Special Report – Evidence Based Wound Management in Primary Care by The Magazine Production Company

Special Report

Evidence Based Wound Management in Primary Care

Evidence Based Use of Advanced Chronic Wound Therapies: The Role of Wound Diagnostics The Causes of the Problem Treating the Wound and Treating the Patient Based on the Evidence Improvements Mean Better Outcome

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Evidence Based Use of Advanced Chronic Wound Therapies: The Role of Wound Diagnostics

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The Role of Wound Diagnostics in the Treatment of Diabetic Foot Ulcers

Dr. Paul Chadwick Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org Publisher Kevin Bell Business Development Director Marie-Anne Brooks Editor John Hancock Senior Project Manager Steve Banks Advertising Executives Michael McCarthy Abigail Coombes Production Manager Paul Davies For further information visit: www.globalbusinessmedia.org The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles.

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The Role of Wound Diagnostics in Treating Chronic Wounds Predictably and Cost-Effectively

Dr. Caroline Dowsett

The Causes of the Problem

John Hancock, Editor

What are Chronic Wounds? Diabetic Foot Ulcers Venous Leg Ulcers Pressure Ulcers Summary

Treating the Wound and Treating the Patient

Camilla Slade, Staff Writer

Prevention First A Treatment Programme Treating the Wound Treating the Patient General

Based on the Evidence

Peter Dunwell, Medical Correspondent

A Different Way of Seeing Applying EBP to Wound Management Evidence on Dressing Effectiveness

Improvements Mean Better Outcomes

John Hancock, Editor

Itâ&#x20AC;&#x2122;s About the Money Current Treatments A Fitting Therapy Advances in Care

References 20

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SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

Foreword T

he more ‘glamorous’ aspects of healthcare,

non-healing wounds are growing today. Chronic

usually some branches of surgery, are

wounds will often seriously degrade a patient’s

often covered in the media and are the subjects

quality of life and their ability to socialise as well as

of popular dramas. However, the topic of wound

adversely affecting their health with problems such

treatment is rarely brought to the public’s attention.

as blood poisoning and gangrene. And long-term

Yet, with heightened military involvement and a toll

wound treatment is a very costly process which, given

of injuries from the many activities in which we can

finite resources, inevitably means that other therapy

meet with accidental harm, you’d expect it to be

opportunities are lost for lack of funds.

more prominent.

For these reasons, wound treatment and the

This Special Report opens with an article that looks

management of chronic non-healing wounds is firmly

at the efficacy of advanced wound care therapy on

on today’s agenda for clinicians who want to improve

chronic hard to heal wounds, both from a clinical

their patients’ outcomes and, if that can result in a cost

and an economic perspective. It includes pieces

saving, so much the better.

by Dr Paul Chadwick, Principal Podiatrist, at Salford

In this paper, we’ll examine what wounds are and

Royal Foundation (NHS) Trust on The Role of Wound

how treatment can improve the wound itself and the

Diagnostics in the Treatment of Diabetic Foot Ulcers,

patient’s quality of life. We’ll also look at how evidence-

and Dr Carole Dowsett, Nurse Consultant, Tissue

based practice is changing the way clinicians look

Viability, East London NHS Foundation Trust on

at wound care and how new developments are

The Role of Wound Diagnostics in Treating Chronic

becoming available for this area of care.

Wounds Predictably and Cost Effectively. These

With comfort so dependent on how wounds are

pieces conclude that understanding of the clinical

managed, proper and effective treatment can be,

and economic value of point of care testing for EPA

literally, life changing and even wounds that were

in clinical practice can facilitate more economic and

previously considered non-healing can be healed

efficacious community-based primary care.

with modern techniques. Wound care really is an area

If wound treatment is unglamorous, the treatment

where a clinician can make a difference.

and management of chronic or non-healing wounds is a positively unpleasant topic. Yet, with the prevalence of obesity and health care issues such as diabetes and heart disease, the conditions that cause

John Hancock Editor

John Hancock has been Editor of Primary Care Reports since launch. A journalist for nearly 25 years, John has written and edited articles, papers and books on a range of medical and management topics. Subjects have included management of long-term conditions, elective and non-elective surgery, Schizophrenia, health risks of travel, local health management and NHS management and reforms – including current changes.

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SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

Evidence Based Use of Advanced Chronic Wound Therapies: The Role of Wound Diagnostics Systagenix

uch has been published in recent years on the efficacy of advanced wound care therapies on chronic hard to heal wounds, both from a clinical and an economic perspective. This is also a topic of much debate as many advanced wound care therapies have been developed to address specific underlying causes of non-healing, such as infection, excess proteases, lack of growth factors, or tissue hypoxia, which means that therapy efficacy can be unpredictable depending on how effectively treatment is targeted. Traditional and contemporary wound care dressings, such as gauze, foams, or hydrocolloids, are mostly aimed at absorbing exudate and exudate management, to create an optimal moist wound healing environment by dealing with the symptoms of stalled wound healing. This article, with contributions from leading UK wound care practitioners, discusses the level of evidence for advanced chronic wound therapies, why treatment decisions continue to be primarily based on clinical experience, and how diagnostic tools could be the key to enabling more targeted use of advanced therapies and therefore more predictable and economical outcomes. Could the arrival of wound

diagnostics help bring about a paradigm shift towards more evidence based practice in wound care?

Evidence Based Use of Advanced Chronic Wound Therapies The Centre for Evidence Based Medicine recognises 5 levels of evidence for the assessment of whether a therapeutic intervention is effective (Figure 1)1, however when we examine the evidence base available for advanced chronic wound therapies we find a lack of level 1 and level 2 evidence, even for advanced therapies that are widely used2. One reason for this could be the unique nature of the way wound care is provided and by whom. There is no medical specialty in the field of wound care and only in recent history have wound care specific qualifications and roles, both for physicians and nurses, begun to become established. Further, wound care in practice is dominated by clinical experience, especially when it comes to dressing selection. This is even the case when significant level 2 evidence is available. This can be demonstrated in the case of Collagen/ ORC containing dressings (Figure 2)1, where in seven randomised controlled trials across all major chronic wound aetiologies, diabetic foot ulcers, venous leg ulcers, and pressure ulcers, superior efficacy can be demonstrated www.primarycarereports.co.uk | 3

SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

specialty in the field of wound care and only in recent history have wound care specific qualifications and roles, both for physicians and nurses, begun to become established.

when compared to traditional / Graph 1: contemporary wound care (moist Protease activity reduction is followed by 3-9 wound healing) (Table 2) . wound area reduction and healing This begs the question why such dressings are not used more widely. One reason could be that superior efficacy means a response rate of 55% or 63%, leaving 45% or 37% of wounds that do not respond to such treatment10, 18. A 63% response rate is a significant improvement Time from initial treatment (weeks) when compared to a 43% Wound Area MMPs Activity response rate to standard care18, Elastase Activity which mostly involves traditional / Cullen, B., Kemp, L., Essler, L. Rebalancing wound biochemistry contemporary wound dressings, improves healing: a clinical study examining effect of PROMOGRAN. however in practice the 37% ‘nonWound Repair Regen. 2004 12(2) A4. responders’ give the impression of a dressing that does not deliver predictable outcomes, while coming at a slightly higher cost per dressing. The result is a continuation of purely experience based treatment decisions at each patient visit, where dressing choices are made based on clinical assessment and past experience in a ‘trial and error’ fashion and where advanced wound care therapies are often used as a last resort. The reality, however, is that even at this level of efficacy superior cost effectiveness of Collagen/ORC treatment has been demonstrated5, 11-13. This raises a second question: How high does the efficacy of an advanced therapy need to be to form a compelling argument for adoption as part of standard care, and how can the efficacy of advanced therapies be improved so that predictable outcomes can be achieved through their use? In the case of Collagen/ORC containing dressings a ‘mode of action’ of the therapy had been established as modulation of elevated damaging protease activity, thus stopping the degradation of extracellular matrix and growth factors, which are critical for a wound to progress from the inflammatory to the proliferative phase of healing14-16. Thus it follows that the up to 40% of non-responders could be explained by there being a reason, other than elevated protease activity, for the stagnation of

Table 2: Wound Type

% Residual

There is no medical

Endpoint

Wollina et al., (2005) Venous Leg Ulcers Improvement in healing response at week 2 52% good or excellent healing response compared to 33% in control group (hydropolymer or hydrocolloid) Vin et al., (2002) Venous Leg Ulcers Improvement in healing rate at week 12 41% healing rate compared to 31% in control group (contact layer, gauze pads, and compression) Lazaro-Martinez et al., (2007) Diabetic Foot Ulcers Significant difference in healing rate at week 6 (p<0.03) 63% healing rate compared to 15% in control group (standard treatment protocol) Veves A et al., (2002) Diabetic Foot Ulcers Improvement in healing rate at week 12 (p=0.12) 37% healing rate compared to 28% in control group (moistened gauze and secondary dressing) Nisi et al., (2005) Pressure Ulcers Improvement in healing rate at week ? 90% healing rate compared to 70% in control group (Gauze, vaseline, and hydropolymer dressing) Zamboni et al., (2008) Venous Leg Ulcers Significant difference in healing rate at week 12 (p=0.04) 73% healing rate compared to 47% in control group (foam + multi-layer compression) Gottrup, F. et al., (2011.) Diabetic Foot Ulcers Significant difference in healed or improved rate at week 4 (p=0.035) 79% healed or improved rate compared to 43% in control group (standard treatment protocol)

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SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

Components of the test

wound healing, which could not be rectified by the Collagen/ORC therapy. This was supported by studies that demonstrated that for responders to the treatment protease activity levels reduced over time in line with wound area reduction (Graph 1)17. It therefore follows that by targeting Collagen/ ORC treatment to chronic wounds with elevated protease activity, the therapyâ&#x20AC;&#x2122;s efficacy should be improved. The recent introduction of a point of care test for elevated protease activity (EPA), WOUNDCHEKâ&#x201E;˘ Protease Status, has finally allowed this theory to be tested. Indeed, a study published in November 2011 confirmed that when targeted to venous leg ulcers with EPA, the efficacy of Collagen/ORC containing dressings was improved by 22% to 77% when compared to universal use of Collagen/ORC across all venous leg ulcers recruited into the study18. More notable, however, is the fact that a chronic wound with EPA only has a 10% chance of healing without appropriate intervention19, so in reality the healing chances of a venous leg ulcer with EPA are improved almost 8-fold with the targeted use of Collagen/ORC therapy. This potential of localised wound diagnostic tests to help improve healing outcomes and bring about more cost effective care has been recognised since 2008, when leading wound care experts published a consensus document on the subject20. More recently consensus has been reached more specifically on the value of a protease test in wound care21, so all that remains to be quantified, now that a test is available, is the impact in clinical practice, both from a clinical, but also an economic perspective.

In reality the healing chances of a venous leg ulcer with EPA are improved almost 8-fold with the targeted use of Collagen/ORC therapy.

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SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

References: 1

OCEBM Levels of Evidence Working Group. “The Oxford 2011 Levels of Evidence”. Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653

Silcock et al., Evidence of Collagen/ORC therapies: in vitro, ex vivo and in clinical practice, Presented at Spring SAWC 2010

Kirsner R.S., The Evidence Base of Advanced Wound Care Technologies, Supplement to WOUNDS September 2007

Wollina et al., Some Effects of a Topical Collagen Based Matrix on the Microcirculation and Wound Healing in Patients With

Chronic Venous Leg Ulcers: Preliminary Observations, D. Int. J. Low. Extrem. Wounds 2005, 4(4): 214-24. Vin et al., The healing properties of Promogran in venous leg ulcers, J. Wound Care, 2002, 11(9), 335-41

Lazaro-Martinez et al., Randomized comparative trial of a collagen/oxidized regenerated cellulose dressing in the treatment of

neuropathic diabetic foot ulcers. F.R. Circ. Esp.2007, 82(1), 27-31 Veves A et al. A randomized , controlled trial of Collagen/ORC vs standard treatments in the management of diabetic foot ulcers.

Arch Surg 2002;137:822-827 Nisi et al., Use of a protease modulating matrix in the treatment of pressure sores, Chir Ital, 2005, 57(4), 465-8.

Zamboni et al – A pilot randomised trial to determine the effects of a new active dressing on wound healing of venous leg ulcers,

presented at EWMA 2008 Gottrup, F. et al. Comparative Clinical Study to show the Combined Mode of Action of Collagen/ORC/Silver in Controlling Bioburden

and Modulating the Wound Microenvironment to Promote Healing, Poster, WIC 2011. Cullen B, Essler A, Wallenfang-Sohle K, Stadler R. Can Biomarkers be used to Predict Clinical Efficacy?

Presented at the Symposium on Advanced Wound Care, 2009 Snyder. Sequential therapies and advanced wound care products as a standard practice in the home care setting.

Home health abstract for SAWC, San Diego, April 2008 (presentation at the J&J satellite symposium) Ghatenekar O. Willis. M. Persson U. Health Economics. ‘Cost effectiveness of treating deep diabetic foot ulcers with collagen/ORC

in four European countries’. J Wound Care, Vol 11, No2. Feb 2002 Tacconi, G., Vagnoni, E., Clinical experiences & cost effective analysis of Collagen/ORC/Silver. EWMA, Finland, 2009

Cullen B. The role of oxidized regenerated cellulose/collagen in chronic wound repair. Part 2. Ostomy Wound Manage.

2002 Jun;48(6 suppl):8-13 Cullen B, Smith R, McCulloch E, Silcock D, Morrison L. Mechanism of action of Collagen/ORC,

a protease modulating matrix for treatment of diabetic foot ulcers. Wound Rep Regen 2002;10:16-25. Smeets R, Ulrich D, Unglaub F, Woltje M, Pallua N. Effect of oxidized regenerated cellulose/collagen matrix on proteases in

wound exudate of patients with chronic venous ulceration. Int Wound J 2008;5:195-203. Cullen, B., Kemp, L., Essler, L. Re-balancing wound biochemistry improves healing: a clinical study examining effect of PROMOGRAN.

Wound Repair Regen. 2004 12(2) A4. Cullen, B., Gibson, M., Nesbit, L. Targeted use of protease modulating dressings improves clinical outcomes.

Presented at Wounds UK, Harrogate 2011. Serena T. et al. Protease activity levels associated with healing status of chronic wounds. Poster, Wounds UK 2011.

World Union of Wound Healing Societies (WUWHS). Principles of best practice: Diagnostics and wounds. A consensus document.

London: MEP Ltd, 2008. International consensus. The role of proteases in wound diagnostics. An expert working group review. London: Wounds International, 2011.

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SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

The Role of Wound Diagnostics in the Treatment of Diabetic Foot Ulcers Dr Paul Chadwick, Principal Podiatrist, Salford Royal Foundation (NHS) Trust

Reading the Result

he incidence of diabetes is escalating worldwide1 and is associated with a number of complications including diabetic foot ulcers2. It is estimated in England that at any given time there are 61,000 diabetic foot ulcers3. Diabetic foot ulcers have significant impacts in terms of adverse outcomes, quality of life, mortality and financial. In England, there are around 6,000 lower extremity amputations a year in people with diabetes, people with diabetic foot ulcers have significantly poorer quality of life scores than many other long term conditions and astonishingly have poorer five year survival rates than many cancers including breast and prostate. In 2010-11 the NHS spent an estimated £639 million to £662 million a year on diabetic foot care, equivalent to £1 in every £150 of total NHS spending3. Good medical management of diabetic foot ulcers should focus on the holistic care of the

person and specifically on pressure relief of the ulcerated area, wound bed preparation (especially debridement) and the careful management of exudate levels, infection and pain4. Despite good wound care, a study by Margolis et al. (1999) showed that only 31% of diabetic neuropathic ulcers heal in 20 weeks5. Similarly, after 12 weeks of good care, approximately 24% of neuropathic ulcers attain complete healing. A more recent estimate suggests that two thirds of diabetic foot ulcers do not heal without surgery3. By the nature of this longevity and failure to heal, diabetic foot ulcers, therefore, are often described as chronic wounds. It is recognised that one of the reasons that wounds become chronic is an elevated protease activity level6. Protease activity is an essential part of wound healing7. However, once out of control, and if left unchecked, proteases in wounds may cause sufficient damage to the extracellular matrix, growth factors and receptors www.primarycarereports.co.uk | 7

SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

None Healing Diabetic Foot Ulcer Pathway None Healing DFU

Holistic assessment

Wound static

Corrective measures put in place e.g. offloading debridement

Test for EPA (MDT decision) Elevated

Record

Treat with Protease modulating dressing

In 2010-11 the NHS spent an estimated £639 million to £662 million a year on diabetic foot care, equivalent to £1 in every £150 of total NHS spending.

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to impair healing and destroy normal tissue. Chronic wounds with elevated protease activity (EPA) have a 90% probability they won’t heal but equally only 28% of non-healing wounds have EPA8.

Integrating WOUNDCHEK™ Protease Status Into Practice It became apparent that in order to help reduce the adverse outcomes described above, the addition of a test to check for EPA could become an important component in our treatment algorithm for diabetic foot ulcers. Initially we undertook an evaluation of WOUNDCHEK™ Protease Status in terms of ease of use and comparability with the literature. The results were positive with practitioner satisfaction above ninety percent in all categories including ease of use and aiding assessment process. It also showed around 30% of patients with static diabetic foot ulcers had EPA9. With all new advanced technologies we developed a treatment pathway to rationalise the use of WOUNDCHEK™ Protease Status (Figure 1). The patient with a static diabetic foot ulcer is assessed by the multidisciplinary team as per NICE CG119 (2011) and all intrinsic and external factors for optimisation of wound healing are addressed, e.g. off-loading, infection control, diabetes control, etc. If on review the wound is still not progressing, the

Wound Improved

Exit pathway on-going care Low Reassess

patient is tested for EPA. If the result is positive for EPA then the patient is reviewed for the possible cause of the EPA and if necessary a protease modulating treatment is prescribed. If the test is negative this is also extremely valuable as it means that there is another reason as to why the wound is not progressing, e.g. more frequent debridement required, lack of adherence to the regime by the patient, etc.. Diabetic foot ulcers are known to be slow to heal or do not heal. The outcomes and quality of life of these patients is poor. It is essential and a requisite of good practice to investigate why these wounds have become static to improve adverse outcomes. The development of a bedside real time test enables practitioners to exclude or include EPA as a reason for non-healing. The fact that 90% of chronic wounds with EPA do not heal but that only 28% of chronic wounds have EPA8 means that this test is vital to ensure that both EPA in a wound is addressed but, equally, that wounds without EPA should be interrogated for why they are failing to heal. Detection of EPA should be seen as a new but integral diagnostic indicator that sits alongside established tests such as x-ray, magnetic resonance imaging, bacterial wound swabs and blood tests to improve the potential for healing in these complex wounds.

SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

References: 1

Wild S, Roglic G, Green A et al.(2004) Global prevalence of diabetes: estimates for the year 2000 and projections for 2030, Diabetes Care 27:1047â&#x20AC;&#x201C;53

Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, et al (2005) The global burden of diabetic foot

disease.The Lancet 366:1719-1724. Kerr M (2012), Foot Care in Diabetes: The Economic Case for Change.

Available from http://www.diabetes.nhs.uk/document.php?o=3488 Accessed 09/11/2012 Frykberg R (2002) Diabetic Foot Ulcers: Pathogenesis and Management Am Fam

Physician;66(9):1655-1663. Margolis DJ, Kantor J, Berlin JA(1999). Healing of diabetic neuropathic foot ulcers receiving

standard treatment. A meta-analysis. Diabetes Care.;22(5):692-5. Gibson D, Cullen B, Legerstee R, et al. MMPs Made Easy. Wounds International 2009; 1(1):

Available from http://www.woundsinternational.com Agren MS, Mirastschijski U, Karlsmark T, Saarialho-Kere UK. Topical synthetic inhibitor of matrix

metalloproteinases delays epidermal regeneration of human wounds. Exp Dermatol 2001; 10(5): 337-48. Serena T. et al. Protease activity levels associated with healing status of chronic wounds.

Poster, Wounds UK 2011. Haycocks S and Chadwick P (2012) Assessing chronic diabetic foot wounds for elevated

protease levels. Poster Presentation. Wounds UK 2012 NICE (National Institute for Health and Clinical Excellence) (2011) Diabetic Foot Guidelines-In-

Patient Management. http://www.nice.org.uk/cg119. Accessed 10/09/2012

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SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

The Role of Wound Diagnostics in Treating Chronic Wounds Predictably and Cost- Effectively Dr Carole Dowsett, Nurse Consultant, Tissue Viability, East London NHS Foundation Trust

Many patients with venous leg ulcers have underlying comorbidities and wound healing problems that make healing difficult and challenging for the practitioner.

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The NHS is facing real challenges with demands for cost efficiency savings of £15-20 billion, and a quality agenda aimed at driving up quality, increasing productivity and ensuring greater patient satisfaction1. Providers of healthcare will be held to account against clinically credible and evidence-based outcome measures and they will be paid according to their performance. For those involved in the delivery of wound care services the challenge is to demonstrate improved quality outcomes that meet this expectation. These include; • Improved healing rates • Reduction in wound recurrence • Greater patient satisfaction • Cost efficiency savings The White Paper ‘Equity and Excellence: Liberating the NHS’ sets out the government’s vision of patients and the public being at the heart of an NHS where they have more influence and choice over their care1. Greater choice and control will include a choice of any qualified healthcare provider (AQP) and in July 2011 operational guidance on extending patient choice of provider was published to include venous leg ulcer and wound healing services2. One of the services which will go out to AQP is venous leg ulcers and wound healing. The service specification in the implementation pack for venous leg ulcers sets out the aims and objectives, pathways, expected outcomes and suggested tariffs for this group of patients. Care pathway one is for venous leg ulcer without complications, expected to heal within 18 weeks. Care pathway two is for venous leg ulcers with complications, expected to heal in 24 weeks (Table 1). Care pathway two includes patients that have elevated protease activity (EPA) which will need to be identified through the use of a wound diagnostic tool. In the UK, between 70,000 and 190,000 people suffer from venous leg ulcers at any one time with over 50% having had their ulcer for more

than one year. The annual cost of managing and treating chronic wounds is estimated to be between £2.3 – 3.1 billion annually with costs of £300 and £600 million per annum attributed to leg ulceration3. There is evidence of wide variation in the assessment and management of leg ulcers with significant potential to improve wound healing rates and reduce reoccurrence4. The mainstay of treatment for venous leg ulcers is compression therapy and patients with simple venous leg ulcers will usually heal successfully in 12 weeks with compression. However, many patients with venous leg ulcers have underlying co-morbidities and wound healing problems that make healing difficult and challenging for the practitioner. Identifying problems at the wound bed through the use of wound diagnostic tools such as a point of care test for EPA allows for targeted interventions that can improve healing rates, increase patient satisfaction and make health economic savings. EPA is recognised as a marker for non-healing wounds. There is a 90% probability that wounds with EPA will not heal without appropriate intervention. EPA is not visible when assessing the wound and nothing in the history taking from the patient will indicate that EPA is present. The recommended pathway is to test all non-healing wounds at 4 weeks and if EPA is present then treat the wound with a protease modulating therapy5. Implementation of this pathway in clinical practice can improve patient outcomes and bring significant health economic gains. Current estimated costs of venous leg ulcer treatment based on the suggested tariffs of £96 per treatment are £1,765 at 18 weeks, £2,335 at 24 weeks and £4,995 at 52 weeks. The cost of testing for EPA and treating accordingly is £1,337 at 12 weeks. Based on the assumption that 100 patients have non healing wounds and a prevalence of EPA of 28% with a cost for standard care per week per patient of £96, if EPA is left undetected 25 wounds will not heal without

SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

Table 1: Any Qualified Provider: Venous leg ulcer pathways Care Pathway 1 – Simple venous leg ulcer

Care Pathway 2 – Complex venous leg ulcer

Ankle brachial pressure index 0.8 – 1.3

Wound less than 10cm in any one dimension

Wound area is greater than 10cm in any one dimension

Ulcer present for less than 1 year on first presentation to the service

Ulcer present for more than 1 year on first presentation to the service

Expected to heal within 18 Weeks

Presence of lymphovenous disease

Size reduction by 20-40% in four weeks of treatment

Wound has failed to reduce in size by 20-40% in four weeks despite best practice

Current infection or history of recurrent infections

Patient has elevated protease activity (measured with a recognised diagnostic tool)

Patient has a history of non-concordanc

appropriate intervention resulting in a potential wasted cost of care of £125,798. If EPA is identified and treated with a protease modulating therapy, healing rates increase to 77%, making a cost saving of 41%. The suggested tariff for complex venous leg ulcers is £1,920 under AQP, so if EPA is not identified and treated and costs escalate then the service provider is unlikely to be able to sustain their service6. The recommended treatment pathway is to identify all non-healing wounds at 4 weeks, test for EPA, and, if elevated, treat with a protease modulator. Then re-assess the patient and the wound after 4 weeks to ensure the wound is progressing to healing. If treatment has been successful then return to standard treatment. The economic benefits from this approach include reduced waste through targeted effective treatment, reduced cost by improving healing, increased productivity as more patients

can be seen and ensuring business continuity. Additionally the benefits to the patient include greater satisfaction and an increase in patient reported outcome measures (PROMs). As wound care practitioners begin to implement point of care testing for EPA in clinical practice, the wound care community can begin to understand its clinical and economic value, but also the true potential of advanced chronic wound care therapies. This could mean an end to years of ‘trial and error’ and purely experience-based practice and the beginning of a more evidencebased approach to wound care facilitated by new diagnostic tools and targeted treatment decisions at the point of care. In the context of the changing UK healthcare system, this could also help with referral decisions with regard to complex wounds and therefore facilitate more economical and efficacious community based primary care.

References: 1

Equity and excellence: Liberating the NHS. White paper., Department of Health, 2010, Crown. ISBN: 9780101788120

Operational Guidance to the NHS: Extending patient choice of provider., Department of Health,

July 2011, Crown Posnett J, Franks P (2008) The burden of chronic wounds in the UK. Nursing Times 104(3); 44-5

Dowsett C, Modernising leg ulcer services through preventing recurrence. Wounds UK 2012,

Vol 8, No 1 ; 53-58. International consensus. The role of protease in wound diagnostics. An expert working group

review. London: Wounds International 2011 Dowsett C, The economic benefits of identifying and treating elevated protease activity.

Symposia. Wound diagnostics: Elevated Protease Activity (EPA) when and where, can you afford to ignore it? Wounds UK conference: Harrogate November 2012.

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SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

The Causes of the Problem John Hancock, Editor The word ‘wound’ is an all-embracing term covering a number of conditions resulting from a range of causes.

A chronic wound is one that does not heal even when subjected to recognised courses of treatment; often such a failure is also associated with other health conditions.

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here are two types of wound: with a closed wound, a blunt force or trauma causes bruising but no external bleeding; whereas, where the skin is torn or punctured is an open wound. Clinicians in any type of practice and mothers with young children will be familiar with, mostly minor, open wounds. The body follows a natural process requiring little more than clean conditions to heal an open wound. In that sense, most are easily treatable either by simple cleaning and drying, the application of a dressing or closure with sutures. However, some wounds are not so easily healed and these chronic wounds can cause considerable long term distress and discomfort to patients as well as being gateways for infections to enter the body and, indeed, the source of infections themselves.

What are Chronic Wounds? A chronic wound is one that does not heal even when subjected to recognised courses of treatment; often such a failure is also associated with other health conditions either directly, interfering with healing through alterations to the body’s natural processes, or indirectly, denying the patient the conditions in which healing can take place, such as when a condition renders a patient bed bound. These are sometime referred to, somewhat bleakly, as non-healing wounds. But the strict definition is of a wound that does not start to heal within four weeks or hasn’t healed within eight weeks1. However, modern clinical practice and the application of evidence based procedures are improving the outlook for patients with chronic wounds by improving their management and propensity to heal. For different patients there will be varying reasons why wounds fail to heal in the normal time, but chronic wounds seem to be more prevalent in people with poor blood circulation or diabetes or restricted mobility. Some of the worst chronic wounds occur as co-morbidities with other long-term conditions such as diabetes. Diabetics are often prone to particular types of open wound such as ulcers, especially on their feet, with some 15% of diabetics in America

suffering in this way. Other types of chronic wound usually result from pressure ulcers (bed sores), peripheral neuropathy (nerve disorders) peripheral vascular disorders (poor circulation) arterial blockages, radiation, osteomyelitis (bone infection) or insect bites. All the above can either cause a wound and/or inhibit any natural healing process.

Diabetic Foot Ulcers Diabetic foot ulcers are often slow to heal or do not heal at all which can contribute to, at the least, a poor quality of life for patients and, at worst, amputation of the foot or lower leg. This is confirmed in a November 2005 article in the Lancet, ‘Treatment for diabetic foot ulcers‘2 which says; “People with diabetes develop foot ulcers because of neuropathy (sensory, motor, and autonomic deficits), ischaemia, or both. The initiating injury may be from acute mechanical or thermal trauma or from repetitively or continuously applied mechanical stress. Patients with clinically significant limb ischaemia should be assessed by a vascular surgeon to determine the need for angioplasty, stenting, or femorodistal bypass. When infection complicates a foot ulcer, the combination can be limb or life-threatening.” There are a number of reasons why people with diabetes might be prone to foot ulcers. Patient. co.uk3 explains that, “Foot ulcers are more common if you have diabetes because one or both of the following complications develop in some people with diabetes: “Reduced sensation of the skin on your feet Your nerves may not work as well as normal because even a slightly high blood sugar level can, over time, damage some of your nerves. This is a complication of diabetes called peripheral neuropathy of diabetes. “Narrowing of arteries (blood vessels) going to the feet If you have diabetes you have an increased risk of developing narrowing of the arteries (peripheral vascular disease). This is caused by fatty deposits called atheroma that build up on

SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

the inside lining of arteries (sometimes called furring of the arteries). This can reduce the blood flow to various parts of the body.” The article continues to explain the factors that can increase the risk of developing foot ulcers: loss of sensation, narrowing of the arteries, a history of ulcerations, diabetes related complications, ill-fitting shoes, etc.

Venous Leg Ulcers These wounds are common in more elderly people, especially women, and are the most common type of skin ulcer (about 1 in 50 people develop a venous leg ulcer at some time) mainly occurring just above the ankle. They can be painless but not always and, like any wound, left untreated will grow and become infected. Again, Patient.co.uk explains the reasons well4; “The root of the problem is increased pressure of blood in the veins of the lower leg. This causes fluid to ooze out of the veins beneath the skin. This causes swelling, thickening and damage to the skin. The damaged skin may eventually break down to form an ulcer.” Sometimes, leg ulcers will be associated with varicose veins, themselves swollen because of an overspill of blood from veins running deep in the muscles of the legs. The problems with varicose veins are not their size, but the high pressure and sluggish flow of blood inside them which can cause aching, cramping, itching, staining of the skin, eczema and finally ulcers. The ulcers are often very painful and can bleed and get infected. In the long-term they can range from a minor handicap to possible serious illness5.

Pressure Ulcers The UK NHS provides an excellent summary of what pressure ulcers are and how they develop6. “Pressure ulcers, also sometimes known as bedsores or pressure sores, are a type of injury that affects areas of the skin and underlying tissue. They are caused when the affected area of skin is placed under too much pressure. Pressure ulcers can range in severity from patches of discoloured skin to open wounds that expose the underlying bone or muscle.” The NHS guidance continues to explain that pressure can either be a heavy pressure over a short time or, commonly, less pressure but over a longer time in a patient who does not move or alter their position often enough to vary pressure points on their body – often someone who is bedbound; hence the common term ‘bedsores’. Pressure ulcers are relatively common with nearly half a million people expected to develop at least one pressure ulcer in any given year. And, for fairly obvious reasons, people over 70 years old are more prone due to their reduced blood supply, aging skin and more than average mobility problems.

Summary While chronic wounds may vary in their nature and levels of severity, they all have the potential to develop life threatening complications such as blood poisoning or gangrene. Therefore the management and treatment of such wounds will not only improve the quality of life enjoyed by patients, but may also help avoid further deterioration in their health and, by so doing, will save the health service significant amounts of money. www.primarycarereports.co.uk | 13

SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

Treating the Wound and Treating the Patient Camilla Slade, Staff Writer

Wound care is also patient care because a wound can have a powerful effect on quality of life and outlook

It is often best to start with steps to avoid the creation of a wound. For instance, for diabetics, regular condition checks, skin care and foot care are very important elements in their therapy.

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Prevention First Sometimes a patient with complex conditions might be at particular risk of suffering from a wound that could become chronic, as a result of one or more co-morbidities associated with their condition. In those circumstances, it is often best to start with steps to avoid the creation of a wound. For instance, for diabetics, regular condition checks, skin care and foot care are very important elements in their therapy. As the NICE (National Institute for Health and Clinical Excellence) clinical guideline 10 ‘Type 2 diabetes foot problems’7 explains; “One of the complications associated with diabetes is peripheral vascular disease (the damage caused to large blood vessels supplying lower limbs). This can cause poor circulation, which can result in pain and also predispose patients’ feet to the development of ulcers, which can lead ultimately to amputation. Another complication is neuropathy (damage/degeneration of the nerves), which can lead to loss of sensation in the feet.” The UK National Health Service (NHS) has a programme designed to care for people at high risk of chronic wounds but, not everything that might avoid wounds is clinical in nature. Patients might be advised on some modifications to their lifestyles (perhaps avoid ill-fitted or ‘fashionable’ footwear, or open-toed shoes and sandals) and some simple steps they can take for themselves such as avoiding going barefoot and keeping their nails properly trimmed. And it is not only diabetics who need to take preventative measures against wound development. People with vascular conditions and especially where that includes varicose veins need to take steps to prevent wounds forming and these might be as simple as wearing a pressure bandage and, again, being careful about foot care. Similarly, people with restricted mobility will usually benefit from being helped to change their position from time to time not only for the sake of their comfort but also to avoid extended periods

of even light pressure on one part of their body that could lead to pressure ulcers. Notwithstanding any preventative measure, patients do present with various chronic wounds and, when that occurs, clinicians must consider what treatment to engage. As always, the earlier that treatment can be commenced, the better for the patient’s comfort and outcome.

A Treatment Programme In healthy people, minor wounds will heal naturally and require little more intervention than to be cleaned and kept clean8. This cleaning process is sometimes referred to as wound toilet. Deeper wounds might require to be closed but there are sometimes concerns that closing a wound too early might increase the likelihood of infection. Where a wound fails to heal, a treatment programme might need to start with an examination and discussion to establish any likely causes for non-healing of the wound9. There are a number of treatment paths which clinicians and their patients can consider.

Treating the Wound With a venous leg ulcer there are several ways in which healing can be supported or promoted. “A venous ulcer can be healed by either applying strong sustained compression with a bandage or a stocking and by treating the underlying cause of the ulcer. When appropriate, both treatments can be used at the same time.” This is the advice from NHS Choices ‘Leg ulcer, venous – information prescription’10. The paper continues through compression treatments to ulcer dressings; “The aim of applying a dressing to an ulcer is to provide conditions for the ulcer to allow healing.” For maximum effectiveness, it might be necessary to prepare the wound by washing (see above) and debridement (removal of dead tissue). Where a wound is infected, any pus should be cleaned away and it should be judged whether the patient will need to have an antibiotic prescribed to

SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

treat the infection. In such cases, any compression may not be applied at first if it is going to cause pain. The NICE guidance referred to above also considers the use of antimicrobial agents, “In the presence of systemic and clinical signs of infection in the patient with a pressure ulcer…” And, in some cases, it might be appropriate to suggest surgery. NICE offers a number of criteria that should be considered as part of this decision process 11 and continues to discuss other therapies that might be appropriate for patients with pressure ulcers; therapies such as topical negative pressure, electrotherapy and electromagnetic therapy, and therapeutic ultrasound. Among the therapies available to treat pressure ulcers are dressings or topical agents (antiinfectives applied to a specific area of the skin and affecting only the area to which it is applied) but clinicians will need to consider a number of factors relating to the wound and the patient in order to ensure that an appropriate dressing is used12.

Wounds are usually sites of pain and of particular nervous sensitivity. In any wound management process, it might be necessary and humane to administer analgesia or

Treating the Patient “Mobilising, positioning and repositioning interventions should be considered for all individuals with pressure ulcers (including those in beds, chairs and wheelchairs). [Also] all patients with pressure ulcers should actively mobilise change their position or be re-positioned frequently.” Further advice from NICE which continues to recommend that carers, “Avoid positioning individuals directly on pressure ulcers or bony prominences, (commonly the sites of pressure ulcer development).”

General Most wounds require a moist environment to heal and this is often provided by a naturally occurring serous fluid called exudate. However, where too much exudate has built up or where it is infected and is the source of a bad odour, it might have

even a local anaesthetic.

to be removed. Moistening can be artificially achieved through MIST Therapy. One thing that must not be forgotten is that wounds are usually sites of pain and of particular nervous sensitivity. In any wound management process, it might be necessary and humane to administer analgesia or even a local anaesthetic in order to make the treatment bearable and ensure that the patient does not avoid future treatment. www.primarycarereports.co.uk | 15

SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

Based on the Evidence Peter Dunwell, Medical Correspondent

Using real reasons to support a treatment choice that will work and suit the patient

As a first stage in treatment of any chronic wound, it is important to discover why the wound is failing to heal, because a treatment that addresses the root cause of non-healing in any particular case is more likely to succeed.

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s a first stage in treatment of any chronic wound, it is important to discover why the wound is failing to heal, because a treatment that addresses the root cause of non-healing in any particular case is more likely to succeed. Studies have revealed a number of underlying causes of non-healing such as infection, excess proteases, lack of growth factors or tissue hypoxia. However, clinicians need to know how these have affected other patients and, in deciding a treatment, need to know what has worked in the past as well as what will suit the patient. This is a new way of looking at medicine.

A Different Way of Seeing Much of modern healthcare is founded on the principle of evidence based practice (EBP), an interdisciplinary approach that has developed since 199213. EBP originated as evidence based medicine (EBM) and was then taken up in other fields – hence its application in wound management and therapies. Other evidence based templates include evidence based guidelines, at an organisational or institutional level and also called evidence based health care, and evidence based individual decision making. The best evidence that any medical therapy is worthwhile is considered to be a randomized prospective double-blind placebo-controlled trial where patients are randomly divided into a treatment and no-treatment group. If the treatment group does better, that’s the best evidence that the treatment works. EBP moves away from the traditional intuitive approach to diagnosis and treatment, to an approach where decisions are made based on evidence from past observations, experiments, studies or researches, along with the expertise and experience of the practitioner plus other environmental social and patient centred criteria. While drawing on research and experience, EBP also recognises that care is an individual matter, often changing and having to take account of uncertainties and probabilities.

Applying EBP to Wound Management In the article, ‘Evidence-Based Medicine for Wound Care ‘on Wounds1.com14, Norman Bauman writes “When doctors want to use the best treatments, they are faced with a paradox. Modern medical science has come up with new, promising treatments. But modern medical science has also come up with the idea of evidence-based medicine. Some new treatments work, and some don’t. Evidencebased medicine is the practice of evaluating |the scientific evidence behind each treatment.” He continues to cite specific cases where evidence has guided wound treatment and management as cited at the 2007 VEITHsymposium™ on vascular surgery in New York where David L. Steed, Jr., M.D, Professor of Surgery, University of Pittsburgh reviewed some of the common treatments for wounds and skin ulcers and summarized the strength of evidence for each. Dr Steed said that leg ulcers often don’t heal because the arteries to the leg are blocked and narrowed with atherosclerosis or other obstructive conditions… Vascular surgeons can often restore the blood supply to the leg by using bypass grafts to go around the obstruction, or by threading a thin balloon into the artery to open it up with air pressure. Revascularization of the ischemic wound is, unquestionably, the most successful form of therapy in the wound healing area. For diabetic foot wounds, pressure offloading and topical growth factors are “clearly of benefit,” said Dr Steed. Screening and referral to wound clinics, systemic hyperbaric oxygen therapy, and living skin equivalents are “probably beneficial,” he said. “There is less convincing evidence for therapeutic footwear...” For venous leg ulcers, compression bandages and stockings are ‘clearly indicated’ for controlling venous hypertension, which is the initial cause of the ulcers. This was supported by Level I evidence. Living skin equivalents and superficial vein surgery are probably of benefit. Most of the other treatments… have varying degrees

SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

of support in the literature, including enzymatic debriding agents, specialty dressings, laser therapy, and topical antibiotic therapy. Returning to the 2007 VEITHsymposium™, and the session ‘Evidence-Based Medicine in Modern Wound Care’ 15, Dr Dirk Ubbink MD PhD from the University of Amsterdam explained that EBM is not a ‘cookbook’ from which clinicians can take solutions. Rather, he said, “It’s using your mind as a doctor. You combine your experience, the patient’s situation [and preference] and the best scientific evidence” when formulating a wound treatment.

Evidence on Dressing Effectiveness The evidence based principle can be applied in other ways, although in some areas of wound care it is still lacking. For instance, the NHS MeReC Bulletin of June 201016 opens with the statement, “… the clinical evidence supporting the use of wound dressings is less well known and of poorer quality than in many other areas of prescribing.” In the bulletin it states; “… dressings must meet the applicable ‘essential requirements’ on safety and performance. Clinical data are usually necessary to demonstrate satisfactory performance of a medical device and

establish any adverse effects. However, unlike medicines, where data from RCTs [randomised controlled trials] are generally required, for devices this can take the form of a review of the relevant scientific literature… clinical trial data are not always required. Standard laboratory performance tests are required that measure the physical properties of dressings (e.g. absorbency, moisture vapour transmission, waterproofness, conformability, etc.). These cannot predict reliably how dressings will perform in the clinical situation” The MeReC Bulletin continues to cover some programmes that have been recently run to gather evidence on the main types of chronic wounds. It is clear that, “An appreciation of evidencebased treatment pathways [is an] important element in the management of patients with chronic wounds.”17 The move to an evidence based approach in wound care with appropriate treatments being used according to the patient, their condition and what has already been proven to work should achieve faster results which will not only improve the outcome for each patient but will also ensure that costs are reduced as less ‘trial and error’ type programmes are commenced.

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SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

Improvements Mean Better Outcomes John Hancock, Editor

They also help to reduce the long-term cost of high quality care

The prescription costs for wound dressings in primary care in England were about £116 million in the year to September 2009.

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It’s About the Money

Current Treatments

As always these days, we cannot ignore the matter of cost and cost effectiveness when dealing with wound care. In the restructured NHS, where GPs will be key commissioning drivers, they will not wish to spend their budgets on protracted wound care if an alternative treatment can bring about a faster healing process and thus potentially improve the patient’s quality of life, while also reducing the long-term cost to the practice. In clinical guidance CG29 on the management of pressure ulcers18, NICE states that “… the cost of treating a grade 4 pressure ulcer is estimated to be £40,000 a year (Collier 1999).” In the NHS MeReC Bulletin of June 201019 it states under the heading ‘What are the costs of wound dressings?’ “Although only representing one route by which dressings are procured for use in the NHS, the prescription costs for wound dressings in primary care in England were about £116 million in the year to September 2009… There is considerable variation in the cost of dressings both between categories and within each category. Silver containing dressings accounted for about 11% of items supplied on prescription but, in view of their relatively high cost, were associated with 22% (£26 million) of the total cost of advanced wound dressings.” There are other ways in which therapies can be made more cost effective if the clinician can discover more detailed information about the wound in order to better target the treatment. For instance, one factor, elevated protease activity (EPA), can significantly affect the outcome of wound treatment. Without appropriate intervention, it is estimated that there is a 90% probability that chronic wounds with EPA will not heal. However, only 28% of non-healing wounds have EPA and it cannot be readily detected during a visual examination of the wound. Using a test to identify whether EPA is present will allow selection of an appropriate therapy with a higher likelihood of healing which, in turn, means a lower long term cost of treatment.

The list of treatments currently available to clinicians would fill more than the space available here. But if the reader goes to an excellent Wound Management Manual from the NHS in Northern Ireland 20 they’ll find a comprehensive list of products and methodologies. As a rule, the NHS considers the most important aspect of treatment for uncomplicated ulcers is the application of high compression using a stocking or bandage and that, in the absence of evidence to promote the use of any particular dressing, “dressings should be simple, low adherent, low cost and acceptable to the patient.” (see the MeReC Bulletin, above).

A Fitting Therapy Whatever dressing is used, it is important that it stays in place, continues to support healing and doesn’t of itself, add to a patient’s discomfort. The skill of how to place a dressing for a patient with a chronic wound is less often discussed but is nonetheless as important as any of the clinical skills required in treatment. “Wounds in some areas of the body are particularly difficult to dress, despite the wide range of dressing products available.” So says World Wide Wounds in its ‘Dressings: cutting and application guide’21. There are several problems that can arise with ill-fitting or poorly placed dressings. If there is leakage or detectable malodour from the wound, the patient may become embarrassed and withdraw from their normal life. Similarly, if the poor placement causes pain, the patient may not return for their redressing until the need becomes acute. Both of these situations will diminish a patient’s quality of life but also, if the result is a reduced frequency of treatment, they will degrade the patient’s health, extend healing time and increase the cost of treatment. Fortunately, there is a large range of dressings in a variety of shapes and sizes to cope with many of the body’s shapes and profiles (evidence

SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

based dressing design) but wounds in some anatomical areas continue to be a challenge. It is worth contacting the manufacturer or consulting other clinicians to find the best way to handle this problem.

A focus on the biology of wound care has resulted

Advances in Care As in any field, there are always advances being made in the treatment and management of wounds. The application of evidence based practice also means that those advances can quickly be applied by clinicians working in the field. A focus on the biology of wound care has resulted in a range of advanced therapeutic products, growth factors, skin substitutes, gene therapy and stem cell therapy. These are all exciting developments; it seems that the science of wound care is advancing rapidly. Along with that, “Clinicians’ understanding of and ability to achieve wound healing has increased significantly over the past few years... Knowledge of scarring has also increased fundamentally, and the science behind wound healing and the identification of the critical components of the healing process have benefited from technical advances…”22 The NHS, as one of the largest healthcare providers in the world, keeps up with developments. For instance, last year it was reported on BusinessWire that the NHS had recommended assessment for elevated protease activity using a diagnostic test to help decide venous leg ulcers’ treatment pathway23. And only recently, the Daily Mail reported how a glue-on skin patch had helped to finally heal a chronic ulcer that had been troubling the patient for 25 years – the cost in quality of life for the patient and resources for the NHS must have been enormous. Wound care may, for some time, have been a Cinderella practice within healthcare circles, but now that is changing and clinicians will do well to discover the latest techniques and how they could assist their own patients as well as free funds.

in a range of advanced therapeutic products, growth factors, skin substitutes, gene therapy and stem cell therapy.

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SPECIAL REPORT: EVIDENCE BASED WOUND MANAGEMENT IN PRIMARY CARE

References: 1

Health First http://www.health-first.org/hospitals_services/wound_faqs.cfm

‘Treatment for diabetic foot ulcers’ The Lancet http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2805%2967699-4/abstract

Patient.co.uk ‘Diabetes, Foot Care and Foot Ulcers’ http://www.patient.co.uk/health/Diabetes,-Foot-Care-and-Foot-Ulcers.htm

Patient.co.uk ‘Venous Leg Ulcers’ http://www.patient.co.uk/health/Venous-Leg-Ulcers.htm

netdoctor ‘Varicose ulcer treatment’ http://www.netdoctor.co.uk/surgical-procedures/varicose-ulcer-treatment.htm

NHS Choices http://www.nhs.uk/Conditions/Pressure-ulcers/Pages/Introduction.aspx

NICE clinical guideline 10 ‘Type 2 diabetes foot problems’ http://publications.nice.org.uk/type-2-diabetes-foot-problems-cg10/guidance

Wikipedia http://en.wikipedia.org/wiki/Wounds

Health First http://www.health-first.org/hospitals_services/wound_faqs.cfm

NHS Choices ‘Leg ulcer, venous – information prescription’

http://www.nhs.uk/Conditions/Leg-ulcer-venous/Pages/Treatment.aspx 11

NICE clinical guideline 29 1.8 ‘Surgery for the treatment of pressure ulcers’ http://www.nice.org.uk/nicemedia/live/10972/57623/57623.pdf

NICE clinical guidelines CG29 1.4 Dressings and topical agents in the treatment of pressure ulcers

http://publications.nice.org.uk/pressure-ulcers-cg29/guidance#dressings-and-topical-agents-in-the-treatment-of-pressure-ulcers 13

Wikipedia http://en.wikipedia.org/wiki/Evidence-based_practice Wounds1.com, ‘Evidence-Based Medicine for Wound Care‘ http://www.wounds1.com/news/mainstory.cfm/98 Medscape https://login.medscape.com/login/sso/getlogin?urlCache=aHR0cDovL3d3dy5tZWRzY2FwZS5vcmcvdmlld2FydGljbGUvNTcwNjI4&ac=401 – you’ll need to register but there is no charge.

NHS MeRec Bulletin of June 2010, ‘Evidence-based prescribing of advanced wound dressings for chronic wounds in primary care’

http://www.npc.nhs.uk/merec/therap/wound/resources/merec_bulletin_vol21_no1.pdf 17

US National Library of Medicine, ‘Evidence-based Management Strategies for Treatment of Chronic Wounds‘

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691645/ 18

NICE CG29 http://publications.nice.org.uk/pressure-ulcers-cg29/key-priorities-for-implementation

NHS MeRec Bulletin of June 2010, ‘Evidence-based prescribing of advanced wound dressings for chronic wounds in primary care’

http://www.npc.nhs.uk/merec/therap/wound/resources/merec_bulletin_vol21_no1.pdf 20

NHSSB http://www.nhssb.n-i.nhs.uk/publications/primary_care/Wound_Manual.pdf

World Wide Wounds, ‘Dressings: cutting and application guide’

http://www.worldwidewounds.com/2007/may/Fletcher/Fletcher-Dressings-Cutting-Guide.html World Wide Wounds, ‘Advanced treatments for non-healing chronic wounds’ http://www.worldwidewounds.com/2005/april/Falanga/Advanced-Treatments-Chronic-Wounds.html BusinessWire http://www.businesswire.com/news/home/20120305005026/en/National-Health-Service-NHS-recommends-assessment-elevated

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