Simplifying Wound Dressing Selection The Australian Experience Ms. Tabatha Rando Nurse Practitioner Wound Management RN, MNP, Grad Dip CHN, Grad Cert STN, Cert WM, Dip FLM, Cert IV WAT Credentialed Wound Clinician registration #: CRED-17-00005
In Australia Conservative cost of wound management each year in Australia
3 per 1000 Australians
50% of patients in public hospitals have a wound
In Chronic Wound Management
Look at the whole person before looking at the hole in the person
Wound Bed Preparation 2015 1. Holistically Assess the Person with a chronic wound address Person/family Centred Concerns Identify & treat cause & contributing factors 2. Identify Healability: Healable or Maintenance or Non healable/palliative Local wound management 3. Tissue Debridement Inflammation/ Infection Moisture Balance Edge Advancement Sibbald RG. Optimizing The Moisture Management Tightrope with Wound Bed Preparation 2015. Advances in Skin & Wound Care 2015;Oct 2015 Vol 28;466-475
1. Wounds Require Debridement When Nonviable Tissue & Biofilm Are Preventing Healing
2. The Presence Of Biofilms In Chronic Wounds Add To Complexity & Incidence of Repeat Infections SOURCE: https://www.zmescience.com/science/what-are-biofilms/
Biofilm Based Wound Care 2 WEEK CHALLENGE CLEANSE DEBRIDE AM SOAK ANTIMICROBIAL DRESSING 3 TIMES PER WEEK FOR 2 WEEKS
3. Not All Nurses Can Conservatively Sharp Debride A Wound
4. Autolytic Dressing Options Can Cause Increased Pain
5. Confusion over choice - over 3000 different wound dressings & devices on the Australian Market
What is the # 1 question asked by wound education participants?
What if 2 dressings could address the majority of wound needs?
HydroTherapy
What do the Other wounds look like?
Risk Mitigation Unknown what the not suitable wounds look like? Identify Educate
Risk Mitigation The Simplicity Project February-August 2017 Adelaide RACFs
Research Project Aim To demonstrate the effectiveness of a SIMPLIFIED dressing selection protocol for nurses in Residential Aged Care Facilities (RACFs)
Methodology 1.MEASURE CURRENT PRACTICE 1/12 3. NEW PRODUCT USE WITH RESIDENTS 4/12 2. STAFF EDUCATION 1/12 4. DATA ANALYSIS & REPORTING 1/12
Inclusion criteria All skin tears Chronic & Pressure Injury wounds (NP assessed)
Exclusions Wounds NOT suitable for Hydrotherapy (NP assessed) e.g. Full thickness burns Palliative wounds Pressure loading Known Sensitivities
Exclusions: Residents or NOK or Medical - preference is not to use Hydro Therapy wound dressing products
Results - Consort Diagram
Results SIMPLIFIED Dressing Protocol SUCCESS MAJORITY of wounds 70.2% (125/178) WERE suitable for Hydrotherapy 96 out of 97 wounds healed All skin tears used hydrotherapy protocol
Results Wounds Assessed as NOT Suitable (29.8%) Apart from the protocol exclusion criteria: Dry haematomas Any wound which had to be Fungal wounds Skin cancers kept dry or a wound that Small & narrow sinus/cavity wounds was too small for the Leaky legs product Non-concordance with VLU compression SDTI/Unstageable PI w stable eschar heels
Results Participant Characteristics Participant Characteristics Participants (n) 93 Value Mean age (years) 88.7 SD 6.39 range 67-101 Gender [% (female/male)] 68 / 32 Total number of wounds 121 Participants sustaining a single wound (%) Participants sustaining two wounds (%) 73 25 Participants sustaining three plus wounds (%) 2
Wound Characteristics Value Incontinence [%(yes/no)] 84 /16 Cognitive impairment [%(yes/no)] 80 / 20 Mobility (%non ambulatory/ambulatory) 43 / 57 Nutritional status [%(normal/under/over or obese)] 53 / 21 / 22 Wound type [%(skin tears, others)] 73 / 27 Wound locations [%(LL, UL, buttocks, trunk/head)] Main mechanism of injury [%(ADL trauma, unknown, fall, pressure)] Wound Characteristics 50 / 34 / 12 / 4 46 / 18 / 17 / 14 Mean wound surface area (cm 2 ) 4.89 SD 11.91 range 0.06-100
Results
Multiple studies note the reduction in wound related pain in the use of HydroClean Plus wound dressings EXUDATE DILUTION Dilute prostaglandins, kinins, cytokines and matrix metalloproteases reducing pain and inflammation LEUKOCYTE RECRUITMENT The Ringer s solution s isotonic nature might be expected to recruit leukocytes that release natural painkillers PH AND IONIC BALANCE The ph and ionic balance will influence the action of sodium and calcium channels involved in the pain response
Results Staff Comments BENEFITS: Very easy to apply, stayed for 5 days. Wound healed properly. Easy to work with, makes dressing change easier as there is only one product. Worked well and would definitely recommend it and use it again. Dressing time (to heal) has halved. Dressing is great. CHALLENGES: Wet & leaking (post shower) Few dislodged older skin issues
Results Cost Analysis (AUD) Pre-intervention Protocol per dressing: Dressing Material $3.45 On average 11min 22sec EN on cost $0.52/min Skin tear on average 7 dressing changes* Total $65.53 per skin tear episode * Working Assumption - both pre intervention and intervention dressings took on average the same amount of time to heal a skin tear (i.e. pre-intervention healing time data was not collected)
Results Cost Analysis (AUD) Intervention Protocol per dressing: Dressing Material $4.40 On average 5min 6sec EN on cost $0.52/min Skin tear on average 4 dressing changes Total $28.21 per skin tear episode
Results - Create a Skin Tear Decision-tree Tools to Guide Use
HydroTherapy Top Tips HYDROCLEAN 1. Always protect the periwound skin with barrier wipe/cream 2. Always double check pad position or tape insitu if not contraindicated 3. Stripes or wording always faces upward (stripes like on zebras on outside & wounds cannot read we can though!) HYDROTAC +/- COMFORT 1. Only start Hydrotac when no slough & edges advancing 2. Do not apply Hydrotac to hypergranulating wounds 3. Hydrotac comfort essential to get a good seal or reinforce with film edging
Ms E 93 year old female HTx, dementia, incontinence, SCC, polypharmacy - 7/12/16 lesion excised Right leg 1.5x1cm Inadine, Melonin, Opsite every 2 days 21/12/2016 3 rd daily 30/12/2016 3/1/2017
8/3/17 Second daily
24/4/17 10 days of Hydroclean Plus 2 times per week (3 changes in total) scab removed via hyperhydration (no sharp debridement)
25/5/17 Hydrotac every 5-7 days commenced 1/5/17
9/6/17 Healed Old dressing regime cost (including dressings & labour) (7/12/16 to 14/4/17)= $416.83 non healing New HydroTherapy regime (including dressings & labour) (14/4/17 to 9/6/17) = $64.78 & healed
Ms C 86 year old female Dementia, Double Incontinence, HF, Polypharmacy spilt coffee burn between the thighs 14/2/17 Right Inner Thigh deep dermal burn Length 8cm x Width 5.5cm x Depth 0.4cm Treatment: Hydrotac Comfort No Image Available 20/2/17 Length 7.8cm x Width 5.5cm x Depth 0.4cm Treatment - Hydroclean Plus & film applied twice per week No Image Available IMAGE 1. Right Medial Thigh 27/2/17 Length 5.2xcm x Width 4.1cm x Depth 0.4cm Treatment - Hydroclean Plus & film applied twice per week
17/3/17 4.5 L x 2.8 W IMAGE 2. Right medial thigh 27/2/17 Length 4.5cm x Width 2.8 cm x Depth 0.3cm Treatment - Hydroclean Plus & film applied twice per week
IMAGE 3. Right medial thigh 27/2/17 Length 3.1xcm x Width 1.8cm x Depth 0.2cm Treatment Hydrotac Comfort once per week
IMAGE 4. Right medial thigh 26/3/17 Healed
Photograph taken on 1/8/18 with Length 3cm x Width 3.3cm x Depth 0.5cm, 80% Granulation tissue 20% slough tissue & bruising of granulation tissue noted at 6-7o'clock (recent trauma/unrelieved pressure) ; moderate puro-serous exudate & malodour present Right ABPI=0.89 taken on 1/8/18; Carer Contract for pressure offloading of heels, nutritional supplements commenced with Arginade BD & HEHP diet. 3-5/60 Povidine Iodine 10% soak reduce malodour/bioburden, then normal saline cleanse, skin protection wipe to periwound skin, HydroClean Plus & Zetuvit Plus Monday/Wednesday/Friday dressing changes
22/8/18 - Length 2.3cm x Width 3.3cm x Depth 0.3cm, minimal to moderate haemoserous exudate 30% hypergranulation mechanically debrided 30% epithelialising 30% granulation 10% slough Continue with current care plan reduce dressing frequency - Carer contract pressure offloading of heels, nutritional supplements Arginade BD & HEHP diet, 3-5/60 Povidine Iodine 10% soak reduce malodour/bioburden, then normal saline cleanse, skin protection wipe to periwound skin, HydroClean Plus & Zetuvit Plus reduced to Monday & Thursday dressing
4/9/2018 - Length: 1 cm Width: 0.5cm Depth: 0.1cm 50% granulation & 50% epithelial tissue, minimal serous exudate, Commenced Hydrotac and periwound moisturise QV cream
Excellent Example of a CRC Partner Industry Project
Published 7 th August 2018
Simplifying Matters
Out of clutter find simplicity Albert Einstein 1879-1955
Thank you
Acknowledgements: Co-authors: Ai Choo Kang², Jo Boylan², Anthony Dyer¹ Institution: Wound Management Innovation CRC¹, Southern Cross Care (SA/NT)Inc.² Michelle Guerin Statistical Analysis Director Positive Practice Marjan De Wilt Care Manager Nan Liu Care Manager Virginia Mc Millan Care Manager Jane Templar Residential Services Manager Nursing staff at The Pines & Bucklands
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Quality Healthcare relies on the skills of frontline health professionals 1. Introduction to Wound Management 7. Pressure Injury Module 2. Carers Healthy Skin Module 8. Perineal Care Module 3. Skin Tear Module 9. Foot Ulcer Module 4. Burns Module 10. Leg Ulcer Module 5. Malignant Wound Module 11. Aboriginal Health 6. Healthy Skin Module (Carer Workers) Practitioner/Worker Module All interactive online modules include: 6 Hours Continuing Professional Development Accreditation & Endorsement Fully responsive learning available on smartphones, tablets & desktop computers
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