Christian Münter (Representative of the Initiative Chronische Wunden).

The purpose of organising this meeting was to create awareness amongst policy and health care decision-makers about the challenges of wound care.

More information: www.ewma.org

MEETING THEME: HEALTH CARE IN TIMES OF DEMOGRAPHIC CHANGES Under the above heading and chaired by Member of the German Parliament and rapporteur for the topic “health policy” in the CDU/CSU-parliamentary group, Mr. Erwin Rüddel, the meeting gathered representatives of the self-governing German healthcare system, professional associations and journalists for a debate about the challenges in the treatment of chronic wounds in Germany as well as across Europe.

Introducing the theme to the 26 participants (including 9 members of the German Parliament), EWMA President Dr Severin Läuchli gave a brief presentation about the current main challenges in the treatment of chronic wounds, stressing amongst other things the transition from inpatient to out-patient care, and highlighting the importance of introducing antimicrobial stewardship in wound care. This introduction was followed by a presentation by Erwin Rüddel who emphasised in particular the importance of overcoming barriers between different healthcare sectors, a better interconnectedness between nurses and physicians as well as a higher flexibility within the health insurance 

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Dr. Severin Läuchli opening the meeting, host Erwin Rüddel (centre) and Prof. Augustin (next right)

system in order to achieve better treatment of patients. He pointed out that in order to tackle the above-mentioned challenges, the current government has already implemented quite a lot of helpful legislation and thus provided more money for the healthcare system. Prof. Matthias Augustin, Director of the Institute for Health Care Research in Dermatology and Nursing at the University Medical Center Hamburg-Eppendorf went on to talk about new insights and solutions in treating chronic wounds in Germany. First, Prof. Augustin called attention to the age-dependent prevalence of chronic wounds and the characteristic presence of multimorbidity, and explained that around 1.2 million people in Germany suffer from chronic wounds every year. For 80 % of them this means a strong or very strong decline in quality of life. However, Prof. Augustin stressed that an improvement of life quality is already achieved when a wound stops smelling or exuding as a result of high quality treatment. This is also a relevant point with regard to the discussion about reimbursement and benefit assessment of modern wound treatment. Prof. Augustin also emphasised the necessity of inter-professional collaboration between the various different medical disciplines and between non-medical staff involved in the treatment of chronic wound patients, and highlighted the fact that “chronic wounds have to be treated by experts”. Ending his presentation, Prof. Augustin presented the following criteria for modern wound management:

n n

innovative technologies patient-oriented reatment

The presentations were followed by a lively debate between the meeting participants. NEXT STEPS The breakfast meeting in Berlin was the first experience of this kind made by EWMA. However, it follows in a tradition of engaging in meeting with members of the European Parliament and national health care decision-makers in a number of European countries during recent years. EWMA will continue to engage in such debates in future years with the purpose of raising the awareness of policy and decision-makers about wound care. A similar event is currently being planned to take place in connection with the 2017 EWMA conference in Amsterdam, The Netherlands. Furthermore, national wound care associations across Europe who collaborate with EWMA as Cooperating Organisations are invited to organise national wound care roundtables on topics which will be supported by participation of EWMA appointed experts. In the meantime, follow-up contacts with the German members of parliament have followed, indicating the local benefit of such a meeting. n

interconnected wound treatment n systematic wound treatment n treatment based on guidelines n

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28th Conference of the European Wound Management Association

EWMA 2018 in cooperation with the Polish Wound Management Association

VISIT EUROPE'S LEADING CONFERENCE ON WOUND MANAGEMENT IN

KRAKOW, POLAND 9 - 11 MAY 2018

W W W.E WM A 2018 .ORG W W W.E WM A .ORG W W W.P TLR .ORG .PL

First EWMA Round Table and Lithuanian annual wound conference in Kaunas, Lithuania Annual wound meetings organised in early spring (March to April) are very popular in Lithuania and attract 300 to 400 participants of various specialties: specialists in primary care, plastic surgeons, vascular surgeons, dermatologists, nurses, and technicians. Rytis Rimdeika Hospital of Lithuanian University of Health Sciences Kauno klinikos, Kaunas, Lithuania

In the past ten years Lithuanian meetings have been held in all major cities of Lithuania, thus ensuring the availability of the latest information in wound care as well as giving the opportunity to hear the best European experts in wound care. On 15 April 2016, the 10th annual conference of the Lithuanian Wound Management Society with the title “Medical equipment and supplies for woundcare: standards, protocols, recommendations and innovations” was held in Kaunas, at the Lithuanian University of Health Sciences. The conference started with the report of President of Lithuanian WMS, Prof. Rytis Rimdeika, who presented the progress of the Lithuanian organisation since its establishment in 2005. Main local achievements were presented as well as international projects successfully implemented in the region in conjunction with EWMA. This conference included a special Round Table session organised on the initiative of EWMA together with Lithuanian WMS. The scope of the Round Table session was the Negative Pressure method in woundcare. The EWMA “Negative Pressure Wound Therapy Position Document”, to be published during 2016, was presented by EWMA Council members Prof. Sue Bale (UK) and Dr. Edward Jude (UK). An introduction to the format of Round Table sessions and EWMA initiatives was made by the director of the EWMA Secretariat, Mr. Henrik Nielsen (Denmark), who was also the moderator of the session. Regional actualities of implementing this advanced wound

care method into the clinical practice in Lithuania, Latvia and Poland were presented by Prof. Rytis Rimdeika, Dr. Dzintars Ozols and Dr. Marcin Malka. Other scientific sessions were dedicated to other innovations in wound care: equipment and supplies for prevention of pressure ulcers, dressings, antiseptics, advanced methods of wound management in different types of wounds, cell and biological technologies. Organisers of the conference were delighted to have Prof. Ojan Assadian from the University of Huddersfield (UK) as a guest speaker, who presented the latest review of antiseptics in treatment and prevention of wound infection, and Vera Buivide from Riga, Latvia with a presentation about multiple layer silicone dressings for pressure ulcer prevention and management. Prof. Liutauras Labanauskas made an introduction into the possibilities of Stroma- Vascular Fraction cells in regenerative medicine and wound care. The participants of the meeting had the chance to visit the exhibition where local teams of manufacturers or distributors exhibited wound care products. The conference ended with the election of new board members. Prof. Rytis Rimdeika completed the second five – year term as a president of Lithuanian society and resigned from this position. Dr. Loreta Pilipaityte, Plastic Surgeon from Lithuanian University of Health Sciences was elected President of the Lithuanian Wound Management Society.

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EWMA

EWMA Journalâ&#x20AC;&#x201A;

2016 vol 16 no 2

Easier dressing regimens and a better quality of life It’s all about the outcome

Mepilex® XT – Take control of exuding wounds. Exuding wounds are a tough challenge for patients and for you. But the right dressing can make a world of difference. Designed for use on all exuding wound healing stages1, Mepilex® XT with Safetac® has been shown to support longer wear times2 and so require fewer dressing changes than other foam dressings2. It, like all dressings with Safetac, minimizes pain and skin damage3,4, supports faster healing5 and helps prevent moisture-related complications6. Mepilex XT. The safe choice for patients and for you. And the proven choice for a better outcome.

References: 1. Lantin, A., Diegel, C., Scheske, J., Schmitt, C., Bronner, A., Burkhardt, S. Use of a new foam dressing with soft silicone in German specialist wound care centres. E-poster presentation at European Wound Management Association conference, London, UK, 2015. 2. Mölnlycke Health Care, Data on file: MXTCost1115. 3. Upton D. et al. The impact of atraumatic vs conventional dressings on pain and stress in patients with chronic wounds. Journal of Wound Care 2012 21(5):209-215. 4. White R. Evidence for atraumatic soft silicone wound dressing use. Wounds UK 2005 1(3):104-109. 5. Gee Kee, E.L., Kimble, R.M., Cuttle, L., Khan, A., Stockton, K.A. Randomized controlled trial of three burns dressings for partial thickness burns in children. Burns 2015, http:dx.doi.org/10.1016/j.burns.2014.11.005 [Epub ahead of print]. 6. Meaume, S., Van De Looverbosch, D., Heyman, H., Romanelli, M., Ciangherotti, A., Charpin, S. A study to compare a new self-adherent soft silicone dressing with a self-adherent polymer dressing in stage II pressure ulcers. Ostomy Wound Management 2003;49(9):44-51.

Find out more at www.molnlycke.com Mölnlycke Health Care AB, P.O. Box 13080, Gamlestadsvägen 3C, SE-402 52 Göteborg, Sweden. Phone + 46 31 722 30 00. The Mölnlycke Health Care, Mepilex® and Safetac® trademarks, names and respective logos are registered globally to one or more of Mölnlycke Health Care Group of companies. © 2016 Mölnlycke Health Care. All rights reserved. HQWC0080

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Make a difference in clinical practice Become a Member of EWMA Benefits of your EWMA Membership: n You make a difference in clinical practice within wound management in Europe n Right to vote and stand for EWMA Council n EWMA Journal sent directly to you two times a year n EWMA news and statements sent directly to you n A discount on your registration fee for EWMA Conferences n Right to apply for EWMA travel grants n Yearly membership fee € 25 n Yearly membership fee for members of cooperating organisations € 10

EWMA Journal

2016 vol 16 no 2

NEW SPONSORS

ZORFLEX® WOUND CONTACT DRESSINGS Antimicrobial Zorflex® wound contact dressings from Chemviron use a triple action to help accelerate wound healing across a wide range of chronic, non-healing wound types. With wound care costs accounting for up to 4% of global healthcare systems’ budgets, faster wound healing helps both to improve patient outcomes and lower overall wound care costs. Consisting of pure activated carbon cloth, Zorflex dressings are highly flexible, conforming to the body’s contours. They are suitable for treating venous, diabetic and pressure ulcers, as well as infected trauma, surgical and excision wounds. They can also be used on infected graft donor and recipient site wounds, and are easy to cut or fold. ZORFLEX TRIPLE ACTION Zorflex uses a triple action to create conditions conducive to accelerated wound healing, while improving patient comfort: 1. Naturally antimicrobial Electrostatic forces of attraction draw, trap and kill microorganisms on the dressing surface. No additives mean there is no chemical donation, either to the wound bed or systemically. 2. Conductivity Zorflex is naturally conductive, restoring the body’s transepithelial potential across the wound bed and assisting the healing process. 78

3. Odour management The electrostatic forces also adsorb odour molecules and destroy odour-causing microbes, helping to manage wound odour and improve patient wellbeing. Accelerated wound healing: the evidence “Wound closure at 90.7% in 5 weeks was far greater than (UK) national healing rates for wounds of 61% healing in a year. “Young S., Gray S., Hampton S. (20 subjects), EWMA 2016 poster (voted among best in show). “Overall, median time to wound closure was 51 days, similar in both truncal and extremity wounds.” Scheer H., Kaiser M., Zingg U. (70 subjects), EWMA 2016 presentation. “Applied directly to chronic wounds, improved the appearance of the wound bed, reduced exudate levels and pain and clinic visits all within a 7-day period.” Murphy, N. (4 subjects), BJN 2016, Vol 25, No 12: Tissue Viability Supplement. For further information: E: info@zorflex.com W: zorflex.com Blog: zorflexions.com

EWMA Journal

2016 vol 16 no 2

octenilin® for a smooth wound healing.

octenilin® wound gel moistens wounds, ensures an ideal healing environment and inactivates pathogens in the gel to build a protective barrier against penetrating germs can be used for up to 6 weeks after the first opening

octenilin® wound irrigation solution cleans wounds efficiently and, at the same time, is very well-tolerated by the skin and tissues can be used for up to 8 weeks after the first opening

www.schuelke.com

Submit your paper to EWMA Journal Volume 17 16 Number 1 2016 April 2016

Volume 16 15 Number 2 2015 October 2015

Volume 14 Number 2 October 2014

Published Published by by European Wound Wound Management Management Association

Published by European Wound Management Association

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on the road to better

PATIENT

sAfETy Volume 14 Number 1 May 2014 Published by European Wound Management Association

Volume 13 Number 2 October 2013 Published by European Wound Management Association

WOUND CARE – SHAPING THE FUTURE

Rf dC

Volume 13 Number 1 April 2013

Volume 12 Number 3 October 2012

Published by European Wound Management Association

EWMA FOCUS ON ANTIMICROBIALS AND DEBRIDEMENT

ORGANISATION IN WOUND HEALING

INNOVATION, KNOW-HOW AND TECHNOLOGY IN WOUND CARE

Published by EUROPEAN WOUND MANAGEMENT ASSOCIATION

www.ewma.org

FOCUS ON

Editorial Board Sue Bale, Editor Severin Läuchli, Editor in Chief Vickie R Driver Georgina Gethin

A PATIENT, PROFESSIONAL, PROVIDER AND PAYER PERSPECTIVE

Martin Koschnick Rytis Rimdeika Salla Seppänen Hubert Vuagnat

Danish Wound Healing Society

NEW SPONSORS

MEDELA SIMPLIFIES THE DELIVERY AND MANAGEMENT OF NPWT MEDELA OFFERS A COMPREHENSIVE PORTFOLIO OF NEGATIVE PRESSURE WOUND THERAPY SOLUTIONS TO SIMPLIFY THE DELIVERY AND MANAGEMENT OF NPWT, MAKING IT EASIER FOR HEALTHCARE PROFESSIONALS TO HELP THEIR PATIENTS HEAL. Clinicians can choose between a reusable system, Invia® LibertyTM, and a single-patient device, Invia® MotionTM. Medela`s Invia Liberty NPWT system includes an intelligent pressure management for reliable negative pressure delivery and control at the wound site1, ensuring therapy confidence. The personal NPWT device, Invia Motion combines the convenience and inherent hygiene of a disposable system with the performance and features associated with a reusable NPWT pump. Invia Motion includes full dual lumen capability with dynamic pressure measurement, adjustable pressure setting, and choice of constant or intermittent therapy modes and is designed to cover the complete therapy for a single patient. The new foam dressings (available in four sizes) complete the portfolio, along with the well-established gauze solutions and the Invia® Silverlon® Antimicrobial Wound Contact Dressing. Medela has over 54 years of experience with medical negative pressure innovations and a long-term history in the NPWT-market. With the launch of its new NPWT range, Medela continues to strengthen their commitment by providing patients and professionals with easy-to-use and trustworthy solutions. 1 Performance data on file at Medela AG

EWMA Journal

2016 vol 16 no 2

EWMA News

ens in January 2016. Information on: beticfoot.org

EWMA STUDY RECOMMENDATIONS NEW JOINT IWGDF-EWMA PUBLICATION

In 2014 EWMA published the document “EWMA study recommendations - for clinical investigations in leg ulcers and wound care”. In September this year, a second publication focusing on diabetic foot studies was published by the International Working Group of the Diabetic Foot (IWGDF) in collaboration with EWMA. The title of the new publication is “Reporting standards of studies and papers on the prevention and management of foot ulcers in diabetes: ot Task Force & Symposium 2016 Sponsor: required details and markers of good quality”. The idea to publish study recommendations originates from discussions in the EWMA Patient Outcome Group concerning evidence and outcome measures in wound care studies. It was agreed that a series of user-friendly documents were needed to assist those new to wound care research in starting on the path to plan, conduct, interpret and disseminate findings from an investigation.

With these publications, EWMA aims to support more investigations that will improve our nordicdiabeticfoot.org understanding of clinical wound healing and raise the evidence level of the work undertaken. Download both documents free of charge at www.ewma.org

SWAN-ICARE The SWAN-iCare project is now progressing into its final phase. The complete system is developed and a clinical feasibility study planned to take place under the coordination of the University of Pisa, by early 2017. During the World Union of Wound Healing Societies (WUWHS) conference in Florence 2529 September 2016, EWMA together with representatives of the consortium members Exus, ICCS, Smith & Nephew and the University of Pisa, organised a focus panel meeting. On this occasion an invited group of clinicians provided input to a number of questions about: n n n

Selected system components Value and use of data generated by the system Expectations of the system and its value

The SWAN-iCare project will close at the end of February 2017, where a final prototype of the developed smart device for distance wound monitoring and therapy will be ready. SWAN-ICare is partially funded under the seventh research and innovation framework programme FP7 by the European Commission.

EWMA Journal

2016 vol 16 no 2

EWMA NEWS

USE OF OXYGEN THERAPIES IN WOUND CARE The vision and concrete plans for this document were presented at a Key Session during the EWMA 2016 Bremen conference. The abstracts are available in the EWMA Conference Knowledge website at http://ewma.conference2web.com/#!contentsessions/4186 The author group chaired by Prof. Finn Gottrup and co-chaired by Prof. Joachim Dissemond recently met in Copenhagen to work on the first draft of the document chapters. Publication of the document is planned for Spring 2017 with the document launch expected to take place during the EWMA 2017 Amsterdam conference. The document is supported by unrestricted grants from:

PREVENTING AND MANAGING SURGICAL SITE INFECTIONS ACROSS HEALTH CARE SECTORS While guidelines for preventing and managing surgical site infections in hospitals are in place in many countries there is still a need for guidance on how to deal with SSI management and prevention in community care. A set of recommendations on this topic covering primary as well secondary care, and targeting health care professionals in hospital as well as community based nurses and general practitioners, does not yet exist. EWMA has therefore decided to focus on surgical site infections (SSI) and initiate a project based on broad interdisciplinary collaboration. Part of this project will be a publication on surgical site infections in Spring 2018. The document will be developed in collaboration with Wounds Australia.

ADVANCED THERAPIES IN WOUND CARE D

T H

A P I ES

E R

DVA NC

Advanced therapies are expected to be increasingly used in the treatment of wounds, however, little overview over the different treatment modalities and evidence of their efficacy exists. This is why EWMA is now developing a document on the topic. The document will investigate and provide an overview of the barriers and possibilities of advanced therapies in the next generation wound management. Cellular therapies, tissue engineering and tissue substitutes are all techniques associated with the clinical discipline of regenerative medicine and will be covered in the document. Moreover, a focus on physical therapies and the potential of sensors and software will be included. The document will include a literature review, expert opinion on the application of advanced therapies and call for research in recommended areas. While the document is expected to be published in Spring 2018, a key session outlining the document will be held at the 2017 EWMA conference in Amsterdam.

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2016 vol 16 no 2

EWMA NEWS

JOINT EPUAP & EWMA PU PREVENTION & PATIENT SAFETY ADVOCACY PROJECT EPUAP and EWMA have established a joint engagement in the pressure ulcer prevention and patient safety agendas at European level as well as at national level in selected European countries. The project is expected to run from 1 July 2016 – 30 June 2018. A joint working group consisting of the following representatives of each association has been established: n EPUAP representatives: Zena Moore (chair), Lisette Schoonhoven, Jane Nixon, Jan Kottner, Adina Markova (secretariat). n EWMA representatives: Jose Verdu Soriano (chair), Hubert Vuagnat, Andrea Pokorná, Jan Kristensen (secretariat).

The project will engage in activities aimed at raising the awareness of policy decision-makers about pressure ulcers, patient safety and wound care through a number of activities. The project will engage in: n Elaboration of a European epidemiology overview based on existing prevalence and incidence data. Data collected will be used to back and sustain planned campaign activities.

Targeting of Members of the European Parliament, the European Commission and other European key stakeholders and decision-makers to raise awareness and call for preventive action against the development of pressure ulcers. n

As a first activity the project was invited to present and engage in debate at the OECD Health Care Quality Indicators Experts meeting in Paris on 4 November 2016. The project is supported by unrestricted educational grants from:

EUROPEAN CURRICULA FOR POST-REGISTRATION QUALIFICATION OF NURSES The care of people with chronic wounds has made enormous progress in recent years throughout Europe. To bring existing knowledge to all professional nurses is a key objective of the European Wound Management Association (EWMA). For this reason EWMA is working on a curriculum for nurses which is aligned to the physicians’ curriculum that has already been developed and approved by the UEMS (April 2015). Since the vocational qualifications in Europe are not all at the same level, two different Curricula Qualification levels are under development. A curriculum covering level 5 EQF (European Qualifications Framework) has almost been finalised, while level 6 is expected to be finalised at the beginning of 2017. Following the finalisation of these curricula, EWMA will work to support the implementation by asking relevant European and international nurse organisations to approve and adopt the curricula. 84

EWMA Journal

2016 vol 16 no 2

Management of the Diabetic Foot Theory & Practice 4 - 7 October 2017

Save the Date

Pisa International Diabetic Foot Course 9th Course · 4 - 7 October 2017 · Pisa · Italy www.diabeticfootcourses.org

Submit your next paper to

Organ der Deutschen Gesellschaft für Phlebologie Organ der Schweizerischen Gesellschaft für Phlebologie, Bulletin de la Société Suisse de Phlébologie Organ der Arbeitsgemeinschaft Dermatologische Angiologie der Deutschen Dermatologischen Gesellschaft Organ des Berufsverbandes der Phlebologen e.V.

Phlebologie 2016. 45. Jahrgang | 6 Hefte jährlich ISSN 0939-978X Jährliche Bezugspreise 2016 *

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EWMA NEWS

EWMA Publications New publications in 2016 and 2017

New document by EWMA and Wounds Australia:

Management of patients with venous leg ulcers – Challenges and best practice. Published April 2016 This document provides clinical practice statements addressing key aspects to consider when developing an evidence-based leg ulcer service that enhances the patient journey. The document also identifies barriers and facilitators in the implementation of best practice in the management of a VLU.

New EWMA document:

Negative pressure wound therapy – Overview, challenges and perspectives Will be published Dec 2016 This document provides an overview of the evidence base for the use of negative pressure wound therapy (NPWT) in wound treatment and covers all three types of NPWT: On open wounds, with instillation and over closed incisions. The document also focuses on the organisational and health economical aspects of NPWT. The document will be presented in a key session during the EWMA 2017 Conference.

Non-antibiotic antimicrobials for the treatment of wounds

A joint EWMA/BSAC document Expected publication May 2017 As part of the ongoing EWMA Antimicrobial Stewardship Programme a document on the existing antimicrobial alternatives to antibiotics is being elaborated. The document is authored by Rose Cooper and David Leaper and presented in collaboration with British Society of Antimicrobial Chemotherapy (BSAC). The document will be launched in a joint EWMA/BSAC symposium during the 2017 EWMA conference in Amsterdam.

Document on the use of oxygen therapies in wound healing

Expected publication: Spring 2017 In 2016-2017, EWMA will work on a document aiming to provide practice-oriented guidance on the use of various forms of oxygen therapies for wound treatment. This document will include an overview of treatment options available and an assessment of the best available evidence for use. In addition, the document will detail specific aspects and current discussions connected with the use of oxygen in wound healing. Expected publication: Spring 2017 The document will be launched in a key session during the EWMA 2017 Conference in Amsterdam.

EWMA Journal

2016 vol 16 no 2

Organisations

AAWC NEWS AAWC AAWC participates at EWMA; May 11-13, 2016: Association for Bringing Diversity Together for the Advancement the Advancement of Wound Care of Wound Care

Greg Bohn, MD, FACS, ABPM/ UHM, CWSP, FACHM President, Association for the Advancement of Wound Care More information: www.aawconline.org ABOUT AAWC As the leading interpro fessional organisation in the United States dedicated to advancing the care of people with and at risk for wounds, AAWC provides a whole year of valuable benefits! Be sure to join us for near daily updates and alerts on Facebook and LinkedIn.

Dear EWMA Colleagues, I am honored to provide an update to EWMA journal readers. The Association for the Advancement of Wound Care (AAWC) is the leading interdisciplinary organization for wound healing in the United States, and we have had tremendous success over the last several years. I proudly became AAWC President position this past April at SAWC Spring in Atlanta, and I look forward to my service through 2018. Having come off a successful SAWC Spring in Atlanta, Dr. Vickie Driver and I had the privilege of attending EWMA 2016 in May in Bremen, Germany. As you know, the conference is a collaboration of wound organizations with a governing council that brings the diverse European Wound Community together for the purpose of education and learning. While that seems a simple statement, what was impressive was the degree to which “collaboration” brought such diversity together for a common goal of advancing the practice of wound care. As a participant at the EWMA Council meeting, interest in AAWC as an organization that represents multi-disciplinary practice in wound care was apparent. AAWC’s joint consolidated guideline development was outlined to the EWMA Council. The leadership displayed by volunteer professionals in AAWC who have worked to bring the consolidated guidelines project to such a successful was applauded. The EWMA council was interested in becoming part of the process to contribute to updates of the guidelines. Additionally, there was interest in development

of clinical endpoints as it relates to a project hosted by AAWC and co-hosted by WHS entitled, “Wound-care Experts/FDA – Clinical Endpoints Project (WEF-CEP).” The efforts of AAWC and WHS to develop relevant clinical endpoints for wound care are of global value. Also of note, EWMA outlined a wound care curriculum that may serve as a useful platform for education and could result in a collaborative exchange with AAWC. EWMA aims to publish wound-related documents on a regular basis and make them available to the membership. Topics of upcoming publications include Advanced Therapies, Surgical Site Infections and The Use of Oxygen in Wound Care. What can we bring back to AAWC from Bremen? There is great value in the diversity within AAWC. Having multiple points of view helps AAWC advance wound care in a broad sense that can improve care for patients on multiple levels. Greater participation within the organization will allow AAWC to get the “wide view” of the issues that we all face. If you have an idea that would improve what we can offer members, let us know. Your contributions can make a difference. We invite our international friends to join AAWC and our mission to advance the care of people with and at risk for wounds. Please contact any board member or the office at any time; we are always happy to hear your suggestions. Visit our website to learn more about getting involved: http://aawconline.org.

Wishing you all the best. Sincerely: Greg Bohn, President, AAWC

EWMA international Partner Organisation

EWMA Journal

2016 vol 16 no 2

www.smith-nephew.com

ÂŠSeptember 2016 Smith & Nephew

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Supporting healthcare professionals for over 150 years

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SILPURAN® – This biocompatible silicone from Wacker Chemie gives you consistent quality for highly efficient manufacturing processes. SILPURAN® provides an optimal wound healing environment and enables atraumatic dressing changes. For less pain, less trauma and more quality of life. Wacker Chemie AG, München, Germany, Tel. + 49 89 6279-0, www.wacker.com/wound-care Contact: Dajana Westenberg, dajana.westenberg@wacker.com, www.wacker.com/socialmedia

Organisations

WOUNDS AUSTRALIA NEWS Dear EWMA members,

Kylie Sandy-Hodgetts Deputy Chair, Wounds Australia More information: www.awma.com.au

I am delighted to update you on the latest developments of Wounds Australia. As you can imagine, activities have increased across all levels of the organisation in preparedness for the Inaugural National Conference, Wounds Awareness Week and on an operational level; the development of the portfolios, and the commencement of recruiting for an Executive Officer. We are pleased to inform EWMA, that shortlisting for the EO has commenced, and soon, we will be announcing who will have the coveted role of steering the organisation towards the future. The Wounds Australia Board has been diligently working away behind the scenes to ensure that we are able to improve our delivery of services for our members. Most notably has been the development of the scholarships and funding programmes available to members. From professional development and research grants to travel scholarships, Wounds Australia has a growing portfolio of funding opportunities available to assist the educational needs of Wounds Australia members. The Board has received many expressions of interest from members to participate in the one or more of the three portfolios that underpin the organisation (education, research and membership). With such a positive response from members and with the calibre of candidates, Wounds Australia is in a strong position to drive plans forward and continue to be the peak body for wound care in Australia. Together with our Wounds Awareness Week (WAW) partner, the Wound Management Innovation CRC, we are pleased to announce Australia’s WAW will be 16th 21st October 2016. Shortly the WAW campaign team will be announcing the national theme and available resources for all branches to promote and celebrate this week. Also a reminder of our Inaugural Wounds Australia Conference in Melbourne, 9-12th November 2016. With an exciting scientific programme and many workshops to cater for member’s educational needs, the conference will be something to remember. On a closing note, the Board would like to thank our international partners, EWMA and Cooperating Organisations for their ongoing patience and support whilst Wounds Australia continues to develop under the new nationalisation structure. We are working hard to benefit members in helping to improve the lives of those with wounds in Australia and beyond.

Kylie Sandy-Hodgetts Deputy Chair, Wounds Australia

EWMA international Partner Organisation

EWMA Journal

2016 vol 16 no 2

WCS: Knowledge Centre Wound Care WCS Wound care Consultant Society

RenĂŠ Baljon, chairman of WCS Knowledge Center Wound Care More information: www.wcs.nl

Since the founding of the Wound care Consultant Society (WCS) in 1984, the organisation has aimed to respond to the increasing demand for sound information about nursing and care, that deals with the care of a wide variety of wounds. To bridge the gap between the industry and what was done in practice, the WCS developed the colour classification (black-yellow-red) model, a model that excelled in its simplicity and is still used worldwide. A significant change for the WCS took place in 2007 when the association changed to a foundation and started to function as a knowledge centre. The objective of the WCS is to function as a national knowledge centre in the field of wound and skin care. Moreover, the WCS aims to enhance the knowledge of healthcare professionals, with the aim to improve the quality of wound and skin care. The foundation seeks to achieve this objective by: 1. organising courses, seminars and lectures, 2. providing, supporting and promoting publications, 3. promoting and encouraging research, 4. and all other acts that are related or may be conducive. Since then the WCS has been known as: WCS Knowledge Centre Wound Care The WCS has made a considerable contribution to the development of wound care in the last decades in The Netherlands; for example; n the development of a trade union for wound care nurses in The Netherlands (V&VN Wond expertise); n starting a post-graduate programme to become a wound care nurse or wound consultant at the Erasmus MC in Rotterdam; n the development of criteria which wound care expertise centres have to live up to; n being the initiator in founding the Wound platform in the Netherlands; n participating in many different guideline committees.

At the moment the WCS participates in a multidisciplinary committee on complex wound care, which develops quality standards to define how wound care is best organised. This committee is commissioned by the Dutch Healthcare government. The WCS is very delighted to be host of the EWMA conference 2017 in Amsterdam. FACTS AND FIGURES: n 1800 subscriptions on the WCS News in The Netherlands and 500 in Belgium; n >70,000 site visitors per year; n >25,000 contacts through monthly e-mail newsletters; n 700 course members per year; n 10 different courses, trainings and masterclasses; n 23,000 readers of the WCS news in The Netherlands; n >2,000 publications in the WCS news since its introduction; n Wound care book: 14th issue. The most extraordinary fact of all is that we are still a voluntary organisation.

EWMA Cooperating Organisation

EWMA Journalâ&#x20AC;&#x201A;

2016 vol 16 no 2

EPUAP2017 The 19th Annual Meeting of the European Pressure Ulcer Advisory Panel

20 â&#x20AC;&#x201C; 22 September 2017 Belfast, Northern Ireland

www.epuap2017.org

One Voice for Pressure Ulcer Prevention and Treatment Challenges and Opportunities for Practice, Research and Education EPUAP Business Office office@epuap.org Tel.: +420 251 019 379

Conference venue

BELFAST WATERFRONT Abstract submission deadline:

15 APRIL 2017 Review notification deadline:

15 MAY 2017 Early registration deadline:

15 JUNE 2017

EPUAP 2017 will be organised by the European Pressure Ulcer Advisory Panel in partnership with the Tissue Viability Nurse Network (Northern Ireland) and the Wound Management Association of Ireland.

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PAUL HARTMANN AG www.hartmann.info

Wound Management Smith & Nephew Medical Ltd www.smith-nephew.com/wound

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EWMA Journal

2016 vol 16 no 2

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Conference Calendar 2016/17 Conferences 2016

Theme

Month

Days

City

Country

APTFeridas Congress

November

3-4

Matosinhos

Portugal

Annual conference of CAWC

November

3-6

Niagara Falls

Canada

The Inaugural Wounds Australia Conference (AWMA)

November

9-12

Melbourne

Australia

Wounds UK Annual Conference

November

14-16

Harrogate

London

WCS Congress

November

Hasselt

Belgium

Decubitus Congress

November

22-23

Venlo

The Netherlands

Interdisciplinary Wound Congress (IWC)

November

Kölln

Germany

Annual Meeting of Danish Wound Healing Society (DSFS)

November

24-25

Kolding

Denmark

Annual Conference of Ukrainian Wound Treatment Organisation

November

24-25

Kiev

Ukraine

Third Congress of the Serbian Wound Healing Society

December

10-12

Belgrade

Serbia

Congress of the Turkish Wound Management Association

December

Antalya

Turkey

State of Play

Conferences 2017 Theme Month Days City Annual Congress of the French & January 17-19 Paris Francophone wound healing Society

Country

15th Annual congress of the Czech Wound Management Soceity

January

25-26

Pardubice

Czech Republic

Norwegian Wound Care Society

February

2-3

Oslo

Norway

Annual Meeting of the Finnish Wound Care Society

February

4-6

Helsinki

Finland

Belgian Wound Care Federation

February

16-17

Torhout

Belgium

6th Annual Congress of SEHER

February

16-18

Madrid

Spain

Danish Wound Healing Society

March

Århus

Denmark

European Pressure Ulcer Advisory Panel Focus meeting

April

4-6

Berlin

Germany

AAWC

April

5-9

San Diego, CA

USA

Swedish Wound Healing Nurses Association (SSIS)

April

26-27

Stockholm

Sweden

EWMA

Annual Conference

May

3-5

Amsterdam

The Netherlands

Symposium of the Australasian Lymphology Association

Symposium

May

Melbourne

Australia

May

Morges

Switzerland

Annual Seminar

Annual congress

Theme Day

Spring Conference

Annual meeting of SAfW Romande (Swiss wound care association, French section)

New Zealand Wound Care Society 8th National Conference May 18-20 Rotorua 14th EADV Spring Symposium May 25-28 Brussels

France

New Zealand Belgium

International Lymphoedema Framework Conference

Annual Conference

June

21-24

Siracusa, Sicily

Italy

13th Conference of the European Council of Enterostomal Therapists (ECET)

Annual conference

June

18-21

Berlin

Germany

19th Annual Meeting of the European Pressure Ulcer Advisory Panel

September

20-22

Belfast

Northern Ireland

36th Annual Meeting of The European Bone & Joint Infection Society (EBJIS)

Annual Meeting

September

7-9

Nantes

France

Italian Association for the study of Cutanecus Ulcers

Annual conference

September

27-30

Torino

Italy

For web addresses please visit www.ewma.org

EWMA Journal

2016 vol 16 no 2

The official journal of the 5 Continent Congress

Now open for submissions Editor-in-Chief Bradley Bloom, New York, N.Y.

Journal of

New!

• Fair and thorough peer review of scientific papers • Easy-to-read additional types of papers • Outstanding 5CC faculty on the Editorial Board • Free online access in 2017 • Free color figures (print and online) For more information and author guidelines visit the journal website at: www.karger.com/ads

The new face of Dermatology New Editor-in-Chief: Gregor B.E. Jemec, Roskilde • New Editorial Board • New thematic sections: ‘Skin Cancer’ (edited by C. Ulrich) ‘Tattoo and Body Art’ (edited by J. Serup and N. Kluger) ‘International Dermatology Outcome Measures’ (edited by A. Garg) • Free access and no page charges for all review papers • Reduced color charges

KI16477

For more information and author guidelines visit the journal website at: www.karger.com/drm

Cooperating Organisations AEEVH

Spanish Association of Vascular Nursing and Wounds www.aeevh.es

AFIScep.be

French Nurses’ Association in Stoma Therapy, Wound Healing and Wounds www.afiscep.be

AISLeC

Italian Nurses’ Cutaneous Wounds Association www.aislec.it

AIUC

Italian Association for the study of Cutaneous Ulcers www.aiuc.it

AMP Romania

Wound Management Association Romania www.ampromania.ro

APTFeridas

Portuguese Association for the Treatment of Wounds www.aptferidas.com

AWTVNF

All Wales Tissue Viability Nurse Forum www.welshwoundnetwork.org

AWA

Austrian Wound Association www.a-w-a.at

BEFEWO

Belgian Federation of Woundcare www.befewo.org

BWA

Portuguese Wound Society www.sociedadeferidas.pt

FWCS

Finnish Wound Care Society www.shhy.fi

GAIF

Associated Group of Research in Wounds www.gaif.net

GNEAUPP

National Advisory Group for the Study of P ressure Ulcers and Chronic Wounds www.gneaupp.org

HSWH

Hellenic Society of Wound Healing and Chronic Ulcers www.hswh.gr

ICW

Chronic Wounds Initiative www.ic-wunden.de

LBAA

Latvian Wound Treating Organisation

LUF

The Leg Ulcer Forum www.legulcerforum.org

LWMA

Lithuanian Wound Management Association www.lzga.lt

MASC

Macedonian Wound Management Association

National Association of Tissue Viability Nurses, S cotland

NIFS

Hungarian Association for the Improvement in Care of Chronic Wounds and Incontinentia www.sebinko.hu

SEHER

The Spanish Society of Wounds www.sociedadespanolaheridas. es

SFFPC

The French and Francophone Society f Wounds and Wound Healing www.sffpc.org

SSiS

Swedish Wound Care Nurses Association www.sarsjukskoterskor.se

SSOOR

Slovak Wound Care Association www.ssoor.sk

SSPLR

The Slovak Wound Healing Society www.ssplr.sk/en

STW Belarus

Icelandic Wound Healing Society www.sums.is

SWHS

Serbian Wound Healing Society www.lecenjerana.com

SWHS

Swedish Wound Healing Society www.sarlakning.se

TVS

NOVW

URuBiH

Croatian Wound Association www.huzr.hr

DGfW

PWMA

German Wound Healing Society www.dgfw.de

Polish Wound Management Association www.ptlr.org.pl

DSFS

SAfW

Danish Wound Healing Society www.saar.dk

SEBINKO

Norwegian Wound Healing Association www.nifs-saar.no

Dutch Organisation of Wound Care Nurses www.novw.org

D A N I S H WO U N D HEALING S O C I E T Y

Serbian Advanced Wound Management Association www.lecenjerana.com

SUMS

Hungarian Wound Care Society www.euuzlet.hu/mskt/

NATVNS

CWA

SAWMA

MSKT

CNC

Czech Wound Management Society www.cslr.cz

Swiss Association for Wound Care (French section) www.safw-romande.ch

Society for the Treatment of Wounds (Gomel, Belarus) www.burnplast.gomel.by

MWMA

CSLR

SAfW

Maltese Association of Skin and Wound Care www.mwcf.madv.org.mt/

Bulgarian Wound Association www.woundbulgaria.org

Clinical Nursing Consulting – Wondzorg www.wondzorg.be

ELCOS

Tissue Viability Society www.tvs.org.uk

Association for Wound Management of Bosnia and Herzegovina www.urubih.ba

UWTO

Ukrainian Wound Treatment Organisation www.uwto.org.ua

Swiss Association for Wound Care (German section) www.safw.ch

EWMA Journal

2016 vol 16 no 2

Organisations

Cooperating Organisations (cont.) V&VN

Decubitus and Wound Consultants, Netherlands www.venvn.nl

WCS Knowledge Center Woundcare www.wcs.nl

WMAI

Wound Management Association of Ireland www.wmai.ie

WMAK

Wound Management Association of Kosova

WMAS

Wound Management Association Slovenia www.dors.si

WMAT

Wound Management Association Turkey www.yaradernegi.net

ILF

International Lymphoedema Framework www.lympho.org

KWMS

Korean Wound Management Society www.woundcare.or.kr/eng

NZWCS

New Zealand Wound Care Society www.nzwcs.org.nz

Associated Organisations Leg Club

Lindsay Leg Club Foundation www.legclub.org

LSN

The Lymphoedema Support Network www.lymphoedema.org/lsn

SILAUHE

Iberolatinoamerican Society of Ulcers and Wounds www.silauhe.org

SOBENFeE

Brazilian Wound M anagement Association www.sobenfee.org.br

WAWLC

World Alliance for Wound and Lymphedema Care www.wawlc.org

Media Partner JWC

Journal of Wound Care www.magonlinelibrary.com

For more information about EWMA’s Cooperating Organisations please visit www.ewma.org

Other Collaborators DFSG

Diabetic Foot Study Group www.dfsg.org

International Partner Organisations AAWC

Association for the Advancement of Wound Care www.aawconline.org

Wounds Australia

Wounds Australia www.awma.com.au

CAWC

Canadian Association of Wound Care www.cawc.net

Debra International

Dystrophic Epidermolysis Bullosa Research Association www.debra.org.uk

EFORT

European Federation of National Associations of Orthopaedics and Traumatology www.efort.org

EADV

European Academy of Dermatology and Venereology www.eadv.org

EBA

European Burns Association www.euroburn.org

ESPEN

The European Society for Clinical Nutrition and Metabolism www.espen.org

ESVS

European Society for Vascular Surgery www.esvs.org

EPUAP

European Pressure Ulcer Advisory Panel www.epuap.org

ETRS

European Tissue Repair Society www.etrs.org

CTRS

Eucomed

(Chinese Tissue Repair Society) www.chinese-trs.com/en

Eucomed Advanced Wound Care Sector Group www.eucomed.org

IWII

ICC

Int. Wound Infection Institute www.woundinfection-institute. com

International Compression Club www.icc-compressionclub.com

WUWHS

The World Union of Wound Healing Societies www.wuwhs.org EWMA Journal

2016 vol 16 no 2

5 Editorial. Severin Läuchli, EWMA President

Book Reviews 34 Essential microbiology for wound care. Pina E

Cochrane Reviews 37 Abstracts of Recent Cochrane Reviews. Rizello G