Wound up for Wounds. In this issue: Contact us: Visit our public website: Issue 5 February 2019

Transcription

1 Wound up for Wounds Issue 5 February 2019 In this issue: 1 Wound up for Wounds 2-3 Wound Bed Preparation 4 Practice Corner 5 Upcoming Courses 6 Patient safety review Contact us: E: jmcswiggan@wrha.mb.ca P: (204) F: (204) Visit our public website: Wound up for Wounds Wound up (verb. To be excited) for Wounds (noun. Injuries to living tissue) Welcome to the February edition of Wound Up for Wounds. I like to refer to Jan Rice as I work with you. An aspect of wound management often overlooked is defining the wound itself. The guiding principles of wound management have always been focused around defining the wound, identifying any associated factors that may influence the healing process, then selecting the appropriate wound dressing or treatment device to meet the aim and aid the healing process. This structured approach is essential, as the most common error in wound management is rushing in to select the wound dressings without actually giving thought to wound aetiology, tissue type and immediate aim - Jan Rice RN, Australia Canada is a leader in wound care methodology with the Wound Bed Preparation paradigm which, if used, provides the clinician with a solid wound assessment and treatment plan including the dressing. At the risk of making some of the readers ill with a picture of a wound, let us put this paradigm to work on Page 2. Enjoy the brighter days and the thoughts of spring. Jane McSwiggan, MSc., OT Reg. (MB), IIWCC 1

2 Did you know? In Manitoba, stages 3, 4 and unstageable pressure injuries are critical incidents. Please report using RL6 or call the Critical Incident Reporting and Support Line (24 hours) at Further information: safety/ criticalincident/report.php Wound Bed Preparation: Your Ticket to Success Wound bed preparation has several steps which I will take you through in the assessment of the wound shown on the next page. Try working through it and see where it takes you. Discuss with your colleagues, come up with a plan. Next edition we will review the wound and give suggestions. Person with a wound Identify/treat the cause Person-centered concerns (pain) Determine Healability: Healable, Maintenance, Nonhealable/Palliative Local Wound Care Tissue(Debridement) Infection/Inflammation Moisture Balance Edge of the Wound Adapted from: Sibbald, R.G., Elliott, J.A., Ayello, E.A., & Somayaji, R. (2015) 2

3 Is it possible to debride it? Remember vascular status. Do not debride stable black eschar on heels and feet. 3. What tools are in your toolkit for debridement? Mechanical (30cc syringe and 18 gauge needle or blunt tip for 8-14 psi) Identify and treat the cause What caused the wound? Consider co-morbid conditions, medications, moisture, nutrition, and age. Improvement is dependent upon removal of the sources of the problem where possible. Person-centered concerns The goals and perspective of the recipient of treatment are paramount. Manage pain. Are there risks to modify, is treatment accessible? Healable, maintenance (non-healing), non healable Is the wound going to heal or are there factors such as the slough we see which will delay healing? Discuss with patient and team at rounds. Assessment of the wound Assessment of the wound seems to make everyone nervous, but assessment can be made a lot less daunting when we use the tools of wound bed preparation. Tissue/Debridement (healable or maintenance wound) 1. Look at the wound & describe the tissue in the wound bed indicating how much of each type by percentage. 2. Is there tissue requiring debridement? Autolytic (*hydrogel with hydrocolloid, dressing cadexomer iodine, hydrophilic paste) Consult advanced wound care clinician for opinion on surgical or conservative sharp wound debridement Infection/Inflammation Look for signs of superficial (3 or more NERDS) or deep/ surrounding infection (3 or more STONEES) N - Non-healing E - Exudate R - Red friable tissue D - Debris S - Smell S - Size increasing T - Temperature elevation O - Os (probes to bone) N - New areas of breakdown E - Exudate E - Edema, Erythema S - Smell What tools are in your toolkit to treat infection? Topical antimicrobial*, for superficial infection, which should be used for 2 weeks. If there is no significant improvement then stop use and consider an alternative or identify other factors impeding healing 1 Don t obtain swabs from superficial ulcers for culture as they are prone to both false positive and false negative results with respect to the cause of the infection - Choosing Wisely Canada Topical antimicrobial* and systemic antibiotic for deep/ surrounding infection. Swab clean wound tissue not slough to direct antibiotic therapy. Moisture Balance Do you need to add or remove moisture to the wound? Dry cells are dead cells and epithelium cannot migrate in a wet environment. Choose a product that donates or manages moisture. Edge of Wound Are the edges lacking new healthy tissue, is there undermining at the wound edges, or are the edges rolled? This indicates that wound healing is not progressing normally. Dead space in undermined areas needs filling and wound edges may need debridement if rolled or unhealthy. * Dressing categories not trade names are used, refer to local advanced wound care formulary 3

4 Additional Information Having trouble signing up for wound care courses? Staff with LMS access Log into the Learning Management System (LMS) from any computer or device at If needed, create a new account by clicking new User. Enter WOUND CARE in the global search bar. Level 1 is a bundle of 8 modules available online; Level 2 and other courses are delivered in the classroom setting. Staff without LMS access Contact Cindy Hoff at choff@wrha.mb.ca or to register. Have a question? Contact Jane McSwiggan, Education and Research Coordinator-Wound Care at jmcswiggan@wrha.mb.ca. Correction from November 2018 issue Skin Tear Treatment if not Bleeding Ensure dressing removal without tissue trauma, use barrier film or barrier wipe Please note that this applies to all dressings except bordered silicone foams (Mepilex border foam on WRHA formulary has silicone) Practice Corner: Dressing Change Question: How often should a dressing be changed? Answer? It depends on the wound and the type of dressing. Gauze has to be changed daily or more than once a day. Advanced wound dressings such as foams, alginates, hydrofibres and slow release iodine dressings can be left in place longer. Change when there is evidence of the dressing being at capacity from exudate, or in the case of a dressing with iodine, that it has been deposited into the wound bed. Always date the dressing. Become familiar with the properties of dressings Learn your local wound care formulary, each site and program has one. Check in with your advanced wound care clinician when you have completed a wound assessment, to discuss your findings and plan. Lanyard card for wound assessment (Print, cut out and laminate) Wound Assessment Identify/Treat the cause Person-centred concerns & pain Healable, Maintenance, Non-Healable? T/D: Type of tissue? Need for debridement? I: Infection/Inflammation NERDS or STONEES? M: Moisture Balance, not too wet, not too dry E: Edge of wound & periwound skin NERDS ( 3 antimicrobial dressing, no swab) Non healing wound Exudative wound Red, friable granulation tissue Debris (slough/eschar) Smell or unpleasant odour STONEES ( 3 antimicrobial dressing, swab, abx) Size is bigger Temperature is Increased Os (probes to bone) New or satellite areas of breakdown Exudate, Erythema, edema Smell or unpleasant odour 4

5 Level 2 Adult Pressure Injuries Upcoming Wound Care Courses Level 2 Adult Pressure Injuries April 4, :30 a.m. to 12:30 p.m. Victoria General Hospital Level 2 Diabetic Foot Ulcers March 21, :30 a.m. to 12:30 p.m. Grace Hospital Practice Days: Wound Assessment and Dressing Selection: four courses (each the same) offered March 14, :30 a.m. to 10:30 a.m. Concordia Hospital March 14, :45 a.m. to 12:45 p.m. Concordia Hospital May 2, a.m. to 12 p.m. St. Boniface Hospital May 22, p.m. to 3 p.m. St. Boniface Hospital Practice Days: ABCs of Leg Wounds and Compression Boot Camp April 2, :30 a.m. to 10:30 a.m. Victoria General Hospital April 2, :45 a.m. to 12:45 p.m. Victoria General Hospital Musculoskeletal Injury Prevention in Wound Care March 25, p.m. to 4 p.m. Health Sciences Centre 1.Wounds UK (2013a) Best Practice Statement: The use of topical antimicrobial agents in wound management. (3rd Ed). London, Wounds UK. Available to download from: 5

6 October 2018 Medical Devices (e.g. brace, cast, splint) Safety Event A recent critical incident review revealed a risk to patients related to the monitoring of skin integrity when a medical device was used. What occurred? A patient fractured their foot and required a cast boot. Admission orders did not include care instructions for the cast boot The in-patient unit does not typically care for these medical devices and resources were unavailable to guide care. There was hesitancy to remove the cast boot for fear of harming the existing fracture. An unstageable ulcer was discovered under the cast boot a week later requiring emergent debridement. The wound initially improved after care but then deteriorated. There were gaps in wound care documentation and escalation to wound care experts. What was learned? Resources and guidelines for management of medical devices, such as cast boots, did not exist within the site at the time of this event. Recommendations 1. The regional wound care committee will develop and implement a regional skin integrity and medical device policy that will include but not be limited to, the requirements for a physician order (activity restrictions, frequency of removal) and a skin assessment, when a medical device is required. 2. The regional wound care committee will develop and implement a regional product reference guide for WRHA staff and physicians concerning medical devices. The reference guide will address the application, best fit, and risks associated with the medical device and will include a contact resource. 3. The Regional Physiotherapy Program will develop and implement educational resources for patients who require a medical device. 4. A medical device can be used to treat a condition and can include braces, splints, neck collars or devices such as oxygen delivery systems. Cast boot example To see additional Patient Safety Learning Advisories go to wrha.mb.ca/quality/event-learning.php This alert represents de-identified information from one or several patient safety reviews and is intended for system-wide learning. If you have any questions, please contact the WRHA Patient Safety Team at patientsafety@wrha.mb.ca or contact Client Relations at