Surgical Diabetic Foot Debridement: Improving Training and Practice Utilizing the Traffic Light Principle.

Comprehensive management of a severe diabetic foot infection focus on clear treatment pathways. Including rapid, radical debridement of all infection in addition to intravenous antibiotics and supportive measures. However, inexperienced surgeons can often underestimate the extent of infection, risking inadequate debridement, repeated theatre episodes, higher hospital morbidity, and hospital length of stay (LOS). This study aims to assess protocolized diabetic-foot-debridement: Red-Amber-Green (RAG) model as part of a value-based driven intervention. The model highlights necrotic/infected tissue (red-zone, nonviable), followed by areas of moderate damage (amber-zone), healthy tissue (green-zone, viable). Sequential training of orthopedic surgeons supporting our emergency service was undertaken prior to introduction. We compared outcomes before/after RAG introduction (pre-RAG, n = 48; post- RAG, n = 35). Outcomes measured included: impact on number of debridement/individual admission, percentage of individuals requiring multiple debridement, and length-of-hospital-stay as a function-of-cost. All-patients fulfilled grade 2/3, stage-B, of the Texas-Wound-Classification. Those with evidence of ischemia were excluded. The pre-RAG-group were younger (53.8 ± 11.0 years vs 60.3 ± 9.2 years, P = .01); otherwise the 2-groups were matched: HbA1c, white blood cell count, and C-reactive protein. The post-RAG-group underwent significantly lower numbers of debridement's (1.1 ± 0.3 vs 1.5 ± 0.6/individual admission, P = .003); equired fewer visits to theatre (8.6% vs 38%, P = .003), their LOS was reduced (median LOS pre-RAG 36.0 vs post-RAG 21.5 days, P = .02). RAG facilitates infection clearance, fewer theatre-episodes, and shorter LOS. This protocolized-management-tools in acute severely infected diabetic foot infection offers benefits to patients and health-care-gain.

Comparison of cosmetic appearances after facial lacerations repaired by junior residents and experts.

PURPOSE: The technical factors which improve cosmetic outcomes and which need to be emphasized in education of junior residents have yet to be described. We compared cases in which suturing was performed by either junior emergency medicine residents or experts, in order to determine the focus of future education and training. METHODS: Wound registry data was reviewed and retrospectively analyzed from September 2015 to February 2016. Only patients who visited the emergency room with facial lacerations were enrolled, and their wound registry data sheets were reviewed. Practitioners were divided into junior resident and expert groups. We assessed the progress using the Stony Brook Scar Evaluation Scale (SBSES) 5-10 days following suturing. RESULTS: Sixty-six patients were enrolled; 43 (65.2%) were men. The median (interquartile range) cosmetic scores (SBSES scale) for suturing performed by junior residents or experts were 3 (2-4) and 5 (4-5), respectively (p = 0.001). The percentage of maximum scores for each SBSES category was significantly lower in the junior resident group than in the expert group for width (68% vs. 86%), hatch marks (68% vs. 93%), and overall appearance (41% vs. 80%) (all p < 0.001). CONCLUSIONS: There were significant differences in scar widths and hatch marks, which were attributable to the skill level of the practitioner who performed the suturing of facial lacerations. Junior residents should be educated about maintenance of proper tension, atraumatic technique, and performing appropriate trimming or debridement.

Simulation Improves Podiatry Student Skills and Confidence in Conservative Sharp Debridement on Feet A Pilot Randomized Controlled Trial.

BACKGROUND:: An essential skill for podiatrists is conservative sharp debridement of foot callus. Poor technique can result in lacerations, infections and possible amputation. This pilot trial explored whether adding simulation training to a traditional podiatry clinical placement improved podiatry student skills and confidence in conservative sharp debridement, compared with traditional clinical placement alone. METHODS:: Twenty-nine podiatry students were allocated randomly to either a control group or an intervention group on day 1 of their clinical placement. On day 4, the intervention group (n = 15) received a 2-hour simulation workshop using a medical foot-care model, and the control group (n = 14) received a 2-hour workshop on compression therapy. Both groups continued to learn debridement skills as opportunities arose while on clinical placement. The participants' debridement skills were rated by an assessor blinded to group allocation on day 1 and day 8 of their clinical placement. Participants also rated their confidence in conservative sharp debridement using a questionnaire. Data were analyzed using logistic regression (skills) and analysis of covariance (confidence), with baseline scores as a covariate. RESULTS:: At day 8, analysis showed that those in the intervention group were 16 times more likely to be assessed as competent (95% confidence interval, 1.6-167.4) in their debridement skills and reported increased confidence in their skills (mean difference, 3.2 units; 95% confidence interval, 0.5-5.9) compared with those in the control group. CONCLUSIONS:: This preliminary evidence suggests that incorporating simulation into traditional podiatry clinical placements may improve student skills and confidence with conservative sharp debridement.

Developing a grapefruit model for assessment and training of diabetic foot ulcer debridement.

INTRODUCTION: Sharp debridement is the criterion standard treatment for diabetic foot ulcers (DFUs) and is performed by podiatrists in the United Kingdom. This study aimed to create a DFU model that could be used as a learning tool for trainees. METHODS: In a pilot study, a penny-sized circle was drawn onto an orange to simulate a DFU. This was then critiqued by podiatrists, and the feedback received was used to create a grapefruit model with irregular shape. All podiatrists supported the switch to a grapefruit model due to improved contrast between skin and fruit. This grapefruit model was then reassessed by 50 podiatrists from the North West of England. Two freely available computer programs were assessed to measure the area debrided, and a depth scale was used to determine the depth debrided. A questionnaire was completed by the podiatrists as to the utility of the model. RESULTS: A DFU was successfully simulated using a grapefruit and plastic template. After debridement, debrided area and depth were calculated using Image J and a depth score. Podiatrists rated this model for its utility as a training tool on a continuous rating scale with an average score of 61.9%. CONCLUSIONS: This model has potential for development as it is inexpensive and easily accessible. This model's fidelity could be bolstered by using more accurate techniques for area and depth measurement. More research is needed to determine the superiority or inferiority of this model to previous simulated DFU models.

Wound debridement: a clinical update.

This article aims to improve nurses' knowledge of wound debridement through a review of different techniques and the related physiology of wound healing. Debridement has long been an established component of effective wound management. However, recent clinical developments have widened the choice of methods available. This article provides an overview of the physiology of wounds, wound bed preparation, methods of debridement and the important considerations for the practitioner in implementing effective, informed and patient-centred wound care.

Simulation based education - models for teaching surgical skills in general practice.

BACKGROUND: Simulation based education is an accepted method of teaching procedural skills in both undergraduate and postgraduate medical education. There is an increasing need for developing authentic simulation models for use in general practice training. OBJECTIVE: This article describes the preparation of three simulation models to teach general practice registrars basic surgical skills, including excision of a sebaceous cyst and debridement and escharectomy of chronic wounds. DISCUSSION: The role of deliberate practise in improving performance of procedural skills with simulation based education is well established. The simulation models described are inexpensive, authentic and can be easily prepared. They have been used in general practice education programs with positive feedback from participants and could potentially be used as in-practice teaching tools by general practitioner supervisors. Importantly, no simulation can exactly replicate the actual clinical situation, especially when complications arise. It is important that registrars are provided with adequate supervision when initially applying these surgical skills to patients.

Prevention and treatment of pressure ulcers.

Pressure ulcer prevention and treatment remains a challenge for interprofessional teams in all health care sectors. Evidencebased pressure ulcer guidelines can be simplified with a bedside enabler utilizing the wound bed preparation paradigm. Key steps involve treatment of the cause, addressing patient-centered concerns, and administering local wound care (debridement, infection/ inflammation control, and moisture balance before considering advanced therapies with the edge effect). Optimal outcomes are achievable with a multi-disciplinary approach that supports patients and their circle of care, which is central to every evaluation and course of treatment decisions.

A simulation-based training system for surgical wound debridement.

A simulation-based training system for surgical wound debridement was developed and comprises a multimedia introduction, a surgical simulator (tutorial component), and an assessment component. The simulator includes two PCs, a haptic device, and mirrored display. Debridement is performed on a virtual leg model with a shallow laceration wound superimposed. Trainees are instructed to remove debris with forceps, scrub with a brush, and rinse with saline solution to maintain sterility. Research and development issues currently under investigation include tissue deformation models using mass-spring system and finite element methods; tissue cutting using a high-resolution volumetric mesh and dynamic topology; and accurate collision detection, cutting, and soft-body haptic rendering for two devices within the same haptic space.

Sharp debridement: the need for training and education.

Until recently there has been a lack of courses demonstrating how to undertake sharp debridement. The clinical governance framework has highlighted that nurses frequently perform the procedure without having received formal education and training (Fairbairn et al, 2002). Clinical governance, which includes risk management, clinical audit and evidence-based practice, aims to help all clinicians to improve quality and safeguard standards of care. The framework seeks to ensure that health professionals have the right training, skills and competencies to deliver the care needed by patients.

A sharp debridement procedure devised by specialist nurses.

In the clinical governance era, self-education is not adequate training for nurses to carry out sharp debridement, which is a risky process. Specialist nurses in south-east London drew up a workable procedure for training and practice.