Integrated Client Care Project


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

1. 2. i. ii. INTRODUCTION .................................................................................................................................... 4 SUMMARY ............................................................................................................................................ 4 Venous Ulcer Care: ........................................................................................................................... 4 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. 4.3. 4.4. “Evaluation and Treatment of Diabetic Foot Ulcers,” by Ingrid Kruse and Steven Edelman.... 16 “Diabetic Foot Ulcers: Pathogenesis and Management,” by Robert Frykberg ........................ 17 “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 Integrated Client care Project, October 15, 2009 Page 2

Wound care best practices and outcomes: A review of the literature 4.6. “Diabetic Foot Ulcers,” by Laura Bolton..................................................................................... 20

4.7. “Best Practice Recommendations for the Prevention, Diagnosis and Treatment of Diabetic Foot Ulcers: Update 2006,” by Heather L. Orsted, Gordon Searles, Heather Trowell, Leah Shapera and John Rahman........................................................................................................................................... 21 4.8. “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. ................................................................................. 22 5. OUTCOMES, OUTCOME MEASURES AND TOOLS IN WOUND CARE ................................................. 22 Synopsis: ................................................................................................................................................. 22 5.1. “Outcomes Research – Measuring Wound Outcomes,” by Marco Romanelli, Valentina Dini, Maria Stefania Bertone and Ciniza Brilli ................................................................................................. 23 5.2. “What are Wound Care Outcomes?” by Steven L. Soon and Suephy C. Chen .......................... 24

5.3. “Use of the PUSH Tool to Measure Venous Ulcer Healing,” by Catherine R. Ratliff and George T. Rodeheaver ......................................................................................................................................... 26 5.4. 5.5. 6. “Analyzing Outcomes in Wound Care,” by Glenda Motta ......................................................... 27 “Improving Accuracy of Wound Measurement in Clinical Practice,” by Madeline Flanagan ... 27

OTHER ARTICLES ................................................................................................................................. 28 Synopsis: ................................................................................................................................................. 28 6.1. “Best Practice: Development, Implementation and Current Status Across Canada,” by Douglas Queen, BSc, PhD, MBA; Tazim Virani, RN, MSc; et al................................................................ 29 6.2. “A Consensus Report on the Use of Vacuum-Assisted Closure in Chronic, Difficult-to-Heal Wounds,” by R. Gary Sibbald, James Mahoney, The V.A.C. (R) Therapy Canadian Consensus Group... 30

Integrated Client care Project, October 15, 2009

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S. which adds to the impetus and urgency for preventing and properly treating such wounds. Venous Ulcer Care: A team. 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. ii. Integrated Client care Project. infection control and compression (through bandages or stockings). 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. 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. In addition. 2009 Page 4 . 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 patient’s feet). this report focuses on venous leg and diabetic foot ulcers. origins and content. experts stress the importance of patient involvement for the successful treatment and prevention of diabetic foot ulcers. Prevention and screening. This includes compliance with prescribed regimens as well as implementing lifestyle changes where necessary. especially for people with past history of foot ulcers. SUMMARY The key patterns of opinion and evidence that emerged from the review of best practice literature are: i. Foot ulcers in people with diabetes and the complications arising from them are the leading cause of lower extremities amputations. As in the case of venous leg ulcers. The majority of articles reviewed below were of Canadian and U. is stressed as being of extreme importance. More specifically. Local wound care in the case of diabetic foot ulcers should encompass three key components: debridement. pressure offloading (through appropriate footwear or casts). Patient involvement in the healing and prevention process is underscored by a number of authors and studies. October 15. Diabetic Foot Ulcer Care: Similarly to the venous leg ulcers. INTRODUCTION The 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. diabetic foot ulcers are complex and require multidisciplinary care. 2.Wound care best practices and outcomes: A review of the literature 1. although there are references to studies done in the UK and elsewhere. While the literature search also encompassed post-surgical wounds. interdisciplinary approach is necessary for the optimal treatment and achievement of best results.

).g. Key Findings The consensus among experts and across best practice documents is that venous leg ulcers are best managed by a multidisciplinary team and with involvement of the patient in the healing process. 3. are intended for bedside use by nursing practitioners and can be readily applied to Integrated Client care Project. Other indicators such as increase/reduction of edema and exudates from the wound are also important in the monitoring of the healing process. At the level of local wound care.4. 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. VENOUS LEG ULCERS Synopsis: 7 # of Articles Reviewed Types of The articles reviewed in this section include various best practice guideline articles documents. practiceoriented recommendations (e.g. One article pointed out the lack of a comprehensive. infection control and compression as the three key. guidelines were included in this review. Detailed documents.) as well as detailed. 3. 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. conference summaries and expert clinicians’ opinions concerned with the treatment and prevention of venous leg ulcers. Wound surface area (accurately determined) as well as wound depth and extent of tissue involvement emerged as the two crucial measures to be monitored. Comprehensive physical examinations and detailed medical history taking are universally recommended. Some disagreement exists as to the efficacy of certain compression mechanism as compared to others.S. easy to use tool for measuring healing progress for venous leg ulcers. There is a consensus on the need for a holistic approach addressing the overall patient health as well as the local wound. October 15. Some recommended tools for wound outcome and healing measurement were the Bates-Jensen Wound Assessment Tool and the PUSH tool – originally designed for assessing pressure ulcers – which one author argues can be used for assessment of venous leg ulcers. such as the RNAO’s Nursing Best Practice Guideline. experts and guidelines almost universally recommend debridement.Wound care best practices and outcomes: A review of the literature iii. Both Canadian and U. crucial areas to be addressed by clinicians. There exist broad guideline documents (e. 3.2. Key A wide variety of literature on evidence based best practice in the treatment and Conclusions prevention of venous leg ulcers is available. 2009 Page 5 .

o As to the utility of compression. Mariam Botros. 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. etc. Best practice recommendations are derived from evidence sources of varying degrees of quality. Some are confirmed by results from controlled.e. randomized trials. Key Findings: o Many clients receiving home care services for wound care had not. October 15. stockings. Laura Lee Kozosy. although other factors such as arterial disease and patient compliance must also be factored in before making a choice.Wound care best practices and outcomes: A review of the literature venous leg ulcer patients. the authors cite studies indicating that no specific dressing type applied in conjunction with compression on the wound. Afsaneh Alavi. One article extensively discussed the importance of proper nutrition as a component of wound treatment and overall patient health. o On the specific best practices in the treatment of leg ulcers. o The authors proposed and tested the interprofessional team and found the outcome to be well-coordinated care delivered in a timely fashion. obtained the optimal assessment and treatment under the existing system. Other Interesting Points 3. Gary Sibbald.) the authors join a number of other specialists cited in the study who believe compression therapy to be crucial – the Recurrence rate of venous leg ulcers was reduced from 75 to 25 per cent through the application of proper compression. Kadhine Wiltshire and R. prior to the study. pressure being applied to the wound through hosiery. while others have been reached as a consensus by a panel of wound care experts and clinicians. The importance of proper compression was a recurrent theme emerging from reviewing the literature. (i. Integrated Client care Project. The study explores the impact of an interdisciplinary team’s initial assessment for a person with a lower extremity wound on the outcomes in those clients. Marjorie Fierheller. is superior to others. High compression is generally recommended over low compression. 2009 Page 6 . 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. 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. The degree of evidence for recommendations cited below is noted. The Ankle Brachial Pressure Index (ABPI) test is universally recommended as a method of ruling out arterial disease and determining wound healability. “A Transprofessional Comprehensive Assessment Model for Persons with Lower Extremity Leg and Foot Ulcers. where known.1.” by Kevin Woo.

through such interdisciplinary.g. 3. choice of dressing and compression. (B) Diagnostic Evaluation. was found to be substantial (48. (E) Infection.e. “Assessment and Management of Venous Leg Ulcers.) and that despite existing evidence for effective treatment practices. Integrated Client care Project. (G) Complementary Therapies. updating and synthesizing available best practice and evidence-based recommendations for venous leg ulcer care. etc. The RNAO guideline represents a consensus document. October 15. etc.2. o Based on the research methodology and criteria. Conclusions: o The introduction of interprofessional teams and consistent best practice adherence has the potential to reduce costs as well as healing time and recurrence rates. arrived at by reviewing. eight individual guideline documents from at least six jurisdictions were evaluated by the RNAO expert panel The key assumptions of the guidelines document include that: o Venous leg ulcers are managed with effective compression and wound management therapy. The document notes that a variety of practices exist in the management of venous leg ulcers (e. (F) Compression. (D) Venous Ulcer Care. The report was initiated in 2001 and draws on a number of best practice guidelines for venous leg ulcers in the literature since 1998. organized under the categories of (A) Assessment. (C) Pain. 2009 Page 7 . interprofessional teams) is crucial to optimizing the level and quality of care for patients with given wound types. o The authors stress that comprehensive assessment of wound patients (i.” an RNAO Nursing Best Practice Guideline.11 per cent reduction in size). which the authors identify as the primary endpoint of wound treatment. The authors also draw attention to the importance of addressing client-centred concerns such as pain management. (H) Reassessment and (I) Secondary Prevention. reduction in surface area. o An Ankle Brachial Index (ABI) measurement must be done prior to commencement of compression therapy.Wound care best practices and outcomes: A review of the literature o o Further. Evidence for each recommendation was derived from the reviewed existing guideline documents as well as other literature and was in turn differentiated by degree of strength into three categories: o Level A: evidence obtained from at least one randomized controlled trial or metaanalysis of randomized controlled trials. many clients are receiving sub-optimal care The panel ultimately arrived at a total of 65 recommendations for the treatment of venous leg ulcers. o Therapy involves client participation. adapting. emotional support.

Recommendation #33 stands out as it states that absent other complications. In terms of reliability. 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. this recommendation is supported by Level “A” evidence.e. For a summary of the 65 recommendations along with the level of evidence in their support. These 16 recommendations are supported by evidence of varying degrees of quality. the highest level of support of the kinds considered in the guideline’s development. o Integrated Client care Project. also noting that compliance among patients with high pressure compression is lower. Out of the 65 recommendations 40 were supported by Level “C” evidence. Among the recommendations. The theoretical amount of pressure produced by a bandage compression method is to be calculated according to the formula P=4630xNxT/CxW where (La Place’s 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. venous leg ulcers are best treated by a combination of compression (i. 12 by Level “B” evidence and 13 by Level “A” evidence. 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. 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. graduated compression bandaging) and exercise. However. the document stresses that the guidelines are not to be applied irrespective of each case’s particularities and specific factors The recommendations made are not binding. Studies considered in the document suggest that clients should be prescribed the highest grade stockings they can wear.e. see pages 10 to 17 of the RNAO document.Wound care best practices and outcomes: A review of the literature Level B: evidence from well designed clinical studies but no randomized controlled studies. o Adherence to the set of recommendations is believed to generally improve outcomes and quality of care. i. October 15. 2009 Page 8 .

Heather Orsted and Gary Sibbald. Debbie Townsend.3. o Determining the cause(s) of the wound. o Implementing appropriate compression method – noted as the most effective treatment for venous leg ulcers. “Best Practice Recommendations for the Prevention and Treatment of Venous Leg Ulcers: Update 2006.). Heather Orsted and David Keast.” by Cathy Burrows. are accompanied by level of evidence classifications reflecting the strength of evidence in support of each recommendation.4.3. It is however contraindicated in cases where the wound is non-healable or where the wound has inadequate vasculature. The 12 recommendations included in this report emphasize: o Thorough history taking and physical assessment – of the wound as well as of the patient overall. assess pain. o The importance of mobility and nutrition. C) are borrowed from the RNAO’s report (see 3. 3.) with the CAWC’s 2001 report on best practice recommendations for the prevention and treatment of venous leg ulcers. The levels (A. this article presents a summary of recommendations issued by the Canadian Association for Wound Care (CAWC) for what the best practices for prevention and treatment of venous leg ulcers consist in. The report’s recommendations (a total of 10). “Best Practices for the Prevention and Treatment of Venous Leg Ulcers. identify factors that may impair wound healing – a physical examination and a thorough history Integrated Client care Project. o The importance of debridement and bacterial balance. Wayne Gulliver. Originally published in Ostomy/Wound Management 2001.” by Brian Kunimoto. 47(2). B. 3.3. Maureen Cooling.Wound care best practices and outcomes: A review of the literature o Collaborative assessment and treatment planning are found as essential and the report encourages existing multidisciplinary teams’ assessment and treatment collaboration as it underscores that venous leg care is an interdisciplinary endeavour. arrived at after a compilation of the CAWC’s 2001 report and the RNAO guidelines document with supplementary literature review covering the period from 2001 to 2006. Gerald MacKean. These recommendations are also summarized and crossreferenced with the RNAO guide for quick reference and comparison (Table 1). connecting these recommendations to evidence. Rob Miller. This report combines the RNAO’s best practice guideline document (3. Pamela Houghton. 2009 Page 9 . Key Findings: o Recommendation #1 & #2: determine venous characteristics. Ritchie Bellefontaine. o Maintaining optimal moisture levels in the wound through using appropriate dressings – moist wound healing is put forward as the best practice accepted by most advanced wound care practitioners. o The communication with patients and their family in order to provide emotional support and establish realistic expectations for wound healing. October 15.

This recommendation. The recommended approach favours multi-layer compression over single-layer as well as high compression over low compression. healing prospects. Recommendation #9: Provide local wound care – debridement. based on previously conducted trials. Recommendation #6: Consider surgical management for certain cases.g.) o o o o o o o o Conclusions: o The 2001 CAWC report’s recommendations can be applied today. etc. Integrated Client care Project. The report’s assessed level of evidence in support of this recommendation is the highest possible – “A”. also supported by level C evidence. infection. The RNAO’s guideline supplies evidence to support and update this list of recommendations. The authors recognize the importance of good communication and of addressing patient-centered concerns such as QoL. Recommendation #5: Implement therapy for the complications resulting from chronic venous insufficiency. the authors agree that further evidence is necessary in order to assess the effectiveness of IPC for venous leg ulcer treatment. long-term outlooks. Recommendation #7: Communicate with patient and his/her family and establish realistic healing expectations. nutrition. The level of evidence for this recommendation is C. The components of the history and physical examinations is recommended to follow the RNAO’s guideline document recommendations 1 through 7 and 14 as well as 9 through 12. o The report underscores the need of multidisciplinary teams in the planning for and actual treatment of venous leg ulcers. healing or maintenance) and other factors. obstruction. 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. 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. mobility. Recommendation #8: Assess the wound. bacterial balance. and mild arterial disease. As noted in the report’s synopsis. barring the presence of complicating factors such as diabetes. or calf muscle pump failure. 2009 Page 10 . October 15. Recommendation #3: determine the cause(s) of the chronic venous insufficiency based on etiology: abnormal valves.g.Wound care best practices and outcomes: A review of the literature are recommended in order to adequately assess the wounds healing prospects and risk factors. The use of Intermittent Pneumatic Compression (IPC) is discussed and. The authors underline the lack of evidence for choosing among different types of high compression. arthritis. moisture balance. Recommendation #4: Implement appropriate compression therapy. 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. compression therapy is consensually deemed the “gold standard” for venous leg ulcer care. etc.

” by E Andrea Nelson. However. comparing different strengths of compression. 2009 Page 11 . according to the authors’ review of the literature and analysis of the two UK trials. o The authors found that in both studies. o The review notes that. which constitutes indirect evidence for the hypothesis that compression reduces recurrence. Key Findings: o Of the two studies. 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 authors restricted the scope of their search to only include randomized controlled trials evaluating compression bandages or hosiery. there exists circumstantial evidence that clients who fail to follow the prescribed compression regiment have higher recurrence rates than those who do follow it. the not wearing of compression hosiery was associated with high recurrence rates of ulcers. there is no statistically significant difference in recurrence rates between using high pressure or low pressure hosiery. 3.5. However. this may represent a lack of evidence of a benefit rather than evidence for the lack of benefit – the use of compression as a post-healing therapy is virtually universal. The review’s aim is to assess the effectiveness of compression therapy (bandages. which makes a controlled trial extremely hard to conduct.g. single layer). The trials included were chosen based on their treatment of the following points: comparing compression versus non-compression . It is the authors’ recommendation that patients are prescribed the highest grade stockings they are able to wear.Wound care best practices and outcomes: A review of the literature o The report also includes a classification by key features of different compression systems (Table 4) and different dressings (Table 6). Integrated Client care Project. The review incorporates the results from two trials conducted in the UK and identified through a 19 database-wide search. 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). different types of compression hosiery and different types of compression regimens (e. compression bandages versus compression hosiery. “Compression for Preventing Recurrence of Venous Leg Ulcers (Review). stockings. in addition. long/short stretch. Conclusions: o There is no evidence that compression prevents the recurrence of venous ulcers. in the long run. Sally EM Bell-Syer and Nicky A Cullum. October 15. o There is no evidence that high compression is more effective than moderate compression in preventing venous ulcer recurrence. comparing different lengths of compression hosiery. compliance is lower in people who wear high level compression hosiery.

cleansing. physical therapists. o C: evidence including one of the following: (1) results of one controlled trial. increased healing rates and improves patients’ quality of life. 2009 Page 12 . The objective of the document is to establish a list of recommendations for achieving optimal results in outcomes of treatment of venous ulcers. Notably. Prepared in the US. 2005.Wound care best practices and outcomes: A review of the literature 3. the highest quality available. podiatrists. nurses and pharmacists. o The outcomes considered for monitoring as indicators of successful venous ulcer care are:  Ulcer healing rate and time  Ulcer recurrence Integrated Client care Project. The potential harms involved depend on potential side effects of and adverse reactions to medications and treatments. o Considering other modalities in case of conservative therapy failing to work within 30 days. “Summary Algorithm for Venous Ulcer Care with Annotations of Available Evidence. (2) results of at least two case series or descriptive studies or a cohort study in humans.” Association for Advancement of Wound Care (AAWC). o Applying compression – the guidelines examine different compression options. this guideline is the product of the work of an interdisciplinary task force including physicians. i. the evidence in support of this recommendation is overwhelmingly of level “A”. 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. managing moisture levels and exudates (includes recommendation for maintaining a most wound environment for healing enhancement and pain management). PhDs. October 15. 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 Local wound care – including debridement.e. Conclusions: o Implementation of best practices and recommendations leads to decreased healing times. 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. (3) expert opinion.6. 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.

The use of hemorheologic agents is not recommended by the author on the basis of clinical studies. o In terms of local/wound bed preparation and care. 2009 Page 13 . go through phases of varying intensity of drainage. The author discusses a holistic approach to treating venous leg ulcers. incorporating nutritional supplementation. SSBs achieve better pressure. namely venous insufficiency. Integrated Client care Project. compression and dressing choices. The different compression systems are divided into short-stretch bandages (SSB). medication therapy (such as edema-preventing drugs). o The author also discusses the use of various adjunctive therapies such as physical therapy. Deficiencies in Vitamins A. anti microbial therapy and dressings (to achieve optimal moisture balance in the wound). but are harder and more cumbersome to use. Level “A” evidence however is expected to increase as more and more trials of the type included in the “A” category are conducted on the steps in the algorithm currently lacking such support. local wound care. C. intermittent pneumatic compression to supplement compression bandages. antimicrobial therapy. October 15. for example. Kunimoto. o It is pointed out that dressing types may well need to be changed or adjusted over the course of treatment as venous leg ulcers. adjunctive therapy and vascular surgery. o The author stresses the importance of “moist” wound healing and thus of choosing the appropriate dressings to ensure optimal for healing moisture balance. This article outlines some generic best practices for the management of wounds as well as leg ulcer-specific measures. o Compression therapy – the author identifies this component as the cornerstone of the wound management process since it addresses the underlying disease.Wound care best practices and outcomes: A review of the literature  Accuracy of diagnostic tests  Adverse effects of treatment  Symptom relief A noted limitation of the guidelines document is that some steps in the algorithm lack “A” level evidence support.7. o 3. LSBs are more widely used across North America. the author recommends focusing on the three areas of debridement. long-stretch bandages (LSB) and stockings. E as well as proteins and zinc all adversely affect the healing process and should be addressed.” by Brian T. “Management and Prevention of Venous Leg Ulcers : A Literature Guided Approach. Key Findings: o It is recommended that patients who are suspected to be malnourished should be examined by a nutritionist or a dietician. o The successful performance of a new human skin equivalent in trials is mentioned and its used encouraged for non-healing wounds.

A multidisciplinary clinical team must address both the local wound and the underlying condition. TCCs are recommended. nutritional deficiencies if present. some articles recommend custom-designed footwear as an acceptable. debridement and infection control and pressure offloading through specialized casts or shoes. Key Conclusions A holistic approach to treatment is crucial. Page 14 Integrated Client care Project. The majority of articles included are presentations of evidence-based practices verified by literature or clinical experience. The University of Texas Classification System emerges as the leading classification tool endorsed by experts in the field. namely a moist wound environment. Some articles represent the authors’ expert opinion. Total Contact Casts (TCCs) and Instant Total Contact Casts (ITCC) emerge as the best methods of pressure offloading. viable alternative.Wound care best practices and outcomes: A review of the literature Conclusions: o The author recommends a holistic approach to the treatment and prevention of venous leg ulcers. proper local wound management (including moisture balance and proper dressing choices) and appropriate compression. including dietary and lifestyle changes and the establishing of realistic expectations and goals regarding the wound are an important part of the treatment process. authors widely agree that the approach to treating foot ulcers in PWD should be that of a multidisciplinary team. with purpose-designed footwear being a good alternative. 2009 . 4. Consensus exists also regarding the key factors which promote foot ulcer healing. DIABETIC FOOT ULCERS Synopsis: 8 # of Articles Reviewed Types of Articles included in this section were selected from U. Experts widely recommend the use of a monofilament test to determine whether loss of such protective sensation in the foot has occurred. 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. Due to the care intensive nature of TCCs.S. and Canadian articles publications and represent a sample of the literature discussing best practices in the treatment and prevention of foot ulcers in people with diabetes (PWD). Given the nature of diabetes and the complications arising from it. Patient involvement and education is also crucial to the successful and timely healing of ulcers and the prevention of future recurrences. Pressure offloading is crucial to the healing process. Patient involvement and compliance. October 15. Different offloading methods are endorsed by different experts and reviews. comprising of addressing the underlying condition (venous insufficiency). 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 methodology of the authors was to construct the list of recommendations based chiefly on the opinions of experts in wound care as to what the best practices are that are also achievable in most clinical situations. depression proneness) is also raised as an important point to be addressed by the treating clinician or team of clinicians. o The authors recommend that diabetic foot ulcers be treated by a multidisciplinary team so as to achieve best results. it is not. alcohol. the article points out that diabetic foot ulcers affect approximately 15 per cent of people with diabetes and that over 85 per cent of lower extremity amputations are preceded by a foot ulcer occurrence. o Patients’ mental health (e. the authors recommendations are focused around three main objectives:  Pressure offloading  Appropriate care for the wound (e. Factors such as diet. prevalence and impact of diabetic foot ulcers and provides a list of eleven recommendations for best practices to be adhered to for achieving optimal results in treatment. Diagnosis and Treatment of Diabetic Foot Ulcers. according to the author. 4. debridement. weight. The opinions and practical experience of wound care experts was additionally supplemented by evidence in the literature and other guidelines in existence to date.g. adequate moisture balance. Heather Orsted and Gary Sibbald.Wound care best practices and outcomes: A review of the literature Other Interesting Points One article mentions that the Wagner Ulcer Classification System is the most widespread tool for wound classification in use. “Best Practices for the Prevention. Notably. A study is cited which shows a reduction in amputations Integrated Client care Project.g. The article presents a brief overview of the causes. October 15. smoking and exercise are noted as important for the success of the overall treatment process. the best at predicting wound healing trajectory. Key Points: o Six of the authors’ eleven recommendations address practices and procedures aimed at preventing ulcers from actually occurring in people with diabetes (PWD). However. monitoring of wound size. preventing infection)  Patient education o The authors recommend the importance of patients’ education and their taking responsibility for their own health.” by Shane Inlow.1. The approach to prevention features:  the taking of a medical history in order to better assess the risk of an ulcer developing  informing and educating the patient about the risks of ulcers in PWD and teaching them to recognize loss of protective sensation in their lower extremities  Classify the patient according to risk and ensure follow-up  Provide pressure offloading if loss of protective sensation is present o With regards to the treatment of already present diebetic foot ulcers. 2009 Page 15 .

o The authors emphasize strongly the need for patient involvement in the care process. October 15. The article points out that each have advantages as well as drawbacks. wedge shoes. size. offloading and infection control. Different methods are discussed (e. diet changes) aimed at improving health and reducing occurrence/recurrence risks. patients do not comply with wearing them.  Offloading is noted as the biggest challenge for clinicians dealing with diabetic foot ulcers. 2009 Page 16 . Key Findings: o In terms of evaluation. while removable casts allow for daily wound inspection. shape. 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 complete wound assessment should take into account wound location.g.Wound care best practices and outcomes: A review of the literature between 58 and 100 per cent after the implementation of a multidisciplinary team approach to care. vascular status of the patient and an examination of the wound itself.e. the authors recommend the assessment of neurological status. including possible life style changes (e.” by Ingrid Kruse and Steven Edelman. among other things. “Evaluation and Treatment of Diabetic Foot Ulcers. o Vascular assessment is deemed by the authors to be essential for the evaluation and healing of the diabetic foot ulcer. depth and border in order to. o The key components of a best practice treatment of diabetic foot ulcers are said to be pressure offloading. 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. smoking cessation.g. Total Contact Casts or TCC and removable casts). Integrated Client care Project. 4.infections must be treated appropriately and in a timely fashion.  Debridement (i. This article presents an overview of major causes of foot ulcers in PWD.2. o The authors’ recommendations for treating diabetic foot ulcers focus on three main areas: debridement.  Infection Control . proper evaluation steps to be taken and the key components of treatment to be applied. Conclusions: o The authors recommend strong preventive measures in order to reduce the incidence of foot ulcers in PWD. maintaining of an appropriate moisture balance and avoidance of infection. For example. o In addition to the above. A recommended method is the application of a 10-g monofilament to the foot in order to assess sensation. rule out other possible causes for the foot ulceration.

debridement and infection control and discusses the challenges and trade-offs involved in selecting and administering appropriate offloading mechanisms to PWD. o The outcome of treatment being to obtain wound closure. according to Frykberg. o As a part of the wound evaluation. rest. elevation of the affected foot and relief of pressure. o Debridement is recommended as a crucial component of the treatment .” by Robert Frykberg. the best practices and recommendations for treatment of foot ulcers and some recommendations for the prevention of diabetic foot ulcers.  The University of Texas diabetic wound classification system is also presented. the author recommends a multidisciplinary approach in accordance with the multifaceted nature of the diabetic foot ulcer. shape.g. depth. penetration and presence of osteomyelitis.Wound care best practices and outcomes: A review of the literature Conclusions: o Given that trauma combined with loss of protective sensation is considered the main cause of diabetic foot ulcers. loss of protective sensation). and said to encompass wound depth and penetration as well as the presence of lower –extremity ischemia and the presence of infection.  The Wagner Ulcer Classification System is briefly outlined and said to be the most widely accepted classification scale.monofilament is recommended for the assessment of sensation/lack thereof in the patient’s extremities. “Diabetic Foot Ulcers: Pathogenesis and Management. Its drawback is that it does not address or take into account ischemia and infection. the components of a proper wound evaluation. the author notes that a majority of foot ulcers are caused by trauma or deformity in the presence of peripheral neuropathy (e. o The key components of treatment are. o Measuring and monitoring wound size. o The authors draws attention to the importance of classification of ulcers according to scales which facilitates the choosing of an approach to treatment and the prediction of outcome.3. with removable TCCs and wedge shoes being acceptable alternatives. wound size. It is based on depth. o The administration of a 10-g. appearance and location are to be taken into account. 4. Key Findings: o Citing a study. 2009 Page 17 . o TCC is put forward as the optimal method of offloading. Integrated Client care Project. o The article recommends three focus-areas for treatment: offloading. The article discusses causes of diabetic foot ulcers. October 15. It is considered to be generally successful in predicting outcomes. the authors recommend a careful neurological evaluation as a preventive measure. depth and border should be a part of the evaluation of the wound.

2009 Page 18 . o The importance of debridement.” by Kyle Goettl. therapeutic shoes and. Christine Pearson and Mariam Botros. The consensus was that the term “offloading” is restricted only to medical devices applied for that purpose. surgical drainage or amputation depending on the severity of the infection) are also identified as crucial points in the treatment process. Integrated Client care Project. multidisciplinary approach is recommended for the prevention of ulcers in PWD. “Diabetic Foot Ulcers. Europe. 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. deformities and previous cases of an ulcer or an amputation should all be taken into account for a complete and thorough evaluation. The SINBAD (Site. pressure offloading and infection control are listed as the three key areas of treatment focus. Neuropathy.Wound care best practices and outcomes: A review of the literature o Infection control and treatment (with antibiotics. Bacterial infection. North America. This is a summary of a conference meeting of the World Union of Wound Healing Societies including presentations from Australia. 4. 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. A team. the Middle East and Japan. Conclusions: the following were presented to have been the main conclusions of the conference o That a thorough and appropriate (i. while patients’ overall activity and lifestyle are also important factors to be considered. in certain cases. Factors such as loss of protective sensation.e. o That best practices must include infection prevention and treatment if necessary. Area and Depth) scale is also noted to have shown recent favourable results in terms of accuracy in predicting ulcer outcome. Ischemia. Regular foot examinations. October 15.4. It was emphasized that patients’ understanding of their condition must be enhanced. o Conclusions: o The author advocates a multidisciplinary approach to diabetic foot ulcer treatment. surgical repair of structural deformities are all said to be important components of an effective preventive program. conducted with the appropriate tool) evaluation of the patient is crucial for both prevention and treatment of diabetic foot ulcers. o Offloading was mentioned as a key treatment pillar discussed by presenters at the conference. 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).

in order to assist healing of the wound. IIa. moisture balance and pressure offloading. III and IV) where level Ia evidence is obtained through a meta-analysis of randomized controlled trials and level IV evidence is derived from expert committee reports or opinions and/or clinical experiences of respected authorities. o For the management and treatment of existing foot ulcers. Key Findings: o The report notes that foot ulcers in people with diabetes are caused predominantly by a combination of trauma. October 15. The guideline was developed by a panel of nurses assembled in January 2004. assessing foot deformity and examining for signs of infection. Frequent wound evaluations are recommended for tracking progress of Integrated Client care Project. produced by the Registered Nurses’ Association of Ontario (RNAO).5.” RNAO Best Practice Document. Based on a set of criteria. including the taking of a complete and detailed patient history. o The report recommends a holistic assessment of diabetic patients. Ib. A search of the literature was conducted and eight existing guideline documents were identified for considerations. 2009 Page 19 . “Assessment and Management of Foot Ulcers for People with Diabetes.  Moisture balance should be maintained. o 4. the report recommends focusing on debridement.Wound care best practices and outcomes: A review of the literature o That pressure offloading – through the use of both medical devices and the making of appropriate lifestyle changes – is a crucial element of the treatment of diabetic foot ulcers. The draft was further submitted to a set of external stakeholders and critiqued using the AGREE instrument (Appraisal Guidelines for Research and Evaluation Instrument. assessing peripheral sensation.  The authors note that infections should be treated rapidly so as to avoid progression and complications such as osteomyelitis. The evidence adduced in support of each recommendation in the report is categorized on the basis of its strength and quality into one of six categories (Ia. considering the wound’s bacterial balance and exudates among other factors. provides guidelines for best practices in the care for patients with diabetic foot ulcers as well as recommendations with policy. This document. deformity and sensation loss. Using the guidelines as well as additional literature. These specific recommendations are supported by evidence of varying strength (categories Ia to III). the panel prepared a draft set of recommendations which was then reviewed by an advisory panel including physicians and other health care professionals. educational and organizational focus. IIb. infection control. the panel selected seven of these eight guidelines for detailed appraisal. That patient education and involvement in treatment and prevention is an important factor to be encouraged by clinicians in their practice.

o A higher rate of healing within 12 weeks was noted for the group using the C/ORC dressing. 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. Some evidence is presented for the effectiveness of total contact casting (TCC). “Diabetic Foot Ulcers. team approach to the treatment of diabetic foot ulcers.6. o The document strongly advocates a teamwork. 2009 Page 20 .  Pressure offloading/redistribution is recommended as a component of the wound treatment and also as a step toward preventing the recurrence of future ulcers. o Recommendations on treatment focus on the areas of debridement. maintenance of an appropriate moisture balance. October 15. Integrated Client care Project. 4. prevention and management of diabetic foot ulcers. The report makes numerous references to the need for a multidisciplinary. monitoring and preventing infection and offloading pressure. Dressings were changed as required for a maximum period of 12 weeks. safety. interdisciplinary approach for managing foot ulcers in people with diabetes. o Patients and physicians alike were found to prefer C/ORC dressings. Healing efficacy. o o Conclusions: o The guidelines document presents a comprehensive recommendations for the assessment. and patient and physician preferences were recorded. The study proceeded with a sample of 138 patients being randomly assigned to either dressing type following the taking of a baseline medical history.” by Laura Bolton.Wound care best practices and outcomes: A review of the literature treatment and making adjustments such as changing the type of dressing if necessary. 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. Key Results: o No significant differences in safety or efficacy were registered between the two dressing types. The guidelines also include the recommendation to evaluate and reassess the treatment’s effectiveness on an ongoing basis and make the necessary adjustments as need arises.

g.5. The report also recommends a continuous. 2009 Page 21 . looking for bony/structural deformities and possible sensation loss. o In terms of treatment of the local wound. which is focused on nursing practices. the report recommends debridement. Integrated Client care Project. The report makes 11 recommendations focused on the prevention. treatment and patient education for people with diabetes. The recommendations are summarized and cross-referenced with the RNAO guidelines corresponding or relating to each. the authors recommend that the first choice be TCCs or removable walkers. Heather Trowell.).Wound care best practices and outcomes: A review of the literature Conclusions: o C/ORC and saline-moistened gauze are comparable in safety and healing effects.). possibly substituted by Darco healing sandals if balance and gait are issues. October 15. although patients and physicians prefer C/ORC dressings. Key Findings: o The taking of a detailed history is recommended. o The authors recommend that clinicians consider the use of biological agents as adjunctive therapies. depth and classifying the ulcer accordingly. o The full physical examination. “Best Practice Recommendations for the Prevention. Orsted. Diagnosis and Treatment of Diabetic Foot Ulcers: Update 2006. o For the purposes of pressure offloading. Leah Shapera and John Rahman.). early detection. ongoing evaluation of treatment methods (e. etc. Unlike the RNAO guideline document. 4. interprofessional view. using a grading system such as the University of Texas Health Center Wound Classification System.” by Heather L. o The establishment of training and education for patients with diabetes is emphasized. including examining the vascular status of the patient. thorough evaluation and monitoring as well as treatment. o The article recommends using a consistent wound classification tool such as the University of Texas-based Diabetic Foot Classification System in order to categorize the wound and facilitate the choice of appropriate methods of treatment. maintenance of proper moisture balance and infection control. The purpose of the report was to incorporate and update the evidence of previous CAWC and RNAO guidelines (see 4.7. dressing choice. this article takes a broader. Gordon Searles. Conclusions: o Guidelines and recommended best practices are focused on prevention. taking into account wound size. measuring and monitoring the wound’s size and edge. o The authors recommend assessing the local wound. The report adopts the RNAO classification of evidence into categories based on levels of strength and quality (see 4.5.

depth.g. Authors recommended that outcomes be patient-oriented and realistic (i. wound dimensions. the authors recommend that the four crucial components for adequate healing are (1) adequate perfusion. exudates levels. Gary Sibbald. for a general overview of the article. Mariam Botros. the authors recommend TCCs or removable casts. 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 authors recommend the use of sharp debridement over other methods for removal of unviable tissue 5. The focus of the treatment should be around debridement. OUTCOME MEASURES AND TOOLS IN WOUND CARE Synopsis: # of Articles Reviewed 5 Types of The articles included in this section focus on defining.1. 4. (3) pressure downloading and (4) sharp surgical debridement. See 3. 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. etc. In a discussion of diabetic foot ulcers.Wound care best practices and outcomes: A review of the literature o o For the purposes of pressure offloading. (2) controlled infection or bacterial damage.” by Kevin Woo. infection control and appropriate moisture balance maintenance. Integrated Client care Project. OUTCOMES.e. and recommending articles 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. Afsaneh Alavi. Marjorie Fierheller.8. Laura Lee Kozosy. setting realistic goals for the healing process and having the patient’s concerns reflected in the goals and outcomes which are monitored). comprehensive and easy to use tool for wound healing assessment for all chronic wounds (including diabetic foot and venous leg ulcers). Kadhine Wiltshire and R. Key There exists a large degree of agreement as to the measures and outcomes Conclusions relevant for adequate assessment and tracking of the wound healing process (e. “A Transprofessional Comprehensive Assessment Model for Persons with Lower Extremity Leg and Foot Ulcers. October 15. Notably. 2009 Page 22 .).

namely the Bates-Jensen Wound Assessment Tool. The authors emphasize the importance of monitoring wound parameters as well as taking a detailed medical history and a thorough physical examination. o For diabetic foot ulcers. reliable Pressure Sore Status Tool.Wound care best practices and outcomes: A review of the literature There is a perceived lack of specially dedicated.1. adapted from the valid. Together with measuring wound depth. transcutaneous oxygen tension measurement is said to be a well Integrated Client care Project. pain and others. Key Findings o The authors point out that ongoing examination and monitoring of the wound is crucial. o The authors cite studies which examine the wound perimeter (length and width) in order to predict healing times with some accuracy.” by Marco Romanelli. standardized visual wound assessment tool content validated for all chronic wounds. 2009 Page 23 .. blood flow. most diagnoses are made on visual observation. The article is focused on wound outcome measures and evaluation criteria to be monitored for wounds in general and for specific wound types. holistic wound assessment tools for chronic wounds such as diabetic foot ulcers and venous leg ulcers. By contrast. October 15. (2) health-related quality of life (HRQoL). the authors note the predominant practice is to trace the wound’s outline on a transparent acetate sheet (in order to determine the wound’s 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 wound’s volume). 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. 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. duration. Other Interesting Points 5. surface area. according to the article. “Outcomes Research – Measuring Wound Outcomes. Goals and outcomes of treatment must be patient oriented – e. o Parameters to monitor include length. o Specific to venous leg ulcers. One article differentiated between outcome measures in three categories: (1) clinical efficacy measures. Valentina Dini. concerned not only with the clinical side of the healing process but with the patient’s quality of life and how it is impacted by the condition and the healing process. inflammation. and (3) health economics. depth. The authors assert that there is only one reliable. hardness. oxygen. patientcentered 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. The authors elaborate on scales and points of interest within each category. tissue viability. width. Also. the authors recommend the combined use of a monofilament and vibration perception tests in order to estimate sensitivity in the patient’s extremities. o According to Romanelli et al.g. this is a key wound parameter to monitor and record. Maria Stefania Bertone and Ciniza Brilli.

(2) psychological well being – i. Chen. etc. such clinical efficacy outcomes may often represent outcomes which are not important or not greatly important to the patient herself. The article presents an overview of three types of wound care outcomes of relevance to clinicians. health-related quality of life and health economics.e. etc. 5. exudates type and amount.2. including depression. one’s ability to engage in meaningful interpersonal relationships. o Health-related quality of life measures (HRQoL) – in contrast to clinical outcome measures. percentage change in wound area debrided. that the surface area and depth of the wound be closely monitored and measured. and (4) somatic sensation – i. one’s sense of physical energy and ability to carry out activities of daily living. These measures are grouped in four categories: (1) physical function – i. Key Findings: o Clinical efficacy measures – the authors list percentage of patients healed. anxiety. predominant tissue type at wound bed . as in the case of venous leg ulcers. infection reduction rate.. fear. one’s psychological response to one’s health. o The authors point out that.e.Wound care best practices and outcomes: A review of the literature established technique for evaluating local ischemia in patients with diabetes. 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. o Along with that. Integrated Client care Project. 2009 Page 24 .e. For patients who have already developed ulcers.(3) social functioning – i. patients and health care administrators. percentage change in wound area. Notably. The authors discuss the appropriate measurements and outcomes to take into consideration in each of the three categories. October 15. with values lower than 40mmHg being an indicator of critical ischemia. these aim to determine the subjective experience of the disease for an individual patient. one’s diseaserelated symptoms such as pain. 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. etc. mean time to complete healing. The outcomes are organized in three categories: measures of clinical efficacy. “What are Wound Care Outcomes?” by Steven L. Soon and Suephy C. while useful from a purely clinical and comparative standpoint. o o 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.e. the authors recommend.

In addition to the straight forward HRQoL measurement approach using the abovementioned scales. By contrast. the authors warn that when using outcome measure tools or reports. education). drug or wound dressing.g. o In comparing the relative strengths and weaknesses of different types of interventions within a specific condition/disease. The article notes that while generic tools allow for comparing HRQoL data across conditions. namely the value for money spent dimension. HRQoL measurements can be further added to any analysis in order to obtain a fuller picture of the actual effectiveness and utility of a given treatment as perceived by the patient.  Cost-effectiveness comparisons are based on the ratio of cost to clinical outcome unit produced as a result of spending that amount on a given therapy. condition-specific HRQoL measurement tools and scales are more sensitive to subtle but important changes in HRQoL in wound care patients for example. etc.e. the Hyland New Ulcer Specific Tool. October 15. o o o o o Conclusions: o The choice of outcome measures is dependent upon the objective of the measurement. to what degree of consistency do they produce the same result under the same circumstances) Integrated Client care Project. This can then be compared to the analogous ratio for comparable treatment options which would allow for the most cost-effective option to be determined. the authors emphasize the third level at which outcomes can be measured.e. 2009 Page 25 . o Lastly.Wound care best practices and outcomes: A review of the literature o The authors compare and contrast generic HRQoL measurement instruments such as the Medical Outcome Study Short-Form (SF-36). health care) is compared to the societal benefit derived from spending the same amount in a different sector (e. The outcome measures in this category are further subdivided into cost-effectiveness. their generality and length makes them inept at capturing condition-specific outcomes which may be of significance in the case of wound care patients. cost-utility and cost-benefit measures. one must make sure that they are valid (in terms of content.  Cost-utility calculations include Quality-adjusted Life Years (QALYs) – a measurement of HRQoL – so that one can compare the number of QALY’s gained for a given amount of expenditure. condition-specific clinical efficacy measures are of most use. criteria. Health Economics – in addition to clinical and patient-centered outcome measures. reliable (i.).g. by noting the value each patient derives from any given outcome and thus more accurately capturing the value of that particular outcome for that patient. i. the Charing Cross Venous Leg Ulcer Questionnaire. the Nottingham Health Profile (NHP) and the Sickness Impact Profile (SIP) to condition-specific instruments applicable to wound care such as Skindex. the authors also point out that one can measure HRQoL via utilities.  Cost-benefit analysis is the highest level of system-wide cost measurement whereby the benefit to society (in terms of utility) derived from spending in a given sector (e.

The article states that no simple. “Use of the PUSH Tool to Measure Venous Ulcer Healing. o The article points out that the three key parameters used by the PUSH tool for pressure ulcers are wound surface area. o It is noted that the literature suggests that these three outcomes/parameters may also be important in monitoring venous leg ulcers. 5. the study concluded that twenty three had a decrease in their PUSH score by the end of the time period. Ratliff and George T. valid and reliable tool exists for the purpose of monitoring the healing process for patient with venous leg ulcers. Conclusions: o The authors note that given the three components measured by PUSH (size. character of exudates and surface appearance of the ulcer. a lack of improvement in all categories should indicate that the course of treatment should be changed. October 15.e. Rodeheaver. o The authors’ descriptive study applied the PUSH tool to assess the healing of venous ulcers in patients over the course of two months. those who did not show a PUSH score improvement were found to have been non-compliant with compression therapy. the extent to which a given instrument is sensitive to important changes in a patient’s condition over time). 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. 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.Wound care best practices and outcomes: A review of the literature and responsive (i.3. Integrated Client care Project.” by Catherine R. o After following twenty seven patients over two months. 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 effectiveness of any particular intervention. Furthermore. The authors point out the critical importance of ongoing monitoring and assessments of wounds over the course of treatment in order to determine progress. exudates. 2009 Page 26 . tissue type). 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. easy to use.

The author suggests that wound area is most accurately measured by accurately determining the wound margins and then determining the surface area. o The article recommends using the following outcomes.g.5. with the help of a portable digital planimetric device). The author discusses the general features that outcome measurements and criteria must satisfy in order to be useful and accurate. “Analyzing Outcomes in Wound Care.e. as indicators of wound healing in full-thickness wounds:  Reduction of erythema. patientoriented and monitored on an ongoing basis in order to ensure successful treatment and make adjustments as necessary. imposing the traced wound outline on a graphed paper and counting the number of pre-measured squares fitting into the outline). among others. Key findings: o Wound area measurement practices – the article points out that common methods used to measure wound surface area are imprecise. The article also cites some specific examples of measures to be monitored for full thickness chronic wounds. leads to an increased likelihood of achieving the outcomes. Integrated Client care Project. 2009 Page 27 . widespread wound measurement techniques .” by Glenda Motta. o The outcomes must be measurable and observable in concrete. A recommended method is using planimetry (e. Key Findings: o The author’s stance is that outcomes should be patient-oriented and realistic (i. “Improving Accuracy of Wound Measurement in Clinical Practice. diameter product measurements are said to be the least reliable method of determining surface area followed by square counting (i. The article focuses on examining means for improving some commonly used. o The article stresses the importance of patient involvement and endorsement of the outcomes and the care plan. Motta argues.Wound care best practices and outcomes: A review of the literature 5. The article is based on a review of evaluative literature across databases from 1965 to 2003. 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. not raising unrealistic expectations for wound healing for non-healable wounds for example).” by Madeline Flanagan.e. This. October 15. 5.4. objective terms. o The article also states that wound outcomes must be strictly measurable.

2009 Page 28 . This applies to both diabetic foot as well as venous leg ulcers. After reviewing the literature. o Moreover. provides a good basis for predicting healing trajectories. October 15. 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. 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 nonhealable ulcers. 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. the differing degrees to which clinicians are prepared or willing to implement those) Integrated Client care Project.g. The article points out that the appearance of the wound bed is an indicator of a healing process.Wound care best practices and outcomes: A review of the literature o Wound depth measurement practices – the article points out that measuring wound depth using a probe consistently underestimates the volume of larger. 6. The author cites evidence that surface area reduction over time is an excellent indicator of wound healing and. furthermore. etc. the author points out the importance of consistent and regular monitoring and measuring of the parameters. OTHER ARTICLES Synopsis: # of Articles Reviewed 2 Types of The articles included in this section focused on salient points not directly related articles to best practices for a specific wound type. The authors point out the difficulties in disseminating best practices (e. No specific depth measurement techniques were endorsed or suggested. more irregularly shaped wounds. 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. o o Conclusions: o Calculating wound surface area is a reliable and valid method of monitoring wound healing. but is subjective and thus not consistently reliable as it relies on the interpretation of a clinician which could vary. so that progress can be tracked and interventions adjusted. o Lastly. which in turn has profound implications for choosing the appropriate course and type of treatment. Key Findings Implementing best practices is seen to improve outcomes and thus as something desirable to be encouraged.

evidence-based health care. o A list of criteria for best practice guidelines including being explicit. 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. evidence-based. evidencebased wound care protocols. with relapse rates (i. On the utility of the VAC therapy for treatment of chronic wounds. Several distinct methods for spreading and encouraging best practice use are outlined and briefly evaluated – a facility/service provider approach. o The authors take note of the fact that the shift toward best practice is difficult to maintain.” by Douglas Queen. logically thorough and avoiding recommending unproven approaches. Following the issuing of best practice and evidence-based recommendations for wound care by the Canadian Association of Wound Care (CAWC) in 2000. clinicians reverting to previous methods. Key Conclusions 6. Heather L. Pat Coutts.  Health Authority-driven – the 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 Integrated Client care Project.Wound care best practices and outcomes: A review of the literature as well as the potential pitfalls of reverting to old practices over time. 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. Gary Sibbald. October 15. Key Points: o Best practice defined as combining evidence. Implementation and Current Status Across Canada. Orsted. this article reviews the different approaches to implementation of evidence-based practice across Canada along with the benefits and problems associated with their implementation. “Best Practice: Development. R. a health authority-driven approach or a province-wide approach.1. o Case Studies: the article reviews four approaches to best practice implementation  Facility-driven – a company in Kitchener. treatments and practices) as high as 80 per cent. experience and opinion to improve client care by reducing inappropriate variations in practice and by promoting the delivery of high-quality. The future of best practice implementation will depend upon the development of electronic health records. the findings suggest that VAC therapy is and can be useful as an adjunctive therapy in the treatment of chronic ulcers. 2009 Page 29 . clinicians find it to be a useful adjunct therapy to supplement the treatment of chronic wounds such as diabetic foot or venous leg ulcers. Ontario champions best practices in wound care through its services which are designed around advanced.e. Best practice implementation is encouraged by clinicians and experts alike. On VAC therapy. 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. Tazim Virani.

before adjunctive therapies (e. Difficult-to-Heal Wounds.A. The Vacuum Assisted Therapy is an adjunctive therapy which works by introducing local negative pressure in the wound area to promote healing. Provincially-driven – Best practices being encouraged and popularized by professional associations such as the Registered Nurses’ Association of Ontario (RNAO) using government funding. including an overall.C.   Conclusions: o Implementing clinical practice guidelines can improve outcomes. The system removes exudates and helps maintain a moisture balance. 2009 Page 30 . the disbelief in the guidelines’ utility on the part of practitioners among other reasons. liquefied. non-viable tissue) from the wound bed.Wound care best practices and outcomes: A review of the literature knowledge through education.2. (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. 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.g. long-term care and acute care. October 15. However such guidelines are often poorly implemented due to lack of information about the content of such guidelines and their availability. o The future of best practice implementation will strongly depend on (1) the proliferation of electronic health records. 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. Integrated Client care Project. The negative pressure further helps remove slough (i. surgery. comprehensive health assessment of the patient to determine any underlying physiological or pharmacological reasons for non-healing. Gary Sibbald.” by R. The authors outline a general approach to be adhered to for patients with chronic wounds.therapeutic ultrasound. James Mahoney. VAC) are considered.e. The V. This article presents the consensus opinion among wound care professionals on the use of Vacuum Assisted Closure treatment. Nationally-driven – the CAWC’s own efforts in promoting adherence to best practices is noted and its role as an enabler underscored. clinical visits and procedure recommendations to staff working for the Calgary Home Care program. (R) Therapy Canadian Consensus Group. The authors identify and acknowledge a need for further controlled studies to guide clinicians in the integration of VAC therapy for chronic wound patients. 6. “A Consensus Report on the Use of Vacuum-Assisted Closure in Chronic.

. With different modes of pressure (low. unless bleeding was a concern. Some modifications. panellists recommended that continuous low-pressure be applied in cases where the VAC treatment is associated with pain. KCI Medical Canada Inc. undreated osteomyelitis and malignancy to be contraindications for the use of VAC therapy. necrotic tissue. The majority of the group’s members stated that they would use VAC therapy on chronic wounds with delayed treatment. etc.g.) available. through the use of local moisture-retentive dressings) and that older patients in particular may not tolerate high pressure well due to capillary fragility. was asked to provide opinions on 13 statements regarding the use of VAC in patients with chronic wounds.Wound care best practices and outcomes: A review of the literature A consensus group. 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. constant. MMENDATION *LEVEL OF EVIDENCE Integrated Client care Project. high. Experts were in general agreement that they would apply VAC immediately after wound debridement. intermittent. 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. The panel considered intracutaneous fistulae. 2009 Page 31 . The panel recommended that any exposed tendons should be kept moist (e. established in 2001 through a research grant by the VAC’s manufacturing company. Conclusions: o The panel made recommendations for the specific adoption of VAC therapy for chronic wounds. October 15.

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