Complex Wound Issues Non-Clinical Quality Pharmacy Training 2017

Transcription

1 Medicine, Nursing and Health Sciences Complex Wound Issues Non-Clinical Quality Pharmacy Training 2017 Complex Wounds Patient needs and preferences Distances Access Carer availability Associate Professor Geoff Sussman Clayton Campus Quality of life issues Economic outcomes Palliative wound care Types of Complex Wounds Pressure Ulcers Cancerous Neuropathic Arterial Factitious Issues with Complex Wounds Cost Compliance Comfort Exudate/ discharge Infection Aesthetics Odour Bleeding Other Issues with Complex Wounds Success of outcome How do we rate success Intervention Management options Viability of intervention or management options Quality of Life Various tools to measure quality of life They are not designed to access someone with a complex wound and therefore the tools are not sensitive to wound care 1

2 Quality of Life Tools Quality of Life SF-36 is a multi-purpose, short-form health survey with 36 questions. It yields an 8-scale profile of functional health and well-being scores as well as psychometrically-based physical and mental health summary measures and a preference-based health utility index. This is the main tool used however it does not relate well to wound issues Evaluation and management of a patient As health practitioners, the difference in a patient are measurable, even if they are not comparable with another patient. Best measure of QOL is participation in life Quality of Life The Illness cycle Patient life is consumed by their wound Life revolves around appointments GP Wound Clinic RDNS ( District Nurse) Social Isolation Patient needs and preferences Outcomes sought Wound healing Pain reduction Cosmetic outcomes Financial burden Socialisation Access Distance Accessibility/ Mobility Carer availability Palliative Management Some wounds cannot or will not heal Wound Factors Patient Factor Environmental and other factors Wound Pain Our Experience A study of Wound Pain in the Wound Clinic Repat Campus Austin Health Consider needs and preferences of the patient Quality of life Cost effectiveness 2

3 METHODS Participants from Wound Clinic. 2 questionnaires: McGill Pain Questionnaire Brief Pain Inventory. Identification of patients with chronic lower limb wounds and pain Pain quality The McGill Pain Questionnaire: multidimensional pain assessment tool Common chosen word descriptors: Sensory: throbbing, stabbing, tender, shooting Affective: exhausting and tiring Evaluative: annoying Miscellaneous: nagging RESULTS Pain quality The Brief Pain Inventory (BPI) mainly for use in cancer The tool is design patients experiencing pain. This tool provides quantitative information on both a sensory and a reactive (degree to which pain interferes with function) dimension. 82 participants (23 male, 59 female) Mean age 74 years. 60%: gaiter area 50%: Stage 2 RESULTS Wound Type Participants Participants with Pain Arterial 7 (8.5%) 4 (57.1%) Venous 41 (50%) 24 (58.5%) Mixed 19 (23.2%) 13 (68.4%) Infectious 1 (1.2%) 1 (100%) Metabolic 4 (4.9%) 1 (25%) Miscellaneous 5 (6.1%) 2 (40%) Vasculitic 5 (6.1%) 5 (100%) Total (61%) CHARACTERISTICS OF PAIN Pain characteristic Descriptors No. participants Nature of pain Intermittent 49 Continuous 1 Pain at its worst during Day 4 Night 23 Pain made worse by Dressing changes 28 Excessive activity 10 Iodosorb 3 Touching the wound 5 Pain relieved by Rest 25 Medication 11 3

4 RESULTS Impact of QoL PAIN INTENSITY and QoL SCORES All wound types had similar impact on patient s QoL. Impact on QoL: sleep and mobility most affected mood, general activity and enjoyment of life were moderately affected relations with others were least affected increased with wound stage Score Q o L Intensity 0 Arterial Venous Mixed Infectious Metabolic Misc. Vasculitic PAIN INTENSITY Comparison of pain scores (PRI-Total) using the MPQ, including chronic wounds DISCUSSION Chronic wound pain: Venous wounds experience as much pain as arterial. Diabetic wound pain due:?neuropathy?ischaemia, Similar level to arthritic pain, fracture pain Word descriptors similar to other painful conditions Deeper the wound the greater the pain and impact of QoL. New patients: after 8 weeks treatment, pain and QoL scores improved. CONCLUSION Osteoarthritis: Schutter et al. (2008) Small sample size of each wound type Co morbidities Implications: Questionnaire specifically designed for lower limb wounds Wound management regime type of wound dressings adjunct therapy Pain management should be incorporated into the wound management program as it can improve QoL and wound healing. A prospective, observational study in 4,263 patients with chronic osteoarthritic pain Patients were enrolled based on physician assessment when NORSPAN patch therapy was indicated The efficacy and safety of NORSPAN patches were assessed over the 8 week observation period Schutter et al. (2008) 4

5 Effectively Relieves Osteoarthritis Pain Improves Ability to Perform Activities of Daily Living Current Pain Intensity Average NPS (0-10) Clinically significant reductions in average pain intensity were observed with NORSPAN patch use (p 0.001) Percentage of patients with satisfactory to very good rating NORSPAN patch use was associated with significant improvements in all aspects of activities of daily life (* p 0.001) * * * * * * (0 = no pain, 10 = worst imaginable pain) (n=3988) (n=3985) (n=3964) (n=3973) (n=3951) (n=3945) Schutter et al.(2008) Schutter et al. (2008) Palliative Management Difficult process Emotive Challenges our personal values The needs and preferences of the patient and family may conflict with our own beliefs or health care training Palliative Management Exudate Management Simple Dressings eg. ExuDry, Mesorb Alternatives eg. Continence pads Odour Management Simple dressings eg. Actisorb, Carbonet Combination dressings eg. Carboflex Topical Antibiotics eg. Metronidazole gel/silver/iodine Pain Management Simple dressings eg. Hydrogels Topical Anaesthetics eg. EMLA Topical Analgesics eg. Morphine gel Oral or Patch Analgesics Issues with Complex Wounds Cost Best quality dressing products may be out of the price range Consider alternatives ie. Nappies/ Incontinence or Sanitary Pads as high absorbing products Compliance Recognise difficulties or challenges and tackle significant issues rather than challenging too many issues Issues with Complex Wounds Comfort Determine cause of pain- dressing change or underlying cause related to cancer, arterial ulcer, vasculitis Treat appropriately and adequately Select dressing products to minimize further discomfort Exudate Can be socially isolating Wound drainage or ostomy bags are an alternative option 5

6 Issues with Complex Wounds Odour Treat any causes Some dressings and drainage bags minimize odour Consider use of room deodorants Bleeding Cancerous wounds are often very fragile and bleed easily This is disturbing to the family Consider haemostatic dressings Issues with Complex Wounds Infection High risk of development in complex wounds such as cancerous, diabetic, patients on immuno-suppresive drugs, older frail patients Identify clinical signs and treat with systemic antibiotics and topical antiseptics Aesthetics The way wee look is significant to all of us. When dealing with someone who is dying this is very important to them and their family. Consider ways to minimize the dressings- skin coloured products, less bulk Consider Other Factors Influencing Healing Consider Other Factors Influencing Healing Manage disease processes appropriately Wounds will heal better in a healthy body Review Medications Lifestyle Factors Obesity Smoking Non compliance Interference Ensure adequate diet and fluid intake Control factors interfering with wound healing Pressure Why pharmacy has a role in wound care How to implement a into community Pharmacy? Quality wound care is multi-disciplinary Medicine, nursing, pharmacy, podiatry, etc Pharmacy supplier of therapeutic products Involved in therapeutic decision making Some products prescription-only medicines Stimulating practice Under-estimated problem Effects of pharmacotherapy on wound healing Stimulate healing, retard healing, cause wounds 6

7 What is contemporary wound care? Modern wound care = Moist Wound Healing scab forms physical barrier to healing Wound exudate contains growth factors and nutrients has antimicrobial properties Moist wounds Heal faster Better quality of tissue Facilitate autolytic debridement Less scarring Improved patient comfort, decreased pain Cost effective The Pharmacist is in a unique position as a primary health professional to deal with simple wound problems as part of their daily practice. What do I need to do to provide this service? 1. Make the decision to provide the service 2. The critical issues are the need to know your own boundaries when you need to refer the patient on for Medical attention 3. It is essential that you have the skill The greater the skill the better the outcome for both you and the patient 4. In wound care the Pharmacist is the product expert on wound pharmaceuticals in the same way as they are with drugs. They should know the most appropriate product to use in a given situation. 7

8 But What Does This Mean? Managing a wound is NOT just taking a product off the shelf and selling it to the customer But What Does This Mean? 1.Define ætiology ( Know what you are treating) 2.Control factors affecting healing 3.Select appropriate dressings Important initial questions to ask Who has the wound? How, when & where wound began? How long wound present? Seen other practitioners, had tests, etc? Current therapy (&previous)? Allergies, skin sensitivities? Who does dressing changes? Pharmacist critical decisions Satisfactory wound progress? Chronic wound with other Health Professionals involved? Need to consult other Health Professionals? Significant/relevant changes since previous visit? Appropriate therapy? Therapy understood/followed? Medical referral always when Wound infected or at high risk of infection Tetanus injection required Loss of function or movement Wound not healing (becomes chronic) Serious tissue loss or bleeding Separated stitches/sutures/tissue glue Painless or chemical burn Large areas involved, especially burns Best outcomes.. Methodical, systematic approach Know resources Appropriate stock range Know abilities AND limitations When to refer Pharmacy assistants to pharmacist Pharmacist to medical services Ongoing involvement after referral 8

9 Outcomes Cost effective therapy for patients Can plan to reduce further risks of wound development or delayed healing Primary Care role Professionally rewarding See physical evidence of impact of therapy Position practice well for future developments Biotech impacts on wound dressings Changes in funding models/structures Important Wound Care Resources a) APF Wound Section b) Therapeutic Guidelines c) Surgical Dressings and Wound Management Stephen Thomas {Medetec} d) Wound Care a Collaborative Practice Manual for Health Professionals {Lippincott Williams & Wilkins} What do you need to Know to assist your practice? Wound Care is a multidisciplinary activity You need the contact details of the following other Heath Professionals i) Patients GP ii) Vascular Surgeon / Plastic Surgeon iii) Medical Specialists a] Endocrinology The additional contacts may include a) OT b) Specialist Shoe Supplier c) Lymphoedema Specialist d) District Nursing Service Wound care it a team sport work with them and everyone will benefit Where do I start? Product Range It means having a range of products to allow you to effectively treat your patients wounds What do you needs? Dressing Range Bandage Range Skin Care Knowledge 9

10 Where do I start? Product Range It Means Locating the Stock in a Prominent Place Grouped in Specific Types & with Companion Products. It Means Knowing Where to Obtain Products Not Stocked QUICKLY! It Means Having a Good General Knowledge of the Various Products on the Market Where do I start? The commitment Low Medium High THE BASIC REQUIREMENTS Level One PRODUCT RANGE Dressings Basic Inert [ Melolin/ Primapore] Film / Island Film Foam/ Silicone Foam Haemostatic Alginate Hydrogels [ Amorphous & Sheet] Tapes Fixamull / Hypafix/ Mefix/Medipore Bandages Light Weight CoHesive TubiGrip THE BASIC REQUIREMENTS Level Two PRODUCT RANGE Dressings Basic Inert [ Melolin/ Primapore, Tulle] Film / Island Film Foam/ Silicone Foam Haemostatic Alginate Hydrogels [ Amorphous & Sheet] Cadexomer Iodine Basic Silver Dressings [ Tulle, Foam] Tapes: Fixamull / Hypafix/ Mefix/Medipore Bandages Light Weight CoHesive, TubiGrip, Elastic Compression THE BASIC REQUIREMENTS Level Three PRODUCT RANGE Dressings Basic and Advanced Inert [ Melolin/ Primapore, Tulle, Silicone Tulle, ExuDry, Mesorb] Film / Island Film Foam/ Silicone Foam Hydrocolloid Haemostatic Alginate Hydroactive Hydrogels [ Amorphous & Sheet] Cadexomer Iodine Advanced Silver Dressings [ Range] Tapes Fixamull / Hypafix/ Mefix/Medipore Bandages: Light Weight & Elastic CoHesive, Tubi Fast,TubiGrip Elastic Compression, Inelastic Compression What don t you needs? Older outdated Dressings Gauze, Jelonet, Some Bandages Crepe, Gauze bandages, Many Adhesive Tapes 10

11 1. Direct charge for a service Who pays for the service? 2. Profits made from supply of products 3. Increased business and traffic 4. Special promotions by companies 5. Complimentary Sales 1. Direct charge for a service A charge can be applied when a specific wound service is provided Every other professional and service provider charges fees The big difficulty is that for year Pharmacy has provided a professional service free of charge 2. Profits made from supply of products Wound management requires the use of dressings, bandages tapes all of these attract sales and potential profit. Wound management also requires post healing skin care and long term prevention eg. The use of compression stockings However personal service and advice is NOT AVAILABLE IN THE SUPERMARKET Remember that chronic wounds require long Term treatment. 3. Increased business and traffic Word of mouth is the best publicity you can have Successful wound service will give you a great professional profile It will provide you and your Staff with considerable professional and personal Satisfaction when you are able to help your customers with a Specific Wound Problems 4. Special promotions by companies From time to time or by arrangement with a wound company for special promotions to be held in your Pharmacy this will also assist in attracting customers. It is important to work together with the other health professionals in your area and as they see your skill they will be happy to work with you and recommend to their clients to use your services. 11

12 5. Complimentary Sales In addition to the direct treatment products required for the wound there will be other products needed to improve both intrinsic and extrinsic factors that may delay wound healing. Is it all too hard? Also once a surgical wound is healing the reduction of scar formation is an important issue. Yes it does require and investment of time and change to your stock and your approach to patients. It is not good enough to sell a product because the customer asked for it. You have to ask the question why This is your opening to discover the underlying problem and then advise. Yes it is scary at first and it will take time to develop the skill and experience, however as you do so your confidence will grow and you will become familiar with different wound types and their management. No Wound Management is a Clinical Skill which will demonstrate to your customers an ability as a Health Professional it will expand your primary health care role and when you combine it with a Residential Age Care medication service it will expand your business potential. With an ageing population and a rapid growth of Diabetes the need for skilled wound professionals will only increase. No it is one of the most professionally rewarding areas of practice. It is one of the only interventions where you can see the results first hand. Healing a wound has a significant impact of the quality of life of a patient. I have had patients and their family in tears when the wound is healed. 12

13 No with the increasing pressures on community Pharmacy developing new areas of primary care is one way of maintaining a viable business. It does require being proactive in many respects of patient and business management. But it is worth it It all depend on your skill and your confidence to diagnose and treat wounds Wound management is an evolving skill so you need to continue to read and up skill your knowledge Journals Wound Practice & Research - the journal of the Australian wound management assoc (AWMA) J. Wound Care (UK - emap communications) International Wound Journal ( UK Wiley-Blackwell ) Other sources of information on wound care World Wide Wounds on line through Wounds International on line Consider the Monash on-line post graduate qualifications Master of Wound Care Everyone will enrol into the Master of Wound Care Exit points at Graduate Certificate or Graduate Diploma Two streams at Master s level Coursework only stream Coursework and research stream For further information, contact Adriana Tiziani ( ) or visit website -care Master of Wound Care Part A: Foundation Studies Principles of Wound Healing Wound Assessment Wound Management Principles Acute and Chronic Wounds Part B: Consolidation Studies Evidence based practice Choose 2 out of 3 from: Integrated wound care practice (on campus)* Diabetes foot Pressure injury management Plus Elective Exit with Graduate Certificate in Wound Care * Compulsory if you are planning to progress to Master s level Master in Wound Care (continued) Part B: Consolidation Studies Exit with Graduate Diploma in Wound Care Coursework Stream Advanced clinical practice in wound care Clinical risk management in wound care Electives (12 credit points) Coursework & Research Stream Epidemiology & Statistics Introduction to research Research 2 Research 3 13