Pressure Ulcers Pressure Injuries

Transcription

1 Volume 19 Number 2 October 2018 Published by European Wound Management Association Pressure Ulcers Pressure Injuries Prevention Management Wound care Risk assessment Self-care Technology Long-term care

2 HydroTac Accelerated wound closure with AquaClear Gel [1, 2] Technology 23.5 % faster epithelialization [* 3] Benefi t from the advantages of HydroTac ** now [* 3] Fast: 23.5 % faster epithelialization than silicone interface [1, 2] Active: 3-times greater concentration of growth factors Effective: Promotes moist wound healing environment via unique AquaClear Gel Technology [4 10] Part of HydroTherapy Efficacy. And Simplicity. hydrotherapy.info * Compared to silicone interface, in-vivo study. ** AquaClear Gel Technology [1] Smola, H. (2016). Simplified treatment options require high-performance dressings from molecular mechanisms to intelligent dressing choices. EWMA Bremen, May, [2] Smola, H.et al. (2016). Hydrated polyurethane polymers to increase growth factor bioavailability in wound healing. HydroTherapy Symposium: A New Perspective on Wound Cleansing, Debridement and Healing. London, 3 March, [3] Smola, H. (2015). Stimulation of epithelial migration novel material based approaches. EWMA Congress. London,13-15 May, [4] Ousey, K. et al. (2016). HydroTherapy Made Easy. Wounds UK 12(4). [5] Knowles, D. et al. (2016). HydroTherapy wound healing of a post amputation site. Wounds UK Annual Conference. Harrogate, November, [6] Smola, H. et al. (2014). Hydrated polyurethane polymers to increase growth factor bioavailability in wound healing. EORS Congress. Nantes, 2-4 July, [7] Ousey, K. et al. (2016). Hydro-Responsive Wound Dressings simplify T.I.M.E. wound management framework. British Journal of Community Nursing 21 (Supplt. 12), pp. S39-S49. [8] Spruce, P. and Bullough, L. (2016). HydroTac : case studies of use. HydroTherapy Symposium: A New Perspective on Wound Cleansing, Debridement and Healing. London, 3 March, [9] Spruce, P. et al. (2016). A case study series evaluation of HydroTac. HydroTherapy Symposium: A New Perspective on Wound Cleansing, Debridement and Healing. London, 3 March, [10] Smola, H. et al. (2016). From material science to clinical application a novel foam dressing for the treatment of granulating wounds. HydroTherapy Symposium: A New Perspective on Wound Cleansing, Debridement and Healing. London, 3 March.

3 5 Editorial. Sebastian Probst, Editor of EWMA Journal Science, Practice and Education 7 The future of pressure ulcer prevention is here: Detecting and targeting inflammation early. Gefen A 15 Heel Pressure Injuries: The need for a structured evidence-based approach for assessment and treatment. Rivolo M, Marcadelli S 23 Using technology to advance pressure ulcer risk assessment and self-care: Challenges and potential benefits. Patton D, Moore Z, O Connor T, Shanley E, De Oliveira A L, Vitoriano A, Walsh S G, Nugent L E 29 Prevalence of pressure injuries and other dependence-related skin lesions among paediatric patients in hospitals in Spain. Pancorbo-Hidalgo P L, Torra-Bou J E, Garcia-Fernandez F P, Soldevilla-Agreda J J 39 Survey of wound prevalence in a long-term care facility. Peckford S Cochrane Reviews 45 Abstracts of Recent Cochrane Reviews. Rizello G 29 TH CONFERENCE OF THE EUROPEAN WOUND MANAGEMENT ASSOCIATION E WM A 2019 EWMA 50 EWMA Journal Previous Issues and Other Journals 52 EWMA 2019 Conference in Gothenburg, Sweden 58 EWMA 2018 Conference in Krakow, Poland 62 EWMA Honorary Speaker 2018 Veronika Gerber. Bale S 63 EWMA 2018 Cooperating Organisations Board Meeting: Flashback and brief reflections. Läuchli S 64 The Cooperating Organisations Workshop on Wound Centres at EWMA 2018 Conference in Krakow. Seppänen S 67 Wound centres in Finland. Lagus H 71 Non-antibiotic antimicrobial interventions and antimicrobial stewardship in wound care. Cooper R, Kierketerp-Møller K 75 The role of pressure ulcer prevention in the fight against antimicrobial resistance. Moore Z, Soriano J V, Pokorna A, Schoonhoven L, Vaugnat H 78 Living with chronic wounds A storytelling journey. Piaggesi A 79 The prevention and management of pressure ulcers: Education module and course endorsement. Touriany E 80 Atypical wounds. Isoherranen K, O Brien J J 83 Determining the current level of wound management education in the pre-registration nursing curricula. Holloway S, Probst S, Murphy S 88 EWMA Publications 90 Appreciations: Leaving Council members 91 New EWMA members & Honorary positions 92 New Corporate Sponsors Organisations 94 Association for the Advancement of Wound Care. Serena T 95 Wounds Australia. Sandy-Hodgetts K 96 Swedish Wound Care Association. Dufva S 98 International Lymphoedema Framework. Kennedy A 99 Corporate Sponsors 100 Conference Calendar 102 Cooperating Organisations, International Partners and Other Collaborators GOTHENBURG SWEDEN 5 7 JUNE //

4 The EWMA Journal ISSN number: Volume 19, No 2, October, 2018 The Journal of the European Wound Management Association Published twice a year Editorial Board Sebastian Probst, Switzerland, Editor Sue Bale, UK Vickie R. Driver, USA Georgina Gethin, Ireland Salla Seppänen, Finland Andrea Pokorna, Czech Republic EWMA website EWMA Council Sue Bale President Georgina Gethin Honorary Secretary Alberto Piaggesi President Elect Scientific Recorder Jan Stryja Treasurer Severin Läuchli Immediate Past President Selcuk Baktiroglu Luc Gryson Samantha Holloway Kirsi Isoherranen Edward Jude Lisabeth Lindahl Editorial Office please contact: EWMA Secretariat Nordre Fasanvej Frederiksberg, Denmark Tel: (+45) Fax: (+45) ewma@ewma.org Layout: Nils Hartmann, Open design/advertising Christian Münter Alexandra Marques Julie Jordan O Brien Pedro Pancorbo- Hidalgo Andrea Pokoma Sebastian Probst EWMA Journal Editor Printed by: Kailow Graphic, Denmark Copies printed: Prices: The EWMA Journal is distributed in hard copies to members as part of their EWMA membership. EWMA also shares the vision of an open access philosophy, which means that the journal is freely available online. Individual subscription per issue: 7.50 Libraries and institutions per issue: 25 The next issue will be published in April Prospective material for publication must be with the EWMA Secretariat as soon as possible and no later than January 15th 2019 The contents of articles and letters in EWMA Journal do not necessarily reflect the opinions of the Editors or the European Wound Management Association. All scientific articles are peer reviewed by EWMA Scientific Review Panel. Copyright of published material and illustrations is the property of the European Wound Management Association. However, provided prior written consent for their reproduction, including parallel publishing (e.g. via repository), obtained from EWMA via the Editorial Board of the Journal, and proper acknowledgement, such permission will normally be readily granted. Requests to reproduce material should state where material is to be published, and, if it is abstracted, summarised, or abbreviated, then the proposed new text should be sent to the EWMA Journal Editor for final approval. All issues of EWMA Journal are CINAHL listed. Massimo Rivolo Sara Rowan COOPERATING ORGANISATIONS BOARD Esther Armans Moreno, AEEVH Christian Thyse, AFISCeP.be Valentina Vanzi, AISLeC Francesco Petrella, AIUC Ana-Maria Iuonut, AMP Romania Aníbal Justiniano, APTFeridas Gilbert Hämmerle, AWA Jan Vandeputte, BEFEWO Vladislav Hristov, BWA Els Jonckheere, CNC Lenka Veverková, CSLR Mirela Bulic, CWA Arne Buss, DGfW Anette Høgh, DSFS Heli Kallio, FWCS Rosa Nascimento, GAIF J. Javier Soldevilla, GNEAUPP EWMA JOURNAL SCIENTIFIC REVIEW PANEL Paulo Jorge Pereira Alves, Portugal Caroline Amery, UK Jan Apelqvist, Sweden Sue Bale, UK Michelle Briggs, UK Stephen Britland, UK Mark Collier, UK Javorka Delic, Serbia Corrado Durante, Italy Bulent Erdogan, Turkey Ann-Mari Fagerdahl, Sweden Madeleine Flanagan, UK Milada Franců, Czech Republic Peter Franks, UK Francisco P. García-Fernández, Spain Magdalena Annersten Gershater, Sweden Georgina Gethin, Ireland Kylie Sandy- Hodgetts Thomas Serena Georgios Vasilopoulos, HSWH Aleksandra Kuspelo, LBAA Loreta Pilipaityte, LWMA Corinne Ward, MASC Hunyadi János, MSKT Suzana Nikolovska, MWMA Øystein Karlsen, NIFS Louk van Doorn, NOVW Arkadiusz Jawień, PWMA Sebastian Probst, SAfW (DE) Maria Iakova, SAfW (FR) Goran D. Lazovic, SAWMA Tânia Santos, ELCOS Ján Koller, SSPLR Mária Hok, SEBINKO F. Xavier Santos Heredero, SEHER Sylvie Meaume, SFFPC Luc Gryson, Belgium Marcus Gürgen, Norway Eskild W. Henneberg, Denmark Alison Hopkins, UK Gabriela Hösl, Austria Dubravko Huljev, Croatia Arkadiusz Jawien, Poland Gerrolt Jukema, Netherlands Nada Kecelj, Slovenia Klaus Kirketerp-Møller, Denmark Zoltán Kökény, Hungary Martin Koschnick, Germany Knut Kröger, Germany Severin Läuchli, Schwitzerland David Tequh, Netherlands Sylvie Meaume, France Zena Moore, Ireland Luc Teot Susanne Dufva, SSIS Jozefa Košková, SSOOR Leonid Rubanov, STW (Belarus) Guðbjörg Pálsdóttir, SUMS Saša Milievic, SWHS Serbia Jasmina Begić-Rahić, URuBiH Yvonne Siebers, V&VN Peter Quataert, WCS Caroline McIntosh, WMAI Skender Zatriqi, WMAK Dragica Tomc, WMAS Hakan Uncu, WMAT Evelien Touriany Christian Münter, Germany Andrea Nelson, UK Pedro L. Pancorbo-Hidalgo, Spain Hugo Partsch, Austria Elaine Pina, Portugal Patricia Price, UK Elia Ricci, Italy Rytis Rimdeika, Lithuania Zbigniew Rybak, Poland Salla Seppänen, Finland José Verdú Soriano, Spain Hubert Vuagnat, Switzerland Richard White, UK Marc Cornock, UK Gerald Zöch, Austria

5 EWMA Journal editorial Pressure ulcers in health care settings Dear readers Autumn is here, and with it comes a new edition of the EWMA Journal. This edition focuses on care bundles within the aetiology of pressure ulcers. The term care bundle was defined in the April edition and again during our conference in Krakow. Pressure ulcers (PU) are a problem in health care settings. The likely PU prevalence rate range in acute care settings worldwide is between 6% and 18.5%. 1 Nurses have a primary role in PU prevention, though patients may also contribute through active participation in PU care. 2 Active patient participation can result in improved patient safety and satisfaction with care. 2,3 Patients stand to benefit when introducing a care bundle. A successful bundle consists of key elements, starting with a thorough head-to-toe skin assessment upon admission and then at least once during every shift for all patients. 4 Other elements of a care bundle may include turning and repositioning, nutritional assessment, bed elevation, incontinence care and pressure relief. 4,5 An Australian cluster-randomised controlled trial with 1598 patients in eight tertiary hospitals encouraged patient participation in PU-prevention care with three simple evidence-based messages: 1) Keep moving, 2) Look after your skin and 3) Eat a healthy diet. 6 The results demonstrated that, due to the introduction of the care bundle, a significant reduction in PU incidence among the intervention group (incidence rate ratio 0.48; 95% CI: 0.33, 0.69; p<0.0001) could be achieved at the hospital (cluster) level. 6 The scientific contributions of this edition of the Journal should provide new knowledge that can be integrated into care bundles. In the scientific section, you will find five articles. One is a cross-sectional study establishing the prevalence of PU, moisture-associated skin damage and skin tears in paediatric hospital units in Spain. A survey from Canada illustrates the wound prevalence in long-term care facilities, and a paper from Israel gives insight into the future of PU prevention, addressing how we can detect and target inflammation early. Additionally a new article from the joint EWMA and EPUAP initiative on PUs and patient safety. Another article illustrates the EWMA education module and a course endorsement about prevention and management of pressure ulcers. We also present a paper describing the challenges and potential benefits of using technology to advance PU risk assessment and self-care and a paper demonstrating the rationale behind the need for a structured, evidence-based approach to assessing and treating HPIs in adult, paediatric and diabetic populations. Some of the conclusions presented in the latter article are part of a wider discussion among different groups of health care professionals engaged in wound management. EWMA has a close collaboration with both the International Working Group of the Diabetic Foot Guidance Group (IWGDF Guidance) and the European Pressure Ulcer Advisory Panel, and involves these groups in questions related to diabetic foot ulcers (DFU) and PU. However, in the context of the EWMA Journal we aim to give space for many different opinions, which may not reflect the official point of view of EWMA. In this edition you additionally will find articles about EWMA projects and activities. This includes a new article from the joint EWMA and EPUAP initiative on PUs and patient safety. Another article illustrates the EWMA education module and a course endorsement about prevention and management of pressure ulcers. I hope you all enjoy this issue, Sebastian Probst, Editor and Council Member Professor of Tissue Viability and Wound Care REFERENCES 1. Tubaishat A, Papanikolaou P, Anthony D, Habiballah L. Pressure Ulcers Prevalence in the Acute Care Setting: A Systematic Review, Clin Nurs Res. 2018;27(6): Dwamena F, Holmes-Rovner M, Gaulden CM, Jorgenson S, Sadigh G, Sikorskii A, et al. Interventions for providers to promote a patient-centred approach in clinical consultations. Cochrane Database Syst Rev. 2012;12:CD Weingart SN, Zhu J, Chiappetta L, Stuver SO, Schneider EC, Epstein AM, et al. Hospitalized patients participation and its impact on quality of care and patient safety. Int J Qual Health Care. 2011;23(3): Tayyib N, Coyer F, Lewis PA. Implementing a pressure ulcer prevention bundle in an adult intensive care. Intensive Crit Care Nurs. 2016;37: Chaboyer W, Bucknall T, Webster J, McInnes E, Banks M, Wallis M, et al. INTroducing A Care bundle To prevent pressure injury (INTACT) in at-risk patients: A protocol for a cluster randomised trial. Int J Nurs Stud. 2015;52(11): Chaboyer W, Bucknall T, Webster J, McInnes E, Gillespie BM, Banks M, et al. The effect of a patient centred care bundle intervention on pressure ulcer incidence (INTACT): A cluster randomised trial. Int J Nurs Stud. 2016;64: EWMA Journal 2018 vol 19 no 2 5

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7 Science, Practice and Education The future of pressure ulcer prevention is here: Detecting and targeting inflammation early The burden of pressure ulcers is one of the most important, yet unsolved, current medical problems. This article reviews the status of technology-based options to prevent pressure ulcers. Amit Gefen, PhD Professor of Biomedical Engineering The Herbert J. Berman Chair in Vascular Bioengineering Department of Biomedical Engineering Faculty of Engineering Tel Aviv University Tel Aviv , Israel ABSTRACT Pressure ulcers (PUs) are one of the largest unsolved medical complications today. The burden of PUs on society and healthcare cost continues to grow rapidly with the ageing population and spread of chronic diseases. The overall absence of advanced biomedical pressure ulcer prevention (PUP) technologies that assess risk and screen for PU formation in the clinic is concerning, especially in light of the progress being made in other fields of medicine. To develop such technologies, an in-depth understanding of the damage cascade resulting in PUs is necessary and is reviewed here in detail from a mechanobiological perspective. The paper describes the sequential and additive nature of the PU damage cascade. Specifically, the damage cascade includes the sequential damage associated with direct deformation, inflammatory response, and ischaemia. The additive nature of these damages highlights the importance of early detection of cell and tissue damage for PUP. Examples of current PUP technologies reviewed here include (i) biocapacitance measurements using a subepidermal moisture scanner, which identifies biophysical changes in tissue properties caused by early inflammation to aid in early detection and (ii) polymeric membrane dressings that prophylactically subdue the activity of nociceptive neurons to mitigate the impact and spread of inflammation. Development of these and other technology-based options to detect and mitigate PU-specific tissue changes caused by exposure to sustained deformations and the resulting inflammation and ischaemia is a timely and feasible endeavour for biomedical engineers and is anticipated to minimize the burden of PUs. INTRODUCTION The fastest growing segment of the human population is the elderly. With increased life expec- tancy, the rates of obesity, diabetes, and cardiovascular diseases climb, and the number of people with sensory or mobility impairments are rising rapidly as well. A major complication of impaired sensory and mobility capacities is the development of pressure ulcers (PUs), also known as pressure injuries in the US and Australia. Treatments for PUs are painful, lengthy, often require surgery, and impose a vast financial burden on healthcare systems worldwide. It is striking that PUs occur in 2.5 million patients annually in the US alone. Moreover, the cost estimates per single case range anywhere from $500 to $150,000 and total an inconceivable $11 billion US dollars annually. 1,2 The death toll from full-thickness or deep PUs is also devastating, totalling approximately 60,000 deaths per year in the US alone. 3 The prevalence and cost associated with PUs clearly indicate that this medical problem is far from being solved and that current clinical approaches are, at best, only partially effective in mitigating the resulting morbidity. In recent papers, our work has suggested that a fundamental factor, which is also a barrier to improved clinical outcomes, is the lack of advanced biomedical technologies that are designated for pressure ulcer prevention (PUP) and used for both risk assessment and screening of PU formation in clinical practice. 4,5 Ideally, such technologies would facilitate cost-effective detection of cell and tissue damage, even under intact skin. Successful development and implementation of relevant technologies require, first and foremost, a deep and thorough understanding of the aetiology of PUs. This aetiology has been explored over the last two decades with the help of mechanobiol- Correspondence: gefen@eng.tau.ac.il Conflicts of interest: Dr. Gefen is a scientific advisor to multiple companies in the field of pressure ulcer/injury prevention, including Bruin Biometrics LLC (CA, USA) and Ferris Mfg. Corp. (TX, USA), whose products are reviewed in this paper. The conclusions of the literature analysis presented here were not affected by this association. EWMA Journal 2018 vol 19 no 2 7

8 Sustained tissue deformations Deformation-induced cell death Plasma membrane poration Cytoskeletal integrity loss Cells further distored Inflammatory oedema Interstitial pressure Figure 1: The vicious cycle of deformation-inflicted and inflammation-related tissue damage in pressure ulcer formation. Sustained tissue deformations caused by bodyweight forces lead to loss of structural integrity in cells, disrupt the transport to cells via plasma membrane poration, and eventually lead to cell death. The first cell death events trigger inflammatory oedema, which increases the interstitial pressure in tissue regions confined between bones and support surfaces. This localized oedema increases cell distortion levels further, accelerating the damage pathway. At a later stage, after several hours of exposure to sustained bodyweight loads and under the influence of elevated interstitial pressure, ischaemic damage may begin to build up (not shown), further increasing the overall extent and rate of tissue damage. ogy. Mechanobiology is an emerging field of science at the interface of engineering and biology that focuses on how physical forces and changes in the mechanical properties of cells, tissues, and their environment influence cell function and viability. As such, mechanobiology is at the heart of these recent scientific developments. The complex structural and mechanical interactions that occur at different dimensional scales between weightbearing tissues and support surfaces or tissues that are continuously distorted by medical devices determine the loading state of tissues and cells. These interactions are affected by intrinsic factors including the tissue composition, tissue stiffness properties, and individual internal anatomy, such as the shape of bone surfaces and the thickness of soft tissue layers. These body-support interactions are further influenced by extrinsic factors such as the design, material, and mode of operation of the specific support surface in use. The pathophysiological responses to these sustained mechanical interactions are also intrinsic to the individual but can be affected by extrinsic factors such as medications. To evaluate these complex interactions in the context of PUs, mechanobiology combines the study of multiphysics, which couples multiple physical phenomena, and multi- 8 scale perspectives, which considers processes that evolve at the micro-, meso-, and macro-scales. PUs and other chronic injuries develop over time, even if this time is relatively short, and do not appear instantaneously. In other words, there is a gradual damage accumulation process as opposed to a traumatic wound. At their initial phase, PUs cannot be detected by the unaided eye (including by expert experienced clinicians) because damage is initiated at the microscopic scale with the death of a few cells or small groups of cells. In many cases, such cell death events may occur over very short time intervals, even within minutes, and may undergo natural and spontaneous repair by the body without evolving into a visible injury. However, in other cases, the microscopic cell death damage initiates a damage cascade that results in the initiation and progression of a clinically significant PU. A significant portion of the mechanobiology of this damage cascade has been revealed by our basic science laboratory work in the last decade and is summarized as follows. Bodyweight forces continuously distort tissues and cause sustained cell deformations that gradually damage the integrity of the cytoskeleton, which is the complex protein EWMA Journal 2018 vol 19 no 2

9 Science, Practice and Education Extent of cell/tissue death (# cells, necrotic tissue volume etc.) MICRO-scale Cell death MACRO-scale Tissue necrosis Cumulative damage (rate + ß + y ) Direct deformation damage (rate ) Inflammatory response - related damage (rate ß) Ischaemic damage (rate y) 0 0 t t deform inflam t ischaem Time (minutes to hours) Figure 2: There are three major contributors to cell and tissue death in pressure ulcers: direct deformation, inflammatory response, and ischaemia. (i) Direct deformation is the initial factor that begins to inflict damage at time point t deform and progresses at a rate α. (ii) Inflammatory response-related damage occurs second at time point t inflam and develops at a rate β. (iii) Finally, ischaemic damage is the last to appear at time point t ischaem and evolves at a rate γ. The combined contributions of these three factors at sequential time points explains the non-linear nature of the cumulative cell and tissue damage. This damage will accelerate from the micro-scale to the macro-scale and eventually exacerbate at a rate of α + β + γ. scaffold that supports the cell structure from within. 6,7 These cell deformations cause the exterior cell walls or plasma membranes, which are structurally supported by the cytoskeleton, to lose their integrity as well. Loss of plasma membrane integrity leads to plasma membrane poration, increased plasma membrane permeability, abnormal transport patterns, and eventually loss of cell homeostasis and apoptotic cell death. 7,8,9 At the early phase of cellular damage, when small numbers of cells have died, the damaged cells release chemokines, which are inflammatory signals that attract immune cells (e.g., neutrophils, macrophages, and T-cells) to the affected site. 5,10,11 While this signalling is essential for repair of the microscopic tissue damage, inflammation itself is a potential contributor to progressive tissue damage. Specifically, the inflammatory chemokines dilate capillaries and increase the permeability of capillary walls adjacent to the damage site to allow leucocytes to leave the vasculature and migrate to the site of cell death. This causes plasma fluids to then leave the blood circulation and accumulate near the damage site, generating localized (micro-scale) oedema that gradually increases the interstitial pressure (Figure 1). Moreover, as these fluids are often confined to a limited tissue volume, such as between an internal bone surface and an external support surface or, in some cases, a medical device that is compressing the surface, there is little or no relief of the interstitial pressure that continues to build up at the initial damage site (Figure 1). Reactive oxygen and nitrogen species are then released to degrade the extracellular matrix (ECM) to relieve the pressure resulting from the accumulated fluids, further inflicting tissue damage. 12,13 The overall result is a tissue degradation spiral or snowball effect where continuous tissue deformation and inflammation result in additional cell death and tissue damage that causes further inflammation and so on. Eventually, the combination of deformation caused by bodyweight or other external forces, the intensifying effects of oedema, and the associated high interstitial pressure begin to obstruct the vasculature and impair blood perfusion at the damage site. As a result, ischaemic damage may develop from that point onwards, in addition to the primary direct deformation damage and the secondary inflammatory damage. Importantly, it is critical to understand that each of these damage pathways begins sequentially at a different time point. Direct deformation damage, which is the primary cause of cell and tissue damage, begins first, followed by inflammatory-related damage, and finally evolves into ischaemic damage. EWMA Journal 2018 vol 19 no 2 9

10 Science, Practice and Education Clinical observations of short-term PU development exist and have been documented in cases of relatively high sustained tissue deformations inflicted over short periods of time, such as in the operation theatre, in labour under epidural administration or with the use of spine boards. 14,15 These are much shorter timeframes than the period of several hours that has been studied in the context of repositioning regimes in the classic PU literature (e.g. 16 ). For extreme support surface conditions, such as stiff spine boards, macroscopic tissue damage is initiated within tens of minutes, and tissue breakdown may occur in less than an hour, even in people with a healthy body habitus. 15 Thus, these laboratory and clinical observations 14,15 could be extrapolated to predict that patients whose tissue composition is abnormal, such as underweight or obese patients, would experience accelerated tissue breakdown in timeframes of less than an hour. In such patients, the internal mechanical stress concentrations within tissues would be especially elevated near bony prominences, even if the support surface envelopment was improved. 17 In general, the tendency for tissue breakdown would strongly depend on the internal anatomical features (curvature of bone surfaces, mass, and composition of soft tissues) and on the interaction of the individual anatomy with the specific support surface that is in use. 18,19 The evolution of cell and tissue damage in pressure ulcers Our cumulative body of research and the work of others demonstrates that vulnerable or fragile patients who are at a chronic (e.g. suffer a spinal cord injury) or acute (e.g. under surgery) phase of susceptibility to PUs will exhibit tissue breakdown within relatively short time periods. 6 In these at-risk individuals, the time until tissue breakdown will likely be less than the typical 2-hour interval. In fact, tissue breakdown may occur within timeframes of an hour or less, merely due to sustained tissue deformation levels. 14 As time progresses during the first several hours of damage onset, there will be additional evolving damage due to the build-up of an inflammatory process, elevated interstitial pressure, and tissue stiffness due to oedema. 20 Ischaemic damage may accompany these tissue injuries or may be slightly delayed in terms of the damage spiral. Damage related to the inflammatory response and ischaemia will exacerbate the tissue status, which has already been compromised by exposure to sustained deformations, and increase the level of damage and fragility of surrounding healthy tissues as time elapses (Figure 2). The evolution of damage schematic, which is presented in Figure 2, describes the concept of a tissue injury threshold and demonstrates why the injury threshold is not only tissue-type specific but also patient-specific. Consistent with the presentation of the damage spiral in Figures 1 10 and 2, the tissue injury threshold of a given tissue type is defined by the transition from micro-scale reversible damage, which typically occurs at the level of cells or cell groups, to macro-scale irreversible tissue damage, which is visible in an imaging examination by ultrasound or MRI, if subdermal, or presents itself on the skin surface (Figure 2). As previously discussed, a tissue injury threshold strongly depends on the characteristics and health status of the individual. For instance, a person with compromised tissue perfusion (e.g., due to peripheral vascular disease, congestive heart failure, or diabetes) would accumulate ischaemic damage faster, initiating the ischaemic damage component sooner. In other words, their tischaem would be shifted closer to the origin of the timescale (horizontal axis) (Figure 2). Likewise, their ischaemic damage buildup would likely occur at a higher rate (i.e., γ rate would be greater) because their tissue would have access to fewer available metabolites than a person whose vasculature is affected by exposure to the deformation but not by the biochemical stress due to a chronic vascular or metabolic disease. Another example illustrating the expected diversity in damage accumulation rates across individuals are patients with chronic inflammation, such as those seen in obese, elderly, and spinal cord injury patients. In such cases, the inflammation-related damage onset time tinflam would likely be shorter due to over-stimulation of the inflammatory system, and the inflammatory damage rate β would also be greater. Importantly, each of the factors contributing to the damage spiral deformation, inflammation, and ischaemia depend on individual intrinsic features as well as on extrinsic/ environmental factors. Specifically, the time of appearance and rate of build-up of the primary deformation-inflicted damage, tdeform and α, respectively, will depend strongly on the anatomical features of the individual, including the sharpness of bony prominences, mass and composition of soft tissue, and characteristics of the bone-soft tissue interactions. Altogether, these characteristics dictate the state of mechanical loading, in terms of magnitude and distribution, at the scale of tissues and cells. The inflammation damage parameters (tinflam and β) and the ischaemia parameters (tischaem and γ) likewise depend on individual intrinsic and extrinsic factors. For example, the presence of intrinsic acute or chronic diseases that affect the immune and cardiovascular/respiratory systems impact the inflammation and ischaemia damage parameters, respectively. Similarly, medications that affect the immune system, such as anti-inflammatory steroids and chemotherapy, or the cardiovascular system, such as vasodilators and vasopressors, are extrinsic factors that respectively influence inflammation and ischaemia parameters as well. Accordingly, at the macro-scale phase of the PU development process, the rate of damage build-up is sensitive to each of the intrinsic EWMA Journal 2018 vol 19 no 2

11 Science, Practice and Education and extrinsic factors that are involved or potentially involved (e.g., the anatomy, support surface, inflammatory response time/extent, effectiveness of perfusion and level of tissue oxygenation, extracellular biochemistry including ph). Together, quantitation of the macro-scale damage rate is simplified to the sum of α +β + γ, as shown in Figure 2. Most notably, the damage threshold of tissues can be defined as the transition from a microscopic (reversible) cell death event to a macroscopic clinical wound presentation and strongly depends on the individual set of time and rate parameters described above (Figure 2). Moreover, acute events in a patient s life, or even during a relatively short hospitalization period, may temporarily affect the individual values of the aforementioned parameters. Examples of these events may include infectious diseases that influence the characteristics of the inflammatory response (e.g., extent of the response, timescale of the response) or the quality and effectiveness of perfusion (e.g., the effectiveness of perfusion would be reduced in pneumonia). Thus, injury thresholds and damage buildup rates are not only variable across populations and individuals but also dynamic in nature. In other words, the tissue injury threshold of the individual changes over time, potentially even during a relatively short period of hospitalization due to acute illness. The extrinsic factors influencing all three damage buildup pathways, namely, deformation, inflammation, and ischaemia, should be discussed separately from the intrinsic factors. As an extrinsic factor, the role of support surfaces is particularly noteworthy. Theoretically, support surfaces should have a direct effect on t issue deformation levels and distributions, which is relevant to the primary deformation damage pathway. However, support surfaces may also affect the level of interstitial oedema through pressure relief and may, therefore, impact the onset and progression of inflammatory damage or the quality of perfusion related to ischaemic damage. More advanced support surface technologies are likely to influence the onset time points of tissue damage and the damage accumulation rates in the individual. For example, alternating pressure mattresses (APMs) provide periodic pressure relief, enabling the restoration of blood supply to tissues. 21,22 Thus, the value of APMs may be due to the reduction of the ischaemic component of damage accumulation, which would enhance overall tissue tolerance. 21,22 Returning to the example of a person with impaired or poor perfusion, a shorter tischaem and greater y rate would be expected. Such a person, if not protected by an APM, would develop a PU sooner because their ischaemic damage would build up rapidly. The APM could, therefore, play an important protective role in delaying the tischaem on the time axis (Figure 2), with the extent of shifting tischaem depending on the specific design and technological features of the APM in use. Despite what appears to be an extremely complex problem that, given the large number and variety of contributing and influencing factors, would make efficient risk assessment and early detection of PUs impossible (Figures 1,2), it appears that the future is quite optimistic or is perhaps already here. As the use of technological aids for PUP is on the rise, the next generation of risk assessment and early PU detection will likely be based on quantitative monitoring of individuals based on the parameters defined in Figure 2 or derivative or physiologically-linked parameters. Therefore, a next step in the evolution of PUP technologies is to integrate these parameters into new risk assessment procedures that will then become objective, standardized, and fully quantitative rather than subjective, non-standard, and qualitative, as in current practice. The vision of the author is that the tdeform, tinflam, and tischaem time points and the α, β, and γ parameters (Figure 2) will be evaluated and quantified for each individual based on a set of biophysical, biomechanical, and physiological measurements. This will ultimately allow PUP devices, including support surfaces and prophylactic dressings, to be evaluated, rated, and classified based on their effect on the deformation, inflammation, and ischaemia parameters. In fact, these technologies are already commercially available and now need to be put in the context of the current understanding of PU aetiology, as illustrated in Figures 1 and 2. Although PU detection and PUP technologies have been recently developed, and new technologies are underway, the time point at which their implementation will be the most effective and allow for the least progression of the damage cascade warrants further discussion. Identifying the very first deformation-inflicted cell death events that occur exactly at the time point tdeform may not be feasible in the foreseen future, particularly considering that damage may, and likely will, evolve in subdermal and deep tissues. Moreover, cell death events occurring near the tdeform time point may be fully reversible if the body is able to repair the damage. Therefore, detecting damage at or very near to the tdeform time point may be too early and, in fact, create many false alarms, or false positives (i.e. low specificity), in a technological implementation method which targets tdeform. Accordingly, the inflammation response to these initial deformation events, which is initiated at time point tinflam, is very likely the next best option. Nevertheless, identifying cell and tissue damage as early or as close to the tinflam time point as possible, or perhaps slightly before tinflam, is still critically important. Altogether, inflammation is the candidate event EWMA Journal 2018 vol 19 no 2 11

12 that presently needs to be targeted by PUP strategies and technologies. Examples for currently available technologies that intervene in the vicious cycle depicted in Figure 1 or target the damage evolution parameters described in Figure 2 are provided below. Examples of novel and available technologies that target early inflammation. The subepidermal moisture (SEM) scanner The SEM scanner (Bruin Biometrics LLC, Los Angeles, CA, USA) is a hand-held device that measures the biocapacitance of tissues at a depth of several millimetres under the skin (the SEM scanner is CE-marked, pending US Food and Drug Administration decision, and not available for sale in the US). tissue biocapacitance rises when extracellular water content, also called SEM, increases due to the localized micro-oedema that forms shortly after the tinflam time point (Figure 2). According to the physics of capacitance, water has a high dielectric constant of 80 compared to dry collagen, which is the major structural component of the ECM and has a much lower dielectric constant of four. As localized (micro-scale) oedema builds up (Figure 2), the effective dielectric constant (EDC) of the tissue region affected by the developing PU rises linearly in relation to the percentage of water in the tissue. 4,5 For example, if the ECM:water content in a healthy tissue region is 40:60, then the EDC of that tissue is the weighted average of the individual dielectric constants, or (0.4 x 4) + (0.6 x 80) =~ 50. An abnormal increase in the water content would change that ratio to 20:80 and would then increase the EDC of the affected tissue to (0.2 x 4) + (0.8 x 80) =~ 65, which is 30% greater than the healthy EDC value. Thus, the time point at which the EDC began to deviate from the normative value and the rate of change in the EDC with the progressive development of tissue damage are biophysical measures indicative of tinflam and β, respectively (Figure 2). In other words, the SEM scanner technology directly targets the early inflammatory response/damage pathway in the damage cascade (Figure 2) and uses the biophysical changes associated with the onset and formation of localized micro-oedema, or SEM, as an effective biophysical marker for early detection of PUs. Polymeric membrane dressings Polymeric membrane dressings (PolyMem, Ferris Mfg. Corp., Fort Worth, TX, USA) are multifunctional dressings that focus and control inflammation and oedema. These dressings subdue the intensity and spread of the inflammatory response and minimize potential secondary oedema-related damage (Figures 1,2). The mitigation of secondary damage increases the likelihood for reversal of the initial injury and self-healing. Published experimental evidence suggests that the design and structure of the PolyMem dressing material inhibits the activity of nociceptive neurons, which produce neurogenic inflam- 12 matory signals through release of calcitonin gene-related peptides. 11,23,24 As the immune and peripheral nervous systems are strongly coupled, inhibition of nociceptive neurons has considerable prophylactic value. Prophylactic use of the PolyMem dressing may help control and contain the inflammatory response, including the formation of oedema and associated damage. 11 Thus, prophylactic use of the PolyMem dressing would shift the onset of inflammatory damage, tinflam, to the right (future) and reduce the rate of inflammatory-related damage, β. Summary and conclusions The burden of PUs appears to be one of the most important yet unsolved current medical problems, and its impact grows continuously with the ageing of populations and spread of chronic diseases and conditions. As such, it is surprising that advanced biomedical technologies for clinical PUP, risk assessment, and screening are sorely lacking. The vicious cycle of deformation-inflicted and inflammation-related tissue damage in PU formation (Figure 1) has been described in this paper. Sustained tissue deformations, caused by either bodyweight forces or external sources (e.g., a ventilation mask tightened to the face), lead to loss of structural integrity in cells, disrupt the transport to cells via plasma membrane poration, and eventually lead to cell death. Importantly, all of these events may transpire within a relatively short time, in the order of tens of minutes to approximately an hour. 7 The first cell death events trigger inflammatory oedema, which increases the interstitial pressure in tissue regions confined between bones and support surfaces. 11 This oedema further increases cell distortion levels, accelerating the deformation damage pathway and so on and so forth. After several hours, the combined effect of deformation forces and increased interstitial pressure begin to impact vascular function, which can adapt in the short term (e.g., via vasodilation) but not over prolonged periods of exposure. 25 At that time, ischaemic damage is initiated and builds, adding to the overall extent of tissue damage. The step-wise additive nature of the damage contributors, deformation, inflammation, and ischaemia, makes the damage development process (and the relationship of damage extent versus time) highly non-linear (Figure 2). In bioengineering terms, the theory developed here to describe the damage evolution breaks the damage process down into three major sequential contributors to cell and tissue death in PUs, as follows (Figure 2). (i) Direct deformation damage, which begins first at time point tdeform and progresses at a rate α. (ii) Inflammatory responserelated damage, which occurs second at time point tinflam and develops at a rate β. (iii) Ischaemic damage, which is the last to appear at time point tischaem and evolves at a rate γ. Together, these variables explain the non-linear nature of the cumulative damage, which is generally expected EWMA Journal 2018 vol 19 no 2

13 Science, Practice and Education to accelerate from the micro-scale to the macro-scale and eventually to a full-scale rate of α + β + γ. The non-linear accelerating nature of the damage curve highlights the necessity of early detection at the soonest possible stage followed by appropriate intervention to relieve tissue deformation and halt the damage aggravation process. Inflammation markers are promising for early detection, as they appear relatively quickly in the damage spiral, while cell death is still contained to the microscopic level, near time point tinflam. Targeting early cell and tissue damage for early PU detection and PUP interventions must be based on an in-depth understanding of the mechanobiological damage cascade. Moreover, these interventions need to be evaluated or classified by the damage development theory that has been detailed here. Recent early detection and intervention advances using the SEM scanner and PolyMem dressing, respectively, have been discussed in the context of the damage evolution process described in Figures 1 and 2. The SEM scanner identifies biophysical changes in affected tissue (biocapacitance) that have resulted from events near the tinflam time point and enables early detection between the tdeform and tinflam time points. On the other hand, prophylactic use of the PolyMem dressing to mitigate the impact and spread of inflammation past the tinflam time point is an example of an effective intervention strategy. Development of a selection of these technology-based options for early detection of events near the tdeform to tinflam time points (Figure 2) and effective intervention as close as possible to the time of detection is necessary to reduce the human suffering and financial burden associated with PUs. Furthermore, it appears that the most opportune time for early detection and intervention is indeed the tdeform to tinflam time range (Figure 2), as opposed to post-tischaem. At these later time points, the direct deformation damage and inflammation-related damage have already occurred, and damage begins to progress at a full rate of α + β + γ. Finally, a major focus of bioengineers should be to work closely with clinicians and basic scientists to bring PUP into the era of science and technology in an effort to solve this unacceptable problem. Development of portable or hand-held systems for detecting multiple biomarkers of inflammatory and PU-specific changes that indicate early cell death is a timely and feasible mission and will ultimately minimize the heavy burden of PUs. m REFERENCES 1. Padula WV, Mishra MK, Makic MB, Sullivan PW. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Med Care. 2011;49(4): Lyder CH, Wang Y, Metersky M, et al. Hospitalacquired pressure ulcers: results from the national Medicare Patient Safety Monitoring System study. J Am Geriatr Soc. 2012;60(9): Kung HC, Hoyert DL, Xu JQ, Murphy SL. Deaths: Final data for National Vital Statistics Reports, 56(10). Hyattsville, MD: National Center for Health Statistics; Gefen A, Gershon S. An observational, prospective cohort pilot study to compare the use of subepidermal moisture measurements versus ultrasound and visual skin assessments for early detection of pressure Injury. Ostomy Wound Manage. 2018, 64(9): Gefen A. The Sub-Epidermal Moisture Scanner: the principles of pressure injury prevention using novel early detection technology. Wounds International 2018b, in press, to be published in the September 2018 issue. 6. European Pressure Ulcer Advisory Panel (EPUAP), National Pressure Ulcer Advisory Panel (NPUAP), Pan-Pacific Pressure Injury Alliance (PPIAA) International Pressure Ulcer Guidelines, Gefen A, Weihs D. Cytoskeleton and plasma-membrane damage resulting from exposure to sustained deformations: A review of the mechanobiology of chronic wounds. Med Eng Phys Sep;38(9): Slomka N, Gefen A. Relationship between strain levels and permeability of the plasma membrane in statically stretched myoblasts. Ann Biomed Eng Mar;40(3): Leopold E, Gefen A. Changes in permeability of the plasma membrane of myoblasts to fluorescent dyes with different molecular masses under sustained uniaxial stretching. Med Eng Phys May;35(5): Turner MD, Nedjai B, Hurst T, Pennington DJ. Cytokines and chemokines: At the crossroads of cell signalling and inflammatory disease. Biochim Biophys Acta Nov;1843(11): Gefen A. Managing inflammation by means of polymeric membrane dressings in pressure ulcer prevention. Wounds International 2018a, 9(1): Moore Z, Patton D, Rhodes SL, O Connor T. Subepidermal moisture (SEM) and bioimpedance: a literature review of a novel method for early detection of pressure-induced tissue damage (pressure ulcers). Int Wound J Apr;14(2): Kim CG, Park S, Woon Ko J, Jo S. The relationship of subepidermal moisture and early stage pressure injury by visual skin assessment. J Tissue Viability : Gefen A. How much time does it take to get a pressure ulcer? Integrated evidence from human, animal, and in vitro studies. Ostomy Wound Manage Oct;54(10):26-8, Hemmes B, de Wert LA, Brink PRG, Oomens CWJ, Bader DL, Poeze M. Cytokine IL1α and lactate as markers for tissue damage in spineboard immobilisation. A prospective, randomised open-label crossover trial. J Mech Behav Biomed Mater Nov;75: Vanderwee K, Grypdonck MH, De Bacquer D, Defloor T. Effectiveness of turning with unequal time intervals on the incidence of pressure ulcer lesions. J Adv Nurs Jan;57(1): Sopher R, Nixon J, Gorecki C, Gefen A. Exposure to internal muscle tissue loads under the ischial tuberosities during sitting is elevated at abnormally high or low body mass indices. J Biomech Jan 19;43(2): Gefen A. Tissue changes in patients following spinal cord injury and implications for wheelchair cushions and tissue loading: a literature review. Ostomy Wound Manage Feb;60(2): Peko Cohen L, Levy A, Shabshin N, Neeman Z, Gefen A. Sacral soft tissue deformations when using a prophylactic multilayer dressing and positioning system: MRI Studies. J Wound Ostomy Continence Nurs in press (available online), DOI: / WON Gefen A. The biomechanics of heel ulcers. J Tissue Viability Nov;19(4): Vanderwee K, Grypdonck M, Defloor T. Alternating pressure air mattresses as prevention for pressure ulcers: a literature review. Int J Nurs Stud May;45(5): Bharucha JB, Seaman L, Powers M, Kelly E, Seaman R, Forcier L, McGinnis J, Nodiff I, Pawlak B, Snyder S, Nodiff S, Patel R, Squitieri R, Wang L. A Prospective Randomized Clinical Trial of a Novel, Noninvasive Perfusion Enhancement System for the Prevention of Hospital-Acquired Sacral Pressure Injuries. J Wound Ostomy Continence Nurs Jul/Aug;45(4): Kahn AR. A superficial cutaneous dressing inhibits inflammation and swelling in deep tissues. Pain Med. 2000,1(2): Beitz AJ, Newman A, Kahn AR, Ruggles T, Eikmeier L. A polymeric membrane dressing with antinociceptive properties: analysis with a rodent model of stab wound secondary hyperalgesia. J Pain (1): Lustig M, Levy A, Kopplin K, Ovadia-Blechman Z, Gefen A. Beware of the toilet: The risk for a deep tissue injury during toilet sitting. J Tissue Viability Feb;27(1): EWMA Journal 2018 vol 19 no 2 13

14 18 20 September 2019 Lyon, France 21 st Annual Meeting of the European Pressure Ulcer Advisory Panel! Pressure ulcer prevention without frontiers Registration opening Abstract submission opening Abstract submission deadline Abstract review notification deadline Early registration deadline January 2019 November April May June 2019 EPUAP Business Office Codan Consulting; Provaznicka 11, Prague 1 office@epuap.org, Tel.:

15 Science, Practice and Education Heel Pressure Injuries: The need for a structured evidence-based approach for assessment and treatment. A preliminary literature review Massimo Rivolo 1 The heel is the second most common anatomical location for pressure ulcers. Heel pressure ulcers (HPIs) are painful and psysically debilitating. This article describes the rationale behind the need for a structured evidence-based approach to assessing and treating HPIs. Dr. Silvia Marcadelli 2 ABSTRACT Background Heel pressure injuries (HPIs) are the second most common type of pressure ulcers. Despite their frequency, however, HPIs are poorly understood and remain difficult to treat. Aim To describe the rationale behind the need for a structured evidence-based approach to assessing and treating HPIs in adult, paediatric, and diabetic populations. Methods Several clinical questions were identified and incorporated into six domains to provide a framework for defining evidence-based recommendations for HPI assessment and treatment. This framework focuses on three populations: adults, paediatric patients, and patients with diabetes. Conclusion This article describes strategies, rationales, and efforts needed to generate a series of evidence-based recommendations in our six identified domains and three patient populations. The Italian Nurses Association for Wound Care (AISLeC) has organized a Consensus Conference on the assessment and management of HPIs to present these results and recommendations in November BACKGROUND A pressure ulcer involves localized injury to the skin and/or underlying tissue. Pressure ulcers usually occur over a bony prominence, and result from either pressure alone or a combination of pressure and shear. 1 The heel is the second most common anatomical location for pressure ulcers. 2 The prevalence rate of visible heel pressure injuries (HPIs) varies from 7.3% 3 to 18.2%. 4 HPIs are painful and physically debilitating. HPIs also can affect rehabilitation and may involve potentially fatal complications, including sepsis, osteomyelitis, cellulitis, or amputation of the affected limb. 6 The main risk factors for the development of HPIs are type 2 diabetes and its associated neuropathy, low albumin concentrations, conditions that limit leg strength (including the hip and the knee), and arterial insufficiency of the lower limb associated with vasoconstrictor drugs. 8 During standing and ambulation, the design of the heel allows it to withstand any incurred forces. The posterior region of the heel, however, is particularly prone to ulceration due to its thin skin and lack of protective fat and muscle coverage. 9 Study models of the heel have identified a triad (Fig. 1) that makes the heel more susceptible to pressure, especially during bedrest. The heel is essentially characterized by heavier foot sharp posterior calcaneus and thin soft tissue padding over the calcaneus. 10 These peculiar features are why even low amounts of pressure can cause extensive damage to the heel. Given the high prevalence of HPIs, a thorough understanding of the dynamics that cause tissue damage in this anatomical area is critical. Unfortunately, there have been no well-conducted studies to clarify the relationship between bedrest and the development of HPIs RN, BSc (Hons), MSc Wound Care 2 RN, MSN, PhD at University of Tor Vergata, Rome Independent researcher, Lead Nurse Ausl Bologna Individual Fellow - England Centre for Practice Development (ECPD) - Canterbury Correspondence to: massimo.rivolo@gmail.com Conflicts of interest: None EWMA Journal 2018 vol 19 no 2 15

16 Heavier foot Thin soft tissue padding over the calcaneus HEEL Sharp pasterior calcaneus Figure 1: The heel-specific triad. The European Pressure Ulcer Advisory Panel (EPUAP) guidelines provide an internationally recognized pressure injury classification with 4 main stages: category/stage I: non-blanchable erythema; category/stage II: partial thickness skin loss; category/stage III: full thickness skin loss; and category/stage IV: full thickness tissue loss. The guidelines also include a classification for unstageable pressure injury, where the depth is unknown (DU) and/or with suspected deep tissue injury (SDTI)(1). Neither the National Institute for Health and Care Excellence (NICE) guidelines, nor the EPUAP guidelines provide clear indication on how to treat HPIs. 5 Gefen noted that despite being so common, despite imposing such high risks, and in spite of being so costly, heel ulcers are considerably understudied in the pressure ulcer literature. 10 The Heel Pressure Ulcer Risk Assessment Tool is one example of a tool that can be used to understand HPIs, but has not been validated. 7 The Italian Nurses Association for Wound Care (AISLeC), therefore, has prioritized the need to produce evidencebased recommendations on HPIs to support best clinical practice and to improve the appropriateness of care, reduce associated costs, and improve outcomes in patients. The AISLeC has identified the Consensus Conference (CC) as the most suitable methodology among those available to identify these recommendations. Specifically, the CC will focus on the assessment and treatment of HPI; prevention is not considered here. METHODS We performed a preliminary review of the literature from the CHINAL, PubMed, Cochrane Wounds, and TRIP databases to identify studies that have assessed and treated HPIs. A Boolean search was conducted using the terms: heel pressure ulcers, pressure ulcers, treatment, lightweight fiberglass heel cast, surgical treatment, negative topical pressure therapy, dressings, vascular assessment, and off-loading. This search yielded systematic reviews, meta-analyses, randomized controlled trials (RCTs), guidelines, and primary and secondary research studies. All the studies included in our analysis were written in English and published between January 2000 and June Our search included studies in three patient populations: adult patients, paediatric patients, and patients with diabetes. The purpose of this review was to formulate evidencebased recommendations for each area of intervention that we identified in Table 1. Table 1: Areas of intervention for heel pressure injuries (HPIs). 1. Vascular assessment 2. Treatment of stage I and II HPIs 3. Treatment of stage III and IV HPIs plus SDTI and DU 4. Biophysical agents 5. Off-loading devices 6. Referral criteria 16 EWMA Journal 2018 vol 19 no 2

17 Science, Practice and Education Vascular assessment Referral criteria Stage 1 and 2 HPIs Adults Pediatrics Diabetics Questions Off-loading devices Stage 3 and 4 HPIs + SDTI and DU Biophysical agents Figure 2: The framework for our review. For each area of intervention, we generated a set of background questions that we aimed to answer from the literature searchand the opinion of experts (Table 2). Table 2: Questions to address based on our literature search. 1. Can we define criteria for SIMPLE HPIs? 2. Can we define criteria for COMPLEX HPIs? 3. Can we define criteria for RECALCITRANT HPIs? 4. Can we define criteria for MILD infection in HPIs? 5. Can we define criteria for MODERATE infection in HPIs? 6. Can we define criteria for SEVERE infection in HPIs? 7. Should an interdisciplinary heel pressure ulcer service be created for this specific type of pressure injury? 8. How many clinicians should be involved as a minimum in an interdisciplinary heel pressure ulcer service? 9. Which timing criteria can potentially be defined to refer patients with grade III and IV to a specialist? Following our initial search, two independent methodologists conducted a more in-depth search using approximately 65 clinical questions based on the EPICOT methodology 14 to improve the accuracy of our initial literature search. The present article outlines the results of our preliminary literature review to provide the reader with a general understanding and rationale for our future Consensus Conference. More definitive literature results will be available at the end of August Results of the preliminary literature review Our initial search yielded 2 relevant guidelines (from 8), 2 relevant research articles (from 24) on CHINAL, 2 relevant research articles (from 68) on TRIP, and 10 relevant articles (from 55) on PubMed. No relevant RCTs were found in the Cochrane Wounds database. 1. Vascular assessment Taylor and Palmer in 1987 described an angiosome as an anatomic unit of tissue (consisting of skin, subcutaneous tissue, fascia, muscle, and bone) fed by a source artery and drained by specific veins. The foot includes six angiosomes (compared to the entire human body, which can be divided into 40 angiosomes). The posterior tibial artery feeds three of these angiosomes, whereas the anterior tibial feeds one angiosome and the peroneal artery feeds two angiosomes. 22 Adjacent angiosomes are connected by a vast compensatory collateral web, which are also called choke vessels. 23 The available data on angiosomes show that the blood supply in the heel is provided by two arteries: the lateral aspect of the heel and the skin is supplied by the lateral calcaneal branch of the peroneal artery, and the heel pad is supplied by the medial calcaneal branch of the posterior tibial artery (PTA). 9 Peripheral vascular disease (PVD), which is also known as lower extremity arterial disease (LEAD), is a chronic, EWMA Journal 2018 vol 19 no 2 17

18 progressive disease. Risk factors for PVD include dyslipidemia, advanced age, tobacco use, diabetes, hypertension, and chronic renal insufficiency. 15 Blood supply to the heel is provided primarily to the posterior tibial and peroneal arteries. A recent observational study carried out in 506 patients with HPIs showed that 83% of those patients exhibited symptoms of PVD(12). One guideline suggests that for people with pressure injuries in the lower extremities over bony prominences (e.g., the heel) or from sustained environmental pressure (e.g., footwear), a vascular assessment of the lower extremities is essential to ensure safety during treatment, identify barriers to healing, and determine appropriate treatment options. 13 The NICE guidelines provide the following recommendation for assessing individuals with suspected PVD: Assess people with suspected peripheral arterial disease by: examining the legs and feet for evidence of critical limb ischemia, for example ulceration; examining the femoral, popliteal, and foot pulses; and measuring the ankle brachial pressure index. 16 Objective evidence to detect the presence or absence of significant LEAD in one or both legs may be obtained reliably (except in those with calcified vessels) using a non-invasive test called the ankle brachial pressure index (ABPI) during the initial visit. 17 The ABPI is the ratio of the ankle to brachial systolic pressure and can be measured using a sphygmomanometer and a hand-held Doppler device. 17 The reliability of this test may be questioned, however, because the data supporting its validity arises mainly from studies on symptomatic patients. 18 Other procedures exist to assess the blood supply in the legs. For example, a small study compared the ABPI and the toe brachial pressure index (TBPI). This study found low sensitivity of ABPI ( %) among patients with diabetes and/or chronic renal failure. This sensitivity is comparable to other diagnostic tests including the TBPI. The toe-finger index (TFI), which is derived from photoplethysmography, achieved the highest sensitivity ( %) in these patients. 19 Despite well-known recommendations and standard procedures for using the ABPI for vascular assessment, a recent study showed that the ABPI is not a sensitive index for diagnosing critical limb ischemia (CLI); only 14 of 237 patients (6%) had an ABPI < 0.4 despite having angiography-confirmed CLI. 20 Furthermore, the ABPI does not provide information about the perfusion of the hindfoot; the ABPI can yield normal readings when the two main arteries (i.e., the dorsalis pedis and posterior tibial arteries) are used despite the presence of an ischemic heel, a concept known as orphan heel syndrome. 21 Based on these findings, a set of recommendations should be established to define what the ideal test is for ruling out vascular impairment in HPIs in the primary care setting. These guidelines should outline whether any additional vascular diagnostic procedures are more effective than the ABPI alone, such as TBPI or transcutaneous oximetry (TcP02). If the TcP02 is recommended, then the guidelines should also define whether hindfoot transcutaneous oximetry is a more useful than the dorsal approach in identifying heel ischemia Treatment of stage I and II HPIs Stage I HPI refers to intact skin with non-blanchable redness in a localized area, usually over a bony prominence(1), whereas Stage II HPI refers to partial thickness skin loss presenting as a shallow open ulcer with a red/pink wound bed but without slough. In stage II, the ulcer may also present as an intact or open/ruptured serum-filled blister. 1 The wound assessment of stage 1 and 2 HPIs should be performed in a structured manner and based on scientific principles. 1 The EPUAP guidelines suggest that all factors affecting the healing potential should be assessed, including impaired perfusion, impaired sensation, and systematic infection. The guidelines include specific recommendations for the vascular assessment of lowerlimb pressure ulcers, which include physical examination, review of history of claudication, and assessment of either the ABPI or the toe Doppler. 1 For stage 1 ulcers, the only treatment considered by the EPUAP is to avoid positioning the individual on the affected bony prominences. 1 For stage 2 ulcers, which do not contain necrotic tissue, 14 the NICE guidelines indicate that healable wounds should be treated with moisture-retentive dressings; however, NICE does not provide any specific recommendations for HPI treatment. 5 Similarly, the EPUAP guidelines list hydrocolloid dressings as an option to manage stage 2 pressure injuries, but do not provide specific recommendations for HPIs. 1,5 Polyurethane film dressings are recommended as useful for autolytic debridement but not for moderate and heavy exudates or in patients with fragile skin. The fragile skin is not an absolute contraindication, precautions have to be taken when they are used. Hydrogel dressings are indicated for shallow, minimally exuding wounds, whereas foam dressings should be considered for pressure ulcers of stage II and above. 1 Many guidelines suggest pressure off-loading, using a pillow or suspension device, as part of the treatment regime for existing pressure ulcers. 1,5,14 Ideally, heels should be free of all pressure a state sometimes called floating 18 EWMA Journal 2018 vol 19 no 2

19 Science, Practice and Education heels. 1 There is currently no specific indication about which device is most effective. A formal series of recommendations for the treatment of stage 1 and 2 HPIs are needed. These recommendations should provide guidance on the following questions: (1) What is the ABPI cut-off or any other vascular assessment cut-off at which a moisture environment is required? (2) Is it safe to use a moisture environment in some specific conditions, e.g., is critical limb ischemia a contraindication for a moisture-retentive dressing? (3) What kind of examination should we perform to evaluate the healing potential before starting any local treatment? (4) Are lowfriction technology devices helpful in managing friction and shearing forces when a stage I or II HPI already exists? (5) What are the most appropriate local treatment and off-loading devices to use in a bed-bound patient? 3. Treatment of stage 3 and 4 HPIs plus SDTI and DU The remaining four stages of HPIs are Stage 3: full thickness skin loss; Stage 4: full thickness tissue loss; and Depth unknown (DU) and Suspected Deep Tissue Injury (SDTI)(1). As suggested by Bosanquet, 9 the management of stage 1-3 HPIs is often achieved with appropriate pressure off-loading and a correct wound care approach, but successful healing of stage 4 HPIs is often possible only with surgical intervention. Generally, HPIs are more complicated to treat and the outcomes are more negative compared to ulcers on other areas of the foot, such as on the toes or on the metatarsal portion of the foot. 26 Moreover, localization of tissue loss in the heel is a significant independent predictor for amputation when compared to other areas of the foot. 27 Stage 3 refers to ulcers where the subcutaneous fat may be visible but bone tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss, and it may also include undermining and tunnelling. 1 Surgical intervention is common for stage 3 ulcers when extensive soft tissue infection, osteomyelitis, or vascular insufficiency is present. 9 The literature does not provide specific recommendations for the treatment of stage 3 HPIs, however; the primary focus is generally on stage 4 ulcers and osteomyelitis-related disease. The EPUAP guidelines indicate that an individual with stage 3 or 4 pressure ulcers with undermining, tunnelling/ sinus tracts, and/or extensive necrotic tissue should be referred for surgical evaluation if the necrotic tissue cannot be easily removed with other debridement methods and when surgery is appropriate to the individual s condition and goals of care. These recommendations are general and not tailored to the treatment of HPIs, however. The recommendation for HPIs is to maintain a stable dry eschar without attempting to debride the ulcer unless there are signs of infection or fluctuance. 1 Thus, while the EPUAP guidelines provide general recommendations about dressings properties and their role in managing Large ulcers Peripheral vascular disease Old wounds Osteomyelitis Figure 3: The four indicators linked with poor outcomes in heel pressure injuries. EWMA Journal 2018 vol 19 no 2 19

20 exudates and bacterial bioburden, no specific guidance on heel treatment is given. Such guidelines should be defined by clinical judgment along with standardized protocols. Stage 4 refers to full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. The lesion often includes undermining and tunnelling. Exposed bone or tendon is visible or directly palpable. 1 This ulcer stage is usually caused by direct pressure with superficial damage due to friction and shearing forces. 9 Nakagami et al. stated that vessel occlusion can also occur with the presence of shearing forces alone, even with lower interface pressure. 28 The National Pressure Ulcer Advisory Panel (NPUAP) has recognized shear forces as a primary cause of pressure ulcers, which supports the notion that friction is not responsible for pressure ulcers. 29 Four indicators are linked with poor outcomes in HPIs (Fig. 3): (1) large ulcers; 30 (2) clinical evidence of PVD(30); (3) old wounds; 31 and (4) soft tissue infection and osteomyelitis. 32 As previously noted, pressure injury guidelines do not provide specific recommendations for treating HPIs. There is also a paucity of strong evidence in the scientific literature. VIP assessment, where V stands for vascular supply, I stands for infection, and P stands for pressure offload, 33 relates primarily to diabetic foot treatment, but has also been indicated for the assessment of HPIs. 9 A strong and structured approach to HPI treatment is needed for those with stage 3 and 4 ulcers, as the consequences related to poor management can seriously impact the patient s activities of daily living and ability to salvage the limb. A few case reports are available in the literature. For example, near total calcanectomy and flap closure is suggested as an alternative to a below-theknee amputation in selected patients with deep HPIs with osteomyelitis. 9,24 For these two pressure injury stages, well-defined recommendations should drive clinical practice and must provide the exact criteria for patient referrals; eligible treatments, including surgical or medical treatment; use of biophysical agents; the appropriateness of a conservative versus non-conservative approach; and evaluation of the healing potential. SDTI and DU are two important lesion types where a formal approach should be defined. SDTI is an area of localized purple or maroon intact skin damage caused by pressure or shearing forces. The tissue may be warm, mushy, firm, or painful. 1 Pressure off-load is critical at this stage, but there are no specific guidelines about the best heel suspension to use. 14 If it is consistent with the 20 patient s general condition, then a pillow placed from the popliteal area to the Achilles tendon should be used to elevate the leg and protect the heel from shearing and pressure. 1 An appropriate local treatment should also be considered based on the patient population, such as in patients with diabetes. DU refers to a pressure ulcer that cannot be staged due to obstruction by slough and/or eschar. Such an ulcer is considered unstageable until the eschar or slough is removed to expose the base of the wound. 1 Guidelines for unstageable ulcers indicate that dry eschar should not be removed from the heel because it serves as the body s natural (biological) cover. 1,14 There is a need, however, to define a formal local treatment to be used whenever possible, especially in neonatal, paediatric, and diabetic populations. 4. Biophysical Agents Biophysical agents may promote healing in pressure ulcers. The EPUAP guidelines recognize the followingbiophysical therapies: 1. Electrical stimulation for recalcitrant stage 2, 3, and 4 pressure ulcers. 2. Pulsed electromagnetic field (PEMF) stimulation for recalcitrant stage 2, 3, and 4 pressure ulcers. 3. NPWT (negative pressure wound therapy) as an early adjuvant for the treatment of deep stage 3 and 4 pressure ulcers when osteomyelitis or other underlying issues are ruled out. 1 Although the EPUAP recognizes these treatments, there is a lack of strong recommendation for which treatment is best. There is also a high cost to these treatments; therefore, further recommendations are needed to take into consideration when these therapeutic approaches should be used given budget constraints. 5. Off-loading devices The choice of off-loading device is important from a clinical practice point of view. A recent RCT reported that booties are more effective than cushions in preventing HPIs. 34 There is a lack of guidance, however, about which off-loading device to use in patients with an existing HPI or after a surgical procedure on the heel. A pillow is not always a realistic solution, and is not recommended for stage 3 and 4 HPIs Referral Criteria HPIs are often complex. It has been suggested by the scientific committee that an Interdisciplinary Heel Pressure Ulcer Service (IHPIS) could be helpful to achieve rapid diagnosis, assessment, and treatment of HPIs. A dedicated service is a well-known and proven strategy in patients EWMA Journal 2018 vol 19 no 2

21 with diabetic foot ulcers (DFUs). Such a service has been shown to improve treatment, outcomes, and patient quality of life among those with DFUs. 35 Following this model, an HPI team should be defined as per the toe and flow concept, 36 with a minimum number of essential members. Such a service can be helpful not only in terms of facilitating a correct diagnosis but also in identifying and allocating the best resources; choosing the most appropriate therapeutic pathways; outlining the need for surgical approaches, biophysical agents, and/or off-loading devices; and monitoring outcomes. We have highlighted the importance of such a service in our questions in Table 2 because we believe the creation of this service is critical for defining different pathways of referral criteria for adult, paediatric, and diabetic populations. CONCLUSION This article has described the strategies, rationale, and efforts needed to generate a series of evidence-based recommendations in our six identified domains and three patient populations for the assessment and treatment of HPIs. In November 2018, there will be a National Congress in Milan to celebrate the 25 years of AISLeC. We will also take the opportunity to celebrate the Consensus Conference, which will convene experts and recognized clinicians across the world. We would like to thank all the people who are helping us with this challenging project. m REFERENCES 1. EPUAP/NPUAP/PPPIA (National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Injury Alliance). Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Pacific Pressure Media: Perth, Australia; 2014 Available online: (accessed 19 July, 2018) 2. Fowler E, Scott-Williams S, McGuire JB. Practice recommendations for preventing heel pressure ulcers. Ostomy Wound Manage 2008; 54(10): 42 8, 50 2, Helvig EI, Nichols LW. Use of high-frequency ultrasound to detect heel pressure injury in elders. J Wound Ostomy Continence Nurs 2012; 39(5): Van Gilder C, Lachenbruch C, Harrison P, Davis D. Overall Results from the 2011 International Pressure Ulcer Prevalence Survey Presented at the Wound +Ostomy and Continence Nursing Society s 44th Annual Conference, Charlotte, NC, USA 5. NICE - National Institute for Health and Clinical Excellence. Pressure ulcers: prevention and management, Clinical guideline Published: 23 April Available at: cg179 Accessed June Sopher R, Nixonb J, McGinnisc E, Gefen A. The influence of foot posture, support stiffness, heel pad loading and tissue mechanical properties on biomechanical factors associated with a risk of heel ulceration. Journal of the mechanical behavior of biomedical materials 4 (2011) Walsh JS, Plonczynski DJ. Evaluation of a protocol for prevention of facility+y-acquired heel pressure ulcers. J Wound Ostomy Continence Nurs 2007; 34(2): : Park SH, Park YS. Predictive Validity of the Braden Scale for Pressure Ulcer Risk: A Meta-analysis. J Korean Acad Nurs ; 44(6): Bosanquet DC. A review of the surgical management of heel pressure ulcers in the 21st century. Int Wound J Feb;13(1): Gefen A. The biomechanics of heel ulcers. J Tissue Viability 2010; 19(4): Spears IR, Miller-Young JE, Sharma J et al. The potential influence of the heel counter on internal stress during static standing: a combined finite element and positional MRI investigation. J Biomech 2007; 40(12): Malik R, Pinto P, Bogaisky M, Ehrlich AR. Older adults with heel ulcers in the acute care setting: frequency of noninvasive vascular assessment, surgical intervention, and 1-year mortality. J AmMedDir Assoc 2013;14: RNAO - Registered Nurses Association of Ontario (2016). Assessment and Management of Pressure Injuries for the Interprofessional Team, Th ird Edition. Toronto, ON: Registered Nurses Association of Ontario Accessed: June Brown P, et al. How to formulate research recommendations. BMJ Oct 14; 333(7572): WOCN - Bonham PA1, Flemister BG, Droste LR, Johnson JJ, Kelechi T, Ratliff CR, Varnado MF.2014 Guideline for Management of Wounds in Patients With Lower-Extremity Arterial Disease (LEAD): An Executive Summary.J Wound Ostomy Continence Nurs Jan-Feb;43(1): NICE - National Institute for Health and Clinical Excellence. Peripheral arterial disease: diagnosis and management. Published date: August 2012 Last updated: February Available at: nice.org.uk/guidance/cg147 Accessed: June Aboyans V, Ricco JB, Bartelink ML, et al ESC Guidelines on the Diagnosis and Treatment of Peripheral Arterial Diseases, in Collaboration With the European Society for Vascular Surgery (ESVS): Document Covering Atherosclerotic Disease of Extracranial Carotid and Vertebral, Mesenteric, Renal, Upper and Lower Extremity Arteries. Eur Heart J 2017;Aug Caruana MF, Bradbury AW, Adam DJ. The validity, reliability, reproducibility and extended utility of ankle to brachial pressure index in current vascular surgical practice. Eur J Vasc Endovasc Surg 2005;29: Jaffer U, Aslam M, Standfield,N. Comparison of Doppler Ultrasound, Photoplethysmographic, and Pulse-Oximetric Calculated Pressure Indices to Detect Peripheral Arterial Occlusive Disease Vascular Disease Management Shishehbor MH, Hammad TA, Zeller T, Baumgartner I, Scheinert D, Rocha-Singh KJ. An analysis of IN. PACT DEEP randomized trial on the limitations of the societal guidelines-recommended hemodynamic parameters to diagnose critical limb ischemia. J Vasc Surg May;63(5): doi: /j. jvs Epub 2016 Feb Crowell A, Meyr AJ. Accuracy of the Ankle-brachial Index in the Assessment of Arterial Perfusion of Heel Pressure Injuries. Wounds 2017;29(2): Epub 2016 November Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental studies and clinical applications. Br J Plast Surg. 1987;40: Alexandrescu V, Söderström M, Venermo M. Angiosome theory: fact or fiction? Scand J Surg. 2012;101(2): Boffeli TJ, Collier RC. Near total calcanectomy with rotational flap closure of large decubitus heel ulcerations complicated by calcaneal osteomyelitis. J Foot Ankle Surg Jan-Feb;52(1): doi: /j.jfas Epub 2012 Jul Izzo V, Meloni M, Fabiano S, Morosetti D, Giurato L, Chiaravalloti A, et al. Rearfoot Transcutaneous Oximetry is a Useful Tool to Highlight Ischemia of the Heel. Cardiovasc Intervent Radiol Jan;40(1): Pickwell KM, Siersma VD, Kars M, Holstein PE, Schaper NC. Diabetic foot disease: impact of ulcer location on ulcer healing. Diabetes Metab Res Rev 2013;29: Tukiainen E, Kallio M, Lepantalo M. Advanced leg salvage of the critically ischemic leg with major tissue loss by vascular and plastic surgeon teamwork: long-term outcome. Ann Surg 2006;244: Nakagami G, Sanada H, Konya C, et al. Comparison of two pressure ulcer preventive dressings for reducing shear force on the heel. J Wound Ostomy Continence Nurse 2006; 33: Brienza D, Antokal S, Herbe L, Logan S, Maguire J, Van Ranst J, Siddiqui A. Friction-Induced Skin Injuries Are They Pressure Ulcers? Wound Ostomy Continence Nurs. 2015;42(1): Chipchase SY, Treece KA, Pound N, Game FL, Jeffcoate WJ. Heel ulcers don t heal in diabetes. Or do they? Diabet Med (9): Bosanquet DC, Harding KG. Wound duration and healing rates: cause or effect? Wound Repair Regen 2014;22: Lipsky BA, Berendt AR, Embil J, De Lalla F. Diagnosing and treating diabetic foot infections. Diabetes Metab Res Rev 2004;20: RNAO - Registered Nurses Association of Ontario (2013). Assessment and Management of Foot Ulcers for People with Diabetes (2nd ed.). Toronto, ON: Registered Nurses Association of Ontario ca/bpg/guidelines/assessment-and-management-footulcers-people-diabetes-second-edition Accessed:June Meyers T. Prevention of Heel Pressure Injuries and Plantar Flexion Contractures With Use of a Heel Protector in High-Risk Neurotrauma, Medical, and Surgical Intensive Care Units: A Randomized Controlled Trial. Journal of Wound Ostomy & Continence Nursing: September/October Volume 44 - Issue 5 - p NICE - National Institute for Health and Clinical Excellence. Diabetic foot problems: prevention and management. Published: 26 August Available at: Accessed:June Rogers LC, et al. Toe and flow: essential components and structure of the amputation prevention team. Journal of the American Podiatric Medical Association (2010): EWMA Journal 2018 vol 19 no 2 21

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23 Science, Practice and Education Using technology to advance pressure ulcer risk assessment and self-care: Challenges and potential benefits Dr. Patton D. 1,a Technology plays an important role in the identification of biomarkers associated with the early development of pressure ulcers. This article discusses some of the current issues in pressure ulcer assessment and how technological approaches can improve the early identification of pressure ulcers in at-risk people living at home. Prof. Moore Z. 2,a ABSTRACT Pressure ulcers are a debilitating health problem. Assessment of early pressure ulcer damage typically relies on a visual assessment of skin condition and the assignment of scores using paper-based assessment tools. It is difficult to obtain reliable and valid risk scores using these methods. The identification of biomarkers has the potential for a more accurate understanding of cellular level mechanisms. Home use of new technology by at-risk patients and their carers could result in significant reductions in the prevalence of pressure ulcers and the associated morbidities and mortality. We propose that technology has an important role in the identification of biomarkers associated with the early development of pressure ulcers. When used at home by at-risk patients, new technology has the potential to replace the expensive and inefficient current approaches used for diagnosis and treatment of earlystage pressure ulcers. The challenge is to develop newer technology-based systems that patients can use at home to detect their own early-stage ulcers and provide their own self-care. Truly innovative technology could also allow the health care practitioner to have remote oversight of the patient s progress in pressure ulcer prevention. This article discusses some of the current issues in pressure ulcer assessment and how technological approaches can solve some of the factors that impede the early identification of pressure ulcers in at-risk people living at home. INTRODUCTION Pressure ulcers (PUs; i.e., bed sores, pressure sores) are localised areas of tissue damage that result from excessive pressure and shearing forces. 1 These wounds range from superficial tissue damage, to severe tissue destruction. 2 Pressure ulcers occur most often in individuals who have limited activity or mobility and are exposed to prolonged periods of pressure or shear forces, or both. 3 Global mortality directly attributable to PUs increased 32.7% from ; 4 PUs also have negative effects on health-related quality of life factors. 5 The values for prevalence of PUs in acute health care settings in Ireland are consistent with the results obtained by studies performed in other countries (10 38%). 6 From a community care perspective, PU prevalence is approximately 4% in urban community health care settings. 7,8 There are also statistically significant increases in prevalence in older age groups; 75% of PUs occur in individuals >60 years of age. 6 Most PUs can be avoided with effective risk assessment and subsequent targeted interventions, 9 but approximately 4% of the annual health care budget in Europe is spent on PU-associated care; nursing time accounts for 41% of this cost. 10 Pressure ulcers increase the lengths of hospital stays, and readmission and mortality rates. 11,12 Despite advances in care and increased funding, PUs remain a significant health care issue. 13 Severe, foul-smelling infections can develop, 14 and pain is one of the most commonly cited complaints. This pain is Dr. O Connor T. 3,a Shanley E. 4,a 1 Senior Lecturer and Director of Nursing and Midwifery Research 2 Professor of Nursing and Head of the School of Nursing and Midwifery 3 Senior Lecturer and Director of Academic Affairs 4 Doctoral Student, Royal College of Surgeons in Ireland a School of Nursing and Midwifery, Royal College of Surgeons in Ireland, 123 St. Stephens Green, Dublin, Ireland To be continued: EWMA Journal 2018 vol 19 no 2 23

24 often intractable and may be exacerbated by some treatments used for wound management. 15 Given the significant human and economic burdens that PUs impose on individuals and societies, it is imperative that focused intervention begins early in at-risk individuals and who preferably have not yet been admitted to an acute hospital setting. Technology focused on biomarker identification is key in helping at-risk individuals, particularly those living at home. Technology can be used to assist with the identification of early damage so that appropriate self-care can begin immediately. Patient involvement in health care and the right of patients to have a central part in the health care process are important components of health care provision. 17,18 Historically, patient involvement in risk assessment and prevention has tended to be limited across the health care spectrum. Health care professionals have been the sole providers of these functions. However, when patients are more engaged in their own health care, they report an improved experience and increased satisfaction; better clinical outcomes and economic benefits also result. 19 The objectives of more use of primary health care, the desire of individuals to remain in their own homes for as long as possible, and the ever increasing reductions in available trained health professionals combine to make it more important than ever that patients are empowered to take leading roles in their own health care. 17 Consistent with the Europe 2020 Digital agenda, the lives of individuals at risk of developing a PU and living at home can be enhanced by revolutionising the methods used to assess the risk of, and prevent, pressure area development through the early identification of biomarkers. This change can occur through the development of smarter system-based approaches. These technologically innovative approaches will include patients self-management of their own risk assessment and active participation in prevention of PU development. Technological challenge Contemporary PU risk detection mainly involves clinician use of paper-based assessment tools to determine the presence or absence of putative risk factors for PU development. 9 One recent paper has in essence challenged the validity of this type of assessment indicating that PU formation begins inside the deeper layers of tissue and emerges outwards towards the skin, 20 thus highlighting the importance of biomarker identification. External skin assessment will not detect damage until skin changes are apparent. At this point, it is too late to prevent damage to the deeper tissue layers. 21 The current assessment tools also include risk factors that are not directly associated with PU development. 22 This has led to growing criticism of these tools because they distract from the primary 24 causes of PUs (i.e., immobility, and pressure and shear forces). 9,23,24 A significant gap in practice has resulted, particularly in primary care. At-risk individuals living at home remain reliant on health care professionals to determine their level of PU risk and subsequent care. Due to the sporadic nature of patient to clinician contact in primary care, a high-risk patient may not be identified in time to prevent tissue damage. More needs to be done to develop and implement simple-to-use technological methods of assessment that allow at-risk patients living at home and their care providers to make decisions that will prevent PU development. Use of this real-time health data will also improve patient self-care and interaction with health care workers. It is the authors view that common thought dictates that those most at risk for PU development (i.e., older people with reduced mobility) are typically not adept at use of new technology. However, >63% of older people (57 77 years of age) are willing to use e-health technology, but in order to optimise use of the technology by the patient, education and time to practice must also be included. 25 Any technological innovation would have to empower those at risk via development of a decision support system to enable informed self-management of PU prevention in real-time. It is clear that technological self-management and its support is critical to the success of using new technology in at risk patients at home. However, self-management is challenging because it includes multiple tasks such as symptom management, adherence to treatment regimes, commitment to appropriate lifestyle changes, and responding to the psychological and physical consequences associated with a condition. Self-management encompasses the ability of the patient to deliver the cognitive, behavioural, and emotional responses necessary to maintain a satisfactory quality of life. 26 In relation to early detection of PUs, using technology geared for patient use has the potential to achieve greater success keeping the skin intact, allowing reperfusion, and promoting cell regeneration. The very early PUs with intact skin can be successfully treated 27 without requiring the input of a physician. Use of biomarker technology is central to achieving this objective. Effects of technology When used by at-risk patients in their homes, technology for risk assessment of PUs may reduce the incidence of formation of severe PUs. This outcome will improve the quality of life of at-risk individuals living at home through the avoidance of the significant morbidity and mortality associated with severe PUs. Patient decision making will be enhanced through increased levels of self-control. Additional potential effects on the individual and on health EWMA Journal 2018 vol 19 no 2

25 Science, Practice and Education services include reduction of direct and indirect costs associated with the management of severe PUs. Finally, because development of a PU in an individual living at home is often a trigger for a hospital or long-term care facility admission, avoiding development of a PU will allow the individual to remain in their own home for a longer period. This outcome results in greater independence and contribution to and longevity within the community setting. Some benefits that can result from the use of technology-based risk assessment are discussed in subsequent sections. Reduced social and personal indirect costs associated with pressure ulcer prevention Presence of a PU has negative emotional, physical, psychological, and social effects. After adjustment for age, sex, and co-morbidities, individuals with PUs have lower health-related quality of life scores than those without PUs. 28 Pain is one of the most commonly cited complaints by those with PUs. 29 In some cases, movement can increase pain so some patients may try to be as still as possible and increase the likelihood of PU development. Greater emphasis on biomarker identification technology will reduce the significant personal and social burdens associated with this health care problem. Increasing lifespan through pressure ulcer prevention PUs contribute to increased risk of mortality. 30 For example, the presence of a PU exposes an individual to the risk of developing a wide range of complications such as local wound infection, osteomyelitis, cellulitis, septicaemia, and bacteraemia. An older person with a PU has a three times greater risk of death compared with an older person without a PU. 31 Studies have found odds ratios (ORs) of 4.19 (p<0.001) 32 and 3.64 (p<0.001) 33 for death of older patients with a PU in acute care settings. Age increases the risk of mortality in patients with a PU. 34 The mortality rate is <0.1% in younger hospitalised patients (<65 years of age) with a principal diagnosis of a PU; in older hospitalised patients, the risk of death increases up to 10% as age increases. 35 Research performed in a community setting has found that older people with PUs and living in the community are more likely to die compared with their counterparts without PUs (RR= 1.92, 95% CI ). 36 Pressure ulcer prevention associated with healthy ageing The association between age and PU development is significant. Demographic forecasts suggest that there will be a three-fold global increase in older persons by Almost 17% of the global population will consist of older individuals, compared with 7% in The skin undergoes some pathological changes as a result of ageing. The elastin and collagen content of the skin changes, reducing its elasticity and resilience. These changes compromise the skin s protective mechanisms against the negative effects of shear and friction. 38 Because 72% of all PU s occur in the over 65 years age group, 39 a greater focus on providing enhanced early prevention strategies will significantly advance progress in healthy ageing in this population. Improving PU prevention and care through engagement with advocacy groups The results of the Eurobarometer Qualitative Study 40 indicated that patient involvement in their own health care is fundamental to enhancing the quality of the health care received. The benefits of patient involvement include enhanced motivation to adhere to specific treatment regimens because the patient has a greater understanding of the illness. The patient also has a feeling of greater empowerment as they self-monitor their health. 40 A recurring need for assistance during active engagement in the prevention strategies is associated with PU monitoring and response. Therefore, this concept can be expanded to include the patient s family and carers. The concept of advocacy is closely linked to health literacy, which is the degree to which an individual has the capacity to obtain, communicate, process, and understand basic health information and services to make appropriate health decisions. Health literacy is enhanced when effective patient education strategies are included with the care programme. The concept of patient education has progressed from telling patients what to do to creating conditions for individuals to make informed and empowered health care decisions under the guidance of health care professionals. 41 Any technological advances must include meaningful engagement with advocacy groups that facilitate collaboration between patients and health care professionals and enable a continuous process of learning aimed at addressing specific health and wellness needs in the field of PU prevention. In practice, this col- De Oliveira A.L. 5,a Vitoriano A. 6,a Walsh S.G. 7,a Dr. Nugent L.E. 8,a 5 Doctoral Student, Royal College of Surgeons in Ireland 6 Doctoral Student, Royal College of Surgeons in Ireland 7 Research Nurse, Royal College of Surgeons in Ireland 8 Lecturer and Programme Director, Royal College of Surgeons in Ireland Correspondence: declanpatton@rcsi.ie Conflicts of interest: None EWMA Journal 2018 vol 19 no 2 25

26 Heels Sacrum Elbows Spine Shoulder Blades Back of Head Ankle Knee Hip Shoulder Ear laboration would include combining the new technology with an education package. Reduced direct costs linked to prevention of pressure ulcers Due to the cost of treatment and the large number of patients affected, PU management is a significant burden on health care systems. In an economically constrained health care service, revenue spent on PUs can impose a significant burden. However, many PUs can be avoided if best practice early risk assessment is completed with the subsequent use of stage-targeted interventions. 9 Despite some efforts to use this approach, approximately 4% of the annual health care budget in Europe is spent on PUs; nursing time accounts for 41% of the costs. 10 Pressure ulcer care adds considerable cost to an episode of hospital care. 12,13,42 But, because most PUs are preventable, greater emphasis on improving prevention strategies will reduce the significant direct costs associated with this health care problem. Use of technologies that enable patients, carers, and clinicians to assess risk could result in significant cost and efficiency savings for services. 26 CONCLUSION New technologies for the early identification of PUs present real opportunities for change in terms of better patient outcomes, reduced burdens on families, and reduced financial burdens on services. For technologies to work, they must be simple to use for patients, carers, and clinicians. Improved user ability will ensure that the full benefits of a technology are realized. Achieving the full effects of any technological advance will also depend on designing in compliance with clinical, digital, medical device, data, and ethics related regulations and standards. Overall compliance with National Information and Communications Technology (ICT) standards and regulations that enable interoperability among systems and devices while providing privacy and security must also be included. The regulatory requirements for new e-health technologies and medical devices change rapidly and often. Therefore, technological advances must be consistent with current and emerging regulatory requirements and guidelines. The success of technology also depends on high levels of participation and satisfaction for users, so it must be simple to use. Overall, PUs present a significant health care problem. The current risk assessment protocols used in primary and community care settings are not optimal. However, technologies that can detect the presence of early stage biomarkers in at-risk people living at home could reduce the effects of current practice limitations. As a result, many at-risk patients will not develop a PU and the associated complications. m EWMA Journal 2018 vol 19 no 2

27 Science, Practice and Education REFERENCES 1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel & Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide (ed. Haesler, E.) Cambridge Media, Perth, Australia, Beeckman D, Schoonhoven L, Boucqué H, Van Maele G. & Defloor T. Pressure ulcers: e-learning to improve classification by nurses and nursing students. Journal of Clinical Nursing 2008; 17: Gefen A, Cornelissen LH, Gawlitta D, Bader DL & Oomens CWJ. The free diffusion of macromolecules in tissue-engineered skeletal muscle subjected to large compression strains Journal of Biomechanics 2008; 41: Lozano R, Naghavi M & et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the Global Burden of Disease Study The Lancet 2010; 380: Gorecki C, Nixon J, Madill A, Firth J & Brown J M. 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Prevalence of Pressure Ulcers in Hospitalized Patients in Germany in 2005: Data from the Federal Statistical Office. Gerontology 2008; 55: Landi F, Onder G, Russo A & Bernabei R. Pressure ulcer and mortality in frail elderly people living in the community. Archives of Gerontological Geriatrics 2007; 44: U.S. Census Bureau Population Division. International Data Base. 15th December 2008 ed 38. Kottner J, Lichterfeld A. & Blume-Peytavi U. Maintaining Skin Integrity in the Aged: A Systematic Review. The British Journal of Dermatology 2013; 169: Russo CA, Steiner C & Spector W. in Healthcare Cost and Utilization Project, Statistical Briefs. Agency for Health Care Policy and Research (US), Rockville (MD), European Commission. Eurobarometer Qualitative study: Patient involvement. (ed. Directorate-General for Communication) European Commission, Brussels, Hoving C, Visserb A, Mullenc P D & Van Den Borne B. A history of patient education by health professionals in Europe and North America: From authority to shared decision making education. Patient Education and Counseling, 2010; 78: Graves N, Birrell F A. & Whitby M. Modelling the economic losses from pressure ulcers among hospitalized patients in Australia. Wound Repair and Regeneration 2005; 13: Make a difference in clinical practice Become a Member of EWMA Benefits of your EWMA Membership: n You make a difference in clinical practice within wound management in Europe n Right to vote and stand for EWMA Council n EWMA Journal sent directly to you two times a year n EWMA news and statements sent directly to you n A discount on your registration fee for EWMA Conferences n Right to apply for EWMA travel grants n Yearly membership fee 25 n Yearly membership fee for members of cooperating organisations 10 n Please register to become a member here:

28 PolyMem wound dressings are designed to focus inflammation to where it is needed the wound site while minimizing inflammation where it isn t needed, in uninjured tissue surrounding the wound. 1 more healing less pain Reduced bruising without compression Focusing the inflammatory process helps reduce secondary cell damage and pain caused by the typical swelling and bruising usually observed beyond the wound site. 1,2,3 PolyMem has been shown to reduce secondary cell damage by reducing the recruitment of adjacent inflammatory nerve endings (also referred to as nociceptors or free nerve endings). 1 These populous nerve endings, found in the epidermis, dermis, muscle, joints and viscera, are responsible for triggering and spreading the inflammatory reaction into surrounding uninjured tissues. 4,5,6,7,8 The spreading of inflammation is often clinically evidenced by increased temperature, bruising, swelling, increased sensitivity to stimuli, and pain beyond the immediate zone of injury. 5,7 Learn more and order at polymem.com References: 1. Beitz, AJ, Newman A, Kahn AR, Ruggles T, Eikmeier L. A Polymeric Membrane Dressing with Antinociceptive Properties: Analysis with a Rodent Model of Stab Wound Secondary Hyperalgesia. The Journal of Pain. Feb 2004;5(1): Knight KL. Chapter 3. Inflammation and Wound Repair In Cryotherapy in Sport Injury Management. Human Kinetics Champaign, IL 3. Merrick MA. Secondary injury after musculoskeletal trauma: a review and update. Journal of Athletic Training 2002;37(2): Clay CS, Chen WYJ. Wound pain: the need for a more understanding approach. Journal of Wound Care. April 2005;14(4): Abraham SE. Pain Management in wound care. Podiatry Management. June/July 2006: Wulf H, Baron R. The Theory of Pain in European Wound Management Association Position Document Pain at Wound Dressing Changes, Medical Education Partnership, London UK, 2002; page Levine JD, Reichling DB. Chapter 2 Peripheral Mechanisms of Inflammatory Pain. In Wall PD, Melzak R, Editors. Textbook of Pain. 4th edition. Edinburgh, UK: Churchill Livingstone, pages Fields HL. Chapter 1 Introduction & Chapter 2 The Peripheral Pain Sensory System In Pain New York; McGraw-Hill 1987 pages Ferris Mfg. Corp. Trademarks are owned by or licensed to Ferris. The marks may be registered or pending in several countries. MKL-745 R0 0218

29 Science, Practice and Education Prevalence of pressure injuries and other dependence-related skin lesions among paediatric patients in hospitals in Spain A recent prevalence study is the first to examine epidemiological data on the different skin injuries that affect neonates and children admitted to paediatric hospitals in Spain. Pedro L. Pancorbo-Hidalgo Ph.D. BSc. RN. Professor. Department of Nursing. Faculty of Health Sciences. Universidad de Jaén. Nursing and Innovation in Healthcare research group. Spain ABSTRACT Introduction Children admitted to hospitals may develop different types of skin injuries (dependence-related skin lesions) caused by pressure, or moisture and/ or friction. Most epidemiological studies examine only pressure injury (PI; previously known as pressure ulcers). There is a wide range in the reported values (0.47% 43%) for the prevalence of PI in paediatric hospital units. Aim To establish the prevalence of PI, moisture-associated skin damage (MASD), and skin tears in paediatric hospital units in Spain. Methods A cross-sectional study (epidemiological survey) was conducted by the Spanish Advisory Group on Pressure Ulcers and Chronic Wounds (GNEAUPP) in All public and private Spanish hospitals were invited to participate. The data were collected using a secure online form; hospital and unit characteristics, numbers of children admitted, and numbers of PIs, MASDs, combined lesions, and skin tears were recorded. Values for prevalence and the associated 95% confidence intervals (CIs) were calculated. Results Seventy-three paediatric units from 23 hospitals completed the survey (total 1,027 patients). The PI prevalence was 3.31% (95% CI 2.38% 4.59%). By unit type, the PI prevalence was 1.79% (0.69% 3.69%) for general paediatrics wards and 9.39% (4.50% 15.11%) for paediatric intensive care units. All PIs were acquired after admission. Most of the PIs (86.1%) were category 1 or 2, and were located on the head (occipital), nose, or other areas of the face. The prevalence of MASD was 1.56% (0.96% 2.52%); that of combined lesions was 0.49% (0.21% 1.13%). There were no statistically significant differences between the general wards and intensive care units. The intensive care unit skin tear prevalence was 0.10% (0.02% 0.55%). Conclusions The prevalence of PI in paediatric hospital units in Spain was low compared with published values for other countries. All the PIs were hospital-acquired (i.e., they developed after admission). PI prevention likely needs improvement in these units. The MASD prevalence was very low; most of the lesions were due to incontinence-associated dermatitis. This national survey is the most comprehensive to date on skin injuries in hospitalised children in Spain. Acknowledgments This research was funded by the Spanish Advisory Group on Pressure Ulcers and Chronic Wounds (GNEAUPP) and by the research group Nursing and Innovation in Healthcare at the University of Jaén. The authors thank all the Spanish hospitals that participated in the survey. INTRODUCTION People admitted to hospitals are often in a vulnerable or dependent condition. The patient s skin is exposed to different and potentially damaging agents and forces such as pressure, moisture, and Joan Enric Torra-Bou Ph.D. MSc. RN. Lecturer. Faculty of Nursing and Physiotherapy. Universitat de Lleida. GRECS Research Group and TR2Lab. Spain Francisco P. Garcia- Fernandez Ph.D. MSc. RN. Professor. Department of Nursing. Faculty of Health Sciences. Universidad de Jaén. Nursing and Innovation in Healthcare research group. Spain J. Javier Soldevilla-Agreda PhD. BSc. RN. Health Service of La Rioja. Professor School of Nursing of Logroño (La Rioja). Director of GNEAUPP. Spain Correspondence: pancorbo@ujaen.es Conflicts of interest: None EWMA Journal 2018 vol 19 no 2 29

30 friction. In this environment, dependence-related skin lesions (DRSLs) frequently develop in adults, neonates, and children. 1 Proposed hypotheses have emerged regarding the aetiopathogenesis of pressure ulcers that place ulcers and injuries within DRSL framework. Within the DRSL-defined framework proposed by García-Fernández et al. in 2014, 1 the term injury has steadily been used more often compared with ulcer because damaged skin remains intact in some cases of pressure injury (PI); this outcome is largely incompatible with the concept of ulcer pathogenesis. Use of the term pressure injury has become current in Southeast Asia, Australia, and New Zealand. In 2016, the term PI was adopted by the National Pressure Ulcer Advisory Panel in the United States and the Spanish Advisory Group on Pressure Ulcers and Chronic Wounds (Grupo Nacional para el Estudio y Asesoramiento en Úlceras por Presión y Heridas Crónicas; GNEAUPP) in Spain. Using the DRSL model, clinical nurses in all health care settings identify and classify different skin injuries according aetiology (i.e., PIs (formerly known as pressure ulcers), moisture lesions, friction lesions, and combined lesions). 2 Correct classification of injuries is important for epidemiological investigation and for the implementation of appropriate preventive and treatment measures. Children admitted to hospitals develop PIs, 3,4 but until recent years this issue was not considered an area for research. 5 Most of the few studies of the epidemiology of PIs in paediatric populations have focused this problem in paediatric intensive care units (PICUs). 3 Since 2001, the GNEAUPP has conducted a national epidemiological study every 4 years to determine the prevalence of PIs in hospitals, nursing homes, and primary care facilities in Spain. 6-9 Since 2002, recognition of the importance of PIs in paediatric populations has been increasing worldwide. The 2007 National Pressure Ulcer Advisory Panel (NPUAP) article, Pressure ulcers in neonates and children: an NP- UAP white paper 10 and other articles emphasise the important role of research in the reduction and prevention of PIs. However, few results are available on the prevalence and incidence of this type of skin lesion in children. The few existing studies are not systematised and present disparate methodological approaches and results. Studies of PI prevalence in paediatric hospital settings have found values ranging between 0.47% and 13.1% in paediatric hospital wards. 3,14,15 A 2005 national GNEAUPP study found a prevalence of 17.77% for PICUs in Spain. 7 Prevalence increased to 33.3% in and 3.33% in VanGilder et al. found a prevalence of 9.3% in US PICUs in 2007, 7.4% in 2008, and 7.2% in In 2013, Still et al. found that the prevalence of pressure ulcers ranged between 8.8% and 23% in US PICUs. 17 Huffines and Logsdon used the Neonatal Skin Risk Assessment Scale to assess skin condition and found a 1997 prevalence of 19% in skin breakdown in high-risk neonates in neonatal intensive care units (NICUs) in the United States. 18 Razmus et al. 19 found 2008 values for prevalence between 0.47% and 13% and August et al. 20 found a 2014 value of 31.2% in US and Australian neonatal ICUs, respectively. The current prevalence of PI in hospitalised children in Spain is mostly unknown. Therefore, this population was targeted in the survey for the 5th national study of prevalence of PI and others dependence-related skin lesions performed in The aim of this study was to establish the prevalence of PI and DRSLs in paediatric hospital units in Spain. METHODS Study design A cross-sectional design was used for the study. All publicly and privately owned and managed hospitals in Spain were invited to complete the epidemiological survey used to collect data for the study. A letter of invitation soliciting participants was widely published in the GNEAUPP social media, forums for wound-related discussions, and sent by to the nurse managers of most Spanish hospitals. The data collection period was open for 2 months (November and December 2017). Each participating hospital chose one day during this period to collect data. Population and sample The study population included all children from 1 day of age to 14 years of age admitted to the hospital paediatric units, both in inpatient wards (general paediatric units) and intensive care units (ICUs) (in Spain, people over 14 years of age are admitted to adult units). Convenience sampling was used; data were collected from hospitals with children s units that chose to participate in the survey. The Research Ethics Committee of Jaen (Jaen, Spain) approved the study protocol. The data were recorded at the unit level; no personal patient data were registered so only anonymised data were used. Data collection The data were collected using a secure online questionnaire. Each hospital had the opportunity to request a specific link to access the survey. The questionnaire asked for information about hospital and unit characteristics; risk assessment scales used; number of patients admitted to the unit; number of patients with any DRSLs (PI, moisture-associated skin damage (MASD), friction inju- EWMA Journal 2018 vol 19 no 2

31 Science, Practice and Education ries, combined injuries, and skin tears); use of preventive mattresses; sex and age of the patients; and ulcer or other lesion characteristics. Whether the lesion developed before or after (i.e., hospital-acquired injury) admission was recorded for each injury. To help clinicians correctly identify and categorise lesions, the research team included detailed written information in the survey on DRSL classification by aetiology, including images of the different injury types. PI, MASD, friction lesions, combined lesions, and skin tears were classified according to the GNEAUPP system. 2 Briefly, this system includes these categories: for PIs, category 1 (Non-blanchable erythema), category 2 (Partial-thickness ulcer), category 3 (Full-thickness skin loss); category 4 (Full-thickness tissue loss); and Deep tissue injury. For MASDs, category 1A (Mild-moderate erythema without loss of skin integrity), category 1B (Intense erythema without loss of skin integrity), category 2A (erythema with loss of skin integrity, erosion < 50% of the area), category 2B (erythema with loss of skin integrity, erosion > 50% of the area). For friction lesions, category 1 (erythema without blister), category 2 (erythema with blister), category 3 (partial-thickness ulcer). Data analysis The data were tabulated into a spreadsheet and checked for inconsistencies. Incomplete or inaccurate records were detected and corrected or removed. Each prevalence value (expressed as a percentage) was estimated by dividing the number of patients with each type of lesion by the total number of patients admitted to a ward. The 95% confidence intervals for mean prevalence values were estimated using the Wilson method. 21 Compared with the commonly-used Wald method, the Wilson method gives more robust estimates of confidence intervals when the data consist of small percentage values. Frequency and percentage values were used to summarise categorical variables. Mean and standard deviation (SD) of the mean values were used to summarise continuous variables. RESULTS A total of 73 paediatric units from 23 hospitals located in 17 provinces of Spain completed the survey; data from 1,027 patients were recorded. Different hospital staff members provided the data for the survey: clinical nurses (8.7%), members of the hospital s Committee of Pressure Ulcers (39.1%), ward managers (34.8%), and hospital nurse managers (8.7%). Table 1 presents the results for the hospitals characteristics. Most of the responding hospitals were publicly owned and managed and were part of the health services for the autonomous regions in Spain. Table 1: Characteristics of hospitals (N=23) with paediatrics units. Frequency (%) Hospital type Public 18 (78.3) Public with private management 4 (17.4) Private 1 (4.3) Size 100 to 199 beds 2 (8.7) 200 to 499 beds 12 (52.2) 500 to 749 beds 2 (8.7) More than 750 beds 7 (30.4) Characteristics of the paediatrics units Of the 73 units, 64.4% (47 / 73) were paediatric hospitalisation wards and 35.6% (26 / 73) were ICUs for children or neonates. The use of pressure ulcer risk assessment scales (PURAS) in each unit was recorded. 46.6% (34 / 73) of the units reported systematic use of PURAS to assess patients; 21.9% (16 / 73) used PURAS occasionally, and 30.1% (22 / 73) did not use PURAS. The scales used were the Braden Q Scale in 24.7% (18 / 73) of the units; both the Braden Q and the Neonatal Skin Risk Assessment Scale (NSRAS) in 16.4% (12 / 73); the Braden Scale in 11.0% (8 / 73); the mental state, Mobility, Incontinence, Nutrition, Activity (EMINA) Scale, in 8.2% (6 / 73); the Norton Scale in 4.1% (3 / 73); and the NSRAS Scale in 4.1% (3 / 73). Up to 23.3% of the units used a PURAS to assess adults but did not use a specific scale to assess children. Prevalence of pressure injury and other dependence-related skin lesions Twenty-six units (35.6%) had at least one patient with any DRSL on the day chosen for data collection. Among these units, the mean ratio for DRSLs per patient was Table 2 presents the results for overall and injury-specific prevalence values for DRSLs. PI was the most frequent type of injury. The mean prevalence of all types of injuries was higher in PICUs than in inpatient wards (Table 3). In the inpatient wards, the percent of children classified as at risk was 7.0% and the frequency of PI among at risk children was 9.87%. In PICUs, the percent at risk was 32.0% and the frequency of PI in at risk children was 17.43%. Most of the units had prevalence values in the range 0% - 4.9%. However, the results indicated that there was a bimodal distribution in numbers of PICUs (i.e., one peak in the 0% - 4.9% group and another in the 20% group) (Figure 1). EWMA Journal 2018 vol 19 no 2 31

32 Table 2: Prevalence of pressure injuries and other dependence-related skin lesions in children admitted to hospitals (N=1,027 children). Type of lesion Number of patients Prevalence 95% CI a Pressure injury % % Moisture-associated skin damage % % Combined lesions b % % Skin tears % % Any dependence-related skin lesion % % a 95% Confidence Interval b Lesions caused by pressure plus moisture or pressure plus friction. Table 3: Prevalence of pressure injuries and dependence-related skin lesions by type of unit. Type of lesion Inpatient wards Intensive care units (N=47) (N=26) Prevalence Prevalence Mean (95% CI) Mean (95% CI) Pressure injury 1.79 ( ) 9.39 ( ) Moisture-associated skin lesion 1.42 ( ) 1.98 ( ) Combined lesions a 0.54 ( ) 0 Skin tears ( ) Any dependence-related skin lesion 3.49 ( ) ( ) a Lesions caused by pressure plus moisture or pressure plus friction. Characteristics of the patients with any DRSL We collected data on 43 paediatric patients with any DRSL. There were 60.5% (26 / 43) male and 37.2% (16 / 43) female patients. The mean age was 17.8 months (SD 39.3; range 1 day to 14 years of age) (Table 4). The results for numbers of DRSLs developed by the patients are presented in Table 5. Patients most often had only one injury in the inpatient wards, but in PICUs some of the patients developed up to three injuries. Table 4: Characteristics of paediatric patients with any dependence-related skin lesion. N (%) Sex Male 26 (60.5) Female 16 (37.2) Age Less than 1 month 17 (39.5) 1 to 6 months 13 (30.2) 6 to 12 months 4 (9.3) 1 to 3 years 4 (9.3) 3 to 6 years 1 (2.3) 6 to 14 years 4 (9.3) 32 The use of pressure relief mattresses (PRMs) was recorded in the group of paediatric patients that had developed at least one DRSL. In the hospitalisation wards, 75% of patients had no PRMs, 15% had static PRMs (viscoelastic), and 10% had a dynamic PRM (alternating air). In the PICUs, 61.9% had no PRM, 33.3% had a static PRM, and 4.8% had a dynamic PRM. Characteristics of the injuries A total of 51 lesions were described for the 43 patients with any DRSL. There were 70.6% (36 / 51) PI lesions, 27.5% (14 / 51) MASD lesions, and 2.0% (1 / 51) skin tear lesion. All injuries were classified as hospital-acquired because they developed after hospital admission. The PI lesions were classified in categories according the GNEAUPP system (2). The number of injuries in each category was: category 1, 44.4% (16 /36) injuries; category 2, 41.7% (15 / 36); category 3, 11.1%) (4 / 36); and category 4, 2.8% (1 / 36). For the MASD lesions, 57.1% (4 / 14) were category I A (mild-moderate erythema without loss of skin integrity), 14.3% (1 /14) was category I B (intense erythema without loss of skin integrity), and 62.3% (9 / 14) were MASD that was not classified. The mean PI area was 0.99 cm 2 (SD 1.68; range cm 2 ). The mean MASD area was 1.6 cm 2 (SD 1.68; range EWMA Journal 2018 vol 19 no 2

33 Science, Practice and Education a Hospitalisation wards b PICUs to 4.95% 5 to 9.9% 10 to 14.9% 15 to 19.9% 20% or more 0 to 4.95% 5 to 9.9% 10 to 14.9% 15 to 19.9% 20% or more Figure 1: Percentage of paediatric hospital units according to pressure injury (PI) and dependence-related skin lesion (DRSL) prevalence. PI DRSL PI DRSL Table 5: Types and numbers of dependence-related lesions that developed in paediatric patients. Number of lesions per patient Inpatient wards PICUs N (%) N (%) Pressure injuries 0 10 (50) 3 (13) 1 10 (50) 15 (65.2) 2 0 (0) 4 (17.4) 3 0 (0) 1 (4.3) MASD 0 10 (50) 19 (82.6) 1 9 (45) 4 (17.4) 2 1 (5) 0 (0) Skin tears 0 20 (100) 22 (95.7) 1 0 (0) 1 (4.3) EWMA Journal 2018 vol 19 no 2 33

34 Table 6: Anatomical locations of injuries according to lesion type. PI MASD Skin tears N (%) N (%) N (%) Head (occipital) 8 (22.9) Nose 5 (14.3) Face 4 (11.4) Heels 3 (8.6) Armpits 3 (8.6) Mouth, lips 3 (8.6) Ears 2 (5.7) Coccyx 1 (2.9) Feet 1 (2.9) 1 (100) Toes 1 (2.9) Back, dorsal spine 1 (2.9) Abdomen 1 (2.9) 1 (7.1) Buttock 1 (2.9) 3 (21.4) Perineal zone 0 9 (64.3) cm 2 ). The only skin tear identified had an area of 0.64 cm 2. The mean length of time since lesion onset for PI was (SD 31.4) days (median 7 days; range days). The mean time to MASD lesion onset was 7.6 (SD 7.47) days (median 5 days; range 1 19 days). The results for anatomical location of the lesions are presented in Table 6. There was a between-lesion difference in location for the PI versus the MASD lesions. A high percentage of the PIs were on the head and face. Medical devices might have caused these PIs, but this factor was not recorded in the survey. DISCUSSION To our knowledge, this study is the first to examine epidemiological data on the different skin injuries that affect neonates and children admitted to hospitals in Spain. Most of the published epidemiological studies only report results on analyses of data on pressure ulcers A few studies examined incontinence-associated dermatitis (IAD). 3 No studies have examined the prevalence of all lesions during the same period. Because children admitted to hospitals are exposed to different agents that can damage the skin, it is important to consider all potential injuries when conducting prevalence studies, not PIs only. A similar study was performed by McLane et al. 3 in nine children s hospitals in the United States. They examined the prevalence of pressure ulcers and other types of skin breakdown in children. The study found a prevalence of 4.0% for pressure ulcers and 14.8% for skin breakdown (e.g., IAD, skin tears, and intravenous extravasation). Neonates and infants are susceptible to skin tears because their skin is 34 very fragile. Therefore, skin tears should be included in prevalence studies, as did McLane et al. Compared with other studies, our study is more representative of a paediatric population; it included the largest sample of paediatric hospital units in Spain to date. Seventy-three units from 23 hospitals were included in this study, compared with 10 units from eight hospitals in the 4th national prevalence survey performed in 2013, 9 or the six hospitals included in the Garcia-Molina et al. study. 22 Most of the published studies on PI epidemiology in children include only one or a few hospitals. 5,23,24 They have value as descriptive or quality evaluation studies, but sampling from the national population is needed to obtain prevalence values for comparison. 3,25 Pressure injuries This study found an overall PI prevalence of 3.3% in Spanish hospitals that responded to the survey. This prevalence value is equal to that found in 2013 in Spain (3.31%). 9,26 It is at the lower end of the range found in other published studies (0.47% to 43.1%. 3,14,16,23,27 However, this 3.3% PI prevalence in Spain is higher than the prevalence values reported for hospitals in the United States in 2012 (1.4%). 25 Although we did not find a high value for prevalence in this study, all the PIs were hospital-acquired, compared with the 1.1% hospital-acquired PI prevalence reported by Rauzmun and Bergquist-Beringer. 25 Our survey was not designed to measure PI incidence, but this result for hospital-acquired PI offers some information about the effectiveness of preventive measures in paediatric units. EWMA Journal 2018 vol 19 no 2

35 We found a difference between the PI prevalence in general paediatric wards (1.79%) versus PICUs (9.39%). This result is consistent with studies that found higher values for prevalence in PICUs. Prevalence was 1.90% in Spain 22 to 4.0% in Brasil 24 in paediatrics wards. Values for PI prevalence in ICUs in several countries have been reported (17.8% in Spain, % in Brasil, % - 9.3% in the United States). 16 The values are higher in NICUs (28.2% in Spain, % 28 and 23% 10 in the United States). Therefore, the PI prevalence in PICUs in Spanish hospitals is likely lower than that reported for most countries, but improvement is needed. The results of our analysis suggested that there was large variability in prevalence values across units from different hospitals. Seventy-four percent (54 out of 73) of the paediatric units reported having no patient with PI at the time of the survey (0% prevalence). By unit type, 83% were general inpatient wards and 57.7% were ICUs. These high numbers of units without patients with PI suggested that the prevention programmes are effective. There were also a number of units (especially PICUs) with prevalence values higher than 20%. Taken together, these results indicate that there is large variability in the effectiveness of prevention practices. The characteristics and functions of these high-prevalence PICUs should be examined to determine the factors that contribute to this variability. Prospective studies of incidence should also be performed to confirm the results of these prevalence studies. Risk assessment using PURAS and the use of PRMs are important aspects of PI prevention. Almost 50% of the units used a scale to systematically assess the risk of PI, but 30% did not. Some specific paediatric scales were used (Braden Q and NSRAS), but some units used scales developed for adults. The use of PURAS is not usually collected in prevalence studies, but our findings were consistent with the findings of other studies; the most often-cited PURAS are the Braden Q for children 12 and the NSRAS for neonates. 18,29 None of the respondents to our survey reported using the Glamorgan scale 15,30 in any of the paediatric units. This difference is likely because there are Spanish-validated versions of the Braden Q 31 and NSRAS 32 scales, but not the Glamorgan scale. Use of a high specification support surface for children at risk for or with a PI is recommended by evidence-based guidelines 33,34 and reduces PI incidence. 26 However, our study found low use of PRMs for at risk children and for children with ulcers. The results indicated that a PRM was not in place in up to 75% of the patients with PI in general paediatric wards and 61.9% of the patients in PI- CUs. Only a limited number of studies of the use of PRM or other preventive measures in children are available for comparison. Most prevalence studies do not collect data on prevention. Some studies found low percentages of patients with pressure ulcers having a PRM at hospitals (42.9% in neonates in Spain 32 and 27% in the United States). 5 Our study found proportions of 86.1% for PI categories 1 and 2, 11.1% for category 3, and 2.8% for category 4. Most other studies found that >80% of PIs are category 1 or category 2. 28,35 However, a US study found lower percentages for categories 1 and 2 (65%), but higher percentages for deep tissue injuries (14.3%) and unstageable pressure ulcers (10.1%). 25 Our results are consistent with the results of other studies that have found that in children the head (occipital), nose, and face are the anatomical locations most frequently affected by PI in children. 5,24,25 Only a small number of children developed PIs affecting the heel or other locations in the foot; no children were affected by a coccyx PI. In contrast, these locations are frequently affected by PIs in adults. 6-9 The ulcers found on the nose and other areas of the face were likely associated with the use of medical devices (e.g., non-invasive ventilation), 22,36 but we did not collect data on the medical devices used. Moisture-associated skin damage We found prevalence values of 1.56% for MASD and 0.49% for combined lesions (pressure plus moisture or friction plus moisture). There was a small difference in the prevalence of MASD for inpatient wards (1.42%) versus PICUs (1.98%). All the lesions, except one affecting the abdomen, were classified as IAD because they were located on the buttocks or perineal area. There are no other study results available on the epidemiology of MASD in children admitted to hospitals in Spain to compare with the low prevalence values found in this study. McLane et al. 3 found a prevalence of 14.8% for skin breakdown (including diaper dermatitis) in paediatric units in the United States. The incidence of MASD (especially IAD) should be considered when planning studies of skin integrity in hospitalised children. These lesions are preventable and likely are indicators of quality of care. Use of the term diaper dermatitis should be avoided when referring to these lesions because, in some way, it implies that the development of these lesions is a normal consequence of caring for infants or incontinent children; which is not true. The measured prevalence values for the MASD and combined lesions are likely lower than the true values. This survey was the first time that these lesions were included in the national survey of DRSLs. It is likely that they are not recorded in the electronic health records of many paediatrics units and that the numbers were underestimated. This study has some limitations. First, study participation was voluntary, so a random sample of the population was EWMA Journal 2018 vol 19 no 2 35

36 not used. It is possible that the hospitals more engaged in PI prevention were more willing to participate, which would bias the results towards lower prevalence values. However, the high number of participating paediatric units from hospitals in different regions in Spain may have reduced the effects of this bias. Second, the data were self-reported by each hospital and were based on the records kept at the institution. This self-reporting could lead to an underestimation of prevalence. The possible effects of bias were likely reduced by the guaranteed anonymity of the survey; no participating hospital was identified. Clinicians and managers likely had confidence in this anonymity because prevalence studies have been conducted in Spain by the GNEAUPP for more than 20 years to obtain reliable prevalence values as standards for comparison. Third, the use of medical devices (e.g., tubes, ventilation masks) was not recorded, so it was not possible to identify what injuries were related to these devices. Implications for clinical practice Infants and children admitted to hospitals may develop PIs and other injuries caused by exposure to moisture or friction, or both. Injuries that occur when people are physically dependent or vulnerability are known as DRSLs. All these aetiologies should be considered together during design of care plans that aim to maintain the skin integrity of children in paediatric hospital units. CONCLUSIONS The prevalence of PI in paediatric hospital units in Spain was 3.3%. This value is low compared with the results for PI prevalence for other countries. All the PIs developed after admission (i.e., all were hospital-acquired PIs); the study revealed that prevention of PIs within these units needs improvement. We found large between-unit variability in PI prevalence, especially in PICUs. Two groups were identified, one had low values for prevalence of hospitalacquired PIs and the other had high values for prevalence of hospital-acquired PIs (>20%). The prevalence of MASD in paediatric units was low; most were associated with IAD and there were no significant differences among general wards and PICUs. The MASD prevalence value was probably underestimated because this survey was the first time that moisture lesions were included the national survey for DRSL. This national survey is the most comprehensive to date of skin injuries in hospitalised children in Spain. m Key Messages n The prevalence of pressure injuries and other dependence-related skin lesions in children admitted to hospitals in Spain was examined using an epidemiological survey. n The aim of this research was to update the estimated values of the prevalence of pressure injuries and other skin injuries in children in hospitals. n The overall prevalence of pressure injuries in paediatric hospitals units in Spain was 3.3%; the prevalence was higher (9.39%) in paediatric intensive care units. n The prevalence of moisture-associated skin damage in children was 1.56%. This type of lesion is not frequently recorded in epidemiological studies. REFERENCES 1. García-Fernández FP, Soldevilla Agreda JJ, Verdú J, Pancorbo- Hidalgo PL. A new theoretical model for the development of pressure ulcers and other dependence-related lesions. J Nurs Scholarsh 2014; 46(1): García-Fernández FP, Soldevilla Agreda JJ, Pancorbo-Hidalgo PL, Verdu Soriano J, Lopez Casanova P, Rodriguez-Palma M. Classification of dependence-related skin lesions: a new proposal. J Wound Care 2016; 25(1): McLane KM, Bookout K, McCord S, McCain J, Jefferson LS. The 2003 national pediatric pressure ulcer and skin breakdown prevalence survey. J Wound Ostomy Continence Nurs. 2004; 31 (4): Waterlow J. Pressure sore risk assessment in children. Paediatr. Nurs. 1997; 9(6): Manning MJ, Gauvreau K, Curley MAQ. Factors associated with occipital pressure ulcers in hospitalized infants and children. Am J Critical Care. 2015; 24: Torra i Bou JE, Rueda J, Soldevilla JJ, Martinez F, Verdú J. 1er Estudio Nacional de Prevalencia de Ulceras por Presión en España. Epidemiología y variables definitorias de las lesiones y pacientes. [1st national study of the prevalence of pressure ulcers in Spain. Epidemiology and characteristics of the lesions and the patients]. Gerokomos 2003; 14(1): Soldevilla Agreda J, Torra i Bou JE, Verdú Soriano J, Martínez Cuervo F, López Casanova P, Rueda López J, Mayán Santos JM. 2º Estudio Nacional de Prevalencia de Úlceras por Presión en España. Epidemiología y variables definitorias de las lesiones y pacientes. [2nd national study of the prevalence of pressure ulcers in Spain. Epidemiology and characteristics of the lesions and the patients] Gerokomos 2006; 17(3): Soldevilla Agreda JJ, Torra i Bou JE, Verdú Soriano J, López Casanova P. 3er Estudio Nacional de prevalencia de úlceras por presión en España, [3rd national study of the prevalence of pressure ulcers in Spain, 2009]. Gerokomos 2011; 22(2): Pancorbo-Hidalgo PL, García-Fernández FP, Torra i Bou JE, Verdú Soriano J, Soldevilla-Agreda JJ. Epidemiología de las úlceras por presión en España en 2013: 4ª Estudio Nacional de Prevalencia. [Epidemiology of pressure ulcers in Spain in 2013: 4th national study of prevalence]. Gerokomos. 2014; 25(4): Baharestani MM, Ratliff CR. Pressure Ulcers in Neonates and Children: An NPUAP White Paper. Adv Skin Wound Care 2007;20: Razmus I, Lewis L, Wilson D. Pressure ulcer development in infants: State of the Science. J Healthcare Qual 2008; 30 (5): Quigley SM, Curley MA. Skin integrity in the pediatric population: preventing and managing pressure ulcers. J Soc Pediatr Nurs. 1996;1(1): Sims A, McDonald R. An overview of pediatric pressure care. J Tiss Viab 2003; 13(4): Baldwin KM. Incidence and prevalence of pressure ulcers in children. Adv Skin Wound Care 2002; 15(3): Willock J, Baharestani MM, Anthony D. The development of the Glamorgan pediatric pressure ulcer risk assessment scale. J Wound Care 2009; 18(1): EWMA Journal 2018 vol 19 no 2

37 16. VanGilder C, Amiung S, Harrison P, Meyer S. Results of the International Pressure Ulcer Prevalence Survey and a 3-year, acute care, unit-specific analysis. Ostomy Wound Manage 2009; 55(11): Still MD, Cross LC, Dunlap M et al. The turn team: A novel strategy for reducing pressure ulcers in the surgical intensive care unit. J Am Coll Surg 2013; 216: Huffines B, Logsdon MC. The neonatal skin assessment scale for predicting skin breakdown in neonates. Issues Comprehes Pediatr Nurs 1997; 20(2): Razmus I, Lewis L, Wilson D. Pressure ulcer development in infants: State of the Science. J Healthcare Qual 2008; 30 (5): August DL, Edmonds L, Brown DK et al. Pressure injuries to the skin in neonatal unit: Fact or fiction. J Neonatal Nurs 2014; 20: Newcombe R. Two-sided confidence intervals for the single proportion: comparison of seven methods.. Stat Med. 1998; 17(8): Garcia-Molina P, Balaguer-Lopez E, Garcia-Fernandez FP, Ferrera-Fernandez MA, Blasco JM, Verdu J. Pressure ulcers incidence, preventive measures, and risk factors in neonatal intensive care and intermediate care units. Int Wound J. 2018; 15(4): Schluer AB, Cignacco E, Muller M, Halfens RJ. The prevalence of pressure ulcers in four paediatric institutions. J Clin Nurs. 2009;18(23): Pellegrino DMS, Chacon JMF, Blanes L, Ferreira LM: Prevalence and incidence of pressure injuries in pediatric hospitals in the city of Sao Paulo, SP, Brasil. J Tissue Viability. 2017; 26: Razmus I, Bergquist-Beringer S. Pressure injury prevalence and the rate of hospital-acquired pressure injury among pediatric patients in acute care. J Wound Ostomy Continence Nurs. 2017; 44(2): Garcia-Molina P, Balaguer-Lopez E, Torra i bou JE, Alvarez-Ordiales A, Quesada Ramos C, Verdu Soriano J. A prospective longitudinal study to assess use of continous and reactive low-pressure mattresses to reduce pressure ulcer incidence in a peadiatric intensive care unit. Ostomy Wound Manag. 2012; 58(7): Barrera Arenas JE, Pedraza Castañeda MC, Perez Jimenez G, Hernandez Jimenez P, Reyes Rodriguez JA, Padilla Zarate MP. Prevalencia de úlceras por presión en hospital de tercer nivel, en Mexico DF [Prevalence of pressure ulcers in a third level hospital in Mexico city]. Gerokomos. 2016; 27(4): Schindler CA, Mikhailov TA, Kuhn EM, Christopher J, Conway P, Ridling D, et al. Protecting fragile skin: nursing interventions to decrease development of pressure ulcers in pediatric intensive care. Am J Crit Care. 2011;20(1): Dolack M, Huffines B, Stikes R, Hayes P, Logsdon MC. Updated neonatal skin risk assessment scale (NSRAS). Ky Nurse. 2013;61(4): Willock J, Anthony D, Richardson J. Inter-rater reliability of Glamorgan Paediatric Pressure Ulcer Risk Assessment Scale. Paediatr Nurs. 2008;20(7): Quesada C, Iruretagoyena ML, González RM, Hernández JM, Ruiz de Ocenda MJ, Garitano B et al. Validación de una escala de valoración del riesgo de úlceras por presión en niños hospitalizados. [Validation of pressure ulcer risk assessment scale in hospitalised children]. Investigación Comisionada. Vitoria-Gasteiz. Departamento de Sanidad y Consumo. Gobierno Vasco, Informe nº: Osteba D Available wp-content/uploads/d_09_08.-%c3%9 Alceras-por-presi%C3%B3n-enni%C3%B1os.pdf 32. Garcia-Molina P, Balaguer Lopez E, Verdu J, Nolasco A, Garcia Fernandez FP. Cross-cultural adaptation, reliability and validity of the Spanish version of the Neonatal Skin Risk Assessment Scale. J Nurs Manag 2018; doi: /jonm National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014 available at: Guideline Development Group. Pressure ulcers: prevention and management of pressure ulcers. National Clinical Guideline Centre. London: National Institute for Health and Care Excellence; Curley MA, Razmus IS, Roberts KE, Wypij D. Predicting pressure ulcer risk in pediatric patients. Nurs Res 2003; 52(1): Bonell-Pons L, Garcia-Molina P, Balaguer-Lopez E, Montal M, Rodriguez M. Neonatal facial pressure ulcers related to noninvasive ventilation: incidence and risk factors. EWMA J. 2014; 14(2): 33. Theory & Practice 2-5 October 2019 Management of the Diabetic Foot 11 th Course 2-5 October 2019 Pisa Italy Save the Date Welcome to Pisa This 4-day theoretical course and practical training gives participants a thorough introduction to all aspects of diagnosis, management and treatment of the diabetic foot. Lectures will be combined with practical sessions held in the afternoon at the diabetic foot clinic at the Pisa University Hospital. Lectures will be in agreement with the International Consensus on the Diabetic Foot and Practical Guideline on the Management and Prevention on the Diabetic Foot. Pisa International Diabetic Foot Course EWMA Journal 2018 vol 19 no 2 The course is endorsed by EWMA

38 Reduce wound wound dehiscence by 38%. dehiscence This changes by 75%. everything. This changes everything. In breast reduction surgery PICO significantly reduced the incidence of post-surgical dehiscence by 38% compared with standard dressings. 1* For clinical outcomes, this changes everything. Getting Helping you closer get CLOSER to zero TO delay ZERO in wound delay in healing. wound healing Supporting healthcare professionals 1. Trademark Holt R and Murphy of Smith J. PICO & Nephew. incision closure All Trademarks in oncoplastic acknowledged. breast surgery: a case August series. British 2018 Smith Journal & of Nephew Hospital Medicine ;76(4): Galiano RD, Hudson D, Shin J, et al. Incisional negative pressure wound therapy for prevention of wound healing complications following reduction mammaplasty. Plast Reconstr Surg Glob Open 2018;6:e1560. *Reduction in dehiscence: 200 patients; PICO 32 patients (16%); standard care 52 patients (26%); p<0.001

39 Science, Practice and Education Survey of Wound Prevalence in a Long-Term Care Facility Pressure injuries are more common in the long-term care (LTC) population. This report presents the results of an analysis of wound practice data collected at a Newfoundland LTC facility in Canada, and describes how a regional strategy for wound care provides the opportunity to develop enhanced wound services and a policy for the prevention of pressure injuries. Susan Peckford BA, BN, RN, MN, NSWOC, WOCC (C) Regional Enterostomal Therapy Clinical Nurse Specialist with the Western Health Authority located at Western Memorial Regional Hospital in Corner Brook, Newfoundland, Canada Wounds are a serious health complication that affect quality of life for the individual and have significant clinical and economic implications. Chronic wounds can create additional challenges for those who have a compromised health status. The lack of appropriate and timely care leads to poor client outcomes. In many cases, the development of chronic wounds can be avoided or, if detected in the early stages, can be managed effectively to reduce the risk of amputation. A regional strategy for wound care provides the opportunity to develop a clear action plan on care coordination and enhanced wound services across the healthcare region (The geographical region covers 500 km and services 80,000 people). This approach will ensure that regardless of where they live, patients will have access to wound care based on evidence-informed practice and provided in a timely manner in the most appropriate settings. According to Wounds Canada (2018), the overall prevalence of pressure injuries across all health care settings is 26%; approximately 70% of these wounds are preventable. This report presents the results of an analysis of wound practice data collected in January 2018 at a Newfoundland Long-Term Care Facility (Corner Brook Long Term Care). The 265 patients were assessed for any skin redness, marks, wounds, or blisters to their skin. These people would then be assessed to determine what type of wound if any they had. The results of the analysis indicated that 38 patients had 45 wounds. The prevalence of all total wounds of any type for the long-term care (LTC) facility was 14.3%. The prevalence rate of pressure injuries only was 8.7%; 23 patients had 26 pressure injuries. Pressure injuries are more common in the LTC population due to their advanced age and possible comorbidities. Values of pressure injury prevalence range from 10% to 54% (Wounds Canada, 2017). The prevalence of skin tears in this LTC facility was 0.4%. This value was lower compared with the 2013 prevalence rate of 14.0% (Tables A, B, and C). Implementation of a standardized wound product formulary improves outcomes. Costs are controlled when product formularies are streamlined to ensure that product use is not duplicated and products are used for their intended purposes. Combining product formulary standardization and protocol standardization decreases the frequency of dressing changes and improves healing outcomes. Thus, patient outcomes improve and costs are controlled. The wound management Table A: Demographics (Patients with Wounds Only) Patients with Wounds (n=39) Average Age 81.8 Males 16 (41%) Females 23 (59%) With Diabetes 15 (38.5%) Without Diabetes 24(61.5%) Correspondence: susanpeckford@ westernhealth.nl.ca Conflicts of interest: None EWMA Journal 2018 vol 19 no 2 39

40 Table B: Types of all wounds n=45 (Pop n=265) Stage I 9 Stage II 12 Stage III 1 Stage IV 0 Stage X 4 Leg Ulcer Arterial 7 Leg Ulcer Mixed Leg Ulcer Venous 3 3 Leg Ulcer Arterial Dermatitis Skin Tear Surgical Closed Trauma Callus Table C: Location of all wounds in corner broock LTC n= Arms 2 Abdomen Back 1 1 Sacrum/Coccyx 18 Buttocks 1 Below Hip to Knee (Inkl Knee) 2 Below knee to ankle (Inkl ankle) 4 Foot 9 Toes 2 Heel 5 40 EWMA Journal 2018 vol 19 no 2

41 Science, Practice and Education products have been standardized in this facility and for the entire region across the continuum of care. The last Wound Prevalence Survey was completed in 2013 at this same facility. Implementation of a program of early detection and appropriate treatment of stage 1 pressure injuries was recommended. A staff education program was included. A Pressure Injury Prevention Program was also developed since the last prevalence survey. Numerous education sessions on pressure injury prevention and management and use of standardized wound management products have been conducted. Three e-learning modules on pressure injury prevention, the Braden Scale, and Wound Healing & Nutrition have been added to the online learning formulary for staff. Electronic online documentation and policies include the Braden Scale, Skin Assessment, Wound Assessment, Dressing Intervention, Negative Pressure, Wound Culture, Falls Prevention, Hydration Program, and Therapeutic Support Surfaces. By implementing preventative measures, nursing staff can have profound effects on improvements in patient outcomes and cost reductions associated with wound care. The Braden Risk Assessment Tool is a validated and reliable tool. When it is implemented frequently and consistently it can help identify patients at risk for the development of pressure injuries and enable caregivers to intervene before skin breakdown occurs. A recent Braden Scale Audit revealed that regional completion rates ranged from 98% 100% (Table D). A Therapeutic Support Surface Policy was incorporated into Meditech. The policy includes a mattress tracking system to ensure that appropriate surfaces are available to patients and residents to prevent pressure injuries. A pamphlet for patients and caregivers, titled Pressure Ulcer Prevention-Tips for Caregivers, was developed by the Regional Wound and Skin Care Committee and it is available for public access. A successful Wound Resource Nurse Education Program was implemented in 2014 after the first prevalence survey. This program includes an annual two-day event attended by the same 60 registered nurses. The program takes place in May every year. The attendees represent the entire region covering long-term, acute, and community care. These wound care resource nurses receive advanced training in effective wound prevention and management. With their annual training these nurses have become an additional and valuable resource for wound care advice throughout the region. A wound management and skin care product list was standardized for the region in This list helps ensure that patients receive the best possible care in the most financially responsible way. A 22-page Wound Management Quick Reference Pocket Guide was developed by a wound care team to assist nurses to make wound-related decisions when care is organized or provided. The guide provides an overview of commonly encountered, but not well understood, wound care topics including fundamentals of wound management, assessment, infection, pressure injuries, arterial ulcers, venous ulcers, incontinenceassociated dermatitis and skin tears, wound management products, and debridement. The current study allowed us to see a breakdown of what stages of pressure injuries were present in the LTC facility and on where they were located on the patient s body. Tables E and F present the results for the stages and locations of pressure injuries found in the LTC facility. Recommendations and Practice Suggestions According to Wounds Canada (2018), the overall prevalence of pressure injuries across all health care settings is 26%; approximately 70% of these wounds are preventable. The prevalence rate for pressure injuries in the LTC Corner Brook facility was 8.7%, compared with the 2013 prevalence rate of 10.3%. However, at this facility the total rate (1.88%) for stage 3, stage 4, and stage X or unstageable pressure injuries was one of the lowest rates in Canada; there were no stage 4 pressure injuries. Skin tears are generally more common among the LTC population. Values for prevalence range from 10% to 54% Table D: Braden risk assessment analysis Risk Level Patients with All Wounds Patients with Pressure Injuries (n=38) (n=23 patients with 26 wounds) No ( 17) 5 (13.2%) 2 (8.7%) Low (15-16) 9 (23.6%) 9 (39.1%) Moderate (13-14) 12 (31.6%) 6 (26.1%) High ( 12) 12 (31.6%) 6 (26.1%) Average Braden 13.9 (Moderate Risk) 14.1 (Moderate Risk) EWMA Journal 2018 vol 19 no 2 41

42 Table E: Stages of pressure injuries Total number of patients with Pressure Injuries, N=23 Total number of Pressure Injuries, N= Stage 1 9 Stage 2 12 Stage 3 1 Stage 4 0 Stage US 4 Table F: Pressure injuries Arms Back 1 1 Sacrum/Coccyx 16 Buttocks 1 Below knee to ankle (Inkl ankle) 2 Foot 1 Heel 4 (Wounds Canada, 2017). The rate of skin tears in the LTC Corner Brook facility was 0.4%, compared with the 2013 prevalence rate of 14.0%. The results of this prevalence survey showed the appropriate usage of wound management products and proper dressing change frequency for all wound types. There has been a significant decrease in preventable wounds and an increase in the use of wound and skin care best practice recommendations. We will continue to follow an integrated approach based on recommendations from Wounds Canada (2018). We will focus on prevention across all areas of the healthcare system to continue to reduce prevalence and incidence rates. The Pressure Injury Prevention Program should be continued and be updated as needed. Annual resource nurse wound education will continue. The results of this survey suggested that the combination of proper education, product use standardization, a team approach, and continued program support will contribute to continued decreased rates in the occurrence of preventable wounds. m REFERENCES Wounds Canada. (2018). Best Practice Recommendations for the Prevention and Management of Pressure Injuries. Retrieved from: docman/public/health-care-professional/bpr-workshop/172-bpr-prevention-andmanagement-of-pressure-injuries-2/file Wounds Canada. (2017). Best Practice Recommendations for the Prevention and Management of Skin Tears. Retrieved from: public/health-care-professional/bpr-workshop/552-bpr-prevention-and-managementof-skin-tears/file 42 EWMA Journal 2018 vol 19 no 2

43 When two forces combine, amazing things are possible Discover what negative pressure and Hydrofiber Technology can do together When it comes to creating an environment conducive to healing, you already know what negative pressure wound therapy can achieve. But combine two powerful technologies, and you could achieve even more.* The Avelle TM Negative Pressure Wound Therapy System brings together negative pressure with the power of Hydrofiber Technology, which is designed to help create an ideal environment for healing. So make a positive change to your Negative Pressure Wound Therapy regime, and choose the Avelle TM system from ConvaTec. Avelle and Hydrofiber are trade marks of ConvaTec Inc ConvaTec Inc. AP MM * Based on the physical properties of Hydrofiber Technology as demonstrated in-vitro. 1,2 1. Waring MJ, Parsons D. Physico-chemical characterisation of carboxymethylated spun cellulose fibres. Biomaterials. 2001;22: Walker M, Hobot JA, Newman GR, Bowler PG. Scanning electron microscopic examination of bacterial immobilisation in a carboxymethylcellulose (AQUACEL ) and alginate dressings. Biomaterials. 2003;24(5):

44 DYNAMIC HEALING REDUCE HEALING TIME BY 100 DAYS 1 FROM DAY 1 TO COMPLETE HEALING LEG ULCERS DIABETIC FOOT ULCERS PRESSURE ULCERS Leg ulcers, diabetic foot ulcers and pressure ulcers take 200 days on average to heal despite standard treatment. 2 UrgoStart Plus is the local treatment that acts from day 1 to complete healing to reduce healing time by 100 days on average. 1 Initiate UrgoStart Plus today and get your patients to the finish line sooner. 1. Münter KC, Meaume S, Augustin M, Senet P, Kérihuel J.C. The reality of routine practice: a pooled data analysis on chronic wounds treated with TLC-NOSF wound dressings. J Wound Care Feb; 26 (Sup2): S4-S15. Erratum in: J Wound Care Mar 2; 26(3): French Health Insurance Report to the Ministry of Health for July 2013.

45 Cochrane Reviews ABSTRACTS OF RECENT COCHRANE REVIEWS Publication in The Cochrane Library Issue 5, 2018 Education of healthcare professionals for preventing pressure ulcers Alison P Porter-Armstrong, Zena EH Moore, Ian Bradbury, Suzanne McDonough Citation example: Porter-Armstrong AP, Moore ZEH, Bradbury I, McDonough S. Education of healthcare professionals for preventing pressure ulcers. Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD DOI: / CD pub2. ABSTRACT Background: Pressure ulcers, also known as bed sores or pressure sores, are localised areas of tissue damage arising due to excess pressure and shearing forces. Education of healthcare staff has been recognised as an integral component of pressure ulcer prevention. These educational programmes are directed towards influencing behaviour change on the part of the healthcare professional, to encourage preventative practices with the aim of reducing the incidence of pressure ulcer development. Objectives: To assess the effects of educational interventions for healthcare professionals on pressure ulcer prevention. Search methods: In June 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, metaanalyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria: We included randomised controlled trials (RCTs) and cluster-rcts, that evaluated the effect of any educational intervention delivered to healthcare staff in any setting to prevent pressure ulceration. Data collection and analysis: Two review authors independently assessed titles and abstracts of the studies identified by the search strategy for eligibility. We obtained full versions of potentially relevant studies and two authors independently screened these against the inclusion criteria. Main results: We identified five studies that met the inclusion criteria for this review: four RCTs and one cluster-rct. The study characteristics differed in terms of healthcare settings, the nature of the interventions studied and outcome measures reported. The cluster- RCT, and two of the RCTs, explored the effectiveness of education delivered to healthcare staff within residential or nursing home settings, or nursing home and hospital wards, compared to no intervention, or usual practices. Educational intervention in one of these studies was embedded within a broader, quality improvement bundle. The other two individually randomised controlled trials explored the effectiveness of educational intervention, delivered in two formats, to nursing staff cohorts. Due to the heterogeneity of the studies identified, pooling was not appropriate and we have presented a narrative overview. We explored a number of comparisons (1) education versus no education (2) components of educational intervention in a number of combinations and (3) education delivered in different formats. There were three primary outcomes: change in healthcare professionals knowledge, change in healthcare professionals clinical behaviour and incidence of new pressure ulcers. We are uncertain whether there is a difference in health professionals knowledge depending on whether they receive education or no education on pressure ulcer prevention (hospital group: mean difference (MD) 0.30, 95% confidence interval (CI) to 1.60; 10 participants; nursing home group: MD 0.30, 95% CI to 1.37; 10 participants). This was based on very low-certainty evidence from one study, which we downgraded for serious study limitations, indirectness and imprecision. We are uncertain whether there is a difference in pressure ulcer incidence with the following comparisons: training, monitoring and observation, versus monitoring and observation (risk ratio (RR) 0.63, 95% CI 0.37 to 1.05; 345 participants); training, Gill Rizzello Managing editor Cochrane Wounds, School of Nursing, Midwifery and Social Work, University of Manchester. Correspondence: gill.rizzello@ manchester.ac.uk More information: Conflicts of interest: None EWMA Journal 2018 vol 19 no 2 45

46 monitoring and observation, versus observation alone (RR 1.21, 95% CI 0.60 to 2.43; 325 participants) or, monitoring and observation versus observation alone (RR 1.93, 95% CI 0.96 to 3.88; 232 participants). This was based on very low-certainty evidence from one study, which we downgraded for very serious study limitations and imprecision. We are uncertain whether multilevel intervention versus attention control makes any difference to pressure ulcer incidence. The report presented insufficient data to enable further interrogation of this outcome. We are uncertain whether education delivered in different formats such as didactic education versus video-based education (MD 4.60, 95% CI 3.08 to 6.12; 102 participants) or e-learning versus classroom education (RR 0.92, 95% CI 0.80 to 1.07; 18 participants), makes any difference to health professionals knowledge of pressure ulcer prevention. This was based on very low-certainty evidence from two studies, which we downgraded for serious study limitations and study imprecision. None of the included studies explored our other primary outcome: change in health professionals clinical behaviour. Only one study explored the secondary outcomes of interest, namely, pressure ulcer severity and patient and carer reported outcomes (self-assessed quality of life and functional dependency level respectively). However, this study provided insufficient information to enable our independent assessment of these outcomes within the review. Authors conclusions: We are uncertain whether educating healthcare professionals about pressure ulcer prevention makes any difference to pressure ulcer incidence, or to nurses knowledge of pressure ulcer prevention. This is because the included studies provided very low-certainty evidence. Therefore, further information is required to clarify the impact of education of healthcare professionals on the prevention of pressure ulcers. Plain language summary Educating healthcare staff to prevent pressure ulcers Background: Pressure ulcers, also known as bed sores or pressure sores, are often experienced by those who find it difficult to walk and spend long periods of time sitting or lying down. Pressure ulcers can range from patches of discoloured, painful skin, to open wounds that can take a long time to heal. Pressure ulcers are prone to infection and have a great impact on people s health and well being. To stop these ulcers from developing in people who are at risk, healthcare staff need to be well informed about how to prevent them. It is important to understand what type of information healthcare staff need, how it might best be delivered to them and whether education can prevent pressure ulcers from developing. Review question: We reviewed the evidence about the effect of the education of healthcare professionals on the prevention of pressure ulcers. We explored all types of education regardless of how it was delivered as long as it focused on preventing pressure ulcers. Healthcare staff included all staff working in pressure ulcer prevention from any professional background. Settings where the care was provided included hospital inpatient and outpatient departments, community clinics, patients own homes, and residential or nursing care homes. 46 What we found: In June 2017 we searched for studies evaluating the effect of the education of healthcare professionals on pressure ulcer prevention, and found five relevant studies. Two studies explored the impact of education on the prevention of pressure ulcers. We are uncertain whether education of healthcare professionals makes any difference to the number of new pressure ulcers that develop. This is because the certainty of the evidence within the studies was very low. Three studies explored the impact of education on staff knowledge of pressure ulcer prevention. The studies compared: education versus no education; components of educational intervention in a number of combinations; and education delivered in different formats. We are uncertain whether education makes any difference to staff knowledge of pressure ulcer prevention, or to the number of new pressure ulcers that develop. This is because the certainty of the evidence within the studies was very low. No study explored the impact of education on the treatment provided by health professionals. Only one study explored the secondary outcomes of interest: pressure ulcer severity, patients views on their quality of life and carers views on the patients ability to carry out daily tasks independently. However, there was not enough information provided within the study to enable our independent assessment of these outcomes. We examined the certainty of the evidence using the GRADE approach and concluded that all of the evidence was of very low certainty. Therefore we are unable to determine whether education can prevent pressure ulcers. We are also unable to determine whether education affects the knowledge that healthcare staff possess about preventing pressure ulcers. The evidence of this review is up-to-date as of 12 June Publication in The Cochrane Library Issue 6, 2018 Dressings and topical agents for treating venous leg ulcers Gill Norman, Maggie J Westby, Amber D Rithalia, Nikki Stubbs, Marta O Soares, Jo C Dumville Citation example: Norman G, Westby MJ, Rithalia AD, Stubbs N, Soares MO, Dumville JC. Dressings and topical agents for treating venous leg ulcers. Cochrane Database of Systematic Reviews 2018, Issue 6. Art. No.: CD DOI: / CD pub2. ABSTRACT Background: Venous leg ulcers are open skin wounds on the lower leg which can be slow to heal, and are both painful and costly. The point prevalence of open venous leg ulcers in the UK is about 3 cases per 10,000 people, and many people experience recurrent episodes of prolonged ulceration. First-line treatment for venous leg ulcers is compression therapy, but a wide range of dressings and topical treatments are also used. This diversity of treatments makes evidence-based decisionmaking challenging, and a clear and current overview of all the evidence is required. This review is a network meta-analysis EWMA Journal 2018 vol 19 no 2

47 Cochrane Reviews (NMA) which assesses the probability of complete ulcer healing associated with alternative dressings and topical agents. Objectives: To assess the effects of (1) dressings and (2) topical agents for healing venous leg ulcers in any care setting and to rank treatments in order of effectiveness, with assessment of uncertainty and evidence quality. Search methods: In March 2017 we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also scanned reference lists of relevant included studies as well as reviews, meta-analyses, guidelines and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. We updated this search in March 2018; as a result several studies are awaiting classification. Selection criteria: We included published or unpublished randomised controlled trials (RCTs) that enrolled adults with venous leg ulcers and compared the effects of at least one of the following interventions with any other intervention in the treatment of venous leg ulcers: any dressing, or any topical agent applied directly to an open venous leg ulcer and left in situ. We excluded from this review dressings attached to external devices such as negative pressure wound therapies, skin grafts, growth factors and other biological agents, larval therapy and treatments such as laser, heat or ultrasound. Studies were required to report complete wound healing to be eligible. Data collection and analysis: Two review authors independently performed study selection, Risk of bias assessment and data extraction. We conducted this NMA using frequentist metaregression methods for the efficacy outcome; the probability of complete healing. We assumed that treatment effects were similar within dressings classes (e.g. hydrocolloid, foam). We present estimates of effect with their 95% confidence intervals (CIs) for individual treatments focusing on comparisons with widely used dressing classes, and we report ranking probabilities for each intervention (probability of being the best, second best, etc treatment). We assessed the certainty (quality) of the body of evidence using GRADE for each network comparison and for the network as whole. Main results: We included 78 RCTs (7014 participants) in this review. Of these, 59 studies (5156 participants, 25 different interventions) were included in the NMA; resulting in 40 direct contrasts which informed 300 mixed-treatment contrasts. The evidence for the network as a whole was of low certainty. This judgement was based on the sparsity of the network leading to imprecision and the general high risk of bias in the included studies. Sensitivity analyses also demonstrated instability in key aspects of the network and results are reported for the extended sensitivity analysis. Evidence for individual contrasts was mainly judged to be low or very low certainty. The uncertainty was perpetuated when the results were considered by ranking the treatments in terms of the probability that they were the most effective for ulcer healing, with many treatments having similar, low, probabilities of being the best treatment. The two most highly-ranked treatments both had more than 50% probability of being the best (sucralfate and silver dressings). However, the data for sucralfate was from one small study, which means that this finding should be interpreted with caution. When exploring the data for silver and sucralfate compared with widely-used dressing classes, there was some evidence that silver dressings may increase the probability of venous leg ulcer healing, compared with nonadherent dressings: RR 2.43, 95% CI 1.58 to 3.74 (moderate-certainty evidence in the context of a low-certainty network). For all other combinations of these five interventions it was unclear whether the intervention increased the probability of healing; in each case this was low- or very low-certainty evidence as a consequence of one or more of imprecision, risk of bias and inconsistency. Authors conclusions: More research is needed to determine whether particular dressings or topical agents improve the probability of healing of venous leg ulcers. However, the NMA is uninformative regarding which interventions might best be included in a large trial, largely because of the low certainty of the whole network and of individual comparisons.the results of this NMA focus exclusively on complete healing; whilst this is of key importance to people living with venous leg ulcers, clinicians may wish to take into account other patient-important outcomes and factors such as patient preference and cost. Plain language summary: Dressings and topical agents (gels, ointments and creams) for treating venous leg ulcers What is the aim of this review?: The aim of this review is to find out which dressings and topical agents (gels, ointments and creams) are most effective for treating a type of wound known as venous leg ulcers. These are long-term wounds in the lower leg caused by problems with blood flow back up the leg through the veins. Researchers from Cochrane found 78 relevant studies (randomised controlled trials) to answer this question. Randomised controlled trials are medical studies where patients are chosen at random to receive different treatments. This type of trial provides the most reliable evidence. We evaluated these studies using a method known as network meta-analysis (NMA), which allowed us to compare treatments across different studies and to rank them in terms of complete ulcer healing. Key messages: We cannot be certain which dressings and topical agents are most effective for healing venous leg ulcers: over all studies there were not enough participants per treatment and there was high risk of bias; this means that many of the studies were conducted or reported in a way that means we cannot be sure if the results are accurate. The main treatment for venous leg ulcers is compression bandages or stockings and the choice of additional dressings or topical treatments should take into account the review findings and their uncertainty, alongside factors such as patient preference and cost. What was studied in the review?: Venous leg ulcers are open wounds caused by poor blood flow through the veins of the lower leg. Increased pressure in the leg veins may cause damage to the skin and surrounding tissues, leading to an ulcer. EWMA Journal 2018 vol 19 no 2 47

48 Venous leg ulcers can be slow to heal and are painful and costly to treat. The main treatment is compression bandages or stockings but these are often combined with dressings (e.g. foam or nonadherent dressings) and topical creams, gels or ointments. We wished to know which of these additional treatments are most effective when it comes to ulcer healing. What are the main results of the review?: We found 78 studies relevant to this question, dating from 1985 to The studies involved 7014 participants (a majority were women, and average age ranged from 46 to 81 where reported). Our NMA included 59 studies (5156 participants) and compared 25 different treatments such as hydrocolloid and silver-impregnated dressings and a variety of creams and gels. Silver dressings may increase the probability of venous leg ulcer healing compared with nonadherent dressings. However, in the light of the rest of the NMA evidence, we cannot be very confident about any conclusion, and the network as a whole represents low-certainty evidence. This was due to the small numbers of people involved across all included studies, the small number of studies focusing on each treatment, and the high risk of bias. We cannot therefore be certain which are the most effective treatments for venous leg ulcers, or even which treatments it would be best to compare in future trials. How up to date is this review? We searched for studies published up to March Publication in The Cochrane Library Issue 7, 2018 Negative pressure wound therapy for open traumatic wounds Zipporah Iheozor-Ejiofor, Katy Newton, Jo C Dumville, Matthew L Costa, Gill Norman, Julie Bruce Citation example: Iheozor-Ejiofor Z, Newton K, Dumville JC, Costa ML, Norman G, Bruce J. Negative pressure wound therapy for open traumatic wounds. Cochrane Database of Systematic Reviews 2018, Issue 7. Art. No.: CD DOI: / CD pub2. ABSTRACT Background: Traumatic wounds (wounds caused by injury) range from abrasions and minor skin incisions or tears, to wounds with extensive tissue damage or loss as well as damage to bone and internal organs. Two key types of traumatic wounds considered in this review are those that damage soft tissue only and those that involve a broken bone, that is, open fractures. In some cases these wounds are left open and negative pressure wound therapy (NPWT) is used as a treatment. This medical device involves the application of a wound dressing through which negative pressure is applied and tissue fluid drawn away from the area. The treatment aims to support wound management, to prepare wounds for further surgery, to reduce the risk of infection and potentially to reduce time to healing (with or without surgical intervention). There are no systematic reviews assessing the effectiveness of NPWT for traumatic wounds. Objectives: To assess the effects of NPWT for treating open traumatic wounds in people managed in any care setting. Search methods: In June 2018 we searched the Cochrane Wounds Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries for ongoing and unpublished studies, and scanned reference lists of relevant included studies as well as reviews, metaanalyses and health technology reports to identify additional studies. There were no restrictions with respect to language, date of publication or study setting. Selection criteria: Published and unpublished randomised controlled trials that used NPWT for open traumatic wounds involving either open fractures or soft tissue wounds. Wound healing, wound infection and adverse events were our primary outcomes. Data collection and analysis: Two review authors independently selected eligible studies, extracted data, carried out a Risk of bias assessment and rated the certainty of the evidence. Data were presented and analysed separately for open fracture wounds and other open traumatic wounds (not involving a broken bone). Main results: Seven RCTs (1377 participants recruited) met the inclusion criteria of this review. Study sample sizes ranged from 40 to 586 participants. One study had three arms, which were all included in the review. Six studies compared NPWT at 125 mmhg with standard care: one of these studies did not report any relevant outcome data. One further study compared NPWT at 75 mmhg with standard care and NPWT 125mmHg with NPWT 75 mmhg. Open fracture wounds (four studies all comparing NPWT 125 mmhg with standard care) One study (460 participants) comparing NPWT 125 mmhg with standard care reported the proportions of wounds healed in each arm. At six weeks there was no clear difference between groups in the number of participants with a healed, open fracture wound: risk ratio (RR) 1.01 (95% confidence interval (CI) 0.81 to 1.27); moderate-certainty evidence, downgraded for imprecision. We pooled data on wound infection from four studies (596 participants). Follow-up varied between studies but was approximately 30 days. On average, it is uncertain whether NPWT at 125 mmhg reduces the risk of wound infection compared with standard care (RR 0.48, 95% CI 0.20 to 1.13; I2 = 56%); very low-certainty evidence downgraded for risk of bias, inconsistency and imprecision. Data from one study shows that there is probably no clear difference in health-related quality of life between participants treated with NPWT 125 mmhg and those treated with standard 48 EWMA Journal 2018 vol 19 no 2

49 Cochrane Reviews wound care (EQ-5D utility scores mean difference (MD) -0.01, 95% CI to 0.06; 364 participants, moderate-certainty evidence; physical component summary score of the short-form 12 instrument MD -0.50, 95% CI to 3.08; 329 participants; low-certainty evidence downgraded for imprecision). Moderate-certainty evidence from one trial (460 participants) suggests that NPWT is unlikely to be a cost-effective treatment for open fractures in the UK. On average, NPWT was more costly and conferred few additional quality-adjusted life years (QALYs) when compared with standard care. The incremental cost-effectiveness ratio was GBP 267,910 and NPWT was shown to be unlikely to be cost effective at a range of cost-per-qalys thresholds. We downgraded the certainty of the evidence for imprecision. Other open traumatic wounds (two studies, one comparing NPWT 125 mmhg with standard care and a three-arm study comparing NPWT 125 mmhg, NPWT 75 mmhg and standard care) Pooled data from two studies (509 participants) suggests no clear difference in risk of wound infection between open traumatic wounds treated with NPWT at 125 mmhg or standard care (RR 0.61, 95% CI 0.31 to 1.18); low-certainty evidence downgraded for risk of bias and imprecision. One trial with 463 participants compared NPWT at 75 mmhg with standard care and with NPWT at 125 mmhg. Data on wound infection were reported for each comparison. It is uncertain if there is a difference in risk of wound infection between NPWT 75 mmhg and standard care (RR 0.44, 95% CI 0.17 to 1.10; 463 participants) and uncertain if there is a difference in risk of wound infection between NPWT 75 mmhg and 125 mmhg (RR 1.04, 95% CI 0.31 to 3.51; 251 participants. We downgraded the certainty of the evidence for risk of bias and imprecision. Authors conclusions: There is moderate-certainty evidence for no clear difference between NPWT and standard care on the proportion of wounds healed at six weeks for open fracture wounds. There is moderate-certainty evidence that NPWT is not a cost-effective treatment for open fracture wounds. Moderatecertainty evidence means that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different. It is uncertain whether there is a difference in risk of wound infection, adverse events, time to closure or coverage surgery, pain or health-related quality of life between NPWT and standard care for any type of open traumatic wound. Plain language summary Negative pressure wound therapy for open traumatic wounds What is the aim of this review?: The aim of this review was to find out whether negative pressure wound therapy (NPWT) (a sealed wound dressing connected to a vacuum pump that sucks up fluid from the wound) is effective for treating open traumatic wounds (injuries such as animal bites, bullet wounds or fractures that result in bone piercing the skin to form open wounds). Researchers from Cochrane collected and analysed all relevant studies (randomised controlled trials) to answer this question and found seven relevant studies. Key messages: We cannot be certain whether NPWT is effective for treating traumatic wounds. We are moderately confident that there is no clear difference in healing rates in open fracture wounds treated with NPWT compared with standard care. We are very uncertain whether people treated with NPWT experience fewer wound infections compared with those treated with standard care. There is moderate-certainty evidence that NPWT is not a cost-effective treatment for open fracture wounds. What was studied in the review?: Traumatic wounds are open cuts, scrapes or puncture wounds, where both the skin and underlying tissues are damaged. These wounds may have jagged edges and contain items such as gravel or glass. Injuries caused by road traffic accidents, stab and gunshot wounds, and animal bites are common types of traumatic wound. NPWT is a treatment that is used widely on different types of wounds. In NPWT, a machine that exerts carefully controlled vacuum suction (negative pressure) is attached to a wound dressing that covers the wound. Wound and tissue fluid is sucked away from the treated area into a canister. This is thought to increase blood flow and improve wound healing. We wanted to find out if NPWT could help open traumatic wounds to heal more quickly and effectively. We wanted to know if people treated with NPWT experienced any side effects or other complications, such as wound infections and pain. We were also interested in the impact of NPWT on people s quality of life. What are the main results of the review?: We found seven relevant studies, dating from , which compared the effect of different strengths of NPWT with standard wound care. The studies involved a total of 1381 participants aged 12 years and over. The participants sex was not recorded. Not all the studies stated how they were funded. One was funded by an NPWT manufacturer. There is no clear difference in healing rates in participants with open fracture wounds treated with NPWT compared with those receiving standard care. There is moderate-certainty evidence that NPWT is not a cost-effective treatment for open fracture wounds. We are very uncertain as to whether NPWT may reduce the likelihood of wound infection compared with standard care. There is no clear evidence that NPWT impacts on people s experience of pain, adverse events or their experience of receiving therapy. How up to date is this review? We searched for studies that had been published up to June m EWMA Journal 2018 vol 19 no 2 49

50 EWMA EWMA Journal Previous Issues Volume 19, no 1, April 2018 Opinions that matter: Patient s perspective of their perioperative management during surgery for diabetic foot Piaggesi A, Bonaventura L, Giusti S, Goretti C, Menichini C Skin tears in the aging population: Remember the 5 Ws Vanzi V, LeBlanc K Recommendations to improve health care for people with chronic diseases Maggini M, Zaletel J Bioburden levels of spools of surgical tape in different healthcare settings Yu V, Deing V, Nehrdich T, Struensee B Specific risk factors for pressure ulcer development in adult critical care patients a retrospective cohort study Ahtiala M, Soppi E, Tallgren M Prevalence of chronic wound in different modalities of care in Germany Kröger K, Jöster M Other journals EWMA wishes to facilitate the exchange of information on wound healing in a broad perspective with this section on International Journals. English Advances in Skin & Wound Care. Sep A Wolf in Sheep s Clothing: An Unusual Presentation of Diabetic Myonecrosis Boinpally H, Howell RS, Slone E, et al The Safety of Negative-Pressure Wound Therapy on Surgical Wounds: An Updated Meta-analysis of 17 Randomized Controlled Trials Ge D The Diabetic Foot Amputation Decision-Making Process Wang SY, Liu JF, Huang YP, et al Monitoring and Molecular Characterization of Staphylococcus aureus Isolated from Chronic Wounds Pires BMFB, de Oliviera FP, de Oliviera BGRP, et al Volume 18, no 2, October 2017 Evaluation of a newly designed moisture management product for use in women giving birth at the Canberra Centenary Hospital for Women and Children. Broom M, Dunk A M, Sheridan D, McLeod M Advancing professional health care practice and the issue of accountability. Cornock M The changing US healthcare climate: What does it mean for wound care? Nusgart M Core outcome set for Venous leg ulceration CoreVen Hallas S, Nelson A, O Meara S, Gethin G Negative Pressure Wound Therapy: Future Perspectives Apelqvist, J, Willy C, Fagerdahl A, Fraccalvieri M, Malmsjö M, Piaggesi A, Probst A, Wowden P Volume 17, no 1, April 2017 Debridement method optimisation for treatment of deep dermal burns of the forearm and hand Zacharevskij E, Baranauskas G, Varkalys K, Kubilius D, Rimdeika R Lived experiences of life with a leg ulcer - a life in hell Lernevall LSD, Fogh K, Nielsen CB, Dam W, Dreyer PS Illness, Normality, and Self-management: Diabetic Foot Ulcers and the Logic of Choice Andersen SL, Pedersen M, Steffen V Essential microbiology for wound care Pina E Volume 16, no 2, October 2016 Efficiency in wound care: The impact of introducing a new foam dressing in community practice Kronert GT, Roth H, Searle RJ Negative pressure wound therapy in the treatment of acute pyoinflammatory diseases of soft tissues Obolensky VN, Ermolov AA, Rodoman GV The use of clinical guidelines during the treatment of diabetic footulcers in four Nordic countries Annersten M The WAWLC Wound Care Kit for less resourced countries: a key tool for modern adapted wound care Vuagnat H, Comte E Finnish Spanish Italian Haava, no 2, National Wound Conference Patient Safety Risto P. Roine Antibiotics - When and How? Matti Karppelin Nutrition of Elderly Focusing on Wound Care Merja Jäntti Wound Care in Home Care Marja Vihavainen Helcos, vol. 29, no. 9, 2018 Prevalence of pressure injuries, incontinence, incontinence associated dermatitis and risk factors associated with pressure injuries in a mother-and-child third level hospital G Perez-Acevedo; A Bosch-Alcaraz ; C Agustin-Mata Prevention of pressure ulcers and repositioning. An integrative review P López-Casanova; J Verdú-Soriano; M Berenguer-Pérez The importance of adequate initial treatment in a subdermal burn in lower limb. Clinical case Approach of a Category III rub injury, with the presence of biofilm, after mechanical containment J Guinot-Bachero; A García-Montero; N Martinez-Blanco JA Hernandez-Ortiz; AM Navarro-Fernandez; AM Galera- Barrero Italian Journal of Wound Care, Vol 2, Skin grafting in the treatment of hard-to-heal leg ulcers Giovanni Mosti, Vincenzo Mattaliano, Pietro Picerni, Costantino Christou The use of modern technologies based on telemedicine in wound care: experience in high-tyrrhenian region and the province of Cosenza, Italy Francesco Giacinto, Ciro Falasconi, Elisabetta Giacinto, et al. The EWMA Journals can be downloaded free of charge from 50 EWMA Journal 2018 vol 19 no 2

51 English English Polish Lithuanian Journal of Tissue Viability, vol. 27, no 2, Evaluation of comfort associated with the use of a robotic mattress with an interface pressure mapping system and automatic inner air-cell pressure adjustment function in healthy volunteers Manaka Saegusa, Hiroshi Noguchi, Gojiro Nakagami et al. Frailty and body mass index are associated with biophysical properties of the skin in community-dwelling older adults Shinji Iizaka The relationship of subepidermal moisture and early stage pressure injury by visual skin assessment Chul-Gyu Kim, Seungmi Park, Ji Woon Ko et al. Investigation of the prevalence of pressure ulcers and patient-related risk factors in hospitals in the province of Erzurum: A cross-sectional study Mağfiret Kaşıkçı, Meyreme Aksoy, Ay Emrah Journal of Wound Care, vol. 27, no 9, Role of platelet-rich plasma in healing diabetic foot ulcers: a prospective study Shailendra Pal Singh, Vishal Kumar, Anand Pandey et al French Canadian translation and the validity and interrater reliability of the ISTAP Skin Tear Classification System Valérie Chaplain, Chantal Labrecque, Kevin, Y. Woo et al Shockwave therapy in selected soft tissue diseases: a literature review Patrycja Dolibog, Andrzej Franek, Ligia Brzezińska-Wcisło et al Skeletal muscle regeneration by extracellular matrix biological scaffold: a case report Jane Y. Zhao, Kathryn D. Bass Leczenie Ran vol. 15, no 2, Modern methods of the assessment of chronic wound healing dynamics medical thermography Cwajda-Białasik J, Moscicka P, Szewczyk MT et al. The usefulness of the selected metods of chronic wounds cleansing in patients under hospice home care Bazalinski D, Baranska B, Kaczmarska D et al. Combination therapy of Crohn s anal fistulas with a single dose of dalbavancin and negative pressure therapy Cwalinski J, Tomczak H, Hermann J et al. Superbacteria in diabetic foot syndrome winning an uneven fight Budzich M, Mrozikiewicz-Rakowska B, Czupryniak L Lietuvos chirurgija, vol. 17 no 1-2, Sepsis infection related life-threatening organ dysfunction Vosylius S, Nekrasiene M The treatment of the thumb carpometacarpal arthritis by an open synovectomy with a jodint debridement: evaluation of long-term postoperative treatment results Tamulevicius M, Minderis M, Pajeda A Arterialisation of Great Saphenous vein in situ for limb salvation: a case report Cvetanovski V, Arsovski A, Stojanovska L, et al. Asherman s syndrome: a clinical case report and review of the literature Buzinskiene D, Drasutiene G, Zdanyte K German Scandinavian Scandinavian English German Phlebologie, vol. 4, Oedema Drainage and Cardiac Insufficiency When is there a Contraindication for Compression and Manual Lymphatic Drainage? T. Hirsch Update on Direct Oral AntiCoagulants (DOACs) Koscielny, J.; Rosenthal, C.; von Heymann, C.: DOAC use in patients with chronic kidney disease Kücükköylü, S.; Rump, L. C.: For surgical treatment of postoperative lymphocels after surgery for recurrent varicosis Baier, P.-M.; Misczcak, Z. T. SÅRmagasinet no 3, Antibiotic Resistance on the Agenda for UN Otto Cars/Christina Lindholm Hygienic challenges in wound management Christer Häggström High frequency of antibiotic bacteria in waste water Inger Kuhn, Roland Möllby Antibiotic resistance and wise use of antibiotics Charlotta Falk Sår (Wounds), no Quality of Life Model in the Healthcare Sector Jane Thinggaard Knudsen Leg Amputations A Better Alternative Jens Fonnesbech Arterial Wounds New Opportunities Eskild Henneberg Wound Consultants The New Black Jens Fonnesbech Wound Repair and Regeneration, vol. 26, no. 1, 2018 A multicenter, randomized, single-blind trial comparing the efficacy of viable cryopreserved placental membrane to human fibroblast-derived dermal substitute for the treatment of chronic diabetic foot ulcers Ananian CE, Dhillon YS, Van Gils CC, et al. Risk factors for recurrence of pressure ulcers after defect reconstruction Wurzer P, Winter R, Stemmer SO, et al. Extracorporeal shockwave therapy for treatment of keloid scars Wang CJ, Ko JY, Chou WY, et al. Influence of human acute wound fluid on the antibacterial efficacy of different antiseptic polyurethane foam dressings: An in vitro analysis Rembe JD, Fromm-Dornieden C, Bohm J, et al. Wund Management, no 4, 2018 Diagnosis and Therapy of Varicose Vein Disease Steffen, H.-P.; Langer, E.; Popovici, C. EWMA Journal 2018 vol 19 no 2 51

52 EWMA EWMA 2019 GOTHENBURG SWEDEN 5-7 JUNE 2019 EWMA 2019 Conference in Gothenburg, Sweden It is a great pleasure to announce the 29 th Conference of the EuropeanWound Management Association, EWMA 2019, which will take place in Gothenburg, Sweden, 5 7 June EWMA 2019 is organised in cooperation with the SSiS, Swedish Wound Care Nurses Association. OTHER COLLABORATORS: Swedish Registry of Ulcer Treatment 52 EWMA Journal 2018 vol 19 no 2

53 THE CONFERENCE THEME IS Person-centred Wound Care. Who is in Charge of the Wound? THE THEME A wound is always part of someone s body; a person has to live with it. The patient therefore qualifies as an important member of the team focusing on wound healing. When all professionals, with their specific competences, work together with the patient, progress can be made and clinical knowledge and competences can be developed and shared. A multidisciplinary inter-professional team and person-centred wound care approach will support the wound healing process, increasing the patient s quality of life and proving cost-effective. ABOUT GOTHENBURG Gothenburg is the second-largest city in Sweden, located on the west coast at the epicentre of Scandinavia and the Baltic States. Experience the light-filled Nordic summer evenings in this charming harbour city, which has an exceptional combination of city life, culture and nature. You will seldom have such easy access to everything you want and need. Within this pedestrian-friendly city, you will find cobbled lanes lined with local design boutiques, Nordic architecture, excellent restaurants and cosy independent cafés and the stunning archipelago is only a tram ride away. Known as a smart city that is going green and open to the world, expect nothing less than to be met by Gothenburg s warm and friendly people and their laid-back attitude. PROGRAMME EWMA 2019 includes a mixture of new topics that are important to the European wound community, in addition to topics that have had enormous appeal during previous EWMA conferences. The sessions deal with the advancement of education and research in relation to epidemiology, pathology, diagnosis, prevention and the management of wounds. EWMA Journal 2018 vol 19 no 2 53

54 SUBMISSION CATEGORIES: n Acute Wounds PROGRAMME HIGHLIGHTS KEY SESSIONS n Opening Key Session: Person-centred Wound Care. Who is in Charge of the Wound? n Pressure Ulcer Prevention n Translational Science and Clinical Opportunities: Basic Science Key Session n Catastrophe and War Wounds n Patient Involvement and Patient Safety n Multidisciplinarity and Organisation n Atypical Wounds n Surgical Treatment of Chronic Wounds n Economics of Wound Management n Burns n Surgical Site Infection n Managing and Preventing Birth-Related Wounds and Post-Caesarean Section Infections. EWMA STREAMS The full-day streams are particularly popular among EWMA Conference delegates, as they foster more indepth discussions. Streams at EWMA 2019 include: n Pressure Ulcer Prevention n Infection, Prevention and Control Stream n Diabetic Foot Ulcers n Debridement Day WORKSHOPS EWMA Workshops are typically held in a smaller setting than the other sessions. The workshops are interactive and give participants an opportunity to address and elaborate on particular aspects of the themes of individual sessions. The workshops will cover: n Debridement n After Debridement n How to Read a Paper. Understanding the Basics. n Diabetic Foot Assessments, Offloading and Footwear n Managing Wounds after Discharge - Case Studies Discussion Workshop n Eczema in Leg Ulcer Patients n Regulatory Workshop n Patient Repositioning and the Properties of the Patient Support Surfaces Used. n Antimicrobials n Basic Science n Burns n Devices & Intervention n Diabetic Foot n Dressings n Education n e-health n Health Economics & Outcome n Home Care n Infection n Leg Ulcer n Negative Pressure Wound Therapy n Nutrition n Pain n Pressure Ulcer n Prevention n Quality of Life n Wound Assessment n Case Studies (e-posters only) n Professional Communication (e-posters only) Submit your abstract and view guidelines and conditions online at Please note that only electronic submissions are accepted. Abstract submission deadline: 1 December 2018 Get inspired and learn more about what an EWMA Scientific Programme may look like by exploring the 2018 programme: www. ewma.org/ewma-conference/2018/scientific/ programme 54 EWMA Journal 2018 vol 19 no 2

55 EWMA FOCUS SESSIONS A focus session is an opportunity to go into depth with a topic. The focus session takes place in a smaller setting and typically features one or two speakers. The 2019 focus sessions are: n Skin Necrosis in Wounds n Malignant and Fungating Wounds n Pain Assessment n Lesions in Fragile Patients n Regenerative Medicine in the Treatment of Chronic Wounds GUEST SESSIONS EWMA has invited a number of organisations to facilitate guest sessions at EWMA This serves to increase scientific cooperation and networking with organisations active in thematic issues related to wound healing and management. ABSTRACT SUBMISSION Abstracts for oral presentations, electronic poster presentations and paper poster displays may be submitted as detailed below: MEET THE EXPERTS A number of meet the experts sessions will take place during EWMA Participants are invited to listen to and discuss with leading experts in an informal setting. REGISTRATION Register for the Conference from November 2018 at www. ewma.org/ewma-conference/2019/registration Registration fees Category FULL 3 DAY CONFERENCE REGISTRATION: Until and incl. 3 April 2019 EWMA Members and Members of National Societies cooperating with EWMA. 483 See link below 1 (386,40 ex. VAT) Non-members Student registration ONE DAY CONFERENCE REGISTRATION: EWMA Members, Members of National Societies cooperating with EWMA 1 and non-members One day registration - exhibition access only: Exhibition access only (no access to sessions & workshops) 583 (466,40 ex. VAT) 295 (236,00 ex. VAT) 315 (252,00 ex. VAT) Same price as after 3 April 4 April - 26 May (456,00 ex. VAT) 670 (536,00 ex. VAT) 295 (236,00 ex. VAT) 348 (278,40 ex. VAT) 322 (257,60 ex. VAT) After 26 May (508,80 ex. VAT) 737 (589,60 ex. VAT) 295 (236,00 ex. VAT) 415 (332,00 ex. VAT) 391 (312,80 ex. VAT) 1 Members of EWMA Cooperating Organisations see: ewma-cooperating-organisations/ Swedish VAT: 25% EWMA Journal 2018 vol 19 no 2 55

56 EWMA See updated programme and topics on WHY ATTEND THE EWMA CONFERENCE? The EWMA Conference offers high-level scientific presentations, networking activities and an excellent opportunity to exchange knowledge and experiences with international colleagues. This is how life feels to people with EB. Their skin is as fragile as a butterfly s wing. They have Epidermolysis Bullosa, a painful and currently incurable skin blistering condition. Think that the conference met their expectations or was better than expected. Think the content of the sessions were either good or excellent. Think the conference was relevant to their work. Connected and networked with other participants during the conference. Gained new knowledge and valuable information and contacts from the exhibiting companies. Would recommend EWMA Conference to others. *EWMA 2017 delegate survey WHY ATTEND THE EWMA CONFERENCE? The EWMA Conference offers high-level scientific presentations, networking activities and an excellent opportunity to exchange knowledge and experiences with international colleagues. We look forward to welcoming you to Gothenburg! IMPORTANT DATES: n Conference dates: 5 7 June 2019 n Registration opens: November 2018 n Abstract submission opens: October 2018 n Abstract submission deadline: 1 December 2018 n Early registration deadline: 3 April 2019 Stay informed by visiting the conference website, for more information about the programme. You can also find updates on EWMA s social media platforms. International. 56 EWMA Journal 2018 vol 19 no 2

57 The peerreviewed, international journal for wound care SAVE 20% Save 20% on your official partner journal Journal of Wound Care (JWC) is the world s leading publication for tissue viability specialists, and an official partner of the European Wound Management Association (EWMA). Focusing on practice, education, research and management, it provides a trusted evidence base to inform advanced knowledge and skills. EXCLUSIVE OFFER FOR EWMA MEMBERS All EWMA members are entitled to a 20% discount on their JWC subscription. To claim this special offer, simply quote code EWMA20 when ordering. From 151,00 120,80 per year MEDLINE LISTED IMPACT FACTOR Frailty and functional disability among older adults with/without MEDLINE diabetes and foot ulcers LISTED Classification, microbiology and treatment of diabetic foot infections FACTOR IMPACT Haemoglobin spray as adjunctive therapy Creating the treatment a culture of sloughy to prevent woundspressure ulcers in older adults in health-care facilities Cost-effectiveness of an electroceutical device in treating non-healing VLUs Traditional culture methods fail to detect pathogens in a necrotising infection Evaluation of an ultrasonic debridement system in patients with diabetic foot ulcers Pressure ulcer prevalence and perceptions on prevention Using AutoCAD software to measure venous leg ulcers Effect of a nitric oxide dressing on bacterial counts on human skin Claim your discount with code EWMA20 magsubscriptions.com/jwc +44 (0) subscriptions@markallengroup.com Postage and packaging not included outside of the UK. If selecting a print product, shipping will be calculated at checkout. For non-eu based subscribers, prices start from $136.80/ with code EWMA20.

58 EWMA EWMA 2018 KRAKOW, POLAND EWMA 2018 Conference in Krakow, Poland The 28 th Conference of the European Wound Management Association, EWMA 2018, was a great conference in many ways! The scientific programme consisted of various key sessions, workshops, focus sessions, full-day streams and satellite symposia and offered the most recent knowledge to participants. The conference provided an energetic environment in which colleagues in the field of wound management from around the world came together for almost 1,000 high-level scientific presentations and great networking opportunities. 58 EWMA Journal 2018 vol 19 no 2

59 The 2018 conference was organised in cooperation with the Polish Wound Management Association (PWMA). The EWMA Conference was held in Poland for the first time, in the historic city of Krakow. With its long history of intellectual heritage and modern, dynamic development, Krakow offered an ideal venue for the EWMA 2018 Conference to gather the European and international wound management communities with the common goal of improving the care of wound patients. A total of 3,500 participants took part in the conference, including a large number of key international opinion leaders and senior industry executives. It was encouraging to see the high standards of the presentations and to reflect upon the strong, continued interest in wound healing across Europe. Our heartfelt appreciation goes out to all the speakers, presenters and organisers who actively participated in the sessions. THE CONFERENCE THEME OF EWMA 2018 WAS Krakow: New Frontiers in Wound Management The theme reflected that wound care technologies are rapidly developing and offering new treatment options that should be used when proven cost-effective and beneficial to patients. The development further stresses the importance of up-to-date and continued education in an interdisciplinary environment. The technological and educational aspects are two important elements of seeking and expanding the new frontiers of wound management. THE SESSIONS The conference included many interesting sessions on a variety of wound-related topics. The sessions covered a variety of topics important to the European wound community in general and dealt with the advancement of education and research in epidemiology, pathology, diagnosis and prevention. Among the sessions were very well attended sessions including Advanced Therapies in Wound Management - Challenges and Opportunities; The Role of the Micro-Environment for Bacterial Persistent in Chronic Wounds; Atypical Wounds - What is your Diagnosis?; Scar Management: What is New?; and the Diabetic Foot Workshop Assessments, Offloading and Footwear. EWMA Journal 2018 vol 19 no 2 59

60 The conference programme included many guest and joint sessions by many wound care-related organisations, including n n n Association of Diabetic Foot Surgeons (ADFS) British Society of Antimicrobial Chemotherapy (BSAC) n Cardiovascular and Interventional Radiological Society of Europe (CIRSE) n Dystrophic Epidermolysis Bullosa Research Association (DEBRA) n European Burns Association (EBA) n European Council of Enterostomal Therapy (ECET) n European Pressure Ulcer Advisory Panel (EPUAP) n European Society for Clinical Nutrition and Metabolism (ESPEN) n European Society of Plastic, Reconstructive and Aesthetic Surgery (ESPRAS) n European Tissue Repair Society (ETRS) n International Lymphoedema Framework, ILF-EWMA Joint Session n International Federation of Podiatrists (FIP-IFP) n International Council of Nurses (ICN) n IWGDF Guidance Group World Alliance for Wound & Lymphedema Care (WAWLC) In addition, EWMA was happy to welcome our international partner association from China, the Chinese Tissue Repair Society (CTRS), which organised the international partner session on Chinese and Western Medicine. The scientific programme would not have been complete without the many submitted abstracts that contributed to 18 free paper sessions and more than 500 e-posters. EWMA greatly appreciates the interest from all clinicians and researchers who submitted abstracts for the conference! Abstracts presented at the conference as oral or e-poster presentations are now available at the EWMA Knowledge Centre website ( SYMPOSIA AND STREAMS One- and two-day streams are organised at the EWMA conferences to place extraordinary focus on a specific topic. In 2018, the EWMA streams included the infection prevention and control stream, including antimicrobial stewardship and surgical site infection, a diabetic foot stream and a revascularization stream. Moreover, the International Conference of the Veterinary Wound Healing Association (VWHA) was held during EWMA The conference provided a unique platform where scientists and other experts in veterinary and human wound management, as well as public health, could meet. The conference offered an opportunity to share new knowledge, identify interfaces between veterinary and human wound research and management and created a basis for achieving synergies. The symposium took place Friday, 11 May. INDUSTRY When speaking of the great successes of EWMA 2018, it is important to stress the great contributions of the industry. The exhibition hall hosted 150 companies, organisations and associations for EWMA participants to visit. The industry-sponsored symposia were of great value, and the Scientific Committee is grateful to all industry partners whose cooperation contributed to the success of EWMA EWMA 2018 was undoubtedly an enjoyable and informative experience for all participants. EWMA s highest priorities are bringing together the European wound healing community and, perhaps most importantly, creating and strengthening links among the national associations that strive to raise the profile of wound management within their respective countries. WEBCASTS Log on to to access the EWMA Knowledge Centre to gain free access to webcasts of selected key sessions, all e-posters and abstracts from EWMA 2018 and previous EWMA conferences. PRIZES AND AWARDS Of the many abstracts chosen for presentation at the conference, one was awarded the First Time International Presenter Prize, and four were awarded e-poster prizes for especially great presentations. 60 EWMA Journal 2018 vol 19 no 2

61 EWMA FIRST TIME INTERNATIONAL PRESENTER AWARD 2018 During the conference, the chairs evaluated the first-time international presenters and selected the following speaker for the First Time International Presenter Award based on the high quality of her presentation, which was especially outstanding: Francesca Latini, Italy Abstract No. OP117, presented during the Acute Wounds free paper session: Dermal Substitutes and Negative Pressure Wound Therapy in the Treatment of Complex Limbs Traumas E-POSTER PRIZES The e-poster prizes are awarded to e-posters that: n Are visually appealing n Are well laid out in a logical manner n Contain relevant, interesting content n Have clear conclusions Prizes were awarded to the following four e-posters: n Anneke Andriessen, EP257 Health Economics & Outcome; The Real Value of Mechanical Debridement in Complex Wounds - A Clinical Study n Annette Downe, EP249 Burns, e-health & Pain; Implementation Plan for the Development of Telemedicine (TM) in the Epidermolysis Bullosa (EB) Service using the Model for Assessment of Telemedicine (MAST) n Jane Hampton, EP403 Quality of Life, Home Care & Nutrition; The Impact of Wound Care Provision in a Community Health Care Organization n Rosemary Hill, EP427 Wound Assessment; Shifting Focus: Implications of Periwound Bacterial Load on Wound Hygiene n Bianca Price, EP155 Diabetic Foot; The Microbiome of a Grade 1B Diabetic Foot Infection and its Susceptibility to Gentamicin Released from Calcium Sulfate Beads. EWMA Journal 2018 vol 19 no 2 61

62 EWMA EWMA Honorary Speaker 2018: Veronika Gerber Sue Bale EWMA President EWMA was pleased to present Veronika Gerber as the Honorary Speaker 2018 at this year s EWMA conference in Krakow. Originally, Veronika Gerber trained as paediatric nurse and she still values the special experiences and privileges that caring for children has brought her very much. Working with children helped her develop the patience, friendliness, empathy and commitment, which is necessary especially in paediatrics, but has stayed with her throughout the whole of her professional life. Not being content with the work in the ward, she started to develop her skills in palliative care. This formerly neglected field of medical work is now a respected sub-discipline in Germany a success to which Veronika Gerber has contributed a tremendous amount. Looking for further new challenges, Veronika Gerber established one of the first wound ambulances in Aurich, a small town in Northwest Germany. From this remote corner, she gained nationwide attention with a new model in wound healing which combined hospital and ambulant care. For many years she has lectured in wound healing. Thousands of German nurses and doctors profited from her teaching, experiences and skills. Her enormous knowledge, huge experience and the ability to motivate colleagues from different disciplines to work together qualified her for leading positions in the newly founded Initiative Chronische Wunden (ICW). After a short time Veronika Gerber was elected as chairperson which is a highly responsible role with a high work load to lead an organization of now nearly 4000 members. Interprofessionality and multidisciplinarity are keystones of modern wound management. Veronika Gerber represents these aspects ideally through the whole course of her life and her always-friendly mediating personality. Correspondence: ewma@ewma.org 62 EWMA Journal 2018 vol 19 no 2

63 EWMA EWMA 2018 Cooperating Organisations Board Meeting: Flashback and brief reflections Severin Läuchli Chair of the Cooperating Organisations Board EWMA Immediate Past President Alita Jaspar presenting experiences from the pilot review of a wound care centre in the Netherlands. Severin Läuchli in dialogue with one of the tables during the debate session. It has become almost a tradition that the appointed representatives of the EWMA Cooperating Organisations meet during the Thursday afternoon of the EWMA conference. The meeting this year brought together 58 representatives from Cooperating Organisations and other partner organisations and the EWMA Council, for networking and the exchange of knowledge and experiences. The main topic of the 2018 presentations and discussion was Experiences with the development and endorsement of wound centres across Europe. The topic was covered in detail through presentations by Hubert Vuagnat, chair of the EWMA Wound Centre Endorsement Working Group, and other presenters (see facts box). The presentations sparked a very engaged and lively debate amongst the meeting s participants, the conclusions of which will be used to develop and further qualify the activities of the working group. For further reading about these activities, please refer to the EWMA website org/it/what-we-do/centre-endorsements/ and the article Wound centres how do we obtain high quality? The EWMA wound centre endorsement project published in the Journal of Wound Care in May cated to the election among three candidates of a new member to replace Barbara den Boogerts- Ruimschotel, representing the Cooperating Organisations on the EWMA Council. The winner was Elisabeth Lindahl, nominated by the Swedish Wound Care Nurses Association (SSiS). She will now join the EWMA Council for a three-year term. Presentations about experiences with the development and endorsement of wound centres across Europe. n Hubert Vuagnat: EWMA endorsement programme: Plans and status n Luc Gryson, Alita Jaspar: Experiences from a review of a Dutch centre, reviewer and centre representative experiences n National endorsement/certification programmes, examples: n Christian Münter: ICW wound centre certifications (Germany) n Maria Signer: SAfW (German section) endorsement programme (Switzerland) n Pedro Luis Pancorbo Hidalgo: GNEAUPP endorsement of centre in Bilbao (Spain) The final part of the board meeting was dedi Correspondence: ewma@ewma.org EWMA Journal 2018 vol 19 no 2 63

64 EWMA Salla Seppänen Director of Faculty of Health Care, Social Services, Culture and Rural Industries, Savonia University of Applied Sciences, Finland EWMA Past President Correspondence: The Cooperating Organisations Workshop on Wound Centres at the EWMA 2018 Conference in Krakow EWMA has made strides in the development of wound centres to increase the quality and impact of wound management. At the moment, wound centres are under discussion and development in many countries, both in and outside Europe, thus the 2018 EWMA conference, held in Krakow, Poland, featured a workshop wherein co-operating organisations could share their experiences and visions of wound centres. The workshop centred on five presentations that provided examples of how wound centres have been conceptualised, established and implemented on national and regional bases in the Netherlands, Switzerland, Denmark, Spain and Finland. Each presentation was followed by a discussion based on the questions raised by the presenter. Ellie Leneslink presented the Dutch model of a wound expertise centre, located in the Hague. She stressed that, in the future, collaborations between primary and secondary care in wound management will be strengthened while the Dutch National Quality Standard for care of complex wounds is launched. As an example of developed patient-centred services, she pointed out a new approach used by a specialised diabetic foot clinic, which offers first aid to patients with diabetic foot problems 24/7. Maria Signer, from Venen Klinik, Kreutzlingen, in Switzerland, shared the model developed by the Swiss Association for Wound Care (SAfW), which aims to standardise the quality requirements and standards of outpatient wound care centres in both hospital and non-hospital contexts. Since 2010, the SAfW has reviewed outpatient wound centres according to a developed catalogue that addresses the complexity of treating patients with acute and chronic wounds. These assessments are done within multiprofessional networks based on presented cases of outpatient wound centres using SAfW s evaluation platform. Once the requirements are met, the outpatient wound centre is listed on the SAfW website as recommended, and the centre can use its logo in documents to show this recognition of quality. Approvals are valid for three years before a re-assessment is needed. Currently, 17 outpatient wound care centres in Switzerland have earned SAfW s approval. Annette Høgh, from the Wound Centre in Viborg, Denmark, stressed the importance of multidisciplinary collaboration in the care of patients with wounds, which has, nationwide, been the structure of wound management teams since the early 2000s. Danish telemedicine is an innovation that has built a bridge between primary health care at the municipality level and secondary health care at the hospital level. The Danish Wound Healing Society aims to convince national health authorities to certify the quality of wound care in wound centres. Part of that includes designing national clinical guidelines for wound care, which are crucial for high-level, standardised wound care. The DWHAS also focuses on the education concerning wound management that is needed for professionals involved in the care of wound patients. The Spanish example of a wound centre was presented by Pedro Pancorbo-Hidalgo, from the University of Jaén. His presentation focused on the model of the Andalusian Health Service, where Advanced Practice Nurses (APN) in wound care play a key role in wound centres. Their pilot programme began in 2015 with five APNs who had master level education and extensive experience in wound care. The wound care APNs worked in collaboration with primary care nurses, general practitioners, nursing home staff, hospital nurses and medical specialists, and the project facilitated the development of a certification process for APNs in wound care. Clinically, the results showed a roughly 20% increase in the use preventive measures for pressure ulcers and a reduction in the mean time of wound healing, from 24 to 11 months. Economic and organisational outcomes showed a 10% reduction in the number of wound 64 EWMA Journal 2018 vol 19 no 2

65 patient referrals to medical specialists and a 3% reduction of patients in-hospital admissions for the surgical debridement of wounds. The Finnish example was presented by Heli Lagus, from the Helsinki Wound Centre, a planned multidisciplinary working group that includes representatives from different specialities and professions who treat patients with wounds. The group has also overseen the integration of primary and specialised care implemented by professionals, nurses and medics who have been placed in charge of wound care. One example of the integration of care is that of consultants from specialised care into wards in primary care settings; this is done once per week, in addition to e-consulting, which is being piloted for future plans to replace some outpatient visits. Lagus stressed that evidence-based treatment is the backbone of any wound centre, thus research is an essential part of wound care centres activities. Through the systematic assessment of wounds, it is possible to establish a wound registry, thus facilitating research activities. In summarising this session on wound centres, I want to highlight the importance of continuity of care for patients with wounds. Wound centres should integrate primary and specialised care and establish shared, evidence-based guidelines and principles of wound management. The notions of interprofessional co-operation and shared learning were focused on in all presentations, thus highlighting that education is essential for achieving, updating and developing professionals competences in wound management. The criteria for wound centres need to be defined nationally, and assessments should be made via regular, reliable documented processes. The recognition of fulfilled criteria is part of wound centres quality management. These national wound organisations have an important role in pushing wound centres toward excellence, and the shared learning they promote within practice, education and research is inevitable. The EWMA Wound Centre Endorsement Programme aims to support the continuing establishment of highquality wound centres that acknowledge the need for multidisciplinary teamwork and evidence-based wound management. The EWMA working group includes wound care experts with experience of developing wound care centres in different European countries by defining the criteria and procedures for wound centre endorsements. These criteria cover centres physical facilities, procedures and equipment available for diagnosis and treatment; centres organisation and staff; referral routes; and research and educational activities. More information is available on the EWMA website; EWMA Journal 2018 vol 19 no 2 3 rd Nordic Diabetic Foot Symposium 2018 Helsinki Finland 6-7 November 2018 Scandic Marina Congress Center The programme will be composed of: Plenary talks Meet the experts sessions Hands-on workshops Copyright Helsinki Marketing Welcome to NDF 2018 The symposium provides a forum for sharing and dissemination of high level scientific evidence as well as local examples of best practice diabetic foot care. It is also a platform for coordinating the joint effort of promoting guideline implementation in each of the Nordic countries. Furthermore, the symposium is an excellent opportunity to exchange knowledge and experiences with peer researchers and clinicians from other Scandinavian countries. For more information, please visit:

66 Closing wounds. Together. I need safe and efficient infection management for my patients. For me, Cutimed Sorbact is a responsible choice. TOGETHER WE CAN MAKE THE CHANGE TO SAFE INFECTION MANAGEMENT Choose Cutimed Sorbact for prevention and infection management 1,2 Be safe as you can use it for chronic and acute wounds with no known contraindications or known side effects Ease your application Treat superficial and deep wounds Visit us during the EWMA 2019 Conference, 5-7 June in Gothenburg 1 Mosti et al., Comparative study of two antimicrobial dressings in infected leg ulcers: a pilot study, Journal of Wound Care, Stanirowski et al., Randomized controlled trial evaluating dialkylcarbamoyl chloride impregnated dressings for the prevention of surgical site infections in adult women undergoing caesarean section,

67 EWMA Wound Centres in Finland Heli Lagus MD, Plastic Surgeon, Chief Physician of the Wound Centre, HUS Helsinki University Hospital The population of Finland is about 5.5 million, and municipalities are responsible for organising social welfare and health care services for their residents. They provide services by themselves, in conjunction with other municipalities or purchase needed services from the private sector. The country s five hospital districts are accountable for all specialised medical care. HUS Helsinki University Hospital Wound Centre The Hospital District of Helsinki and Uusimaa is the largest hospital district in Finland, providing coverage for around 1.85 million residents. The need for a wound centre has been evident for decades in the District. Today, the number of chronic wound patients is increasing, due to the ageing population and increased prevalence of diabetes and obesity, all of which lead to rising costs. Another challenge has been the level of education and awareness among health care personnel concerning the variety of wounds; chronic wounds are often neglected, perceived as a symptom of a disease and often not properly diagnosed. In the Finnish health care system, wound patients are first treated mainly in primary care by personnel who have varying degrees of familiarity with wound healing. This can sometimes lead to remarkable delays in diagnoses and referrals. An influential working group made an enormous effort to establish a wound centre in 2008, but at that time, decision-makers were not convinced of the benefits of such a centre. In November 2016, with the permission of the Chief Medical Officer of the HUS Helsinki University Hospital, a new large, multidisciplinary working group was established with multiple subgroups. The working group consisted of more than 100 people tasked with planning the structure and function of a wound centre for the hospital district. The working group included representatives from all different specialties and different professions treating wound patients, including primary care, with members from the very top of each organisation to grass-roots level professionals. The aim of the project was to establish a wound centre in Helsinki that would comprise more of an idea of co-ordination and co-operation than a physical centre, and to organise the wound care for the whole hospital district. Only the most difficult and complicated cases would be referred to, assessed and treated by a multidisciplinary team at the wound centre itself. One of the key points of HUS Helsinki University Hospital s Wound Centre has been its effort to strengthen education, networking and referral pathways between primary and specialised care. Initially, the hospital district area was very heterogeneous in terms of wound care. In some areas, wound care practices were already very well developed, but in others, there were no care pathways for wound patients. During the project, vertical and horizontal integration efforts were accomplished; those in charge of wound care (mainly wound care nurses and doctors) in primary care and those in special health care formed a live wound care network based on tight co-operation throughout the system. Care pathways for the most common wound types were then developed in accordance with national and various international guidelines. All referrals concerning wounds are now sent to a wound-referral centre, and from there the referrals are distributed as needed, either to different specialties or to multi-professional teams at outpatient clinics. In difficult situations, more conservative treatment is given in a dermatology ward (where 10 hospital beds are reserved for wound patients); all vascular problems are treated in the vascular surgery department (as are revisions and amputations); and revisions, ampu- Correspondence: heli.lagus@ehus.fi EWMA Journal 2018 vol 19 no 2 67

68 Primary care Primary care Primary care Primary care Raasepori district hospital Lohja district hospital Hyvinkää district hospital Porvoo district hospital Primary care Kirkkonummi Primary care Kauniainen Jorvi hospital HUS wound centre Melilahti campus Plastic surgery Vascular surgery + Endocrinology Dermatology Virtual health village Wound house Espoo hospital, primary care ward for wound patients Laakso hospital, primary care ward for wound patients Vantaa hospital, primary care ward for wound patients Centralized wound care health centers Centralized wound care health centers x 4-5 Centralized wound care health centers Primary care Espoo Primary care Helsinki Primary care Vantaa tations and especially reconstructions are performed in the plastic surgery department. The largest cities in the district have established primary care wards for wound patients, and consultants and tissue viability nurses from special care units make rounds in these wards once per week to support and educate the primary care personnel. Other areas addressed in the project were as follows: 1) Planned education of all health care professionals dealing with wound patients, including medical and nursing students and patients. 2) Prevention measures were overseen by a special prevention group setting local guidelines for prevention measures according to the main chronic wound types, including peer support of patients in a local version of Leg Clubs. 3) Multidisciplinary e-consultations are in a pilot phase, not only to treat challenging wound patients, but also to educate health care personnel. In the future, e-consultations, especially e-video consultations, will replace some outpatient visits. A virtual wound house in a virtual health village is being established in co-operation with other university hospitals to form a national wound house. The wound house includes instructions and information for referrals, care pathways, wound care, wound care products, self-care and prevention, guidelines (both national and international) and so on both for health care professionals and patients, in separate sections. The working group is also making assessments of wound care products, dressings, off-loading devices, compression stockings and other equipment and devising guidelines for their use. 4) Research is an essential part of wound care, to secure both evidence-based guidelines and quality of care, and a systematic means for assessing wound care via a wound registry is being established, highlighting that all wound care must be evidence-based. The way health records are completed, and their content, are also being assessed to aid in the development of software to generate records more easily, and in a more unified manner, with better quality and comparability. HUS Helsinki University Hospital Wound Centre was established in February 2018 with three different specialists (a vascular surgeon, a plastic surgeon and a dermatologist) and a tissue viability nurse. Since then, the staff has increased, including a tissue viability nurse, a GP trainee and two vascular surgery nurses. New facilities for the wound centre will be ready by 2021, in conjunction with expansions in the Plastic Surgery Department. Tampere University Hospital Wound Centre Pirkanmaa Hospital District oversees the care for roughly 1.11 million people. Tampere University Hospital s Wound Centre was the first wound centre to open in Finland. It began as an in-patient clinic in 2012, with nine hospital beds in a former dermatology ward, and focussed on treating chronic ulcers. The centres background objectives were: 1) to provide patient-centred care policies, 2) to provide more efficient treatment strategies and 3) to ensure more a focused use of available resources. Care 68 EWMA Journal 2018 vol 19 no 2

69 EWMA pathways for wound patients were established. At Tampere University Hospital s Wound Centre, a dermatologist, a plastic surgeon and an internist, together with nurses, make daily rounds. In addition to these daily rounds, a vascular surgeon, an orthopaedic surgeon, a specialist in infectious diseases, a physiotherapist and a nutritionist support weekly multidisciplinary rounds. In 2017, approximately 300 surgeries were performed on ulcer patients treated in the wound centre ward. An outpatient clinic was established in March The work performed there consists of: one dermatologist working 2.5 days/week, an internist 2 days/week, a plastic surgeon 1.25 days/week, tissue viability nurses 9 working days/week, a diabetic nurse 2 days/week, podiatrists 10 days/week and, when needed, vascular and orthopaedic surgeons, a nutritionist, a social worker and a physiotherapist as consultants. The weekly schedule consists of traditional patient appointments and multidisciplinary appointments. In 2017, the centre booked approximately 60 patient appointments weekly. Tampere University Hospital Wound Centre was also the first facility in the country to implement a wound register, in June At Tampere, new premises are currently in the planning stage; there is a desire for the outpatient clinic and the ward to be situated adjacent to each other, and to add more hospital beds and staff resources. Kuopio University Hospital Wound Centre The Hospital District of Northern Savo covers around 840,000 inhabitants. In Kuopio, a wound centre has opened as an outpatient clinic. The aims of the wound centre project were: 1) to create a multidisciplinary, evidence-based operating model and to devise a holistic care plan for each patient during his or her first visit; 2) to unify and integrate the care pathways of chronic wound patients from primary care to specialised care; 3) to enhance the knowledge and skills of wound care doctors and nurses; and 4) to improve the communication and information transportation across the boundaries between primary and specialised care (e.g., low threshold for consultations). Currently, Kuopio s outpatient clinic averages five multidisciplinary patient appointments per month. The centre also trains chain ambassadors who function as liaison officers between primary and specialised care to help to spread knowledge and skills, and knowledge of the care pathways, via a one-week training programme conducted at the University Hospital. To date, they have trained one doctor and 29 nurses from primary care. Many educational events have also been held in local health care centres comprising such topics as wound centres, pressure ulcer care pathways and the ABCs of wound care. Web pages have been established both on the hospital s intranet and on the Internet on the topic. A photo consultation pilot proved to be successful, and now a mobile app has been distributed to the specialised care staff. It is currently awaiting distribution to other municipalities. Further, a video consultation programme has started in two health centres, in Pielavesi and in Varkaus. The public sector is now well informed about the wound centre and its functions, but the private care system has not yet been integrated. Oulu University Hospital Wound Centre Northern Ostrobothnia Hospital District oversees the care of around 1.12 million people. Oulu University Hospital does not yet have a wound centre, but a multidisciplinary team is planning to start one as a part of Oulu University Hospital s Future Hospital project. Current operating models are being assessed. The future integration of wound care with primary care is planned for the next few years. Wound care at Turku University Hospital The Hospital District of Southwest Finland covers about 870,000 people. A wound centre project aiming to centralise the wound care process by crossing boundaries between primary and specialised care has begun, but, as was the case several years ago in the Hospital District of Helsinki and Uusimaa, policy and decision makers have not been willing to establish a wound centre at Turku University Hospital. Even so, wound care professionals have been training chain ambassadors for primary care since This training has been targeted for tissue viability for nurses. Turku was also one of the first university hospitals to establish care pathways for chronic wound patients. The Working Group of Special Competence in Wound Management, which is a part of the Finnish Medical Association, is working hard to unify practices and policies throughout the country in wound diagnostics and treatment, and to facilitate the co-operation between different health professionals together with the Finnish Wound Care Society. At the moment, the working group is in the process of selecting a minimum set of parameters that should be recorded for every wound patient in every location throughout the country, to facilitate the collection of comparable data. Wound centres may, of course, collect a larger set of data for research purposes or for monitoring the quality of care, but at least this minimum data set should be included in the health records of every wound patient in the future. In the background, there is an aim to create a national wound registry with high quality, comparable data. The members of the working group are also involved in creating the national virtual wound house. m EWMA Journal 2018 vol 19 no 2 69

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71 EWMA New publication on antimicrobial stewardship in wound management: Non-antibiotic antimicrobial interventions and antimicrobial stewardship in wound care As part of the ongoing Antimicrobial Stewardship Programme, Rose Cooper and Klaus Kirketerp-Møller have published a paper entitled Non-antibiotic antimicrobial interventions and antimicrobial stewardship in wound care. The paper was published in Journal of Woundcare earlier this year. Non-antibiotic antimicrobial interventions and antimicrobial stewardship in wound care Control of wound infection today relies largely on antibiotics, but the continual emergence of antibiotic-resistant microorganisms threatens a return to the pre-antibiotic era when physicians used antiseptics to prevent and manage infection. Some of those antiseptics are still used today, and others have become available. A diverse variety of non-antibiotic antimicrobial interventions are found on modern formularies. Unlike the mode of action of antibiotics, which affect specific cellular target sites of pathogens, many non-antibiotic antimicrobials affect multiple cellular target sites in a non-specific way. Although this reduces the likelihood of selecting for resistant strains of microorganisms, some have emerged and crossresistance between antibiotics and antiseptics has been detected. With the prospect of a post-antibiotic era looming, ways to maintain and extend our antimicrobial armamentarium must be found. In this narrative review, current and emerging nonantibiotic antimicrobial strategies are considered and the need for antimicrobial stewardship in wound care discussed. Caring for wounds has long involved antimicrobial treatments. Historically, topical remedies derived from local and natural sources were widely used; these included plant extracts, minerals, silver, grease, honey, wine and vinegar. 1,2 During the 19 th century the development of the chemical industry provided antiseptics such as hypochlorite, iodine, phenol and hydrogen peroxide, 3 and ways to prevent the spread of infection were introduced handwashing by Ignaz Semmelweis, 4 and decontamination of surgical equipment and environments (aseptic surgery) by Joseph Lister. 5 Since the late 19 th century, when the role of microbial species in causing wound infection was established, a rationale for antimicrobial intervention has existed. At the beginning of the 20 th century Paul Ehrlich developed the concept of selective toxicity with magic bullets designed to inhibit the pathogen rather than the host. 6 The discovery of antibiotics 7 later provided many generations of natural and semi-synthetic agents capable of rapidly inhibiting infectious agents by targeting specific intracellular sites or biosynthetic pathways not present in the host. Since the 1940s antibiotics have been used systemically for treating spreading and systemic infections of acute and chronic wounds. However, their widespread use and misuse in medicine and agriculture has allowed the emergence of microbial strains with resistance to one or more antibiotics. 8 Hence, efficacy has diminished and prospects for continued effective control of wound infection have lessened significantly. The lack of new antibiotics being developed is of particular concern. 9 Organisms implicated in wound infection were in the World Health Organization s (WHO) 2017 top five most urgent categories of pathogens for which the development of new antibiotics is urgently needed. 10 Antimicrobial resistance (AMR) has now become a global crisis 11 which demands global action. 12 Demand for antibiotics increased by 40% between 2000 and 2010, which, together with interna- Rose Cooper 1 BSc, PhD, PGCE Professor Microbiology Klaus Kirketerp-Møller 2 MD Orthopaedic Surgeon 1 Department of Biomedical Science, Cardiff School of Health Sciences, Cardiff Metropolitan University, United Kingdom 2 Copenhagen Wound Healing Center, Department of Dermatology and Wounds, Bispebjerg University Hospital, Denmark Correspondence: rosecooper1947@icloud.com Conflicts of interest: None EWMA Journal 2018 vol 19 no 2 71

72 EWMA tional travel and migration, contributed to the spread of antibiotic-resistant pathogens. 9 By 2050, AMR is predicted to lead to 10 million annual deaths and economic losses of $100 trillion. 9 The risks of AMR for wound care have been recognised, 13,14 especially the need to conserve the use of antibiotics. 15 However, because a diverse range of non-antibiotic antimicrobial interventions is used in managing wounds, it is imperative that clinical practices should minimise the possibility of selecting resistance to all of these therapies. With ageing populations, increased prevalence of diabetes, 16 rising costs of wound treatment 17 and diminishing prospects of developing new antibiotics, 9 novel approaches to optimising and conserving all antimicrobial interventions in wounds are indicated. The European Wound Management Association (EWMA) works actively to promote the concept of antimicrobial stewardship (AMS) in wound management. Here we aim to provide a narrative outlook on the potential challenges and opportunities of responsibly using non-antibiotic antimicrobial interventions in the future. About the EWMA/BSAC collaboration on Antimicrobial Stewardship in wound management Antimicrobial stewardship programmes are increasingly advocated as a means to decrease misuse of antimicrobial agents. Along with infection prevention and control, hand hygiene and surveillance, antimicrobial stewardship is considered a key strategy in local and national programmes to prevent the emergence of antimicrobial resistance and decrease preventable healthcare associated infection. The overall aim of EWMA s antimicrobial stewardship programme is to reduce inappropriate use and overuse of antimicrobials in wound care by promoting, facilitating and teaching good antimicrobial practice. With a focus on the health professional s role in the area of appropriate use of antimicrobials across health care settings, the programme is targeting health professionals involved with wound care - doctors, nurses, pharmacists, microbiologists, but also reaching out to policy makers, such as clinical administrators or managers at local, regional or national level. The EWMA/BSAC collaboration is considered mutually beneficial for both organisations. BSAC is entirely dedicated to the issues concerning antimicrobial use, and has been spearheading the agenda by advocating the need for the effective use of antimicrobials. However, collaborating with practitioners associations like EWMA allows for the messages of the stewardship concept to be brought directly to the clinicians who are acting in the centre of the resistance problem. REFERENCES 1 Majno G. The healing hand: man and wound in the ancient world. Harvard University Press Forrest RD. Early history of wound treatment. J R Soc Med 1982; 75(3): Hugo WB. A brief history of heat and chemical preservation and disinfection. J Appl Microbiol 1991; 71(1): Best M, Neuhauser D. Ignaz Semmelweis and the birth of infection control. Qual Saf Health Care 2004; 13(3): org/ / qshc Pitt D, Aubin JM. Joseph Lister: father of modern surgery. Can J Surg 2012; 55(5):E8 E9. org/ /cjs Schwartz RS. Paul Ehrlich s magic bullets. N Engl J Med 2004; 350(11): NEJMp Fleming A. On the antibacterial action of cultures of a Penicillium with special reference to their use in the isolation of B. influenza. Br J Exp Pathol 1929; 10(3): Lobanovska M, Pilla G. Penicillin s discovery and antibiotic lessons for the future. Yale J Biol Med 2017; 90(1): O Neill J A review on antimicrobial resistance. Tackling drug-resistant infections globally. tinyurl.com/zmylsav (accessed 24 May 2018) 10 World Health Organization. Who publishes list of bacteria for which new antibiotics are urgently needed (accessed 14 May 2018) 11 World Health Organization. Global action plan on antimicrobial resistance j6b3cdn (accessed 14 May 2018) 12 O Neill J Tackling drug-resistant infections globally: final report and recommendations. tinyurl.com/la9b5cb (accessed 14 May 2018) 13 Gottrup F, Apelqvist J, Bjarnsholt T et al. EWMA document: antimicrobials and non-healing wounds. Evidence, controversies and suggestions. J Wound Care 2013; 22(Sup5 Suppl):S1 S89. org/ /jowc sup5.s1 14 Roberts CD, Leaper DJ, Assadian O. The role of topical antiseptic agents within antimicrobial stewardship strategies for prevention and treatment of surgical site and chronic open wound infection. Adv Wound Care 2017; 6(2): wound Lipsky BA, Dryden M, Gottrup F et al. Antimicrobial stewardship in wound care: a position paper from the British Society for Antimicrobial Chemotherapy and the European Wound Management Association. J Antimicrob Chemother 2016; 71(11): jac/dkw Sen CK, Gordillo GM, Roy S et al. Human skin wounds: a major and snowballing threat to public health and the economy. Wound Repair Regen 2009; 17(6): org/ /j x x 17 Guest JF, Ayoub N, McIlwraith T et al. Health economic burden that wounds impose on the National Health Service in the UK. BMJ Open 2015; 5(12):e Barrera Arenas JE, Pedraza Castañeda MC, Perez Jimenez G, Hernandez Jimenez P, Reyes Rodriguez JA, Padilla Zarate MP. Prevalencia de úlceras por presión en hospital de tercer nivel, en Mexico DF [Prevalence of pressure ulcers in a third level hospital in Mexico city]. Gerokomos. 2016; 27(4): Schindler CA, Mikhailov TA, Kuhn EM, Christopher J, Conway P, Ridling D, et al. Protecting fragile skin: nursing interventions to decrease development of pressure ulcers in pediatric intensive care. Am J Crit Care. 2011;20(1): Dolack M, Huffines B, Stikes R, Hayes P, Logsdon MC. Updated neonatal skin risk assessment scale (NSRAS). Ky Nurse. 2013;61(4): Willock J, Anthony D, Richardson J. Inter-rater reliability of Glamorgan Paediatric Pressure Ulcer Risk Assessment Scale. Paediatr Nurs. 2008;20(7): Quesada C, Iruretagoyena ML, González RM, Hernández JM, Ruiz de Ocenda MJ, Garitano B et al. Validación de una escala de valoración del riesgo de úlceras por presión en niños hospitalizados. [Validation of pressure ulcer risk assessment scale in hospitalised children]. Investigación Comisionada. Vitoria-Gasteiz. Departamento de Sanidad y Consumo. Gobierno Vasco, Informe nº: Osteba D Available wp-content/uploads/d_09_08.-%c3%9 Alceras-porpresi%C3%B3n-en-ni%C3%B1os.pdf 32. Garcia-Molina P, Balaguer Lopez E, Verdu J, Nolasco A, Garcia Fernandez FP. Cross-cultural adaptation, reliability and validity of the Spanish version of the Neonatal Skin Risk Assessment Scale. J Nurs Manag 2018; doi: /jonm National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Quick Reference Guide. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Australia; 2014 available at: line.com/static/pdfs/npuap-epuap-pppia-puquick- ReferenceGuide-2016update.pdf 34. Guideline Development Group. Pressure ulcers: prevention and management of pressure ulcers. National Clinical Guideline Centre. London: National Institute for Health and Care Excellence; Curley MA, Razmus IS, Roberts KE, Wypij D. Predicting pressure ulcer risk in pediatric patients. Nurs Res 2003; 52(1): Bonell-Pons L, Garcia-Molina P, Balaguer-Lopez E, Montal M, Rodriguez M. Neonatal facial pressure ulcers related to noninvasive ventilation: incidence and risk factors. EWMA J. 2014; 14(2): EWMA Journal 2018 vol 19 no 2

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74 Come and join the largest international scientific meeting on lower extremity problems in diabetes. Meet your colleagues from all over the world and let renowned experts bring you up to date with the latest developments and innovations MAY 2019 World Forum - The Hague - The Netherlands IMPORTANT December 10, 2018: Deadline abstract submission, withdrawal and change of abstract content DEADLINES February 11, 2019: Notification of abstract scheduling/rejection to submitting author March 4, 2019: Deadline early registration Preliminary program available on

75 EWMA Zena Moore 1 Professor of Nursing and Head of the School of Nursing & Midwifery, Royal College of Surgeons in Ireland The joint Pressure Ulcer Prevention and Patient Safety Advocacy Project of the European Pressure Ulcer Advisory Panel (EPUAP) and EWMA has now entered its third and final year. The project is continuing with some activities from the previous years, including the publishing of joint statements and articles of which the most recent is included below this box, as well as the collaboration with the OECD Health Care Quality Outcomes project. Further, the project, during this year, will engage in the elaboration of generic patient case studies to exemplify the patient and health economic value of preventing pressure ulcers from occurring. Case studies will be the way to highlight the problem also from patients and lay carers perspective and their quality of life. In terms of the earlier described engagement (see EWMA Journal 2017 Vol.18 No.2) with representatives of the EU Commission and members of the European Parliament, this activity has recently led to an official Parliamentary Question directed to the EU Commission by MEP Karin Kadenbach. The question and response is available at: Doc.do?type=WQ&reference=E &language=EN. Based on the response, EPUAP and EWMA during the next months will consider how to contribute to the EU best practice portal referred to in the response. The article below, as well as earlier articles and updates about the project, are available at the EWMA.org and the EPUAP.org websites. The role of pressure ulcer prevention in the fight against antimicrobial resistance Jose Verdu Soriano 1 Senior Lecturer and researcher at the Faculty of Health Sciences. University of Alicante, Spain Andrea Pokorna 2 Associate Professor, Department of Nursing, Faculty of Medicine, Masaryk University, Brno Lisette Schoonhoven 2 Professor of Nursing, Faculty of Health Sciences, University of Southampton Hubert Vuagnat 2 Head of Division of the Department of Rehabilitation and Palliative Care. University Hospitals of Geneva 1 Chair of the Joint EPUAP & EWMA Pressure Ulcer Prevention & Patient Safety Advocacy Project 2 Member of the Joint EPUAP & EWMA Pressure Ulcer Prevention & Patient Safety Advocacy Project Every year over 25,000 patients die in the EU alone as a result of infections caused by antibiotic resistant bacteria. Globally the number of deaths due to antimicrobial resistance (AMR) was estimated to be 700,000 1 in 2014 and that number has been calculated to rise to at least 10 million by The continuing emergence of AMR has become a recurring topic in the international health agenda as the increasingly serious threat to cross-border public health is recognised. From WHO to OECD, international bodies are constantly monitoring, reporting and formulating strategies to contain AMR. AMR is defined by WHO as the ability of microorganisms to survive antimicrobial treatments; consequently, prophylactic and therapeutic regimens are ineffective in controlling infections caused by resistant bacteria, fungi, parasites and viruses. 2 The situation has deteriorated dramatically in the past decade with AMR reaching levels of 80% in some countries. 3 Correspondence: ewma@ewma.org Conflicts of interest: None EWMA Journal 2018 vol 19 no 2 75

76 EWMA How has this happened? Whereas greater investment and skill in reporting of AMR may be one reason, an important consideration is that AMR is a natural and inevitable process which is aggravated by the inappropriate use of antimicrobial agents. Healthcare authorities have been aware of the consequences of overuse of antibiotics in animal and human health, yet relatively few actions have been implemented to slow the process down. 4 The good news is that the EU has made a significant step forward to gain a global lead in the fight against AMR. In June 2017 the Commission adopted the ambitious EU One Health Action Plan against AMR (as requested by the Member States in the Council Conclusions of 17 June 2016). The key objectives of the new plan are founded on three pillars: (1) making the EU a best practice region; (2) boosting research, development and innovation; (3) shaping the global agenda. The most urgent actions (under the first pillar) are reducing inappropriate use of antimicrobials, better prescribing practices, respecting the recommended dosages and fostering infection prevention. Wound care and pressure ulcer prevention can play a key role in addressing AMR: better wound care and early detection of pressure ulcers can prevent affected tissue infection, allowing faster resolution by uninterrupted healing and avoiding the need for antimicrobial interventions. Pressure ulcers, also known as bedsores, decubitus ulcers and pressure injuries, are wounds involving the skin and often the tissue that lies underneath. Pressure ulcers may become infected, affecting people s quality of life and require antimicrobial therapies when systemic symptoms occur. It is important to identify the patients at risk to act promptly, avoid complications and ultimately reduce the use of antibiotics. People at risk of developing pressure ulcers include those with spinal cord injuries, those who are immobile, or have limited mobility, such as elderly people, and people who are ill, as well as children and neonatal patients in intensive care units. in healthcare settings. On average, 20% of persons will suffer from pressure ulcers in our hospitals. Both EPUAP and EWMA have (jointly and separately) been working to place prevention of pressure ulcers as a major health care and patient safety issue. As most of health stakeholders, the two organisations believe that AMR is one of the most serious global public health threats of this century, and they strongly advocate acknowledgement of the importance of the prevention of pressure ulcers and their complications (e.g. infections) as part of the solution. Awareness of the seriousness of the situation and urgent actions are required globally, at EU and national level. Following the recent adoption of the EU Action Plan on AMR and the vote at the European Parliament plenary on September 2018, it is very important that EU institutions and countries gain momentum and build something more concrete on infection prevention and patient safety, especially recognising severe pressure ulcers as a big threat for citizens well-being and their prevention as part of the AMR strategy. The European Health Forum in Gastein in October 2018 is representing a valuable opportunity to tackle Europe s health challenges head on and a chance to talk about pressure ulcer prevention and appropriate wound care as key assets in the fight against antiseptic and antibiotic misuse. REFERENCES 1 European Commission, AMR: a major European and Global challenge, Factsheet Available at: en.pdf 2 The World health Organisation, Key Facts on Antimicrobial Resistance, last update February Available at: antimicrobial-resistance 3 The Parliament Magazine, Antibiotic resistance: A silent tsunami, 7 July Available at: 4 ibid. 5 J. Norman, Z. Moore, J. Tanner, J. Christie, S. Goto, Antibiotics and antiseptics for pressure ulcers, 4 April 2016, Cochrane Wounds Group. Available at: cochranelibrary-wiley.com/doi/ / cd pub2/full m Once pressure ulcers become infected, antibiotics, or antiseptics are used to treat the micro-organisms causing the infection and prevent an infection from getting worse, or spreading. This helps the ulcer to heal. A range of treatments with antimicrobial properties are widely used in the treatment of pressure ulcers. 5 However, antibiotics are often misused when infections do not occur. It is highly important to foster prudent use of antimicrobial agents in human medicine, such as in the care of pressure ulcers. Pressure ulcers are one of the most frequent types of complex wounds and are a commonly occurring condition 76 EWMA Journal 2018 vol 19 no 2

77 SAVE THE DATE September 2019 Antwerp Belgium Important deadlines Abstract submission: 12 April 2019 Early registration: 1 July 2019 EBJIS th Annual Meeting of the European Bone and Joint Infection Society We look forward to seeing you in Antwerp! 30 TH CONFERENCE OF THE EUROPEAN WOUND MANAGEMENT ASSOCIATION EWMA 2020 IN COOPERATION WITH THE TISSUE VIABILITY SOCIETY, TVS

78 EWMA Aurora Piaggesi Storyteller and filmmaker Living With Chronic Wounds - A Storytelling Journey What does it really mean to live with chronic wounds? What are the everyday struggles and conflicts of those affected by wounds, and of those working in wound-care? What are the stories behind the wounds? Correspondence: ewma@ewma.org To answer these questions, storyteller and filmmaker Aurora Piaggesi spent the summer visiting a number of wound care clinics across Europe. The tour brought her to the United Kingdom, France, Czech Republic, Switzerland and Finland, where she met with several EWMA members and their patients. The goal was to help them tell their stories through the visual medium of film. This tour is part of the new EWMA project Living With Chronic Wounds (LWCW). The project aims to illustrate the experiences of wound patients through a number of recorded interviews with them and the health care professionals responsible for their treatment and care. It also includes interviews with representatives of health care institutions. Piaggesi visited patients homes and the clinics where their wounds are treated, filming them in their everyday environment, while asking them to speak about their situation. The meetings with patients suffering from the most common types of non-healing wounds, such as diabetic foot ulcers, pressure ulcers and venous leg ulcers, have shown that living with chronic wounds is a complex situation. It requires not only the involvement of good health care professionals, but sometimes the patient s whole family as well. During these interviews, the various challenges that the healthcare professionals face in their everyday practice also emerged. The stories and images Piaggesi collected will be translated and published through several media channels. Together with the professionals involved, EWMA will also write and present a paper during the 2019 conference, which will be held in Gothenburg, Sweden. The series of videos, currently in the subtitling process, will be available for use in education, advocacy activities and various communication activities at in the spring of The journey is far from over! Follow Aurora Piaggesi s work as she continues the Living With Chronic Wounds tour this autumn. Follow us on Facebook, Twitter and Instagram #LivingWithChronicWounds #LWCWtour #LWCW 78 EWMA Journal 2018 vol 19 no 2

79 EWMA The Prevention and Management of Pressure Ulcers: Education Module and Course Endorsement This issue of the EWMA Journal focuses on pressure ulcers, as the education module Prevention and Management of Pressure Ulcers has recently been reviewed. This is a perfect opportunity to highlight some of the activities of the EWMA Education Committee. The Education Committee coordinates all activities related to education, one of EWMA s focus areas since its foundation. Producing a flexible framework for the delivery of interdisciplinary wound management education across Europe is the committee s main goal. This framework incorporates various aspects of wound management into several education modules, which are developed by members of the education committee and/or affiliated wound care specialists. All modules are based on a standard template, yet each is still individually focused on a specific aspect of wound management. Each module specifies learning outcomes for knowledge and practical skills acquisition and for specific wound types or wound-related topics. Evelien Touriany Nurse, Wound Management Coordinator, Queen Astrid Military Hospital, Brussels, Belgium Vice-President, CNC vzw Wound Management Association, Belgium EWMA Council member The education module Prevention and Management of Pressure Ulcers was developed in April The module aims to broaden participants knowledge and understanding of the prevention and management of pressure ulcers. As updated guidelines are published, and new knowledge is gained from scientific research, a review of all modules is, of course, necessary. The latest update of this module was completed in October 2015, so a new update was needed. EWMA Education Modules The module can give guidance for developing courses regarding the prevention and management of pressure ulcers, to ensure that all the necessary topics are covered. By standardising the course content, EWMA provides quality standards against which other organisations can evaluate existing wound management programmes. EWMA wishes to identify high standard education courses and programmes throughout the European wound healing and management field, so if a course meets the content criteria, an application for EWMA course endorsement can be filed. EWMA endorsements of courses focus on the educational content of e-learning modules or face-to-face courses/programmes, rather than on specific structural issues or learning methods. An EWMAendorsed course has some advantages, such as increased visibility for an institution or company, a demonstration of educational n Patient and Wound Assessment n Wound Infection n Management of Traumatic Wounds n Assessment and Management of the Diabetic Foot n Prevention and Management of Pressure Ulcers n Seeking and Appraising Evidence n Prevention and Management of Leg Ulcers n Management of Oncology Wounds n Introduction to Wound Management n Physiology of wound healing & tissue repair n Skin Associated Considerations of Wound Care n Assessment and Management of Skin Tears n Lymphoedema All modules are available for free download at ewma.org/it/what-we-do/education/ excellence (peer-reviewed) and improvements in marketing efforts to potential students. EWMA s endorsement process also provides opportunities for course developers to work together with other European course providers. In addition to the module on pressure ulcer prevention and management, other modules have been developed (see text box). Correspondence: ewma@ewma.org EWMA Journal 2018 vol 19 no 2 79

80 EWMA Atypical Wounds Dr. Kirsi Isoherranen Editor of the EWMA Atypical Wounds document EWMA Council Member New EWMA document about Atypical Wounds is being prepared for publication in spring 2019 Julie Jordan O Brien Co-editor of the EWMA Atypical Wounds document EWMA Council Member Kirsi Isoherranen addressing the Atypical Wounds focus session at the EWMA 2018 Krakow Conference. Correspondence: ewma@ewma.org An author group chaired by Document Editor Dr Kirsi Isoherranen is currently working on a new EWMA document that will be published and launched at the EWMA 2019 conference in Gothenburg, Sweden. The overall topic of the document is atypical wounds, those wounds that create the most challenging situa-tions for clinicians and/or patients from prevention, treatment and organisational perspectives. Atypical wounds include a broad spectrum of conditions or diseases caused by inflammation, infection, malig-nancy, chronic illnesses or genetic disorders. An atypical wound may be suspected if the wound has an ab-normal presentation or location and does not heal following a good treatment plan. The prevalence of atypi-cal wounds can be as high as 10% of all wounds, and it is probable that many of these wounds are underdiag-nosed. The aim of the document is to bring awareness to the clinical picture, diagnosis and treatment of these wounds. Typical challenges include considerable diagnostic delays and prolonged healing times; for example, inflammatory and vasculopathy wounds (such as pyoderma gangrenosum, an inflammatory neutrophilic dis-order and cutaneous vasculitis). In addition, many atypical wounds have an enormous impact on the quality of life in the affected individuals, and a multidisplinary team approach is neccesary to ensure patients receive high quality treatment in a timely fashion. Content The document is expected to include the following chapters. However, as the drafting of the document is still in an early stage, changes to the chapters/content and names of chapters may still occur. Chapters n Definitions and Abbreviations n Introduction and Overview n Pyoderma Gangrenosum n Vasculitic Ulcers n Livedoid Vasculopathy 80 EWMA Journal 2018 vol 19 no 2

81 n Calciphylaxis and Martorell Hyperten-sive Ulcers n Hidradenitis Suppurativa n Malignant Ulcers n Artefactal Ulcers n Other Types of Atypical Wounds n Dermato-pathology of Atypical Wounds n Ecthyma and Ecthyma Gangrenosum n Local Treatment of Atypical Wounds n Patient Perspective n Health Economy and Organisation Author Group The author group includes prominent and well-respected clinicians who have all volunteered to use their ex-pertise to describe the aetiologies and treatment strategies of different types of atypical wounds. Current members of the author group are: The document will be elaborated with support from an unrestricted educational grant provided by: Wrong or delayed diagnosing is one of the challenges in the work with Atypical Wounds. The picture shows the leg of a 74- year old woman who was treated in home care for one year with the diagnosis of venous leg ulcers, but the ulcer turned to be a squamous cell carcinoma and the leg was amputated because of chronic osteomyelitis and tibial fracture. If you would like to know more about the EWMA Atypical Wounds document, please contact the document editor, Kirsi Isoherranen, or the EWMA Secretariat at jnk@ewma.org. Kirsi Isoherranen (editor) Julie Jordan O Brien (co-editor) Joachim Dissemond Jürg Hafner Gregor B. E. Jemec Jivko Kamarachev Severin Läuchli Stephan Nobbe Elena Conde Montero Cord Sunderkötter MD, PhD Specialist in dermatology, Helsinki University Central Hospital, Skin and Allergy Hospital, Helsinki, Finland RNP, MSc Nursing Advanced Nurce Practitioner Plastic Surgery, Beaumont Hospital, Dublin, Ireland Professor, MD University Hospital of Essen Clinic and Policlinic for Dermatology, Venerology and Allergology, Essen, Germany Professor, MD Department of Dermatology, University Hospital of Zurich, Switzerland Professor, MD Department of Dermatology, Roskilde Hospital, Roskilde, Denmark MD, PHD Zürich Dermatology Clinic, Zürich, Switzerland MD Department of Dermatology, University Hospital of Zurich, Switzerland MD, PHD Department of Dermatology, Cantonal Hospital of Frauenfeld, Switzerland MD, PHD Department of Dermatology, Hospital Universitario Infanta Leonor, Madrid, Spain Professor, MD Department of Dermatology and Venerology Uni-versity and University Hospital of Halle, Germany EWMA Journal 2018 vol 19 no 2 81

82 Granulox Wound oxygenation Topical oxygen supply for accelerated wound healing Time to heal diabetic foot ulcers 50 % shorter than with standard of care 1 Twice as many chronic wounds healed at 8-16 weeks compared to standard of care 1,2,3 More than 70 % lower average pain scores at four weeks than with standard of care in chronic wounds 3 Mölnlycke acquires SastoMed Granulox enables Mölnlycke to take wound management to the next level of evidencebased, accelerated wound healing 12 ml unit = 3 months treatment* *May vary slightly depending on wound size 1 Hunt SD, Elg F. Clinical effectiveness of hemoglobin spray (Granulox ) as adjunctive therapy in the treatment of chronic diabetic foot ulcers. Diabetic Foot & Ankle 2016, 7: Elg F, Hunt S. Hemoglobin spray as adjunct therapy in complex wounds: Meta-analysis versus standard care alone in pooled data by wound type across three retrospective cohort controlled evaluations. SAGE Open Med Jun 27;6: Hunt S, Elg F. The clinical effectiveness of haemoglobin spray as adjunctive therapy in the treatment of chronic wounds. J Wound Care Sep 2;26(9): Find out more at Mölnlycke Health Care AB, Box 13080, Gamlestadsvägen 3C, SE Göteborg, Sweden. Phone The Mölnlycke and Granulox trademarks, names and logotypes are registered globally to one or more of the Mölnlycke Health Care Group of Companies Mölnlycke Health Care AB. All rights reserved. HQ-IM Granulox won the 2018 Innovation Award at EWMA Congress in Krakow!

83 EWMA Preliminary survey results from the UK and Ireland: Determining the current level of wound management education in the pre-registration nursing curricula Samantha Holloway Senior Lecturer, Centre for Medical Education, School of Medicine, Cardiff University, Wales, United Kingdom Background and aim of the project Evidence from industrialised countries has identified a gap regarding wound care teaching within the nursing curricula. 1-5 Furthermore, the number of hours of teaching, as well as how this information is delivered, also varies. 3 Based on these facts, the Teacher Network of the European Wound Management Association undertook a project to determine the current level of wound management education in pre-registration nursing curricula. This article reports the preliminary results of an online survey from England, Scotland, Wales and the Republic of Ireland. Permission to undertake the survey was granted by the School of Medicine s Research Ethics Committee at Cardiff University, UK. undertaken using an online cross-sectional survey approach. The purpose of the pilot was to test the online survey software and to gather responses from participants to inform the development of a subsequent survey. The initial survey comprised of 12 questions, which examined the following areas: n Numbers of pre-registration (student) nurses enrolled in BSc/BA/BN programmes in nursing n Skin health and wound management topics included in the current curriculum (open question) n In what years of study the topics are taught Sebastian Probst Professor of Tissue Viability and Wound Care, HES-SO University of Applied Sciences and Arts Western Switzerland, School of Health Sciences, Geneva, Switzerland Methods An online questionnaire was developed based on the Nursing and Midwifery Council (NMC) standards for skin health and wound management. 6 In June 2016, as initial pilot study of higher education institutions in Wales (n=4) was n Number of classroom-based and skills laboratory teaching hours allocated to these topics n Learning outcomes associated with these topics n Assessment methods Table 1: Number of Students Enrolled England Scotland Wales Republic of Ireland Number of students enrolled in a degree Siobhan Murphy College Lecturer, Catherine McAuley School of Nursing and Midwifery, University College Cork, Ireland Table 2: Percentage of Time Devoted to Theoretical and Clinical Training Wales England Scotland Republic of Ireland (n=2) (n=6) (n=6) (n=5) Theoretical Training i.e. Nursing School / college / 50% 50% 50% 45-50% University Clinical Training i.e. Hospital Placement 30-50% 25-60% 25-40% 40-55% Community Placement 20% 8-40% 10-25% 5-10% Correspondence: Hollowaysl1@cf.ac.uk EWMA Journal 2018 vol 19 no 2 83

84 n Lecturing staff (faculty) members and specialist qualifications n Opportunities for clinical placements in clinics/ with specialist staff. Data collection was carried out in June Survey results Out of 89 institutions, 21% (n=19) participated in the survey. The number of students enrolled in these courses is shown in Table 1. The results of the survey showed that the institutions provided the expected level of theory versus practical training, according to NMC standards. The findings also identified that the percentage of clinical training hours provided in hospitals versus community settings varied (Table 2). The results indicate that a wide range of wound care topics is taught (Table 3). Wound assessment, wound dressings/bandages and principles of asepsis were taught most frequently (Table 4). A majority of institutions (n=-16) reported that skin anatomy and physiology and skin roles and functions were taught in Year 1 (Table 5). A majority of subjects are taught in Year 2, with fewer in Year 3. For some respondents, it was difficult to determine in which year a topic was taught, as the subject area might feature across one or more years. In terms of learning assessments, the most frequently used assessment methods were short answer questions and direct observations in clinical practice (Table 7). In terms of other healthcare professionals being involved in teaching, the numbers were quite low; however, the number of institutions offering placement opportunities with a specialist nurse or area was high (Table 8). Conclusion The results of the survey indicate an encouraging level of teaching related to skin health and wound management. There is a mismatch between the information and the years in which certain topics are taught. The number of classroom-based teaching hours provided by the institutions was difficult to quantify. A subsequent report will present the findings of the wider survey undertaken to include results from 14 additional countries. m Table 3: Topics Taught as Part of the Theoretical Training Topic/ Subject Area Total (n=19) Skin anatomy and physiology 18 Skin function Effects of ageing on the skin Skin assessment Skin care Factors affecting healing Wound assessment Wound infection / Wound bioburdens Pressure ulcers Principles of asepsis / Non-touch techniques Physiology of normal and abnormal wound healing 17 Wound debridement Wound dressings / bandages Surgical wounds Psycho-social factors affecting healing 16 Leg ulcers Nutrition assessment and wounds Wound documentation MASD/ IAD 15 Diabetic foot ulcers Multi-disciplinary teamwork in wound care Wound pain: Assessment and management Wound bed preparation (TIME) 14 Common skin conditions Adjunctive devices in wound care Burn injuries Legal and professional issues Skin tears 13 Traumatic wounds Lymphoedema Malignant wounds / Palliative wound care 12 Unusual / Atypical wound presentations 11 Management of fistulas and drains 84 EWMA Journal 2018 vol 19 no 2

85 EWMA Table 4: Topics Taught Using Laboratory or Simulation-Based Teaching Topic/ Subject Area Total (n=19) Wound assessment 16 Wound dressings / bandages Principles of asepsis / Non-touch techniques Physiology of normal and abnormal wound healing 15 Skin assessment Wound pain: Assessment and management Wound documentation Skin care 13 MASD/ IAD Pressure ulcers Surgical wounds Wound debridement 12 Wound infection / Wound bioburdens Adjunctive devices in wound care Wound bed preparation (TIME) 11 Leg ulcers Diabetic foot ulcers Nutrition assessment and wounds Factors affecting healing 10 Skin function 9 Effects of ageing on the skin Traumatic wounds Management of fistulas and drains Skin tears 8 Burn injuries 7 Skin anatomy and physiology Common skin conditions Malignant wounds / Palliative wound care Unusual / Atypical wound presentations 6 Lymphoedema Multi-disciplinary teamwork in wound care Legal and professional issues Table 5: Years in Which Topics are Taught Topic Area Year Number (mode) Skin anatomy and physiology 1 16 Skin roles and function 16 Effects of ageing on the skin 14 Skin assessment 12 MASD / IAD 11 Skin care 15 Physiology of normal and abnormal wound healing 8 Principles of asepsis / Non-touch techniques 16 Wound assessment Common skin conditions 2 6 Skin tears 10 Factors affecting healing 11 Psycho-social factors affecting healing 9 Wound debridement 9 Wound Infection / Wound bioburdens 11 Wound bed preparation (TIME) 7 Wound dressings / bandages 9 Adjunctive devices in wound care 6 Pressure ulcers 11 Diabetic foot ulcers 10 Burn injuries 6 Traumatic wounds 8 Surgical wounds 9 Unusual / Atypical wound presentations 9 Nutrition assessment and wounds 8 Wound pain: Assessment and management 7 Multi-disciplinary teamwork in wound care 9 Legal and professional issues in wound care 6 Management of fistulas and drains Wound documentation Leg ulcers 3 9 Lymphoedema 6 Malignant wounds / Palliative wound care 5 EWMA Journal 2018 vol 19 no 2 85

86 Table 6: Number of Hours Taught within the Classroom Topic/ Subject Area Range of Hours Principles of asepsis / Non-touch 1-12 techniques Wound pain: Assessment and management Skin anatomy and physiology 1-8 Skin care MASD/ IAD Physiology of normal and abnormal wound healing Factors affecting healing Psycho-social factors affecting healing Wound assessment Pressure ulcers Wound dressings / bandages Nutrition assessment and wounds Surgical wounds Skin function 1-6 Effects of ageing on the skin Skin assessment Common skin conditions Wound documentation Wound Infection / Wound bioburdens Leg ulcers 1 5 Diabetic foot ulcers 1-4 Legal and professional issues Wound bed preparation (TIME) Adjunctive devices in wound care 1-3 Skin tears Wound debridement Burn injuries Traumatic wounds Unusual / Atypical wound presentations Management of fistulas and drains Multi-disciplinary teamwork in wound care Lymphoedema 1-2 Malignant wounds / Palliative wound care Table 7: Assessments of Clinical Competence Topic / Subject Area Total (n=19) Principles of asepsis / Non-touch techniques 16 Wound documentation 12 Skin assessment 11 Wound assessment Wound pain: assessment and management Wound dressings / bandages 9 Nutrition assessment and wounds Skin care 8 Skin anatomy and physiology 7 Skin function Physiology of normal and abnormal wound healing Pressure ulcers Surgical wounds Multi-disciplinary teamwork in 6 wound care MASD/ IAD 5 Factors affecting healing Wound bed preparation (TIME) Diabetic foot ulcers Psycho-social factors affecting healing 4 Wound debridement Management of fistulas and drains Wound Infection / Wound bioburdens 3 Leg ulcers Traumatic wounds Malignant wounds / Palliative wound care Legal and professional issues Effects of ageing on the skin 2 Skin tears Lymphoedema Adjunctive devices in wound care Burns injuries Unusual / Atypical wound presentations 1 Common skin conditions 86 EWMA Journal 2018 vol 19 no 2

87 EWMA Table 8: Assessment Methods, Faculty Members, Other Healthcare Professionals and Placement Opportunities Assessment Methods Wales England Scotland Republic of Ireland Total (n=2) (n=6) (n=6) (n=5) (n=19) Essays Short answer questions Multiple choice questions Objective structured clinical examinations Direct observation in clinical practice Other Number of Lecturers Other Healthcare Professionals involved as Teachers Hospital / Community-based Registered Nurses Specialist Nurse (please state speciality below) Medical staff Podiatrists Dieticians Physiotherapists Occupational therapists Other Placement Opportunities Tissue viability nurse Clinical nurse specialist Specialist wound clinic Burn unit Leg ulcer service The EWMA Teacher Network The EWMA Teacher Network is open for all professionals engaged in wound management education. The network meets once annually during the EWMA Conference and is chaired by Samantha Holloway (EWMA Council member and Senior Lecturer, Cardiff University, Wales UK). A primary objective of the network is to increase European collaboration on objectives, structure and content of future wound management education and training in Europe. REFERENCES 1. Ayello EA, Zulkowski KM, and Capezuti E. Pressure ulcer content in undergraduate programs. Nursing Outlook , e4. 2. Huff JM. Adequacy of wound education in undergraduate nursing curriculum. J WOCN , 2, pp Moore Z and Clarke E. A survey of the provision of education in wound management to undergraduate nursing students. EWMA Journal , 1, pp Romero-Collado A, Raurell-Torreda M, Zabaleta-del-Olmo E et al. Course content related to chronic wounds in nursing degree programs in Spain. Journal of Nursing Scholarship , 1, pp Welsh L. Wound care evidence, knowledge and education amongst nurses: A semi-systematic literature review. Int Wound J , pp Nursing and Midwifery Council. Standards for pre-registration nursing education. NMC London. standards-for-pre-registration-nursing-education/ EWMA Journal 2018 vol 19 no 2 87

88 EWMA EWMA Publications New and coming soon: Publications in New EWMA document: ADVANCED THERAPIES IN WOUND MANAGEMENT. CELLS AND TISSUE-BASED THERAPIES, PHYSICAL AND BIO-PHYSICAL THERAPIES, SMART AND IT-BASED TECHNOLOGIES. HEALTH ECONOMICS AND REGULATORY ISSUES The document was published as an online supplement to the Journal of Wound Care in May This document investigates the barriers and possibilities of advanced therapies in the next generation of wound management, including technologies based on cellular therapies, tissue engineering and tissue substitutes, all of which are technologies associated with the clinical discipline of regenerative medicine. The document also describes new treatments based on physical therapies and the potential of sensors, software and internet technologies. New EWMA document: SURGICAL SITE INFECTIONS Expected publication: Will be published in spring 2019 and presented at the EWMA2019 conference in Gotherburg While guidelines for preventing and managing surgical site infections (SSI) in hospitals are in place in many countries, there is still a need for guidance on how to deal with SSI management and prevention in community care. A set of recommendations on this topic covering both primary and secondary care, and targeting both health care professionals in hospitals and community-based nurses and general practitioners does not yet exist. To address this, EWMA is currently at work on a document covering SSI management recommendations across the primary and secondary health care sectors. New EWMA document: ATYPICAL WOUNDS Expected publication: Spring 2019 Also read this article on page This document will provide an overview of recent knowledge and evidence on the types of wounds characterised as atypical. The document will target wound care specialists with a special interest in this area. The objectives of the document are to provide an overview of which wounds are typically considered atypical and to present the diagnostic criteria, comorbidities and diagnostic tools for these wounds and the available best-documented treatment options, including immunosuppression and other modern/advanced wound healing therapies (e.g., NPWT). Further, the document will define the challenges and recommendations related to organising treatment and care and health economy. EWMA WOUND CURRICULUM FOR NURSES: POST-REGISTRATION QUALIFICATION WOUND MANAGEMENT. EUROPEAN QUALIFICATION FRAMEWORK LEVEL 6 The wound curriculum for nurses (EQF level 6) will be published as an online supplement to the Journal of Wound Care in EWMA is about to finalise the second curriculum in a series of curricula intended for use in levels 5 7 of the European Qualifications Framework (EQF). The aim of these is to support a common approach to post-registration qualification in wound management for nurses across Europe. EWMA hopes for and will work toward a close collaboration with European nursing organisations and educational institutions to implement these common curricula. 88 EWMA Journal 2018 vol 19 no 2

89 R I R T H B E L A T E D S W O U N D Planned projects & publications New EWMA document: BIRTH-RELATED WOUNDS Expected publication: Winter 2019/2020 The objective of this paper is to develop resources targeting health care professionals who provide care to women who have undergone childbirth (vaginal or by caesarean section), including obstetricians, midwives, nurses and general practitioners. This material will provide a useful basis for developing tools for the training of health care professionals with the objective of enhancing their wound management skills, thereby supporting the prevention and treatment of birth-related wounds and post-caesarean section infections. I P A T E N T I N V O L V E M E N T New EWMA project: PATIENT INVOLVEMENT AND CONCORDANCE IN WOUND MANAGEMENT Expected publication: Spring 2020 EWMA has decided to focus on patient involvement and concordance in wound management in the period This initiative will concentrate on patient groups with specific needs for patient engagement, such as patients with diabetic foot and/or leg ulcers, and provide recommendations for health professionals on how to address issues related to patient concordance. The project will also address the involvement of family members and close relatives and include the development of materials targeting patients and private caregivers. PATIENT CARE BUNDLES News from the EWMA Care Bundles Working Group In Spring 2018, the EWMA Council decided to establish a working group which will focus on the development of care bundles for wound management as a way to support the implementation of evidence into practice. EWMA has invested much time and energy into assimilating evidence into Position Documents as a way to educate and support of good wound management practice across Europe. Taking this work forward in developing care bundles the EWMA Council believes that this approach provides the next steps in supporting the implementation of wound management guidelines. EWMA has initiated a collaboration with the Institute of Healthcare Improvement (IHI) to use its methodology to develop a care bundle programme for management of the diabetic foot, with the primary objective to reduce the number of amputations. The EWMA Care Bundles working group currently includes the following members: Sue Bale (EWMA President, chair, UK), Sara Rowan (Italy), Julie Jordan O Brien (Ireland), Evelien Touriany (Belgium), Jan Stryja (Czech Republic) For more information about care bundles, please visit the IHI at For download or more information about the above publications and initiatives, please visit or contact the EWMA Secretariat: ewma@ewma.org EWMA Journal 2018 vol 19 no 2 89

90 EWMA Appreciations: Leaving Council Members By Sue Bale, EWMA President EWMA warmly thanks the following leaving Council members for their contributions and engagement in the work of EWMA: Barbara E. den Boogert-Ruimschotel Barbara joined the EWMA Council in 2010 (elected & ) and has, since then, contributed to the work of several EWMA Committees. As a member of the council elected by the EWMA Cooperating Organisations Board, Barbara was a member of the Cooperating Organisations Liaison Group (COLG), which is responsible for maintaining and strengthening the link between the EWMA Council and the national wound management associations. In relation to the EWMA 2017 Conference in Amsterdam, Barbara was an invaluable source of information about wound management organisation and stakeholders in the Netherlands. Barbara has also been an active member of the Education Committee, the Patient Liaison Group and the Wound Centre Endorsement Committee. Barbara will continue her engagement in the Wound Centre Endorsement Committee, which is currently working to establish a European programme for wound centre development and evaluation. We will miss Barbara s warm and engaged personality on the EWMA Council. Magdalena Annersten Gershater Magdalena joined the EWMA Council in 2012 and has contributed to its work with her skills in nursing research and education. She was engaged in the Scientific Committee of EWMA and thus involved in the development of several conference programmes, the latest of which is the programme for the EWMA 2019 Conference, which will be held in her home country, Sweden. Magdalena has also been a part of several projects aiming to standardise and raise the quality of wound management education in Europe, such as the wound management curricula for doctors and nurses and a set of basic e-learning modules targeting health care professionals with no wound care specialisation. Magdalena has an interest in targeting the bigger gaps in wound management and trying to solve them. We will miss her dedicated effort to address these issues. 90 EWMA Journal 2018 vol 19 no 2

91 EWMA New EWMA Council Members Luc Gryson Alexandra Marques Andrea Pokorná Sebastian Probst Elisabeth Lindahl The individual members and the Cooperating Organisations Board elected five EWMA Council members during the EWMA 2018 Conference in Krakow. n Luc Gryson, Belgium n Alexandra Marques, Portugal n Andrea Pokorná, Czech Republic n Sebastian Probst, Switzerland n Elisabeth Lindahl, Sweden (Elected by the EWMA Cooperating Organisations Board) The EWMA Council welcomes all new members and looks forward to a fruitful collaboration. The CVs and photos of all EWMA Council members can be viewed at EWMA Honorary positions Alberto Piaggesi Alberto Piaggesi was elected President-Elect by the EWMA Council in May Alberto already holds the post of EWMA s Scientific Recorder and will remain in this role for the year EWMA Journal 2018 vol 19 no 2 91

92 B-SPONSOR Medi Wound Care Effective therapy chain for the treatment of venous leg ulcer The medi Wound Care therapy chain is based on international guidelines and offers effective products for each phase and individual needs of the patients. The medi Wound Care approach is time- and cost-saving which has been proven in studies 1. Furthermore, physicians and therapists are able to treat their patients in a guideline-compliant and safe way for a longterm treatment success. device. Furthermore patients are able to wear their familiar shoes. The first step Wound debridement is essential, as only a clean wound is able to heal. UCS Debridement provides the optimum solution for debriding the wound, wound edges and care of the surrounding skin. The pre-moistened, sterile debridement cloth is ready to use and eases the wound cleansing and maintenance debridement process. The second step Therapy for the underlying disease is anchored in international guidelines as compression plays a major role in treating venous leg ulcers. With the adjustable compression device circaid juxtacures, medi offers an easy to handle, time-saving and cost-effective solution. The device can be easily customised to the patient s individual leg circumferences. Additionally, thanks to the integrated Built-In-Pressure system, medical healthcare professionals are able to set and readjust the therapeutically necessary compression to the patient s leg. Consistent compression therapy and movement improves the venous blood flow and reduces oedema. As soon as leg circumferences decrease, the device can be cut to the reduced measurements of the patient to provide a new customised compression 92 As soon as the wound is closed compression therapy should be continued to prevent recurrence. Within this third step medi offers a broad range of round- and flatknitted mediven compression stockings, which are available in a wide choice of colours, patterns and as twotoned compression stockings. Furthermore medi also offers an alternative for patients who cannot apply or tolerate compression stockings: circaid juxtalite. medi - I feel better. medi is one of the leading manufacturers of medical aids with its products and supply concepts. Around 2,600 employees worldwide make a significant contribution to making people feel better. The range of services includes medical compression stockings, adjustable compression devices bandages, orthoses, thrombosis prophylaxis stockings, compression clothing and shoe insoles. In addition, more than 65 years of experience in the field of compression technology has resulted in the development of sports and fashion products of the brands CEP and ITEM m6. The company supplies with a worldwide network of distributors and own subsidiaries in over 90 countries of the world. 1 Elvin S. Cost-efficacy of using juxtacures and ucs debridement cloths. JCN; 29(2): EWMA Journal 2018 vol 19 no 2

93 NEW B-SPONSOR MESI Determine a safe level of compression with 1-minute Ankle Brachial Index measurement MESI helps health care providers diagnose diseases in early stages using state-of-the-art clinical knowhow and connected technologies. Our MESI ABPI MD helps you perform an Ankle-Brachial Index measurement in just 1 minute. The device detects very low index, alerts you if the worst PAD is present and gives you an objective print out report. Arterial assessment should be performed before assigning any level of compression therapy to rule-out a possible underlying arterial condition, as adequate arterial blood flow in lower extremities prior to compression therapy or wound debridement is crucial for the wound healing potential. With MESI ABPI MD, the process consists of three simple steps. STEP 1: Identifying the patients: Indication for ABI according to WOCN* n Determine adequate arterial blood flow prior to compression therapy n Rule out PAD/LEAD with a lower extremity wound n Assess wound healing potential n Evaluate therapeutic outcome n Determine safe level of compression *ABI: Quick Reference Guide for Clinicians (WOCN guidelines). STEP 2: Performing an ABI measurement, obtaining a reliable ABI and Pulse waveforms for all extremities 09:15 Results LEFT ABI PAD RIGHT ABI :15 Waveforms Brachial pressure SYS: 125 mmhg DIA: 75 mmhg Heart rate 80 bpm STEP 3: Defining the treatment Abnormal low ABI < 0.90 Indication of PAD/LEAD Perform advanced vascular testing or refer to specialist VASCULAR RESULT Normal ABI Monitor risk factors/symptoms SAFE MEDICAL COMPRESSION Abnormal high ABI >1.40 Indication of PAD/LEAD Perform advanced vascular testing or refer to specialist Venous Ulcer ABI > 0.81 High compression mmhg is advised Mixed Ulcer ABI Modified low compression mmhg is advised Arterial Ulcer ABI < 0.50 Refer for vascular treatment EWMA Journal 2018 vol 19 no 2 93

94 Organisations AAWC Association for the Advancement of Wound Care Thomas Serena AAWC President More information: WOUND CARE NEWS It is a pleasure to update EWMA members on the activities of the Association for the Advancement of Wound Care The Association for the Advancement of Wound Care (AAWC) is an international multidisciplinary society with membership encompassing the specialties practicing wound care in thirty countries. The AAWC serves to promote and advance the burgeoning specialty of wound care, championing the healing cause for our patients, clinicians and care givers. We aim to set a standard in wound care for all of medicine to follow. In 2018 the AAWC introduced the first Pressure Ulcer Summit (PrUSummit) featuring an international forum of experts in the prevention and treatment of pressure ulcers. The event benefitted from the support of a dozen partnering organizations. The lecturers and attendees critically analyzed and debated the current state of knowledge on the causative factors for pressure ulcer formation. The summit concluded with goals for the description, management and prevention of pressure related skin breakdown. Buoyed by the success of this year s event, the AAWC will hold its second annual PrUSummit at The Westin Atlanta Airport in Atlanta, Georgia on February 8-9, Registration will open on September 10, We expect a sell-out crowd again in Visit PrUSummit.com to join this important initiative. Ever inclusive, the AAWC has partnered with societies in the United States and across the globe in several collaborative efforts. The Wound-care Experts/FDA Clinical Endpoints Project (WEF-CEP) is designed to develop scientifically rigorous yet achievable clinical endpoints for research and product approvals through the FDA. The recognition of surrogate endpoints will lead to the approval of products focused on specific aspects of wound healing, such as the efficacy of debridement. The AAWC Pressure Ulcer Description Tool (PUDT), designed to simplify the identification and description of pressure ulcers, will enter clinical trials this Fall. Guidelines for the treatment of all wound types are available through our website, aawconline.org. In addition, AAWC is moving beyond guidelines to analyze of the effectiveness of treatment modalities in chronic wounds. The AAWC is a resource for practitioners seeking professional development. One of the newer programs available to our members is a monthly Journal Club webinar. The on-line interactive presentations review and discuss a journal article of interest to the broad membership. We choose articles that will immediately impact the clinician s practice and decision making. The AAWC strives to speak with one voice on behalf of its membership to government agencies and regulators. The Healthcare Public Policy Committee, a vigilant group of members, reviews and comments on regulations, policies and legislation affecting patients, providers and access to advanced modalities. The committee provides regular updates and rallies members to action when the field is threatened. They also represent our members at the Alliance of Wound Care Stakeholders in which the AAWC is a member organization. The AAWC is the unifying voice within the US wound care community. We look forward to forming stronger bonds with the EWMA and the other societies of the world. EWMA International Partner Organisation 94 EWMA Journal 2018 vol 19 no 2

95 WOUNDS AUSTRALIA NEWS It is a pleasure to update EWMA members on the activities of Wound Australia Wounds Australia Organisations Wounds Australia is now almost in its third year of operations as a national company in the not-for-profit sector, and we are proud to announce some key achievements during Our membership continues to grow with increased benefits for members such as wound care educational events, scholarship and grant funding opportunities, as well as professional development opportunities. Key to the growth of Wounds Australia, is the development and implementation of our Strategic Plan. The Wounds Australia Strategic Plan was developed by the Board and launched earlier this year with five central themes identified; sustainable growth, knowledge, advocacy, awareness and membership. Current activities of Wounds Australia are focussed on delivering the strategic goals of the organisation, with our CEO conducting the implementation phase of the strategic plan. We are pleased to announce that Wounds Australia will be delivering a wound care credentialing programme for all wound care professionals in Australia. The Wounds Australia Credential recognises the expertise, skills and evidence based practice of clinicians who are currently delivering wound care services in line with the Wounds Australia National Standards for Wound Prevention and Management. Credentialing of wound care clinicians increases the awareness of the profession, and provides recognition of those clinicians who are delivering evidence based practice within the Australian National Standards Framework. This is part of the ongoing commitment of Wounds Australia to grow the work force capacity, and empower clinicians in the delivery of wound care services to ultimately improve patient outcomes. Kylie Sandy-Hodgetts Chair, Board Wounds Australia More information: The Wounds Australia Board recently consulted with the Australian Federal Government Department of Health representatives and the Medicare Benefits Schedule (MBS) Review Taskforce. Improvements in rebates for wound care service for high-value care based upon evidence-based practice in the primary health setting featured highly in the discussions. Wounds Australia continues to work closely with key stakeholders at the state and federal level, to assist in improving the health care sector in wound care services reform and accessibility for all patients. We are now very close to our bi-annual National Conference, which will be held October, in Adelaide and are pleased to have Professor Sue Bale, EWMA President, attend and share the EWMA vision with our Australian members. We are also delighted to have a number of EWMA delegates attending including Professor Alberto Piaggesi in continuing our knowledge sharing and collegiate relationships which have been, and continue to be, a very rewarding experience for Wounds Australia, and EWMA members and, ultimately, our patients. We hope to see you Down Under at our conference in Adelaide! EWMA International Partner Organisation EWMA Journal 2018 vol 19 no 2 95

96 Organisations SSiS Swedish Wound Care Nurses Association SSiS NEWS The Swedish Wound Care Nurses Association (SSiS) is an association for nurses and students with an interest in wounds and wound healing from a professional and nursing science perspective. SSiS works to improve the treatment and quality of life for patients with wounds through research, development and education in Sweden. Susanne Dufva SSiS President More information: SSiS main objectives include: n Striving for wound care to be conducted in accordance with science and proven experience, and in keeping with laws and regulations aimed at increasing the quality of care for people with wounds and who are at risk of developing wounds; n Monitoring and promoting research, development and education on the care of people with wounds or who are at risk of developing wounds; n Stimulating cooperation and knowledge sharing among different stakeholders; n Contributing to education and educational activities in the field of wound healing; n Strengthening and clarifying the role of nurses in wound care; n Creating trusting cooperation with companies within the wound care field and providing advice to these companies; and n Being a meeting place and force for stimulating cooperation and knowledge exchange among interest groups from different specialist areas in wound care and wound healing, both nationally and internationally. SSiS has several scholarships for participation in conferences as well as to develop wound management. SSiS publishes the journal SårMagasinet, distributed to 4,700 nurses around the country. The EWMA 2019 Conference is organised in cooperation with SSiS. SSiS is a section within The Swedish Society of Nursing, a non-profit organisation and a forum for discussing and developing nursing care by promoting nursing research, ethics, education and quality in nursing. The Society contributes to a high standard of nursing and health care for the benefit of patients and the people close to them. EWMA Cooperating Organisation 96 EWMA Journal 2018 vol 19 no 2

97 14 TH CONFERENCE OF THE European Council of Enterostomal Therapists ECET June 2019 Rome Italy 9 th International Lymphoedema Framework Conference SAVE THE DATE Co-hosted by the American Lymphedema Framework Project ILF JUNE 2019 CHICAGO USA. Elevate your view. #ILF2019

98 Organisations ILF NEWS ILF International Lymphoedema Framework Anna Kennedy Member of the ILF Board of Directors Executive Director of the Canadian Lymphedema Framework and Editor of Pathways-Lymphedema More information: Moving the Manangement of Lymphoedema Worldwide The International Lymphoedema Framework (ILF) community now includes 14 countries with established national frameworks, all united in their vision to change how lymphoedema is diagnosed, treated and reimbursed. Patients remain at the heart of all activities, and collaborating in multidisciplinary partnerships between all stakeholders and with the national frameworks is essential to the ILF s success. With a proven track record of challenging important issues and creating methodologies that engage with multiple stakeholders to gain consensus, the ILF is committed to generating high-level evidence and continuing reviews of international research. The ILF has identified a number of key priority areas that are inhibiting the recognition of chronic oedema as a major, emerging public health care problem. The need for international epidemiology to provide evidence of the size and impact on health care services is being addressed within the LIMPRINT project, an international study focused on providing evidence to support the development and reimbursement of lymphoedema-related services. This collaborative project involved 40 sites located in 9 countries and collected data on more than 15,000 participants. The study results will be published in The lack of international standards and methods for assessing and reporting the outcomes of treatments in patients with different forms of chronic oedema has prohibited reimbursement in many countries, the evaluation of clinical and patient-centred outcomes within services, the benchmarking of chronic oedema care and robust clinical studies using internationally agreed outcomes. The Chronic Oedema Outcome Measures (ILF-COM) project s goal is to agree on and validate international measures that will be used by the lymphoedema community in both clinical practice and research. This, in turn, should assist in providing robust guidance for reimbursement agencies. It is considered essential that all health care professionals have a basic understanding of lymphoedema and be able to provide patients with education and support. The Lymphoedema Education Benchmark Statements (LEBS) were developed through a process of expert panel consensus and identify minimum standards and content that should be built into existing professional health care curricula. A user-friendly web-based document has been launched for this purpose ( and the next initiative will support the global ILF community in developing, disseminating and evaluating the LEBS in their own countries. ILF s international strategy of defining and improving the care of children with lymphoedema focuses on empowering children, their families and the health professionals who care for them. One important aspect is the ILF Children s Camps, which bring children and their families together to learn more about self-care for lymphoedema, and to build networks of families coping with the same situations. The two primary vehicles for organising and presenting the ILF s work are publications (such as Compression Therapy: A Focus Document on Compression Bandaging (2012)) and annual conferences, which allow for collaboration with the greater lymphedema community. Publications are free to download from the ILF website ( The next conference will be co-hosted with the American Lymphedema Framework Project (ALFP) and held in Chicago, Illinois from June 13 15, Visit People can learn more by signing up to receive quarterly communications and also be eligible for reduced rates to ILF conferences. See for more details. EWMA International Partner Organisation 98 EWMA Journal 2018 vol 19 no 2

99 Corporate A Corporate Sponsors Coloplast KCI an Acelity company Smith & Nephew Medical Ltd ConvaTec Europe Lohmann & Rauscher URGO Medical/Laboratoires Urgo Essity Mölnlycke Health Care AB Wacker Chemie AG Paul Hartmann AG Ferris Mfg. Corp. Corporate B 3M Health Care Beier Drawtex Healtcare Kerecis TM Nutricia Advanced Medical Nutrition ABIGO Medical AB Aurealis Pharma, Itd Fidia farmaceutici S.p.A. Flen Health SA Freudenberg Performance Materials SE & Co. KG KLOX Technologies Inc Medela AG Medi GmbH & Co. KG SastoMed GmbH SOFAR S.p.A. Stryker B. Braun Medical Frontier Medical Group MESI, development of medical devices, Ltd Vancive Medical Technologies vancive.averydennison.com Chemviron Juzo Julius Zorn GmbH Mimedx Group, Inc. Welcare Industries Spa EWMA Journal 2018 vol 19 no 2 99

100 Conference Calendar 2018/19 For web addresses please visit Conferences 2018 Theme Month Days City Country 18 th Conference of Diabetic Foot Global Annual conference October Houston, TX USA Conference (DFCon) Belgian Federation of Wound Care (BEFEWO) Annual conference October 18 Bruxelles Belgium Wounds Australia National Conference Advancing Healing Horizons October Adelaide Australia towards the cutting edge in wound care Association for the Advancement of Symposia on Advanced Wound November 2-4 Las Vegas, NV USA Woundcare (AAWC) Care (SAWC) Wounds UK Annual conference November 5-7 Harrogate United Kingdom 3 rd Nordic Diabetic Foot Symposium 2018 (NDF) November 6-7 Helsinki Finland Conference of Slovak Wound Healing Annual congress November 9-10 Hotel Jacna, Slovakia Society (SSPLR) Demänovská dolina Czech Wound Management Association (CSLR) Symposium on Pressure ulcers November 10 Brno Czech Republic Wounds Canada Fall conference November 8-11 London, Ontario Canada Portuguese Association for the Treatment 20 th Anniversary November Gondomar Portugal of Wounds (APTF) 11 th Congress of Ibero-Latin American Congress November Rome Italy about Ulcers and Wounds (SILaUhe) Danish Wound Healing Society (DSFS) Annual conference November Odense Denmark Conference of Italian Nurses Cutaneous Annual conference November Milano Italy Wounds Association (AISLeC) National Advisory Group for the Study of Annual congress November Valencia Spain Pressure Ulcers and Chronic Wounds (GNEAUPP) Ukrainian Wound Treatment Organisation (WUTU) 18 th Annual Conference November Kyiv Ukraine 1 st Conference of Wound Management On the same road: Wound- December 6-8 Nuremberg Germany in Nuremberg (WUKO) healing, research and wound management 13 th Congress of Turkish Wound Management 13 th national wound congress December Antalya Turkey Association Conferences 2019 Theme Month Days City Country French Wound Healing Society (SFFPC) Journées Cicatrisations January Paris France Czech Wound Management Society Annual congress January Pardubice Czech Republic Finnish Wound Care Society (FWCS) Acute wounds - Help in time Jan/February 31-1 Helsinki Finland Congress of Norwegian Wound Care Society (NIFS) Annual congress February TBA Oslo Norway 8 th Congress of Spanish Society of Wounds (SEHER) Annual congress February Madrid Spain Diabetic Limb Salvage Conference Annual conference April 4-6 Washington, DC USA Tissue Viability Society (TVS) Annual congress May 1-2 Southampton United Kingdom Association for the Advancement of Symposion on Advanced Wound May 7-11 San Antonio, TX USA Woundcare (AAWC) Care Spring (SAWC Spring) Deutcher Wound Congress 2019 (DWEC) May 8-10 Bremen Germany Australasian Lymphology Association (ALA) Annual congress May Sydney Australia International Symposium on the Annual Symposium May The Hague The Netherlands Diabetic Foot (ISDF) New Zealand Wound Care Society (NZWCS) Bi-ennial conference May Dunedin New Zealand 29 th Conference of the European Wound Annual conference June 5-7 Gothenburg Sweden Management Association 2019 (EWMA) 100 EWMA Journal 2018 vol 19 no 2

101 Conference Calendar 2019 For web addresses please visit Conferences 2019 Theme Month Days City Country 20 th congress of The European Federation of Registries & Impact On Practice June 5-7 Lisbon Portugal National Associations of Orthopaedics and Traumatology (EFORT) 9 th International Conference of the International Annual conference June Chigago, IL USA Lymphoedema Network (ILF) 14 th Conference of European Council of Annual conference June Rome Italy Enterostomal Therapy (ECET) 51 th Conference of Wound Ostomy and Annual conference June Nashville, TN USA Continence Nurses Society (WOCN) 19 th Congress of DGfW Annual congress June TBA Germany 38 th Annual meeting of the European Bone Annual meeting September Antwerp Belgium and Joint Infection Society (EBJIS) 55 th Annual Meeting of the European Association Annual meeting September Barcelona Spain for the Study of Diabetes (EASD) European Pressure Ulcer Advisory Panel (EPUAP) EPUAP & PERSE Joint annual September Lyon France meeting th Pisa International Diabetic Foot Course October 2-5 Pisa Italy European Academy of Dermatology and Annual congress October 9-13 Madrid Spain Venereology (EADV) Association for the Advancement of Symposion on Advanced October Las Vegas, NV USA Woundcare (AAWC) Wound Care (SAWC Fall) Dutch Knowledge Centre for Wound Care (WCS) Wound Care Congress November Utrecht The Netherlands Submit your paper to the April 2019 issue of EWMA Journal April 2019 issue is committed to Patient involvement - an aspect of the EWMA 2019 conference theme Person-centred Wound Care. Who is in Charge of the Wound? Deadline for scientific papers is 15 January 2019 EWMA Journal Author Guidelines available at ewma@ewma.org Published by EUROPEAN WOUND MANAGEMENT ASSOCIATION Editorial Board Sebastian Probst, Editor Sue Bale, Editor in Chief Vickie R Driver Georgina Gethin Salla Seppänen Andrea Pokorná