Foot ulcers are one of the major

Article Conservative sharp wound debridement by community nurses for clients with diabetic foot ulcers: A quality improvement initiative Connie L Harris, Sarah Burns-Gibson, Beth Byrnes, Annette Harris Conservative sharp wound debridement (CSWD) is within the scope of practice for registered nurses working in the community setting in Ontario. Although part of the RNAO s Clinical Best Practice Guidelines: Assessment and Management of Foot Ulcers for People with Diabetes, it is an expectation that is not delivered uniformly by community nurses. This article looks at a quality initiative training a small group of nurses to become competent in this skill. The quantitative and qualitative outcomes of performing CSWD on 26 consenting clients on service with neuropathic diabetic foot ulcers are examined. Although the results are not compelling from a quantitative perspective, the qualitative data provides incentive to expand this practice. Foot ulcers are one of the major complications of neuropathy in people with diabetes. Neuropathy eliminates the protective signal of pain, and the motor component leads to muscle atrophy, foot deformity, altered biomechanics, and increased plantar pressure, often resulting in traumatic injuries and skin breakdown. The increased local plantar pressure and trauma is associated with callus formation that usually precedes skin breakdown. Without callus debridement and pressure relief, persons in this situation develop chronic non-healing ulceration (Bus et al, 2005). The majority of these individuals with neuropathic diabetic foot ulcers (DFU) are cared for by physicians, nurses and allied health in the community sector. Once the neuropathic ulceration has occurred, frequent sharp debridement of ulcers having adequate circulation has been strongly linked to increased wound closure (Steed et al, 1996). In their randomized controlled trial, all wounds were initially extensively debrided removing all necrotic and/or abnormal granulation tissue and the undermined skin containing the callus, also called saucerizing. On follow-up visits, paring of callus around the ulcers and debridement of necrotic tissue were done as needed. There was an improved response rate with ulcers receiving more frequent debridement that was independent of the treatment group. Aggressive debridement is a Controlled Act under the Regulated Health Professions Act of Ontario (1991), for a physician, chiropodist or podiatrist, and outside the scope of practice for nursing. Conservative sharp wound debridement (CSWD) includes paring callus (down to viable epidermis but not through the epidermis) and removal of non-viable (necrotic) tissue from the wound bed. CSWD may be performed by nurses who are competent in this skill in situations allowed by provincial legislation and agency policy (Rodd-Neilsen and Harris 2013). Removal of plantar callus reduces pressures by up to 30%, creating an environment conducive to healing (Young et al, 1992; Potter and Potter, 2000; Slater et al, 2006), while necrotic tissue delays healing and can be a locus for infection. Figures 1 and 2 demonstrate a pre- and post- CSWD by a competent RN ET nurse on an admission visit. The Registered Nurses Association of Ontario (RNAO) Clinical Best Practice Clinical Guideline, Assessment and Management of Foot Ulcers for People with Diabetes (2005) contains 30 practice, educational, organizational and policy Citation: Harris CL, Burns- Gibson S, Byrnes B, Harris A (2014) Conservative sharp wound debridement by community nurses for clients with diabetic foot ulcers: A quality improvement initiative. Diabetic Foot Canada 2: 31 7 Article points 1. Conservative sharp wound debridement is not delivered uniformly by community nurses in Ontario. 2. A quality initiative trained a small group of nurses to become competent in wound debridement. 3. Nurse and patient feedback was collected and analysed. Key words - Debridement - Neuropathy - Nurse education Authors Connie L. Harris RN, ET, IIWCC, MSc - Senior Clinical Specialist Wound and Ostomy, Red Cross Care Partners, Kitchener, ON Sarah Burns-Gibson RN, BHScN, MSc, CCHN(C) - Clinical Practice Manager- Red Cross Care Partners, Kitchener, ON Beth Byrnes RN Regional Manager, South West Division, Tillsonburg, ON Annette Harris RN, IIWCC - Clinical Nurse Educator, Red Cross Care Partners Central East Division, Oshawa, ON Diabetic Foot Canada Volume 2 No 1 2014 31

The recommendations for local wound care for individuals with DFUs with adequate circulation include debridement, infection control and a moist wound environment. Figure 1. Before conservative sharp wound debridement Figure 2. After conservative sharp wound debridement recommendations, based on published evidence. These include systemic factors that should be modified, including co-factors that may interfere with or negatively impact healing. Extrinsic factors including pressure redistribution must be corrected, which may require an interdisciplinary referral. The recommendations for local wound care for individuals with DFUs with adequate circulation include debridement, infection control and a moist wound environment. Surprisingly, the document cautions that the Cochrane review (Smith, 2002) stated that sharp debridement has not shown significant benefit in promoting wound healing, citing the need for more research to evaluate the effects of debridement. More recent work reinforces the need for frequent sharp debridement as part of routine care (Saap and Falanga, 2002; Sheehan et al, 2003; Snyder et al, 2010). CSWD is not a standalone intervention, and there may be many confounding factors present, such as poor glycemic control, multiple co-morbidities and the inability to obtain off-loading devices due to economic hardship. Other specialties that may be involved are infectious diseases physicians, orthopedic surgeon, vascular surgeon, diabetic clinic, orthotists etc. Significance In 2010, our nursing agency became a RNAO Best Practice Spotlight Organization (BPSO) candidate (http://rnao.ca/bpg/bpso). This competitive initiative is funded by the Ontario Ministry of Health and Long-Term Care. One of the requirements of the candidacy is to conduct research regarding implementation of one of RNAO s Clinical Best Practice Guidelines (CBPG). We chose a conservative sharp wound debridement (CSWD) program for diabetic foot ulcers by nurses, and examined the outcomes. Our clinical nurse specialist in wound care had already demonstrated statistically significant positive outcomes using a similar model (Harris and Shannon, 2008; Shannon et al, 2008), and believed that the success could be replicated. Performance improvement processes Ethics, consents and approvals Ethics approval was obtained through the Homewood Health Centre Research Ethics Board, Guelph, ON. Consent from two Community Care Access Centres (CCACs) was obtained. An information letter explaining the intervention was sent to physicians to obtain medical approval and client information was provided, and consent obtained for each client. Nursing education Six registered nurses in two of the nursing branches contracted under two CCACs, approximately 200 km apart, were willing to be trained in CSWD. The education program was updated and implemented at both sites, and described in detail in a previously published article (Harris, 2013). In brief, the education included a pre-reading of Wound Bed Preparation Best Practice Recommendations (Sibbald et al, 2006), a didactic session outlining the Best Practice Interventions for care of Neuropathic Diabetic Foot ulcers, principles of CSWD including precautions and contraindications, two videos of sharp debridement techniques, 32 Diabetic Foot Canada Volume 2 No 1 2014

written post tests, and a skills lab using pig s feet and candles. Mentored visits followed, to perform the skill on actual clients in order to gain competency, in accordance with our agency s policy and procedure. At the completion of the training and mentorship, the nurses were: Competent in providing sharp callus reduction or non-viable necrotic tissue debridement. Knowledgeable about recommendations to the physicians to saucerize the wound edges if required. Instructed to document each episode of CSWD. Knowledgeable regarding the need for pressure offloading, and would facilitate referrals to specialists as needed. One nurse had been competent in performing CSWD for >4 years, and mentored the nurses acquiring the skill in her area. Client selection All clients either already on service or admitted to service with neuropathic diabetic foot ulcers were possible candidates for CSWD by the nurses. The exceptions would be for those with peripheral arterial disease (PAD) or those whose wounds would be maintenance or nonhealable. CSWD of the feet and lower limbs is considered by many to be contraindicated in people with PAD, e.g. an ankle brachial pressure index (ABPI) <0.6 and/or signs and symptoms of arterial disease. Maintenance wounds have healing potential, but various patient factors are compromising wound healing at this time e.g. need vascular surgery, or failure to obtain pressure offloading orthotic devices. Nonhealable/palliative wound are those in which the individual has no ability to heal due to untreatable causes such as severe ischemic disease (Despatis et al, 2008). Medical supplies Wound dressings were provided by the local CCAC, as per normal practice, while offloading devices were the responsibility of the individual client to purchase. One CCAC provided the sharps instruments (sterile disposable iris scissors and tissue forceps and scalpels) with which to Table 1. Data entered in documentation forms 1. Percentage reduction in healing while on nursing services. 2. Changes to the Bates-Jensen Wound Assessment Tool scores over time. 3. Time to healing (for those clients who remain on service until healed). 4. Number of nursing visits while on nursing service for this wound. 5. Number of ETN visits. 6. Length of time on nursing services. 7. Presence of orthotic footwear designed to offload pressure in clients with diabetic foot ulcers. 8. Saap and Falanga s (2002) debridement performance index scores (Table 2). 9. Frequency of sharp callus reduction or non-viable debridement. 10. Frequency of referral to physician for subcutaneous debridement (saucerizing). 11. Wound size pre- and post-debridement. 12. Bates-Jensen Wound Assessment Tool scores pre-and post-debridement for four characteristics: edges, undermining, necrotic tissue type, and necrotic tissue amount (same visit). 13. The number of packages of iris scissors/forceps used for sharp debridement. 14. The number of packages of scalpel blades used for sharp debridement. 15. If the client was placed on antibiotics since last visit for DFU infection. 16. If the client was admitted to hospital since last visit due to DFU complications. perform CSWD, but the second did not and the agency had to cover those costs. Documentation The regular agency wound flow sheet was used as per all wound care clients, which captured items 1 6 (Table 1). Additional data pertinent to CSWD was documented on an additional sheet (items 7 16 Table 1). The clients were also given a patient teaching handout My Diabetic Foot Ulcer, courtesy of the South West CCAC s Wound Care Initiative (2011) and printed by our agency for clients in the Central East CCAC. An updated version of this booklet can be found at: http://bit.ly/1fvvqsb Table 2. Debridement Performance Index (DPI) Category Debridement intervention Needed but not done Needed and done Not needed Score Callus 0 1 2 0 to 2 Skin undermining Wound bed necrotic tissue DPI = Total score 0 to 6 0 1 2 0 to 2 0 1 2 0 to 2 Diabetic Foot Canada Volume 2 No 1 2014 33

Table 3: Nursing satisfaction survey Questions 1. The (didactic) education was helpful in facilitating my learning 2. The hands-on workshop was helpful in facilitating my learning 3. I felt competent to perform this skill on my own after the mentoring visits with the ET nurses. 4. Possible risks and problems in performing this skill were explained to me during the training 5. I felt empowered to be able to provide this care to my clients. 6. The extra time required to perform this skill is not unreasonable in a usual day of visits. 7. The Teaching Handouts helped me to teach my client about their diabetic foot ulcer. 8. I saw improvement in my clients wounds because I was able to provide this care. 9. Overall, I was satisfied with the education to gain this competency. 10. Overall, I was satisfied with the support provided to me to gain this competency. 11. The extra time to perform this skill added minutes to my normal visit for this wound. Enter minutes below. Strongly agree 4=80% 1=20% 4=80% 1=20% 2=40% 3=60% 3=60% 2=40% 3=60% 2=40% Agree Disagree Strongly disagree 2=40% 1=20% 2=40% 2=40% 2=40% 1=20% 2=40% 3=60% 3=60% 2=40% 2=40% 3=60% N/A 20 35 20 30 20 30 20 60 Post-intervention chart audits Chart audits performed in February 2012 included collection of the information shown in Table 1. There was a limited amount of time in which to implement the intervention and to collect the data so the total length of time on service before the chart audit varied between clients. Outcomes Quantitative data Using the inclusion/exclusion criteria, 27 clients who consented to receive CSWD were enrolled between 1 April and 22 December 2011. Of interest, five individuals had already been on service for >300 visits and one >200 visits, due to multiple comorbidities and complications suchas chronic Charcot foot, amputation and/or MRSA infection. Nine had non-healing DFUs >1 year. At the time of the February chart audit, 14 individuals achieved 100% healing after CSWD was implemented by the nurses, nine had 75 98% healing at the time of the audit, two were lost to follow-up (one admitted to hospital, one moved and chart not retrieved) and one was excluded because their physician refused to have his patient participate because CSWD was being done in his clinic. One was excluded due to not having an open ulcer, only thick callus. We did not track the number of clients who were ineligible. Unfortunately, the additional CSWD study data collection tool (double-sided one page) was missing from five charts, which affected the richness of reporting items 7 16 (Table 1). Nine clients who had CSWD implemented within one month of being admitted had 100% healing, with a range of 11 to 304 days on service and median of 123. Three clients also on service less than 1 month pre-cswd had a range of healing of 58 to 98% at the time of the audit, with a range of days on service of 108-117 days. Two with 100% healing were on service more than 1 month but less than one year prior to CSWD, with a range of 165 to 362 days and median of 264 days on service. Perhaps surprisingly, three had 100% healing who were on service more than one year pre- CSWD. Six who were on service more than 1 year pre-cswd did not heal; 4 out of 6 had 80% reduction in size (since admission). One wound deteriorated, and an ulcer on a toe went on to amputation, neither related to the CSWD. Using the DPI and documenting the four BWAT characteristics pre- and post- CSWD added to the documentation workload for the nurses, but provided important information from a quality perspective. The DPI captured the need for CSWD and what was done without a narrative note. The scores were consistent for clients at CSWD episodes, demonstrating that there was an ongoing need, with the scores reducing just prior to discharge for only five individuals. The preand post scores for the four BWAT characteristics 34 Diabetic Foot Canada Volume 2 No 1 2014

demonstrated what the wound edges and necrotic tissue in the base were like before and after the CSWD, documenting an average reduction in the score of 4 points, suggesting that there was improvement as a result of the intervention. Qualitative nursing feedback Five of the six nurses who participated in the CSWD intervention responded to the on-line, anonymous nursing satisfaction survey. There were 11 questions (Table 3), 10 of which used a Likert scale for responses, with the opportunity to write comments after each question. Additional comments from the nurses ranged from the negative to the positive: The extra time required to perform the skill was significant and increased stress/frustration on days when total numbers of client visits were high. The number of visits to perform CSWD in one day needed to be manageable. Keeping in close communication with the physician added time to their day. Some clients were still mostly non-compliant (with making lifestyle changes regarding healing their DFU). The challenge was in getting a proper offloading assessment, and garnering adherence to the treatment plan. Nurse was not sure that it was the CSWD intervention alone that made the difference; when combined with pressure offloading and a referral to the local diabetic foot clinic, there was significant improvement. The more they practiced, the more confident and able they became. CSWD helped them to feel more connected to wound care and the client. While they initially booked these clients weekly for CSWD, they were able to decrease the frequency for some based on their assessment of how much callous had recurred on the next visit. They saw improvement in their clients wounds because they were able to provide the care. Qualitative client feedback To obtain qualitative feedback from the clients, a registered nurse made two phone attempts to reach clients enrolled in the study; during both day and evening. Table 4: Client satisfaction survey Questions The nurse explained why it was important to remove dead tissue from around my wound. The Teaching Handouts that the nurse gave me helped me remember information about my diabetic foot ulcer. The nurse took the time to answer my questions. The nurse helped me understand why I have to change my lifestyle. I.e. getting footwear that would reduce the pressure on my ulcer, checking the bottom of my feet daily for any red or open areas. My plan of care was discussed with me. Possible risks were explained to me. I feel that my ulcer got better as a result of having the nurse remove dead (skin) tissue from around my wound. Overall, I was satisfied with the care I received from the nurses. Strongly agree Thirteen clients were reached and agreed to interviews, with no refusals. Some clients were inaccessible because their phones were disconnected or the numbers had changed. A Likert scale was also used for the questions, but with the inclusion of an I can t remember choice (Table 4 ). The clients were also given the opportunity to make comments. Comments from the clients were positive on the whole: The ulcer got better for a while, but after their physician told them to walk more, it got worse. The ulcer was coming back again; they had tried to trim it themselves, but it was time to be seen again. The timing between interventions was too Agree Disagree Strongly disagree Cannot remember 9=69% 2=15% 0 1=8% 1=8% 6=46% 5=38% 0 1=8% (stated did not receive a handout) 8=62% 5=38% 0 0 0 5=38% 7=54% 0 1=8% 0 6=46% 7=54% 0 0 0 6=46% 7=54% 0 0 0 7=54% 5=38% 1=8% 0 0 10=77% 3=23% 0 0 0 1=8% Diabetic Foot Canada Volume 2 No 1 2014 35

They would welcome the creation of a program where registered nurses would perform CSWD in collaboration with the physician. long, but they preferred the way that the nurse (performed the debridement) rather than their physician, perhaps because he was afraid of getting too close to the wound. The nurses are my saviors. I don t know what I would do without them. Was thankful that the nurse recognized that the wound had reached a plateau and requested a referral to a specialist doctor, after which the wound improved. They received excellent/awesome care (n=3),the care was fantastic and had given them the incentive to prevent it from happening again. Had to arrange their visits for when the one nurse who was qualified to do the debridement was going to be at the clinic. Discussion This evaluation had very small numbers of nurses and clients. Further evaluation with larger numbers and better data collection with an economic evaluation is needed to draw any statistical conclusions. Any client needing CSWD for a DFU needed to be seen by one of the three trained nurses on a regular basis. That nurse would not necessarily be part of the usual team for that client s area. One of our goals was to have frequent opportunities for the nurses to practice and maintain this new competency. However, performing CSWD increased their workload, requiring extra driving time for clients seen in their own home, or having to schedule the CSWD on the days that the nurse was available in the clinic. Unfortunately, the nurses were not always able to do the next CSWD as planned. There were times when the visit that had been pre-scheduled for CSWD was pulled from that nurse, and given to another who could not provide that care. This happened due to capacity challenges with new admissions or complexity of other clients, or high visit volume. We did not think to track how many times CSWD visits had been booked but then postponed. In future, a better plan may be to have at least one nurse trained in CSWD for each nursing team or clinic location, and to identify that visit as CSWD in the scheduling planner so that it would not be moved to another nurse. If CSWD is performed more frequently, it should not require as much time as when a thick callus has formed again. We should also define the frequency with which nurses are able to perform CSWD to maintain their competency. Ten clients had already been on nursing service for their wounds for one to four years before implementation of the CSWD intervention. Wounds in these individuals could have been considered maintenance, and while highly unlikely that the addition of CSWD would suddenly enable these wounds to heal, the nurses and the clients wanted to try. It is noted that if truly maintenance, they should have been excluded according to the criteria. It was not our intention to portray this as a singleservice solution for DFUs, but to examine the implementation of CSWD as part of the multifocused best practice guideline. The average length of time on service was shortest for the healed group when the intervention was started within one month after admission, higher when the intervention started more than one month to <1 year after admission, and not surprisingly, highest when >1 year. Two unanticipated positive responses to the project occurred. Clients receiving CSWD in a nursing clinic would see other clients with a bandaged foot, and strike up a conversation. The client already receiving CSWD from the clinic nurse would suggest that the other client ask their nurse about it, because it was making such a difference with their wound s progress. The other was uptake by the physicians in the community, one of whom called the principal investigator to praise the initiative. He requested the intervention in several referrals, once he was certain of the type of preparation that the nurses had received, and that it was within their scope of practice provincially. We are also aware, from discussion with physicians in both locations who routinely see the diabetic foot population as a focus for their care, that it is difficult for them to book followup visits for debridement as often as they feel the patient needs due to funding/capacity issues. They would welcome the creation of a program where registered nurses would perform 36 Diabetic Foot Canada Volume 2 No 1 2014

CSWD in collaboration with the physician, to occur between the physician appointments. They identify this as a current gap in the provision of evidence-based care. Conclusion and implications Without a comparison control group, it is difficult to support the qualitative improvement that many clients and nurses believed happened. This was a pragmatic trial that did not exclude individuals with co-morbidities (other than ischemic arterial disease) or length of time on service. Tighter inclusion/exclusion criteria may have helped to clarify the significance of the outcomes. There is opportunity and need for community nursing agencies and CCACs to look seriously at the benefits of expanding the competencies of registered nurses to perform CSWD. This should be part of an inter-professional approach to evidence-based care, supported by the RNAO s Clinical BPG for Assessment and Management of Foot Ulcers for People with Diabetes. At this time, some CCACs see CSWD as an exceptional service beyond the basic forceps needed for dressing changes, and provide the sterile iris scissors, tissue forceps and scalpels as part of their medical supply catalogues. Other CCACs do not. To provide an idea of the cost to the nursing service provider agency, an estimated retail cost is $3.50 per set for sterile scissors and forceps, and $1.70 for scalpels (SWCCAC medical supply catalogue v30 May 2012). One episode of CSWD may require two scalpels plus a set of scissors and forceps, depending on the thickness of the callus and the presence of necrotic tissue. This cost is significant, given that pricing restraints have been in effect since 2009 resulting in a freeze in rates for CCAC service providers at the 2008 level (i.e. no annual cost of living increase). The cost of this equipment, required to provide evidence-based care to this population, must come out of that per-visit fee where CCACS do not provide it. In spite of this, our agency supports and believes that this is something that we should be providing to our clients, by nurses who have been trained and are competent, as part of the interdisciplinary approach to diabetic foot ulcer care. n Bus SA, Maas M, de Lange A et al (2005) Elevated plantar pressures in neuropathic diabetic patients with claw/ hammer toe deformity. J Biomech 38(9): 1918 25 Despatis M, Shapera L, Parslow N, Woo K (2008) Complex wounds. Wound Care Canada 8(2): 24 5 Harris C, Shannon R (2008) An innovative enterostomal therapy nurse model of community wound care delivery: a retrospective cost-effectiveness analysis. J Wound Ostomy Continence Nurs 35(2): 169 83 Harris C (2013) Creating a Conservative sharp wound debridement (CSWD) education program for frontline nurses. Wound Care Canada 11(2):18-24. Potter J, Potter MJ (2000) Effect of callus removal on peak plantar pressures. The Foot 10: 23 6 Rodd-Nielsen E, Harris CL (2013) Conservative sharp wound debridement: a snapshot of Canadian education, practice, risk and policy. J Wound Ostomy Continence Nurs 40(6): 594 601 Saap LJ, Falanga V (2002) Debridement performance index and its correlation with complete closure of diabetic foot ulcers Wound Repair Regen 10(6): 354 9 Shannon R, Harris C, Harley C et al (2008) The importance of sharp debridement in foot ulcer care in the community. Wound Care Canada Suppl 5(1): S51 6 Sheehan P, Jones P, Caselli A et al (2003) Percent change in wound area of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Diabetes Care 26(6): 1879 82 Sibbald RG, Orsted HL, Coutts PM, Keast DH (2006) Best practice recommendations for preparing the wound bed: update 2006. Wound Care Canada 4(1): 15 29 Slater RA, Hershkowitz I, Ramot Y et al (2006) Reduction of digital plantar pressure by debridement and silicone orthosis. Diabetes Res Clin Pract 74(3): 263 6 Smith J (2002) Debridement of diabetic foot ulcers. Cochrane Database Syst Rev (4):CD003556 Snyder RJ, Cardinal M, Dauphinée DM, Stavosky J (2010) A post-hoc analysis of reduction in diabetic foot ulcer size at 4 weeks as a predictor of healing by 12 weeks. Ostomy Wound Manage 56(3): 44 50 Steed DL, Donohoe D, Webster MW, Lindsley L (1996) Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic Ulcer Study Group. J Am Coll Surg 183(1): 61 4 Teague L, Arnott C, Bruton K et al (2005) Assessment and management of foot ulcers for people with diabetes. Registered Nurses Association of Ontario Nursing Best Practice Guidelines. RNAO, Toronto, ON Young MJ, Cavanagh PR, Thomas G et al (1992) The effects of callus removal on dynamic plantar foot pressures in diabetic patients. Diabetic Med 9(1): 55 7 This is something that we should be providing to our clients, by nurses who have been trained and are competent, as part of the interdisciplinary approach to diabetic foot ulcer care Diabetic Foot Canada Volume 2 No 1 2014 37