Medical device-related pressure injury from compression therapy.

The use of compression therapy is known to be effective in the management of patients with venous leg ulceration and is commonly recommended as a first-line treatment. A rare but known complication of compression therapy is pressure damage to the limb, also referred to as bandage damage, which should be categorised as a medical device-related pressure injury. Patients should receive a comprehensive, holistic assessment before any compression therapy is applied. Risk factors for compression therapy injury include peripheral arterial disease, older age, fragile skin, pronounced bony prominences or tendons, calf atrophy, foot drop, neuropathy/absent sensation, limited movement, cognitive impairment and receiving end of life care. Risks can be mitigated through a variety of approaches, and practitioners should be aware that these can change depending on the patient's condition. A community improvement initiative, illustrated with a case study, introduced a clinical pathway that can facilitate the identification and management of patients who are at risk of developing pressure injuries as a result of compression therapy.

Compression therapy for NHS inpatients with leg ulcers: a literature review.

OBJECTIVE: Leg ulcers are common, distressing and painful for patients, and are a significant financial burden to healthcare providers. Compression therapy is the mainstay of treatment for venous leg ulceration. Several studies have evaluated leg ulcer management and compression therapy in the community. However, little is known about the prevalence of leg ulceration and use of compression therapy in acute hospitals. The aim of this study was to explore the published literature on the use of compression therapy for inpatients with leg ulcers in UK National Health Service hospital settings. METHOD: A literature search was undertaken to identify published papers reporting on inpatient leg ulcer populations and the use of compression therapy in hospitals using the following databases: CINAHL, MEDLINE Complete, Embase and PubMed. RESULTS: The literature review identified 364 articles, of which three met the eligibility criteria. These studies reported on the prevalence of leg ulceration, the number of Doppler assessments conducted for patients and the use of compression therapy. CONCLUSION: This review confirmed a lack of information on the prevalence of hospital inpatients with leg ulcers, and identified the need to conduct prevalence audits, establish leg ulcer services to streamline inpatient leg ulcer care and provide staff and patient education programmes.

The role of venous intervention for the treatment of patients with venous leg ulceration.

More than 1 million people are estimated to have lower limb venous ulceration in the UK. Such wounds are predominantly caused by sustained venous hypertension, as a result of chronic venous insufficiency, often due to venous valve incompetence or an impaired calf muscle pump. Compression therapy is key to venous leg ulcer management and the majority of nurses are aware of the importance of starting patients on compression therapy as early as possible. However, there appears to be a lack of awareness of the importance of venous assessment and that more patients could benefit from endovenous correction of superficial venous incompetence.

International validation of a venous leg ulcer risk assessment tool.

OBJECTIVE: To internationally validate a tool for predicting the risk of delayed healing of venous leg ulcers (VLUs). METHOD: A 10-item tool including sociodemographic factors, venous history, ulcer and lower limb characteristics, compression and mobility items to determine the risk of delayed healing of VLUs has previously been developed and validated in Australia. This study prospectively validated this tool using receiver operating characteristic (ROC) methods; using the area under the curve (AUC) to quantify the discriminatory capability of the tool to analyse the international populations of the UK, Austria and New Zealand. RESULTS: The validation of the tool in the UK, Austria and New Zealand has indicated that the model has moderate discrimination and goodness-of-fit with an AUC of 0.74 (95% CI: 0.66-0.82) for the total risk assessment score. CONCLUSION: The international validation of a risk assessment tool for delayed healing of VLUs will allow clinicians globally to be able to determine realistic outcomes from an early assessment and to be able to guide early tailored interventions to address the specific modifiable risk factors and thus promote timely healing.

Use of ankle-brachial pressure index to assess patient suitability for lower limb compression.

BACKGROUND: Compression therapy is a safe, effective treatment for lower leg conditions such as lymphatic insufficiency and venous hypertension. The most common method of arterial assessment is the calculation of a patient's ankle-brachial pressure index (ABPI). The need for ABPI is highlighted in many best practice statement and local policies. ABPI compares the arterial flow of the arms and the legs, providing a ratio used to determine the presence and severity of peripheral artery disease and assess whether a patient is suitable for compression therapy. AIM: This study critically reviews and analyses findings from contemporary literature with the aim of evaluating the effectiveness of the ABPI screening tool. METHOD: A structured literature review using a narrative approach was carried out. RESULTS: Four studies were identified for inclusion, which involved medical, nursing and allied health professional staff in primary and secondary care, with a total of 51 patients. Analysis generated eight themes: appropriateness of the ABPI tool; clinician education; referral process; access to appropriate equipment; lack of time to conduct the assessment; competence; associated costs; and role definition. CONCLUSION: It is important to undertake a holistic assessment of the patient, incorporating ABPI assessment where not contraindicated. Further research to explore patient experience and safety when assessing a patient's suitability for lower limb compression therapy is required.

Introducing a new approach to debridement and wound bed preparation.

Debridement of devitalised tissue and wound biofilm is vital to promote healing. This article introduces an innovative debridement product, ChloraSolv Wound Debridement Gel, which is as effective as a blade but also selective, atraumatic and fast-acting and does not require specialist training. Its ease of use makes it suitable for all settings and staff.

Foreword.

Leanne Atkin, Vascular Nurse Consultant, Mid Yorkshire Hospitals NHS Trust and University of Huddersfield.

The importance of periwound skin in wound healing: an overview of the evidence.

DECLARATION OF INTEREST: The authors have no conflicts of interest.

Embedding Wound Hygiene into a proactive wound healing strategy.

FOREWORD. WOUND HYGIENE: THE NEXT STAGE: Since a panel published the first consensus document on Wound Hygiene in March 2020, there has been a flurry of activity in support of this newly established concept in proactive wound healing.1 The document concluded that all wounds, particularly hard-to-heal ones, will benefit from Wound Hygiene, which should be initiated at the first referral, following a full holistic assessment to identify the wound aetiology and comorbidities, and then implemented at every dressing change until full healing occurs.1 The consensus has since been bolstered by educational webinars; competency-based skills training and support; development of international Wound Hygiene ambassadors; a survey of 1478 respondents, published in July 2021;2 and a case study supplement, published in January 2022, featuring a range of wound types, anatomies and underlying conditions on the improvements in wound-healing progress that can be achieved.3 Wound Hygiene has gained its own identity and is now a term in and of itself, that encompasses a 4-step protocol of care. It is an antibiofilm approach that is increasingly being used across wound care. The results of the survey2 were particularly encouraging for seeing how far Wound Hygiene has come, and how quickly: More than half (57.4%) had heard of the concept of Wound Hygiene Of those, 75.3% have implemented Wound Hygiene Overall, following implementation of Wound Hygiene, 80.3% of respondents reported improved healing rates.2 However, the top three barriers identified by the survey-lack of confidence, competence and research data-show that there is more to be done to support Wound Hygiene in practice.2 As a result, a consensus panel of international key opinion leaders convened virtually in the summer of 2021 to discuss what has been done so far, the outputs of the survey, and ideas for addressing the unmet needs identified by the results. The result is this publication, which represents an addendum to the initial consensus document, broadening support for implementation of Wound Hygiene. This document will reflect on the reasons Wound Hygiene has been successful in its first two years of implementation, reiterating its DNA: Do not wait to treat hard-to-heal wounds Use a simple 4-step approach Enable all healthcare professionals to implement and use Wound Hygiene. The document will also discuss the evolution of the Wound Hygiene concept, focusing on how and when to implement Wound Hygiene on all tissue types of hard-to-heal wounds, and proposing what these are. The panel has expanded the framework in which Wound Hygiene is used, with the ultimate objective of introducing the concept of 'embedding Wound Hygiene intro a proactive wound healing strategy.' Key inefficiencies are often observed along the journeys of people living with hard-to-heal wounds. The limited number of specialised healthcare professionals and the resulting delays in reaching them may increase the likelihood of a hard-to-heal wound developing. In a world where so much is happening so quickly that we may, at times, feel powerless to drive change, the panel wants to provide further guidance to propel the use of Wound Hygiene. The concept of Wound Hygiene is resonating, and the panel wants you to know that in whatever region you work, in whatever area of clinical practice, you are enabled to make this change. Wielding the 4-step Wound Hygiene protocol consistently is a key action every healthcare professional in every care setting can take to tackle the global wound care crisis. Wound Hygiene has taken off-now, where do we want to land? In a place where Wound Hygiene is practised on all wounds, at every stage, until healing. The panel once again recognises that the community of global healthcare providers should consider their local standards and guidelines when applying the recommendations of this document. To this end, the panel has created a flexible 3-phase framework that situates Wound Hygiene as integral to proactive wound healing. The panel hopes you will continue to implement Wound Hygiene and see the benefits it can bring to people living with wounds, as well as those who care for them.

Antimicrobial stewardship: a JWC Masterclass.

This paper presents an overview of a Journal of Wound Care (JWC) webinar 'Antimicrobial Stewardship Masterclass' which took place on 17 June 2021, bringing together international experts in the field of wound care. The webinar was undertaken to provide an educational platform elucidating the basis of an effective antimicrobial strategy in wound care, and to demonstrate how it impacts on wound care clinicians and their day-to-day practice, using examples of 'real-life' patient outcomes.

Encuesta sobre la higiene de las heridas: conocimiento, implementación, obstáculos y resultados.

OBJETIVO: Se ha desarrollado una encuesta para comprender el conocimiento y la implementación actual del concepto de higiene de las heridas un año después de su difusión. También se analizaron los obstáculos para su implementación y los resultados. MÉTODO: La revista Journal of Wound Care (JWC), con la colaboración de ConvaTec, desarrolló una encuesta de 26 preguntas, compuesta por respuestas de opción múltiple y texto libre, que distribuyó globalmente por correo electrónico y en línea; la encuesta estuvo abierta unas 12 semanas. Debido a la naturaleza exploratoria de la investigación, se utilizó una técnica de muestreo no probabilístico. Los autores analizaron los resultados de la encuesta para sacar conclusiones de los datos. RESULTADOS: Un total de 1478 participantes dio su consentimiento para el uso de sus datos combinados anonimizados. Casi el 90% era de Estados Unidos o el Reino Unido. La mayoría se desempeñaba como especialista en el cuidado de las heridas y estaba distribuido equitativamente entre centros de atención primaria y hospitales de agudos. El 66,6% había trabajado en el área de cuidado de las heridas durante más de 8 años. Los encuestados trabajaban con una amplia variedad de tipos de heridas. Más de la mitad (57,4%) había oído hablar del concepto de higiene de las heridas, y entre ellos, el 75,3% la había implementado; el 78,7% respondió que la aplicaba "siempre", mientras que el 20,8% lo hacía "a veces". Los tres principales obstáculos para su adopción fueron la confianza (39,0%), el deseo de que haya más estudios sobre la higiene de las heridas (25,7%) y la competencia (24,8%). En general, tras la implementación de la higiene de las heridas, el 80,3% informó que las tasas de cicatrización de sus pacientes habían mejorado. CONCLUSIÓN: Los encuestados estuvieron totalmente de acuerdo en que la implementación de la higiene de las heridas es un método exitoso para el tratamiento del biofilm y un componente fundamental para mejorar las tasas de cicatrización en heridas de difícil cicatrización. Sin embargo, los obstáculos para su adopción e implementación demuestran que se necesitan cursos integrales de educación y capacitación, apoyo institucional para los cambios de política, protocolos, y más estudios clínicos para promover la higiene de las heridas.

A dual pressure indicator, two-layer compression system for treatment of venous leg ulcers: a review.

OBJECTIVE: Venous leg ulcers (VLUs) are considered the most frequent category of hard-to-heal limb ulcers. Although evidence-based care of VLUs suggests that compression therapy plays a pivotal role in the standard of care, patient adherence is considered low, with at least 33% non-compliance, either due to perceived problems from clinicians regarding their own competency in applying the bandages, or from the patient finding the wrapping bothersome. For many years, four-layer bandaging has been considered the 'gold standard', but application can be difficult and may also prove uncomfortable for patients. Accurate application may be facilitated by a stretch indicator which has been engineered to act as a surrogate for appropriate pressure application that can address the skill concern, while fewer layers can save clinicians' time and improve the quality of life of patients. Here, we review the literature supporting a two-layer system which combines elastic (long stretch) and inelastic (short stretch) components as well as both layers having graphic markers to define that the dressing has been applied at the proper tension. METHOD: An initial search was conducted on PubMed and then followed up by a manual search of Google Scholar to retrieve evidence of different levels, in order to evaluate the outcomes of use of the specific two-layer compression system with pressure indicators in the management of patients presenting with VLUs. RESULTS: A total of four papers discussing the specific compression system in question were identified from 32 publications retrieved from PubMed, while a further six were retrieved from Google Scholar. These 10 publications were considered relevant to the two-layer system and were analysed for the outcomes of care, including wound healing, appropriate application, time-saving and better patient acceptance and adherence. CONCLUSION: Previous authors have demonstrated that two-layer systems are equivalent to four-layer systems. However, the ability to reproducibly apply appropriate compression has remained a question. The papers reviewed demonstrate that evidence suggests that the two-layer compression bandage system with indicators provides continuous, consistent and comfortable treatment that may be easier to apply with accurate pressure levels due to their indicator systems, and therefore, is a procedure that may increase patient adherence and acceptability to the wound therapy.

Making Legs Matter: A Case for System Change and Transformation in Lower-Limb Management.

This consensus document is endorsed by The Queen's Nursing Institute (QNI) and The Queen's Nursing Institute Scotland (QNIS).

Wound hygiene survey: awareness, implementation, barriers and outcomes.

OBJECTIVE: In light of the COVID-19 pandemic, which has resulted in changes to caseload management, access to training and education, and other additional pressures, a survey was developed to understand current awareness and implementation of the wound hygiene concept into practice one year on from its dissemination. Barriers to implementation and outcomes were also surveyed. METHOD: The 26-question survey, a mixture of multiple choice and free-text, was developed by the Journal of Wound Care projects team, in consultation with ConvaTec, and distributed globally via email and online; the survey was open for just over 12 weeks. Due to the exploratory nature of the research, non-probability sampling was used. The authors reviewed the outputs of the survey to draw conclusions from the data, with the support of a medical writer. RESULTS: There were 1478 respondents who agreed to the use of their anonymised aggregated data. Nearly 90% were from the US or UK, and the majority worked in wound care specialist roles, equally distributed between community and acute care settings; 66.6% had been in wound care for more than 8 years. The respondents work across the spectrum of wound types. More than half (57.4%) had heard of the concept of wound hygiene, of whom 75.3% have implemented it; 78.7% answered that they 'always' apply wound hygiene and 20.8% 'sometimes' do so. The top three barriers to adoption were confidence (39.0%), the desire for more research (25.7%) and competence (24.8%). Overall, following implementation of wound hygiene, 80.3% reported that their patients' healing rates had improved. CONCLUSION: Respondents strongly agreed that implementing wound hygiene is a successful approach for biofilm management and a critical component for improving wound healing rates in hard-to-heal wounds. However, the barriers to its uptake and implementation demonstrate that comprehensive education and training, institutional support for policy and protocol changes, and more clinical research are needed to support wound hygiene.

Potential cost-effectiveness of using adjunctive dehydrated human amnion/chorion membrane allograft in the management of non-healing diabetic foot ulcers in the United Kingdom.

The aim of this study was to estimate the cost-effectiveness of using dehydrated human amnion/chorion membrane (dHACM) allografts (Epifix) as an adjunct to standard care, compared with standard care alone, to manage non-healing diabetic foot ulcers (DFUs) in secondary care in the United Kingdom, from the perspective of the National Health Service (NHS). A Markov model was constructed to simulate the management of diabetic lower extremity ulcers over a period of 1 year. The model was used to estimate the cost-effectiveness of using adjunctive dHACM, compared with standard care alone, to treat non-healing DFUs in the United Kingdom, in terms of the incremental cost per quality-adjusted life year (QALY) gained at 2019/2020 prices. The study estimated that at 12 months after the start of treatment, use of adjunctive dHACM instead of standard care alone is expected to lead to a 90% increase in the probability of healing, a 34% reduction in the probability of wound infection, a 57% reduction in the probability of wound recurrence, a 6% increase in the probability of avoiding an amputation, and 8% improvement in the number of QALYs. Additionally, if £4062 is spent on dHACM allografts per ulcer, then adjunctive use of dHACM instead of standard care alone is expected to lead to an incremental cost per QALY gain of £20 000. However, if the amount spent on dHACM allografts was ≤£3250 per ulcer, the 12-month cost of managing an ulcer treated with adjunctive dHACM would break-even with that of DFUs treated with standard care, and it would have a 0.95 probability of being cost-effective at the £20 000 per QALY threshold. In conclusion, within the study's limitations, and within a certain price range, adjunctive dHACM allografts afford the NHS a cost-effective intervention for the treatment of non-healing DFUs within secondary care among adult patients with type 1 or 2 diabetes mellitus in the United Kingdom.