Trials of telehealth Wound Nurse Specialist clinics began earlier this year to connect wound care patients at health centres in Balclutha and Dunstan with vascular surgeons at Dunedin Hospital.

Emil Schmidt, the clinical nurse specialist who leads the monthly telehealth clinics, said the success of the clinics to date means the team hope to expand to other locations next year.

Wound care specialists like himself work with patients requiring the most complex treatment regimens  – like patients with diabetic ulcers or peripheral vascular disease – that need frequent follow-up assessments and adjustments to their therapy.

Providing care for such patients is particularly challenging when they live a distance from a secondary care hospital so the telehealth clinics, linked by video, can help specialists work with district nurses at the rural hospitals to help heal the demanding wounds.

The clinics video link with consultants via secure connections and both sites have shared access to electronic patient records, and specialist wound imaging, measurements and documentation system.

“We can directly communicate, face-to-face,” said Schmidt. “We can zoom-in on the wound and make decisions together on the best approach to caring for the patient.”

He said that patients appreciated the convenience of telehealth appointments and healthcare teams were equally pleased with the quality and efficiency of the appointments.

“In-person appointments are still a part of the patients’ care plan but by providing these clinics we are able to reduce the number of times patients have to travel long distances. It also helps to free up appointments in outpatients clinics for first specialist appointments and other treatments for other patients, so everyone benefits,” said Schmidt.

It is estimated about 55,000 Kiwis suffer after developing a pressure injury (PI) each year. The most common PIs are discovered at stage one – a reddened patch of intact skin that doesn’t blanch on touch – but they can progress all the way through to stage four, where the skin and tissue loss is so severe that bone, tendon, muscle or cartilage are exposed. Deaths are not unknown.

Heather Lewis, a clinical nurse specialist for soft tissue infections and cellulitis, was the organisation lead of a PI working group that in 2011 started an intervention to reduce the number of hospital-acquired pressure injuries at Counties Manukau Health’s five hospitals.

PI numbers fell sizably and in September Lewis was the lead author of an article in the New Zealand Medical Journal indicating that the group’s intervention had saved the DHB millions.

What the intervention entailed

Concern about the high prevalence of PIs found in annual audits starting in 2009 at the DHB’s five hospitals – Middlemore, Manukau Surgery Centre, Auckland Spinal Rehabilitation Unit, Pukekohe and Franklin – prompted the setting up of the PI working group.

In February 2011 regular, monthly prospective audits were introduced and undertaken on five randomly chosen patients per ward. The audits recorded the number of patients with stage one, two, three, four and unstageable PIs.

The intervention included identifying nurse wound care champions in each ward or unit (who took part in the monthly audits) and standardisation of risk assessments across the DHB. It also set the expectation that PI assessments would be carried out within six hours of admission, and appropriate bundles of care provided to patients based on their assessment score and clinical judgement.  

The nurse champions completed a full PI risk assessment, including a full visual skin check, documentation review and recording of any pressure relieving equipment in use.

The champions also promoted education packages – mainly targeted at nursing staff – that included ward resource folders, a pressure injury website, e-learning packages and patient information leaflets. Feedback from a staff survey on pressure relieving rental equipment also led to a more streamlined process being implemented in 2014.

Results and savings

The monthly audits showed a downward trend in PIs in the four years after the intervention was addressed. The random sample audits in 2011 found 101 stage one PIs and this tracked steadily down to 32 in 2015. The number of stage three, four and unstageable PIs went from a high of 16 in 2011 to seven in 2015.

Lewis and her colleagues found a 2004 study that estimated the mean cost of treating a stage one to stage four PI in a hospital or long-term care setting in the UK. These costs included nurse time, dressings, antibiotics, diagnostic tests, support surfaces (it assumed surfaces were purchased rather than rented) and extra inpatient days.

The team adjusted the 2004 UK costs for inflation and converted them into New Zealand dollars, resulting in estimated treatment costs ranging from about $2,400 for a stage one PI up to $23,750 for a stage four PI (see details below). They then extrapolated out the random audit sample results to get a likely estimate of the number of DHB hospital patients to develop the different stages of pressure injuries for each of the years from 2011 to 2015.

The results showed that the estimated cost of treating PIs for the DHB in 2015 was $14.18 million – more than $12 million less than the $26.47 million estimated to have been spent in 2011. The results did indicate an upsurge in PIs and costs in 2014, compared with 2012, 2013 or 2015, but that was still $6 million less than 2011.

Lewis and the team said they accepted the estimated savings were very approximate and relied on a UK study’s finding rather than actual recorded costs.

“However, we are confident that our study does at least indicate that savings can be made by the implementation of interventions such as ours to manage pressure injuries in hospitals.”

She said their conclusion was that interventions such as that of Counties Manukau could lead to potentially large financial savings for hospitals and reduce the burden of managing this difficult condition for patients and staff.

Estimated cost of treating a pressure injury*

• Stage one NZ$2,395.36
• Stage two NZ$9,910.13
• Stage three NZ$16,463.12
• Stage four NZ$23,753.24

*Based on inflation-adjusted and currency-converted costs from:Bennett G, Dealey C and Posnett J. The Cost of Pressure Ulcers in the UK. Age and Ageing, 33(3): 230–35, 2004.

The hospital has swapped using an antibiotic cream applied in the nose before and after cardiac surgery – to prevent staphylococcus aureus (staph) surgical site infections – and replaced it with an antiseptic iodine nasal swab instead.

The change to the ‘anti-staph’ infection prevention bundle was initiated by infection prevention and control (IPC) clinical nurse specialist Karen Corban with the support of her mentors cardiothoracic surgeon Sean Galvin and microbiologist Professor Tim Blackmore.

Corban said the project arose when she chose to audit the hospital’s cardiac surgery anti-staph bundle as part of an IPC quality improvement course being offered through the Health Quality and Safety Commission (HQSC) and linked to its national surgical site infection (SSI) improvement project.

Wellington Hospital had introduced an anti-staph bundle two years ago, targeted at reducing cardiac SSIs, that included an antiseptic body wipe (chlorhexidine) and also applying mupirocin (also known as Bactroban) antibiotic cream in the nose before and after surgery.

Corban said the audit showed up low compliance with the mupirocin ointment component of the bundle, which involved applying the antibiotic cream the night before surgery and then twice a day for five days. A brain storming session with ward staff found non-compliance was due to a number of reasons including the cream going missing and not all staff being aware of the need for the twice-daily regime. Staff questioned why there wasn’t something that only needed to be done once to reduce the risk of nasal bacteria causing SSIs.

Looking for an answer she turned to her mentors Galvin, who was part of the HQSC’s group looking at preventing cardiac SSI, and Blackmore, who was leading the DHB’s antimicrobial stewardship project. At the same time late last year HQSC put out an anti-staph bundle discussion paper that examined the latest literature and suggested that an antiseptic nasal swab containing an iodine product could be just as effective as mupirocin. (See related research articles below).

Corban said using an antiseptic rather than an antibiotic was also seen to reduce the risk of patients becoming resistant to mupirocin and meant the antibiotic cream could be saved for when it was needed to fight an infection. Using povidone-iodine swabs to decolonise the nose was also much cheaper with iodine swabs costing around 80c each compared to $50 per tube of antibiotic ointment. Corban said the swabs also reduced the need for some laboratory tests and in total the swabs could save around $100 per patient so the project had already saved about $25,000 since it got underway in January.

Another advantage was that the swabs only needed to be done once – about one to two hours before the patient went to theatre – and provided cover for 12 hours.

So the decision to swap from the antibiotic cream to swabbing from the start of this year was backed by nurses who felt they were being listened to and saw the swabbing as a more practical alternative. She said the move had also been supported by HQSC which was exploring different options for introducing anti-staph bundles to DHBs across the country.

Corban said part of the project was developing a process for carrying out the antiseptic swabbing that including testing it out by inserting swabs up her own nose and the nose of a fellow IPC nurse specialist. “When we taught the process we gave everyone a swab that they could do themselves, or utilise on each other, so they knew what it felt like to be a patient and have that up their nose.”

The swabbing process involves one swab in the first nostril for 30 seconds, followed by another swab for 30 seconds in the second nostril and then repeated with a further 30 second swab to each nostril.

An important part of the antiseptic swabbing was amount of contact time with the mucosa so Corban developed a swabbing technique and pattern that takes 30 seconds to complete so nurses don’t have to keep an eye on a fob watch.

Corban, an ex-cardiothoracic charge nurse, followed up the swabbing training by coming in to the ward 6.30am every morning for five days a week for 20 weeks to observe pre-surgery swabs being given. She then followed it up with two months of observing five swabs a week and now is down to three-monthly checking of swabbing technique.

A staph aureus information sheet was developed for registered nurses plus an information sheet for patients about the process. She also surveyed a 100 patients with more than 90 per cent of them reporting the swab process was neither pleasant or unpleasant and it was found to be well-tolerated.

The DHB does about 550 cardiac surgeries a year but is now looking to roll out the anti-staph bundle to orthopaedic surgery.

Corban, who has a masters in public health, said the success of anti-staph bundle project has also seen her invited by HQSC to join its anti-staph bundle working group.

Further reading:

Discussion paper: Anti-staphylococcal bundle to reduce surgical site infections in orthopaedic and cardiac surgery (November 2016), HQSC

Anti-staphylococcal bundle to reduce surgical site infections in orthopaedic and cardiac surgery (March 2017) HQSC

Beboko S, Green D & Awad S (2015) Effect of a Preoperative Decontamination Protocol on Surgical Site Infections in Patients Undergoing Elective Orthopedic Surgery With Hardware Implantation. JAMA Surg. 2015;150(5):390-395. doi:10.1001/jamasurg.2014.3480

Anderson MJ, David M, Scholz M et al (2015) Efficacy of Skin and Nasal Povidone-Iodine Preparation against Mupirocin-Resistant Methicillin-Resistant Staphylococcus aureus and S. aureus within the Anterior Nares. Antimicrobial Agents and Chemotherapy 59(5)

The panel, comprising Karen Sangster, Counties Manukau’s chief nurse advisor for primary and integrated care; nurse practitioner Rosemary Minto, vice president of NZNO; and consultant Mark Heslop, recommended that the vast majority of Marlborough’s district nurses should relocate to a Health Hub in Blenheim’s town centre.

An anonymous Blenheim district nurse has been reported as telling the Marlborough Express that the team was “completely gutted” by the decision, which she believed was “political and corporate” as it was only in 2009 that district nurses were given a custom-built department at Wairau Hospital (see below for more on the hub plans).

“[The board members] don’t actually know what happens at the coalface,” she told the Express. “We’ve been trying to defend what’s been running to date, because we’re located in the best place possible.”

The panel commended the Top of the South district nursing team for their “high level of care, compassion and commitment” and said it was clear from consumer group meetings that it was highly regarded. The panel said its recommendations aimed to take the services form “good to great” and one of those recommendations was for a “thorough review” of district nurse staffing levels across the Nelson, Wairau (Marlborough) and Golden Bay districts as staff were showing signs of being overworked and understaffed.

The main indicators of under-staffing included: nurses having to prioritise patient care; most nurses working through their breaks and working after hours to write up patient notes; fewer staff engaging in professional development and non-clinical activities like training practice; insufficient aged care nurses in wound care; and a reduction in those nurses taking annual leave. A particular indicator was “noticeable high levels of stress and low morale of district nurses interviewed in Nelson, Golden Bay and Wairau district locations”.

The panel reported that district nursing FTE staffing numbers had been reduced by 1.8 FTE over the past two years and a further reduction of 0.9 was budgeted for this year. It said the lower district nursing numbers had reduced district nurses’ capacities to meet their key objectives of preventing avoidable hospitalisation and enabling early discharge and providing support at home for patients with short- and long-term health conditions, let alone meeting new objectives for collaboration with other services and providing education to other nurses. It recommended that the review of district nursing staffing levels includes looking at dedicated clerical administration support across the district and allocating more district nursing resource to supporting, educating and training other community healthcare providers.

The DHB’s director of nursing and midwifery Pamela Kiesanowski said she was pleased to see the role of the district nursing team so strongly affirmed.

“We are now focused on ensuring that this remains the case as we meet the future needs of our community,” she said.

Cathy O’Malley, GM Strategy, Planning and Community, said the reviewers made it clear that the DHB provided a good and highly valued service “but it is not without its pressures and challenges”.

“This report is the roadmap by which we can navigate our services improvements,” she said.

Hub plans

Marlborough district nurse-led clinics are currently held at Wairau Hospital for Marlborough patients. The proposal endorsed by the panel is for district nurses to shift into a centre of town health hub that is a joint venture between the Marlborough PHO and the DHB. Phase 1 of the hub opened in 2015 and is home to the PHO and public health services including nurses and a range of other community-based services: sexual health, community midwives and child and adolescent mental health. For Phase 2 it was proposed that district nurses be based there along with specialty nurses in long-term conditions and family planning.

Community opposition to the move included concerns about parking and access but the panel said these concerns would be met by the addition of more dedicated car parks and ensuring easy wheelchair access. There were also concerns about access to the IV and other supplies required by district nursing services, but the panel said a pharmacy and on-site storage would resolve these concerns.

The panel responded to concerns that the district nursing service would become disconnected from the hospital by recommending that the wound specialist district nurse remains based at Wairau Hospital initially and a transition-to-care liaison role is established at the hospital.

This learning activity is relevant to the Nursing Council registered nurse competencies 1.1, 1.4, 2.1-2.4, 2.6, 2.8-2.9.

Learning outcomes

Reading and reflecting on this article will enable you to:

• further your understanding of how the quality of clinical service delivery is measured in your workplace
• review your understanding of skin tear injuries and their significance for the individual concerned.

Introduction

Henry had been living in an aged residential care facility for several years. He was now frail and confused, requiring assistance with almost all aspects of daily living. Paul, Henry’s son, visited him at least twice weekly, and on a recent visit noticed that his lower arm was bandaged. Staff were unable to tell Paul what had happened to Henry’s arm, and there was no wound assessment or treatment plan. According to the wound register, Henry had two other skin tears on his legs, but the status of these wounds was unclear.

When the registered nurse removed Henry’s arm bandage, two large and inflamed skin tears (each with a partial flap loss) were found. Skin closure strips had been used on both injuries and then covered with dry dressings, which had adhered to the wounds. Henry moaned loudly and kept trying to move his arm away when the areas were being redressed¹.

Although skin tears represent more than half of all skin injuries in older adults, they have been described as forgotten wounds², receiving little attention or research.

Skin injuries such as skin tears are often regarded as inevitable, and remain underappreciated, under-reported and essentially invisible³. Yet nurses working with older adults in all clinical settings are likely to encounter skin tears on a very regular basis.

The factors that contribute to the quality of nursing service delivery for older adults are complex, and singling out just one measure alone cannot offer a valid representation of the quality of service delivery. However exploring events and injuries such as skin tears in more depth enables clinical staff and management to identify opportunities for improving service delivery and reducing potential/actual distress and injury for older adults.

Skin tears revisited

Skin tears are “wounds caused by shear, friction, and/or blunt force, resulting in separation of skin layers. A skin tear can be partial thickness (separation of the epidermis from the dermis) or full thickness (separation of both epidermis and dermis from underlying structures)”⁴. (Refer to the STAR Skin Tear Classification System [see Box 1 Next page]⁵ and the learning activities associated with this article for further information on skin tear classifications and management). Although there are a number of commonly recognised classification tools for assessing and documenting skin tears, international research suggests these are not used regularly⁶.

Internationally, information on the skin tear prevalence and incidence rates are limited². It has been suggested that under-reporting occurs because of a primary focus on pressure injuries, and that iatrogenic skin injuries, such as skin tears, and incontinence-associated dermatitis, are regarded as an inevitable part of ageing³. The New Zealand prevalence rate (number of new and current skin tears) is unknown⁷.

ACC accepts claims for primary injuries that include skin damage, injury or tears related to treatment by a registered health practitioner, but it cannot provide data specific to skins tears. Between 2011 and 2016 the number of accepted treatment-related claims for skin damage, injury or tears varied between 161 and 239 per year, with an average of 181 claims per year.

Since data was collected in 2005, 79 per cent of accepted claims for this primary treatment injury relate to individuals aged over 65 years of age. Nursing is the lead ‘context’ of these injuries and the top three treatment events that resulted in the injury are firstly removal of dressings/wound care; secondly patient transfer, and lastly removal of strapping⁸.

Australian researchers identified an incidence rate of 10.6 per 1,000 occupied bed days in their control group of residents in aged care facilities, while another study identified a 20 per cent prevalence rate in adults aged over 80 years living in the community⁹.

The skin of older adults is particularly vulnerable to injury, and iatrogenic skin injuries result from complex, multifactorial and interconnected threats³. Tissue tolerance is affected by:

• advancing age
• pre-existing health status and comorbidities
• level of nutrition
• medications
• perfusion
• oxygenation
• mobility
• sensory perception³.

Environmental factors, such as staff turnover, skill mix, and knowledge and care practices all have the potential to exacerbate skin tear rates.

Skin tear outcomes

Skin tears range from relatively minor to extensive and complex wounds, although they may be perceived by some as minor injuries¹⁰. Like any wound, they are a potential site of infection, especially in the frail elderly, as well as impacting on the person’s quality of life. Skin tears can be painful, as the superficial nerve endings are usually affected¹⁰ and have the potential to become chronic wounds.

The management of skin tear injuries further adds to staff workloads and care delivery costs. When older adults experience skin tears on a regular basis, keeping track of multiple injuries and their healing status can prove challenging. This is especially so when these wounds may not require daily changes of dressing if appropriate dressings are used, meaning there is an increased potential for them to be overlooked.

The experience of a skin injury, such as a skin tear, is unique and specific to each individual injury, and can impact on all aspects of the person’s wellbeing³. Ongoing skin tears can be a very visible and unwelcome reminder for both individuals and their families of physical deterioration. When a person experiences multiple skin tears over time, they also have the potential to cause family members to question the quality of service delivery.

BOX 1

STAR Skin Tear Classification System Guidelines

1. Control bleeding and clean the wound according to protocol.
2. Realign (if possible) any skin or flap.
3. Assess degree of tissue loss and skin or flap colour using the STAR Classification System.
4. Assess the surrounding skin condition for fragility, swelling, discolouration or bruising.
5. Assess the person, their wound and their healing environment as per protocol.
6. If skin or flap colour is pale, dusky or darkened reassess in 24-48 hours or at the first dressing change.

STAR Classification System

1. Category 1a

A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is not pale, dusky or darkened.

2. Category 1b

A skin tear where the edges can be realigned to the normal anatomical position (without undue stretching) and the skin or flap colour is pale, dusky or darkened.

3. Category 2a

A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is not pale, dusky or darkened.

4. Category 2a

A skin tear where the edges cannot be realigned to the normal anatomical position and the skin or flap colour is pale, dusky or darkened.

5. Category 3

A skin tear where the skin flap is completely absent.

From: STAR Skin Tear Classification Tool developed by Skin Tear Audit Research (STAR). Silver Chain Group Limited, Curtin University. Revised 4 February 2010. Reprinted August 2012. You can download full STAR tool and glossary at: www.woundsaustralia.com.au/wa/resources.php

Is our service up to standard?

Measuring the quality of care is a complex and multifaceted undertaking.

All healthcare services in New Zealand are regularly assessed against the Health and Disability Sector Standards (2008)¹¹. Compliance with these standards includes having a plan for measuring the quality of services, which may involve monitoring quality indicators (see Box 2), complaints, service user satisfaction surveys, and responses to identified issues.

New Zealand’s Health Quality and Safety Commission¹² has developed a set of quality markers that track progress over time in the health and disability sector relating to four key priority areas – falls, healthcare associated infections, surgical harm and medication safety.

A Standards New Zealand Working Party developed specific clinical indicators for individuals requiring aged care or dementia care in 2005 (see Box 2)¹³. Indicators include pressure injuries, falls, urinary tract infections and staffing hours but not skin tear rates. However, skin tear rates should be included as a clinical indicator for any organisation providing services to older adults because of the frequency of these injuries, their impacts on individuals, and the many opportunities for preventing/minimising their occurrences.

Monitoring skin tear injury rates provides a valuable overview of service delivery, while auditing individual cases (tracer methodology) offers a window into systems and processes. The Ministry of Health¹⁴ suggests that examining the journey of a specific client/resident/patient facilitates understanding of the care that is being provided and shows if staff know how to deliver care, tests systems and processes and their function and validates the individual’s journey and outcomes (p.4).

A detailed review of just one service user’s experience with a skin tear injury can provide a range of valuable information, including:

• wound management practices and consistency with service policies – systems and processes for assessing/classifying/evaluating and reporting on wound progress; evidence-based wound management practices (e.g. not using skin closures on skin tears¹⁵); use of appropriate wound care products; monitoring for infection; checking that wounds are regularly monitored until they heal
• assessment and care planning – short-term plans related to the skin injury and its associated clinical requirements, such as analgesia, enhanced nutrition; strategies to minimise risk of skin injuries or further injuries, such as avoiding soaps and using skin moisturisers twice daily⁹, and the use of appropriate transfer equipment, for example, slider sheets
• capturing relevant data – initial and ongoing documentation in the clinical record related to the injury; completion of an accident/incident report; open disclosure to the individual and/or family; analysis of incident and accident data; mechanisms for responding to findings, reporting results to staff, actioning any identified deficits.

In conjunction with reviewing individual cases, an analysis of skin tear injury rates across the service can tell us about environmental factors that may contribute to these injuries, such as the times of day the injuries occur; the skin tear site; staff skill mix and ratios; staff education and knowledge deficits. These are modifiable factors the organisation can work towards addressing.

BOX 2: Indicators for safe aged care

An indicator is a measure or flag against which some aspect of a standard can be assessed. Indicators generally simplify and quantify complex phenomena and aid the communication of information about those phenomena. Indicators are information tools. They summarise data on complex issues to indicate the overall status and trends on those issues. Indicators are generally measures that link the processes of care with desirable outcomes¹³ (p.13-14).

Conclusion

Unfortunately, skin tears are a common occurrence for many older adults, resulting in pain, distress, and the potential for chronic wounds. Skin tear injuries result from many interlinked factors relating to the individual, the environment, and care practices. Some of these factors are modifiable, such as patient handling procedures, and others, such as significant frailty, are not.

While it is important that skin tears are prevented when possible, and when they occur are carefully and appropriately managed using best practice, these injuries also offer a picture into the quality of care received by individuals and a patient cohort. Rather than being a forgotten and inevitable wound for older adults, skin tears should be a key reminder of the complexity of care for this growing population.

View the PDF of this learning activity here >>

About the authors:

• Lesley Batten RN PhD is a senior researcher at Massey University, Palmerston North.
• Marian Bland RN PhD is a healthcare auditor.

This article has been peer reviewed by:

• Julie Betts RN MN, who is a wound care nurse practitioner at Waikato District Health Board.
• Rebecca Aburn RN MN, who is an infection prevention and control nurse specialist at Southern District Health Board with a special interest in wound care.

Recommended resources

• The International Skin Tears Advisory Panel website includes a range of resources, including the Skin Tear Resource Kit, a skin tear decision algorithm, and consensus statements relating to the prevention, prediction, assessment and treatment of skin tears. www.skintears.org
• The New Zealand Health and Safety Commission website includes comprehensive information on evaluating health quality.
  www.hqsc.govt.nz/our-programmes/health-quality-evaluation
• Pharmac’s 2015 Seminar Series focusing specifically on wounds is available via You Tube. The first part of the fourth video in this series, titled From skin tears to leg ulcers, covers a range of information relevant to skin tear prevention and management.
  www.youtube.com/watch?v=JKme8c9KyB4
• The Skin Safety Model proposed by Campbell, Coyer and Osborne offers a new perspective on older adults’ vulnerability to skin injuries and outlines a framework for skin care and the promotion of skin integrity. CAMPBELL J, COYER F & OSBORNE S (2016). The skin safety model: reconceptualising skin vulnerability in older patients. Journal of Nursing Scholarship 48(1) 14-22.
  http://onlinelibrary.wiley.com/doi/10.1111/jnu.12176/full
• Detailed information on the selection of wound products for skin tears can be found in the following article: LEBLANC K, BARANOSKI S & LANGEMO, D et al (2015) The art of dressing selection: a consensus statement on skin tears and best practice. Advances in Skin and Wound Care 29(1) 32-46.
• Information relating to the prevention of skin tears is outlined by: SUSSMAN G & GOLDING M (2011). Skin tears: should the emphasis be only their management?
  Wound Practice and Research 19(2), 66-70.

References

1. Personal anecdote as told to Marian Bland.
2. LEBLANC K & BARANOSKI S (2014) Skin tears: the forgotten wound. Nursing Management 45(12) 36-46.
3. CAMPBELL J, COYER F & OSBORNE S (2016) The skin safety model: reconceptualising skin vulnerability in older patients. Journal of Nursing Scholarship 48(1) 14-22. http://onlinelibrary.wiley.com/doi/10.1111/jnu.12176/full
4. INTERNATIONAL SKIN TEARS ADVISORY PANEL (2015). www.skintears.org
5. SILVER CHAIN GROUP & CURTIN UNIVERSITY (2007) STAR skin tear classification system. Retrieved from www.woundsaustralia.com.au/publications/2010_wa_star-skin-tear-tool-g-04022010.pdf
6. HOLLISTER AND INTERNATIONAL SKIN TEARS ADVISORY PANEL (2013). Skin tear resource kit. www.skintears.org/pdf/Skin-Tear-Resource-Kit.pdf
7. MILNER E (2013). Simple tear but complex wound. Nursing Review 13, 18-19. www.hqsc.govt.nz/assets/Falls/10-Topics/Milner-Nursing-Review-Nov-2013-Skin-tears.pdf
8. ACC TREATMENT INJURY DATA FROM 1 JULY 2005. [Skin treatment injury data emailed by ACC to Nursing Review on 21 April 2017 following request for information.]
9. CARVILLE K, LESLIE G, OSSEIRAN-MOISSON R, NEWALL N & LEWIN G (2014). The effectiveness of a twice-daily skin-moisturising regimen for reducing the incidence of skin tears. International Wound Journal 11, 445-53.
10. STEPHEN-HAYNES J & CARVILLE K (2011). Skin tear made easy. Wounds International 2(4). Retrieved from www.woundsinternational.com/media/issues/515/files/content_10142.pdf
11. MINISTRY OF HEALTH (2016a). Service standards. www.health.govt.nz/our-work/regulation-health-and-disability-system/certification-health-care-services/services-standards.
12. HEALTH QUALITY AND SAFETY COMMISSION NEW ZEALAND (2016). Health Quality and Safety Indicators. www.hqsc.govt.nz/our-programmes/health-quality-evaluation/projects/health-quality-and-safety-indicators
13. STANDARDS NEW ZEALAND AND MINISTRY OF HEALTH (2005) New Zealand Handbook – indicators for safe aged-care and dementia-care for consumers. SNZ HB 8163:2005.
14. Ministry of Health (2014). Tracer methodology revisited. HealthCert Bulletin: Information for Designated Auditing Agencies 11, 4. www.health.govt.nz/system/files/documents/pages/healthcert-bulletin-11-april-2014.pdf
15. LEBLANC K, BARANOSKI S & LANGEMO, D et al. (2015). The art of dressing selection: a consensus statement on skin tears and best practice. Advances in Skin and Wound Care 29(1) 32-46.
16. NURSING COUNCIL OF NEW ZEALAND (2012)  Competencies for registered nurses. Retrieved January 2016 from www.nursingcouncil.org.nz/Publications/Standards-and-guidelines-for-nurses

Coleman said it was estimated that every year in New Zealand about 55,000 people suffer from pressure injuries (PIs) – with more than 3000 of those causing significant harm. “They (PIs) can cause pain, disability, hospitalisation, and sometimes even death, yet most are preventable.”

The Guiding principles for pressure injury prevention and management in New Zealand were created by an expert reference panel including wound care nurse practitioners, nurse consultants and clinical nurse specialists and has been endorsed by the Ministry of Health, ACC and the Health Quality & Safety Commission.  The document sets out a high-level national framework for best-practice care in preventing PIs and includes practical recommendations for implementing best practice in health settings from hospitals and home-care settings to hospices and residential care facilities.

The ACC’s latest treatment injury report found that the major causes of claims for pressure injuries occurring in public hospitals in 2015 were a lack of identifying PI risk factors (65%), immobilisation (17%) and splints or other casts (8%).

Associate health minister Peter Dunne said the just launched guideline principles are part of a wider piece of work on pressure injuries that also included developing a national approach to measure and report pressure injuries, as well as raising public and health practitioners’ awareness of pressure injury prevention and management.

The six guideline principles are: people first; leadership; education and training; assessment; care planning and implementation; and collaboration and continuity of care (see more details below).

A pdf of the ACC7758 Guiding principles for pressure injury prevention and management in New Zealand can be downloaded at:

http://www.acc.co.nz/publications/index.htm

The Southern District Health Board clinic has a diabetes nurse specialist, herself, a vascular surgeon, orthopaedic surgeon, a podiatrist and the orthotics team offering a holistic approach to patient-centred care, including optimising diabetes control, effective wound care and infection control, pressure-relieving techniques and ensuring adequate blood flow to the limb.

Aburn believes that if people, when first diagnosed with diabetes, could see the potential impacts on their feet of diabetes complications like neuropathy and peripheral vascular disease, then health professionals may see a lot fewer diabetic foot or lower leg ulcers.

She is a strong supporter of nurses providing quality foot care education right from the outset of diabetes diagnosis and regular foot screening thereafter – annual screening for the low risk and more frequently for those with poorly controlled diabetes, loss of sensation and other risk factors.

She also believes a key message for nurses wanting to help prevent diabetes foot disease is to try and help address the underlying causes of why the person has difficulty controlling their diabetes or is at risk of foot disease. And if the nurse is not a specialist in treating diabetic wounds – or people at risk of them – to promptly refer them to a service or clinic where they can get the specialist care required.

“You can’t muck around with diabetic feet by waiting around to see whether a wound is infected or giving oral antibiotics in the hope it goes away.”

Aburn shares some case studies illustrating how quickly a simple rubbing injury or blister may lead to an ulcer requiring months to heal or the loss of toes or even a foot.

The case studies also show that every wound, like every Kiwi, has a story and Aburn believes it helps to know the ‘story’ or underlying causes if you are going to help somebody successfully heal or avoid another wound in the future.

CASE STUDY: The fashion shoe-lover

A 40-year-old woman newly diagnosed with type 1 diabetes wanted to keep wearing fashion shoes as she had a corporate-type job. Her first blister saw her heel go black; a pharmacist gave her an antimicrobial cream but the infection escalated until she needed a skin graft and was hospitalised for a long time.

The woman had been fit, healthy and had her diabetes well under control until the ulcers developed.

Following her first bad experience she inserted some gel pads into a pair of old fashioned boots in the belief she was doing the right thing. But the pad altered the position of her foot so she ended up with six blisters on her other foot – three of which turned into ulcers.

Because of her job she was very reluctant to wear a moon boot, an off-loading shoe, or go into a total contact cast, so the diabetes foot clinic team had to find a more attractive footwear solution that worked for her.

 It took three months to heal the ulcers. After a tough learning curve the woman has not re-presented at the clinic with any more ulcers.

CASE STUDY: The recently widowed

A  woman turned up at the diabetes foot clinic with multiple small wounds on her feet. The team discovered she hadn’t been managing herself or her diabetes well since losing her husband. She had lost her appetite, smoked, had peripheral vascular disease and hadn’t been looking after her skin so had callouses and cracks on her feet. The cracks had broken open and bacterial infection had set in.

 Recognising the multiple factors behind the wounds, the clinic worked with her to boost her nutrition with supplements and help her sign up to a quit smoking programme with the support of her GP and practice nurse.

A recent clinic appointment showed her wound had taken a turn for the worse and the team discovered she’d had a bad week where she stopped taking her supplements and begun to smoke heavily again.

 They sat down and talked with her again about the benefits of eating better and smoking less. They also showed her on the electronically graphed treatment record how her bad week had impacted on the healing of her wound. Seeing the reality on the graph meant the woman agreed to try to cutting back on the cigarettes and eating better to get healing back on track.

CASE STUDY: The whitebaiter

A trim man in his 60s with well-controlled type 2 diabetes had gone whitebaiting at the weekend in his gumboots and got a very small blister on the right side of his foot.

He went to his GP on the Monday and Rebecca Aburn, a district nurse at the time, was assigned to change his dressing on the Wednesday.

 “I took the dressing down and there was a very small wound area – probably less than 5mm but the surrounding area was grey and boggy.”

She knew his history included vascular surgery about seven years previously so sent him straight into the diabetic foot clinic. On arrival he was quickly admitted to hospital as his underlying vascular disease had deteriorated, which meant the tiny innocuous gumboot blister had an impact far beyond its actual size. They had to debride his foot back to the bone and he eventually lost two toes. The healing time was more than six months.

But for people with diabetes these experiences may mean they are just a few numb and unfeeling steps away from a diabetic foot ulcer. And for some those steps could be taking them down the path to losing toes, a foot or even a lower leg.

The International Diabetes Federation reports that every 20 seconds somebody with diabetes has a limb amputated.

Statistics from New Zealand’s Artificial Limb Service show that people with diabetes have gone from making up 24 per cent of new amputees each year to 38 per cent of new amputees (174 people) in less than a decade. And that doesn’t include toes.

Sadly, it is estimated that 85 per cent of all amputations caused by diabetes are preventable if foot complications like diabetic foot ulcers are detected and treated early.

It is also estimated that 15 per cent of the more than 257,000 people in New Zealand with diabetes will have a foot ulcer in their lifetime – that percentage is stable but the number of people getting diabetes is not, so the number needing specialist foot and wound care keeps growing.

Foot screening: “notoriously poorly done”

Michele Garrett is a diabetes specialist podiatrist at Waitemata District Health Board providing such specialist foot care.

She says an unfortunate reality of today’s “flat out and full on” general practice is that annual diabetes foot checks are “notoriously poorly done”.

“Some anecdotal data tells that only about 40 per cent are done and some other audits show that between 30–60 per cent of people with diabetes get an annual foot screen when it is meant to be everybody.”

Garrett says there are multiple factors influencing the poor statistics including patients not liking showing their feet, the doctor or nurse doing the screening not liking feet and sometimes feeling pushed for time to get the person to take their shoes and socks off. “It is amazing how many foot screens get done with footwear still on.”

She says health professionals can’t just ask people with diabetes about their feet – they have actually got to see the feet.

“You must remember that neuropathy or numbness is a major contributing factor to foot problems,” says Garrett. “People will say that their feet are okay but very few foot ulcers are identified by the patient – quite often they are only identified at opportunistic screenings because numbness meant the person was unaware.”

Garrett was part of the New Zealand Society for the Study of Diabetes podiatry team that developed the 2014 diabetes foot screening and risk stratification tool. The tool is built on the Scottish guideline, but with the addition of Māori ethnicity as a risk factor to reflect the much higher risk of amputation experienced by Māori with diabetes (see link in resources next page).

The latest international guidelines recommend on top of the annual diabetes foot screen that all people with high risk feet or neuropathy should have their feet checked each time they see a health professional. This is because people with numb feet may not have pain “as their friend or indicator” that something is wrong. Also obesity, age, vision impairment and other factors sees some people struggle to adequately care for or check their feet.

Bare feet and jandals – the Kiwi attitude to feet

Kiwis also typically think their feet are ‘tough’.

Garrett recently undertook some qualitative research looking at how growing up ‘Kiwi’ influenced the attitudes of people with diabetes towards their feet.

“All of them went barefoot as children and didn’t wear special footwear for sport and grew up with a real ‘she’ll be right’ attitude to their feet,” says Garrett.

The most people did was “dab a bit of Dettol” on a cut or a blister, but once people have diabetes such cursory first aid is not enough as a simple cut can quickly become a major issue for people with a moderate to high risk of diabetes foot ulcers.

Garrett says people with diabetes need to be told not only how to take good care of their feet but also why and the what if consequences of activities like walking barefoot on a black sand beach on a hot summer day with numb feet through neuropathy. :

Regular foot screening is key

The annual diabetes foot screen provides an opportunity for just such patient education as well as detecting any new risk factors or spotting active or potential ulcers.

Garrett says a good foot screen can be a simple process needing only your eyes and fingers and taking just a few minutes.

With their fingers nurses can check the pulses in the feet for signs of vascular problem. Also, if a nurse doesn’t have a 10g monofilament on hand for the neurological test, they can just use their fingers instead to carry out the Ipswich touch test to assess for loss of sensitivity to the toes (see link in resources sidebar).

After asking the set questions on the NZSSD foot screening checklist, the screening process is finished with a visual inspection of the feet for callouses, redness, blisters, cuts or ulcers.

Depending on the screening results, the response can range from patient education and self-management for the low risk foot through to referral to a podiatrist for the moderate to high-risk foot.

For people with active foot disease most regions have some form of specialist diabetes foot clinic that people can be urgently referred to, with clinics often working in conjunction with a district nursing service, says Garrett.

She says it is imperative with foot ulcers to offload the pressure on the foot by putting people in special surgical shoes, moon boots or casts. “It is the constant pressure (on the foot) combined with the diabetes that inhibits ulcers healing.”

Rapid referral to a specialist service with the right offloading strategies in place can see ulcers heal relatively quickly and stop them progressing to complex chronic wounds that are much more time-consuming to heal. It also reduces the risk of amputations.

Foot screening is not only important in primary health settings but also if a person with diabetes or neuropathy is admitted to hospital, because of the increased risk of pressure injuries on their heels and the bottom of their feet, says Garrett.

Also people with neuropathy may be allowed to wander around the ward in bare feet and socks when they should be wearing special footwear.

Urgent hospital admission is needed for people found to have severe or spreading infection or critical ischaemia.

Garrett hopes that regular screening, education and rapid referral can help more Kiwis with diabetes work through their ‘she’ll be right’ attitude to their numb feet and see fewer face chronic ulcers or risk amputations.

It happens all the time. A hammer heading for the nail hits the thumbnail instead. Or a lapse of attention sees fingers jammed in a door, drawer, or machinery.

The wounds may be small but the pain of a throbbing swollen finger or fingers is not easily forgotten.

“Mostly the (crushed finger) injuries that present at ED are people who may have been chatting to someone with their hand on the open car door and then they have inadvertently closed the door,” says Auckland Hospital ED nurse practitioner Margaret Colligan.

She says the pain that brings people into ED is usually caused by bleeding under the nail (subungual haematoma) following a minor laceration.

“The blood that forms under the nail has nowhere to go because it is such a small compressed area and that is why it throbs so much.”

When a nurse in a general practice, rest home, or other community setting has a patient present with a throbbing finger and a subungual haematoma, they need to follow initial first aid steps (see sidebar). They then need to assess whether they can care for the wound or if the damage is such that the person needs to be sent to ED.

Colligan says in the case of industrial accidents, the blow to the finger can have significant force behind it and often the worker may have also broken the bone underneath the nail and suffered significant damage to the nail.

In cases where the patient has a very sore and swollen finger or fingers and there is a suspected fracture of the bone and/or the nail is badly crushed or cracked, the person needs to be referred to ED or an A&E clinic as the nail is likely to have to be removed and the nail bed repaired. An X-ray will also be required.

If the nail is intact and bone fracture unlikely, the nail can be assessed by the nurse for trephination (i.e. making a hole in the nail to release the blood and so reduce the pressure and pain).

Colligan says one factor nurses have to take into account before trephination is how recent the injury is. After 12–24 hours, the blood under the nail is likely to be clotted and trephining will have less impact.

If the haematoma covers 50 per cent or more of the nail, trephination is likely to be worthwhile in relieving pain. If the coverage is 25 per cent or less, a judgment call needs to be made on whether trephination will benefit the person.

Before trephination the nail must be cleaned. The best way to actually carry out trephination is a matter of some discussion (see sidebar).

Colligan says her preferred method is to use a sterile 18-gauge needle and gently rotate the needle (between finger and thumb) down through the nail until it pierces the nail and blood comes out.

If there is a fracture underneath the nail, there is conflicting evidence about whether prophylactic antibiotics should be used after trephination because there is a portal through the nail for infection into the tissue.

“I can’t find any good evidence to support that (prophylactic antibiotics), but anecdotally, that seems to be the practice,” says Colligan.

“This is particularly the case if the injured person is, for example, a mechanic in a garage who is going to continually get the finger dirty. I would have a higher threshold for giving them antibiotics then somebody who works in an office environment.”

Colligan says nails usually grow back within three to six months without any complications.

The aim of wound care is always to help, not hinder, the healing of a wound.

There is a myriad of modern dressings available to aid wound healing but wound care nurse specialist Emil Schmidt says to make the most of these – often quite expensive – products you first need to ensure the wound bed is properly prepared.

For this the wound needs to be not only cleaned but also often debrided. Schmidt has been working as the Southern District Health Board’s wound care specialist for more than a decade and in 2013 also became the president of the New Zealand Wound Care Society. Earlier this year he presented on aspects of debridement at the society’s biennial conference in Blenheim.

Schmidt says sometimes people get confused over the differences between cleansing a wound and debriding a wound. To put it simply, cleansing usually involves washing a wound to remove loose dirt and foreign materials, while debridement is the removal of dead, adhered and contaminated tissue and needs to continue until a healthier wound bed has been created. “So debridement can also be referred to as a form of wound bed preparation.”

Wound bed preparation is particularly important in chronic wounds like leg ulcers, where health professionals often need to intervene to facilitate or speed up the healing process.

This article looks at how nurses can use debridement so modern wound dressings can be placed on a healthy wound bed and be their most effective.

“If we don’t prepare the wound properly, modern wound dressings are a waste of time and money,” says Schmidt.

Deciding which form to use

Debridement itself can take many forms. Deciding when to debride a wound, and the most appropriate form, depends on many factors.

There first needs to be a full assessment of the patient, including their level of pain, circulation and any comorbidities (such as diabetes).The diagnosis of different tissue types and bioburden (viable bacteria) covering the wound, combined with the state of the wound edge as well as the periwound skin, will assist in deciding which form of debridement will be the most appropriate.

Schmidt says the rough rule of thumb is that all wounds with dead tissue (i.e.slough) need to be considered for debridement. What needs to be taken into account is the speed of healing.

“If the wound, despite a moderate amount of slough, is healing then obviously there is no problem,” he says. “But if the wound is covered with tenacious slough, the wound edges are not progressing, the surrounding skin is macerated and the wound is static, then you need to act, because the slough is delaying wound healing, and is often harbouring harmful bacteria that is critically colonising the wound.”

If wound healing has come to a halt then some form of debridement is indicated. The right diagnosis and identifying the tissue type is important to define the right time for debridement and to identify the most appropriate method. Another important factor is to define the exudate levels of the wound bed (ranging from dry to wet). Other parameters that need to be considered include pain, the patient’s environment, quality of life, patient’s choice, age and, in particular, the skill and resources of the health professional.

If the assessment reveals that the wound may already be outside of the particular nurse’s skill set – for example, it is showing signs of local infection, is painful, odorous, has a lot of dead tissue or lot of tenacious slough– then it is important to seek support from a wound care specialist. The earlier the better, says Schmidt, who often gets photos of wounds emailed to him by colleagues from throughout Otago seeking advice on wounds they are treating. He says often a sound care plan can be established using email consultation, and he values and is very proud of the close working relationships he has developed over the years with many healthcare professionals in Otago.

Wound care plan important

Before starting any form of debridement, Schmidt emphasises the importance of debridement being seen as part of an integrated wound care plan. For example, he says it doesn’t make sense to just look at the sticky slough on a lower leg and apply a hydrogel to an ulcer without using appropriate compression support.

The wound care plan needs to include the aims of the debridement, timeframe and a goal.
Those goals (i.e. reducing the amount of dead tissue) need to be reassessed at regular intervals. If the goals haven’t been achieved then an alternative plan should be considered. Again he says, bear in mind that assistance is only a phone call or an email away.

The type of debridement will not only be influenced by the wound and patient assessment but also by the clinical setting, as the range of debridement products and tools available to a nurse in a general practice or a rest home may differ greatly from those available to a wound specialist in a tertiary hospital or outpatient clinic. The skills and experience of the nurse also need to be considered, along with any workplace regulations or guidelines they work under.

Schmidt says forms of debridement can be loosely grouped into several categories.

Autolytic debridement

Autolytic debridement is the most common form used and basically involves encouraging or enhancing the body’s natural debridement process by keeping the wound moist.

A wound can naturally rid itself of dead cells by producing slough, which is often quite wet, says Schmidt. The moist slough helps shift and shed the dead or non-viable tissue from the wound bed but when the slough dries and becomes sticky the natural debridement process can need a helping hand.

Autolytic debridement involves adding a dressing with a high water content to the wound to moisten and loosen the thickened slough or necrotic tissue.

Dressings commonly used for this purpose include hydrogel orhydrocolloid and all operate on the principle that they add moisture to the wound bed.

These dressings are usually changed three or four times a week until the slough can be removed by simply washing the wound. Autolytic is the least invasive of the debridement techniques, says Schmidt. It doesn’t require specialist skill and should be able to be applied in many healthcare settings. Some of the advantages are that it is virtually pain free. However, autolytic debridement also has its disadvantages. It is a slow process, can lead to maceration of the surrounding skin and the moist environment can potentially allow bacteria to multiply.

Enzymatic debridement

Patients with chronic wounds have been treated with topical application of proteolytic enzymes, found naturally in fruits like papaya and kiwifruit, for hundreds of years. Enzymatic debridement uses proteolytic enzymes (proteinases) to help break down proteins in the wound or slough. Few commercially available enzyme products are available here in New Zealand.

Mechanical debridement

Traditionally mechanical debridement involves applying a dry gauze dressing to a wound. After the wound dries out – and the dead tissue sticks to the gauze – the dressing is ripped off, removing the dead tissue and dry slough with it.

“That can be very, very painful and is not recommended practice,” says Schmidt.

Recently another form of mechanical debridement became available in New Zealand using a monofilament pad (Debrisoft) that is said to be a less painful method.

Larval (or biosurgery) debridement

Larval debridement (maggot therapy) is now more readily available in New Zealand. The local supplier of sterile medical maggots last year reported up to several orders a week from nurses and doctors using larval debridement on hard-to-heal wounds.

Schmidt says the method is most often used by wound care specialists and specially trained district nurses. “It has to be the right diagnosis, tissue type and patient who can tolerate this type of treatment. “The larvae feed on dead tissue and exudates within the wound and therefore remove devitalised tissue. The digestive juices secreted by larvae contain proteolytic enzymes which selectively debride dead tissue, leaving viable tissue unharmed.

“Maggots are like micro-surgeons as they won’t touch living tissue,” says Schmidt. Special protocols need to be followed to ensure it is the right method for the wound and the larvae can do their job effectively.

Direct debridement

In recent years a number of new high-tech forms of debridement have been introduced – mostly for use in hospitals but also some specialist clinics.

These include Versajet, in which a high-flow jet of sterile water is directed at the wound to wash away dead tissue (also known as hydrosurgery) while the patient is under anaesthetic. Another form is low frequency ultrasound debridement (LFUD) that uses ultrasonic waves combined with highly charged saline bubbles to debride wounds. LFUD can be safely used on the bedside or in an outpatient setting, saving theatre time and aiding early discharge. This technique has been used overseas for a decade but hardly ever in
New Zealand. Schmidt has been using the only system available in the country for almost three years. He and his vascular team colleagues are currently undertaking a three-year-long, randomised control trial in Dunedin Hospital on all patients with lower limb wounds and he says that early results are very promising.

Conservative sharp debridement

Conservative sharp debridement requires training, experience and confidence to perform safely. This form of debridement involves using a sterile sharp spoon (curette), scissors or scalpel to remove necrotic tissue. A thin margin of non-viable tissue is left surrounding the wound bed. “So it doesn’t go into bleeding tissue”, says Schmidt.

Sharp debridement is often done in an outpatient clinic setting. Local anaesthetic may be required for painful wounds.

Surgical debridement

Surgical debridement is more extensive and deeper than sharp debridement and includes cutting into bleeding, living tissue. It is often, but not exclusively, done in an operating theatre.

Lack of guidelines in Australasia for sharp and surgical debridement

Schmidt, in his role as president of the New Zealand Wound Care Society, is very conscious of the lack of a recognised training framework or guidelines for sharp and surgical debridement in Australasia.

Nurses are expected to use their professional judgement of what is within their skills and scope, so only experienced wound care nurses will carry out sharp or surgical debridement.

But at present there is no formal certification programme to assure the patient, (or the nurse) that they have the necessary skills, unlike the United States where individual state boards of nursing set out clear guidelines on what skills are required to be competent to perform sharp debridement.

“It is a complex topic, not only inNew Zealand but throughout the Australasia region, as lots of colleagues debride [sharp or surgical] but there is no standardised training programme,” says Schmidt. Often nurses specialising in wound care first learn by watching others and then hone their skills under the supervision of a surgeon, podiatrist or other specialists, so in time it can become part of their own practice skill set.

The New Zealand Wound Care society always includes a sharp debridement training workshop at its conference where nurses can learn some theory and do some practical debridement sessions. Those workshops are extremely popular and are booked out very quickly. But there is no national, standardised training framework where a recognised qualification can be obtained, which is a concern as sharp debridement can be potentially dangerous.

“Nursing colleagues tell us that they want more formal training,” Schmidt says.

He says the New Zealand and Australian wound care societies have worked successfully together to write guidelines for leg ulcer and the prevention of pressure injuries and he is hopeful that in the future the societies will also develop standards and an educational framework for debridement.

Meanwhile, unless nurses are trained to the point that they are competent, they should not attempt sharp debridement and opt instead for a less invasive debridement form. It’s most important to remember that if a wound is not healing within a certain timeframe then help should be sought from a wound care specialist. :

Reference

Strohal R, Apelqvist J, Dissemond J et al. EWMA Document: Debridement. Journal of Wound Care 2013; 22 (Suppl. 1): S1–S52.