iccp-wound care literature review

8/13/2019 ICCP-Wound Care Literature Review

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2009

Integrated Client Care

Project

WOUND CARE BEST PRACTICES

AND OUTCOMES: A REVIEW OFTHE LITERATURE


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Wound care best practices and outcomes: A review of the literature

Integrated Client care Project, October 15, 2009 Page 2

Contents

1. INTRODUCTION .................................................................................................................................... 4

2. SUMMARY ............................................................................................................................................ 4

i. Venous Ulcer Care: ........................................................................................................................... 4

ii. Diabetic Foot Ulcer Care:.................................................................................................................. 4

iii. Outcomes/Outcome Measurements:............................................................................................... 5

3. VENOUS LEG ULCERS ............................................................................................................................ 5

Synopsis: ................................................................................................................................................... 5

3.1. A Transprofessional Comprehensive Assessment Model for Persons with Lower Extremity

Leg and Foot Ulcers,by Kevin Woo, Afsaneh Alavi, Mariam Botros, Laura Lee Kozosy, Marjorie

Fierheller, Kadhine Wiltshire and R. Gary Sibbald. ................................................................................... 6

3.2. Assessment and Management of Venous Leg Ulcers,an RNAO Nursing Best Practice

Guideline ................................................................................................................................................... 7

3.3. Best Practices for the Prevention and Treatment of Venous Leg Ulcers,by Brian Kunimoto,

Maureen Cooling, Wayne Gulliver, Pamela Houghton, Heather Orsted and Gary Sibbald. ..................... 9

3.4. Best Practice Recommendations for the Prevention and Treatment of Venous Leg Ulcers:

Update 2006,by Cathy Burrows, Rob Miller, Debbie Townsend, Ritchie Bellefontaine, Gerald

MacKean, Heather Orsted and David Keast. ............................................................................................. 9

3.5. Compression for Preventing Recurrence of Venous Leg Ulcers (Review),by E Andrea

Nelson, Sally EM Bell-Syer and Nicky A Cullum. ..................................................................................... 11

3.6. Summary Algorithm for Venous Ulcer Care with Annotations of Available Evidence,

Association for Advancement of Wound Care (AAWC), 2005. ............................................................... 12

3.7. Management and Prevention of Venous Leg Ulcers : A Literature Guided Approach,by

Brian T. Kunimoto ................................................................................................................................... 13

4. DIABETIC FOOT ULCERS ...................................................................................................................... 14

Synopsis: ................................................................................................................................................. 14

4.1. Best Practices for the Prevention, Diagnosis and Treatment of Diabetic Foot Ulcers,by

Shane Inlow, Heather Orsted and Gary Sibbald ..................................................................................... 15

4.2. Evaluation and Treatment of Diabetic Foot Ulcers,by Ingrid Kruse and Steven Edelman.... 16

4.3. Diabetic Foot Ulcers: Pathogenesis and Management,by Robert Frykberg ........................ 17

4.4. Diabetic Foot Ulcers,by Kyle Goettl, Christine Pearson and Mariam Botros ........................ 18

4.5. Assessment and Management of Foot Ulcers for People with Diabetes,RNAO Best Practice

Document................................................................................................................................................ 19


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1. INTRODUCTIONThe purpose of this review is to provide an overview and summary of clinical evidence and opinions on

best practices and outcome measures in the area of wound care. More specifically, this report focuses

on venous leg and diabetic foot ulcers. While the literature search also encompassed post-surgical

wounds, it found that the existence of evidence and best practice guidelines specific to their treatment

is not yet developed to the extent that it is for the above two wound types. In addition, articles

discussing the kinds of outcome measurements to be used in wound care and the importance of

properly recording and analysing outcome data are included. The majority of articles reviewed below

were of Canadian and U.S. origins and content, although there are references to studies done in the UK

and elsewhere.

2. SUMMARYThe key patterns of opinion and evidence that emerged from the review of best practice literature are:

i. Venous Ulcer Care:A team, interdisciplinary approach is necessary for the optimal treatment and

achievement of best results.

In terms of caring for the local wound itself, best practice indicates that the key areas

for clinicians to focus on are debridement, infection control and compression (through

bandages or stockings).

Patient involvement in the healing and prevention process is underscored by a number

of authors and studies. This includes compliance with prescribed regimens as well as

implementing lifestyle changes where necessary.ii. Diabetic Foot Ulcer Care:

Similarly to the venous leg ulcers, diabetic foot ulcers are complex and require

multidisciplinary care. Foot ulcers in people with diabetes and the complications arising

from them are the leading cause of lower extremities amputations, which adds to the

impetus and urgency for preventing and properly treating such wounds.

Prevention and screening, especially for people with past history of foot ulcers, is

stressed as being of extreme importance. Experts and recommended guidelines advise

that it is crucially important that patients be monitored for loss of protective sensation

in their lower extremities (the usually suggested method is by way of applying a

monofilament test to the patients feet).Local wound care in the case of diabetic foot ulcers should encompass three key

components: debridement, infection control, pressure offloading (through appropriate

footwear or casts).

As in the case of venous leg ulcers, experts stress the importance of patient involvement

for the successful treatment and prevention of diabetic foot ulcers.


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iii. Outcomes/Outcome Measurements:The consensus among experts and across studies is that accurate and ongoing

measurement of relevant outcomes is of pivotal importance for choosing and adjusting

treatment options and achieving end results.

Wound surface area (accurately determined) as well as wound depth and extent of

tissue involvement emerged as the two crucial measures to be monitored.

Other indicators such as increase/reduction of edema and exudates from the wound are

also important in the monitoring of the healing process.

One article pointed out the lack of a comprehensive, easy to use tool for measuring

healing progress for venous leg ulcers.

Some recommended tools for wound outcome and healing measurement were the

Bates-Jensen Wound Assessment Tool and the PUSH tooloriginally designed for

assessing pressure ulcerswhich one author argues can be used for assessment of

venous leg ulcers.

3. VENOUS LEG ULCERSSynopsis:

# of Articles Reviewed 7

Types of

articles

The articles reviewed in this section include various best practice guideline

documents, conference summaries and expert clinicians opinions concerned with

the treatment and prevention of venous leg ulcers.

Both Canadian and U.S. guidelines were included in this review.

Key Findings The consensus among experts and across best practice documents is that venousleg ulcers are best managed by a multidisciplinary team and with involvement of

the patient in the healing process. Comprehensive physical examinations and

detailed medical history taking are universally recommended. The literature

shows an agreement that the underlying cause(s) of the ulcer needs to be treated

parallel to the local wound itself in order to both facilitate healing and prevent

future recurrences.

At the level of local wound care, experts and guidelines almost universally

recommend debridement, infection control and compression as the three key,

crucial areas to be addressed by clinicians. Some disagreement exists as to the

efficacy of certain compression mechanism as compared to others.

Key

Conclusions

A wide variety of literature on evidence based best practice in the treatment and

prevention of venous leg ulcers is available.

There is a consensus on the need for a holistic approach addressing the overall

patient health as well as the local wound.

There exist broad guideline documents (e.g. 3.4.) as well as detailed, practice-

oriented recommendations (e.g. 3.2.).

Detailed documents, such as the RNAOs Nursing Best Practice Guideline, are

intended for bedside use by nursing practitioners and can be readily applied to


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venous leg ulcer patients.

The Ankle Brachial Pressure Index (ABPI) test is universally recommended as a

method of ruling out arterial disease and determining wound healability.

The importance of proper compression was a recurrent theme emerging from

reviewing the literature. High compression is generally recommended over low

compression, although other factors such as arterial disease and patientcompliance must also be factored in before making a choice.

Other

Interesting

Points

Best practice recommendations are derived from evidence sources of varying

degrees of quality. Some are confirmed by results from controlled, randomized

trials, while others have been reached as a consensus by a panel of wound care

experts and clinicians. The degree of evidence for recommendations cited below

is noted, where known.

The multi-disciplinary nature of venous leg ulcer care and the need for patient

compliance and education along the way of treating and preventing future

recurrences is underscored by most authors and panels.

One article extensively discussed the importance of proper nutrition as a

component of wound treatment and overall patient health.

3.1.A Transprofessional Comprehensive Assessment Model for Persons with Lower Extremity Legand Foot Ulcers,by Kevin Woo, Afsaneh Alavi, Mariam Botros, Laura Lee Kozosy, Marjorie

Fierheller, Kadhine Wiltshire and R. Gary Sibbald.

The study explores the impact of an interdisciplinary teams initial assessment for a person with

a lower extremity wound on the outcomes in those clients.

The study followed 111 clients over the course of four weeks while they were being cared for in

accordance with the CAWC/RNAO guidelines for the treatment of venous leg and diabetic foot

ulcers by an interprofessional team.

Key Findings:

o Many clients receiving home care services for wound care had not, prior to the study,

obtained the optimal assessment and treatment under the existing system.

o This in turn negatively impacted the clients healing times and resulted in spending in

excess of what would be sufficient under a comprehensive assessment model.

o The authors proposed and tested the interprofessional team and found the outcome to

be well-coordinated care delivered in a timely fashion.

o On the specific best practices in the treatment of leg ulcers, the authors cite studies

indicating that no specific dressing type applied in conjunction with compression on the

wound, is superior to others.

o As to the utility of compression, (i.e. pressure being applied to the wound through

hosiery, stockings, etc.) the authors join a number of other specialists cited in the study

who believe compression therapy to be crucialthe Recurrence rate of venous leg

ulcers was reduced from 75 to 25 per cent through the application of proper

compression.


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o Level B: evidence from well designed clinical studies but no randomized controlled

studies.

o Level C: evidence from expert committee reports and opinions and/or clinical

experience or respected authorities but without directly applicable studies of good

quality.

Out of the 65 recommendations 40 were supported by Level C evidence, 12 by Level B

evidence and 13 by Level A evidence.

For a summary of the 65 recommendations along with the level of evidence in their support, see

pages 10 to 17 of the RNAO document.

Among the recommendations, Recommendation #33 stands out as it states that absent other

complications, venous leg ulcers are best treated by a combination of compression (i.e.

graduated compression bandaging) and exercise. In terms of reliability, this recommendation is

supported by Level A evidence, i.e. the highest level of support of the kinds considered in the

guidelines development.

The subsequent 16 recommendations (#34 through #49) deal with specifics and details

regarding the level of compression which is suitable and the method(s) of its application as well

as long-term considerations for venous leg ulcer clients. These 16 recommendations are

supported by evidence of varying degrees of quality.

The document states that there is no evidence to support the use of high over moderate

pressure compression hoisery or vice versa in the prevention of ulcer recurrence, also noting

that compliance among patients with high pressure compression is lower. Studies considered in

the document suggest that clients should be prescribed the highest grade stockings they can

wear.

The theoretical amount of pressure produced by a bandage compression method is to be

calculated according to the formula P=4630xNxT/CxW where (La Places Law)o P=sub-bandage pressure (mmHg)

o N=number of layers

o T=tension within bandage (Kgforce)

o C=limb circumference (cm)

o W=width of bandage (cm)

Conclusions:

o The best practice guideline recommendations set is intended to improve outcomes for

venous leg ulcer clients by assisting practitioners and clients decisions regarding

appropriate care methods and options.o Adherence to the set of recommendations is believed to generally improve outcomes

and quality of care. However, the document stresses that the guidelines are not to be

applied irrespective of each cases particularities and specific factors The

recommendations made are not binding.


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are recommended in order to adequately assess the wounds healing prospects and risk

factors. The components of the history and physical examinations is recommended to

follow the RNAOs guideline document recommendations 1 through 7 and 14as well as

9 through 12. The level of evidence for this recommendation is C.

o Recommendation #3: determine the cause(s) of the chronic venous insufficiency based

on etiology: abnormal valves, obstruction, or calf muscle pump failure. This

recommendation, also supported by level C evidence.

o Recommendation #4: Implement appropriate compression therapy. As noted in the

reports synopsis, compression therapy is consensually deemed the gold standard for

venous leg ulcer care. The reports assessed level of evidence in support of this

recommendation is the highest possibleA. Pressure therapy is not suitable in cases

where arterial disease is also present. The report conforms to the RNAO assessment in

stating that high pressure compression should be the default choice, barring the

presence of complicating factors such as diabetes, arthritis, infection, and mild arterial

disease. The use of Intermittent Pneumatic Compression (IPC) is discussed and, based

on previously conducted trials, the authors agree that further evidence is necessary in

order to assess the effectiveness of IPC for venous leg ulcer treatment. The

recommended approach favours multi-layer compression over single-layer as well as

high compression over low compression. The authors underline the lack of evidence for

choosing among different types of high compression.

o Recommendation #5: Implement therapy for the complications resulting from chronic

venous insufficiency.

o Recommendation #6: Consider surgical management for certain cases.

o Recommendation #7: Communicate with patient and his/her family and establish

realistic healing expectations. The authors recognize the importance of good

communication and of addressing patient-centered concerns such as QoL, healing

prospects, long-term outlooks, etc.

o Recommendation #8: Assess the wound.

o Recommendation #9: Provide local wound caredebridement, bacterial balance,

moisture balance. This recommendation is strongly supported by evidence (level A).

The recommendation is to consider and select the appropriate method of debridement

and moisture regulation while taking into account the goal of treatment (e.g. healing or

maintenance) and other factors.

o Recommendation #10: incorporate specialists from other disciplines in order to ensure

proper addressing of other factors and co-factors in the wound healing/maintenance

process (e.g. mobility, nutrition, etc.)

Conclusions:

o The 2001 CAWC reports recommendations can be applied today. The RNAOs guideline

supplies evidence to support and update this list of recommendations.

o The report underscores the need of multidisciplinary teams in the planning for and

actual treatment of venous leg ulcers.


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o The report also includes a classification by key features of different compression

systems (Table 4) and different dressings (Table 6).

3.5.Compression for Preventing Recurrence of Venous Leg Ulcers (Review),by E Andrea Nelson,Sally EM Bell-Syer and Nicky A Cullum.

The reviews aim is to assess the effectiveness of compression therapy (bandages, stockings,

socks) in preventing the recurrence of pressure ulcers as well as to determine whether there is

an optimal level of pressure associated with the prevention of recurrence.

The review incorporates the results from two trials conducted in the UK and identified through a

19 database-wide search. The authors restricted the scope of their search to only include

randomized controlled trials evaluating compression bandages or hosiery.

The trials included were chosen based on their treatment of the following points: comparing

compression versus non-compression ; comparing different strengths of compression;

comparing different lengths of compression hosiery, compression bandages versus compressionhosiery, different types of compression hosiery and different types of compression regimens

(e.g. long/short stretch, single layer).

Key Findings:

o Of the two studies, one compared the use of moderate versus high pressure

compression hosiery (Harper 1996) and the other juxtaposed the effectiveness of two

types of moderate compression stockings in community clinics (Franks 1995).

o The authors found that in both studies, the not wearing of compression hosiery was

associated with high recurrence rates of ulcers, which constitutes indirect evidence for

the hypothesis that compression reduces recurrence.

o The review notes that, in the long run, there is no statistically significant difference inrecurrence rates between using high pressure or low pressure hosiery.

Conclusions:

o There is no evidence that compression prevents the recurrence of venous ulcers.

However, according to the authors review of the literature and analysis of the two UK

trials, this may represent a lack of evidence of a benefit rather than evidence for the

lack of benefitthe use of compression as a post-healing therapy is virtually universal,

which makes a controlled trial extremely hard to conduct; in addition, there exists

circumstantial evidence that clients who fail to follow the prescribed compression

regiment have higher recurrence rates than those who do follow it.o There is no evidence that high compression is more effective than moderate

compression in preventing venous ulcer recurrence. However, compliance is lower in

people who wear high level compression hosiery. It is the authors recommendation

that patients are prescribed the highest grade stockings they are able to wear.


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3.6.Summary Algorithm for Venous Ulcer Care with Annotations of Available Evidence,Association for Advancement of Wound Care (AAWC), 2005.

Prepared in the US, this guideline is the product of the work of an interdisciplinary task force

including physicians, PhDs, podiatrists, physical therapists, nurses and pharmacists.

The objective of the document is to establish a list of recommendations for achieving optimal

results in outcomes of treatment of venous ulcers.

The evidence used to support each recommendation was classified according to strength in one

of tree categories

o A: evidence including results from at least two randomized controlled trials in humans

o B: evidence of two or more historically controlled trials or convenience assignment or

convenience assignment or non-randomized controlled trials.

o C: evidence including one of the following: (1) results of one controlled trial; (2) results

of at least two case series or descriptive studies or a cohort study in humans; (3) expert

opinion.

The task force examined existing algorithms for care published prior to August 2002 and

evaluated the quality of evidence according to the scale above. Recommendations were arrived

on by way of expert consensus within the task force.

Key Findings: the recommendations emphasize the following steps in the care/treatment of

venous leg ulcers (level of evidence in support of each varies):

o A diagnosis consisting of taking a detailed patient history, a differential diagnosis

including taking an ankle-brachial index and a physical examination.

o Removing the cause or addressing the ulcer etiology by aiding venous return and

providing skin care.

o Applying compressionthe guidelines examine different compression options. Notably,

the evidence in support of this recommendation is overwhelmingly of level A, i.e. the

highest quality available.

o Local wound careincluding debridement, cleansing, managing moisture levels and

exudates (includes recommendation for maintaining a most wound environment for

healing enhancement and pain management).

o Considering other modalities in case of conservative therapy failing to work within 30

days.

Conclusions:

o Implementation of best practices and recommendations leads to decreased healing

times, increased healing rates and improves patients quality of life. The potential harmsinvolved depend on potential side effects of and adverse reactions to medications and

treatments.

o The outcomes considered for monitoring as indicators of successful venous ulcer care

are:

Ulcer healing rate and time

Ulcer recurrence


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Conclusions:

o The author recommends a holistic approach to the treatment and prevention of venous

leg ulcers, comprising of addressing the underlying condition (venous insufficiency),

nutritional deficiencies if present, proper local wound management (including moisture

balance and proper dressing choices) and appropriate compression.

4. DIABETIC FOOT ULCERSSynopsis:


Types of

articles

Articles included in this section were selected from U.S. and Canadian

publications and represent a sample of the literature discussing best practices in

the treatment and prevention of foot ulcers in people with diabetes (PWD).

The majority of articles included are presentations of evidence-based practices

verified by literature or clinical experience. Some articles represent the authors

expert opinion.

Key Findings The review showed a consensus among experts that the chief cause of foot ulcers

in PWD is the combination of trauma and/or deformity and loss of protective

sensation in the extremities. Experts widely recommend the use of a

monofilament test to determine whether loss of such protective sensation in the

foot has occurred.

Consensus exists also regarding the key factors which promote foot ulcer healing,

namely a moist wound environment, debridement and infection control and

pressure offloading through specialized casts or shoes.

Different offloading methods are endorsed by different experts and reviews. Total

Contact Casts (TCCs) and Instant Total Contact Casts (ITCC) emerge as the best

methods of pressure offloading. Due to the care intensive nature of TCCs, somearticles recommend custom-designed footwear as an acceptable, viable

alternative.

Given the nature of diabetes and the complications arising from it, authors widely

agree that the approach to treating foot ulcers in PWD should be that of a

multidisciplinary team. Patient involvement and education is also crucial to the

successful and timely healing of ulcers and the prevention of future recurrences.

Experts are in agreement that ulcer classification is an important step in

predicting the course of healing and the choosing/adjusting of treatment

methods. The University of Texas Classification System emerges as the leading

classification tool endorsed by experts in the field.

Key

Conclusions

A holistic approach to treatment is crucial. A multidisciplinary clinical team must

address both the local wound and the underlying condition.

Pressure offloading is crucial to the healing process; TCCs are recommended, with

purpose-designed footwear being a good alternative.

Patient involvement and compliance, including dietary and lifestyle changes and

the establishing of realistic expectations and goals regarding the wound are an

important part of the treatment process.


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between 58 and 100 per cent after the implementation of a multidisciplinary team

approach to care.

Conclusions:

o The authors recommend strong preventive measures in order to reduce the incidence of

foot ulcers in PWD.

o The key components of a best practice treatment of diabetic foot ulcers are said to be

pressure offloading, maintaining of an appropriate moisture balance and avoidance of

infection.

o The authors emphasize strongly the need for patient involvement in the care process,

including possible life style changes (e.g. smoking cessation, diet changes) aimed at

improving health and reducing occurrence/recurrence risks.

4.2.Evaluation and Treatment of Diabetic Foot Ulcers,

by Ingrid Kruse and Steven Edelman.

This article presents an overview of major causes of foot ulcers in PWD, proper evaluation steps

to be taken and the key components of treatment to be applied.

Key Findings:

o In terms of evaluation, the authors recommend the assessment of neurological status,

vascular status of the patient and an examination of the wound itself.

o Neurological assessment is to be conducted in order to assess whether or not loss or

protective sensation in the lower extremities has set in. A recommended method is the

application of a 10-g monofilament to the foot in order to assess sensation.

o Vascular assessment is deemed by the authors to be essential for the evaluation and

healing of the diabetic foot ulcer.o In addition to the above, a complete wound assessment should take into account

wound location, size, shape, depth and border in order to, among other things, rule out

other possible causes for the foot ulceration.

o The authors recommendations for treating diabetic foot ulcers focus on three main

areas: debridement, offloading and infection control.

Debridement(i.e. removal of all non-viable tissue) should be performed to

decrease the risk of infection and facilitate the wound closing process by

reducing peri-wound pressure.

Offloadingis noted as the biggest challenge for clinicians dealing with diabetic

foot ulcers. Different methods are discussed (e.g. wedge shoes, Total ContactCasts or TCC and removable casts). The article points out that each have

advantages as well as drawbacks. For example, while removable casts allow for

daily wound inspection, patients do not comply with wearing them.

Infection Control - infections must be treated appropriately and in a timely

fashion.


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o Infection control and treatment (with antibiotics, surgical drainage or amputation

depending on the severity of the infection) are also identified as crucial points in the

treatment process.

o A team, multidisciplinary approach is recommended for the prevention of ulcers in

PWD. Regular foot examinations, therapeutic shoes and, in certain cases, surgical repair

of structural deformities are all said to be important components of an effective

preventive program.

Conclusions:

o The author advocates a multidisciplinary approach to diabetic foot ulcer treatment.

o The importance of debridement, pressure offloading and infection control are listed as

the three key areas of treatment focus.

o The article also makes recommendations as to the appropriate preventive measures to

be taken for preventing the occurrence or recurrence of diabetic foot ulcers in PWD.

4.4.Diabetic Foot Ulcers,by Kyle Goettl, Christine Pearson and Mariam Botros.This is a summary of a conference meeting of the World Union of Wound Healing Societies

including presentations from Australia, North America, Europe, the Middle East and Japan.

Key Findings:

o The authors note that the conference reinforced the importance of foot examination

and evaluation of neuropathies in the prevention and timely addressing of diabetic foot

ulcers. Factors such as loss of protective sensation, deformities and previous cases of an

ulcer or an amputation should all be taken into account for a complete and thorough

evaluation. The use of the monofilament test to assess sensation is endorsed.o The article discusses briefly the discrepancy between the best predictive scale for foot

ulcer classification (the University of Texas scale) and the most widely used (the Wagner

system). The SINBAD (Site, Ischemia, Neuropathy, Bacterial infection, Area and Depth)

scale is also noted to have shown recent favourable results in terms of accuracy in

predicting ulcer outcome.

o Offloading was mentioned as a key treatment pillar discussed by presenters at the

conference. The consensus was that the term offloading is restricted only to medical

devices applied for that purpose, while patients overall activity and lifestyle are also

important factors to be considered. It was emphasized that patients understanding of

their condition must be enhanced.

Conclusions: the following were presented to have been the main conclusions of the conference

o That a thorough and appropriate (i.e. conducted with the appropriate tool) evaluation

of the patient is crucial for both prevention and treatment of diabetic foot ulcers.

o That best practices must include infection prevention and treatment if necessary.


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treatment and making adjustments such as changing the type of dressing if

necessary.

Pressure offloading/redistribution is recommended as a component of the

wound treatment and also as a step toward preventing the recurrence of future

ulcers. Some evidence is presented for the effectiveness of total contact casting

(TCC). Ultimately attention is drawn to the importance of using some method of

pressure relief and educating the patient of the importance of this for their

wound healing.

o The report makes numerous references to the need for a multidisciplinary, team

approach to the treatment of diabetic foot ulcers.

o The guidelines also include the recommendation to evaluate and reassess the

treatments effectiveness on an ongoing basis and make the necessary adjustments as

need arises.

Conclusions:

o The guidelines document presents a comprehensive recommendations for the

assessment, prevention and management of diabetic foot ulcers.

o Recommendations on treatment focus on the areas of debridement, maintenance of an

appropriate moisture balance, monitoring and preventing infection and offloading

pressure.

o The document strongly advocates a teamwork, interdisciplinary approach for managing

foot ulcers in people with diabetes.

4.6.Diabetic Foot Ulcers,by Laura Bolton.The article is a report on the results of a study conducted to compare the effects of a

collagen/oxidized regenerated cellulose (C/ORC) dressing versus the saline-moistened gauze in

diabetic patients with foot ulcers.

The study proceeded with a sample of 138 patients being randomly assigned to either dressing

type following the taking of a baseline medical history. Dressings were changed as required for a

maximum period of 12 weeks. Healing efficacy, safety, and patient and physician preferences

were recorded.

Key Results:

o No significant differences in safety or efficacy were registered between the two dressing

types.o A higher rate of healing within 12 weeks was noted for the group using the C/ORC

dressing.

o Patients and physicians alike were found to prefer C/ORC dressings.


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o For the purposes of pressure offloading, the authors recommend TCCs or removable

casts.

o The focus of the treatment should be around debridement, infection control and

appropriate moisture balance maintenance.

4.8.A Transprofessional Comprehensive Assessment Model for Persons with Lower Extremity Legand Foot Ulcers,by Kevin Woo, Afsaneh Alavi, Mariam Botros, Laura Lee Kozosy, Marjorie

Fierheller, Kadhine Wiltshire and R. Gary Sibbald.

See 3.1. for a general overview of the article.

In a discussion of diabetic foot ulcers, the authors recommend that the four crucial components

for adequate healing are (1) adequate perfusion, (2) controlled infection or bacterial damage,

(3) pressure downloading and (4) sharp surgical debridement.

Notably, the authors recommend the use of sharp debridement over other methods for removal

of unviable tissue

5. OUTCOMES, OUTCOME MEASURES AND TOOLS IN WOUND CARESynopsis:


Types of

articles

The articles included in this section focus on defining, and recommending

measures and outcomes to be used in monitoring and assessing wound healing.

Some articles discuss individual measures and factors while others discuss and

recommend holistic tools for overall wound outcome measurement and tracking

Key Findings The consensus among experts is that there exists a lack of a holistic,

comprehensive and easy to use tool for wound healing assessment for all chronic

wounds (including diabetic foot and venous leg ulcers).

Some tools which have been adapted and can be used for that purpose are the

PUSH (Pressure Ulcer Scale for Healing) which has been used to assess venous leg

ulcers and the Bates-Jensen Wound Assessment Tool which is adapted from the

Pressure Sore Status Tool and can be used reliably for all chronic wounds

according to one article.

The clinical outcomes most widely recommended as crucial to accurate wound

healing rate predictions as well as monitoring were wound surface area (length

and width) and wound depth.

Authors recommended that outcomes be patient-oriented and realistic (i.e.

setting realistic goals for the healing process and having the patients concerns

reflected in the goals and outcomes which are monitored).

Key

Conclusions

There exists a large degree of agreement as to the measures and outcomes

relevant for adequate assessment and tracking of the wound healing process (e.g.

wound dimensions, depth, exudates levels, etc.).


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There is a perceived lack of specially dedicated, holistic wound assessment tools

for chronic wounds such as diabetic foot ulcers and venous leg ulcers.

Goals and outcomes of treatment must be patient orientede.g. concerned not

only with the clinical side of the healing process but with the patients quality of

life and how it is impacted by the condition and the healing process.

OtherInteresting

Points

One article differentiated between outcome measures in three categories: (1)clinical efficacy measures; (2) health-related quality of life (HRQoL); and (3) health

economics.

The authors elaborate on scales and points of interest within each category,

noting that clinical outcomes should not be a stand-alone goal and thus should

not be the only thing measured along the course of care. By contrast, patient-

centered measures such as the value gain/loss to the patient from the condition

and its improvement is a critical outcome measure for determining the success of

a given intervention or type of treatment.

5.1.Outcomes Research Measuring Wound Outcomes,by Marco Romanelli, Valentina Dini,Maria Stefania Bertone and Ciniza Brilli.

The article is focused on wound outcome measures and evaluation criteria to be monitored for

wounds in general and for specific wound types.

The authors emphasize the importance of monitoring wound parameters as well as taking a

detailed medical history and a thorough physical examination.

Key Findings

o The authors point out that ongoing examination and monitoring of the wound is crucial.

o Parameters to monitor include length, width, depth, surface area, tissue viability,

duration, blood flow, oxygen, hardness, inflammation, pain and others.

o Specific to venous leg ulcers, the authors note the predominant practice is to trace thewounds outline on a transparent acetate sheet (in order to determine the wounds

perimeter) and to fill the wound with a hypoallergenic material to create a cast which is

then measured or use a cotton swab inside the wound (in order to determine the

wounds volume).

o According to Romanelli et al., most diagnoses are made on visual observation. The

authors assert that there is only one reliable, standardized visual wound assessment

tool content validated for all chronic wounds, namely the Bates-Jensen Wound

Assessment Tool, adapted from the valid, reliable Pressure Sore Status Tool.

o Determining the healability of an ulcer early on in the course of treatment as well as

tracking its healing course is stated to be greatly beneficial.o The authors cite studies which examine the wound perimeter (length and width) in

order to predict healing times with some accuracy. Together with measuring wound

depth, this is a key wound parameter to monitor and record, according to the article.

o For diabetic foot ulcers, the authors recommend the combined use of a monofilament

and vibration perception tests in order to estimate sensitivity in the patients

extremities. Also, transcutaneous oxygen tension measurement is said to be a well


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established technique for evaluating local ischemia in patients with diabetes, with

values lower than 40mmHg being an indicator of critical ischemia.

o For patients who have already developed ulcers, the authors recommend, as in the case

of venous leg ulcers, that the surface area and depth of the wound be closely monitored

and measured.

o Notably, the authors recommend that changes in patient-reported pain or sensation of

heat in the foot are important indicators to be accounted for as they may indicate a

potential bone involvement.

Conclusions:

o The authors believe that measuring wound surface area (length and width) is one of the

best and most important measurement indicators for tracking and predicting wound

healing for chronic wounds such as venous leg and diabetic foot ulcers.

o Along with that, the authors emphasize the importance of measuring wound depth and

taking a comprehensive medical history as being an important part of the best practices

toolkit to be applied in wound care.

5.2.What are Wound Care Outcomes?by Steven L. Soon and Suephy C. Chen.The article presents an overview of three types of wound care outcomes of relevance to

clinicians, patients and health care administrators.

The outcomes are organized in three categories: measures of clinical efficacy, health-related

quality of life and health economics. The authors discuss the appropriate measurements and

outcomes to take into consideration in each of the three categories.

Key Findings:o Clinical efficacy measuresthe authors list percentage of patients healed; mean time to

complete healing; percentage change in wound area; percentage change in wound area

debrided; exudates type and amount; infection reduction rate; predominant tissue type

at wound bed , etc.

o The authors point out that, while useful from a purely clinical and comparative

standpoint, such clinical efficacy outcomes may often represent outcomes which are not

important or not greatly important to the patient herself.

o Health-related quality of life measures (HRQoL)in contrast to clinical outcome

measures, these aim to determine the subjective experience of the disease for an

individual patient. These measures are grouped in four categories: (1) physical functioni.e. ones sense of physical energy and ability to carry out activities of daily living; (2)

psychological well being i.e. ones psychological response to ones health, including

depression, anxiety, fear, etc.;(3) social functioningi.e. ones ability to engage in

meaningful interpersonal relationships; and (4) somatic sensationi.e. ones disease-

related symptoms such as pain, etc.


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and responsive (i.e. the extent to which a given instrument is sensitive to important

changes in a patients condition over time).

5.3.Use of the PUSH Tool to Measure Venous Ulcer Healing,by Catherine R. Ratliff and George T.Rodeheaver.

The article reports the results of a study examining the viability of the Pressure Ulcer Scale for

Healing (PUSH) tool to assess healing in patients with venous leg ulcers.

The authors point out the critical importance of ongoing monitoring and assessments of wounds

over the course of treatment in order to determine progress.

The article states that no simple, easy to use, valid and reliable tool exists for the purpose of

monitoring the healing process for patient with venous leg ulcers.

Key Findings:

o The authors lay out the results of examining studies validating the use of the PUSH tool

in evaluating and monitoring pressure ulcer healing.o The article points out that the three key parameters used by the PUSH tool for pressure

ulcers are wound surface area, character of exudates and surface appearance of the

ulcer.

o It is noted that the literature suggests that these three outcomes/parameters may also

be important in monitoring venous leg ulcers.

o The authors descriptive study applied the PUSH tool to assess the healing of venous

ulcers in patients over the course of two months. The PUSH tool was administered and a

PUSH score was given to patients on the initial and then subsequent clinic visits in order

to monitor and track progress.

o After following twenty seven patients over two months, the study concluded thattwenty three had a decrease in their PUSH score by the end of the time period.

Furthermore, those who did not show a PUSH score improvement were found to have

been non-compliant with compression therapy.

Conclusions:

o The authors note that given the three components measured by PUSH (size, exudates,

tissue type), a lack of improvement in all categories should indicate that the course of

treatment should be changed.

o The use of the PUSH tool further allows for the comparison of treatment effectiveness

across clinics or across wound types, but cannot provide a measure of the effectivenessof any particular intervention.


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5.4.Analyzing Outcomes in Wound Care,by Glenda Motta.The author discusses the general features that outcome measurements and criteria must satisfy

in order to be useful and accurate. The article also cites some specific examples of measures to

be monitored for full thickness chronic wounds.

Key Findings:

o The authors stance is that outcomes should be patient-oriented and realistic (i.e. not

raising unrealistic expectations for wound healing for non-healable wounds for

example).

o The outcomes must be measurable and observable in concrete, objective terms.

o The article stresses the importance of patient involvement and endorsement of the

outcomes and the care plan. This, Motta argues, leads to an increased likelihood of

achieving the outcomes.

o The article recommends using the following outcomes, among others, as indicators of

wound healing in full-thickness wounds:

Reduction of erythema, edema or induration

Removal of necrotic debris

Surface area changes

Exudates is serious with no odour

Conclusions:

o The author recommends patient involvement and setting realistic goals for treatment

outcomes.

o The article also states that wound outcomes must be strictly measurable, patient-

oriented and monitored on an ongoing basis in order to ensure successful treatment

and make adjustments as necessary.

5.5.Improving Accuracy of Wound Measurement in Clinical Practice,by Madeline Flanagan.The article focuses on examining means for improving some commonly used, widespread

wound measurement techniques .

The article is based on a review of evaluative literature across databases from 1965 to 2003.

Key findings:

o Wound area measurement practicesthe article points out that common methods used

to measure wound surface area are imprecise. The author suggests that wound area is

most accurately measured by accurately determining the wound margins and thendetermining the surface area. A recommended method is using planimetry (e.g. with the

help of a portable digital planimetric device); diameter product measurements are said

to be the least reliable method of determining surface area followed by square counting

(i.e. imposing the traced wound outline on a graphed paper and counting the number of

pre-measured squares fitting into the outline).


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o Wound depth measurement practicesthe article points out that measuring wound

depth using a probe consistently underestimates the volume of larger, more irregularly

shaped wounds. The author stresses that measuring would depth and thus volume is

crucial to planning and setting realistic healing goals as full-thickness wounds generally

take longer to heal than partial-thickness wounds. No specific depth measurement

techniques were endorsed or suggested.

o The article points out that the appearance of the wound bed is an indicator of a healing

process, but is subjective and thus not consistently reliable as it relies on the

interpretation of a clinician which could vary.

o The author cites evidence that surface area reduction over time is an excellent indicator

of wound healing and, furthermore, provides a good basis for predicting healing

trajectories. This applies to both diabetic foot as well as venous leg ulcers.

Conclusions:

o Calculating wound surface area is a reliable and valid method of monitoring wound

healing.

o Moreover, the percentage change in wound area over the course of the first few weeks

of treatment is shown to be a helpful indicator for distinguishing healable from non-

healable ulcers, which in turn has profound implications for choosing the appropriate

course and type of treatment, etc. After reviewing the literature, the author concludes

that a surface area reduction of less than 20% to 40% over the initial 2 to 4 weeks is a

reliable indicator that the wound is not responding well to treatment.

o Lastly, the author points out the importance of consistent and regular monitoring and

measuring of the parameters, so that progress can be tracked and interventions

adjusted.

6. OTHER ARTICLESSynopsis:


Types of

articles

The articles included in this section focused on salient points not directly related

to best practices for a specific wound type.

One article presents a discussion of the importance and status of best practice

implementation across Canada and the other is a discussion of a specific type of

therapy and its applications for the treatment of chronic wounds.

Key Findings Implementing best practices is seen to improve outcomes and thus as something

desirable to be encouraged.

The authors point out the difficulties in disseminating best practices (e.g. the

differing degrees to which clinicians are prepared or willing to implement those)


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6.1.Best Practice: Development, Implementation and Current Status Across Canada,by DouglasQueen, Tazim Virani, Pat Coutts, Heather L. Orsted. R. Gary Sibbald.

Following the issuing of best practice and evidence-based recommendations for wound care by

the Canadian Association of Wound Care (CAWC) in 2000, this article reviews the different

approaches to implementation of evidence-based practice across Canada along with the

benefits and problems associated with their implementation.

Key Points:

o Best practice defined as combining evidence, experience and opinion to improve client

care by reducing inappropriate variations in practice and by promoting the delivery of

high-quality, evidence-based health care.

o The authors take note of the fact that the shift toward best practice is difficult to

maintain, with relapse rates (i.e. clinicians reverting to previous methods, treatments

and practices) as high as 80 per cent.

o A list of criteria for best practice guidelines including being explicit, evidence-based,

logically thorough and avoiding recommending unproven approaches.

o Case Studies: the article reviews four approaches to best practice implementation

Facility-drivena company in Kitchener, Ontario champions best practices in

wound care through its services which are designed around advanced, evidence-

based wound care protocols.

Health Authority-driventhe Calgary Home care Skin and Wound Assessment

and Treatment Team (SWAT) is a multidisciplinary team facilitated by the

Calgary Home Care program with the aim to disseminate best practice

as well as the potential pitfalls of reverting to old practices over time.

Several distinct methods for spreading and encouraging best practice use are

outlined and briefly evaluateda facility/service provider approach, a health

authority-driven approach or a province-wide approach.

On the utility of the VAC therapy for treatment of chronic wounds, the findings

suggest that VAC therapy is and can be useful as an adjunctive therapy in thetreatment of chronic ulcers.

The article reviewed here acknowledges the need for further research into the

effects and benefits of VAC and urged that best practices such as taking a

complete medical history and performing a comprehensive medical examination

are crucial parts of the treatment process.

Key

Conclusions

Best practice implementation is encouraged by clinicians and experts alike.

The difficulties in best practice implementation and observance as well as the

different methods of best practice dissemination and encouragement are well

noted and documented.

The future of best practice implementation will depend upon the development of

electronic health records, the degree to which clinicians and health authorities

collaborate and the extent to which there is interest and work in the area of filling

gaps in the evidence and expanding on the existing best practice literature.

On VAC therapy, clinicians find it to be a useful adjunct therapy to supplement

the treatment of chronic wounds such as diabetic foot or venous leg ulcers.


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knowledge through education, clinical visits and procedure recommendations to

staff working for the Calgary Home Care program.

Provincially-drivenBest practices being encouraged and popularized by

professional associations such as the Registered Nurses Association of Ontario

(RNAO) using government funding. The RNAO developed and publicized a

comprehensive guideline for the assessment and management of venous leg

ulcers (reviewed below) by drawing on the expertise and opinion of a

multidisciplinary team including experts from private practice, long-term care

and acute care.

Nationally-driventhe CAWCs own efforts in promoting adherence to best

practices is noted and its role as an enabler underscored.

Conclusions:

o Implementing clinical practice guidelines can improve outcomes. However such

guidelines are often poorly implemented due to lack of information about the content

of such guidelines and their availability, the disbelief in the guidelines utility on the part

of practitioners among other reasons.

o The future of best practice implementation will strongly depend on (1) the proliferation

of electronic health records, (2) the progression of the trend for shared decision-making

between involved clinicians and (3) the increase/decrease in demand for information to

fill the gaps in research on best practices in specific wound care areas.

6.2.A Consensus Report on the Use of Vacuum-Assisted Closure in Chronic, Difficult-to-HealWounds,by R. Gary Sibbald, James Mahoney, The V.A.C. (R) Therapy Canadian ConsensusGroup.

This article presents the consensus opinion among wound care professionals on the use of

Vacuum Assisted Closure treatment.

The authors identify and acknowledge a need for further controlled studies to guide clinicians in

the integration of VAC therapy for chronic wound patients.

The article attempts to bridge that gap in available literature and controlled research by

synthesizing the opinions and recommendations of clinicians with experience in applying VAC

therapy.

The authors outline a general approach to be adhered to for patients with chronic wounds,

including an overall, comprehensive health assessment of the patient to determine anyunderlying physiological or pharmacological reasons for non-healing, before adjunctive

therapies (e.g.therapeutic ultrasound, surgery, VAC) are considered.

The Vacuum Assisted Therapy is an adjunctive therapy which works by introducing local

negative pressure in the wound area to promote healing. The system removes exudates and

helps maintain a moisture balance. The negative pressure further helps remove slough (i.e.

liquefied, non-viable tissue) from the wound bed.


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A consensus group, established in 2001 through a research grant by the VACs manufacturing

company, KCI Medical Canada Inc., was asked to provide opinions on 13 statements regarding

the use of VAC in patients with chronic wounds.

The majority of the groups members stated that they would use VAC therapy on chronic

wounds with delayed treatment. The panel considered intracutaneous fistulae, necrotic tissue,

undreated osteomyelitis and malignancy to be contraindications for the use of VAC therapy.

Experts were in general agreement that they would apply VAC immediately after wound

debridement, unless bleeding was a concern.

With different modes of pressure (low, high, constant, intermittent, etc.) available, panellists

recommended that continuous low-pressure be applied in cases where the VAC treatment is

associated with pain.

The panel recommended that any exposed tendons should be kept moist (e.g. through the use

of local moisture-retentive dressings) and that older patients in particular may not tolerate high

pressure well due to capillary fragility.

Conclusions:

o The panel made recommendations for the specific adoption of VAC therapy for chronic

wounds. Some modifications, such as not applying the VAC pressure immediately after

debridement in order to control bleeding and adjusting pressure to achieve optimal

tissue tension and fluid balance were recommended.

o The consensus group also recommended (and have since participated in) further clinical

controlled research into the use of VAC therapy for treating chronic wounds.

MMENDATION *LEVEL OF EVIDENCE

iccp-wound care literature review

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