EWMA Journal 2015, October Issue by EWMA European Wound Management Association

Volume 16 15 Number 2 2015 October 2015 Published Published by by European Wound Wound Management Management Association

on the r oad to better

PATIENT

safety

The EWMA Journal ISSN number: 1609-2759 Volume 16, No 2, October, 2015 The Journal of the European Wound Management Association Published twice a year

EWMA Council Severin Läuchli

Salla Seppänen

President

Immediate Past President

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

Luc Gryson Treasurer

Alberto Piaggesi Secretary

José Verdú Soriano 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

Margo Asimus

Sue Bale

EWMA Journal Editor

Barbara den Boogert-Ruimschotel

Vickie Driver

Mark Collier

Georgina Gethin

Layout: Nils Hartmann Cover: Nils Hartmann, Open design/advertising

Magdalena Annersten Gershater

Arkadiusz Jawien

Edward Jude

Knut Kröger

Christian Münther

Andrea Pokorná

Sebastian Probst

Robert Strohal

Jan Stryja

Hubert Vuagnat

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 2016. Prospective material for publication must be with the EWMA Secretariat as soon as possible and no later than January 15th 2016. 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.

COOPERATING ORGANISATIONS’ BOARD Esther Armans Moreno, AEEVH Christian Thyse, AFISCeP.be Massimo Rivolo, 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 Anette Norden, DSFS Heidi Castrén, 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 Tania Asantos, ELCOS

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 Maarten J. Lubbers, 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

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26th Conference of the European Wound Management Association 7 Editorial Sepännen S, Gethin G

Science, Practice and Education 11 15 23

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 29 The Psychological Effect of Malignant Fungating Wounds on the Patient. Reynolds H, Gethin G 34 The Pressure Ulcer Guidance (PUG) Tool. Barnard J, Copson D 37 Development and Implementation of a Tool to Assess and Differentiate Moisture Lesions and Pressure Ulcers. Stephen-Haynes J, Callaghan R, Evans M, Simm S 41 The Fluorescent Diagnosis of Stoma Mucosa. Wai H C, Ngai T C, Shan S Y, Wing P Y, Yan C W 47 Overcoming Challenges when Introducing eHealth - Momentum Workshops. Whitehouse D, Lange M

EWMA 2016

BREMEN germany 11-13 MAY 2016

patients · wounds · rights

Cochrane Reviews 51 Abstracts of Recent Cochrane Reviews. Rizello G

Book Reviews 58 Fast Facts About Pressure Ulcer Care for Nurses – How to Prevent, Detect and Resolve them in a Nutshell. Gethin G

Bremen

EWMA 60 EWMA Conference 2015, in London, UK Verdú Soriano J 67 Cooperating Organisations Activities During EWMA 2015 Apelqvist J 71 Focus and Objectives of the EWMA Presidency 2015-2017 72 EWMA Celebratates 25th Anniversary 74 Appreciations Leaving Council members Sepännen S, Läuchli S 75 New and re-elected Council members 76 ACRM AWARD Recipient Hubert Vaugnant 78 EWMA Activities and News 80 Position Paper on Antimicrobial Stewardship 83 EWMA Exploring the Potential of Phage Therapy in Wound Care Apelqvist J 85 Wound Care Curriculum for Physicians Approved by the UEMS Strohal R 86 EWMA Pilot Project: Wound Centre Endorsement Gottrup F 88 Visit EWMA 2016 Bremen, Germany 91 Bring Your Students to a Whole New Level, The UCM Model 92 Organisation of Wound Care in Germany Gerber W 94 About ICW Gerber W 95 About Wund-D-A-CH Strohal R 96 Messe Bremen; Deutscher Wundkongress Continues to Grow 98 EWMA Journal Previous Issues and Other Journals

Organisations 100 101 102 103 105 106 108 110

AAWC News Driver V R AWMA News Asimus M, Rando T CAWC News Botros M WAWLC New Keast D, Vaugnant H NEW International Partner: International Wound Infection Institute Swanson T, Keast D Corporate Sponsors Conference Calendar Cooperating Organisations, International Partners and Other Collaborators; An Overview

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Editorial

Promoting Evidence-Based Practice

ealthcare systems throughout Europe are attempting to address the challenge of contraction in social and healthcare resources. According to the latest projections from the Organization for Economic Cooperation and Development (OECD), both healthcare and long-term care will be driving up public spending1, which is the greatest fiscal challenge facing countries now and into the future. In a cost-containment scenario, the average public healthcare expenditure in OECD countries is projected to increase from 5.5% of gross domestic product (GDP) in 2010 to 8% of GDP in 2060, whereas public long-term care expenditure is projected to increase from 0.8% of GDP to 1.6% of GDP over the same period1. Drivers of expenditure differ across countries and are influenced by technology, relative prices and policies, increased dependency due to non-communicable diseases, obesity, and dementia. All of those factors raise concerns for the future1. Long-term spending projections are inherently uncertain. Higher health-related spending could arise due to increased healthcare needs near the end of life as longevity increases or higher-than-expected costs related to technical progress1. We can expect the costs associated with wound care to increase as the prevalence of chronic wounds increases and new technologies and advanced therapies become available. According to the World Health Organization, chronic disease accounts for half of all deaths among persons < 70 years of age, and four major non-communicable diseases (NCDs) account for 82% of deaths due to NCDs (www. who.org). Those NCDs include cardiovascular disease, cancer, chronic respiratory disease, and diabetes, which are also among the most common co-morbidities for patients with chronic wounds. Thus, all efforts to improve prevention and treatment strategies are warranted, including the generation of clinical practice guidelines (CPGs). According to Porter et al., the primary objective of a healthcare system should be to provide value for patients, as measured by health outcomes per dollar expended to achieve the outcomes2. To achieve healthcare objectives and better outcomes and results, we depend on research and evidence-based practice (EBP). The core of EBP is the integration of patient preference with research and clinical expertise. One step in achieving that is the development,

dissemination, and implementation of guidelines. CPGs are ‘systematically developed statements to assist practitioner and consumer decisions about appropriate health or disability care for specific circumstances, taking into account evidence for effectiveness and competing claims, forming a fundamental basis for planning’3. Central to the ethos of CPGs is that they are not prescriptive and account for individual patient perspectives and that they are used in conjunction with clinical judgment. In discussing guidelines for wound care, the following points must be considered. 1. In wound care, the evidence base upon which guidelines are developed is still under construction, and there remains a reliance on Grade 2 evidence and consensus approaches. This is exemplified in the recent European Pressure Ulcer Advisory Panel/National Pressure Ulcer Advisory Panel guidelines for the management of pressure ulcers, in which there is no Grade 1A evidence supporting statements about assessment (www.epuap.org). Similarly, in the CPGs from the Society of Vascular Surgery and the American Venous Forum, only one out of 86 statements, a statement about compression therapy, is based on Grade 1A evidence4. That underscores the need to support the production of high-quality, methodologically rigorous, multicenter collaborative research to improve the strength of recommendations related to wound care. 2. There is a risk of assuming that if guidelines are followed, outcomes will improve. Guidelines have a tendency to focus on processes such as assessment and on treatment options. Guidelines should consider the monitoring and recording of outcomes so that they can be refined through collaboration with all stakeholders. 3. Guidelines are almost exclusively focused on one specific disease. In the future, we must consider how guidelines integrate with each other as the complexity of patients attending for care, particularly in the later years of life, increases and challenges clinicians to deliver EBP that is strongly adapted to individual patients’ life context. In wound care, we run the risk of focusing on a biomedical model of healing and losing sight of a holistic approach to 

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2015 vol 15 no 2

Editorial care. It is the role of healthcare professionals to advocate for patients in order to practice true collaboration and ensure that we focus on outcomes of relevance to patients and not just on outcomes of relevance to the healthcare system. The Institute of Medicine defines advocating as “providing care that is respectful and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions’5. In partnership with the patient, healthcare professionals can help patients to take an active role in the decision-making process and define common goals and effective care strategies. EWMA contributes to the advancement of best practices in wound care and has a significant focus on patients’ perspectives through EWMA initiatives such as the Patient Outcome Group and the Patient Panel, both of which will be discussed during the EWMA conference in 2016 in Bremen. Additionally, a multidisciplinary team within EWMA and Australian Wound Management Association is currently appraising and comparing guidelines for the

management of venous leg ulceration. That project will be complete in Spring 2016 and will provide a comprehensive resource to help clinicians make decisions and contribute to improving clinical practice and patient outcomes. n Salla Seppänen, EWMA Immediate Past President Georgina Gethin, EWMA Council

REFERENCES 1. De la Maisonneuve C, Oliveria J. Public spending on health and long-term care: a new set of projections. A going for growth report. Paris: OECD Economic Policy Papers; 2013. 74 p. 2. Porter M: Defining and Introducing value in health care. In: McClellan M, McGinnis J, Nabel E, Olsen L, editors. Evidence-based medicine and the changing nature of healthcare: meeting summary (IOM roundtable on evidence-based healthcare). Washington: ©The National Academies Press; 2008. 3. New Zealand Guidelines Group (NZGG): Handbook for the preparation of explicit evidence-based clinical practice guidelines. Wellington, (New Zealand): NZGG; 2001. 4. O’Donnell T, Passman M, Marston WA, Ennis W, Daising M, Kistner R, et al: Management of venous leg ulcers: clinical practice guidelines of the Society for Vascular Surgery (R) and the American Venous Forum. Journal Vascular Surgery. 2014; 60(August Supplement):3-59.

Visit EWMA on our Social Media platforms Follow us and get the latest updates about the EWMA 2016 Bremen Conference as well as other EWMA activities

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EWMA Journal

2015 vol 15 no 2

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Science, Practice and Education

London · UK

EWMA n london 2015 Submitted to EWMA Journal, Based on presentation given in the key session Wound Care & Geriatrics / Dementia in Wound Care.

Of Youth and Age - What are the Differences Regarding Skin Structure and Function?

INTRODUCTION The skin is often regarded as the largest organ of the human body, fulfilling a variety of tasks. It forms a boundary between the inside of the body and the usually dryer and cooler environment, provides protection against mechanical and chemical threats, participates in innate and adaptive immune defences, enables vitamin D production, acts as a sensory organ, and has important psychosocial functions1, 2. From birth until death, the skin and subcutaneous tissues grow, mature and age. SKIN AGEING AND CLINICAL CHALLENGES The physiologic cause of skin ageing is often called ‘intrinsic’ ageing3.This is a time-dependent, stochastic process. Intrinsically aged skin has a lax appearance with decreased elasticity and fine wrinkles3, 4.Continuous and repeated exposures to environmental factors, such as ultraviolet radiation, air pollution, and smoking, lead to ‘extrinsic’ skin ageing. This type of skin ageing results in course wrinkles, increased thickness, and dyspigmentation5, 6. In addition to these morphological changes, skin and tissue ageing leads to the loss of functional capacity7. The skin is less able to cope with external stresses and is more susceptible to a wide range of age-related conditions, diseases, injuries, and wounds4, 8, 9. For example, altered lipid content and reduced water, sebum production, and natural moisturizing factors of the stratum corneum may cause dry skin and pruritus. Empirical evidence suggests that dry skin (xerosis cutis), including cracks and inflammation (eczema craquelé), is one of the most frequent skin conditions in the elderly (Fig. 1). The prevalence varies between 6% and 77% in outpatient settings10, 11 and between 30%

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2015 vol 15 no 2

and 85% in long-term care12, 13.There is a clear association between dry skin and pruritus, which is one of the most distressing and burdensome skin symptoms in the elderly. Across all care settings, the prevalence of pruritus ranges from 1%14 to 36%15. Severely dry skin leads to a high risk of secondary infection. An impaired acidification of the skin surface leads to decreased stratum corneum cohesion, disturbed skin barrier recovery, and increased susceptibility to pathologic colonization and infection16, 17. Due to diminished immune responses, aged skin reacts more slowly to irritants and allergens but is more susceptible to infections18. Fungal infections of the feet, especially between the toes and of the nails, are also very frequent in the elderly populations (Fig. 2)19. Approximately one half of long-term care patients is affected by tinea unguium20.The prevalence of tinea pedis ranges from 18% in home care12 to 34% in nursing homes21. The flattening of the dermalepidermal junction increases the risk for shear-type injuries, such as skin tears, and bullae formation. There is substantial evidence that chronological age is an independent predictor for the reduced strength of the dermoepidermal adhesion22. Due to a loss of collagen and extracellular matrix proteins, the dermis becomes thinner. Aged skin is less elastic and less deformable, increasing the susceptibility to deformation injuries, such as pressure ulcers 23. Decreases of dermal vessels and capillary loops24 lead to impaired thermoregulation. A selection of age-related changes and associated risks and conditions is shown in (Table 1). A pronounced loss of functional and protective capacity may result in extreme fragility, leading to lacerations, nonhealing atrophic ulcers, and dissecting hematomas25.

Jan Kottner PhD, Scientific Director Clinical Research Charité-Universitätsmedizin Department of Dermatology and Allergy, Clinical Research, Center for Hair and Skin Science Berlin, Germany.

Correspondence: jan.kottner@charite.de Conflicts of interest: None



Figure 1. Dry skin with cracks and inflammation (Eczema craquelé).

Figure 2. Fungal infection of the nail (Onychomycosis).

Table 1. Selected age-related skin and subcutaneous tissue changes and clinical relevance4, 8, 34

Changes

Skin surface • Increase of pH

Epidermis

Risks and conditions

• Pathologic colonization and infection • Reduced cohesion of the stratum corneum

• Reduced stratum corneum hydration

• Xerosis cutis, pruritus

• Altered intercellular lipid composition • and corneocyte morphology • • Reduced barrier function

• Increased susceptibility against physical, chemical, • and biological insults (“immunosenescence”)

• Reduced number and function of • melanocytes and Langerhans cells

• Increased risks for actinic keratosis and tumors • Delayed epithelialization and barrier recovery

• Dysregulation of cytokine function • Change in number and function of • antimicrobial peptides • Reduced activity of basal cells and • reduced epidermal turnover

Dermo-epidermal • Flattening junction

• Increased risk for shear-type injuries •(skin tears) and blister development

Dermis • Reduced number of dermal papillae • Reduced sensory perception

• Increased risk for injuries (e.g., due to heat) • and ulceration

• Reduced dermal circulation and PIV

• Delayed wound healing

• Reduced collagen production

• Altered thermoregulation

Subcutis • Atrophy

• Increased risk for injuries and pressure ulcers

Abbreviation: PIV, pressure-induced vasodilation.

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2015 vol 15 no 2

Science, Practice and Education

SKIN CARE IN THE ELDERLY Preventive strategies play a major role in maintaining and enhancing skin and tissue integrity and health in elderly individuals8, 26. These strategies include not only wellknown approaches to preventing specific conditions, such as diabetic foot27 or pressure ulcers28, but also general health promoting skin care strategies, including healthy lifestyles and appropriate cleansing and skin care8, 29.The current evidence supporting skin care practice in the elderly is poor. One reason is that the elderly populations are frequently excluded from clinical trials, especially in skin research9. However, based on recent systematic literature reviews30-32 and clinical experience33, selected best practice recommendations include: n Limit exposure to water and alkaline soaps. Use slightly acidic, mild cleansers. Avoid cleansing products containing anionic surfactants, are found in traditional soaps. n Avoid or limit immersion in water, such as full baths. n Keep the water temperature cool. Do not use hot water. n Dry the skin carefully and gently but thoroughly, especially in areas of skin-to-skin contact.

REFERENCES 1. Chuong CM, Nickoloff BJ, Elias PM, Goldsmith LA, Macher E, Maderson PA, et al. What is the ‘true’ function of skin? Experimental Dermatology. 2002 Apr;11(2):159-87. 2. Gupta MA, Gilchrest BA. Psychosocial aspects of aging skin. Dermatologic Clinics. 2005 Oct;23(4):643-8. 3. Pierard GE, Paquet P, Xhauflaire-Uhoda E, Quantresooz P. Physiological Variations During Aging. In: Farage MA, Miller KW, Maibach HI, editors. Textbook of Aging Skin. Berlin: Springer; 2010. p. 45-54. 4. Gilchrest BA. Skin aging and photoaging: an overview. Journal of the American Academy of Dermatology. 1989 Sep;21(3 Pt 2):610-3. 5. Dobos G, Trojahn C, Lichterfeld A, B DA, Patwardhan SV, Canfield D, et al. Quantifying dyspigmentation in facial skin ageing: an explorative study. International Journal of Cosmetic Science. 2015 Oct;37(5):542-9. 6. Dobos G, Lichterfeld A, Blume-Peytavi U, Kottner J. Evaluation of skin ageing: a systematic review of clinical scales. The British Journal of Dermatology. 2015 May;172(5):1249-61. 7. Ghadially R, Brown BE, Sequeira-Martin SM, Feingold KR, Elias PM. The aged epidermal permeability barrier. Structural, functional, and lipid biochemical abnormalities in humans and a senescent murine model. The Journal of Clinical Investigation. 1995 May;95(5):2281-90. 8. Kottner J, Lichterfeld A, Blume-Peytavi U, Kuhlmey A. Skin health promotion in the elderly. Zeitschrift fur Gerontologie und Geriatrie. 2015 Apr;48(3):231-6. 9. Chang AL, Wong JW, Endo JO, Norman RA. Geriatric dermatology review: Major changes in skin function in older patients and their contribution to common clinical challenges. Journal of the American Medical Directors Association. 2013 Oct;14(10):724-30. 10. Yap KB, Siew MG, Goh CL. Pattern of skin diseases in the elderly seen at the National Skin Centre (Singapore) 1990. Singapore Medical Journal. 1994 Apr;35(2):147-50. 11. Paul C, Maumus-Robert S, Mazereeuw-Hautier J, Guyen CN, Saudez X, Schmitt AM. Prevalence and risk factors for xerosis in the elderly: a cross-sectional epidemiological study in primary care. Dermatology. 2011;223(3):260-5.

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2015 vol 15 no 2

n Apply moisturizers with a high content of lipids regularly for dry skin. n Do not apply moisturizers in skin folds or the skin between the toes. n Avoid skin exposure to urine, stool, and other body fluids. Use a skin protectant if urine or stool comes in contact with the skin. OUTLOOK Despite the above-mentioned risks, skin ageing per se is not a disease that must be treated. Ageing is a normal biological process affecting every organ and biological system. However, compared to the skin of youth, aged skin is compromised in many ways. Besides physiologic skin and tissue alterations over time, aged skin may also be negatively affected by other circumstances common in the elderly, including general functional impairments (e.g., immobility, incontinence), chronic disease (e.g., diabetes mellitus), and medications commonly used in geriatric care23. Thus, preventive skin care strategies are of the utmost importance to maintain skin integrity in the increasing elderly population. n

12. Beauregard S, Gilchrest BA. A survey of skin problems and skin care regimens in the elderly. Archives of Dermatology. 1987 Dec;123(12):1638-43. 13. Weismann K, Krakauer R, Wanscher B. Prevalence of skin diseases in old age. Acta dermato-venereologica. 1980;60(4):352-3. 14. Siragusa M, Schepis C, Palazzo R, Fabrizi G, Guarneri B, Del Gracco S, et al. Skin pathology findings in a cohort of 1500 adult and elderly subjects. International Journal of Dermatology. 1999 May;38(5):3616. 15. Adam JE, Reilly S. The prevalence of skin disease in the geriatric age group. The Australasian Journal of Dermatology. 1987 Aug;28(2):72-6. 16. Behne MJ, Meyer JW, Hanson KM, Barry NP, Murata S, Crumrine D, et al. NHE1 regulates the stratum corneum permeability barrier homeostasis. Microenvironment acidification assessed with fluorescence lifetime imaging. The Journal of Biological Chemistry. 2002 Dec 6;277(49):47399-406. 17. Hachem JP, Crumrine D, Fluhr J, Brown BE, Feingold KR, Elias PM. pH directly regulates epidermal permeability barrier homeostasis, and stratum corneum integrity/cohesion. The Journal of Investigative Dermatology. 2003 Aug;121(2):345-53. 18. Castelo-Branco C, Soveral I. The immune system and aging: a review. Gynecological endocrinology : the official journal of the International Society of Gynecological Endocrinology. 2014 Jan;30(1):16-22. 19. Hof H, Mikus G. Candida infections in the elderly. Zeitschrift fur Gerontologie und Geriatrie. 2013 Jan;46(1):64-70. 20. Kilic A, Gul U, Aslan E, Soylu S. Dermatological findings in the senior population of nursing homes in Turkey. Archives of Gerontology and Geriatrics. 2008 Jul-Aug;47(1):93-8. 21. Smith DR, Sheu HM, Hsieh FS, Lee YL, Chang SJ, Guo YL. Prevalence of skin disease among nursing home patients in southern Taiwan. International Journal of Dermatology. 2002 Nov;41(11):754-9. 22. Hatje LK, Richter C, Blume-Peytavi U, Kottner J. Blistering time as a parameter for the strength of dermoepidermal adhesion: a systematic review and meta-analysis. The British Journal of Dermatology. 2015 Feb;172(2):323-30. 23. Kottner J, Beeckman D. Incontinence-associated dermatitis and pressure ulcers in geriatric patients. Giornale Italiano di Dermatologia e Venereologia. 2015 Jul 17.

24. Helmbold P, Lautenschlager C, Marsch W, Nayak RC. Detection of a physiological juvenile phase and the central role of pericytes in human dermal microvascular aging. The Journal of Investigative Dermatology. 2006 Jun;126(6):1419-21. 25. Kaya G, Saurat JH. Dermatoporosis: a chronic cutaneous insufficiency/fragility syndrome. Clinicopathological features, mechanisms, prevention and potential treatments. Dermatology. 2007;215(4):28494. 26. Gilchrest BA. Geriatric skin problems. Hospital Practice. 1986 Sep 30;21(9A):55, 9-65. 27. Bakker K, Apelqvist J, Schaper NC, International Working Group on Diabetic Foot Editorial B. Practical guidelines on the management and prevention of the diabetic foot 2011. Diabetes/metabolism Research and Reviews. 2012 Feb;28 Suppl 1:225-31. 28. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Osborne Park, Western Australia: Emily Heasler, editor, Cambridge Media; 2014. 29. Cowdell F. Promoting skin health in older people. Nursing Older People. 2010 Dec;22(10):21-6. 30. Lichterfeld A, Hauss A, Surber C, Peters T, BlumePeytavi U, Kottner J. Evidence-Based Skin Care: A Systematic Literature Review and the Development of a Basic Skin Care Algorithm. Journal of wound, ostomy, and continence nursing : official publication of The Wound, Ostomy and Continence Nurses Society. 2015 Jul 10. 31. Kottner J, Lichterfeld A, Blume-Peytavi U. Maintaining skin integrity in the aged: a systematic review. The British Journal of Dermatology. 2013 Sep;169(3):528-42. 32. Cowdell F, Steventon K. Skin cleansing practices for older people: a systematic review. International Journal of Older People Nursing. 2015 Mar;10(1):313. 33. Cowdell F. Older people, personal hygiene, and skin care. Medsurg Nursing. 2011 Sep-Oct;20(5):235-40. 34. Fenske NA, Lober CW. Structural and functional changes of normal aging skin. Journal of the American Academy of Dermatology. 1986 Oct;15(4 Pt 1):571-85.

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Science, Practice and Education

Pressure Ulcer Incidence:

The Development and Benefits of 10 Year’s-experience with an Electronic Monitoring Tool (PUNT) in a UK Hospital Trust Introduction In settings without any systematic, on-going and validated pressure ulcer registration system, estimating the incidence and prevalence of pressure ulcers will most often be an academic and time consuming exercise leading to imprecise estimations based on subjective data. This is the case in most places, both nationally (within the United Kingdom, UK) and internationally, as the data behind these numbers are generally incomparable across local and national boundaries because the reported data are collected using various criteria in both clinical and academic settings. The development of an electronic tool like the Pressure Ulcer Notification Tool “PUNT” offers the opportunity to report reliable and comparable data. Although there have been efforts to develop a national Registry of Ulcer development1, the need for such a tool to be widely available is evident given the need for accurate and easily accessible data locally, nationally, and internationally. These data may illustrate the magnitude of the problem in different settings, supporting the development of targeted prevention strategies and health economic evaluations of available pressure ulcer prevention and management strategies. Background Pressure ulcers, referred to in the literature as bedsores or decubitus ulcers and commonly referred to as “pressure sores” by patients and their relatives, are areas of localised injury to the skin and/or underlying tissue, usually over a bony prominence, as a result of pressure or pressure in combination with shear2. The resultant tissue

injury is caused by the inability of the skin and the supporting structures to redistribute external pressure causing alterations to the pressure gradient within the local vascular network. Approximately 70% of all pressure ulcers occur over the sacral area, heels, and buttocks3.

Mark Collier Nurse Consultant, Tissue Viability, United Lincolnshire Hospital NHS Trust (ULHT).

The prevention and management of pressure ulcers represents a serious health problem in both acute and long-term health care settings worldwide. According to the Joint Commission in the United States, “more than 2.5 million patients in United States acute care facilities suffer from pressure ulcers, and 60,000 die from pressure ulcer complications each year.” The economic burden associated with pressure ulcers is also profound. Across Europe, the cost estimates for pressure ulcer care range from between £1.4 and £2.1 billion for the (UK)4 to €1.0 to €2.3 billion in Germany. For many this expenditure is considered at the very least wasteful, and many feel it could be avoided5. Although the economic burden is high and likely to continue to increase as a result of demographic changes and an ageing population, it could be argued that the issue has until recently received unassertive attention from economists, politicians, and clinicians alike5. Pressure ulcer aetiology has been extensively studied, and clinically, relevant research has historically focused on pressure ulcer risk assessment and treatment. Health economic policies have also historically focused on treatment – not prevention. Prevalence rates are commonly cited to suggest the development of relevant and innovative care

Correspondence: mark.collier@ulh.nhs.uk Conflicts of interest: None

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strategies6, however, pressure ulcer incident data is likely to be a better indicator of an organisation’s performance in pressure ulcer prevention and damage minimisation. Aim The aim of this paper is to illustrate the development and the redevelopment of an online Pressure Ulcer Notification Tool (PUNT) used within the United Lincolnshire Hospitals NHS Trust (ULHT) to facilitate ‘real-time’ recording of any assessed in-patient pressure damage - all categories2 (PUNT is also directly linked to the Trusts patient management system, which allows the author to report current prevalence and incidence rates every day if required) - irrespective of whether new or developed elsewhere at the time of the patients admission to secondary care. A basic online form was originally developed and launched in early 2004, but more recent interest and guidance on pressure ulcer prevention/management within the UK prompted the latest major redevelopment of PUNT in 2011. This redevelopment effort resulted in a more robust tool to record and report all pressure ulcer activity within the United Lincolnshire Hospitals NHS Trust (ULHT) in line with all relevant national and international guidance2,9,10,11. PUNT has been reported to greatly reduce the overhead / staff time required to report and monitor pressure ulcers6,8. PUNT has also led the way in the development of other electronic tools for recording pressure ulcers throughout the NHS12 and was part of both a body of research information provided by the Royal College of Nursing and a recent major White Paper report released by Deloitte Consulting5. Development process and tool description PUNT improves the process of patient information management across all four hospital sites (six in 2003) that make up ULHT. The original idea for PUNT was pitched by the author and was developed with the technical assistance of Christopher Bailey, Senior Applications Developer, ULHT Information Communication Technology “ICT” Department. Development was driven by the desire to report accurately (both externally as well as internally) the Trusts pressure ulcer incidence across the Trust as a whole and also within each hospital location across a rural setting. This goal was originally supported by only one other team member; but is now fully supported by seven team members. The Trust, one of the largest acute trusts in the country, primarily serves the 757,000 residents of Lincolnshire, which is one of the fastest growing populations in England. PUNT was developed according to the industry stand-

ard technologies and meets all patient safety related Data Standard Change Notifications, including the use of NHS/ Microsoft Common User Interface components. Following a patient’s clinical skin assessment, which is performed either on admission or ongoing (at least weekly or as the patients clinical condition changes), the health practitioner working with the patient will record any noted pressure damage using the PUNT system, which can then be accessed at any time via the Trust intranet. The minimum dataset that is completed for all patients on initial assessment includes: admission date to hospital and ward or clinical area (Adult, Paediatrics, or Maternity), speciality of the clinical setting to which the patient was admitted, and several relevant patient details including NHS number, date of birth, gender, date of admission, prior physical location (home, internal hospital transfer, or transfer from other hospital or nursing home), pressure ulcer present on admission (yes/no), grade/category of ulcer on admission, date ulcer was first assessed, locations and categories of any further ulcers (the most pressure ulcers reported in the system on initial assessment to date has been 24), initial diagnosis, and a free-form text box to input other relevant information such as Suspected Deep Tissue Injury. Additionally, appropriate ‘at risk’ scores, such as the Waterlow, Glamorgan or Plymouth scores, are included in the tool (the tool will default in the assessment risk score box as the user identifies the clinical area in which the patient is being nursed) and may be updated either weekly or as the patient’s clinical condition dictates. Finally, a number of appropriate care interventions are also included in the tool (all linked to current evidence based guidance) to assist the practitioner in both planning immediate care and to facilitate audit of subsequent care. See (Fig. 1) for an illustration of the PUNT data recording schematic. Whenever relevant pressure ulcer guidelines are updated, PUNT can be updated at the same time; however, it should be noted that the classification/grading tool currently used by PUNT is consistent with the latest National Institute for Clinical Excellence “NICE” pressure ulcer guidance14 even though this does differ slightly from the classification tool within the latest EPUAP/NPUAP PU Guidelines15.Within the United Kingdom, all NHS Trusts are expected to utilize/comply with all current and relevant NICE guidance and compliance rates with this instruction are measured by the Department of Health/NHS England. Only trained personnel can use the system and are mandatorily trained at the start of employment using an e-learning application within ULHT that trains and tests the user and only permits system access when the user has

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Science, Practice and Education

Figur 1: Screen shot of intial PUNT data recording page.

met the required competency level (pass mark = 100%). PUNT data can be referenced at any time between planned assessment dates, which should be no more than one week apart, via individual ward dashboards. To aid the user, the system highlights when subsequent assessments are overdue. User feedback confirms that the system is easy to use and subsequent (weekly) ulcer reviews only require a quick record edit.

When any patient record is assessed, appropriate ulcer history (category 3 or 4 damage reported during any previous hospital admission), will appear as an alert to assist practitioners in the identification of potential ‘at risk’ anatomical areas at the time of the patient’s new admission, readmission, or reassessment. On the rare occasion when a patient’s pressure ulcer is the subject of an ongoing complaint or root cause analysis 

Table 1: All PUNT reported pressure ulcers (hospital acquired or inherited) across six body sites are listed for years 2004-2015.

All sites

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

All PU

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

Heel Lower Limb Occiput Sacrum Trunk Upper Limb

21 33 1 156 3 4

143 117 13 698 20 27

169 112 10 817 31 36

261 159 12 1013 42 29

299 217 21 1257 39 40

356 307 27 1781 72 87

367 329 16 1927 63 63

537 565 15 2069 56 116

627 504 1 2099 36 94

631 418 9 2267 26 95

696 499 2 2401 26 120

Total

218

1018

1175

1516

1873

2630

2765

3358

3361

3446

3744

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

Heel Lower Limb Occiput Sacrum Trunk Upper Limb

5 7 0 30 2 0

43 13 4 139 6 7

59 14 5 202 9 13

95 24 8 314 21 12

99 35 11 404 14 12

168 70 18 535 34 28

146 56 8 556 22 33

181 107 10 608 23 28

156 74 0 470 4 32

126 72 3 453 6 22

135 78 1 366 2 28

Total

212

302

474

575

853

821

957

736

682

610

Hospital acquired PU

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investigation (RCA), the patient’s complete pressure ulcer record can be retrieved via the ICT Department during normal working hours and reviewed for all relevant demographic and specific pressure ulcer details to assist with complaint or RCA investigation resolution. Results The current Trust pressure ulcer incidence (all categories) equals 0.5% hospital acquired (HA) ulceration – down from a peak of 6% since PUNT was introduced in 2004, although initially, pressure ulcer incidence increased as a result of improved ulcer monitoring and reporting. Specifically, peaks were noted as additional Tissue Viability (TV) staff were recruited to support the use of the tool internally on various hospital sites. Professional compliance with PUNT has risen from around 50% to over 95% (internal safety and quality monitoring data) since the launch of the redeveloped tool in April 2011. Furthermore, a review of PUNT data at this time highlighted that the Trust had a Heel Pressure Ulcer incidence rate of around 25%. Therefore in late 2011, a ‘pilot’ Standard Operating Procedure (SOP) was introduced within an Orthopaedic ward in one of the Trust Hospitals that included the use of an alternating pressure mattress (e.g., Nimbus 3) and prophylactic heel protection pads and devices for all patients with a fractured neck of femur. These therapeutic measures were used from the time of admission until the patient was actively mobile and resulted in a decreased incidence of hospital acquired heel pressure ulcers. Due to the success of this pilot SOP - the incidence within this one clinical setting reduced from 25% to NIL within the first six months - the use of prophylactic heel protection in conjunction with all specialist patient support surfaces, e.g., alternating pressure mattresses, has been promoted actively Trust-wide since 2012, with positive outcomes clearly evidenced pan-trust (Table1). Notably, the number of reported hospital acquired heel pressure ulcers has decreased by over 30% since 2011. Patient quality of care has been demonstrably improved since the implementation of PUNT. Specifically: n The updated PUNT process has already been demonstrated to improve skin assessment and the patient’s relevant personal care needs. n The tool includes data about where patients were admitted from – home, nursing home, internal trust transfer or other hospital - which is instrumental in informing the local Care Commissioning Groups and other community care settings of potential ‘hot spots’ or areas for further support. n Previous significant ulcers (category 3 and 4) are always highlighted when a patient record is retrieved.

n PUNT is fully audited so all user actions can be identified to an individual. This enhances the account ability of an individual for the benefit of their patients. n PUNT is linked to the Trusts patient administration system – initially TotalCare PAS but now Medway - for positive identification of patients and patient demographics, which minimises the risk of incorrect entries and therefore inappropriate care planning for any hospitalized patient with a pressure ulcer. n All data is validated by a member of the ULHT TV team to avoid invalid data input and reporting. n To ensure assurance for any requested or required data reports (both internal and external), data in the PUNT system can only be altered by an identified individual within the ULHT ICT Team (Chris Bailey or David Black) with the express permission of the Nurse Consultant - Tissue Viability and with a full e-mail trail clearly identifying the rationale for the change. n PUNT improves the legibility of information transferred between clinicians. n PUNT improves the reliability of data required by and reported to external agencies. Further planned developments A further functionality of the PUNT system is currently being developed and tested by David Black, a ULHT ICT Applications Developer who is primarily responsible for the day to day smooth running of the system. The new PUNT functionality will allow clinical photographs of pressure ulcers recorded within PUNT to be taken both on admission and discharge and then uploaded into PUNT for review in conjunction with the concordant individual pressure ulcer record (all pressure ulcers recorded have a unique identifier clearly visible in all relevant viewing fields). National perspectives In spring 2012, the Stop the Pressure campaign10, a national drive to reduce the incidence of all preventable pressure ulcers kicked off in the UK. The campaign was an effort by department of health to ensure all hospitals report pressure ulcer data in a consistent and comparable way. The tool Safety Thermometer was chosen to record and report this data; however, because the tool only facilitates once monthly data collection, only prevalence data is collected. Because incidence data is likely to be a better indicator than prevalence data of an organisation’s performance in pressure ulcer prevention and damage minimisation, the collection of this data is integral to the evaluation of pressure ulcer treatment and prevention strategies. In the UK, incidence data is generally collected in paper format, representing a very labour intensive task, particularly as the data are collated retrospectively and are usually circulated

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Science, Practice and Education

only after the patient has been discharged. In this author’s experience, using a paper based system can result in a time lag of between 6 and 12 weeks between the creation of a pressure ulcer record by a health care professional and the official report of said ulcer. This is due to the use of a paper “register,” which is collected either weekly or monthly, followed by manual input of the data from the paper register into a relevant database, at which point a report can finally be generated12. PUNT can make the collection of incidence data much simpler than this because it facilitates the reporting of both prevalence and incidence data at any time, including in ‘real time,’ since this data is updated immediately after assessment. Therefore, the latest information is always available to all ward based clinical staff, the TV team, the Risk Management team, and other designated senior individuals within the organisation. PUNT also allows frequent reports, including Weekly, Monthly, Quarterly, Annual Directorate, and Trust Board reports, to be generated for review and discussion (Graph 1-4). PUNT could potentially be used by any hospital and in any healthcare setting, and a number of healthcare organisations have already shown interest in the system when PUNT data has been presented at various conferences, both nationally and internationally 7,8, including the Healthcare Events “Avoiding Preventable Pressure Ulcers” annual meet-

Graph 1. Hospital acquired PUNT monitoring data for each recorded anatomicalsite from 2004 to 2014. Further examples of ULHT PUNT report graphs generated for the ULHT Trust Board (as titled)

Graph 2. Highlights the number of new patients reported via PUNT (first asessment) with Hospital Acquired Pressure Ulcers per month.

Graph 3. Highlights the number of ulcers reported via PUNT that have deteriorated (worst category only) within the month.

Graph 4. Highlights the number of additional pressure ulcers that have devloped (all categories) in the month on any patient already reported via PUNT.

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Science, Practice and Education

ing. Furthermore, an international company recently approached ULHT to discuss the possibility of developing PUNT further for wider national use across the NHS and possibly implementing PUNT as an “add-on value product” to support their own commercial activities. In summary Since the launch of PUNT in 2004, clinical staff across the Trust have not only been able to both review and report reliable pressure ulcer data, both internally and externally, but have also been able to make and demonstrate improvements in patient care. Most importantly, improved patient outcomes, such as the reduction in the incidence of pressure ulcer development, have been reported. The author would recommend the use of this tool to all when

References 1. Sen CK, Gordillo GM, Sashwati R, Kirsner R, Lambert L, Hunt TK et al. Human Skin Wounds: A Major and Snowballing Threat to Public Health and the Economy. Wound Repair Regen 2009;17(6):763–71. 1. Öien RF. Registering Ulcer Treatment through a national quality register: RUT - a winning concept for both patients and the health care sector. EWMA Journal 2009, 9(2):41-4. 2. European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. Treatment of pressure ulcers: Quick Reference Guide. Washington DC: National Pressure Ulcer Advisory Panel; 2009. 3. Bates-Jensen, B.M. Pressure Ulcers: Pathophysiology, Detection, and Prevention. In: Sussman, C, BatesJensen, B.M, editors. Wound Care: A Collaborative Practice Manual for Health Care Practitioners. 4th ed. Baltimore, USA: Lippincott Williams & Wilkins; 2012. 4. Bennett G, Dealey C, Posnett J. The cost of pressure ulcers in the UK. Age and Ageing. 2004; 33(3):230235. 5. Deloitte Consulting. Do Healthcare Systems Promote the Prevention of Pressure Ulcers? Belgium: The Creative Studio at Deloitte; 2014. 32 p.

commercially available or the development of a tool whilst PUNT is not commercially available to record data as accurately as possible (note: any electronic tool can only be as accurate as the input data) and report pressure ulcer incidence, whether in the primary or secondary care setting. n Remember: The accurate monitoring of performance improvement is impossible unless you have a robust and reliable monitoring system in place first!

6. NHS Safety Thermometer [Internet]. NHS Safety Thermometer: It’s not just counting, its caring. [Updated 10.09.15]. Available from: www.safetythermometer.nhs.uk 7. Collier M. The development and redevelopment of an electronic Pressure Ulcer Notification Tool (PUNT) within an acute care setting. Paper presented at: The 14th EPUAP Conference; 2011 August-September 31-2; Oporto, Portugal. 8. Collier M. The development and benefits of 10 years’ experience of monitoring pressure ulcer prevalence and incidence with a dedicated electronic tool (PUNT) in a UK hospital trust. Paper presented at: The EWMA Conference; 2014 May 14-16 May; Madrid, Spain. 9. NHS Institute. High Impact Actions - Your Skin Matters. London: 2011.

12. Plaskitt A. Recording pressure ulcer risk assessment and incidence. Nursing Standard. 2015 Jul. 15; 29(46):54-61. 13. National Institute for Health and Care Excellence (NICE). Pressure ulcers: prevention and management of pressure ulcers CG179. England: The National Clinical Guideline Center; 2014. 14. National Institute for Health and Care Excellence (NICE). Pressure Ulcer Quality Standard 89. England: The National Clinical Guideline Center; 2015 Jun. 15. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler, Editor. Perth, Australia: Cambridge Media; 2014.

10. National Institute for Health and Care Excellence (NICE). Pressure Ulcer Management Clinical Guideline 29. 2005, London. 11. NHS [Internet]. Stop the pressure. England: Suzanne Banks; [Updated 18.02.15]. Available from: www. stopthepressure.com

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2015 vol 15 no 2

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References: 1. Data on file, 2012 2. Data on file, 2013 3. Chadwick P et al. Biatain Silicone Dressings: A case series evaluation, Wounds International 2014;5(1) 4. Marburger M, Andersen MB. In vitro test of eight wound dressings with silicone adhesive: Fluid handling capacity and absorption under compression, Presented at Wounds UK 2013 5. Klode J et al. Investigation of adhesion of modern wound dressings: a comparative analysis of 56 different wound dressings. J Eur Acad Dermatol Venereol. (2011) 25(8):933-9 6. Data on file, 2013.

Science, Practice and Education

Preparing Student Nurses for the Future of Wound Management: Telemedicine in a Simulated Learning Environment Abstract Background: The Danish Society for Wound Healing advocates for the use of telemedicine in chronic wound management. It is crucial that student nurses are prepared for the technological demands of the future so that they will be competent to manage chronic wounds. Aim: The aim of this project was to integrate the concept of telemedicine for wound care into a simulation-based class for undergraduate student nurses and to evaluate their experiences with this integrated learning method. Methods: Five medium-fidelity mannequins were used in a simulated learning environment consisting of a simulated laboratory and a simulated wound clinic. A primitive electronic platform was used to allow the students to experience the benefits and challenges of telemedicine in wound care. At the end of the course, the students were asked to evaluate the course based on their experiences with telemedicine and simulation. Finding: Students found the concept of telemedicine relevant and enjoyable, and the challenges and benefits of telemedicine clearly emerged in the simulated learning environment. Conclusion: Based on student evaluations and the need to prepare students for “real-life” telemedicine for wound management, the simulated learning environment seems to be a constructive didactic method. The simulated learning environment should also be tested with postgraduate nurses with less experience in telemedicine.

Introduction The government of Denmark has initiated targeted telemedicine trials for routine care to evaluate the efficacy of telemedicine in clinical practice. The goal in the near future is for 80% of municipalities to offer telemedical wound assessment to 40% of relevant patients1. This initiative is supported by the Danish Society for Wound Healing, which aims to facilitate the use of telemedicine throughout Denmark2. Surveys taken in Denmark indicate that patients and healthcare staff have positive attitudes towards telemedicine, even though staff face challenges related to the technology. It has been shown that staff experience difficulty with the technology related to telemedicine, thus preparing staff to use this technology is important3. This supports the need to prepare nursing students to use this technology and suggests that it is important to integrate elements of telemedicine early during general training and during wound management training. The aim of this project was to integrate the concept of telemedicine for wound care into a simulation-based class for undergraduate student nurses and to evaluate their experiences. Since 2013, undergraduate student nurses have taken a simulation-based course in chronic wound management4, but telemedicine was excluded from the student learning outcomes. Although increased knowledge of wound healing does not automatically lead to changes in clinical practice5, studies have shown that simulations improve learning outcomes, increase critical reflection, improve patient safety, and enhance practical skills6-9. Simulation has been used to educate healthcare staff for decades10 and has been defined as “A dynamic process involving the creation of a hypothetical opportunity that incorporates an authentic representation of reality, facilitates active student engagement, and integrates the complexities of practical and theoretical learning with the opportunity for repetition, feedback and reflection11. Simulations include a variety of options, such as anatomical models, task train-

Sytter Christiansen MSN, Associate Professor*

Anita Rethmeier MSc, Associate Professor* *Department of Nursing in Randers, School of Health Sciences, VIA UC, Denmark.

Correspondence: sytt@via.dk Conflicts of interest: None

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2015 vol 15 no 2

ers, role plays, games, standardised patients, and low- to high-fidelity mannequins10. In a recent review, Topping et al. states that for integration of simulation in a teaching environment to be successful, provision of a simulation environment in itself is not enough, rather, a multi-skilled educator is also required12. Telemedicine Telemedicine is defined as “The use of electronic information and communication technologies to provide and support healthcare when distance separates the participants13. Telemedicine is an efficient method for chronic wound management. The expected gains include shorter healing times, increased skills for local nurses, increased patient satisfaction, and reduced travel time2. In 2010, Ekeland et al., concluded that gains from telemedicine are not uniformly substantiated from the literature14. In addition, Zarchi et al. claimed that as of 2014 there has been no convincing evidence to support the clinical efficacy of telemedicine in wound management. Nevertheless, Zarchi et al. showed that providing wound management advice through telemedicine was associated with increased healing when compared to conventional practice15. Because understanding and evaluating telemedicine is complex, further research is necessary. The MAST (Model for ASsesment of Telemedicine application) model may be a useful tool to determine whether telemedicine should be implemented16. As described in the joint document “eHealth in Wound Care – from conception to implementation”, wound care is a complex process that requires preparation and careful planning17. Methods Prior to the evaluated course students had been studying 25 weeks. On average, 20 students attended, and to enhance student learning, three facilitators were present. The learning content was based on the curriculum18 and the specific learning outcomes of the module19. Box 1 lists the expected learning outcomes. The course consisted of six lessons covering chronic wound management and took place in a traditional classroom, a simulated wound clinic, and in our simulation laboratory. We used five medium-fidelity “Nursing Anne” mannequins from Laerdal that had artificial wounds made of wax or latex. The wounds were painted to mimic different types of chronic wounds (Picture 1). Besides simulation-based learning, the course also included elements of a “flipped classroom”, which is a method that requires 24

Box 1: Learning outcomes n Ability to explain the physiological processes that occur during wound healing n Ability to identify risk factors n Ability to describe and assess the type of chronic wound n Ability to assess and argue for the choice of dressing n Ability to use telemedicine

students to obtain instruction online prior to attending class so that students and teachers may work together constructively during class20. We presented some of the lectures on wound care theory as online videos, and students were required to watch these and other online videos and read relevant parts of the curriculum as preparation for class. It was crucial that students prepared in advance to have practice time during class. Wound assessment was performed in teams of three or four students. An overview of the pedagogical design is shown in (Fig. 1). One member of each group (five groups total) represented the wound clinic, which was located away from the simulation laboratory. The groups in the simulation laboratory removed the bandages from the mannequins, took pictures of the wounds (Picture 2), and uploaded the pictures to an electronic platform (Fig. 1 steps 3, 4). The students that represented the wound clinic received the pictures and were allowed to discuss their picture with their fellow students. Next, each student in the wound clinic made a plan based on the elements in Box 2.

Box 2: Elements to reflect upon n Identify factors related to the patient’s risk of developing a wound based on the patient’s history n Determine whether critical information is missing n Focus on the picture of the wound and collect data n Evaluate the wound bed, edges, and periwound skin n Describe a management plan with the patient based on the Triangle of Wound Assessment

The Triangle of Wound Assessment is a tool for the evaluation of the wound bed, wound edges, and periwound skin. Furthermore, this model is holistic and assesses factors that are unique to each patient, such as comorbidities, infection, pain, and how the wound affects daily life21. The students that are with the patients in the simulation laboratory also reflect on the elements listed in Box 2. After completing step five of the pedagogical design shown in Figure 1, the students in the wound clinic meet with their group members in the simulation laboratory and discuss the following questions: EWMA Journal

2015 vol 15 no 2

Science, Practice and Education

Figure 1:Diagram illustrating the pedagogical design og the course.

Step 2 A student from eachgroup forms the clinic.

Step 1 Simulation Laboratory (SL) : Five groupswith four students in eachgroup.

Step 5 In the clinic the students determine further action inwound care based on the information rece ivedfrom SL.

Step 4 Pictures and patient history are sent electronicallyto the clinic.

Step 3 In SL the rest of the group take pictures of the wounds.

1. Which advantages of telemedicine can you identify? 2. Which downsides of telemedicine can you identify? 3. How was your experience working with telemedicine? In order to identify the potential shortcomings of telemedicine in a structured and holistic manner, we encouraged students to reflect on these questions while considering the domains covered by the MAST-model, which include patient perspectives, organisational constraints, sociocultural aspects, and ethical aspects16. For example, when determining if a patient is suited for treatment by telemedicine, the age and overall health of the patient must be considered; some frail, elderly patients with numerous comorbidities may not be eligible for telemedicine and may benefit more from traditional consultations. This level of reflection should enable students to understand that telemedicine is more than just Picture 1. Nursing Anne equipped with chronic wound made of latex.

Step 6 All students aregatheredin SL where theydiscuss telemedicinein woundcare and carryout woundcare.

technology. In fact, a recent study by Rasmussen et al. emphasised the need for further investigations to identify groups of patients that may not be suited for telemedical care22. After discussing the questions, students cleansed and dressed the wounds (Picture 3). At the end of the course, students completed a short questionnaire, which was developed to allow students to evaluate whether the course experiences satisfied the learning outcomes of the course. Students ranked 1) practical skills training for cleansing and dressing wounds and 2) a learning strategy that combined telemedicine and simulation using a five-point scale that included “very good,” “good,” “appropriate,” “could be better”, or “poor”. Results 70% of the students evaluated the overall skills training positively with scores ranging from “very good” to “approPicture 3. Student nurses cleans the wound.

Picture 2. Student nurses removing dressing from pressure ulcer.

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priate.” The remaining 30% of the students thought that the exercise “could be better”. 39% of the students evaluated the telemedicine component positively with scores ranging from “very good” to “appropriate,” whereas the remaining 61% of the students expressed that it “could be better”. Although 61% of the students thought that the exercise could be better, the evaluations also showed that students found simulation to be a suitable method for integrating telemedicine. When asked whether the learning outcomes related to telemedicine and if chronic wounds were met with the simulation-based method, the students responded positively. In addition, the students stated that the course offered insight into wound management and that they liked practicing skills in an authentic environment. However, they pointed out that time was limited and that they wished for the course to be extended. They also commented that the electronic platform did not support the ability to send descriptions and pictures of the wound along with patient history; the students who worked in the wound clinic found this to be a challenging limitation. One of the expected learning outcomes was the ability of students to use and reflect on telemedicine. During course discussions, students were able to highlight the advantages and disadvantages of telemedicine, and this can be interpreted as an indicator of the ability to reflect on telemedicine. Discussion Because studies have shown that students prefer simulation-based learning to traditional classroom learning23,24 and because motivation is crucial to learning, we maintained simulation as the foundation of the course. In addition, providing meaningful content in an authentic environment enhances learning outcomes25 and simulation can be a way to bridge the gap between theory and practice26. Students evaluated their learning outcomes, and 77% of the students evaluated the learning outcome related to cleansing and dressing the wound positively, whereas only 39% evaluated the learning outcome related to telemedicine positively. This may be due to the fact that students are familiar with the mannequins and the simulation laboratory, whereas the concept of telemedicine is new to them. As expected, students stated that they would like to spend more time in the simulation laboratory, and based on their evaluations, they recognise the need for practical skill competencies within the field of chronic wound management. At this time, expanding the course is not possible. But, there will be a new nursing curriculum in 201627, and we may have the opportunity to emphasise the need to incorporate technology into chronic wound management courses.

One of our concerns prior to the development of this course was the use of a primitive electronic platform as the medium for telemedicine. We selected this electronic platform because our students were familiar with it and could easily navigate it, but as described above, we also need to consider whether students can receive detailed wound descriptions when they ‘work’ in the clinic. Sixtyone percent of the students evaluated the telemedicine component of the course as “could be better”. Student comments revealed that the poor evaluation was based on a desire for more time and the inability of the platform to facilitate communication between the wound clinic and the simulation laboratory. In the future, we may accommodate this criticism by purchasing a realistic and authentic teaching module from the Danish organisation PlejeNet28 that would align with simulation as the chosen pedagogical strategy. In tandem with clinical practice, we familiarise our students with EPJ, a platform for electronic patient journals, and students are expected to work with this platform during clinical practice and in the simulation laboratory. We have observed that nurses in clinical practice successfully navigate and use this platform. Thus, we believe that students can become proficient with PlejeNet when it is incorporated into an appropriate simulated learning environment. Future demands When simulation is the chosen didactic strategy, the environment must be authentic to enhance learning outcomes24. In the future, caring for patients will be more complex and will involve technology. Tasks that hospital nurses perform will also extend to nurses employed in municipalities29, and this must be considered when designing courses. In our current simulation, students meet patients that were admitted to the hospital, but in our future simulations, we would like our students to meet patients in their own home. Nurses employed in municipalities must be able to make autonomous decisions and must be familiar with technology. In the future, we would like to invite an outpatient nurse to participate in simulated training to give our students first-hand insight into the challenges present in home care. The need to maintain wound management and technology in the nursing curriculum is based on the future roles of nurses and the expected increase in the number of people living with a chronic wound. Madsbjerg et al. and Dowsett emphasise using a holistic approach for wound management in which the “active patient” is taken into consideration21,30. This approach can be difficult to incorporate into a learning environment. In our course, three facilitators were present to take on the roles of the patient in only three out of five patient cases. Thus, to some degree, students were given the opportunity to consider and

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reflect on patient experience, compliance, and resources in addition to practical skills. Our reflections and the student evaluations support our assumption that introducing telemedicine in a teaching environment through simulation is appropriate. We need to improve the electronic platform to allow for communication and wound descriptions. The possibility of im-

plementing a suitable platform in the next course will be explored. We believe that implementation of a suitable platform will prepare students for future demands in the nursing profession. We are also convinced that the concepts of telemedicine and simulation are suitable for postgraduate education. n

References 1 Medcom [Internet]. Det danske sundhedsdatanet. Telesår udbredelsesprojekt. Iben Søgaard; [updated:2015 09 14;cited 2012 08 31]. Available from: http://medcom.dk/wm112455 2 Henneberg WE. Telemedical woundassessment on the way to large scale deployment in Denmark. EWMA Journal. 2014; 2:43-46. 3 Enheden for brugerundersøgelser [Internet]. Telemedicinsk sårvurdering. En kvalitativ brugerevaluering blandt patienter og sundhedsfagligt personale i Region Hovedstaden. [updated:2013 03 01;cited 2013 02 01]. Available from: http://patientoplevelser. dk/sites/patientoplevelser.dk/files/dokumenter/artikel/ telemedicinsk_sv_2013.pdf 4 Christiansen S, Rethmeier A, Vajse-Engelbrecht P. Implementering af VIA´s visioner, strategier og initiativer i sygeplejerskeuddannelsen. Uddannelsesnyt. 2013; 4(24):33-37. 5 Bermark S, Zimmerdahl V, Weibel K. Øget viden om sår ændrer ikke nødvendigvis praksis. Sygeplejersken. 2009; 109(15):40-44. 6 Richardson KJ, Claman F. High-fidelity simulation in nursing education: a change in clinical practice. Nurs Educ Perspec. 2014; 35(2):125-27. 7 Issenberg S, McGaghie W, Petrusa E, Gordon D, Scalese R. Features and uses of high-fidelity medical simulations that lead to effective learning: a BEME systematic review. Med Teach. 2005; 27(1):10-28. 8 Shearer JE. High-fidelity simulation and safety: an integrative review. J Nurs Educ. 2013; 52(1):39-45. 9 Hope A, Garside J, Prescott S. Rethinking theory and practice: Pre-registration student nurses experiences of simulation teaching and learning in the acquisition of clinical skills in preparation for practice. Nurse Educ Today. 2011; 31(7):711-15. 10 Nehring WM, Lashley FR. Nursing simulation: A review of the past 40 years. Simulation & Gaming 2009: 40(4):528-52. 11 Bland AJ, Topping A, Wood B. A concept analysis of simulation as a learning strategy in the education of undergraduate nursing students. Nurse Educ Today. 2011; 31(7):664-70.

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12 Topping A, Bøje RB, Rekola L, Hartvigsen T, Prescott S, Bland A, et al. Towards identifying nurse educator competencies required for simulation-based learning: A systemised rapid review and synthesis. Nurse Educ Today. 2015. (In press).

22 Rasmussen BSB, Froekjaer J, Bjerregaard MR, Lauritsen J, Hangaard J, Henriksen CW, et al. A Randomized Controlled Trial Comparing Telemedical and Standard Outpatient Monitoring of Diabetic Foot Ulcers. Diabetes Care. 2015; 38(8):1723-29.

13 Field, MJ. Commitee on Evaluating Clinical Applications of Telemedicine. A Guide to Assessing Telecommunication in Health Care. Washington D.C: National: Acadamy Press; 1996.

23 Lapkin S, Levett-Jones T, Bellchambers H, Fernandez R. Effectiveness of patient simulation manikins in teaching clinical reasoning skills to undergraduate nursing students: A systematic review. Clinical Simulation in Nursing. 2010; 6(6):207-22.

14 Ekeland AG, Bowes A, Flottorp S. Effectiveness of telemedicine: a systematic review of reviews. Int J Med Inf. 2010; 79(11):736-71. 15 Zarchi K, Haugaard VB, Dufour DN, Jemec GB. Expert Advice Provided through Telemedicine Improves Healing of Chronic Wounds: Prospective Cluster Controlled Study. J Invest Dermatol. 2014; 135(3):895-900.

24 Jeffries PR. A frame work for designing, implementing, and evaluating simulations used as teaching strategies in nursing. Nurs Educ Perspec. 2005; 26(2):96-103. 25 Raaheim A. Læring og undervisning. Bergen: Fagbokforlaget; 2011.

16 Kidholm K, Ekeland AG, Jensen LK, Rasmussen J, Pedersen CD, Bowes A, et al. A model for assessment of telemedicine applications: mast. Int J Technol Assess Health Care. 2012; 28(1):44-51.

26 Udvalg for kvalitet og relevans i de videregående uddannelser [Internet]. Nye veje og høje mål. [updated:2015 01 29;cited 2015 01 29]. Available from: http://ufm.dk/publikationer/2015/nye-veje-oghoje-mal

17 Moore Z, Angel D, Bjerregaard J, O´Connor T, McGuiness W, Kröger K, et al. eHealth in Wound Care- From conception to implementation. J of Wound Care. 2015; 24(5):1-44.

27 Nissen-Petersen S [Internet]. Ny sygeplejerskeuddannelse på vej. [updated 2014 11 14;cited 2014 11 14]. Available from: http://www.dsr.dk/Nyheder/ Sider/Ny-sygeplejerskeuddannelse-p%C3%A5-vej.aspx

18 Undervisningsministeriet [Internet]. Bekendtgørelse om uddannelsen til professionsbachelor i sygepleje. [updated:2015 09 14;cited 2008 01 29]. Available from:https://www.retsinformation.dk/Forms/R0710. aspx?id=114493

28 Dansk Telemedicin A/S [Internet]. Sårjournal. [updated 2015 09 14]. Available from: https://www. telemed.dk/Solutions.asp

19 VIA University College [Internet]. Modulbeskrivelse. Modul 3. [updated:2015 08 05;cited 2014 06 19]. Available from: http://www.viauc.dk/sygeplejerske/ randers/Documents/Modul_3/Modulbeskriv-m3.pdf 20 Bergmann J, Sams A. Flip your classroom: Reach every student in every class every day. International Society for Technology in Education. USA: ISTE & ASCD; 2012. 21 Dowsett C, Groonemann MN, Harding K. Taking wound assessment beyond the edge. Wound International. 2015; 6(1):19-23.

29 Sundhedskartellet [Internet]. Kompleks fremtid og refleksive sundhedsprofessionelle. Om videreudvikling og forbedring af sundhedsuddannelserne. Hellerup: Implement Consulting Group; 2014: 1-50. [updated:2014 11 11]. Available from: http://www.dsr.dk/ Documents/Fag/Uddannelse/Afrapportering%20Sundhedskartellets%20uddannelsesprojekt%20-endelig.pdf 30 Madsbjerg C, Krenchel M, Ramsey-Elliot M, Hesselholt G [Internet]. A Case for Ethnography in the Study for Coporate Competencies. [updated 2015 09 14]. Available from: http://www.redassociates.com/ conversations/sense-making/a-case- for-ethnographyin-the-study-of-corporate-competencies/

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Science, Practice and Education

The Psychological Effects of Malignant Fungating Wounds Summary Malignant fungating wounds (MFWs) are a result of cancerous cells invading the skin and nearby vessels1. They are most common in patients with breast cancer but also have a high incidence in patients with head and neck cancers2, 3. MFWs typically occur at the site of the primary cancer as well as in the surrounding lymph nodes3. MFWs have a multitude of physical effects on patients including pain, bleeding, and exudate. It is important, however, to understand the psychological impacts that MFWs and the symptoms associated with MFWs have on the lives of patients. The aim of this article is to review the literature on the psychological impacts of MFWs. A search of four databases identified 24 papers comprising four main themes: the physical symptoms of MFWs, the effects of MFWs on patients’ sense of self, the effects of MFWs on patients’ relationships, and support for patients with MFWs. MFWs have a profound impact on the psychological well-being of patients and contribute to how patients view themselves and their illness. Feelings of isolation tend to predominate, but the impact of MFWs on the lives of patients and patients’ families can be mitigated with specialist and supportive care. Introduction A malignant fungating wound (MFW) is the result of a tumour or metastasis penetrating the skin. MFWs can also affect lymph and blood vessels around the site of penetration (e.g. the breast)4. If a tumour is not treated sufficiently, it can spread to nearby local tissue and cause vascular damage or severe ulceration5. MFWs can occur anywhere on the body, but they are most commonly found on the breast (62%) and the head and neck (24%)6. The prevalence of MFWs is unclear, due in part to insufficient documentation and identification of MFWs in cancer registers7. A survey in the United Kingdom in 1992 reported 2,417 new cases of MFW per year, with 5% of those cases caused by a primary tumour and 10% caused by EWMA Journal

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metastatic disease8. The pathology of the remaining 85% of the MFW cases in the survey was not identified. The prevalence has remained constant over the years since the 1992 survey, with reports that 5–10% of patients with cancer develop an MFW9-12. However, Prevalence may be higher as some patients do not report MFWs due to embarrassment. Although the prevalence of MFWs is unclear, there is a need to understand the impact that MFWs have on patients. The aim of this review is to gain a better understanding of the psychological effects that MFWs have on patients. Method The Cinahl, PsychINFO, Scopus, and CancerLit databases were searched between 31 August 2014 and 11 November 2014 using the following keywords either alone or in combination: ‘fungating’, ‘wounds’, ‘patient’, ‘psychological’, and ‘palliative’. The searches were limited to articles published in English in peer-reviewed journals since 2000. Twenty-four papers met the review criteria, including 8 original research articles, 14 literature reviews, and 2 case studies. Four major themes emerged from the literature: the physical symptoms of MFWs, the effects of MFWs have on patients sense of self, the effects MFWs on patients’ relationships, and support for patients with MFWs. Although each of those themes is discussed here in detail, it should be noted that the number of papers related to each theme was very small. Physical symptoms (Theme 1) One of the most prevalent issues for patients with MFWs is how to cope with physical symptoms including pain, exudate, odour, itch, and bleeding11, 13-16. Using an interpretative phenomenological analysis, Probst et al. interviewed nine patients with breast cancer17. All of the patients reported that pain had a major and serious impact on their

Helen Reyonlds BSc Nursing (4th year student)*

Georgina Gethin PhD, PG Dip Wound Healing, Senior Lecturer*

*School of Nursing and Midwifery, National University of Ireland Galway, Ireland.

This paper was completed in part fulfilment of BSc Nursing. Correspondence to: h.reynolds3@nuigalway.ie Conflicts of interest: None

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life and described the pain as ‘stabbing’, ‘sharp’, or ‘acute’. The patients were all afraid to use prescribed pain relief on a regular basis for fear that they would become addicted. The patients who took over-the-counter pain medication all noted that those medications did not have an effect on the pain. Additionally, multiple studies reported that pain occurred as a consequence of the MFW, and multiple descriptors were used to describe the pain including ‘constant’, ‘stabbing’, ‘spontaneous’, ‘persistent’, and ‘inflammatory’15, 16. Bleeding was reported as both a fear and a reality for many patients with MFWs11, 15, 18, 19. In one study, a patient described how her wound began to bleed during a work meeting and produced visible marks on her clothing [18]. Because of that, she always had to carry spare clothing and dressings with her, and she found the bleeding to be a major source of embarrassment. Another patient stated that she could no longer attend the sauna because of the ‘unpredictable nature of the wound’ related to bleeding. Because bodily fluids are usually confined within the body, patients felt that their bodies were letting them down and that bleeding was a major issue that affected their lives18. One patient used complimentary alternative medicine in the form of compressions made of cured cheese in efforts to manage bleeding caused by an MFW [18]. She stated that she managed to keep the bleeding under control using that method, although she still found the process distressing. Another patient stated that a scab would eventually form at the site of her MFW but would come off after every shower, returning the wound to its initial stage. The duration of the bleeding episodes varied, and in a study by Lo et al., one patient stated that she always had bleeding from the wound following a dressing change or exercise, which rarely subsided until the following day11. Exudate and its management had a considerable psychological effect on patients as the patients tried to cope not only with the visible signs but also with the constant dressing changes and reminders of the underlying disease11, 15, 18. Feelings of stress and exacerbation were reported as patients struggled with excessive amounts of exudate, requiring multiple clothing changes and considerable time spent reapplying dressings (which is described as very labour intensive), causing distress, anxiety, worry, and also the financial burden of sourcing adequate dressings11, 15, 18. The management of excessive exudate caused many patients to remain in their own homes for long periods just to be able to manage their wounds. Throughout the studies, the participants remarked on the embarrassment of the exudate, which could become visible at any time11, 18, 20. Patients consistently identified odour as the worst element of their MFW and stated that the wound odour significantly affected their quality of life and the quality of life of those who cared for them15, 19, 21-24. In some 30

studies, patients described the odour as ‘mouldy’, ‘putrid’, or ‘similar to spoiled meat’ and reported feelings of living within a body that was ‘rotting’18. All of the patients found it difficult to mask the odour. One patient remarked that if she could smell the wound, she knew that others could too. That was borne out in many studies in which patients feared that others could smell their wound, which in turn led to the patients isolating themselves within the confines of their home from family and caregivers17-19. Many of the patients found that the only way to disguise the odour was to wash the wound many times per day, but they found that to be time consuming, which again caused them to stay indoors. One patient used tissue to pack the wound and perfume to disguise the smell, while others resorted to using baby talcum powder and essential oils. A recent international survey showed just how challenging wound odour management can be; clinicians and patients reported using a multitude of agents topically and within the wound environment to manage the odour, with no clear recommendations emerging on how best to manage the problem24. Although less common than odour and pain, itch (pruritus) was a significant source of distress for individuals with MFWs15. For some patients, itching occurred both inside the wound and in the area surrounding the wound. One patient identified ‘tensions’ in the breast; she knew that a few days later, the itch would commence15, 17. Effects on sense of self (Theme 2) In a study by Lund-Nielsen et al. of 12 women undergoing treatment in Denmark for progressive breast cancer, 42% of the women reported that their wounds had a negative effect on their femininity25. The inability to wear a bra because of the dressing affected the ability to choose clothes of a feminine nature. The older women (>70 years of age) did not report a particular loss of femininity but stated that if they were younger, the wound might have had a significant impact on their sense of femininity. The effects of pain on femininity are documented throughout many studies17, 25. A new sense-of-being in the world was described in a very profound way by the participants in one study. Those patients reported that they had to find a new existence and reasoning within the world that they had become accustomed to since becoming ill20. The patients described feeling that the MFW dictated their lives and that they had a very different existence compared with the existence they once knew. The patients described ‘mourning’ the life they once had and finding it very difficult to accept and adjust to a new life of acceptance, loss, and confusion. The patients described lives prior to having an MFW that included interactions with their family, friends, and wider community; a sure sense of self; and connections with the various elements of life to which they had beEWMA Journal

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come accustomed. Living with an MFW greatly affected those interactions and connections. Patients described the wound as symbolising the end of their life, as many of the elements of their former daily life were replaced by loss of independence, embarrassment, anger, depression, and fear20. A sense of embarrassment emerged very strongly from the patient narratives17. Embarrassment due to the wound dressing became very difficult for some patients, impacting on the activities of daily living, causing further embarrassment with family members. Some patients described becoming isolated in their own homes due to the embarrassment caused by the symptoms of the wound. One patient described herself as ‘falling apart’ and feeling marginalised from society, safe only in her own surroundings and away from the eyes of others18. Probst et al. reported patients feeling isolated and trying to disguise the problem18. The patients found it difficult to hide the problem, however, because of associated issues like lymphedema. Attempts to disguise the MFW often left the patients isolated, as they did not want anyone else to know about the problem. Some of the patients who lived with family members avoided talking about the wound. They never showed it to family members, and some members of the family did not even know the wound existed25. One participant could not bring herself to tell her husband but confided instead in close friends, which provided a way for her to voice her concerns and anxieties. There were reports throughout the literature of patients feeling a stigma associated with the wound. Patients recounted how they would keep the wound a secret and how the wound affected them socially and greatly compromised their body image and confidence11, 17, 19, 25. One patient had previously always travelled with his family but no longer did so because of his MFW. All the patients found their wound to be a constant reminder of their cancer. One patient stated: ‘I don’t want to die, but this wound looks as if death is more and more near me. I can’t escape’. Some patients viewed the MFW as a visible demonstration of what the tumour was doing to the inside of their body19. One patient was very distressed at the thought of what the tumour was doing inside her body when she could see what the MFW was doing on the outside. Lack of control over the body was another common issue among the study participants. A loss of self, meaning one is no longer the person he or she used to be, caused patients to lose faith in their body and to not trust in their body’s capabilities. Loss of identity was a major factor for patients. Reconciling what patients expected of their body with the reality of the disease was a huge hurdle. Effects on relationships (Theme 3) The odour and the appearance of the wound were two eleEWMA Journal

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ments that caused patients to feel self-conscious regarding their sexual being25, 26. They were a constant reminder to both patients and the patients’ spouses of living with a rapidly progressing terminal illness. The pain, irritation, reduced mobility, and discomfort caused by the wound made it difficult for patients to relax during sexual intimacy, and spouses feared causing even more pain or discomfort during intimacy26. In the study by Probst et al., one patient was concerned about her partner’s acceptance of her wound, and another reported that her spouse did all he could not to touch the breast during sexual activity18. All the patients reported a significant loss of intimacy and an impact on the quality of relationships. Some partners were afraid that they would hurt their spouse, while others would not discuss or touch the breast, as it was a constant reminder of the condition26. Patients spoke about the effect of the wound on their partners19. They stated that they no longer felt attractive or feminine. Many asked the question: ‘How can he still love me when I’m not the girl he fell in love with?’ One participant stated that she would not sleep beside her partner naked. Guilt and blame were major factors for some patients, especially in regard to their children. One patient talked about feelings of loss due to not being able to see her children grow into adulthood. All of the patients reported guilt in relation to not being able to fulfil their role within certain relationships. Support (Theme 4) One patient found that although she could not confide in her husband, she was able to talk to the community nurses and also to her close friends17. Another patient was able to talk to her family and found that to be a great support. Patients identified the need for help with wound care, pain relief, and financial support from specialists in the early stages of their illness11. Many patients reported very positive results following expert help and advice on dressings, wound care strategies, and what to expect from the wound, noting, for example, improved appetite, emotional stability, decreased malodour, reduced levels of pain, feeling more relaxed, sleeping better, generally improved quality of life and ability to live more positively with the wound11. Advice, appropriate dressings, and the ability to selfcare for the wounds in an appropriate manner were all important elements in giving patients autonomy of care going forward11, which in turn led to a more realistic care plan, making the experience less daunting for the patient. Some patients noted that since being able to appropriately manage the wound, they were able to go out more and to feel more comfortable doing so. One patient noted that the specialist nurse was excellent, especially in educating and supporting the patient’s daughter regarding 

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the MFW. One patient said of the wound-care specialist nurse: ‘I think that the wound specialist nurse is my angel, because she drives out my malodour and exudate. I was very pleased to have met her’11. Discussion There is a dearth of research on the impact that MFWs have on individuals, but the studies identified here reveal a very strong sense of isolation, loss of sexual identity, fear, anxiety, and distress. Those feelings were inextricably linked to the symptoms and the daily challenges of managing the wound and a body that could not be trusted. Physical symptoms such as pain, odour, bleeding, and exudate all negatively impact on patients and patients’ relationships. The visual deterioration of the wound leads to physical, emotional, psychological, and spiritual distress, which is linked to the loss of many elements of the patient’s life as he or she knew it, such as the patient’s sense of identity, body in which he or she trusts, dignity, and sense of control13, 19. Of particular relevance is the isolation that patients either feel or self-impose due mainly to the physical symptoms of the wound. The reality is that all patients with MFWs will die. The prevalence of MFWs points to a great need for further research in that area. Although a substantial percentage of patients with cancer have an MFW, it is important to understand that the prevalence of MFWs is more than likely underestimated because of patients’ reluctance to identify or disclose important information. Such reluctance is commonly related to embarrassment, denial, or REFERENCES 1. Grocott P. The management of fungating wounds. Journal of Wound Care. 1999; 8(5):232-34. 2. Maida V, Corbo M, Dolzhykov M, Ennis M, Irani S, Trozzolo L. Wounds in advanced illness: a prevalence and incidence study based on a prospective case series. International Wound Journal. 2008; 5(2):30514. 3. Young T. The challenge of managing fungating wounds. Community Nurse. 1997; 3(9):41-4. 4. Grocott P. Palliative management of fungating malignant wounds. Journal of Community Nursing. 2000; 14(3):31-31-32, 35-36, 38. 5. Mortimer P. Management of skin problems: medical aspects. In: Doyle D, Hanks G, Cherney N, Calman K, editors. Oxford Textbook of Palliative Medicine. 3rd ed. Oxford: Oxford University Press; 2003. 6. Naylor W. Malignant wounds: aetiology and principles of management. Nursing Standard. 2002; 16:45-46. 7. Grocott P, Cowley S. The palliative management of fungating malignant wounds - generalising from multiple-case study data using a system of reasoning. International Journal Of Nursing Studies. 2001; 38(5):533-45. 8. Thomas S. Current Practices in the Management of Fungating Lesions and Radiotherapy Damaging Skin. In: The Surgical Materials Testing Laboratory. Bridgend; 1992. 9. Alvarez OM, Meehan M, Ennis W, Thomas DR, Ferris FD, Kennedy KL, et al. Chronic wounds: palliative management for the frail population. Wounds: A Compendium of Clinical Research & Practice. 2002; 14(8):4S-27s. 10. Alvarez OM, Kalinski C, Nusbaum J, Hernandez L, Pappous E, Kyriannis C, et al. Incorporating Wound Healing Strategies to Improve Palliation (Symptom

fear. The problem could be addressed in part through more education for clinicians surrounding MFWs and more psychological support for patients and families at the stage when an MFW is diagnosed. When patients’ psychological needs are met early on, patients are able to better cope with and manage their disease11 and to sustain a positive sense of identity. Recently, some studies have sought strategies to improve MFW management, but there is still an urgent need for more research in that area24, 27, 28. Research should focus on the relief of the physical symptoms, which will in turn help to alleviate the psychological distress. Conclusion The literature on the impacts of MFWs has predominantly focused on the physical symptoms. This review gives voice to the profound and distressing psychological impact that MFWs have on patients and families. MFWs are difficult to endure and often represent a terminal stage of an illness. What is notable is the constant reference to isolation due to the wound, which comes at a time when family and other support structures are very important. It is incumbent upon healthcare professionals to understand the psychological impacts of MFWs in order to help and support patients and patients’ families. Healthcare professionals also must face the challenge of finding methods to effectively manage distressing symptoms of MFWs such as odour and itch, because more effective management of the symptoms will improve quality of life for patients and patients’ families. n

Management) in Patients with Chronic Wounds. Journal of Palliative Medicine. 2007; 10(5):1161-89. 11. Lo S, Hu W, Hayter M, Chang S, Hsu M, Wu L. Experiences of living with a malignant fungating wound: a qualitative study. Journal Of Clinical Nursing. 2008; 17(20):2699-2708. 12. Alexander S. Malignant fungating wounds: epidemiology, aetiology, presentation and assessment. Journal Of Wound Care. 2009; 18(7):273. 13. Grocott P. Care of patients with fungating malignant wounds. Nursing Standard. 2007; 21(24):57-62. 14. Probst S, Arber A, Faithfull S. Malignant fungating wounds: a survey of nurses’ clinical practice in Switzerland. European Journal of Oncology Nursing. 2009; 13(4):295-98. 15. Maida V, Ennis M, Kuziemsky C, Trozzolo L. Symptoms associated with malignant wounds: a prospective case series. Journal of Pain & Symptom Management. 2009; 37(2):206-11. 16. Schultz V, Triska O, Tonkin K. Malignant wounds: caregiver-determined clinical problems. Journal of Pain & Symptom Management. 2002; 24:572-77. 17. Probst S. Malignant Fungating Wounds: the meaning of living in an unbounded body. European Journal of Oncology Nursing. 2013; 17(1):38-45. 18. Probst S, Arber A, Faithfull S. Coping with an exulcerated breast carcinoma: a phenomenological study. Journal of Wound Care. 2013; 22(7):1-7. 19. Piggin C, Jones V. Malignant fungating wounds: an analysis of the lived experience. Journal Of Wound Care. 2009; 18(2):57. 20. Alexander S. An intense and unforgettable experience: the lived experience of malignant wounds from the perspectives of patients, caregivers and nurses. International Wound Journal. 2010; 7(6):456-65.

21. Kalinski C, Schnepf M, Laboy D, Hernandez L, Nusbaum J, McGrinder B, et al.Effectiveness of a topical formulation containing metronidazole for wound odor and exudate control. Wounds: A Compendium of Clinical Research & Practice. 2005; 17(4):84-90. 22. Young C. The effects of malodorous fungating malignant wounds on body image and quality of life. Journal of Wound Care. 2005; 14(8):359-63. 23. West D. A palliative approach to the management of malodour from malignant fungating tumours. International Journal of Palliative Nursing. 2007; 13:137-42. 24. Gethin G, Grocott P, Probst S, Clarke E. Current practice in the management of wound odour: an international survey. International Journal Of Nursing Studies. 2014; 51(6):865-74. 25. Lund-Nielsen B, Muller K, Adamsen L. Qualitative and quantitative evaluation of a new regimen for malignant wounds in women with advanced breast cancer. Journal Of Wound Care. 2005; 14(2):69-73. 26. Lund-Nielsen B, Muller K, Adamsen L. Malignant wounds in women with breast cancer: feminine and sexual perspectives. Journal Of Clinical Nursing. 2005; 14(1):56-64. 27. Lund-Nielsen B, Adamsen L, Kolmos HJ, Rørth M, Tolver A, Gottrup F. The effect of honey-coated bandages compared with silver-coated bandages on treatment of malignant wounds-a randomized study. Wound Repair And Regeneration: Official Publication Of The Wound Healing Society [And] The European Tissue Repair Society. 2011; 19(6):664-70. 28. Robson V, Cooper R. Using leptospermum honey to manage wounds impaired by radiotherapy: a case series. Ostomy Wound Management. 2009; 55(1):38.

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2015 vol 15 no 2

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Science, Practice and Education

London · UK

Extended Abstract: Design and implementation of a local strategy to increase the accuracy of pressure ulcer classification:

The Pressure Ulcer Guidance (PUG) Tool

Judith A Barnard BSc (Hons) RN,Tissue Viability Nurse Specialist, North Lincolnshire and Goole NHS Foundation Trust, Scunthorpe General Hospital, Cliff Gardens, Scunthorpe, UK.

Dale L Copson MSc, BSc (Hons) RN, Medical Affairs Specialist, ConvaTec UK, Deeside, Flintshire, UK.

Conflicts of interest: ConvaTec sponsored the attendance of Judith Barnard to attend and present at EWMA 2015 conference in London.

Submitted to EWMA Journal, Based on presentation given in the free paper session Pressure Ulcer 2.

INTRODUCTION The Trust Tissue Viability service receives referrals on a daily basis requesting clinical review for pressure ulcer verification. It was apparent that classification skills amongst adult nursing staff within our organisation were poor. Distinguishing between various pressure ulcer stages and differentiating “superficial” pressure ulcers from moisture lesions was problematic, often leading to inaccurate reporting and inappropriate management. This extended abstract describes the development and implementation of a local PUG tool and the supporting poster, which is designed to educate nursing staff and thereby overcome these difficulties.

RESULTS n The Pressure Ulcer Guidance (PUG) logo, tool, and supporting poster were developed (Fig. 1, 2, & 3), and feedback on their design and usability were well received by the nursing staff.

METHOD Utilizing the European Pressure Ulcer Advisory Panel (EPUAP 2014) classification guidance1:

n Approval was given by the Chief Nurse to implement the tool and poster within the Trust.

n An easy-to-use, image-illustrated, decision- making tool was designed and shared with the Tissue Viability Link Nurse Group.

n Trust funding was secured for the first print, and the tool was piloted on five acute wards.

n Twenty nurses were asked to classify 15 verified pressure ulcer and five moisture lesion images without assistance. Correspondence: judith.barnard@nhs.net and dale.copson@convatec.com

EWMA n london 2015

n Immediately after, the same nurses were asked to repeat the exercise on another set of verified pressure ulcer and moisture lesion images, this time using the decision-making tool to assess its accuracy. n A logo and supporting poster were also designed and presented to the link nurse group for feedback.

n Preliminary testing with the 20 nurses for all of the verified PU and ML images without the use of the PUG Tool yielded an accuracy rate of 80%. n Repeat testing using another set of images, with the PUG Tool for assistance, yielded an accuracy rate of 100%.

n Further external support was provided by a commercial company to fund reprinting for full implementation. DISCUSSION We were very pleased with the initial results and feedback from the pilot project. A full (Trustwide) implementation of this local strategy is currently being phased in. The main aim is to provide a consistent approach to clinical practice, which complements patient assessment, care planning, and documentation. In the short period of time that this project has been running, the Tissue Viability team has noticed a slight increase

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in the number of stage 2 pressure ulcers being reported; however, there has been a noticeable decrease in full thickness (stage 3/4) ulcers reported, and the use of the tool as an assessment guide when ulcers are reported is being acknowledged. CONCLUSION Implementation of this local strategy raised awareness of the importance of pressure ulcer prevention and management within our Trust, facilitated the accurate classification of pressure ulceration, and guided clinical staff towards differentiating them from moisture lesions, improving the accuracy of pressure ulcer reporting. Pressure

ulcers that are assessed and classified correctly can be appropriately managed, and this may lead to faster healing, improved patient quality of life, and ultimately a reduction in the associated costs. Plans are now being prepared to expand the use of this tool into Children’s Services with the acute Trust and to implement it into the local community care setting. n Acknowledgements: J. Barnard: PUG Logo, PUG Tool, Poster illustrations©. LINET UK Ltd;2014. Figure 1, 2 and 3. Special thanks to: The management staff & Tissue Viability Link nurses at NLAG NHS Foundation Trust for their feedback and support.

REFERENCE 1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, and Pan-Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Osborne Park, Western Australia: Emily Haesler, editor. Cambridge Media; 2014. 75 p.

Figure 1. PUG Logo.

Figure 2. PUG Tool. Laminated, double-sided wheel, one side referring to Pressure Ulceration and the other referring to Suspected Deep Tissue Injury or Moisture Lesion.

Figure 3. Poster illustrations. Draft illustrations for the PUG Poster have been designed based on EPUAP 2014 classification guidance. Illustrations for Stage/Grade 4-Depth Unknown and Stage/Grade 4-Suspected Deep Tissue Injury are yet to be added.

EWMA Journal

2015 vol 15 no 2

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*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.

EWMA Journal

2015 vol 15 no 2

Science, Practice and Education

London Âˇ UK

EWMA n london 2015 Submitted to EWMA Journal, Based on presentation given in the free session Pressure Ulcer. 1

Extended Abstract:

Development and Implementation of a Tool to Assess and Differentiate Moisture Lesions and Pressure Ulcers

Aim The aim of this project was to develop and implement a care support tool to enable staff to differentiate between moisture lesions and pressure ulcers. This project was important for the organisation because it supported appropriate assessment and care delivery as well as supporting the collection of accurate pressure ulcer data Skin integrity maintenance ranks high on clinical and political agendas. A key focus is on prevention strategies affected by distinct policies and guidelines. These strategies include patient safety1, pressure ulcer prevention2 and continence care3. A pressure ulcer is a localised injury to the skin or underlying tissue, or both. Pressure ulcers are usually located over a bony prominence; ulcers in this location result from pressure or pressure associated with shear4. Gray et al.5 identifies the main characteristics of moisture lesions as erythema, erosion or loss of skin barrier function, and maceration. The skin provides an external protective layer, but is susceptible to the individual and combined effects of damage from excessive moisture from wound exudate, urine, faeces, or perspiration6. Methods The Moisture or Pressure Tool (MOPT) was developed following a literature review by a UK Community National Health Services (NHS) Trust. A tissue viability (TV) team, a continence team, honorary contract TV nurses, and primary care clinical staff were included on the project team. The draft MOPT was presented during seven educational events on pressure ulcer prevention and management, which were presented to

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2015 vol 15 no 2

Jackie Stephen-Haynes Professor in Tissue Viability, Professional Development Unit, Birmingham City University and Consultant Nurse*

Trust members. The staff members were qualified health care professionals and were predominantly nursing staff who regularly had access to education and training in pressure ulcer prevention. The MOPT guide is a folded, double-sided, A3 paper size, leaflet for staff use. The centre of the guide contains the MOPT, which prompts the clinician to consider wound presentation characteristics (e.g., cause, location, shape, presence of necrosis, wound edge and colour). Images of characteristics are provided, and the staff selects the most appropriate image. If any characteristics on the right-hand side of the page are selected, then the wound is classified as a pressure ulcer, or an ulcer combined with another type of wound. The reverse side of the MOPT reminds staff about key management and reporting points for pressure ulcers, moisture lesions, and combination wounds. TV staff contact information is also included. The MOPT tool was modified following feedback received during the educational events. After the seven events were completed, the 225 staff members who had attended them were invited to complete an anonymous questionnaire about using the MOPT in clinical practice. The development process followed the agreed Trust process and included clinical governance support. Results and Discussion Because the aim of this project was to develop and implement a care support tool to enable staff to differentiate between moisture lesions and pressure ulcers, staff were asked to evaluate the

Rosie Callaghan Tissue Viability Specialist Nurse*

Moira Evans Honorary Tissue Viability Nurse* Sue Simm Honorary Tissue Viability Nurse*

*Worcestershire Health and Care NHS Trust.

Correspondence: jackies_h@btinternet.com Conflicts of interest: None

î&#x201A;Š

Science, Practice and Education

MOPT and the education delivered to support its development. n 95

% (n= 243) said that the MOPT was easy to use n 95

%(n=243) said it assisted with differentiation n 100% (n=255) said the education supported their clinical practice n 100 %(n=255) said the tool and education supported the development of appropriate care strategies n 100 %(n=255) said the tool raised the profile of appropriate continence and tissue viability care

Consistent with NHS England recommendations, the Trust has implemented a system that requires all clinical staff to report all category 2–4 pressure ulcers using a data recording system. This system allows for accurate tracking and monitoring of all patients with pressure ulcers. TV staff members verify that a pressure ulcer is present. No moisture lesions have been reported as pressure ulcers on the Trust reporting system. This result supports achievement of the quality target. Staff members have consulted the continence team for advice and are reporting that patients are receiving more appropriate care. The ability of the MOPT to differentiate between moisture lesions and pressure ulcers will continue to be monitored.

The MOPT is being developed into an e-learning module. The NHS Care Trust will require this module as training for all registered Trust health care professionals with responsibility for categorising pressure ulcers, and differentiating pressure and moisture damage. Conclusion In this challenging area of wound care, the effects of introducing the MOPT across the Trust were successfully reinforced during education and training. The audit results clearly indicated that the MOPT was easy to use, assisted with differentiation, supported appropriate care delivery strategies, and increased the profile of appropriate tissue viability and continence care. The staff also indicated that the education supported their clinical practices and appropriate care delivery. This result was confirmed by quantifiable improvement in assessment and categorisation of pressure ulcers in that no moisture lesions were recorded as pressure ulcers. n Colleagues A copy of the Moisture or Pressure Tool (MOPT) is available. Following the EWMA presentation, a group-based survey will be available that can be used to evaluate the tool within specific clinical areas. Registered participants can contact Jayne Allchurch (Jayne.Allchurch@hacw.nhs.uk) to receive a copy of the MOPT, the MOPT presentation, and the link to the questionnaire.

References 6. Evans J, Stephen-Haynes J. Identification of superficial pressure ulcers. J Wound Care. 2007;16(2): 54-56.

1. National Patient Safety Agency [Internet]. 2010 NHS to adopt zero tolerance to pressure ulcers. [updated 2014 09 24; cited 2007 09 13]. Available from: www. npsa.nhs.uk/nrls

3. National Institute for Health and Clinical Excellence (NICE) [Internet]. The management of urinary incontinence in women. [updated 2015 09 08; cited 2015 04 27]. Available from:http://www.nice.org.uk/

2. National Institute for Health and Care Excellence (NICE) [Internet]. Pressure ulcers: prevention and management of pressure ulcers. Guideline development: 179. [updated 2015 09 08; cited 2014]. Available from: https://www.nice.org.uk/guidance/ cg179

4. European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler, editor. Perth, Australia: Cambridge Media; 2014. 75 p.

7. Defloor T, Schoonhoven L, Fletcher J. Pressure ulcer classification differentiation between pressure ulcers and moisture lesions. EPUAP Review. 2005 6(3);815. [Internet] [updated 2011 02 22]. Available from: http://www.epuap.org/archived_reviews/EPUAP_ Rev6.3.pdf

5. Gray M, Bliss DZ, Ermer-Sulten Kennedy-Evans KL, Palmer MH. Incontinence associated dermatitis: a consensus. Journal of Wound, Ostomy and Continence Nursing. 2007; 34(1):45-54.

8. Defloor T. The effect of a pressure-reducing mattress on turning intervals in geriatric patients at risk of developing pressure ulcers. Int. J. of Nurs. Stud. 2005; 42(1):37–46.

EWMA Journal

2015 vol 15 no 2

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Science, Practice and Education

London · UK

EWMA n london 2015 Submitted to EWMA Journal, Based on presentation given in the free paper session Wound Assessment.

The Fluorescent Diagnosis of Stoma Mucosa

Abstract The aim of this study was to explore the use of fluorescence technology to distinguish and explore different types of stoma mucosal lesions that often appear as healthy under white light. Fluorescence technology is a fast and noninvasive method for imaging tissue in many situations. Fluorescence technology is a very sensitive and specific technique useful in diagnosing small changes that are invisible using white lighting procedures. In stoma nursing care, this technique allows the clinician to view the nature of the mucosa concisely and detect aberrant tissues in detail. However, fluorescence technology is not widely practised. Methods From June 2014 to May 2015, we examined 127 patients with stoma (colostomy or ileostomy) in the Wound and Stoma Clinic. Patients with Urostomy were excluded from this study. In addition to the standard examination by white light, stoma were examined with fluorescence. We used a fluorescent strip that was immersed in 10ml of 0.9% normal saline. The stained saline was applied to the stoma mucosa, then visualised with a microscope under blue light with a 10x objective. The resultant red-green image was evaluated for etiological changes not otherwise visible. Results A variety of diagnoses were determined using the fluorescence technology despite the appearance of viable red stoma under white light. Stoma diagnoses were classified as mucositis, local ulceration, laceration, local bleeder, mucosal tear, and nothing abnormal. Conclusions Although a stoma may appear healthy under the naked eye, minor stoma complications may be overlooked. Fluorescence imaging technology is a user-friendly, non-invasive, and sensitive diagnostic tool for clinicians to examine stoma mucosal lesions and the underlying structures in a more detailed manner. EWMA Journal

2015 vol 15 no 2

HO Chi Wai Nurse Consultant (Wound and Stoma Care), Department of Surgery*

Background An intestinal stoma is the surgical opening through the abdominal wall for faecal or urinary diversion. The stoma is a part of the small or large bowel that can be seen protruding through the abdominal wall. A stoma is commonly indicated in operations for malignant colorectal cancers. Every patient needs to learn stoma and skin care for rehabilitation during recovery, whether the stoma is temporary or permanent in nature. During the rehabilitation period, patients may need to come back for stoma examination and rehabilitative care assessment in the clinic. The risk of complications from stoma formation is life long, but the incidence of complications is highest in the first 5 years of the postoperative period. Complications are generally classified as early or late complications. Early complications include inappropriate location, skin excoriation, leakage, stoma retraction, dehydration, and stoma necrosis. Late complications include parastomal hernia, stomal prolapse, stenosis, and peristomal dermatitis1. The most frequent stoma complications can be classified as stoma-related or peristomal skin disorders. A study by Kalashnikovs et al. showed that among 1,427 patients, 533 patients had 742 stoma complications. Of the 742 stoma complications, 387 were stoma-related and 355 were peristomal skin disorders. The most frequent stoma-related complications were parastomal hernia (25%), mucocutaneous separation (19%), retraction (14%), prolapse (17%), and stenosis (10%). On the other hand, the most frequent peristomal skin disorder was contact dermatitis (89%)2. Complications resulting from a stoma undermine a patient’s ability to manage their own care, prolong adaptation to the stoma, and lead to repeated hospitalisations3. Stoma nurses play an important role in assessing patient risks. The common practises that most stoma nurses focus on during a patient’s visit to the clinic include determining if appliances leak, examining peristomal skin, and evaluating the paras-

Dr Tang Chung Ngai Chief of Service (Surgery), Director of Minimal Access Surgery Training Centre, Deputy Hospital Chief Executive*

Dr Cheung Yui Shan Hester, Consultant Surgeon, Chief of Colorectal Team, Department of Surgery*

Mr Poon Yan Wing Lawrence, Cluster General Manager (Nursing)*

Ms Chan Wai Yan Ada, Advanced Practice Nurse (Wound & Stoma Nurse Specialist), Department of Surgery* *Pamela Youde Nethersole Eastern Hospital, Hong Kong. Correspondence: hocw7777@gmail.com Conflicts of interest: None



tomal condition, as well as physical rehabilitation. Surprisingly, about 65% of patients complain of stoma mucosal bleeding. However, stoma nurse specialists may not recognise the bleeding and may ignore minor symptoms. Minor bleeding from the exposed mucosa is thought to be inevitable, and most likely can be controlled by topical medications or direct pressure. However, stoma bleeding from mucous membranes can be a sign of mucositis 4,5. Mucositis is an inflammatory process of the mucosa due to radiation or chemotherapy, characterised by atrophy of squamous epithelial tissue, vascular damage, and inflammatory infiltration concentrated at the basement region. Epithelial atrophy is followed by ulceration. Sites of mucositis are often covered by a fibrous-inflammatory (pseudomembranous) exudate6.However, stoma mucositis may not be easily detected by the naked eye. Mucositis can occur anywhere along the digestive tract from the mouth to the anus, at different levels4, and ranges from redness to severe ulceration6. Furthermore, inappropriate stoma pouching skills may cause mucosal injury or ulceration. When patients carelessly or incorrectly place the stomahesive base plate, the base plate edge can rub against the stoma and cause an abrasion at the stoma base. The resulting invisible lesion may lead to stomal bleeding or wound lesions. Commonly, diagnostic tools in stoma nursing are rare. The stoma examination is limited to visual inspection and palpation of the stoma wound, and the peristomal and parastomal skin. Sometimes digital stoma examination may be indicated to diagnose a stenosis or to rule out faecal impaction in the general examination. On rare occasions, mini endoscopy with a lubricated test tube may be indicated to examine the level of stoma necrosis in the early postoperative period. Fluorescence is one of the first diagnostic tools allowing nurses to evaluate the stoma mucosa objectively. Stoma bleeding from the mucosa is one of the most frequent symptoms (about 75% in the patient group) among stoma patients in the clinic; however, stoma bleeding is often overlooked. Nurse practitioners do not actively determine why stoma bleeding occurs, because minor stoma bleeding is thought to be inevitable due to exposed friable mucosal tissue. Stoma bleeding is often asymptomatic, because bleeding eventually stops, even when clotting time is prolonged. Nurse practitioners often suggest observation and gentle stoma cleansing for easily controlled stoma bleeding, whereas topical silver nitrate may be indicated for persistent stoma bleeding. However, the causes and preventive measures for stoma bleeding have not been investigated. Stoma mucosa may be prone to bleeding due to exposure to air, inflammation and infection, repeated trauma, tearing, or inappropriate stoma care. Uncontrolled stoma bleeding may result in unnecessary hospital admissions and blood transfusion for massive bleeding. Visual examination with a torch can identify 42

significant bleeders or injuries to the mucosa; however, fluorescence is an objective diagnostic tool to explore different stoma appearances even when a lesion is not visible. Fluorescence not only aids in accurately locating a lesion, but also aids in identification of mucosal ulceration to minimise the risk of stoma perforations. What is Fluorescence? Clinically, fluorescence is commonly used in medicine and surgery. In ophthalmology, foreign bodies in the cornea, lacrimal tests, corneal abrasions or ulcers can be easily detected by fluorescence under a slit lamp. Neoplasms, tumours, and abnormal cells with extravasation can be easily observed in the gastrointestinal tract with fluorescence. In colorectal nursing, the use of fluorescence for stoma mucosa assessment is a new concept. In many studies, fluorescence diagnostics have been described as very sensitive and specific, especially in diagnosing small changes that are invisible under white light endoscopic procedures. Fluorescence is generated by endogenous molecules, such as aromatic amino acids, nicotinamide adenine dinucleotide, or porphyrins2. Fluorescence is a fast and non-invasive method for imaging precancerous and cancerous tissues in many situations. This method has been discussed in a variety of applications in the fields of oncology, dermatology, laryngology, pulmonology, gynaecology, and gastroenterology8. Intestinal stoma assessment is often limited to visual examination and palpation. Endoscopy is occasionally needed to determine the level of stoma necrosis postoperatively and identify the need for emergency revision surgery. Stoma assessment should be performed in good light, and the use of a magnifying glass can be helpful. However, even with the assistance of a magnifying glass, only the surface structure of the mucosa can be seen by visual inspection under white light. Detailed examination by experienced stoma nurses is necessary to detect complications. In the clinical setting, the stoma mucosa may appear healthy, red, and moist, but have invisible signs and symptoms. Fluorescent diagnostics have evolved, and fluorescence is now useful for the diagnosis of mucosal lesions. Aim The aim of this study was to explore the use of fluorescence technology to identify different types of stoma mucosal lesions, which often appear healthy under standard examination with white light. This study is the first advanced nursing innovation to use fluorescence diagnostics technology for a detailed examination of the stoma mucosa. Methods Patient recruitment was performed by a nurse consultant during the stoma patient follow up visit to the â&#x20AC;&#x153;Wound and Stoma Clinicâ&#x20AC;?. The recruited subjects varied from EWMA Journalâ&#x20AC;&#x201A;

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Science, Practice and Education

the early postoperative period to 3 years post-operation. Subjects were recruited for fluorescence examination if they complained of stoma bleeding. The stoma mucosa was examined with a simple light source (standard stoma nursing assessment). For the fluorescence examination, a fluorescent strip was completely immersed in 10ml of 0.9% normal saline. The stained saline was applied to the stoma mucosa. The stoma was visualised using a microscope with a 10X objective and blue light in the dark. The principle of fluorescence diagnostics is based on scanning and analysing the reflected light from the mucosa. Thus, under blue light, a red-green image of the stained stoma

is created. Healthy stoma mucosa appears as a smooth, moist, evenly reflective layer with no staining. On the other hand, an unhealthy or injured stoma appears rugged, dry, leathery and stained under fluorescence. Results From June 2014 till May 2015, we examined 127 patients with stoma (either colostomy or ileostomy) in our wound clinic. Interestingly, we noted several clinical findings that were not easily diagnosed without fluorescent examination of the stoma, but appeared clearly under fluorescence. We identified different types of target diagnoses (Fig. 1a – 1d) 

Figure 1a. The stoma appears as normal mucosa, with a smooth and evenly reflective surface under fluorescence.

Figure 1b. Fluorescence detects a diffuse fibrous/inflammatory mucosal surface identified as mucositis.

Figure 1c. The fluorescence demonstrates a linear tear corresponding to the site of bleeding.

Figure 1d. The fluorescence clearly demonstrates a patchy mucosal abrasion at the stoma base.

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Figure 2. The stoma appears hypertrophic with several bleeders.

Figure 3. The “Plaque Layer” is firstly coated by a topical application of stoma powder.

Figure 4. The “Sealant Plaque” is well formed by the stoma protective spray of the coated layer.

Figure 5. The stoma mucosa is plicated with 3/O Nylon stitches to stop bleeding from the ulcer.

despite the appearance of viable red stoma. In total, we examined 127 stomata using fluorescence, with 153 diagnoses including mucositis (47%), local ulceration (7%), laceration (3%), local bleeder (14%), mucosal tear (13%), and nothing abnormal (16%). Perspectives for Wound Care Wound management of stomal mucositis is focused on the control of bleeding and the treatment of local inflammation. Bleeding often occurs in different areas from the stoma mucosa. Thus, a sealant plaque is applied to protect the whole stoma mucosa. The sealant plaque is formed by a “stoma powder” containing pectin and karaya (Fig. 2-3), coupled with a stoma skin protective spray (Fig. 4). The sealant plaque minimises and stops bleeding from dilated capillaries in the mucosa. Haemostatic outcomes may be markedly and gradually improved by the sealant in a week, as the sealant layers become more firm and thickly coat the stoma mucosa. The challenge is to encourage patience and provide detailed patient education, including an instruction sheet. Patients may return early for plication of stitches (Fig. 5) or local treatment with an adrenaline and silver nitrate stick if the stoma bleeding cannot be easily controlled. Alternatively, for patients who are diagnosed with stoma ulceration or laceration, hydrogel may be applied to the affected lesions after stoma cleansing. Discussion Like any other assessment tool, there are limitations to fluorescence diagnosis of stoma mucosa. The main concern

is vascular integrity, which may not be clearly detected, leading to a misdiagnosis under fluorescence. Vascular compromise of intestinal stomata ranges from mild ischaemia and vasospasm with mucosal sloughing, to infarction and necrosis. Additionally, venous outflow obstruction may lead to significant venous congestion and compromised bowel perfusion, which may also cause necrosis of the stoma. Vascular compromise represents the most serious early complication of stoma creation.7 Failure to trans-illuminate the nonviable mucosa beneath the stoma surface may lead to stoma revision. Vascular compromise below the fascia can also be evaluated with a paediatric proctoscope or flexible endoscope.7 Although fluorescence is a highly sensitive diagnostic tool to identify different mucosal aetiologies in a clinical setting, the limitation is low validity among different stoma nurse practitioners in different centres. The validity may be improved if fluorescence diagnostic tools can be standardised in nursing protocols and included in clinical training. In addition, the lighting hue and the low frequency of the blue light, plus the low power of the hand-held microscope may affect diagnostic accuracy. The technology of fluorescence diagnostic tools, as well as nursing protocols for examining stoma, may advance in the near future. Conclusion Stoma mucosal lesions are often inevitable. Careful consideration of patients’ complaints and a detailed examination of the stoma are of the utmost importance in stoma nurs-

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ing care. Although a stoma may appear healthy under the naked eye, minor stoma complications may exist. Fluorescence diagnostics is a user-friendly, non-invasive, and sensitive diagnostic tool for examining stoma mucosal lesions and underlying structures in a more detailed manner (Fig. 6). Promotion of the advantages of this diagnostic method is necessary, and fluorescent technologies warrant further assessment among clinicians. Based on the fluorescence diagnostics technique, we are going to explore algorithms for diagnosis and treatment of “invisible” stoma mucosal lesions and advanced wound assessment in the near future. n

Acknowledgements: We would like to acknowledge Ada, Chan Wai Yan, who played a critical role in the discovery of this nursing innovation of using fluorescence in stoma diagnosis. We give our unspoken thanks to Dr. Tang Chung Ngai and Dr. Hester Cheung for clinical guidance and supervision, and Mr. Lawrence Poon for administrative support in nursing innovation. This clinical innovation could not be achieved without their hospital management and clinical support..

Fig 6. Stoma examination using the Fluorescence Diagnostics in the Wound and Stoma Clinic.

References 1. Siero A, Siero-Stołtny K, Kawczyk-Krupka A, Latos W, Kwiatek S, Straszak D, Bugaj AM. The role of fluorescence diagnosis in clinical practice. Onco Targets Ther. 2013; 6:977-82. 2. Kalashnikovs I, Achkasov S, Fadeeva S, Vorobiev G. The development and use of algorithms for diagnosing and choosing treatment of ostomy complications: results of a prospective evaluation. Ostomy Wound Management. 2011 Jan; 20-27.

3. Buckle N. The dilemma of choice: introduction to a stoma assessment tool. Gastrointestinal Nursing. 2013; 11(4):26-32. 4. Cancer related mucositis management. Gippsland Oncology Nurses Group Cancer Care Guidelines. 2007; Jun:1-4. 5. Mount Laurel NJ. Stoma complications: Best practice for clinicians. Wound, Ostomy and Continence Nurses Society. 2014:2-25.

6. Prevention and treatment of oral mucositis in cancer patients. Best Practice: Evidence Based Practice Information. Sheets for Health Professionals. 1998; 2(3):1-6. 7. Kann BR. Early Stomal Complications. Clinics in Colon and Rectal Surgery. 2008; 21(1):23-30. 8. Hegyi J, Hegyi V, Ruzicka T, Arenberger P, Berking C. New developments in fluorescence diagnostics. JDDG. 2011; 9:368–72.

6 Recognising innovation and excellence in research and practice ENTER NOW: ENTRIES CLOSE 30 NOVEMBER 2015 Categories include: Innovation Patient Wellbeing Military Wound Care Infection and Biofilm Chronic Oedema and Compression Cost-effective Wound Management

Pressure Care Best Clinical Research Professional Education Wound Assessment and Diagnostics Best Laboratory/Preclinical Research Best Research from a Developing Country

For more information visit www.jwcawards.com JWC Awards2016_210x142.indd 1

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Overcoming Challenges When Introducing eHealth: The MOMENTUM Blueprint and Toolkit Facing challenges Telemedicine involves “the provision of healthcare services at a distance” to “help improve the lives of European citizens, both patients and health professionals, while tackling the challenges to healthcare systems”1. Europe’s healthcare systems are facing four noticeable difficulties: socio-economic demands placed on healthcare as a result of the Union’s changing demographics; growing numbers of people with chronic diseases; increased demands from patients for more quality in the provision of healthcare services; and major shortages in healthcare personnel1. Evidence shows that when telemedicine and innovative information and communication technologies are combined with proper organisation, leadership, and skills, they can provide significant benefits in terms of

Momentum Workshop in Kristiansand with the aim to achieve consensus regarding eHealth success and identify potential barriers.

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improving healthcare services2. In particular, the European Union’s Competitive and Innovation Programme was established to deal with these challenges and encourage the work of large-scale (and public sector) initiatives to scale-up electronically-based initiatives, including eHealth3. MOMENTUM MOMENTUM is an example of an initiative that aimed to create an understanding of the best ways to establish and scale-up telemedicine, telehealth, and telecare, and to explore good practices for mainstreaming telemedicine deployment in daily practice4. It focused on processes and procedures, not on any single form of technology. MOMENTUM concentrated on addressing the needs of “telemedicine doers”, people actively involved in deploying telemedicine around Europe and beyond. These telemedicine doers include leaders in healthcare authorities, hospital managers, public administrators, clinicians, entrepreneurs, and business executives. The MOMENTUM project was conducted with the support of a consortium of 20 organisations, including health professional associations, telemedicine associations, and competence centres. European stakeholder associations participating in the initiative represented healthcare professionals, healthcare organisations, telecare organisations, health insurers, and technology vendors. Participants originated from Denmark, Estonia, France, Germany, Greece, Netherlands, Poland, Spain, Sweden, and the United Kingdom. Israel and Norway also contributed to the project.

Diane Whitehouse, eHealth expert, EHTEL.

Marc Lange, Secretary General, EHTEL. About EHTEL European Health Telematics Association is engaged in supporting the transformation of the health care practice in Europe through eHealth. EHTEL provides 60 corporate members with a platform for information, representation, networking and cooperation. Ehtel offers expert advice and educational services to individuals and organisations working in the field of digital healthcare.

Correspondence: marc.lange@ehtel.eu Conflicts of interest: None



BOX: MOMENTUM’S 18 CRITICAL SUCCESS FACTORS n Ensure that there is cultural readiness for the telemedicine service. n Come to a consensus on the advantages of telemedicine in meeting compelling need(s). n Ensure leadership through a champion. n Involve healthcare professionals and decision-makers. n Put the patient at the centre of the service. n Ensure that the technology is user-friendly. n Pull together the resources needed for deployment. n Address the needs of the primary client(s). n Prepare and implement a business plan. n Prepare and implement a change of management plan. n Assess the conditions under which the service is legal. n Guarantee that the technology has the potential for scale-up. n Identify and apply relevant legal and security guidelines. n Involve legal and security experts. n Ensure that telemedicine doers and users are “privacy aware”. n Ensure that the appropriate information technology infrastructure and eHealth infrastructure are in place. n Put in place the technology and processes needed to monitor the service. n Establish and maintain good procurement processes.

MOMENTUM Guidelines and Toolkit The MOMENTUM project identified 18 critical success factors considered vital for telemedicine deployment (see BOX). These became a set of guidelines called the MOMENTUM Blueprint. To arrive at these results, MOMENTUM analysed three case studies, as well as 25 other telemedicine services. The three case studies all represent established services that support routine care: 1) The Intervention of Treatment of Hypertension Arterial in Catalonia (ITHACA) Programme provides telemedicine services for chronic hypertensive patients in the Catalonian region. It supports the work of local healthcare professionals. 2) The Maccabi Telemedicine Centre for Chronic Patients (MOMA) in Israel has reduced hospitalisations by lowering patients’ depression and thereby helping them attain healthier lifestyles. Maccabi’s doctors and nurses are pleased with its support services. 3) The Norwegian Teledialysis programme, with the remote support of a high-level tertiary care centre, enables dialysis patients to be treated in their own community. Local treatment allows patients, as well

as doctors and nurses, to avoid considerable travel, time, and resource demands. To make the guidelines even more practical and ready for use by doers, the MOMENTUM Toolkit was developed for measuring the extent to which each success factor is present in a particular telemedicine setting. Through the use of this Toolkit, all 18 critical success factors are now featured in an online questionnaire survey, and the survey results are processed electronically. The goal of identifying MOMENTUM’s 18 critical success factors in an organisation’s specific setting is to help doers develop their own telemedicine action plans. By using the MOMENTUM guidelines and building their own action plans, doers can achieve the deployment of telehealth in both routine care and on a large scale. MOMENTUM Toolkit in Practice The MOMENTUM guidelines and Toolkit now also serve as the basis for a series of facilitated workshops. The objective of a workshop is to perform a health assessment of a particular service’s deployment processes. All key stakeholders in a telemedicine setting – such as healthcare services’ chief medical officers, chief executive officers, and chief information officers, plus leaders in specialist medical areas (e.g., chronic diseases) – meet to-

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gether. The workshop is designed to help achieve a consensus regarding their eHealth successes and to identify and overcome any gaps or potential barriers. Together with the relevant health/medical staff, the participants can build an agreed-upon action plan for deploying their telemedicine or eHealth service. Within the project, a MOMENTUM workshop was successfully conducted in the municipality of Kristiansand, Norway, in the context of United4Health5. More recently, MOMENTUM has been used twice at the national level in Scotland. In April 2015, a MOMENTUM workshop was conducted with the country’s Joint Improvement Team to perform a gap analysis or “health check”6. In September 2015, MOMENTUM was used to examine the kinds of business models that can emerge for telemedicine/ integrated care in local Scottish settings in 2016-2020.

In the future, the MOMENTUM team looks forward to applying the MOMENTUM Toolkit in many other settings. The project was completed officially earlier this year, in February 2015. Its project members continue, however, with other engagements and commitments related to MOMENTUM (e.g., the MOMENTUM workshop training described above). n For more information about MOMENTUM about the workshops held, see the MOMENTUM and EHTEL websites, or contact info@telemedicine-momentum.eu.

REFERENCES 1. European Commission. Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee and the Committee of the Regions on telemedicine for the benefit of patients, healthcare systems and society. /* COM/2008/0689 final */. Brussels, Belgium: European Commission; 04.11.2008. 14p. 2. European Commission. Telemedicine for the benefit of patients, healthcare systems and society. Commission Staff Working Paper. SEC(2009)943 final. Brussels, Belgium: European Commission; 06.2009. 30p.

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3. European Commission [Internet]. Competitiveness and Innovation Framework Programme (CIP). Brussels, Belgium: European Commission; [updated 2015 09 03;cited 2011 11 30] Available from: http:// ec.europa.eu/cip/ 4. The Momentum Telemedicine Network [Internet]. European Momentum for Mainstreaming Telemedicine Deployment in Daily Practice. Brussels, Belgium. The European Health Telematics Association ( EHTEL); [updated 2015 09 17 ;cited 2012 02]. Available from: http://telemedicine-momentum.eu/

5. European Commission. [Internet]. United4health. European Commission; [updated 2015 09 17;cited 2015] Available from: http://united4health.eu 6. European Health Telematics Association (EHTEL) [Internet]. Assessment of the Critical Success Factors for Mainstream Adoption of Technology-Enabled Care in Scotland. Scotland: European Health Telematics Association; [updated 2015 07 15;cited 2015 03]. Available from: http://www.jitscotland.org. uk/resource/assessment-of-the-csf-for-mainstreamadoption-of-tec/

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Cochrane Reviews

ABSTRACTS OF RECENT COCHRANE REVIEWS Publication in The Cochrane Library, Issue 2, 2015

Hydrogel dressings for treating pressure ulcers Jo C Dumville, Nikki Stubbs, Samantha J Keogh, Rachel M Walker, Zhenmi Liu Citation: Dumville JC, Stubbs N, Keogh SJ, Walker RM, Liu Z. Hydrogel dressings for treating pressure ulcers. Cochrane Database of Systematic Reviews 2015, Issue 2. Art. No.: CD011226. DOI: 10.1002/14651858. CD011226.pub2. Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

or no dressing in the treatment of pressure ulcers (stage II or above). Data collection and analysis: Two review authors independently performed study selection, the risk of bias assessment, and data extraction. Main results: We included 11 studies (523 participants) in this review. Ten studies had two arms and one had three arms that were all relevant to this review. Three studies compared a hydrogel dressing with a basic wound contact dressing; three studies compared a hydrogel dressing with a hydrocolloid dressing; three studies compared a hydrogel dressing with another hydrogel dressing; one study compared a hydrogel dressing with a foam dressing; one study compared a hydrogel dressing with a dextranomer paste dressing and one study compared a hydrogel dressing with a topical treatment (collagenase). Limited data were available for analyses in this review; we conducted no meta-analyses. Where data were available, there was no evidence of a difference between hydrogel and alternative treatments in terms of complete wound healing or adverse events. One small study reported that hydrogel dressings are, on average, less costly than hydrocolloid dressings, but this estimate was imprecise and its methodology was not clear. All included studies were small, had short follow-up times and were at unclear risk of bias.

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

Authors’ conclusions: It is not clear whether hydrogel dressings are more or less effective than other treatments for healing pressure ulcers or whether different hydrogels have different effects. Most trials in this field are very small and poorly reported, so the risk of bias is unclear.

Plain-language summary Hydrogel dressings for treating pressure ulcers Background: Pressure ulcers, also known as bedsores, decubitus ulcers or pressure injuries, are areas of injury to the skin or underlying tissue, or both. Because pressure ulcers can be painful and may become infected, they adversely affect quality of life. People with spinal cord injuries and people who are immobile or have limited mobility, such as some elderly people and people with acute or chronic conditions, are at risk of develop-

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

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ing pressure ulcers. In 2004, the total annual cost of treating pressure ulcers in the UK was estimated at GBP 1.4 to 2.1 billion, equivalent to 4% of total NHS expenditures. Pressure ulcers have been shown to increase the length of hospital stay and associated hospital costs. Figures from the USA indicate that ‘pressure ulcer’ was noted as a diagnosis in 500,000 hospital stays in 2006; for adults, the total hospital cost of these stays was USD 11 billion. Dressings are one treatment option for pressure ulcers. There are many types of dressings that can be used, and they can vary considerably in cost. Hydrogels are one type of available dressing. Hydrogel dressings contain a large amount of water that keeps ulcers moist rather than letting them become dry. Moist wounds are thought to heal more quickly than dry wounds. In this study, we investigated whether there is any evidence that pressure ulcers treated with hydrogel dressings heal more quickly than those treated with other types of dressings or skin surface (topical) treatments. What we found: In June 2014, we searched for as many relevant medical studies as we could find that had a robust design (randomised controlled trials) comparing hydrogel dressings with other treatments for pressure ulcers. We found 11 studies involving a total of 539 participants. From the results of these studies, we could not tell whether hydrogel wound dressings heal pressure ulcers more quickly or slowly than other types of dressings or topical treatments. Generally, the studies we found were small and the results inconclusive. Some studies lacked information about how they were conducted, and it was difficult to tell whether the results presented were robust. More research of better quality is needed before it can be determined whether hydrogel dressings are better or worse at healing pressure ulcers than other types of dressings or topical treatments.

Publication in The Cochrane Library, Issue 3, 2015

Honey as a topical treatment for wounds Andrew B Jull, Nicky Cullum, Jo C Dumville, Maggie J Westby, Sohan Deshpande, Natalie Walker Citation: Jull AB, Cullum N, Dumville JC, Westby MJ, Deshpande S, Walker N. Honey as a topical treatment for wounds. Cochrane Database of Systematic Reviews 2015, Issue 3. Art. No.: CD005083. DOI: 10.1002/14651858.CD005083.pub4. Copyright © 2014 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Abstract Background: Honey is a viscous, supersaturated sugar solution derived from nectar gathered and modified by the honeybee, Apis mellifera. Honey has been used since ancient times as a remedy in wound care. Evidence from animal studies and some trails in humans has suggested that honey may accelerate wound healing.

Objectives: The objective of this review was to assess the effect of honey compared with alternative wound dressings and topical treatments on the healing of acute (e.g., burns, lacerations) and/or chronic (e.g., venous ulcers) wounds. Search methods: For this update of the review, we searched the Cochrane Wounds Group Specialised Register (searched 15 October 2014); The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2014, Issue 9); Ovid MEDLINE (1946 to October, week 1, 2014); Ovid MEDLINE (InProcess & other Non-Indexed Citations, 13 October 2014); Ovid EMBASE (1974 to 13 October 2014); and EBSCO CINAHL (1982 to 15 October 2014). Selection criteria: Randomised and quasi-randomised trials that evaluated honey as a treatment for a variety of acute or chronic wounds were sought. There were no restrictions in terms of source, date of publication or language. Wound healing was the primary endpoint. Data collection and analysis: Data from eligible trials were extracted and summarised by one review author using a data extraction sheet and independently verified by a second review author. All data were subsequently checked by two additional authors. Main results: We identified 26 eligible trials (total of 3,011 participants). Three trials evaluated the effect of honey on minor acute wounds; 11 trials evaluated honey on burns; 10 trials recruited people with different chronic wounds, including 2 trials in people with venous leg ulcers, 2 trials in people with diabetic foot ulcers and 1 trial each involving infected post-operative wounds, pressure injuries, cutaneous Leishmaniasis and Fournier’s gangrene. Two trials recruited a mixed population of people with acute and chronic wounds. The quality of the evidence varied between different comparisons and outcomes. We downgraded the quality of evidence primarily for risk of bias, imprecision and, in a few cases, inconsistency. There is high-quality evidence (2 trials, n=992) that honey dressings heal partial-thickness burns more quickly than conventional dressings (WMD −4.68 days, 95% confidence interval [CI] −5.09 to −4.28), but it is unclear whether there is a difference in rates of adverse events (very low-quality evidence) or infection (low-quality evidence). There is very low-quality evidence (4 trials, n=332) that burns treated with honey heal more quickly than those treated with silver sulfadiazine (SSD) (WMD −5.12 days, 95% CI −9.51 to −0.73), and there is high-quality evidence (6 trials, n=462) that although there is no difference in overall risk of healing within 6 weeks for honey compared with SSD (relative risk [RR] 1.00, 95% CI 0.98 to 1.02), there is a reduction in the overall risk of adverse events with honey relative to SSD. There is low-quality evidence (1 trial, n=50) that early excision and grafting heals partial- and full-thickness burns more quickly than honey followed by grafting as necessary (WMD 13.6 days, 95% CI 9.82 to 17.38). There is low-quality evidence (2 trials, different comparators, n=140) that honey heals a mixed population of acute and chronic wounds more quickly than SSD or sugar dressings.

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There is moderate-quality evidence (1 trial, n=50) that honey heals infected post-operative wounds more quickly than antiseptic washes followed by gauze and is associated with fewer adverse events (RR of healing 1.69, 95% CI 1.10 to 2.61). There is very low-quality evidence (1 trial, n=40) that honey heals pressure ulcers more quickly than saline soaks (RR 1.41, 95% CI 1.05 to 1.90) and heals Fournier’s gangrene more quickly than Eusol soaks (1 trial, n=30, WMD −8.00 days, 95% CI −6.08 to −9.92 days). The effects of honey relative to comparators are unclear for: venous leg ulcers (2 trials, n= 476, low-quality evidence); minor acute wounds (3 trials, n=213, very low-quality evidence); diabetic foot ulcers (2 trials, n=93, low-quality evidence); Leishmaniasis (1 trial, n=100, low-quality evidence) and mixed chronic wounds (2 trials, n=150, low-quality evidence). Authors’ conclusions: It is difficult to draw overall conclusions regarding the effect of honey as a topical treatment for wounds due to the heterogeneous nature of the patient populations and comparators studied and the general low quality of the evidence. The quality of the evidence was downgraded primarily for risk of bias and imprecision. Honey appears to heal partial-thickness burns more quickly than conventional treatments (which include polyurethane film, paraffin gauze, soframycin-impregnated gauze, sterile linen and leaving the burn exposed) and that it heals infected post-operative wounds more quickly than antiseptics and gauze. Beyond these comparisons, any evidence for differences in the effect of honey versus comparators is of low- or very low-quality and does not form a robust basis for decision making. Plain-language summary: Honey as a topical treatment for acute and chronic wounds We reviewed the evidence concerning the effect of applying honey on the healing of various kinds of wounds. We found 26 studies involving 3,011 people with many different kinds of wounds. Honey was compared with many different treatments in the included studies. The differences in wound types and comparators make it impossible to draw overall conclusions about the effect of honey on wound healing. The evidence for most comparisons is of low or very low quality. This was largely because we thought that problems with the design of some of the studies made their results unreliable, and for many outcomes, there was only a small amount of information available. In some cases, the results of the studies varied considerably. There is high-quality evidence that honey heals partial-thickness burns around 4 to 5 days quicker than conventional dressings. There is moderate-quality evidence that honey is more effective than antiseptic followed by gauze for healing wounds infected after surgical operations. It is not clear whether honey is better or worse than other treatments for burns, mixed acute and chronic wounds, pressure ulcers, Fournier’s gangrene, venous leg ulcers, minor acute wounds, diabetic foot ulcers and Leishmaniasis, as most of the evidence that exists is of low or very low quality. This evidence is current to October 2014.

Publication in The Cochrane Library, Issue 5, 2015

Alginate dressings for treating pressure ulcers Jo C Dumville, Samantha J Keogh, Zhenmi Liu, Nikki Stubbs, Rachel M Walker, Mathew Fortnam Citation: Dumville JC, Keogh SJ, Liu Z, Stubbs N, Walker RM, Fortnam M. Alginate dressings for treating pressure ulcers. Cochrane Database of Systematic Reviews 2015, Issue 5. Art. No.: CD011277. DOI: 10.1002/14651858.CD011277.pub2. Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Abstract Background: Pressure ulcers, also known as bedsores, decubitus ulcers or pressure injuries, are localised areas of injury to the skin or underlying tissue, or both. Dressings are widely used to treat pressure ulcers and there are many options to choose from, including alginate dressings. A clear and current overview of current evidence is required to facilitate decision making regarding dressing use for the treatment of pressure ulcers. This review is part of a suite of Cochrane reviews investigating the use of dressings in the treatment of pressure ulcers. Each review will focus on a particular dressing type. Objectives: To assess the effect of alginate dressings for treating pressure ulcers in any care setting. Search methods: For this review, we searched the following databases in April 2015: the Cochrane Wounds Group 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. There were no restrictions based on language or date of publication. Selection criteria: Published or unpublished randomised controlled trials (RCTs) comparing the effect of alginate with alternative wound dressings or no dressing in the treatment of pressure ulcers (stage II or above). Data collection and analysis: Two review authors independently performed study selection, the risk of bias assessment, and data extraction. Main results: We included six studies (336 participants) in this review; all studies had two arms. The included studies compared alginate dressings with six other interventions that included: hydrocolloid dressings, silver-containing alginate dressings and radiant heat therapy. Each of the six comparisons included just one study, and these had limited participant numbers and short follow-up times. All the evidence was of low or very low quality. Where data were available, there was no evidence of a differ

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ence between alginate dressings and alternative treatments in terms of complete wound healing or adverse events. Authors’ conclusions: We included six studies (336 participants) in this review; all studies had two arms. The included studies compared alginate dressings with six other interventions that included: hydrocolloid dressings, silver-containing alginate dressings and radiant heat therapy. Each of the six comparisons included just one study, and these had limited participant numbers and short follow-up times. All the evidence was of low or very low quality. Where data were available, there was no evidence of a difference between alginate dressings and alternative treatments in terms of complete wound healing or adverse events.

Plain-language summary Alginate dressings for treating pressure ulcers What are pressure ulcers, and who is at risk? Pressure ulcers, also known as bedsores, decubitus ulcers or pressure injuries, are wounds involving the skin and sometimes the tissue that lies underneath. Because pressure ulcers can be painful and may become infected, they adversely affect people’s quality of life. People with spinal cord injuries and those who are immobile or who have limited mobility, such as the elderly and people who are ill as a result of short- or long-term medical conditions, are at risk of developing pressure ulcers. In 2004, the total annual cost of treating pressure ulcers in the UK was estimated at GBP 1.4 to 2.1 billion, equivalent to 4% of total National Health Service expenditures. People with pressure ulcers have longer stays in the hospital, and this increases hospital costs. Figures from the USA for 2006 suggest that 500,000 hospital stays had ‘pressure ulcer’ noted as a diagnosis; the total hospital cost of these stays was USD 11 billion. Why use alginate dressings to treat pressure ulcers? Dressings are one treatment option for pressure ulcers. There are many types of dressings that can be used, and they can vary considerably in cost. Alginate dressings are highly absorbent and so can absorb the fluid (exudate) that is produced by some ulcers. What we found: In June 2014, we searched for as many relevant studies as we could find that had a robust design (randomised controlled trials) comparing alginate dressings with other treatments for pressure ulcers. We found six studies involving a total of 336 participants. In these studies, alginate dressings were compared with hydrocolloid dressing (a type of alginate dressing), dextranomer paste dressing, silver-alginate dressing, silver-zinc sulfadiazine cream and treatment with a radiant heat system. There was no evidence from these studies to suggest that alginate wound dressings are more effective in healing pressure ulcers than other types of interventions, dressings or skin surface (topical) treatments. Generally, the studies we found did not have many participants, and the results were often inconclusive. Some study reports did not provide information about how they were conducted, and therefore, it was difficult to tell whether the results presented were likely to be true. More research of better quality is needed to find out whether alginate dressings are better at healing pressure ulcers than other types of dressings or treatments. This review is part of a suite of reviews investigating dressings for the treatment of pressure ulcers 54

This plain-language summary is up to date as of June 2014.

Negative-pressure wound therapy for treating pressure ulcers Jo C Dumville, Joan Webster, Debra Evans, Lucy Land Citation: Dumville JC, Webster J, Evans D, Land L. Negativepressure wound therapy for treating pressure ulcers. Cochrane Database of Systematic Reviews 2015, Issue 5. Art. No.: CD011334. DOI: 10.1002/14651858.CD011334.pub2. Copyright © 2015 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Abstract Background: Pressure ulcers, also known as bedsores, decubitus ulcers or pressure injuries, are localised areas of injury to the skin or underlying tissue, or both. Negative-pressure wound therapy (NPWT) is a treatment option for pressure ulcers; a clear, current overview of the evidence is required to facilitate decision making regarding its use. Objectives: To assess the effects of NPWT for treating pressure ulcers in any care setting. Search methods: For this review, we searched the following databases in May 2015: the Cochrane Wounds Group 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. There were no restrictions based on language or date of publication. Selection criteria: Published or unpublished randomised controlled trials (RCTs) comparing the effect of NPWT with alternative treatments or different types of NPWT in the treatment of pressure ulcers (stage II or above). Data collection and analysis: Two review authors independently performed study selection, the risk of bias assessment, and data extraction. Main results: The review contains four studies with a total of 149 participants. Two studies compared NPWT with dressings; one study compared NPWT with a series of gel treatments, and one study compared NPWT with ‘moist wound healing’. One study had a 24-week follow-up period, and two had a 6-week follow-up period; the follow-up time was unclear for one study. Three of the four included studies were deemed to be at a high risk of bias from one or more ‘risk of bias’ domains, and all evidence was deemed to be of very low quality. Only one study reported usable primary outcome data (complete wound healing), but this had only 12 participants and there were very few events (only one participant healed in the study). Only minimal useful data were available from the included studies regarding positive outcomes such as wound healing or negative outcomes such as adverse events.

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Authors’ conclusions: There is currently no rigorous RCT evidence available regarding the effect of NPWT compared with alternatives for the treatment of pressure ulcers. High uncertainty remains about the potential benefits or harms, or both, of using this treatment for pressure ulcer management.

Citation: Dumville JC, Owens GL, Crosbie EJ, Peinemann F, Liu Z. Negative-pressure wound therapy for treating surgical wounds healing by secondary intention. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD011278. DOI: 10.1002/14651858.CD011278.pub2

Plain-language summary

Negative-pressure wound therapy for treating pressure ulcers Background: Pressure ulcers, also known as bedsores, decubitus ulcers or pressure injuries, are areas of injury to the skin, the tissue that lies underneath, or both. Because pressure ulcers can be painful and may become infected, they negatively affect people’s quality of life. People with spinal cord injuries and those who are immobile or who have limited mobility are at risk of developing pressure ulcers. In 2004, the total annual cost of treating pressure ulcers in the UK was estimated at GBP 1.4 to 2.1 billion, equivalent to 4% of total National Health Service expenditures. People with pressure ulcers stay longer when admitted to the hospital, and this increases hospital costs. Figures from the USA for 2006 suggest that 500,000 hospital stays had ‘pressure ulcer’ noted as a diagnosis; the total hospital cost of these stays was USD 11 billion. A wide variety of treatment options are available for pressure ulcers, such as dressings, creams, redistribution of pressure and negative-pressure wound therapy (NPWT). NPWT is a technology that is used widely and is promoted for use on wounds, including pressure ulcers. In NPWT, a machine that exerts carefully controlled suction (negative pressure) is attached to a wound dressing that covers the pressure ulcer. This sucks any wound and tissue fluid away from the treated area into a canister. The researchers tried to discover whether NPWT works well as a treatment for pressure ulcers.

Abstract Background: Following surgery, incisions are usually closed by fixing the edges together with sutures (stitches), staples, adhesive glue or clips. This process helps the cut edges heal together and is called ‘healing by primary intention’. However, not all incised wounds are closed in this way; where there is high risk of infection or when there has been significant tissue loss, wounds may be left open to heal from the ‘bottom up’. This delayed healing is known as ‘healing by secondary intention’. Negativepressure wound therapy (NPWT) is one treatment option for surgical wounds that are healing by secondary intention. Objectives: To assess the effects of NPWT on the healing of surgical wounds healing by secondary intention (SWHSI) in any care setting. Search methods: For this review, we searched the following databases in May 2015: the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials; Ovid MEDLINE; Ovid MEDLINE (In-Process & other NonIndexed Citations); Ovid EMBASE; and EBSCO CINAHL. There were no restrictions based on language or date of publication.

What we found: We searched the medical literature up to May 2015 for robust medical studies (randomised controlled studies) comparing NPWT with other treatments for pressure ulcers. We identified four studies involving a total of 149 participants. Two studies compared NPWT with dressings, one compared NPWT with a series of topical treatments and one study compared it with what was described only as ‘moist wound healing’. The trials were small, poorly described, of fairly short or unclear duration and contained little in the way of useful data. As a result of the limited amount of research evidence available, we were not able to draw any conclusions regarding the potential value (or harm) of NPWT as a treatment for pressure ulcers. More research of better quality is needed if this is an important and relevant question for decision makers. This plain-language summary is up to date as of May 2015.

Selection criteria: Published or unpublished randomised controlled trials (RCTs) comparing the effect of NPWT with alternative treatments or different types of NPWT in the treatment of SWHSI. We excluded open abdominal wounds from this review, as they are the subject of a separate Cochrane review that is in draft.

Publication in The Cochrane Library, Issue 6, 2015

Authors’ conclusions: There is currently no rigorous RCT evidence available regarding the clinical effectiveness of NPWT in the treatment of SWHSI as defined in this review. The potential benefits and harms of using this treatment for this wound type remain largely uncertain.

Negative-pressure wound therapy for treating surgical wounds healing by secondary intention Jo C Dumville, Gemma L Owens, Emma J Crosbie, Frank Peinemann, Zhenmi Liu

Data collection and analysis: Two review authors independently performed study selection, the risk of bias assessment and data extraction. Main results: We located two studies (69 participants) for inclusion in this review. One study compared NPWT with an alginate dressing in the treatment of open, infected groin wounds, and one study compared NPWT with a silicone dressing in the treatment of excised pilonidal sinus. The trials reported limited outcome data on healing, adverse events and resource use.

Plain-language summary: Negative-pressure wound therapy for treating surgical wounds healing by secondary intention (open surgical wounds) 

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Background: Following surgery, incisions are usually closed by fixing the edges together with sutures (stitches), staples, adhesive glue or clips. This process helps the cut edges heal together and is called ‘healing by primary intention’. However, not all incised wounds are closed in this way; where there is high risk of infection or when there has been significant tissue loss, wounds may be left open to heal from the ‘bottom up’. Treating open surgical wounds can be challenging, as the wounds can be large, deep, at risk of infection and can produce a lot of liquid (called exudate), which is difficult to manage. Treatment options include wound dressings and the use of negative-pressure wound therapy (NPWT), which is becoming a common treatment for a variety of wound types. NPWT involves the application of a wound dressing to the wound, followed by the attachment of a machine that applies a carefully controlled negative pressure (or vacuum) to the dressing. This sucks any wound and tissue fluid away from the treated area into a canister. NPWT may have a more positive effect on wound healing than alternative treatments. We investigated the evidence for the effectiveness of NPWT as a treatment for surgical wounds healing by secondary intention. What we found: Despite extensive searching for relevant medical studies that might provide evidence about the effectiveness of NPWT for treating surgical wounds healing by secondary intention, we found only two eligible studies. One study compared NPWT with the use of an alginate dressing for surgical wounds healing by secondary intention. The study was small, with only 20 participants, and reported very limited information (data) regarding wound healing, which was the outcome in which we were most interested. Time to healing was shorter for participants in the NPWT group than participants in the alginate dressing group (median of 57 days to healing for the NPWT group compared with 104 days for the alginate dressing group). Although some participants in this very small study needed an amputation or died, there was no difference between treatments in the number of amputations or number of deaths. A second study compared NPWT with a silicone dressing in participants who had undergone surgical removal of a pilonidal sinus; the median time to healing in the NPWT group was 84 days, compared with 93 days in the dressing group. There is currently a lack of data regarding either the benefits or potential harms of NPWT. More research of better quality is needed to determine the effectiveness of NPWT on surgical wounds that are healing by secondary intention. This research was assessed as being up to date as of May 2015.

Devices and dressings to secure peripheral venous catheters to prevent complications Nicole Marsh, Joan Webster, Claire M Rickard, Gabor Mihala Citation: Marsh N, Webster J, Mihala G, Rickard CM. Devices and dressings to secure peripheral venous catheters to prevent complications. Cochrane Database of Systematic Reviews 2015, Issue 6. Art. No.: CD011070. DOI: 10.1002/14651858. CD011070.pub2.

Abstract Background: A peripheral venous catheter (PVC) is typically used for short-term delivery of intravascular fluids and medications. PVCs are essential elements of modern medicine, and their insertion is the most frequent invasive procedure performed in hospitals. However, PVCs often fail before intravenous treatment is completed; this can occur because the device is not adequately attached to the skin, which may allow the PVC to fall out and lead to complications such as phlebitis (irritation or inflammation of the vein wall), infiltration (fluid leaking into surrounding tissues) or occlusion (blockage). An inadequately secured PVC also increases the risk of catheter-related bloodstream infection, as the piston-like action (moving back and forth in the vein) of the catheter can allow migration of organisms along the catheter and into the bloodstream. Despite the many dressings and securement devices available, the impact of different securement techniques for increasing PVC dwell time remains unclear; there is a need to provide guidance for clinicians by systematically reviewing current studies. Objectives: To assess the effects of PVC dressings and securement devices on the incidence of PVC failure. Search methods: We searched the following electronic databases to identify reports of relevant randomised controlled trials (RCTs): the Cochrane Wounds Group Register (searched 08 April 2015): The Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 3), Ovid MEDLINE (1946 to 07 March 2015); Ovid MEDLINE (In-Process & other Non-Indexed Citations, 07 March 2015); Ovid EMBASE (1974 to 07 March 2015); and EBSCO CINAHL (1982 to 08 March 2015). Selection criteria: RCTs or cluster RCTs comparing different dressings or securement devices for the stabilisation of PVCs. Cross-over trials were ineligible for inclusion unless data for the first treatment period could be obtained. Data collection and analysis: Two review authors independently selected studies, assessed trial quality, and extracted data. We contacted study authors for missing information. We used standard methodological procedures expected by Cochrane. Main results: We included six RCTs (1,539 participants) in this review. Trial size ranged from 50 to 703 participants. The six included trials made four comparisons, namely: transparent dressing versus gauze; bordered transparent dressing versus a securement device; bordered transparent dressing versus tape; and transparent dressing versus sticking plaster. There is very low-quality evidence of fewer catheter dislodgements or accidental removals with transparent dressings compared with gauze (two studies, 278 participants, relative risk [RR] 0.40; 95% confidence interval [CI] 0.17 to 0.92, P = 0.03). The relative effects of transparent dressings and gauze on phlebitis (RR 0.89; 95% CI 0.47 to 1.68) and infiltration (RR 0.80; 95% CI 0.48 to 1.33) are unclear. The relative effect on PVC failure of a bordered transparent dressing and a securement device was assessed in

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only one small study, and the results were unclear. There was very low-quality evidence from the same single study indicating less frequent dislodgement or accidental catheter removal with bordered transparent dressings compared with securement devices (RR 0.14, 95% CI 0.03 to 0.63), but more phlebitis was observed with bordered dressings (RR 8.11, 95% CI 1.03 to 64.02) (very low-quality evidence). A small, single study compared bordered transparent dressings with tape and found very low-quality evidence of more PVC failures with the bordered dressing (RR 1.84, 95% CI 1.08 to 3.11); however, the relative effect on dislodgement was not clear (very low-quality evidence). The relative effect of transparent dressings and sticking plaster were compared in one small study, but the results were unclear. More high-quality RCTs are required to determine the relative effects of alternative PVC dressings and securement devices. Authors’ conclusions: It is not clear whether any one dressing or securement device is better than any other in securing PVCs. There is a need for further independent, high-quality trials evaluating the many traditional as well as newer, high-use products. Given the large cost differences between various dressings and securement devices, future trials should include a robust costeffectiveness analysis.

Plain-language summary Effectiveness of dressings and other devices that are used to keep a peripheral venous catheter in place Background: Most people admitted to an acute/emergency hospital ward require the insertion of a peripheral venous catheter/ cannula (PVC), often known as a ‘drip’ or ‘IV’. A PVC is a flexible, hollow, plastic tube that is inserted into a peripheral vein, most commonly in the hand or lower arm. Up to half of all PVCs stop working before treatment has finished, necessitating the insertion of a new one. This is uncomfortable for the patient and costly to the healthcare system. One of the reasons PVCs fail is that the products used to hold them in place are not fully effective and allow the PVC to move around. This movement may cause redness, inflammation and even blood infections. The PVC can become blocked, or its contents may leak into the surrounding tissues. PVCs may even fall out as a consequence of movement. The function of PVC dressings and/or securement devices is to keep the PVC in the vein and to cover the insertion site so that it is kept dry and clean and protected from infection.

3. A bordered transparent dressing compared with non-sterile medical tape; and 4. A plain transparent film dressing compared with sticking plaster. The participants in the studies were both adults and children on medical and surgical wards. There were no studies based in emergency departments. Key results: Two studies provided very low-quality evidence that PVCs are less likely to fail when a transparent dressing is used rather than gauze. Other positive outcomes favouring one dressing over another were based on the results of very low-quality, single studies. Overall, there is a lack of high-quality evidence, resulting in continued uncertainty regarding the best method of securing a PVC. More high-quality research is needed in this area. Quality of the evidence: We assessed a number of quality indicators regarding the methods used in each study and graded the overall quality of studies as very low. Each study had a high or unclear risk of bias for some of the quality indicators. For example, the clinical staff responsible for assessing participants’ outcomes likely knew the treatment group to which each person belonged, as the securement methods for PVCs looked different. There were only a limited number of studies available for consideration in this review, and they did not investigate some securement products that are in common use. n

Review question: We reviewed available evidence to determine the effect that different PVC dressings and securement devices have on the PVC failure rate. Study characteristics: We searched the medical literature for studies that compared different types of products used to keep PVCs in place. We found six studies (involving 1,539 participants) comparing four different ways of securing PVCs. These included: 1. A plain transparent film dressing compared with a gauze (woven fabric) dressing; 2. A bordered transparent dressing (clear transparent window with a reinforced fabric edge) compared with a securement device (a device that has anchor points or clips that hold the PVC in place over a strong adhesive base pad on the skin) used in conjunction with a transparent film dressing;

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Book Reviews

Book Review Fast facts about Pressure Ulcer Care for Nurses: How to prevent, detect, and resolve them in a nutshell. Mary Ellen Dziedzic, Springer Publishing Company, New York, 2014.

Georgina Gethin PhD, PG Dip Wound Healing, Senior Lecturer School of Nursing and Midwifery, National University of Ireland, Galway, Ireland.

Correspondence: Georgina.gethin@ nuigalway.ie Conflicts of interest: None

The sheer volume of new publications on strategies for the prevention, detection and management of pressure ulcers makes it difficult for the practicing nurse to keep up to date with the latest research in this field. This publication Fast facts about Pressure Ulcer Care for Nurses: How to prevent, detect, and resolve them in a nutshell, aims to address this through assimilating the most up to date resources and research in this field in one pocket size book. The title of the book is quite ambitious, as it aims to synthesise the latest evidence into fast facts and easy to remember pieces. It has achieved this well throughout. The introduction sets the scene as the author recounts her experience of looking after a young man who developed a pressure ulcer following surgery. The case report acts as a warning, and a reminder that anyone can get a pressure ulcer if the conditions are right. Indeed the use of case studies is replicated throughout the book to emphasise points or to explain strategies. Each chapter has clearly stated learning outcomes, thus making it very useful for revision and teaching purposes. The writing style is clear, with a logical flow to the layout of the chapters, making it particularly suited to readers for whom English is not their first language. In a novel approach, Florence Nightingale’s concepts of health have been used in chapter 4 (Back to basics in skin care and assessment) as a framework to describe how to apply interventions to maintain health. This is a key chapter in the book, as it describes skin assessment techniques including: inspection, palpation and smell; managing pressure points, assessing the obese patient and outpatients. The issue of ‘consistency of patient assessment’ and skin inspection in order to detect subtle changes in skin condition is reiterated throughout, the emphasis being on visual inspection for which there is no substitute.

The author recognises the importance of team approaches to prevention strategies, and recounts her own experiences of initiating changes in practice with a subsequent reduction in the incidence of pressure ulcers of 75%, with the incidence of stage 111 and 1V decreasing to zero. The author further acknowledges that pressure ulcer prevention is a patient safety issue and discusses the topic of creating an environment of ‘skin safety’. This is a new term which conveys the importance that must be placed on prevention of pressure ulcers as a patient safety issue, just as much as medication errors and falls prevention. A full chapter is dedicated to the issue of safety and it is this chapter that helps to make this book unique, but also further underscores the importance of whole systems and multidisciplinary approaches to patient care. While the use of photographs helps distinguish different stages of pressure ulcers, it is, perhaps, a limitation that greater use was not made of photographs or illustrations to break up the text. That said, each chapter has key pieces of information in text boxes to hold the reader’s attention and emphasise key points. The appendices provide a wealth of resources on support surfaces, choosing a dressing, information hot-lines and E-resources. This book would be suitable for allied health professionals and, indeed, care assistants and not solely nurses. I would recommend this for any practicing nurse in any care setting as an up to date resource in helping to deliver best practice in the management of pressure ulcers. n

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Guidance Document on eHealth in Wound Care

eHealth in Wound Care - From conception to implementation is a new document aiming to support the wound care professionalsâ&#x20AC;&#x2122; interest and engagement in the development of eHealth solutions to benefi t patients, health care professionals, and health care systems. The document includes an introduction to terminology, a method for evaluation of eHealth solutions, an overviewof available evidence, a discussion about the barriers and facilitators for the use of eHealth in wound care, and a road map for implementation in clinical practice. The document is a joint publication by EWMA and the Australian Wound Management Association, developed in connection with the United4health project, www.united4health.eu. It was published in April 2015 as an online supplement of the Journal of Wound Care and can be downloaded free of charge at www.ewma.org

The project United4Health is partially funded under the ICT Policy Support Programme (ICT PSP) as part of the Competitiveness and Innovation Framework Programme by the European Commission

EWMA CONFERENCE 2015 IN LONDON, UK

José Verdú Soriano EWMA Scientific Recorder

Correspondence: ewma@ewma.org

Exhibition area.

The 25th Conference of the European Wound Management Association (EWMA) was held in London, UK, on 13-15 May 2015. The conference was organised in cooperation with the Tissue Viability Society (TVS) and had the highest number of attendees in the history of the association with almost 4200 participants.

he conference provided an energetic environment in which colleagues within the field of wound man-agement came together from all over the world for more than 900 high-level scientific presentations and great networking opportunities. Representatives from 78 countries attended, including many European key opinion leaders and industrial senior executives. A variety of sessions and conference workshops provided participants with opportunities for interactive and hands-on learning experiences.

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 all the speakers, presenters, and organisers who actively participated in the sessions. Conference Theme The conference theme of EWMA 2015, Wound Care – Shaping the Future. A Patient, Professional, Provider and Payer Perspective reflected the belief that interdis-

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ciplinary teamwork and collaboration between patients, professionals and policy makers is essential for facilitating good practice and providing continuity of care. This will be even more important in the future as health care systems throughout Europe have to cope with increasing pressure both to demonstrate efficient and cost-effective use of resources and to optimise wound care with the help of innovative procedures and practices. It is imperative that all these perspectives are considered if we are to realise the goal of successful wound management. This theme was addressed in the Opening Plenary sessions, where representatives of each perspective debated and discussed the challenges for the future of wound care. The session was very popular and had more than 1200 participants.

The sessions The conference included many interesting sessions prepared by EWMA and TVS 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 palliative wound care, geriatrics, leg ulcer diagnosis and treatment, eHealth in wound care, tissue engineering and paediatric wound care. A number of workshops offered participants both theoretical and hands-on experiences with maggot therapy, debridement, podiatry, Cochrane reviews and biofilm. 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 Tissue Repair Society (ETRS), International Compression Club (ICC), International Lymphoedema Framework (ILF), International Wound Infection Institute (IWII), Leg Ulcer Forum (LUF) and World Alliance for Wound & Lymphedema Care (WAWLC). In addition, EWMA was happy to welcome our international partner association from the United States, the Association for the Advancement of Wound Care (AAWC), to present a session on A Global View of Wound Care: Past, Present and Future. The scientific programme would not have been complete without the many submitted abstracts – more than 800. These contributed to 22 free paper sessions and more than 500 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 www.ewma2015.org. 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. Symposia A number of symposia were also included in the programme: EWMA symposium: eHealth in wound care – from the perspective of the health care professionals examined the state of eHealth services already in use in wound care, as well as expectations for future health care 

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Participants viewing e-posters.

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 posters: First Time International Presenter Award 2015 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: Ho Chi Wai, Hong Kong Abstract No. 141: The 1st pioneer local report: Fluorescence diagnostics of stomal mucosa by nurse Free paper session: Wound Assessment

n EP092: Isabel Vieira Santos, Brazil:

Validity and reliability of the evaluation method of wounds through tissue percentage

n EP154: Chun Yang, USA: Hair follicle

transplantation as a novel approach to healing chronic wounds in the Porcine model

n EP186: Vojtech Pavlik, Czech Republic:

Povidon-Iodine exerts only superficial antimicrobial effect in porcine skin wound biofilm model

n EP255: Pauline Wilson, Ireland:

Evaluation of a skin care product in the treatment of Xerosis in patients with diabetes n EP259: Elisabeth Iacopi, Italy: Direct

revascularization according to the Angiosome Model (AM) prevents major amputations and increases life expectancy in patients with Critical Limb Ischemia (CLI) and Diabetic Foot Ulceration (DFU)

systems. Participants debated the need for organisational changes and shifts in the roles and responsibilities of patients and healthcare professionals to facilitate eHealth implementation and delivery of eHealth-supported care. The symposium took place Friday 15th May. 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 insufficient implementation of basic policies to promote rational use. Infection is one of the most frequent complications in wound management; consequently, antimicrobial agents are readily used in the treatment of wounds. Alarmingly, approximately 50% of antibiotic use, in both outpatient and inpatient settings, is inappropriate. Specific for wound management is the use of topical antimicrobial agents, for which misuse is believed to be as serious as the misuse of orally or intravenously administered antibiotics. EWMA is dedicated to facing this challenge. To strengthen the knowledge base and educational EWMA Journalâ&#x20AC;&#x201A;

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The Opening Ceremony of EWMA 2015.

power of the meeting, EWMA joined forces with the British Society for Antimicrobial Chemotherapy in the symposium held Thursday 14th May. The Nursing in the Community: Challenge your Practice: Wound Management and dressing selection in the community gave accessible, practical guidance on understanding, assessing, and managing wounds. Attendees gained a clear working knowledge of what needs to be done in community care to achieve better outcomes. The symposium took place Thursday 14th May Furthermore the International Conference of the Veterinary Wound Healing Association was held during EWMA 2015. 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 and Friday during EWMA 2015. Exhibition When speaking of the great success of EWMA 2015 conference, it is also important to stress the large contribution of industry. The exhibition hall hosted 131 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 2015. Networking EWMA 2015 was undoubtedly an enjoyable and informative experience for all participants. EWMA’s highest priorities are bringing together the European wound healing community and, perhaps most importantly, creating and 

Conference dinner at the Guoman Tower Hotel. EWMA Journal

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View from the Guoman Tower Hotel.

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strengthening links among national associations that strive to raise the profile of wound management within their respective countries. In addition to the scientific part of the conference, social events, including a pre-registration reception celebrating the 35th anniversary of the TVS and the main Conference Dinner held 14th May at the Guoman Tower Hotel just next to Tower Bridge, provided great opportunities for informal networking and simply having a great time with other conference attendees. 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 Bremen for EWMA 2016, 11-13 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. The conference theme will be PATIENTS. WOUNDS. RIGHTS. The patient is more than a person with a wound. He or she is a human being with needs and rights! According to the United Nations Universal Declaration of Human Rights, everyone has the right to health, implying that

prevention and treatment of non-healing wounds must be available to everyone. Thus, securing patients’ quality of life is a political responsibility as well as a clinical one. Patients’ access to wound care requires the collaboration of patients, professionals, and policy makers. Care access for all is a cornerstone of good practice in wound management and a fundamental objective of the interdisciplinary team approach. The 26th Conference of the European Wound Management Association is being organised in cooperation with the Initiative Chronische Wunden e.V. (ICW) and the collaboration of German-speaking wound associations (WundD·A·CH). Thank you for joining us for EWMA 2015 in London; please come join us for the next conference in Bremen, Germany! n

See you 11-13 May 2016 for EWMA 2016! www.ewma2016.org

Submit your paper to EWMA Journal 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

Published by EUROPEAN WOUND MANAGEMENT ASSOCIATION

Editorial Board Sue Bale, UK, Editor Severin Läuchli, Switzerland Georgina Gethin, Ireland Martin Koschnick, Germany

Rytis Rimdeika, Lithuania Salla Seppänen, Finland Hubert Vuagnat, Switzerland

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3 EPUAP rd

FOCUS MEETING The Role of Skin and Tissue Maturation and Aging in Pressure Ulcer Research and Practice 4 – 6 April 2016 | Berlin, Germany www.focusmeeting2016.org

Organised by the European Pressure Ulcer Advisory Panel

in partnership with Charité-Universitätsmedizin Berlin and Leeds University

Registration will open October 2015 · VENUE: Kaiserin Friedrich-Haus CONTACT: EPUAP Business Office, office@epuap.org, Tel: +420 251 019 379; Contact person: Adina Markova

E-Learning

about Pressure Ulcers and Incontinence - Associated Dermatitis (IAD)

What is new?

• Four modules: • Introduction to pressure ulcers • Introduction to Incontinence- Associated Dermatitis (IAD) • Pressure ulcer classification • Differentiation between pressure ulcers and IAD • Assessment modules and certificate • Separate assessment module including cases and photographs • Simpler navigation and content separation

EPUAP members have free access to PUCLAS3! More information available at www.epuap.org and www.PuClas3.UGent.be

EWMA

Cooperating Organisations activities during the EWMA 2015 London conference As in previous years, the annual European Wound Management Association (EWMA) Conference hosted two events for representatives of the cooperating organisations of EWMA: The Cooperating Organisations Board Meeting and the Cooperating Organisations Workshop. Through these meetings, EWMA aims to support sharing of experiences and international collaboration among representatives from the national wound management associations. The Cooperating Organisations Board meeting It was my pleasure to welcome a total of 45 participants to this year’s traditional annual Cooperating Organisations Board meeting. Thirty-five participants were members of the Cooperating Organisations Board, or were appointed substitutes. Ten participants were EWMA Council representatives, invited speakers, or observing visitors. Election of Cooperating Organisation representative to the EWMA Council The two candidates competing for election to the one vacant EWMA Council seat were Mrs. Barbara den Boogert-Ruimschotel (V&VN, Netherlands) and Dr. Selcuk Baktiroglu (WMAT, Turkey). After an initial tie vote, a second vote resulted in the election of Barbara den BoogertRuimschotel as the new EWMA Council member. I welcome Barbara back to the EWMA Council (she previously represented the V&VN during the 2010–2013 period). Ms. Ann-Mari Fagerdahl stepped down as Cooperating Organisations elected member of the EWMA Council. Her work is acknowledged in the Appreciations section of this EWMA Journal issue. Discussions about the EWMA focus on areas in eHealth and wound care research Ann-Mari Fagerdahl presented a status update on EWMA activities carried out since the 2014 meeting.

Jan Apelqvist revealed some of the activities the EWMA is planning for the future. During the same presentation, he announced that the EWMA Council plans to introduce a new initiative that will be arranged in collaboration with the cooperating organisations. Wound academies on various focus topics will be held in conjunction with the national meetings of selected cooperating organisations. The Council plans to begin this new initiative in autumn, 2016.

Jan Apelquist Previous Chair, Cooperating Organisations Board

Two recently published EWMA focus documents were presented and discussed during the meeting: n The newly published EWMA document, “eHealth in wound care: From conception to implementation”, presented by former EWMA President, Professor Zena Moore. n The document, “EWMA study recommen dations for clinical investigations in leg ulcers and wound care”, published in 2014, was presented by Jan Apelqvist. Both documents are available for free download at www.ewma.org. Round table discussions were conducted that focused on the topics of these two presentations. The discussions were based on a framework of questions for each topic: eHealth in wound care: Based on wound management experiences in your country, please discuss:

Correspondence: ewma@ewma.org

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n the value of eHealth services in wound care with regards to supporting high quality and cost-effective care. n the barriers and facilitators for implementation of eHealth services in wound care.

Recommendations for clinical investigations of leg ulcers and wound care: Based on wound management experiences in your country, please discuss: n how and by whom are research activities generally performed? n the size of the research community. n the challenges related to study design and ethical approval. These debate sessions were characterised by engaged and lively group discussions and provided many constructive comments and ideas. Economic and patient-related issues were raised in the discussions about eHealth and wound care. From an economic perspective, the potential to improve the costeffectiveness of wound management through standardization was emphasised. However, the participants agreed that the lack of interoperability between systems presents a problem that must be solved before efficient eHealthsupported wound management can be achieved. From a patient perspective, it was emphasised that eHealth allows for enhanced involvement of the patient and the family, which presents significant opportunities. However, discussion participants were also concerned that eHealth and distant monitoring removes the opportunity to evaluate some aspects of wound healing status and patient well-being. The potential for establishment of databases via telemedicine or telehealth services was also discussed. The barriers mentioned were primarily concerned with privacy issues, which vary from country-to-country. During the debate session that focused on research and study recommendations, the participants agreed that a lack of research funds is a common problem. The participants highlighted the importance of distinguishing between the different conditions applied to commercial and noncommercial funding. The ownership of the idea and the research process should always be clarified, particularly when the research activities are industry-funded. Also emphasised was that most countries have a small research community, and include â&#x2030;¤5â&#x20AC;&#x201C;10% of the nurses and physicians who provide wound care. Cooperating Organisations Workshop Prior to the conference, the cooperating organisations were invited to submit abstracts describing their recent activities. Four of the abstracts were selected to be presented

during the Cooperating Organisations Workshop held at the EWMA 2016 Conference. The objective of this workshop was to give the cooperating organisations an opportunity to showcase their national initiatives and lessons learned, so that other societies may be inspired by, and benefit from, the information. The presenting organisations and their selected topics were: n Association for Wound Management in Bosnia & Herzegovina (URuBiH). This presentation by the Balkan Wound Management Association included the goals, objectives, and prospects for the founding of this new association. n Hellenic

Society of Wound Healing (HSWH): The problem of uninsured patients with wounds in Greece.

The presentation addressed an important Greek health care system issue. The rate of unemployment has been rapidly increasing as a result of the national financial crisis. Many of the unemployed are not covered by medical insurance. Many Greek people are unable to pay for sufficient health care, or even a medical examination. This major effect of the financial crisis presents enormous problems for the Greek health care system.

n Chronic

Wounds Initiative (ICW, Germany): Perspectives in Education: New course models.

The abstract presented by the ICW aimed to discuss the need to ensure increased quality of the wound healing courses offered in Europe. In the clinical setting, wound healing is mostly managed by nurses who have attended only a basic knowledge wound healing course. To ensure continued professional development among experts, the ICW aims to enhance the medical and administrative skills of doctors and experienced nurses involved in wound care management.

n Wound Management Association of Ireland (WMAI): RISE for the prevention of pressure ulcers.

The WMAI presented four basic principles that they aim to emphasise within the wound care field, particularly for informal carers: Reposition, Inspect, Skin Care, Eat well (RISE). A RISE leaflet has been developed as a project output that will be used to promote pressure ulcer prevention awareness.

The abstracts and the presentations are available at the EWMA website for download. EWMA Journalâ&#x20AC;&#x201A;

2015 vol 15 no 2

13th Scientific Meeting of the

Diabetic Foot Study Group of the EASD

Hubert Vuagnat, current EWMA Council member, welcomes Barbara Den Boogert-Ruimschotel back to the EWMA Council.

9-11 September 2016 Stuttgart, Germany

Conference theme: Advancement of knowledge on all aspects of diabetic foot care

Many Cooperating Organisations Board members were present at the meeting which opened up for good and constructive discussions.

Main subjects during conference:  Epidemiology  Basic and clinical science  Diagnostics  Classification  Foot clinics  Biomechanics, Osteoarthropathy  Orthopaedic surgery  Infection  Revascularisation

Each debate group presented their discussed topics and gave input to further developments within the field.

I encourage any cooperating organisation that wishes to share lessons learned with fellow cooperating organisations to submit an abstract for the 2017 Cooperating Organisations Workshop. The abstract deadline is 15 January 2016.



Uraemia



Wound healing/outcome

Acknowledgements: My thanks to all Board meeting members and workshop participants for their input and contributions to the continued collaboration between the EWMA cooperating organisations. I also wish my successor, Immediate Past President Mrs. Salla Seppänen, the best of luck in her new position as Chair.

EWMA Journal

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2015 vol 15 no 2 DFSG_ann.indd 1

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EWMA

FOCUS & OBJECTIVES OF THE EWMA PRESIDENCY 2015-2017 PATIENTS’ RIGHTS AND COLLABORATION ACROSS DISCIPLINES AND BORDERS

Interview with Severin Läuchli, EWMA President By Søren Riisgaard Mortensen, EWMA Secretariat

When a new association president accepts the task of leading the organisation, it provides the opportunity to reflect on what has been achieved, as well as the future goals of the organisation. EWMA’s new president, Severin Läuchli, has outlined his objectives for the 2015-2017 presidency, that build on foundations established by previous EWMA Presidents. When setting the course for the future, he emphasises the importance of acknowledging and respecting the complexities of the objectives and programs that have been developed and refined over many years. “EWMA’s objectives have set the path for the work of the organisation and have been honed over many years. A broad scope of activities are carried out by the EWMA Council and active members of the EWMA committees and boards in order to meet these objectives. It is my goal and obligation to all stakeholders to build on this and strengthen EWMA’s role as a leading organisation in wound care,” says Severin Läuchli. He believes that interdisciplinary collaboration is essential to achieve high-quality wound care, and he aims for the presentation of consistent, high-quality scientific content at EWMA Conferences and at other EWMA activities. He will further develop these focus areas during his EWMA presidency. The complete list of focus areas for the 2015-2017 EWMA presidency can be found on the EWMA webpage (www.ewma.org). One of the focus areas he wishes to continue to strengthen, is the effort to ensure international collaboration and support modern wound care in limited resource settings. Severin Läuchli elaborates: “EWMA holds a central position in wound care and this gives a responsibility to manage it

EWMA Journal

2015 vol 15 no 2

Newly elected EWMA president Severin Läuchli at the EWMA 2015 conference closing ceremoni.

well. EWMA’s position provides an excellent basis for sharing knowledge and experiences, to the benefit of individual health care professionals, patients, and organisations in European countries, as well as in the rest of the world, via our extended collaboration with organisations operating outside Europe.” Severin Läuchli also stresses the importance of continuing the primary focus of his predecessor, Salla Seppänen: Putting the patient first in all activities. In his objectives, Severin Läuchli emphasises the continued need to promote a holistic approach to treating chronic wounds and to promote patients’ rights for prevention and modern wound care in healthcare systems across Europe: “To me, the patient plays the most important role in wound care and should always be the centre of all our activities. I see a lot of skin conditions in the Department of Dermatology at the University Hospital in Zürich and it is easy to forget what is behind a chronic wound: the person. We all need to constantly remind ourselves and our surroundings of the fact that every person is different and has different requirements. People come from different backgrounds and thus, have different factors influencing the treatment. Salla Seppänen 

EWMA

, immediate past president of EWMA, started the EWMA Patient Panel initiative to address these issues, and I personally think this is the right way to go. I see it as a major objective to continue this focus in EWMA and in wound care in general. At our next conference, we will also centre some activities around the fact that patients have rights.” Severin Läuchli began his term as EWMA President at the Annual General Meeting during the EWMA Conference in London, May 2015. He will direct EWMA for the next two years. During his term, EWMA’s 25th anniversary will be commemorated with different activities during 2016, including the EWMA Conference in Bremen, Germany. This

milestone event will provide a specific occasion to review the current state of wound care management and to address new challenges. Asked about his obligations as EWMA President for the next three years, he says: “I look forward to an exciting term in office where I, together with the EWMA Council, will engage personally and rely on the collaboration with EWMA members and other stakeholders to work towards the continuous improvement of healthcare services offered to patients with wounds,” Visit www.ewma.org for the complete list of the focus areas for the 2015-2017 EWMA presidency. n

EWMA celebrates 25th Anniversary

Throughout the year 2016, EWMA will celebrate its 25th Anniversary. A number of different events and activities will highlight important milestones in the history of EWMA and wound management in general. Many of these events and activities will take place during the EWMA 2016 Conference in Bremen, Germany, 11-13 May 2016. We hope that EWMA members, collaborating partners and other stakeholders will join us and use this opportunity to share their experiences and views on the past as well as the future of wound management. More information will follow on ewma.org and www.ewma2016.org

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2015 vol 15 no 2

yo Bo ur ok NO pl W ace !

20th & 21st April 2016 Cardiff City Hall www.tvs.org.uk

Tissue Viability Society

TVS 2016

The Conference Topical, current, thought provoking... Join The Tissue Viability Society for what promises to be an exciting two days at Cardiff City Hall for TVS 2016. We have a brilliant line up of speakers and sessions for you including lectures, discussions, workshops and our outstanding free paper and poster presentations. You can also join us for dinner on the 20th April at the beautiful Cardiff National Museum. Look out for more information at

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To find out more: T: 0845 527 6651 E: tvs@pinkatpink.com W: www.tvs.org.uk

Appreciations

leaving Council members by Salla Seppännen and Severin Läuchli

Jan Apelqvist has done excellent work for EWMA during his time in Council from 2008-2015. As the EWMA President from 2011-2013, he developed activities geared toward influencing EU policy, specifically advocating for more effective wound care and stressing the need for the transfer of knowledge between different health care disciplines and medical specialties. Jan’s involvement in EWMA has contributed to the innovative atmosphere that currently characterizes Council meetings, and he is directly responsible for the increased scientific impact of EWMA as a whole. Jan’s ability to analyse and think critically about how current activities will shape the future, in different contexts, has especially been key. Wisdom and discretion, essential management skills that cannot be learned, are a natural part of his personality. We will all miss Jan in Council meetings, but we also know that he is willing to provide his time and knowledge to EWMA, and he will continue his commitment to work for more cost-effective wound care. We are most pleased that he will continue as chair of the EWMA Patient Outcome Group and as an EWMA representative on the board of the Association for the Advancement of Wound Care (AAWC) for a period of time.

Ann-Mari Fagerdahl, elected by the Cooperating Organisations for the period 2012–2015, has been a valuable addition to the EWMA council. As a PhD student and nurse with a scientific background, she provided important input on many EWMA projects and activities. For example, she was one of the major proponents of the upcoming EWMA document on “Health Related Quality of Life – the Patient’s Perspective,” and will continue a member of the working group dedicated to the development of this document during 2015-2017. Additionally, Ann-Mari successfully represented the EWMA on short notice at the 2014 Australian Wound Management Association (AWMA) conference in Brisbane. We will miss Ann-Mari’s lively, warm-hearted personality and positive energy in the EWMA Council.

Dubravko Huljev has been a member of the EWMA Council from 2010-2015, and he served as Honorary Secretary from 2012-2015. His relaxed but determined manner of conducting meetings has given Council meetings an encouraging atmosphere, making it easy for Council members to express personal opinions and share ideas. Additionally, Dubravko has many years of experience and a great depth of knowledge in wound care, which he is willing to share respectfully, acknowledging the opinions and views of others. We have come to know Dubravko as a kind and supportive person, who is loved by his colleagues and patients alike. Dubravko will continue his work in EWMA as a member of the Antimicrobial Committee, and will hopefully continue the development of international wound care practices.

Gerrolt Jukema, Council member from 2009-2015, was one of the key personalities in maintaining and strengthening the quality of EWMA meetings and other activities. A trauma surgeon with a strong scientific background, Gerrolt has an impressive publication list. Gerrolt was elected as scientific recorder for 2011-2014, and during those three years he had a major impact on all EWMA activities, especially the scientific programmes of EWMA conferences. As such, he strengthened the collaboration between EWMA and the European Tissue Repair society (ETRS), contributing a basic research approach to wound healing.

Martin Koschnick, a plastic surgeon based in Germany and previously in Portugal, served in the EWMA Council from 2009-2015. Martin contributed to the high scientific standard of EWMA activities, and his energy and analytic mind were valuable contributions to the EWMA activities he participated in. Martin will continue to contribute to the work of EWMA through his membership of the Education Committee and the Editorial Board of the EWMA Journal.

Rytis Rimdeika is an active developer with a passion for making a difference clinically, scientifically, and organisationally. Rytis has been a member of the EWMA council from 2009-2015 and has actively contributed to development and implementation of several EWMA projects. Rytis has been the major EWMA ambassador in countries where Russian is widely spoken, such as Belarus and Ukraine, and he has significantly strengthened the co-operation of EWMA and national wound care organisations and alliances in those countries. We have come to know Rytis as a gentleman with extensive knowledge and devotion to the development of the field of wound care. Rytis will continue his work in EWMA as a member of the Editorial Board, and we look forward to his continued co-operation within EWMA. 74

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EWMA

New and re-elected EWMA Council Members

Sue Bale

Magdalena Annersten Gershater

Georgina Gethin

Christian Münther

Sebastian Probst

Barbara den Boogert-Ruimschotel

The individual members and the Cooperating Organisations Board elected six EWMA Council members during the EWMA 2015 Conference held in London. n

Sue Bale (United Kingdom)

n Magdalena Annersten Gershater (Sweden),

[Re-elected] Georgina Gethin (Ireland), [Re-elected]

Christian Münther (Germany)

n Sebastian Probst (Switzerland) n Barbara Esther den Boogert-Ruimschotel

(The Netherlands), [Elected by the Cooperating Organisations Board]

After the Annual General Meeting, Salla Seppänen stepped down as President and became the Immediate Past President. President-elect Severin Laüchli stepped up as the new president. Additionally, Alberto Piaggesi took the position of Honorary Secretary, replacing Dubravko Huljev. The EWMA Council welcomes all new Council members and is looking forward to a fruitful collaboration.

AAWC and AWMA representation at the EWMA Council This year, the EWMA Council welcomed representatives of the Association for the Advancement of Wound Care (AAWC) in the USA and the Australian Wound Management Association (AWMA) as official members of the EWMA Council. This represents the natural next step toward the formalisation and further strengthening of our long-standing collaboration and knowledge sharing with these international partners. Dr. Vickie Driver, President of the AAWC, and Ms. Margo Asimus, President of the AWMA, were appointed by their respective associations as EWMA Council members with full voting rights.

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Vickie Driver is Professor of Orthopedic Surgery at Brown University School of Medicine (clinical) and President of the AAWC since 2014.

Margo Asimus is a nurse practitioner in wound management and President of the AWMA since May 2014.

EWMA

ACRM award recipient Hubert Vuagnat

Hubert Vuagnat will be awarded the Edward Lowman Award for his dedication towards interdisciplinarity. The Swiss doctor and head of the University Hospitals of Geneva Interdisciplinary Wound Care Team, is very honoured to be awarded this prize. ” Interdisciplinarity really does play a major role in all activities I’m either leading or participate in”, he says in a statement on the ACRM webpage. The Lowman Award was established in 1989 in honour of Edward Lowman, MD, who recognised the importance of multidisciplinary teams in rehabilitation. Honorees are ACRM members whose careers reflect an energetic promotion of the spirit of interdisciplinary rehabilitation.

EWMA Council member Dr. Hubert Vuagnat, University Hospitals of Geneva has recently been announced as the winner of one of the prestigious American Congress of Rehabilitation Medicine (ACRM) awards. ACRM awards are given to people who have made a significant contribution to the field of rehabilitation medicine and the advancement of the ACRM mission to improve lives through rehabilitation research. Dr.

The award will be presented at the 92nd Annual ACRM Conference in Dallas on 29th October 2015. Dr. Hubert Vuagnat is past president of the French speaking Swiss Association for Woundcare (SAfW Romande) and current treasurer of the World Alliance for Wound and Lymphoedema Care (WAWLC). He has been a member of the EWMA Council since May 2014. n

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

2015 vol 15 no 2

27 TH CONFERENCE OF THE EUROPEAN WOUND MANAGEMENT ASSOCIATION EWMA 2017 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

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

New activities: Document on Oxygen Therapy This document will provide an overview of available oxygen treatment options and discuss the use of oxygen in wound healing. The document will explore differences between the USA and Europe in the use of oxygen therapies for wound healing and the potential for increasing the use of oxygen therapies in Europe. The document is planned for publication in Spring 2017.

Document on HRQoL - the patient´s perspective EWMA is currently planning a new focus document on health-related quality of life (HRQOL), with the objective to highlight the importance of evaluating the patient´s HRQoL in wound management. With this document, EWMA aim to provide an overview of available instruments to measure HRQoL and their documentation. The document will also include recommendations for evaluating specific wound related QoL issues, such as pain, sleep, well-being, social impact and psychological impact. The document is planned for publication in Spring 2017.

EWMA post graduate nurse wound curriculum EWMA is now working on a European curriculum for post graduate nurses, with the objective to support more standardised content in post graduate nurse education on wound management. The group responsible for developing this curriculum aims to finalise the work in Spring 2016 and then to bring it to the European nurse organisations for official approval and adoption.

On-going activities: Negative Pressure Wound Therapy (NPWT) Guidance Document The primary objective of this document is to provide guidance and consensus about the use of NPWT in wound treatment across European countries. The document will cover all three types of NPWT: on open wounds, with instillation and over closed incisions, and focus on areas such as evidence, organisation and health economy. The document will be published in the spring of 2016 and presented at the EWMA 2016 Conference in Bremen, Germany. Publication of this document is supported by an unrestricted grant from Acelity, BSN Medical, Mölnlycke Healthcare, Schüelke & Mayr, Smith & Nephew and Spiracur.

Leg Ulcer Guidance Document The leg ulcer guidance document aims to support the establishment of high-quality leg ulcer management throughout Europe by identifying barriers to the implementation of recommended services and referral routes, and by providing general recommendations for leg ulcer management. The document is planned for publication in Spring 2016 and will be presented during the EWMA 2016 Conference in Bremen, Germany. The document will be developed in collaboration with the Australian Wound Management Association (AWMA). Publication of this document is supported by an unrestricted grant from Activa, BSN, Lohmann & Raucher, Urgo and Welcare.

This work is inspired by the development of a European wound care curriculum for physicians that was successfully approved by the European Union Of Medical Specialists (UEMS) in April 2015. 78

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This year’s eHealth symposium will examine the state of the art of eHealth services already in use in wound care, as well as expectations for future health care systems. It will delve into the need for organisational changes and shifts in the roles and responsibilities of the patients and healthcare professionals in eHealth implementation and delivery of eHealth supported care. Finally, the programme will present some of the recent technical developments in this field. The programme will conclude with a wrap-up session aiming to highlight the main conclusions of the day.

On-going activities: EWMA Patient Outcome Group (POG) The dialogue forum between EWMA health professionals and industry representatives, the EWMA Patient Outcome Group is working since 2008 to uncover the barriers and facilitators of advanced wound care across Europe. The current agenda of the POG is centred around ; antimicrobial stewardship and its impact on the wound care market and advocacy collaborations with other wound care associations. Currently with a key focus on Germany the POG work to raise the profile of wound care and attract media interest in wound care leading up to the EMWA Conference 2016 in Bremen, Germany.

The purpose of the wrap up session is also to generate discussion about ways of moving forward towards the large-scale deployment of high quality eHealth services in wound care.

08.00 - 09.30

Remote assessment in wound care: Towards mature

10.15 - 11.15

The healthcare system of the future – healthcare w

11.15 - 12.15

The organisational dimension of eHealth implemen

12.30 - 13.30

New technologies - new opportunities

14.15 - 15-15

Wrap up session: State of the art of eHealth in wou

EWMA

Read more about the symposium programme at www.ewma2015.org/scientific/ehealth-symposium

The eHealth symposium is held in connection with the United4health pro

www.united4health.eu

United4Health

EWMA has invited some of the leading experts, researchers, and experienced practitioners within the field of eHealth and wound care to guide the audience through these topics.

EWMA Secretariat · Nordre Fasanvej 113, 2 · DK-2000 Frederiksberg · Denma

The United4Health project is coming to an end in December 2015. The core aim of this project is to study and support large scale deployment of telehealth solutions targeting patients suffering from Chronic Heart Failure (CHF), Chronic Obstructive Pulmonary Disease (COPD) and diabetes. As one of the supporting activities, EWMA has been responsible for developing an eHealth dissemination framework targeting wound care professionals. The objective of this was to support discussions about the use of eHealth services in wound management. One of EWMA’s dissemination activities was the annual eHealth symposia during the EWMA conferences. EWMA also published the document “eHealth in wound care – from conception to implementation” in April 2015. We hope these have planted some seeds for future development within the field. EWMA will continue to collect relevant guidance material and support the establishment of networks among the wound care experts with experience in eHealth or an interest in exploring the opportunities offered by this. More information about eHealth in wound care can be found at www.ewma.org. United4Health is partially funded under the ICT Policy Support Programme (ICT PSP) as part of the Competitiveness and Innovation Framework Programme by the European Commission.

SWAN-iCare SWAN-iCare is developing a smart device for distance wound monitoring and therapy. With the aim of sharpening the product specifications at a critical point in the development phase, a panel of EWMA wound experts were invited to join a focus panel at the EWMA 2015 conference, to give their independent opinion on the prototype. At next year’s EWMA conference in Germany a similar focus panel will be held. This time the purpose will be to investigate how sensors developed for the SWAN-iCare device could potentially be utilised in other types of wound care products with a broader market scope.

Other projects: FOR MORE INFORMATION ABOUT OTHER PROJECT ACTIVITIES SEE: • Position paper on Antimicrobial Stewardship pp. 80-81 • Wound Care Curriculum for Physicians Approved by the UEMS p. 85 • EWMA Pilot Project Wound Centre Endorsement pp. 86-87

Another project delivery of major focus in the coming period for EWMA is an organisational feasibility study to supplement the technical feasibility study currently underway. SWAN-iCare is partially funded under the seventh research and innovation framework programme FP7 by the European Commission.

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POSITION PAPER ON ANTIMICROBIAL STEWARDSHIP IN WOUND CARE Interview with Prof. Dr. Finn Gottrup, Senior Author of the BSAC/EWMA Position Paper on Antimicrobial Stewardship in Wound Care By Klaus Boberg Pedersen, EWMA Secretariat

About BSAC BSAC is an inter-professional organisation with 40 years of experience and achievement in antibiotic education, research and leadership, dedicated to saving lives through appropriate use and development of antibiotics now and in the future. BSAC communicates effectively about antibiotics and antibiotic usage via workshops, professional guidelines and its own high impact international journal.

We are proud to announce that EWMA, together with the British Society for Antimicrobial Chemotherapy (BSAC), have embarked on a mission against antimicrobial resistance, and are now to write a joint position paper on antimicrobial stewardship in wound management. The position paper is due to be published and presented at the EWMA Conference 2016. ‘We are extremely pleased with this collaboration’ says Prof Finn Gottrup, who will be EWMA’s senior author of

the document, and continues ‘We strongly believe that antimicrobial stewardship is an essential key in the fight against antimicrobial resistance. Yet, while the concept is now being adopted across most healthcare settings, it is still as good as unknown to wound care professionals, but with help from BSAC we will work to get this implemented in wound care.’ This is the second collaboration between the

Leading author of the upcoming joint BSAC/EWMA Position Statement on Antimicrobial Stewardship in Wound Management Prof. Benjamin Lipsky in discussion with the two session chairs; EWMA Past President, Prof. Finn Gottrup and BSAC President, Prof. Dilip Nathwani at the BSAC/EWMA Joint Symposium on Antimicrobial Stewardship in Wound Management, EWMA 2015 conference.

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

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EWMA

two organisations, which was kick-started at the EWMA conference back in May with the hugely successful Joint Symposium 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 messages of the stewardship concept to be brought directly to the clinicians who are acting in the centre of the resistance problem. During the recent decade, countless guidelines on antimicrobial prescription have been published, and as BSAC President Prof Dilip Nathwani pointed out during his talk at the stewardship symposium at EWMA in London, publishing yet another guideline will not solve the problem of antimicrobial misuse and subsequent development of resistance. Instead, the critical com-

ponents of successful antimicrobial stewardship programmes are education and cultural change. In recognition of this, BSAC shows the way by launching the world’s first Massive Open Online Course on Antimicrobial Stewardship in partnership with the FutureLearn platform. This free of charge course was recently launched, and is open for all health professionals with interest and prior experience in the prevention, diagnosis and management of infection. Empower yourself to provide safe, high-quality antibiotic use and sign up here: www.futurelearn.com/courses/antimicrobialstewardship EWMA Antimicrobial Stewardship programme 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, microbiologists, but also reaching out to policy makers, such as clinical administrators or managers at local, regional or national level. n

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www.charcotfootcourses.org

The Neuropathic Osteoarthropathic Foot 23-25 June 2016 (Charcot Foot Course) Rheine, Germany

About the 3rd Charcot Foot Course The three day theoretical & practical course gives participants a thorough view of the different aspects of the diagnosis, treatment and management of the Charcot Foot. The course will consist of practical sessions in small groups, where the main focus will be on training the diagnostic and treatment skills necessary for the interdisciplinary treatment of Charcot patients. In addition, state of the art lectures as well as pro and contra presentations of disputed topics will be given by international specialists in the field.

Venue, practical part: Mathias-Spital, Interdisciplinary Diabetic Foot Centre, Rheine, Germany Venue, theoretical part: Mathias-Spital, University of Applied Sciences, Rheine, Germany Form: Hands-on workshops/training in clinic combined with lectures Language: English Participant registration fee: Early registration (before 1 March 2016): 950 â&#x201A;Ź excl. accommodation Late registration (from 1 March 2016): 1150 â&#x201A;Ź excl. accommodation

www.charcotfootcourses.org

EWMA

EWMA EXPLORING THE POTENTIAL OF PHAGE THERAPY IN WOUND CARE As antibiotic resistant bacteria threaten a public health crisis, biotechnology is forced to look in new directions. An old technology, bacteriophage therapy or simply ‘phage’ therapy, is being taken down from the shelf where it has gathered dust for almost a century. But does phage therapy have a place in wound care?

AN ANTIBIOTIC ALTERNATIVE Phage therapy is the therapeutic use of bacteriophages to treat pathogenic bacterial infections. Although developed and extensively used since the 1920s in former Soviet Union countries, the treatment is not currently approved in countries other than Russia and Georgia. Phage therapy has many potential applications in human medicine as well as in dentistry, veterinary science, and agriculture. In the West, no phage therapies are currently authorised for use in humans, although phages are used for killing food poisoning bacteria (Listeria). Bacteriophage treatment offers a possible alternative to conventional antibiotic treatments for bacterial infection. Bacteriophages are much more specific than antibiotics, so they can hypothetically be chosen to be harmless not only to the host organism (human, animal, or plant), but also to other beneficial bacteria, such as gut flora, reducing the chances of opportunistic infections. On the other hand, this specificity is also a disadvantage: a phage will only kill a bacterium if it is a match to the specific strain. Consequently, phage mixtures are often applied to improve the chances of success, or samples are taken and an appropriate phage identified and grown. Phage therapy should have a high therapeutic index, that is, it is expected to give rise to few side effects. Because phages replicate in vivo, a smaller effective dose can be used. PHAGES IN WOUND CARE A particular concern related to the treatment of wound infections, as distinct from systemic infections, is the widespread use of topical antimicrobial agents. The use of topical antimicrobials, particularly antibiotics, is surrounded by controversy since antibiotic resistance of skin wound flora has emerged as a significant problem. Remarkably, EWMA Journal

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topically administered phages are considered to have certain advantages over conventional antibiotics, which is leading some researchers to claim that phages could be a long sought after new antimicrobial agent in wound management. In wound care, phages have great therapeutic potential: n Phages tend to be more successful than antibiotics when a biofilm is covered by a polysaccharide layer, which antibiotics typically cannot penetrate. n Phages can increase the effects of antibiotics. n Phages may be used for decontamination of carriers of multiresistant bacteria. n Phages could be used prophylactically to prevent colonisation. Clinical trials Currently some very interesting phage therapy projects are ongoing. One of these comes from the Portuguese biotech company, TechnoPhage (www.technophage.p). TechnoPhage has recently received authorisation from the FDA to investigate application of a bacteriophage cocktail for the treatment of infected chronic ulcers, namely diabetic foot infections. TechnoPhage is now starting trials in humans to confirm the safety and efficacy of the therapy, which has already been assessed in a laboratory environment. In support of TechnoPhage’s work, EWMA is now helping to retrieve microbiological samples from diabetic foot patients. Another exciting project is Phagoburn (www. phagoburn.eu), which is funded by the EU FP7 programme. The project aims to evaluate phage therapy for the treatment of burn wounds infected with Escherichia coli and Pseudomonas aeruginosa bacteria. The treatment will be tested through

Dr. Jan Apelqvist Chair of the EWMA Committee on Antimicrobials and Antimicrobial Resistance

Correspondence: ewma@ewma.org Conflicts of interest: None

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EWMA

a phase I-II clinical trial. In addition, results obtained by Phagoburn will contribute to optimisation of current regulatory guidelines in phage therapy. At this point, four clinical trials of phage therapy in wound care are ongoing in the West, with two in the EU and two in the USA. THE MEDICAL AUTHORITIES ARE ACTING The rebooted academic interest in phage therapy is expanding to government and regulatory authorities. In June, EWMA was invited to contribute to a closed workshop organised by the European Medicines Agency (EMA). The specific aim of the workshop was to discuss issues related to phage therapy with stakeholders from the academic, regulatory, and industrial sectors. It also provided an initial discussion on how a regulatory framework for phage therapy in Europe might look. Such a workshop is one of the ways that the EMA explores

opportunities for development of new anti-bacterial treatment options, and as a key stakeholder, EWMA has a natural interest in facilitating this agenda. PHAGE THERAPY AT THE EWMA CONFERENCE 2016 EWMA recognises that phage therapy could eventually prove to be of key value in modern wound care. As part of the EWMA Antimicrobial Stewardship Programme, the EWMA Scientific Committee has therefore decided that EWMA will play an active role in support of phage therapy development. As a first step, the EWMA conference in 2016 will include a symposium dedicated to phage therapy in wound care, where industry researchers and academic scientists will be invited to present and discuss the topic. With this event, EWMA hopes to stimulate research in the area and to mediate collaborations among the academic, industry, and regulatory sectors. n

A bacteriophage is a virus attacking bacteria and looks like a true extraterrestrial.

PROTEIN COAT

DNA SHEATH

CORE

CELL WALL

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EWMA

WOUND CARE CURRICULUM FOR PHYSICIANS APPROVED BY THE UEMS

Robert Strohal EWMA Liaisons Officer

In Spring 2014, EWMA developed a curriculum for physicians involved in wound care, which aims to ensure that physicians have sufficient expertise to provide efficient and safe treatment of their patients. The curriculum was submitted for evaluation by the Dermatology Section of the European Union of Medical Specialists (UEMS) and was approved in April 2015. Background and aim of the initiative Despite the fact that patients with chronic hardto-heal wounds are a typical, almost daily, part of medical practice, they still constitute a specific challenge for the treating physician. Consequently, we believe that the essential aspects of this medical field should be familiar to all physicians, and in particular those who deal with wounds regularly as a result of their specialisation. To optimise the treatment of patients with chronic wounds, physicians must select both therapy appropriate to the underlying aetiology and the correct local therapeutic measures. By developing the wound care curriculum presented here, EWMA aims to support development of these skills for physicians involved in wound management. Content of the curriculum The curriculum includes wound healing fundamentals as well as information on chronic wound pathogenesis, clinical assessment, and development of therapeutic concepts, wound prevention, and collaboration with other specialists, nurses, and health care providers treating this patient population. It also aims to recognise the value of interdisciplinary team work with regards to optimising treatment for all patients with wounds.

This key knowledge in the medical field of wound healing is suggested for inclusion in the broad post-graduate training for general practitioners, angiologists, diabetologists, dermatologists, general surgeons, plastic surgeons, geriatricians, and vascular surgeons. The curriculum’s content can be tailored to the relevant post-graduate training programmes. Next steps EWMA is now seeking co-operation with the European scientific societies for medical specialities to establish wound healing courses based on the developed curriculum as joint activities between EWMA and training programmes. Our objective is to support the implementation of the curriculum in the post-graduate activities of relevant specialists. n

An EADV Fostering Specialist Course on wound care will be held 23-25 October 2015 in Zürich, Switzerland. This course is based on the wound care curriculum developed by EWMA. More information: www.eadv.org/fostering-courses

More information: www.ewma.org

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EWMA PILOT PROJECT:

WOUND CENTRE ENDORSEMENTS

Finn Gottrup Wound Centre reviewer

Hubert Vuagnat Chair of the EWMA Wound Centre Endorsement Working Group

Professor Finn Gottrup discuss procedures of the wound centre with Dr. Wen, Head of the Beida Hospital wound healing centre, during his visit.

During the period of April to September 2015, EWMA carried out an evaluation of the Wound Healing Centre of the Peking University First Hospital (also called Beida Hospital). This was done as part of an EWMA Wound Centre endorsement pilot project, which aimed to design and test a procedure for international wound centre endorsements. The overarching goal of this initiative is to support the continuing establishment of high quality wound centres that acknowledge the need for multidisciplinary teamwork and evidence-based management in wound care. Development of the EWMA wound centre endorsement programme

More information: www.ewma@ewma.org

A working group including wound care experts with prior experience developing wound care centres in different European countries has defined a set of criteria as well as a procedure for wound centre endorsements. These criteria cover the centre’s physical facilities, procedures and equipment available for diagnosis and treatment, organisation and staff, referral routes as well as research and educational activities. These criteria were tested in a pilot project that was focused on a wound centre based inside of a hos-

pital and including an in-patient ward. EWMA also plans to develop specific criteria for wound centres based outside of hospitals, as the health care services offered by these are not directly comparable with in-hospital based centres. EWMA may develop endorsement criteria for additional types of wound centres in the future Pilot endorsement of a Chinese wound centre

Finn Gottrup was responsible for evaluating the Wound Healing Centre of the Peking University First Hospital (Beida Hospital) based on the endorsement criteria described above. The Peking University wound centre was asked to describe their services by completing an endorsement application form, which was reviewed as part of the initial evaluation of the centre. In addition, the centre was asked to translate (into English) and forward excerpts of the clinical guidance documents that were currently in use by the centre. Based on this material, the wound centre was pre-approved for endorsement. A two day visit to the wound centre was arranged to perform the final evaluation. During this visit, Finn Gottrup followed the centre’s patient pathways and proEWMA Journal

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Professor Finn Gottrup signs a provisional wound centre endorsement certificate, together with Dr. Wen, Head of the wound healing centre, and Dr. Wang Ping, Assistant Dean of Beida Hospital.

cedures, observed operational procedures, met the staff directly employed by the centre, evaluated the diagnostic, treatment and prophylaxis procedures used by the centre, and visited selected collaborating hospital departments. This visit confirmed that the Wound Healing Centre of the Peking University First Hospital (Beida Hospital) is a modern wound healing centre with several state of the art resources available to clinicians and other centre personnel and with good procedures. Finn Gottrup granted the centre a provisional endorsement and is now evaluating whether full approval is warranted, with or without requested amendments to the centre’s current structures and practices. What next?

The EWMA now looks forward to evaluating the pilot endorsement and to further developing the strategy for future assessments of wound centres. It is hoped that this effort will lead to the establishment of an international collaboration that will facilitate the easy sharing of knowledge about the development and maintenance of high quality wound centres. These should offer access to a multidisciplinary team of health care professionals, have established clear referral routes, and base their wound management on evidence-based guidelines, to the extent to which these are available. n

The EWMA wound centre endorsements group: Hubert Vuagnat (Chair, Switzerland), Finn Gottrup (Denmark), Luc Gryson (Belgium), and Severin Laüchli (Switzerland), Andrea Pokorna (Czech Republic). The development of the EWMA Wound Centre Endorsement Programme is supported by an unrestricted grant from the Coloplast Partnership Programme Access to Healthcare.

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IMPORTANT DATES Conference dates: 11-13 May 2016 Registration and abstract submission open: November 2015 Abstract submission deadline: 1 December 2015 Early registration deadline: 15 March 2016

Bremen

VISIT EWMA 2016 BREMEN, GERMANY The 26th conference of the European Wound Management Association will take place on 11-13 May 2016 in the great city of Bremen, Germany. EWMA 2016 is organised in cooperation with the Initiative Chronische Wunden e.V. (ICW) and in partnership with the GermanSpeaking Wound Associations WundD·A·CH. The theme for this year’s conference is:

Abstract Submission

Patients. Wounds. Rights.

Abstract Categories

The patient is more than a person suffering from 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, which implies that prevention and treatment of non-healing wounds must be available to everyone. Thus, securing patients’ quality of life is both a political and clinical responsibility. Enabling patient access to wound care requires the collaboration of patients, professionals and policymakers. It is a cornerstone of good practice in wound management and a fundamental objective of the interdisciplinary team approach. The conference is bilingual and offers sessions in English and German. Several streams will include simultaneous interpreting. Preliminary Programme

In 2016 the conference will offer a variety of topics relating to wound healing to be presented in plenary sessions, key sessions, workshops, full-day EWMA streams and guest sessions. The programme will feature a diverse gathering of scientists from across Europe and the rest of the world who will present new results and developments within the field of wound healing.

Abstracts for oral free paper and electronic poster presentations play a major role in the conference programme. We hope that many of you will wish to share your work at the 2016 conference. To submit an abstract for EWMA 2016, please visit www.ewma2016.org. Guidelines for abstract submission are provided online.

Abstracts for oral presentations and electronic poster (e-poster) presentations can be submitted on any topic relating to wound healing and wound management. Primary categories are: n Acute Wounds n Antimicrobials n Basic Science n Burns n Devices & Intervention n Diabetic Foot n Dressings n Education n e-Health n Health Economics & Outcome n Home Care n Infection n Leg Ulcers n Negative Pressure Wound Therapy n Nutrition n Pain n Pressure Ulcers n Prevention n Quality of Life n Wound Assessment n Case Studies n Professional Communication n Students’ Free Paper Session

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EWMA

Key Sessions

EWMA 2016 will present a variety of new topics that are important to the European wound community in general along with topics that have elicited tremendous interest during previous EWMA conferences. The sessions will cover the advancement of education and research in relation to wound epidemiology, pathology, diagnosis, prevention and management. Key sessions at EWMA 2016 include: n New Technologies in Wound Care n Migration, Culture and Ethnic Skin n Bariatric Wound Care n Biofilm n Evidence and Outcome n Cell Therapies n Leg Ulcer Guidance (EWMA document) n Oxygen Treatment in Wound Healing n Health-Related Quality of Life (EWMA document) n Antimicrobial Stewardship Programme n Negative-Pressure Wound Therapy (EWMA document) n Networking Structures in Wound Care n Individualized Diagnostics n Local Wound Infection n Compression Therapy Workshops

Several workshops will be offered at EWMA 2016. These are typically held in more intimate settings than those used for key sessions and free paper sessions. EWMA workshops are interactive and give participants an opportunity to address and elaborate on specific aspects of the session themes. n Alternative Medicine and Treatment n Biofilm n Clinical Trials n Debridement n Diabetic Foot n Electro Stimulation n How to Make a Paper, How to Make a Poster n How We Do That: A Practical Approach to Clinical Practice n Military Wounds n Pain Management in Patients with Wounds n Patient Education n Skin Care in Leg Ulcers n Use of Information Technology in Wound Care n Wound Assessment Guest Sessions

EWMA will invite various organisations to present a guest session at EWMA 2016. Guest sessions increase awareness

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DEADLINE: ABSTRACT SUBMISSION 1 DECEMBER 2015!

and allow conference participants to learn more about activities related to wound healing and management. They also encourage scientific cooperation and networking with organisations that are active in issues related to wound healing and management. At EWMA 2015, 13 associations participated in guest sessions and we expect a similar level of participation in 2016. Confirmed guest sessions:

EWMA Symposia

The full-day streams and symposia are especially popular among EWMA conference delegates because they foster more in-depth discussions. Planned symposia for EWMA 2016 are: n

Phlebology Revasc for Healing n Diabetic Foot (including focus on registers) n Antimicrobial Stewardship n

For more information about other focus areas, abstract submission, terms and conditions and programme updates, please see the conference website: www.ewma2016. org. FOR MORE INFORMATION ABOUT THE CONFERENCE, PLEASE VISIT: WWW.EWMA2016.ORG Registration Fees

EWMA 2016 will be held jointly with the German Wound Congress organised by our German, Austrian and Swiss cooperating organisations. In accordance with the local customs of the German Wound Congress, participant entitlements will not include coffee breaks or lunch, which may instead be purchased at the conference venue. For this reason, the registration fee has been lowered for 2016. î&#x201A;Š Registration Fees see page 90

EWMA 2016 BREMEN Germany

11-13 MAY 2016

Registration fees - including 19% VAT DAYS

DESCRIPTION

PROFESSION

3-DAY CARD

ICW*, AWA* and SAfW* members

3-DAY CARD

BEFORE 15 MARCH 2016

15 MARCH - 1 MAY 2016

AFTER 1 MAY 2016

Doctors Nurses and assistant doctors Students

200 € 125 € 60 €

225 € 150 € 70 €

275 € 200 € 85 €

EWMA members

428 €

506 €

565 €

3-DAY CARD

Non-members

518 €

595 €

655 €

2-DAY CARD Wed.-Thurs. or Thurs.-Fri. 1-DAY CARD

ICW*, AWA* and SAfW* members ICW*, AWA* and SAfW* members

Doctors Nurses and assistant doctors Students

170 € 100 € 48 €

190 € 120 € 55 €

230 € 160 € 67 €

Doctors Nurses and assistant doctors Students

130 € 70 € 36 €

145 € 85 € 46 €

170 € 110 € 53 €

1-DAY CARD

EWMA members/ Non-members

280 €

309 €

369 €

* Requires membership in the relevant national organisation 2 months prior to the conference: ICW for German participants (www.icwunden.de), AWA for Austrian participants (www.a-w-a.at) and SAfW for Swiss participants (www.safw.ch).

Bremen

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THE EWMA UNIVERSITY CONFERENCE MODEL (UCM):

Bring your students to a whole new level

Introduction EWMA strongly encourages teaching institutions and students from all countries to benefit from the possibilities of international networking and access to lectures by many of the most experienced wound management experts in the world. The EWMA Conference offers a unique setting for learning, which international wound care specialists, studying post-graduate qualifications in wound management at universities all over Europe use each year as part of the curriculum while engaging in a network of peers. The concept Since 2007, the EWMA UCM programme offers groups of post-graduate wound management students from institutes of higher education across Europe the opportunity to take part of their academic studies whilst participating in the EWMA Conference. Following the intense 3-day EWMA conference, EWMA UCM participants will engage in additional interactive learning activities that complement the main EWMA scientific programme. Participation in the EWMA UCM is available to all teaching institutions with wound management courses for health professionals. The initiative has proven to be an immensely successful way for universities to utilise the EWMA conference programme as a supplement to their curriculum. The opportunities At the EWMA 2016 Conference in Bremen the programme will offer UCM Lectures as well as EWMA Journal

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assignments and workshops arranged specifically for the EWMA UCM participants and excellent networking opportunities between current and future wound specialists from various, international groups; all with the aim to learn. The EWMA UCM has also provided some students with the opportunity to present in the free paper sessions, which facilitates their ability to gain confidence as active participants and establish their own expertise in wound management. The benefits The EWMA UCM activities are designed to develop an independent attitude to the information presented at the conference and critically assess innovations, new products, and recent recommendations in wound healing. Feedback from participants mentioned the professional yield, networking opportunities, knowledge exchange, and presentation of new information and tools as highlights. In the words of one participant: “These experienced speakers presented a ‘real life’ view of best practice, current opinion, debate, and evidence base which was both inspiring and challenging, and reinforced my drive, motivation, and determination to develop my practice and local wound management services.” We hope to see you in Bremen May 2016 Chair of the EWMA Education Committee

Luc Gryson 91

ICW

Organisation of Wound Care in Germany

Chronic Wounds Initiative

Key Points

Veronika Gerber ICW e.V., German wound Society Initiative Chronische Wunden e.V., Chairperson.

Social health insurance in Germany guarantees access to health care for all insured citizens, but patients must pay entirely for some essential wound care products. The organisation of wound care varies across Germany, is largely unregulated, and the care provided to people with chronic wounds is characterised by large variations in quality. Different professional groups follow different curricula when caring for chronic wounds, and the current curricula are regularly evaluated and developed. Nurses, doctors, and health insurers have demonstrated a growing interest in these programmes. A re-organisation of the health system appears to be necessary to provide adequate care to wound patients. Wound specialists in clinics and in ambulant settings are attempting to establish new forms of cooperation with health insurers. Introduction

The social health insurance system in Germany is mandatory and paid for by employers and employees, and the government insures unemployed patients. The German health care system aims to provide as much care in the home environment as possible. Financial incentives in the diagnosisrelated group (DRG) system reduce the time that patients spend in hospitals. Consequently, patients with complicated wounds are discharged to their home environment, where the quality and organisation of care varies greatly, early. Organisation of care

Correspondence: gerber@icwunden.de

Mobile patients visit a general practitioner, wound specialist, or hospital outpatient clinic, whereas bedridden patients are treated in their home environment where the family doctor installs a treatment regime and prescribes the necessary medical wound care products. The care is then provided by the health care staff in charge,

thus, the quality of care depends on the qualifications of the “health and medical nurse” or the “nurse for the elderly”. Many care providers currently employ nurses with additional wound care qualifications, but it is not required by law. Management

Wound care is not a medical specialisation, thus the responsibility for wound care provision lies at many levels of the healthcare system and in the hands of many different specialists, such as the family doctor, surgeon, internist, dermatologist, diabetologist, and angiologist. Knowledge regarding chronic wounds and chronic wound therapy differs greatly among these specialists. Medical standards of wound care, which are various, are not established or mandatory in Germany. In contrast, an “expert standard for the care of people with chronic wounds” exists for nurses, and this standard demands that a nurse specialising in wound care shall be consulted at the beginning of treatment to perform a thorough anamnesis, develop a detailed treatment plan, and regularly evaluate wound development. This specialised nurse shall establish communication between the patient, family, family doctor, and homecare service. The wound care specialists often recommend wound care supplies and medications, which are then prescribed by the family doctor. Financing

Two insurance systems, health insurance and long-term care insurance, are concerned with wound care. The health insurance system pays for acute wound care, and all wound dressings are, in principle, free of charge for patients, but patients must pay a receipt fee of 5 Euros per product. In addition, patients must purchase some essential treatment supplies themselves, EWMA Journal

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Nordic Diabetic Foot Symposium 2016 Join us to take an active role in implementing Best Practice Diabetic Foot Care in the Nordic countries

26-27 October 2016, Copenhagen, Denmark

such as antiseptics, skin protection products, and cleansing fluids. Long-term care insurance covers devices that facilitate the lives of elderly people living at home, such as special beds or mattresses. Coverage for home care services, either by health insurance or by long-term care insurance, requires a prescription from a doctor. Summary

In Germany, protection in case of illness is largely secured by the compulsory insurance system, which guarantees access to care by covering the cost of care and, to some extent, medical supplies. The quality of care is the responsibility of the service providers, which includes the doctors and nurses. However, there are no rules or regulations to ensure that doctors, nurses, and homecare providers have sufficient or up-to-date wound care knowledge. In addition, the outcomes of chosen treatment strategies are rarely evaluated, thus the efficacy of most treatment regimens is not known. In summary, wound care patients in Germany have free and mandatory access to wound care. However, equal access to high quality care is constrained by a lack of knowledge among care providers regarding the best and most appropriate wound care. For patients with limited financial resources, co-payments for medical supplies pose a great barrier to accessing care. In recent years, there has been a growing awareness that there are constraints to equal access to appropriate and high quality wound care across Germany. To address this problem, the current organisation and financing of wound care must be re-evaluated and adjusted. n

The program will cover a mix of: Traditional presentations Hands-on workshops Meet the expert sessions â&#x20AC;&#x201C; addressing best practice treatment regimes Concluding panel debate defining strategies to pursue implementation of Guidelines Meetings with the National Working Groups Examples of topics to be covered: Basic pathophysiology of diabetic foot problems Introduction to IWGDF guidelines Overview of current situation of care in the Nordic Countries Screening Diagnosing neuropathy Diagnosing and treating charcoot foot Vascular assessment Debridement Surgery and use of flaps Role of negative pressure wound therapy Choice of dressings Offloading Amputation and rehabilitation Role of podiatry Organisation of diabetic foot teams Quality control and registers Patient education and compliance

Registration opens in January 2016. Information on: www.nordicdiabeticfoot.org

Supported by

Nordic Diabetic Foot Task Force & Symposium 2016 Sponsor:

www.nordicdiabeticfoot.org EWMA Journalâ&#x20AC;&#x201A;

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ICW

Chronic Wounds Initiative

ABOUT ICW - A German Wound Healing Society History and Organisation

Veronika Gerber ICW e.V., German wound Society Initiative Chronische Wunden e.V., Chairperson.

Founded in 1995 by a group of wound specialists, the ICW (Initiative Chronische Wunden) first drew the attention of doctors and clinicians after publishing consensus orientated guidelines. Those guidelines of particular interest were those describing recommendations for the prophylaxis and treatment of pressure sores and venous leg ulcers. The ICW has been recognized as a medical society since 2002, and takes part in official wound healing consultations in Germany. The ICW is structured into 34 regional groups that are distributed throughout the country and has more than 2600 members Main Focus and Activities

The main focus of the ICW is education. In 2006, the ICW initiated a collaboration with TÜV Rheinland, an approved certification society. Together, the two organisations launched a basic course “Wundexperte”, which was first endorsed by the EMWA in 2009 and re-endorsed in 2015. The course is offered by 152 providers, who also take care of quality by consequent using the topis from curriculum. As of 2015, more than 35000 participants had successfully finished the course.

More information: www.icwunden.de

Over the past few years, several new courses have also been established. To meet the career goals of several ICW colleagues, the courses “Pflegetherapeut” and “Fachtherapeut” are now offered. These courses provide participants with profound knowledge of the organisation of wound healing institutions, such as hospital units and ambulances (Pflegetherapeut) or of diagnostic and therapeutic skills on an advanced level (Fachtherapeut). The relative reluctance of many doctors to discuss the issues surrounding wound healing, typically because of a lack of knowledge about this highly

specific topic, is a problem that is not unique to Germany. Knowledge of the specific medical methods required for successful treatment of chronic wounds will enable doctors to enthusiastically discuss the topic and to encourage their colleagues-both in Germany and in other countries-to also do so. The course “Ärztlicher Wundexperte” addresses this issue, as it is open to doctors from all disciplines. Thus far, the most interest has been received from surgeons, general practitioners and geriatricians. The best designed and most well taught course cannot guarantee that the participant will work according to the course contents after the final exam. For institutions that require that their medical personnel demonstrate special competence in the treatment of chronic wounds, the certification “Wundsiegel” is available. This certification demands that the certified person demonstrate high standards of internal organisation and of networking with neighbouring institutions to ensure that the interdisciplinary approach taught by the course is followed as faithfully as possible. Regular re-certification every 4 years is mandatory. The ICW is also involved in several activities outside of its education efforts. It organises both regional and nationwide congresses. The Bremer Wundkongress, a particularly influential congress, is an annual event that regularly draws more than 4500 attendees. All ICW, as well as interesting scientific publications and news from the field of wound care, are reported in “Wundmanagement,” the official publication of the Swiss and Austrian wound healing societies and which is published every two months. n

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About WundD·A·CH In Europe, the interdisciplinary medical field of wound management is quite diverse. In most northern European countries, including the United Kingdom, certain nurses such as tissue viability nurses have the authority to make diagnoses and write prescriptions. However, in German-speaking countries, the authority of nurses is more limited, requiring greater reliance on medical doctors in the clinical setting. Consequently, the guidelines, consensus documents, and clinical algorithms developed on a European basis are often difficult to apply in German-speaking countries.

Robert Strohal WundD·A·CH President

To address diversity in wound management across German-speaking countries, the umbrella organisation WundD·A·CH was created. The core of this coalition, which covers a population exceeding 100 million people, is represented by the German wound-management association (ICW), the Austrian wound-management association (AWA), and the Swiss wound-management association (SAfW). In addition, various other specialties involved in wound management are also associated with WundD·A·CH. One major goal of WundD·A·CH is to organise a German-speaking, multinational congress every third year. The 2013 congress in Friedrichshafen was a great success. The 2016 congress will be cohosting with EWMA and ICW in Bremen, based on the close co-operation between EWMA and WundD·A·CH In addition to organising the congress, WundD·A·CH is engaged in condensing national guidelines and expert consensus documents from Germany, Austria, and Switzerland into a single version of the documents for all German-speaking countries. For example, WundD·A·CH is currently drafting a consensus document on compression. Another WundD·A·CH project involves developing e-learning resources. It is also convening a panel of experts who are addressing specific, difficult questions related to wound management. The close cooperation of the different German-speaking national wound-management associations and EWMA, a successful multinational German-speaking congress, and a focus on various interdisciplinary projects make WundD·A·CH a strong representative in the field of wound management for all German-speaking countries in Europe. n

More information: www.wund-dach.org

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MESSE

BREMEN

Deutscher Wundkongress Continues to Grow Since 2007, Bremer Pflegekongress and Messe Bremen have hosted the Deutscher Wundkongress at Messe Bremen’s exhibition centre. The dual congress has grown continuously since its inception, establishing itself as an important forum in the health care sector for discussion, education, and networking. Participation increased from 2,000 medical professionals, caregivers, and other health care industry attendees in 2007 to over 4,900 in 2015. This year, the program offered over 200 sessions. Information was presented about the latest findings and innovations in the areas of wound care. This congress had several new programs, such as a roundtable session with experts where renowned experts discussed the latest research and innovations, including the application of spider silk as an experimental treatment for problematic wounds. At the accompanying exhibition, 108 organisations presented their products and services. This dual congress is one of over 60 events hosted by Messe Bremen annually. Approximately 20 of these events are its own, and the remainder are guest events. More than 415,000 people visited the exhibition centre during the past fiscal year. Bremen is a popular venue for trade fairs and conferences. This is due to, among other things, the excellent space. Six exhibition halls and the ÖVB-Arena offer approximately 40,000 square metres of total exhibition space. This exhibition space is adjacent to the Congress Centrum Bremen (CCB), which has 16 functional conference rooms and an additional 100,000 square metres of open, versatile space. The exhibition centre is located in the heart of the city, making it an extremely attractive and convenient venue. It is only five minutes on foot from the nearest train station and 15 minutes from the airport via tramway. Those travelling by car are guided to the exhibition centre and its 2,850 parking stalls with the help of an electronic traffic management system. 96

For those seeking relaxation after the congress, Bremen is an ideal place. Numerous hotels at various price points can be found in close proximity. The Hanseatic city offers a wealth of attractions and sights for the adventurous visitor. The sculpture of the Town Musicians, the Roland statue, and various architectural marvels, such as the expressionistic Böttcherstraße and the town hall, a designated UNESCO World Heritage Site, are well-known attractions in Bremen. n For further information, please visit www.deutscher-wundkongress.de and www.messe-bremen.de/eng.

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34. JAHRESTAGUNG Deutschsprachige Arbeitsgemeinschaft für Verbrennungsbehandlung Verbrennungsmedizin im interdisziplinären Kontext – Gemeinsam sind wir stark

13.–16. JANUAR 2016 I Berchtesgaden Schwerpunktthemen • Infektiologie • Wundbehandlung, Antiseptika Verbandsregime • Intensivmedizin aus pﬂegerischer und ärztlicher Sicht • Rekonstruktion bei Schwerverbrannten

• Innovationen/Neuerungen in der Verbrennungsbehandlung • Rehabilitation, Physio-und Ergotherapie des Schwerbrandverletzten • Psychologische Betreuung des Schwerbrandverletzten • Qualitätssicherung

www.dav2016.de © fotolia.com/photoCD/sclos/WavebreakmediaMicro/Karramba Production/Dan Race/Photographee.eu • shutterstock.com/nikkytok

A combined programme in partnership with swiss orthopaedics

17TH EFORT Congress | Geneva, Switzerland: 01-03 June 2016 A combined programme in partnership with swiss orthopaedics

Main Theme: Maintaining Activity Through Life

www.efort.org/geneva2016 Ad_A5_land_gva_sub.indd 1

#EFORT2016

Key dates

Abstract submission & registration open: 15 September 2015 Abstract submission closes: 30 October 2015 at 15:59 CET Early registration deadline: 29 February 2016 On-site rates apply: 03 May 2016

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EWMA Journal

Other journals

Volume 15, no 1, April 2015

EWMA wishes to facilitate the exchange of information on wound healing in a broad perspective with this section on International Journals.

Previous Issues

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

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

Volume 14, no 2, October 2014

Italian

Management and outcome of patients with chronic wound treated by hyperbaric oxyge¬nation Nasole E, Spazzapan L, Solagna E, et al. Use of a topical preparation based on lacto¬ferrin to manage acute and chronic cutaneous dyschromia and hypotrophy Musso A, Aloesio R, Caponi R. Hyperbaric oxygen therapy in the diabetic foot: history, mode of action, indications, contrain¬dications Iacopi E, Coppelli A, Goretti C, et al. Rectus sheath hematoma in an 80-year-old man with venous leg ulcer infection: a case report Spazzapan L, Papa G, Nasole E, et al. English

Prevalence of pressure ulcers in hospitalized patients in Germany Heidi Heinhold, Andreas Westerfellhaus, Knut Kröger Excess use of antibiotics in patients with non-healing ulcers Marcus Gürgen Regenerative medicine in burn wound healing: Aiming for the perfect skin Magda MW Ulrich Promising effects of arginine-enriched oral nutritional supplements on wound healing Jos M.G.A. Schols Efficacy of platelet-rich p lasma for the treatment of chronic wounds Vladimir N. Obolenskiy, Darya A. Ermolova, Leonid A. Laberko, Tatiana V. Semenova.

Secondary Analysis of Office of Inspector General’s Pressure Ulcer Data: Incidence, Avoidability, and Level of Harm Levine J M, Zulkowski K M. Finnish

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

Haava, no. 2, 2015 www.shhy.fi Multiprofessional co-operation – Wound Care Path in City of Helsinki Lepäntalo M. National Guideline for Prevention of Transmission of Multiresistent Microbes Kavola H. Skin Problems Related to Ostomy Isoherranen K. Wound Infection Related to Treatment Arifulla D.

Spanish

Helcos, vol. 26, no. 1, 2015 Interobserver reliability in EVARUCI and EMINA scales for intensive care unit Roca-Biosca A, et al. Alternative to chronic wound closure by Revertin grafts and growth factors in ambulatory surgery minor Javier Pérez Vega F, et al.

Volume 13, no 2, October 2013 Risk assessment scales for pressure ulcers in intensive care units: A systematic review with meta-analysis F. P. García-Fernández et al. Pressure-time integral of elastic versus inelastic bandages H. Partsch, G. Mosti VERUM – A European approach for successful venous leg ulcer healing R. Brambilla et al. Effect of topical h aemoglobin on venous leg ulcer healing M. Arenbergerova et al. The effects of an arginine-enriched oral nutritional supplement on chronic wound healing in non-malnourished patients J. Schols et al. Efficacy of honey gel in the treatment of chronic lower leg ulcers O. Tellechea et al.

Advances in Skin & Wound Care, vol. 28, no 9, 2015 www.aswcjournal.com Epidermal Micrografts Produced via an Automated and Minimally Invasive Tool Form at the Dermal/Epidermal Junction and Contain Proliferative Cells That Secrete Wound Healing Growth Factors Osborne S, Schmidt A M, Derrick K, et al. Randomized Controlled Study of Innovative Spray Formulation Containing Ozonated Oil and α-Bisabolol in the Topical Treatment of Chronic Venous Leg Ulcers Stru L, Stîncanu A, Ascentiis A, et al. Comparison of the Cytotoxicities and Wound Healing Effects of Hyaluronan, Carbomer, and Alginate on Skin Cells in Vitro Guo X, Huang S, Sun J, et al.

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 Volume 14, no 1, May 2014

Acta Vulnologica, vol. 13, no 2, 2015 www.vulnologia.it

English

International Wounds Journal vol. 12, no 5, 2015 www.jwcregister.com Founder of Leg Club model awarded Order of the British Empire in recent Queen’s Birthday Honours Harding K, Queen D. Vessel transformation in chronic wounds under topical negative pressure therapy: an immunohistochemical analysis Malsiner CCM, Schmitz M, Horch RE, et al. A closer examination of atraumatic dressings for optimal healing Davis SC, Li J, Gil J, et al.

EWMA Journal

2015 vol 15 no 2

EWMA English

Journal of Tissue Viability, vol. 24, no 2, 2015 www.journaloftissueviability.com

Scandinavian

Wounds (SÅR) no 2, 2015 www.saar.dk Vacuum Bandages for caesarean section in overweight patients Fonnesbech J. Oncology wounds. How they diagnosed and when to be suspicious of skin cancer Fonnesbech J. Patients are satisfied with telemedicine Good initiative. Handicare’s Pressure Ulcer-seminar April 14, 2015, Hvidovre Jørgensen B

English

Wound Repair and Regeneration, vol. 23, no. 3, 2015

3D anatomy and deformation of the seated buttocks Sonenblum S.E, Sprigle S.H, Cathcart J.M, et al. Challenges to measure hydration, redness, elasticity and perfusion in the unloaded sacral region of healthy persons after supine position Scheel-Sailer A, Frotzler A, Mueller G, et al. Clinical Study: Impact of daily cooling treatment on skin inflammation in patients with chronic venous disease Kelechi T.J, Mueller M, King D.E. et al. Wrinkling over finger tip Nagar R. English

Journal of Wound Care, vol. 24, no 8, 2015 www.journalofwoundcare.com Pressure ulcer prevalence and prevention practices: a cross-sectional comparative survey in Norway and Ireland Moore Z, Johansen E, Etten M et al. Clinical effectiveness of a silicone foam dressing for the prevention of heel pressure ulcers in critically ill patients: Border II Trial Santamaria N, Gerdtz M, Liu W, et al. Microcirculatory responses of sacral tissue in healthy individuals and inpatients on different pressure-redistribution mattresses Bergstrand S, Källman U, Ek A-C, et al. Pressure ulcer prevention and healing using alternating pressure mattress at home: the PARESTRY project Meaume S, Marty M.

Polish

Brief Communication: Health literacy and diabetic foot ulcer healing Margolis D J, Hampton M, Hoffstad O. et al. Mechanical cues in orofacial tissue engineering and regenerative medicine Brouwer K M, Lundvig D, Middelkoop E, et al. Improving the ability to eliminate wounds and pressure ulcers Kuffler D P. Cutaneous wound healing in aging small mammals: a systematic review Kim D J, Mustoe T, Clark R F German

Migration specific diversity and transcultural competence in nursing care: Austrian perspectives Binder-Fritz C. Patients with migration background – Demands made on the healthcare system Bühlmann R, Liewald K. “Food won’t make you ill” – Diabetes mellitus in turkish people living in Germany Babadagi Z, Kröger K

Leczenie Ran vol. 12, no 3, 2015 www.journalofwoundcare.com Guidelines: The Organization Of Health Care Of Patients With Diabetic Foot Syndrome. Guidelines Of Polish Wound Management Association Mrozikiewicz-Rakowska B, Jawień A, Sopata M, et al. Abstracts From The 5th Congress Of Polish Wound Management Association antiseptic Westgate SJ, Cutting KC German

Lithuanian

Lietuvos chirurgija, vol. 2, no 3, 2015 www.chirurgija.lt Experience of total knee replacement operations performed by computer-assisted navigation in Lithuania Butėnas P, Penikas P, Vizgirda A, et al. Long-term results after laparoscopic sleeve gastrectomy Juodeikis Z, Brimas E, Straukas J, et al. Implant and spinal mobility influence on the spinal curvature correction in adolescent idiopathic Lenke I type scoliosis Bernotavičius G, Saniukas K, Vaičiulėnaitė J, et al. Postpartum diastasis of the pubic symphysis: case report and literature review Uvarovas V, Zukauskas P, Siatkus T, et al.

Dutch

NTVW vol. 9, 2015 www.ntvw.nl Editorial: ‘Payed content is coloured’ Nonnekes J. Opinion: ‘Woundcare needs intensified attention’ Tange A. Interview: ‘Retro-innovation as an approache for complex wounds’ Homecare organisation Buurtzorg Nederland Column:’The unsuspected power of de negation’ Gagestein S.

German

Phlebologie, vol. 4, 2014 www.schattauer.de

Wund Management, no 4, 2015

Zeitschrift für Wundheilung, vo. 20, no. 1, 2015 www.dgfw.de Knowledge on Ulcer Pressure – what knowledge is being taught on German Nursing Schools? Strupeit S, Buss A, Hasseler M, Dassen T. Can lymphological compression bandaging reduce lymphostatic fibrosklerosis in phase II of complex physical decongestion therapy? Strubel G, Kottmann T, Wörmann P. et al. Pressure Ulcer: Risk Factors in Inpatient Care – a Rapid Review Burckhardt M, Waldvogel-Röcker K. Sclerotisation of a repeated bursa pseudocyste recrudescence by stimulation therapy with concentrated lactic acid Barnikol W. K. R, Pötzschke H

Management of difficult soft tissue infection after variceal operation Improved vascularized tumor of the calf Improved erectile function after laser ablation of VSM Treatment with a EHIT Rivarixaban

EWMA Journal

2015 vol 15 no 2

AAWC NEWS AAWC Association for the Advancement of Wound Care

Vickie R. Driver President of AAWC 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 Colleagues and Friends at EWMA, This year commemorates 20 years of historical and successful evolution of the leading interdisciplinary association for wound healing in the United States, the Association for the Advancement of Wound Care (AAWC). The patients we serve and the diverse interprofessional membership are AAWC’s inspiration. Diversity keeps our organisation strong. AAWC’s strategic plans are designed to raise awareness, promote growth in the field, and give everyone involved a voice. Moreover, we eagerly endeavor to strengthen our ties with wound-care associations across the globe. In the spirit of world-wide collaboration, we are working with major international societies to consolidate clinical guidelines. While each association involved will continue to advance its own mission through various projects, AAWC’s vision is that there will be a single set of clinical guidelines supported by tens of thousands of professionals one day. I was pleased to represent AAWC at the EWMA conference in May, along with AAWC Secretary Barbara Bates-Jensen, PhD, RN, FAAN. We presented a well-received international partner session entitled, “A Global View of Wound Care: Past, Present, and Future.” In various meetings, I proudly represented AAWC as a voting member of the EWMA Council. AAWC looks forward to continuing its valuable partnership with EWMA. Additionally, AAWC is a supporting society of the World Union of Wound Healing Societies congress to be held in Florence, Italy in 2016. Aligned with AAWC’s goals, the theme of the conference is “One Vision, One Mission.” Our Association will send three key leaders to present a multidisciplinary-focused lecture. **

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In the United States, our leadership is creating a strong, united voice in government and public policy. We are dedicated to collaboration with entities that focus on issues relevant to our members and their futures. As an integral resource for the Food and Drug Administration (FDA), Centers for Medi-

care and Medicaid Services, National Quality Forum, and many other agencies, we provide much feedback, guidance, and support in this area. AAWC, along with the Wound Healing Society, continue as hosts for the Wound-care Experts/FDA – Clinical Endpoints Project (WEF-CEP). Because complete wound closure is the only endpoint the FDA considers when determining drug and device approvals, our teams are collecting data to define additional scientifically rigorous, yet achievable, clinical endpoints. The FDA will consider the proposed endpoints as it develops a 2016 guidance document for the industry. The inaugural AAWC Clinical Practice Track at the Symposium on Advanced Wound care ( SAWC ) Spring meeting was an astounding success. AAWC provided four of the top six rated lectures. We encourage you to attend the next SAWC Spring meeting in Atlanta, Georgia, where the AAWC Clinical Practice Track will provide evidence-based, patient-centred, interdisciplinary, practical information that clinicians will be able to share with decision makers and colleagues after the conference. We are immensely grateful to our board members, volunteers, members, and staff who are monumental contributors to our success. We greatly value our productive partnership with our corporate advisory team and sponsors, who help greatly to improve education for the generalist and to strategically align goals for continued access to evidence-based products and services. AAWC is represented by over 70 members from more than 30 countries and warmly invites EWMA readers to join AAWC. Please learn more at www. aawconline.org. Together, we can advance the practice of wound care throughout the world.

Sincerely, Dr. Vickie R. Driver President, AAWC

EWMA Journal

2015 vol 15 no 2

Organisations

AWMA NEWS AWMA Australian Wound Management Association

Margo Asimus AWMA, President

Impending Launch of Wounds Australia in 2015 The Australian Wound Management Association (AWMA) celebrated its 20th anniversary in 2014. A year later, a necessary part of its evolution from a volunteerbased group to a professional company limited by guarantee came to fruition. National members have voted to wind up the AWMA and transfer assets and functions to a new entity called Wounds Australia. This transition from eight individual state and territory AWMA associations to one nationalised body has been a 5-year process. The changes will benefit wound management, multidisciplinary professional members, and ultimately, patients with wounds. The strong links with our corporate partners were recently celebrated at a corporate planning day in Sydney, and 19 companies were represented. Nationalisation is an exciting period for Wounds Australia with all states and territories working together as a single body to bring about many benefits including: n Establish a professional organisation representing wound management

in Australia.

n Consolidate the separate state and territory associations and the AWMA,

which have previously functioned under individual constitutions.

n Pool accumulated funds to better achieve the organisationâ&#x20AC;&#x2122;s national and

Tabatha Rando AWMA, Vice President www.awma.com.au

local objectives.

n The implementation of a broader national Board of Directors that will include

key wound management health professionals in addition to persons with expertise in specific areas, i.e., legal skills, accounting, or promotions.

n Employ staff to develop and grow the organisation. n Increased influence and respect in political, policy, and jurisdictional areas. n Provide consistent national privileges and benefits for members. n The introduction of an internationally recognisable brand name. n Partnership opportunities that will continue with the Wound Management

Innovation CRC.

By November this year, the AWMA membership will be celebrating its transition to Wounds Australia and all benefits that this transition will deliver to accommodate the growth of wound management in Australia.

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CAWC NEWS CAWC Canadian Association of Wound Care

Mariam Botros Executive Director, CAWC www.cawc.net ABOUT CAWC Established in 1995, the Canadian Association of Wound Care (CAWC) is a non-profit organisation dedicated to advancing skin health and wound management in Canada. Dedicated staff and volunteers work to improve the health of Canadians at risk for skin breakdown and the practice of the health professionals who care for them.

The CAWC is a leader in bringing evidence-based best practices to health professionals, and we are now reaching out to raise awareness of the importance of effective, evidence-informed wound management and prevention for all Canadians. The CAWC is also developing a public advocacy programme to help patients, their families and caregivers make their issues and concerns a priority for government action.

In 2015, the CAWC is focused on four priorities: Professional Education The CAWC offers opportunities to health-care professionals using various methods to provide flexible, interprofessional education that supports the learning needs and professional career growth in the areas of skin health, wound prevention and management. The strength of the programmes lays not only in their content and delivery methods, but also because they are part of a continuum of learning aimed at improving the practice of healthcare professionals all levels, in all settings and across the entire country.

Each year the CAWC delivers the largest accredited wound-specific conference in Canada. This year it will be held in Toronto between October 29th and November 1st. Advocacy The CAWC is dedicated to giving a voice to patients living with wounds. It starts with educating policymakers, clinicians and the general public about the needs of people with wounds or at risk for wounds. As understanding improves, this will ensure that people at risk or living with wounds receive improved care and face fewer barriers to a healthier life. Research The Research Committee of the CAWC is mandated to support and promote research within the wound community and contribute to the evaluation of new wound prevention and management strategies based on patient outcomes and health economic analyses. Partnerships Over the last few years, the CAWC has been actively participating in conferences around the country, connecting with Health Canada and provincial health ministries, and developing partnerships with other non-profit organisations, universities and industry to advance skin health and wound care across Canada. n

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Organisations

WAWLC NEWS WAWLC World Alliance for Wound and Lymphedema Care

Dr. David Keast President of WAWLC

Dr. Hubert Vuagnat Treasurer of WAWLC

www.wawlc.org

Conference activities In November 2014, the World Alliance for Wound and Lymphoedema Care (WAWLC) annual meeting was held jointly with the Canadian Association of Wound Care (CAWC) conference (October 29th-November 1st) Toronto, Canada. The WAWLC hosted a one day livestream at the conference, providing two panel sessions: “New Lessons and Knowledge about Wound Care in Limited Resource Countries” and “Debate around a Standard Wound Care Kit for Limited Resource Countries.” Annual general meeting At the 2014 WAWLC Annual General Meeting, Dr. John Macdonald asked to be relieved of his duties as General Secretary. Robyn Bjork was elected to take over this duty. Dr. Macdonald, due to his role as the founding General Secretary, was appointed Secretary Emeritus by the WAWLC board. The entire committee was re-elected. The wound care kit for limited resource settings Dr. Eric Comte continues to lead work done by a committee toward defining the content of a basic wound care kit, which would, with little equipment and following modern concepts (wound bed preparation, moist environement), facilitate the treatment of chronic wounds in limited resource settings. A public working session focusing on the status of the wound care kit was held during the EWMA 2015 Conference in London, held from 13-15 May. Input on the kit was provided during this interactive discussion session. The committee that designed the wound care kit is currently focusing on building a kit pre-prototype, af-

ter which it will assemble 10 to 12 prototypes to be sent to three reference centres (Benin, Cameroon, Haiti) for practical testing. Once the test data are gathered and the kit modified accordingly, a more massive production will take place and NGOs that could benefit from the kit will be contacted. Information about the wound care kit can be found at www.ewma.org project activities in Cameroon Through Doctors without Borders (MSF) financial and administrative support, the Buruli Program at the Akonolinga District Hospital has become an innovative general chronic wound treatment program. As a spin-off from these activities, we have fostered a basic wound care course (5 days of theory and 5 days of general practice) in collaboration with local teachers. EWMA’s commitment allowed Professor Same Ekobo from Yaoundé, Cameroon to report on these activities during the EWMA-GNEAUPP 2014 conference (14-16th May 2014 Madrid). In June 2014, the MSF handed back its program to the ministry of health, causing program setbacks, including a reduction of the local workforce by one half and financial stress that made it difficult to obtain new supplies. These setbacks delayed the third wound care course (after those held in July 2013 and April 2014), which was scheduled from December 2014 to January 2015. With financial support from the University Hospitals of Geneva and the Swiss Association for Wound Care, Drs. Vuagnat and Comte were able to offer the course in January 2015. Through the same sources, financial provision will allow two further courses, one in December 2015 and one in 2016. Furthermore, with WAWLC financial support and private funding, 

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Participants of the third wound care course in Yaoundé.

2015 vol 15 no 2

Dr Hubert Vuagnat receiving his teaching diploma from Professor Njamshi, Vice Dean of the Faculty, during the third wound care course in Yaoundé.

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This is how life feels to people with EB. Their skin is as fragile as a butterfly’s wing. They have Epidermolysis Bullosa, a painful and currently incurable skin blistering condition. www.debra-international.org

Drs. Vuagnat and Comte were able to support the local team by providing basic dressing materials such as petroleum jelly, dry gauze, soap, tape, palmist oil, etc. The goal driving these efforts is not only to promote modern wound care but also to aid well-trained and dedicated people while establishing a NGO that could attract more stable funding. A financial commitment by the WAWLC allowed Dr. Franck Wanda, a junior collaborator in Cameroun, to attend the WHO Buruli Symposium held in Geneva in March 2015 to report on the teaching efforts in his country. Furthermore, this financial commitment allowed Dr. Vuagnat and six members of Akonolinga chronic wound care team to attend the African Parasitology Congress held April 28th-30th 2015 in Bandjoun, Cameroon, where they gave oral and poster presentations. Participants from across Africa greatly appreciated learning about new wound dressing techniques from Dr. Vuagnat and his team. Wound care training on the Ivory Coast The American Leprosy Mission (ALM) invited Dr. Hubert Vuagnat on two occasions to work with MAP International and Linda Lehmen to teach a basic wound care and rehabilitation course at the Adzope Raoul Follereau Institute, which is a reference centre both in Lepra and Buruli. During the two-week course, participants learned basic wound care and disability prevention (from a manual), and their course participation and learned skills will be endorsed by the Ivory Coast Ministry of Health. Buruli Ulcer Research Project in Ghana, Benin, and Cameroon Drs. John MacDonald and Terry Treadwell are currently involved in a 500 patient controlled trial for the treatment of Buruli ulcer with all oral antibiotics, instead of intramusculary and modern wound care techniques instead of dry gauze. Enrolment is slowly progressing. Wound and lymphoedema care in Haiti The Wound Centre at Bernard Mevs Hospital in Port-au-Prince, Haiti, is continuing under the able leadership of Dr. Adler Francius, who is guided by on-going support from Dr. John Macdonald. A new collaboration with Fondation Haitienne de Diabete et des Maladies Cardio-Vasculaires (FHADIMAC) will establish a comprehensive diabetic foot ulcer clinic. Through the work of Robyn Bjork and Heather Hettrick on behalf of the WAWLC and with support from the Brazilian embassies in Haiti and Nova Southeastern, the University of Notre Dame Lymphatic Filariasis Program’s lymphoedema management clinic in Leogane was reopened. The WAWLC contributed 1,500 USD for bandages, and local clinicians were trained to provide care. Hôpital de L’Université D’Etat D’Haïti, Port-au-Prince has requested that Dr. Terry Treadwell allow surgical residents to complete a preceptorship with the Institute for Advanced Wound Care in Montgomery, Alabama, U.S.A. Burden of illness in emerging markets study The WAWLC has appointed Dr. Vuagnat as its key resource person providing clinical guidance to an on-going literature review of the burden of wound care in Brazil, China, and India. The study is supported by an unrestricted educational grant from three international companies engaged in wound care. Results are expected to be published in 2016. n EWMA Journal

International.

2015 vol 15 no 2

Organisations

new international partner:

The International Wound Infection Institute IWII is a multidisciplinary inclusive society, providing a global perspective on the latest developments in wound infection.

Terry Swanson Immediate Past Chair

Dr David Keast Chair Written in collaboration with the IWII committee members. www.woundinfectioninstitute.com.

Membership to the IWII is free and available through our website, www.woundinfection-institute. com. We aim to inform and educate specialist and generalist practitioners in wound infection prevention and management and create a positive impact on patient-care outcomes. We currently have over 1,700 registered members from over 20 countries and hope to increase this membership base over the next 2 years. Members have full access to a wealth of material on the IWII web site, including the latest research on and education in wound infection prevention and management. We recently updated our website and would like to acknowledge our financial supporters, Martindale Pharma and Phoenix Eagle, for making that possible. The IWII is managed by elected committee members, who uphold the aim and objectives of the IWII in a volunteer capacity. As of 2013, our secretariat is Omnia-Med Ltd., previously known as Schofield

Healthcare, in the United Kingdom. The IWII has been instrumental in producing a number of internationally acknowledged documents such as the review and extension of the TIME principal as well publications in the International Wound Journal, Journal of Wound Care, Wounds International, and other relevant journals. The TIME Update has had significant exposure and been referenced in leading documents and journal articles internationally since its publication. In 2014, we published three “Top Ten Tips” in Wounds International on the following topics: surgical site infections, biofilm, and antibiotic resistance. Future Vision: We aim to build our international membership and professional and commercial networks for those interested in the prevention and management of wound infection. We seek to develop best-practice guidelines on wound care for both health care professionals and patients and to obtain sustainable financial support, which will enable us to advance our research and education goals. n

The current committee is: Chair: Dr David Keast, Wound Care Theme Leader. ARGC, Parkwood Institute, London, Canada. Immediate Past

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Chair: Terry Swanson, Nurse Practitioner, South West Healthcare, Australia Vice Chair: Professor Rose Cooper, Professor of Microbiology, Cardiff Metropolitan University, Wales Secretary: A/ Professor Joyce Black, University of Nebraska Medical Center, USA Treasurer: A/Prof Geoff Sussman Faculty of Medicine, Nursing and Health Science Monash University Australia Education: Jacqui Fletcher, Clinical Strategic Director, Welsh Wound Innovation Centre, UK Evidence: Professor Keryln Carville, Silver Chain and Curtin University, Australia Research: Professor Gregory Schultz, University of Florida, USA Membership: A/Prof Geoff Sussman Faculty of Medicine, Nursing and Health Science Monash University Australia Translation: Dr. Jose Contrearas Ruiz, Dermatologist, Mexico Funding: Terry Swanson, Nurse Practitioner, South West Healthcare, Australia General Committee: Donna Angel, Nurse Practitioner Royal Perth Hospital, Australia Wayne Naylor, Director of Nursing at Hospice Waikato, New Zealand Dr Evan Call, Adjunct Faculty, Weber State University Department of Microbiology Dr Gojiro Nakagami, University of Tokyo, Japan Secretariat: Rob Yates Secretariat IWII, rob.yates@woundsgroup.com Kathy Day Secretariat IWII, Kathy.day@woundsgroup.com

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EWMA

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Lohmann & Rauscher www.lohmann-rauscher.com

Mölnlycke Health Care Ab www.molnlycke.com

Ferris Mfg. Corp. www.PolyMem.eu

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

sorbion GmbH & Co. KG www.sorbion.com

Corporate B

3M Health Care www.mmm.com Chemviron www.chemvironcarbon.com

ABIGO Medical AB www.abigo.se

Boyd Technologies www.boydtech.com

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Covalon Technologies Ltd www.covalon.com

Nutricia Advanced Medical Nutrition www.nutricia.com

SastoMed www.sastomed.com

DryMax www.absorbest.se/ drymax-woundcare

SOFAR S.p.A. www.sofarfarm.it

KLOX Technologies Inc www.kloxtechnologies.com

Söring Gmb www.soering.com

Stryker www.stryker.com

Laboratoires Urgo www.urgo.com

Welcare Industries SPA www.welcaremedical.com

EWMA Journal

2015 vol 15 no 2

Bremen

PATIENTS 路 WOUNDS 路 RIGHTS

Conference Calendar 2015/16 Conferences 2015

Theme

Month

17th Annual Meeting of the Austrian Wound Association (AWA)

October

2015 Conference of Wound Management Who is Navigating the October Association of Ireland (WMAI) Destiny of Wounds

Days

City

2-3

St. Pölten Austria

2-3 Dublin

13th Annual Congress of the Italian Association October 7-10 Bari, Fiera del for the study of Cutanecus Ulcers (AIUC) Levante 24th Conference of the European Academy of Dermatology and Venereology (EADV)

October

7-11

The Diabetic foot problems symposium

October

9 Helsinki

Country

Ireland Italy

Copenhagen Denmark Finland

National Multidisciplinary Congress (NOVW) Trilogy about Wounds October

13 Ede Netherlands

XVIII Congress of the Hungarian Wound Care Society (MSKT)

October

15-16 Budapest Hungary

Annual conference of SUMS (SUMS)

October

16 Reykjavik

Iceland

7th Joint Meeting of the European Tissue Repair ‘From Bed to Bench’ - on Tissue October Society (ETRS) & the Wound Healing Society (WHS) Repair and regeneration.

20-22

8. Symposium. Cronic wounds - care in primary care (CWA)

22-23 Tuhelj

Croatia

1st EADV Fostering Specialist Course Wound Care Fostering Specialist Course October Wound Care

23-25

Switzerland

21st Annual Conference of Canadian Association October of Wound Care (CAWC) -November

29-1 Toronto

Canada

VIII Ibero-Latin American Congress about Ulcers and Wounds (SILAUHE)

November

11-13

Mexico

9th National Wound Care Congress (BEFEWO)

November

9 Dilbeek Belgium

Wounds UK Annual Conference

November

9-11 Harrogate

United Kingdom

Conference and workshop of APTFeridas

“Say NO to Pressure Ulcers” November

20-21

Portugal

2nd Iberian Symposium on Diabetes (ELCOS, ULCUS, Évora)

November

20-21 Arronches

October

Copenhagen Denmark

Zürich

Mérida

Porto

Portugal

15th Congress of the Wound Care Society (WCS) Together - Smarter in Woundcare November

24-25

Utrecht The Netherlands

Symposium APTFeridas 2015

November

26-27 Exponor

Portugal

11th Annual Conference of Ukraine Wound Treatment Organisation (UWTO)

November

26-28

Ukraine

Annual Meeting of Danish Wound Healing Society (DSFS)

November

27-28 Billund Denmark

10th National Congress of the Turkish Wound Management Association (WMAT)

December

2-5 Antalya Turkey

Kiev

Conferences 2016 Theme Month Days City 20th Annual Conference of the French and January 17-19 Paris Francophone Society of Wounds and Wound Healing (SFFPC)

Country

14th National Congress of CSLR

“Interdisciplinary cooperation in the treatment of wounds and skin defects”

January

21-22

Czech Republic

XIX National Wound Management Conference (FWCS)

February

4-5 Helsinki

Finland

5th Congress of SEHER

February

5-6

Spain

Pardubice

Madrid

France

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2015 vol 15 no 2

Organisations

Conference Calendar - cont. Conferences 2016

Theme

Wound Conference of SSiS

Days

City

Country

Wound Care of the Future April

20-21

Umeå

Sweden

Tissue Viability Society 2016 – The Conference! (TVS)

April

20-21

Cardiff

Wales

9th Ibero Latin American Congress on Ulcers and Wounds (GNEAUPP)

May

4-6

Logrono

Spain

26th Conference of the European Wound Management Association (EWMA) in collaboration with Deutscher Wundkongress (DeWu) and WundD-A-CH

Patients.Wounds.Rights

May

11-13 Bremen

Germany

16th Malvern Diabetic Foot Conference

May

18-20 Oxfordshire

United Kingdom

13th EADV Spring Symposium

May

19-22 Athens

Greece

17th EFORT Congress

June

01-03

Switzerland

28th National Congress of Nursing and Vascular Wounds (AEEVH)

June

9-10 Barcelona

Spain

1st DGfW Akademy-day

June

Germany

3rd international Course on the Neuropathic Osteoarthropathic Foot (Charcot Foot Course)

June

23-25 Rheine

Germany

5th congress of the WUWHS. One Vision, One Mission

September

25-29

Florence

Italy

2nd conference of the Association for Diabetic Foot Surgeons

September

Stuttgart

Germany

13th meeting of the Diabetic Foot Study Group (DFSG) of the European Association for the Study of Diabetes (EASD)

September

9-11

Stuttgart

Germany

25th EADV Congress

September /October

28-02

Vienna Austria

Denmark

Nordic Diabetic Foot Symposium 2016

Month

October

Geneva

Giessen

For web addresses please visit www.ewma.org

EWMA Journal

2015 vol 15 no 2

109

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

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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

2015 vol 15 no 2

Organisations

Cooperating Organisations (cont.)

NZWCS

V&VN

SILAUHE

Decubitus and Wound Consultants, Netherlands www.venvn.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

International Partner Organisations AAWC

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

AWMA

Australian Wound Management Association 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

CTRS

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

IWII

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

ILF

International Lymphoedema Framework www.lympho.org

KWMS

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

EWMA Journal

2015 vol 15 no 2

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

Associated Organisations Leg Club

Lindsay Leg Club Foundation www.legclub.org

Iberolatinoamerican Society of Ulcers and Wounds www.silauhe.org

LSN

SOBENFeE

The Lymphoedema Support Network www.lymphoedema.org/lsn

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

WAWLC

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

Other Collaborators

Media Partner JWC

Journal of Wound Care www.magonlinelibrary.com

DFSG

Diabetic Foot Study Group www.dfsg.org

EADV

European Academy of Dermatology and Venereology www.eadv.org

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

Eucomed

Eucomed Advanced Wound Care Sector Group www.eucomed.org

HomeCare Europe www.homecareeurope.org

ICC

International Compression Club www.icc-compressionclub.com

MSF

Médecins Sans Frontières www.msf.org

WUWHS

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

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7 Editorial Sepännen S, Gethin G

Science, Practice and Education 11 Of Youth and Age - What are the Differences regarding Skin Structure and Function ? Kottner J 15 The Development and Benefits of 10 year´s Experience with an Electronic Monitoring Tool (PUNT) in a UK Hospital Trust. Collier M 23 Preparing Student Nurses for the Future of Wound Management: Telemedicine in a Simulated Learning Environment. Christiansen S, Rethmeier A 29 The Psychological Effect of Malignant Fungating Wounds on the Patient. Reynolds H, Gethin G 34 The Pressure Ulcer Guidance (PUG) Tool. Barnard J, Copson D 37 Development and Implementation of a Tool to Assess and Differentiate Moisture Lesions and Pressure Ulcers. Stephen-Haynes J, Callaghan R, Evans M, Simm S 41 The Fluorescent Diagnosis of Stoma Mucosa. Wai H C, Ngai T C, Shan S Y, Wing P Y, Yan C W 47 Overcoming Challenges when Introducing eHealth - Momentum Workshops. Whitehouse D, Lange M

Cochrane Reviews 51 Abstracts of Recent Cochrane Reviews. Rizello G

Book Reviews 58 Fast Facts About Pressure Ulcer Care for Nurses – How to Prevent, Detect and Resolve them in a Nutshell. Gethin G

Organisations 100 101 102 103 105 106 108 110