Reduction in wound healing times,cost of consumables and number of visits treated through the implementation of an electronic wound care system in rural Australia

Globally, wound care costs the health care system 2–3% of the total expenditure on health, which equates to several billion dollars annually. To date, there are little data on the cost and healing rates of various wounds. This has been partly because of the difficulty in tracking wound management as the majority of wound care data has been focused on retrospective data from hospitals, general practice clinics and aged care facilities. This study reports on wound healing and cost of wounds collected from a larger project using the mobile wound care (MWC) electronic documentation system, which has been described elsewhere. The study involved 2350 clients from four health service districts in the Gippsland region in rural Australia who received treatments as part of the MWC research project (2010–2012), with a total of 3726 wounds identified (so an average of 1·6 wounds per client). By the end of the data collection period, 81% of these wounds had healed. A significant drop in healing time, cost of consumables and number of visits was found across the 3‐year period.     

Evaluation of the impact of restructuring wound management practices in a community care provider in Niagara, Canada

The burden of chronic wounds is substantial, and this burden is set to increase as the population ages. The challenge for community health services is significant. Wound care is labour intensive, and demand for services is set to increase at a time when the availability of nursing resources is likely to be severely limited. In March 2005, the Niagara community health care provider implemented a radical reorganisation of wound management practices designed to ensure that available resources, particularly nurse time, were being used in the most efficient way. An evaluation of the impact of the reorganisation has shown improvements in clinical practice and better patient outcomes. The use of traditional wound care products reduced from 75% in 2005 to 20% in 2007 in line with best practice recommendations, and frequency of daily dressing changes reduced from 48% in 2005 to 15% in 2007. In a comparison of patients treated in 2005 and 2006, average time to healing was 51.5 weeks in 2005 compared with 20.9 weeks in 2006. Total treatment cost was lower in 2006 by $10,700 (75%) per patient. Overall, improvements in wound management practice led to a net saving of $3.8 million in the Niagara wound care budget.     

An audit to assess the perspectives of US wound care specialists regarding the importance of proteases in wound healing and wound assessment

Chronic wounds represent an aberrant biochemistry that creates a toxic proteolytic milieu which can be detrimental to the healing process. Rebalancing the wound microenvironment and addressing elevated protease activity (EPA) could therefore help facilitate healing. To understand how clinicians currently diagnose and manage excessive proteolytic activity, 183 survey responses from US wound specialists were collated and analysed to find out their perceptions on the role of proteases. The majority of respondents (>98%) believed proteases were important in wound healing and that a point‐of‐care (POC) protease test could be useful. This study yielded a low response rate (7·1%, n = 183); however, there were adequate data to draw significant conclusions. Specialists perceived that fibrin, slough, granulation tissue and rolled wound edges could indicate EPA. About 43% of respondents, however, failed to give a correct response when asked to review photographs to determine if excessive protease activity was present, and the perceived visual signs for EPA did not correlate with the wounds that had EPA; no statistical differences between professions were observed. Respondents chose debridement, wound cleansing and advanced therapies as important in reducing excessive protease activity. It was concluded that specialists have a need for POC diagnostic tests. On the basis of the responses to wound photos, it was determined that there were no visual cues clinicians could use in determining excessive protease activity. Additional research is recommended to evaluate the efficacy of a POC diagnostic test for protease activity and the treatments and therapies applied when EPA is found.     

Simplified negative pressure wound therapy: clinical evaluation of an ultraportable,no‐canister system

The aim of this study was to evaluate a prototype negative pressure wound therapy (NPWT) system that has been developed to simplify NPWT for wounds at the lower end of the acuity scale. The new device has a single preset pressure of ?80 mmHg, is single use and operates without an exudate canister. The disposable NPWT system (PICO?) was tested in a prospective, non‐comparative, multicentre clinical trial to assess device functionality and clinical acceptance. Twenty patients were recruited for a maximum treatment period of 14 days. The NPWT devices were fitted with data log chips to enable longitudinal assessment of negative pressure and leak rates during therapy. Sixteen (80%) patients had closed surgical wounds, two (10%) patients had traumatic wounds and two (10%) patients received meshed split thickness skin grafts. The mean study duration was 10·7 days (range: 5–14 days) and the mean dressing wear time per individual patient was 4·6 days (range: 2–11). Fifty‐five percent of wounds had closed by the end of the 14‐day study or earlier, with a further 40% of wounds progressing to closure. Real‐time pressure monitoring showed continuous delivery of NPWT. Three cases are discussed representing different wound locations and different patient factors that can increase the risk of post‐surgical complications. Clinical studies of the disposable NPWT system confirmed the ability of the simplified single‐use device to function consistently over the expected wear time. The anticipated reduced costs, ease of use and increased mobility of patients using this system may enable NPWT benefits to be available to a greater proportion of patients.     

Advancing age and trauma: Triage destination compliance and mortality in Victoria,Australia

Objective

To describe the association between increasing age, pre-hospital triage destination compliance, and patient outcomes for adult trauma patients.

Methods

A retrospective data review was conducted of adult trauma patients attended by Ambulance Victoria (AV) between 2007 and 2011. AV pre-hospital data was matched to Victorian State Trauma Registry (VSTR) hospital data. Inclusion criteria were adult patients sustaining a traumatic mechanism of injury. Patients sustaining secondary traumatic injuries from non-traumatic causes were excluded. The primary outcomes were destination compliance and in-hospital mortality. These outcomes were evaluated using multivariable logistic regression.

Results

There were 326,035 adult trauma patients from 2007 to 2011, and 18.7% met the AV pre-hospital trauma triage criteria. The VSTR classified 7461 patients as confirmed major trauma (40.9% > 55 years). Whilst the trauma triage criteria have high sensitivity (95.8%) and a low under-triage rate (4.2%), the adjusted odds of destination compliance for older trauma patients were between 23.7% and 41.4% lower compared to younger patients. The odds of death increased 8% for each year above age 55 years (OR: 1.08; 95% CI: 1.07, 1.09).

Conclusions

Despite effective pre-hospital trauma triage criteria, older trauma patients are less likely to be transported to a major trauma service and have poorer outcomes than younger adult trauma patients. It is likely that the benefit of access to definitive trauma care may vary across age groups according to trauma cause, patient history, comorbidities and expected patient outcome. Further research is required to explore how the Victorian trauma system can be optimised to meet the needs of a rapidly ageing population.     

Animal‐inflicted open wounds in rural Turkey: lessons learned and a proposed treatment algorithm for uncertain scenarios

Uncertainty in the management of animal‐inflicted injuries, especially in rural settings, usually results in a general approach to leave all wounds to heal with secondary intention, which can lead to unsightly scarring and functional loss. This study focusus on different circumstances dealt with by plastic surgeons in a rural setting in Turkey and aims to configure what the general approach should be through an analysis of a wide spectrum of patients. Between June 2013 and December 2014, 205 patients who presented to the emergency department for animal‐inflicted injuries were retrospectively analysed. Patients who consulted for plastic surgery were included in the analysis to determine which wounds require further attention. Patients with past animal‐inflicted injuries who presented to the outpatient plastic surgery clinic with concerns such as non‐healing open wounds or cosmetic or functional impairment were also evaluated. Statistical analysis demostrated a significantly lower rate of infection encountered in animal‐inflicted open wounds (AIOWs) of patients who consulted for plastic surgery from the emergency department than those who presented to the outpatient clinic (P < 0·05). The main concern in the management of animal‐inflicted wounds is their potential for infection, but this does not mean that every wound will be infected. The most important factor is being able to distinguish wounds that have a higher potential for infection and to select the type of wound management accordingly. An algorithm has been proposed as a guidance for the management of AIOWs, which covers the approach towards both domestic and stray animal‐inflicted injuries.     

Comparison of tissue damage,cleansing and cross‐contamination potential during wound cleansing via two methods: lavage and negative pressure wound therapy with instillation

The use of lavage was compared to negative pressure wound therapy (NPWT) with instillation (NPWTi) to assess extent of soft tissue damage, debris removal and environmental cross‐contamination susceptibility in three distinct models. Scanning electron microscopy in an ex vivo model showed increased visible tissue trauma from lavage treatment at low and high pressures versus NPWTi, with the degree of trauma relative to the pressure of the irrigant. These results were corroborated in granulating full‐thickness excisional swine wounds coated with dextran solution to simulate wound debris. Both low‐pressure lavage and NPWTi demonstrated effective cleansing in this model, reducing debris by >90%. However, using three‐dimensional photography to evaluate tissue damage by measuring immediate tissue swelling (changes in wound volume and depth) showed significantly greater (P < 0.05) swelling in low‐pressure lavage‐treated wounds compared with NPWTi‐treated wounds. Lastly, bench top wound models were inoculated with fluorescent bacterial particles to assess environmental cross‐contamination potential and collected at measured distances after treatment with low‐pressure lavage and NPWTi. No evidence of cross‐contamination was found with NPWTi, whereas one‐half of the particles became ‘aerosolised’ during low‐pressure lavage (P < 0.05). Collectively, these studies demonstrate the effective wound cleansing capabilities of NPWTi without the tissue damage and environmental contamination associated with lavage.     

Epidemiology and use of compression treatment in venous leg ulcers: nationwide claims data analysis in Germany

Chronic venous diseases are the most common causes of leg ulcers. Compression treatment (CT) is a central component of venous leg ulcer (VLU) therapy along with prevention based on guidelines and clinical evidence. However, large‐scale data on the use of CT are rare. In particular, there have not yet been published nationwide data for Germany. We analysed data from a large German statutory health insurance (SHI) on incident VLU between 2010 and 2012. VLUs were identified by ICD‐10 diagnoses. The status of active disease was defined by wound‐specific treatments. Compression stockings and bandages were identified by SHI medical device codes. The overall estimated incident rate of active VLU of all insured persons was 0·34% from 2010 to 2012. Adapted to the overall German population, n = 229 369 persons nationwide had an incident VLU in 2010–2012. Among all VLU patients, only 40·6% received CT within 1 year, including 83·3% stockings, 31·8% bandages and 3·1% multi‐component compression systems. Compression rates showed significant differences by gender and age. Large regional variations were observed. Validity of data is suggested by high concordance with a primary cohort study. Although recommended by guidelines, there is still a marked under‐provision of care, with CT in incident VLUs in Germany requiring active measures.     

Development and evaluation of a digital education tool for medical students in wound care

The aim of this study was to develop and evaluate an interactive, video‐enhanced, and case‐based online course for medical students. We chose a case about wound care since this topic is still underrepresented in the medical curriculum. First, instructional videos were created to teach practical skills in wound care. These were implemented into a case‐based online course, using the online learning platform ILIAS. In a comparative initial and final survey, numbers of users were assessed, content and structure of the course, as well as the thematic interest of the students and self‐assessed gain of competence, were evaluated. Since the summer of 2019, 310 students have successfully completed the course. The survey data showed a high participation rate and a positive response regarding the content as well as the structural concept. Most of the students rated the content within the course as useful for their future medical work (86.1%) and the gain of knowledge superior to a traditional lecture (69.4%). Self‐assessments of video‐mediated skills showed a significant increase in subjectively perceived competence. The online course is an efficient way to reach many students by the small use of resources. It resembles an option to arouse growing interest in wound care in medical students.     

Assessment and documentation of non‐healing,chronic wounds in inpatient health care facilities in the Czech Republic: an evaluation study

The foundation of health care management of patients with non‐healing, chronic wounds needs accurate evaluation followed by the selection of an appropriate therapeutic strategy. Assessment of non‐healing, chronic wounds in clinical practice in the Czech Republic is not standardised. The aim of this study was to analyse the methods being used to assess non‐healing, chronic wounds in inpatient facilities in the Czech Republic. The research was carried out at 77 inpatient medical facilities (8 university/faculty hospitals, 63 hospitals and 6 long‐ term hospitals) across all regions of the Czech Republic. A mixed model was used for the research (participatory observation including creation of field notes and content analysis of documents for documentation and analysis of qualitative and quantitative data). The results of this research have corroborated the suspicion of inconsistencies in procedures used by general nurses for assessment of non‐healing, chronic wounds. However, the situation was found to be more positive with regard to evaluation of basic/fundamental parameters of a wound (e.g. size, depth and location of a wound) compared with the evaluation of more specific parameters (e.g. exudate or signs of infection). This included not only the number of observed variables, but also the action taken. Both were significantly improved when a consultant for wound healing was present (P = 0·047). The same applied to facilities possessing a certificate of quality issued by the Czech Wound Management Association (P = 0·010). In conclusion, an effective strategy for wound management depends on the method and scope of the assessment of non‐healing, chronic wounds in place in clinical practice in observed facilities; improvement may be expected following the general introduction of a ‘non‐healing, chronic wound assessment’ algorithm.     

Adipose‐derived stem cells and keratinocytes in a chronic wound cell culture model: the role of hydroxyectoine

Chronic wounds represent a major socio‐economic problem in developed countries today. Wound healing is a complex biological process. It requires a well‐orchestrated interaction of mediators, resident cells and infiltrating cells. In this context, mesenchymal stem cells and keratinocytes play a crucial role in tissue regeneration. In chronic wounds these processes are disturbed and cell viability is reduced. Hydroxyectoine (HyEc) is a membrane protecting osmolyte with protein and macromolecule stabilising properties. Adipose‐derived stem cells (ASC) and keratinocytes were cultured with chronic wound fluid (CWF) and treated with HyEc. Proliferation was investigated using MTT test and migration was examined with transwell‐migration assay and scratch assay. Gene expression changes of basic fibroblast growth factor (b‐FGF), vascular endothelial growth factor (VEGF), matrix metalloproteinases‐2 (MMP‐2) and MMP‐9 were analysed by quantitative real‐time polymerase chain reaction (qRT‐PCR). CWF significantly inhibited proliferation and migration of keratinocytes. Addition of HyEc did not affect these results. Proliferation capacity of ASC was not influenced by CWF whereas migration was significantly enhanced. HyEc significantly reduced ASC migration. Expression of b‐FGF, VEGF, MMP‐2 and MMP‐9 in ASC, and b‐FGF, VEGF and MMP‐9 in keratinocytes was strongly induced by chronic wound fluid. HyEc enhanced CWF induced gene expression of VEGF in ASC and MMP‐9 in keratinocytes. CWF negatively impaired keratinocyte function, which was not influenced by HyEc. ASC migration was stimulated by CWF, whereas HyEc significantly inhibited migration of ASC. CWF induced gene expression of VEGF in ASC and MMP‐9 in keratinocytes was enhanced by HyEc, which might partly be explained by an RNA stabilising effect of HyEc.     

Patient education materials on pressure injury prevention in hospitals and health services in Victoria,Australia: Availability and content analysis

Pressure injuries (PIs) are a common quality indicator for hospital care, and preventing PIs often requires patient engagement; as such, Australian consensus research has recommended that high‐quality education materials be made to patients for PIs via hospital networks. The purpose of the present study was to assess the availability and accuracy of patient education materials on PIs in publicly available hospital websites in Victoria, Australia. Two independent coders assessed 212 websites for content on PI prevention and management, analysing availability and accuracy of PI definitions, risk factors, preventive strategies, referral, visual tools, consumer endorsement, information for family/carers, and translation on community languages. A greater proportion of hospitals did not have any patient education materials on PI prevention publicly available, with private hospitals (compared with public) and metropolitan hospitals (compared to rural) more likely to have materials available on their sites. The available materials contained accurate messages on PI defining characteristics and risk factors for PIs, although there was considerable variability on the availability of other information. Our findings suggest a significant deficit in the availability of educational materials for acute care patients and their families. There is a need for evidence‐based, consumer‐endorsed, uniform materials on all hospital websites to prevent PIs in acute care.     

Analysis of run-in and treatment data in a wound outcomes registry: clinical impact of topical platelet-rich plasma gel on healing trajectory

Randomised controlled trials in chronic wounds typically exclude patients with comorbidities and confounding factors. Well‐designed observational studies can provide complementary clinical evidence that randomised trials cannot address. This study determined if wound care registry outcomes could be an alternative data source and if the results would be robust and valid. Changes in wound area and depth were hypothesised to be different between run‐in therapies and platelet‐rich plasma (AutoloGel?, Cytomedix, Inc) treatment. From a treatment registry of 285 chronic wounds, 46 had run‐in and post‐treatment data. Seven chronic wound categories were identified. Mean wound age at study start was 52·4 days. General linear model repeated measures showed a credible and robust data set. Statistically significant differences for wound area and depth were observed between run‐in and post‐treatment period at multiple time points. Wound area and depth ≥50% reduction were analysed using Kaplan–Meier methods. During run‐in, 15% of wound area improved compared to 28% post‐treatment and 11% of wound depth improved during run‐in compared to 39% post‐treatment. Significant clinical outcomes indicated many previously non responsive wounds began actively healing in response to platelet‐rich plasma therapy, indicating that registry data can be used as a complementary source of evidence.     

Feasibility of an electrostimulation system treatment for wound healing: a case series of patients with chronic ulcers in Barbados

Major advances have been made in the development of new therapies for chronic wounds. Fenzian?, an electrostimulation system (ES), has been clinically used for a variety of conditions. The ES was recently tested in the Barbadian population for tolerability and acceptability by asthma patients, with encouraging results. Barbados has an estimated 170 people with diabetes having some form of lower‐extremity amputation annually. Here, we describe a case series of 21 chronic ulcer patients with diabetes recruited as inpatients (n = 10) and outpatients (n = 11) in a pilot study to evaluate the feasibility and acceptability of ES in the Barbadian population. Results showed statistically significant improvement among those in the inpatient‐ versus outpatient‐recruited group for wound perimeter (P = 0·04), wound surface area (P = 0·03) and wound volume (P = 0·08). We also demonstrate that the improvement continued after cessation of ES treatment. Participants reported increased levels of pain at the end of treatment, and there was no statistically significant change in the reported quality of life. Our results showed greater improvements in reduction of ulcer size for participants from the inpatient‐ versus outpatient‐recruited group.     

Epidermal grafting for wound healing: a review on the harvesting systems,the ultrastructure of the graft and the mechanism of wound healing

Epidermal grafting for wound healing involves the transfer of the epidermis from a healthy location to cover a wound. The structural difference of the epidermal graft in comparison to the split‐thickness skin graft and full‐thickness skin graft contributes to the mechanism of effect. While skin grafting is an epidermal transfer, little is known about the precise mechanism of wound healing by epidermal graft. This paper aims to explore the evolution of the epidermal graft harvesting system over the last five decades, the structural advantages of epidermal graft for wound healing and the current hypotheses on the mechanism of wound healing by epidermal graft. Three mechanisms are proposed: keratinocyte activation, growth factor secretion and reepithelialisation from the wound edge. We evaluate and explain how these processes work and integrate to promote wound healing based on the current in vivo and in vitro evidence. We also review the ongoing clinical trials evaluating the efficacy of epidermal graft for wound healing. The epidermal graft is a promising alternative to the more invasive conventional surgical techniques as it is simple, less expensive and reduces the surgical burden for patients in need of wound coverage.