Volume 17
16
Number 1
2016
April 2016
Published
Published by
by
European Wound
Wound
Management
Management
Association
The EWMA Journal
ISSN number: 1609-2759
Volume 16, No 1, April, 2016
The Journal of the European
Wound Management Association
Published twice a year
EWMA
Council
Severin Läuchli
President
Salla Seppänen
Immediate Past President
Editorial Board
Sue Bale, UK, Editor
Severin Läuchli, Switzerland
Vickie R. Driver, USA
Georgina Gethin, Ireland
Martin Koschnick, Germany
Rytis Rimdeika, Lithuania
Salla Seppänen, Finland
Hubert Vuagnat, Switzerland
Luc Gryson
Treasurer
Alberto Piaggesi
Secretary
José Verdú Soriano
Scientific Recorder
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2
COOPERATING ORGANISATIONS’ BOARD
Esther Armans Moreno, AEEVH
Christian Thyse, AFISCeP.be
Valentina Vanzi, AISLeC
Corrado Maria Durante, AIUC
Ana-Maria Iuonut, AMP Romania
Aníbal Justiniano, APTFeridas
Gilbert Hämmerle, AWA
Kirsty Mahoney, AWTVNF
Jan Vandeputte, BEFEWO
Vladislav Hristov, BWA
Els Jonckheere, CNC
Lenka Veverková, CSLR
Mirela Bulic, CWA
Arne Buss, DGfW
Susan Bermark, DSFS
Heli Kallio, FWCS
Rosa Nascimento, GAIF
J. Javier Soldevilla, GNEAUPP
Georgios Vasilopoulos, HSWH
Björn Jäger, ICW
Aleksandra Kuspelo, LBAA
Susan Knight, LUF
Loreta Pilipaityte, LWMA
Corinne Ward, MASC
Hunyadi János, MSKT
Suzana Nikolovska, MWMA
Linda Primmer, NATVNS
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
Susanne Dufva, SSIS
Jozefa Košková, SSOOR
Leonid Rubanov, STW (Belarus)
Guðbjörg Pálsdóttir, SUMS
Cedomir Vucetic, SWHS Serbia
Magnus Löndahl, SWHS Sweden
Tina Chambers, TVS
Jasmina Begić-Rahić, URuBiH
Natalia Vasylenko, UWTO
Barbara E. den Boogert-Ruimschotel, V&VN
Caroline McIntosh, WMAI
Skender Zatriqi, WMAK
Dragica Tomc, WMAS
Mustafa Deveci, WMAT
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
Rose Cooper, 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
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
Christian Münter, Germany
Andrea Nelson, UK
Pedro L. Pancorbo-Hidalgo, Spain
Hugo Partsch, Austria
Elaine Pina, Portugal
Patricia Price, UK
Sebastian Probst, Schwitzerland
Elia Ricci, Italy
Rytis Rimdeika, Lithuania
Zbigniew Rybak, Poland
Salla Seppänen, Finland
José Verdú Soriano, Spain
Robert Strohal, Austria
Richard White, UK
Carolyn Wyndham-White, Switzerland
Gerald Zöch, Austria
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References
1. H. Joy et al. A collaborative project to enhance efficiency through dressing change practice (N=37). Journal of Wound Care
Vol 24. No 7. July 2015. 2. D. Simon et al. A structured collaborative approach to appraise the clinical performance of a new
product. Wounds UK. Vol 10. No 3. 2014. 3. A. Rossington et al. Clinical performance and positive impact on patient wellbeing
of ALLEVYN LIFE. Wounds UK. Vol 9. No 4. 2013. 4. O’Keefe. Evaluation of a community based wound care programme in an
urban area. Poster presented at EWMA Conference. 2006. 5. J. Stephen-Haynes et al. An appraisal of the clinical performance
and economic benefits of a silicone foam in a large UK primary care organization. Journal of Community Nursing. 2013.
Supporting healthcare professionals for over 150 years
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27 TH CONFERENCE
7 Editorial. Läuchli S
Science, Practice and Education
11 Development of an evidence-based global consensus for diabetic
foot disease: The 2015 guidance of the International Working
Group on the Diabetic Foot. Van Netten JJ, Bakker K, Apelqvist J,
Lipsky BA, Schaper NC,
17 Clinical challenges of differentiating skin tears from pressure ulcers.
LeBlanc K, Alam T, Langemo D, Baranoski S, Campbell K, Woo K
25 Primary Care Patient Safety (PISA) Research Group - Identifying
priorities for pressure ulcer prevention in primary care. Samuriwo R,
Evans HP, Carson-Stevens A, Rees P, Hibbert P, Makeham M, Williams H
29 Challenges faced by healthcare professionals in the provision of
compression hosiery to enhance compliance in the prevention of
venous leg ulceration. Tandler SF
OF THE EUROPEAN WOUND MANAGEMENT ASSOCIATION
IN COOPERATION WITH WCS KNOWLEDGE CENTRE WOUND CARE
EWMA
2017
A M S T E R DA M
THE NETHERL ANDS
3 - 5 M AY 2017
35 Pressure Ulcer Incidence: Do patients retain information?
Vowden K, Warner V, Collins J
39 Wound management in epidermolysis bullosa, Denyer J
45 Skin aging: a global health challenge. Vuagnat H
Cochrane Reviews
49 Abstracts of recent Cochrane reviews. Rizello G
Celebration of EWMA’s 25 year anniversary
62 Milestones in EWMA’s history
66 25 years of EWMA conferences
70 Making a difference in wound care
EWMA
78 EWMA 2016 Conference in Bremen, Germany
81 Document summary: Management of patients with venous leg ulcers:
challenges and current best practice. Franks PJ, Barker J
90 New corporate sponsors
92 EWMA News
Organisations
98 Wounds Australia News. McGreogor H
99 AAWC News. Driver VR
101 WAWLC News. Keast D, Vuagnat H
102 Review of the 8th Symposium on Chronic Wound organised by CWA.
Kucisec-Tepes N
105 New impulses for the care of burn patients. Vogt PM
106 Manchester - a centre of excellence in wounds research. Paden L
107 2nd International Congress Fellows in Science and the 10th National
Croatian Congress of plastic, reconstructive and aesthetic surgery
110 Corporate Sponsors
112 Conference Calendar
114 Cooperating Organisations, International Partners and Other
Collaborators; an overview
W W W.EWM A 2017.ORG
W W W.EWM A .ORG
W W W.WCS.NL
Granulox transports oxygen to the wound base.
Studies show how effectively it helps heal.
PubMed – Granulox clinical trial studies
ewMa 2015, Posters
Arenbergerova M, Engels P, Gkalpakiotis S, Dubská Z, Arenberger P.
ToPicAl hEMoGlobin ProMoTES wounD hEAlinG of PATiEnTS wiTh
vEnouS lEG ulcErS.
hautarzt. 2013 Mar; 64(3):180-6. [Article in German]
[EP020] TrEATMEnT of chronicAl lowEr lEG ulcErS wiTh ToPicAl hEMoGlobin SPrAy. Danijela Semenic, Adrijana Debelak, irena Jovisic, Janja nikolic,
Dragica Maja Smrke Slovenia , university Medical center ljubljana; Department
of Surgical infections
Arenberger P, Engels P, Arenbergerova M, Gkalpakiotis S, García luna Martínez
fJ, villarreal Anaya A, Jimenez fernandez l.
clinicAl rESulTS of ThE APPlicATion of A hEMoGlobin SPrAy To ProMoTE hEAlinG of chronic wounDS.
GMS Krankenhhyg interdiszip. 2011; 6(1): Doc 05.
[EP165] A ToPicAl hAEMoGlobin SPrAy for oxyGEnATinG chronic vEnouS
lEG ulcErS: A PiloT STuDy. ray norris, Joy Tickle
PubMed – Granulox case rePorts &
Pilot studies
bateman SD.
uSE of ToPicAl hAEMoGlobin on SlouGhy wounDS in ThE coMMuniTy
SETTinG.
br J community nurs. 2015 Sep; 20 Suppl 9: S. 32-9.
Tickle J.
A ToPicAl hAEMoGlobin SPrAy for oxyGEnATinG PrESSurE
ulcErS: A PiloT STuDy.
br J community nurs. 2015 Mar; Suppl wound care: S. 12, S. 14-8
norris r.
A ToPicAl hAEMoGlobin SPrAy for oxyGEnATinG
chronic vEnouS lEG ulcErS: A PiloT STuDy.
br J nurs. 2014 nov; 23 Suppl 20: S. 48-53.
babadagi-hardt Z, Engels P, Kanya S.
wounD MAnAGEMEnT wiTh coMPrESSion
ThErAPy AnD ToPicAl hEMoGlobin SoluTion in
A PATiEnT wiTh buDD-chiAri SynDroME.
J Dermatol case rep. 2014 Mar 31; 8(1).
barnikol wK, Pötzschke h.
coMPlETE hEAlinG of chronic wounDS of A lowEr
lEG wiTh hAEMoGlobin SPrAy AnD rEGEnErATion of
An AccoMPAnyinG SEvErE DErMAToliPoSclEroSiS wiTh
inTEr-MiTTEnT norMobAric oxyGEn inhAlATion (inboi):
A cASE rEPorT.
Ger Med Sci. 2011 Mar 30; 9: Doc 08.
Arenberger P, Elg f, Petyt J, cutting K.
ExPEcTED ouTcoMES froM ToPicAl hAEMoGlobin SPrAy in nonhEAlinG AnD worSEninG vEnouS lEG ulcErS.
J wound care. 2015 May; 24(5): 228-36.
[EP177] TrEATMEnT of infEcTED chronic lEG ulcErS coMbininG infEcTion
conTrol, SurGicAl MoDAliTiES, hEMoGlobin SPrAy, wounD DrESSinG,
AnD coMPrESSion ThErAPy. Peter Engels, nesat Mustafi
[EP249] TrEATMEnT of burnS wiTh hAEMoGlobin SPrAy AS ADJuncTivE
ThErAPy To STAnDArD cArE. nesat Mustafi & Peter Engels
[EP417] fAST hEAlinG of vluS wiTh innovATivE AnD coMbinED TEchnoloGiES. florin Paraschiv, bucharest, romania
[EP425] ThE SynErGy bETwEEn hEMoGlobin SPrAy AnD DAcc DrESSinGS.
robert Tudoriu, bacau, romania, fan life-home care Services
[EP430] AccElErATE TrEATMEnT of A vEry olD AnD infEcTED fiSTulA.
Mitu roxana, bucharest, romania, bio hygiene-home care Services
[EP441] ThE uSE of GrAnulox To hEAl A fooT ulcEr in A hiGh riSK
PATiEnT wiTh DiAbETES: A clinicAl cASE STuDy.
Alexandra whalley, uK, bolton Diabetes centre
[EP443] uSinG hAEMoGlobin To iMProvE oxyGEn DiffuSion
in coMPlEx chronic ulcErS lEADS To fASTEr hEAlinG AnD
rEDucED coST of DrESSinG chAnGES AnD nurSinG cArE
– 3 cASE STuDiES. luxmi Mohamud, london, uK, Guys and
St Thomas community Services; Dulwich community hospital
[EP451] hEAlinG A 14 yEAr-olD lEG ulcEr in four MonThS
wiTh ToPic hEMoGlobin. Annemiek Mooij , Amsterdam,
netherlands, Slotervaartziekenhuis
[EP519] uSE of ToPicAl hAEMoGlobin in PoSTTrAuMATic
wounD wiTh ExPoSED hArDwArE. Marin Marinovid, Josip
Spanjol , Davor Primc, Stanislava laginja, nera fumid , bore bakota ,
branka Spehar, Eva Smokrovic, Aldo ivancic. university hospital rijeka;
ogulin, Karlovac & home healthcare and rehabilitation
[EP520] iS AMPuTATion ThE only SoluTion for ThE DiAbETic fooT? Stanislava laginja, Marin Marinovid, General hospital of ogulin & university hospital
rijeka
wounds uK 2015
PubMed – Granulox review articles
AccElErATE wounD hEAlinG of AcuTE AnD chronic wounDS in PATiEnTS
wiTh DiAbETES: ExPEriEncE froM MExico uSinG SuPPlEMEnTAry hAEMoGlobin SPrAy. obdulia lopez lopez, Peter Engels, fredrik Elg
Dissemond J, Kröger K, Storck M, risse A, Engels P.
ToPicAl oxyGEn wounD ThErAPiES for chronic wounDS: A rEviEw.
J wound care. 2015 feb; 24(2): 53-4, 56-60, 62-3.
ThE uSE of A novEl hAEMoGloblin SPrAy To ProMoTE hEAlinG in chronic wounDS. Eleanor wakenshaw, Tissue viability nurse, and ruth ropper,
lead nurse Tissue viability, nhS lothian, Scotland
Marinović M, Spanjol J, fumić n, bakota b, Pin M, cukelj f.
uSE of nEw MATEriAlS in ThE TrEATMEnT of chronic PoST-TrAuMATic
wounDS.
Acta Med croatica. 2014 oct; 68 Suppl 1: 75-80. [Article in croatian]
DiAbETic fooT ulcErATion – PoSiTivE ouTcoMES uTiliSinG ToPicAl
hAEMoGlobin SPrAy. Sharon Dawn hunt, Advanced nurse Practitioner, South
Tees nhS foundation Trusts
Prof. Dr. Dr. von Eiff w.
focuSinG on QuAliTy, wEll-bEinG of PATiEnTS, AnD coSTS.
hcM. 2013 nov; 4th vol.: 38-41.
other (non-PubMed) Granulox references
ToPicAl oxyGEn-hAEMoGlobin uSE on SlouGhy wounDS: PoSiTivE
PATiEnT ouTcoMES AnD ThE ProMoTion of SElf-cArE. Sharon Dawn hunt,
wounds uk 2015 vol 11 issue 4 p. 90-95
APProPriATE uSE of ToPicAl hAEMoGlobin in chronic wounD MAnAGEMEnT: conSEnSuS rEcoMMEnDATionS. wounds uK, 11/05/15 Paul chadwick,
Joanne Mccardle, luxmi Mohamud, Joy Tickle, Kath vowden, Peter vowden.
PiloT STuDy: hAEMoGlobin SPrAy in ThE TrEATMEnT of chronic DiAbETic fooT ulcErS. chadwick, Paul; wounds uK; nov 2014, vol. 10 issue 4, p. 76
www.granulox.de
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Editorial
EWMA celebrates
the 25th anniversary
T
hroughout the year, EWMA celebrates the 25th
anniversary of the Association. As this represents
one of the first significant milestones for EWMA,
we have used the opportunity to dig into the EWMA
archives and memories of key players of the Association.
This made us realise once again that EWMA has played a
vital role in the development of wound care over the past
25 years. In this issue of the EWMA Journal we invite
our readers to learn more about EWMA’s history and
development since the constitution in 1991, in a series
of articles as well as EWMA facts and figures.
The role and obligations of the many associations representing health care professionals working within different disease domains varies according to their topic of
interest and national or international level of operation.
However, for most associations, the network and good
collaboration with partner organisations and stakeholders is key to a continuous development and successful
achievement of goals. By establishing and safeguarding
a strong multidisciplinary profile, as well as exchange of
knowledge and challenges experienced in the different
European countries and internationally, EWMA has consistently aimed to define focus topics with a high degree
of topicality and relevance for individual members as well
as our collaborating partner organisations. We would like
to use the opportunity to thank the EWMA Cooperating
Organisations for the close collaboration (the formal collaboration was established in 2001) and the international
partner organisations for common discussions and collaboration on various activities such as joint documents
and awareness campaigns or conference session exchanges.
Finally, we would like to thank our corporate sponsors for
their stable support of EWMA’s core activities. Some of the
companies which are still supporting EWMA today have
been with us from the early years and both these and new
sponsors have earned our gratitude for ensuring a steady
financial basis for EWMA to work on.
Last, but not least, an association is constituted by the
people behind it. EWMA would not have been where it
is today, without the active EWMA presidents and council
members who represent the faces of the association during
the time of their involvement. Many have stayed involved
in EWMA after the end of their term, to contribute to the
work of EWMA Committees and project working groups.
By consistently honouring visionary ideas from the key
people involved and striving to develop and to address
the current challenges in wound management, EWMA
has managed to stay a vibrant association today, 25 years
after the constitution.
We look forward to the continuous collaboration with all
our partners and stakeholders.
Severin Läuchli, EWMA President
EWMA Journal 2016 vol 16 no 1
7
© Ljupco Smokovski / Fotolia.com
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UAW with SONOCA 185 ensures quick and safe wound cleansing as a measure of wound bed
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weaken bacterial ability to rebuild biofilms.4,5,6
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1. Herberger K et al. Efficacy, tolerability and patient benefit of ultrasound-assisted wound treatment versus surgical debridement: a randomized clinical study. Dermatology 2011; 222(3):244-9. 2. Lázaro-Martinéz JL et al. Preliminary case series results evaluating Ultrasonic-Assisted Wound Debridement (UAW) for treatment of complicated diabetic foot ulcers (DFU). Poster presentation, ISDF conference, May 20-23, 2015; The Hague, Netherlands.
3. Crone S et al. A novel in vitro wound biofilm model used to evaluate low-frequency ultrasonic-assisted wound debridement. Journal of Wound Care 2015; 24(2):64-72. 4. Yarets Y et al. The biofilm-forming capacity of staphylococcus aureus from chronic wounds can be used for determining Wound bed Preparation methods. EWMA Journal 2013; 13(1):7-13. 5. Yarets Y. Clinical experiences with Ultrasonic-Assisted Wound Debridement (UAW)
used for wound bed preparation before skin grafting. Abstract for oral presentation at free paper session: Infection and Antimicrobials, EWMA conference, May 13-15, 2015; London, UK. 6. Lázaro-Martínez JL et al. Improved
Wound Conditions and Reduced Bacterial Load as a Result of Sequential Low-Frequency Ultrasound Wound Debridement in Neuroischemic Diabetic Foot Ulcers. Poster presentation, SAWC, April 13-17, 2016; Atlanta, USA.
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Science, Practice and Education
Development of an
evidence-based global
consensus for diabetic
foot disease:
Jaap J. Van Netten1
The 2015 guidance
of the International
Working Group on
the Diabetic Foot
Karel Bakker2
Jan Apelqvist3
ABSTRACT
Background
Conclusions
Foot complications are a frequent and severe complication of diabetes. To prevent, or at least reduce,
the incidence and adverse outcomes of these foot
problems, the International Working Group on
the Diabetic Foot (IWGDF) develops and updates
evidence-based global consensus guidance documents.
Aim
To describe the development of the 2015 IWGDF
Guidance documents on the prevention and management of foot problems in persons with diabetes.
Methods
The IWGDF empanelled five working groups of
international experts to undertake seven systematic reviews of the literature. These were designed
to provide evidence to support development of
guidance documents on five topics: prevention;
footwear and offloading; diagnosis, prognosis and
management of peripheral artery disease; diagnosis
and management of foot infections; and interventions to enhance healing.
We believe clinician compliance with the recommendations of the 2015 IWGDF Guidance documents will likely result in a reduction in, or better
outcomes of, foot problems in persons with diabetes, helping to reduce the morbidity and mortality
associated with this problem.
INTRODUCTION
The International Diabetes Federation estimates
that by 2035 the global prevalence of diabetes
mellitus will rise to almost 600 million, and
around 80% of these people will live in low- and
middle-income countries.1 Foot problems are a
frequent consequence of diabetes and a major
cause of morbidity, mortality, and financial costs.2
The frequency, type, and severity of foot problems
varies within and among geographical regions,
largely due to differences in socioeconomic conditions, prevalence of various comorbidities, type of
footwear worn, and standards of foot care. Ulcers
of the foot, usually related to peripheral neuropathy, are the most common foot complication, with
a yearly incidence of around 2-4% in high-income
countries2 and likely even higher in developing
countries.
Results
The five 2015 IWGDF guidance documents make
a total of 77 recommendations, each of which was
assigned a Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)
rating. These documents are now published and
available for free on the IWGDF website.
EWMA Journal 2016 vol 16 no 1
Managing diabetic foot ulcers requires local, and
often systemic, treatments given by knowledgeable providers to adherent patients.3 This is not
a “one doctor disease”– optimising outcomes requires multidisciplinary care. Furthermore, as a
Benjamin A. Lipsky4
Nicolaas C. Schaper5
1Department
of Surgery,
Ziekenhuisgroep Twente,
Almelo and Hengelo, the
Netherlands
2The
International Working
Group on the Diabetic Foot,
Heemstede,
the Netherlands
3Department of Endocrinology, University Hospital of
Malmö, Sweden
4University of Oxford, Green
Templeton College, Oxford,
United Kingdom
5Division of Endocrinology,
Maastricht University Medical Centre+, Cardiovascular
Research Institute Maastricht, and Care and Public
Health Research Institute,
Maastricht, the Netherlands
Correspondence to:
jaapvannetten@gmail.com
www.iwgdf.org
Conflicts of interest: None

11
notoriously unglamorous problem, appropriate care of
the diabetic foot depends on dedicated clinicians working together in a team of health-care providers to care for
a complex patient – a scenario some clinicians prefer to
avoid, but others relish.3
When a foot complication develops in a person with diabetes, it not only represents a major personal tragedy, but
also affects that person’s family and places a substantial
financial burden on the patient, the healthcare system, and
society in general. In low-income countries, the cost of
treating a complex diabetic foot ulcer can be equivalent to
5.7 years of annual income, potentially resulting in financial ruin for these patients and their families.4 Investing in
evidence-based, internationally appropriate diabetic foot
care guidance is likely among the most cost-effective forms
of healthcare expenditure, provided it is goal-focused and
properly implemented.5-6
The International Working Group on the Diabetic Foot
(IWGDF) was founded in 1996 and includes experts from
virtually all of the many disciplines involved in the care
of patients with diabetes and consequent foot problems.
Among the goals of the IWGDF are to prevent, or at least
reduce, the adverse effects of foot problems in persons with
diabetes in part by developing and continuously updating
international guidance documents for use by all health
care providers involved in diabetic foot care.7 In 1999, the
IWGDF first published “International Consensus on the
Diabetic Foot” and “Practical Guidelines on the Management and the Prevention of the Diabetic Foot.” Various
versions of these documents have been translated into 26
languages, and more than 100,000 copies have been distributed globally. In 2015, the most recent version of the
“IWGDF Guidance on the Prevention of Foot Problems
in Diabetes” was published.7-20
METHODS
The IWGDF Editorial Board selected chairs and, in collaboration with the chairs, a secretary and about a dozen
international expert members for each of five working
groups. Each group was assigned to produce a guidance
document on one of the following topics:
Interventions to enhance healing of chronic ulcers of
the foot in diabetes.
n
Each of the five working groups followed the same methods in producing its guidance document. First, each group
performed a systematic review of a selected aspect of the
available literature on its topic. The working groups produced seven systematic reviews (the peripheral-arterialdisease group produced three) that included over 80,000
articles for screening, of which they selected 429 for final
analyses.14-20 Following the systematic review, the working
group members formulated recommendations that they
developed based on the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system
for grading evidence.21 This system allowed the experts to
link the available scientific evidence to specific recommendations for daily clinical practice. Each recommendation
was rated as either strong or weak, and the quality of the
evidence underlying this recommendation as high, moderate, or low. Interested readers are referred to reference 7
for further information on the grading system used. When
the five guidance documents were completed, the Editorial
Board sent them to over 100 IWGDF expert representatives, asking for their comments and, after revision of the
documents, to obtain their approval. Finally, the IWGDF
Editorial Board produced a “Summary Guidance for Daily
Practice” based on these five documents; this summary
was designed to serve as a short outline of the essential
approaches to the prevention and management of foot
problems in diabetes.
RESULTS
The IWGDF Guidance on the Prevention and Management of Foot Problems in Diabetes consists of seven chapters: the five guidance documents discussed above;8-12 the
summary on the development of the guidance;7 and the
summary guidance for daily practice.13
n
These documents make clear the factors involved in the
pathogenesis of diabetic foot disease, particularly peripheral sensory (and motor) neuropathy and peripheral arterial disease. Treatment is most effective when it involves
clinicians who are experts in medical, surgical, podiatric,
nursing, and other specialties. It is also crucial that these
specialists use an integrated, interdisciplinary approach to
optimise clinical and technological methods for management.3 From the five cornerstones of prevention, to an
effective and well-organised team, prevention and management of foot problems in diabetes requires a multidisciplinary approach that covers all bases.8
Diagnosis and management of foot infections in persons
with diabetes, and
At the core of the 2015 IWGDF guidance are the 77 total
recommendations provided in the seven different guidance
documents. Rather than outline these recommendations in
n
Prevention of foot ulcers in at-risk patients with diabetes,
Footwear and offloading to prevent and heal foot ulcers
in diabetes,
n
Diagnosis, prognosis, and management of peripheral
artery disease in diabetic patients with foot ulcers,
n
12
EWMA Journal 2016 vol 16 no 1
Science, Practice and Education
the current article, we refer the reader to the original documents.7-20 Each of these is published in a special supplement of the November 2015 issue of Diabetes/Metabolism
Research and Reviews and is available to all at no charge
as open access articles on both the journal’s website and
that of the IWGDF (www.iwgdf.org).7-20
DISCUSSION
In 2015, for the fifth time since 1999, the IWGDF updated, expanded, and improved their guidance on the
prevention and management of foot problems in diabetes. Improvements on earlier versions include having a
systematic review for at least one key aspect of each topic
and grading the strength and quality of recommendations
using the GRADE system. The IWGDF Editorial Board
also made special efforts to seek review of the documents
by experts in many fields from countries all over the world.
These efforts have resulted in evidence-based, global consensus guidance.7-20
The principles and recommendations outlined in this new
guidance will now have to be adapted or modified for
different countries, taking into account local and regional
differences in the socioeconomic situation, accessibility
to and sophistication of healthcare resources, and various cultural factors. Once modified into a local guideline,
the next crucial step is implementation. Only when the
guidelines are used in daily clinical practice throughout
the world will they be able to contribute to improvement
in outcomes for diabetic patients with foot problems.
On a pre-planned Consensus-Implementation Day immediately prior to the 7th International Symposium on
the Diabetic Foot, held May 19th 2015 in The Hague,
the leaders of the IWGDF invited all of the international
representatives of the organisation to convene to discuss
implementation of the IWGDF Guidance documents.
Nearly 100 representatives from six continents attended
and discussed the next steps. These local “champions”
are the trailblazers, bringing back home their knowledge,
ideas, and enthusiasm to inspire others. Some of them have
already made major steps in implementation, such as with
national diabetic foot care programs in the United Kingdom,21 Belgium22 and Germany,23 and with “Step-byStep,” a program developed by the International Diabetes
Federation, IWGDF, and the World Diabetes Federation,
in close cooperation with many local frontrunners to help
less technologically advanced countries improve diabetic
foot care.24 With the worldwide diabetes epidemic, it is
now more imperative than ever that more countries and
clinicians follow these, or other, paths to improved foot
care. All people with diabetes, regardless of their age, geographic location, and socioeconomic status, need access
to quality, evidence-based foot care. Notwithstanding the
limited published evidence of improved outcomes associated with using these guidance documents, we believe
that following the recommendations of the 2015 IWGDF Guidance will almost certainly result in improved
management of diabetic foot problems and a subsequent
worldwide reduction in the largely preventable tragedies
they cause.
IMPLICATIONS FOR CLINICAL PRACTICE
The “2015 IWGDF Guidance on the Prevention and
Management of Foot Problems in Diabetes” provides clinicians with an evidence-based, practical, global consensus
guidance. With a summary guidance for clinical practice
and 77 recommendations (each assessed for the strength
of the recommendation and the quality of the supporting
evidence), this document summarises the most important steps in prevention and treatment of diabetic foot
problems. Following these recommendations will almost
certainly result in improved management of foot problems
in diabetes and a subsequent worldwide reduction in the
largely preventable tragedies they cause.
FURTHER RESEARCH
Different chapters of the guidance outline areas for further
research in the field of foot problems in Diabetes. Apart
from these specific topics, we encourage those interested
in the field to consider doing research into the effectiveness of guidance implementation to improve outcomes of
diabetic foot disease. n
REFERENCES
1. International Diabetes Federation. IDF Diabetes
Atlas, 6th ed. Brussels, Belgium: International
Diabetes Federation, 2013.
2. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G,
Apelqvist J. The global burden of diabetic foot
disease. Lancet 2005 Nov 12; 366(9498): 17191724.
3. Lipsky BA, Apelqvist J, Bakker K, van Netten JJ,
Schaper NC. Diabetic foot disease: moving from
roadmap to journey. Lancet Diabetes Endocrinol
2015 Sep; 3(9): 674-5.
4. Cavanagh P, Attinger C, Abbas Z, Bal A, Rojas N, Xu
ZR. Cost of treating diabetic foot ulcers in five
different countries. Diabetes Metab Res Rev 2012
Feb; 28 Suppl 1: 107-111.
5. International Diabetes Federation - Clinical Guidelines Task Force. Guide for Guidelines; A guide for
clinical guideline development. Brussels: International
Diabetes Federation; 2003.
6. Van Houtum WH. Barriers to the delivery of diabetic
foot care. Lancet 2005 Nov 12;366(9498):16781679.
7. Bakker K, Apelqvist J, Lipsky BA, Van Netten JJ,
Schaper NC. The 2015 IWGDF Guidance Documents
on Prevention and Management of Foot Problems in
Diabetes: Development of an Evidence-Based Global
Consensus. Diabetes Metab Res Rev 2015; in press.
8. Bus SA, Van Netten JJ, Lavery LA, Monteiro-Soares
M, Rasmussen A, Jubiz Y, et al. IWGDF Guidance on
the prevention of foot ulcers in at-risk patients with
Diabetes. Diabetes Metab Res Rev 2015 Sep 3 [Epub
ahead of print].
9 Bus SA, Armstrong DG, Van Deursen RW, Lewis J,
Caravaggi CF, Cavanagh PR. IWGDF Guidance on
footwear and offloading interventions to prevent and
heal foot ulcers in patients with Diabetes. Diabetes
Metab Res Rev 2015; in press.
10. Hinchliffe RJ, Brownrigg JR, Apelqvist J, Boyko EJ,
Fitridge R, Mills JL, et al. IWGDF Guidance on the
Diagnosis, Prognosis and Management of Peripheral
Artery Disease in Patients with Foot Ulcers in
Diabetes. Diabetes Metab Res Rev 2015 Sep 2 [Epub
ahead of print].
EWMA Journal 2016 vol 16 no 1
13
Science, Practice and Education
11. Lipsky BA, Aragón-Sánchez J, Diggle M, Embil J,
Kono S, Lavery LA, et al. IWGDF Guidance on the
Diagnosis and Management of Foot Infections in
Persons with Diabetes. Diabetes Metab Res Rev
2015; in press.
12. Game FL, Apelqvist J, A,C., Hartemann A, Hinchliffe
RJ, Löndahl M, et al. IWGDF guidance on use of
interventions to enhance the healing of chronic ulcers
of the foot in Diabetes. Diabetes Metab Res Rev 2015
Sep 5 [Epub ahead of print].
13. Schaper NC, Van Netten JJ, Apelqvist J, Lipsky BA,
Bakker K. Prevention and Management of Foot
Problems in Diabetes: A Summary Guidance for Daily
Practice Based on the 2015 IWGDF Guidance
Documents. Diabetes Metab Res Rev 2015 Sep 3
[Epub ahead of print].
14. Van Netten JJ, Price PE, Lavery LA, Monteiro-Soares
M, Rasmussen A, Jubiz Y, et al. Prevention of foot
ulcers in the at-risk patient with Diabetes: a systematic review. Diabetes Metab Res Rev 2015 Sep 5
[Epub ahead of print].
15. Brownrigg JR, Hinchliffe RJ, Apelqvist J, Boyko EJ,
Fitridge R, Mills JL, et al. Effectiveness of bedside
investigations to diagnose peripheral arterial disease
among people with Diabetes mellitus: a systematic
review. Diabetes Metab.Res.Rev. 2015; in press.
annonce Journal.indd 14
1
16. Brownrigg JR, Hinchliffe RJ, Apelqvist J, Boyko EJ,
Fitridge R, Mills JL, et al. Performance of prognostic
markers in the prediction of wound healing and/or
amputation among patients with foot ulcers in
Diabetes: a systematic review. Diabetes Metab Res
Rev. 2015 Sep 5 [Epub ahead of print].
17. Hinchliffe RJ, Brownrigg JR, Andros G, Apelqvist J,
Boyko EJ, Fitridge R, et al. Effectiveness of Revascularisation of the Ulcerated Foot in Patients with
Diabetes and Peripheral Artery Disease: A Systematic
Review. Diabetes Metab Res Rev. 2015 Sep 5 [Epub
ahead of print].
18. Bus SA, Van Deursen RW, Armstrong DG, Lewis J,
Caravaggi C, Cavanagh PR, et al. Footwear and
offloading interventions to prevent and heal foot
ulcers and reduce plantar pressure in patients with
Diabetes: A Systematic Review. Diabetes Metab Res
Rev. 2015 Sep 5 [Epub ahead of print].
19. Peters EJ, Lipsky BA, Aragon-Sanchez J, Bakker K,
Boyko EJ, Diggle M, et al. Interventions in the
management of infection in the foot in Diabetes: a
systematic review. Diabetes Metab Res Rev. 2015 Sep
7 [Epub ahead of print].
the foot in Diabetes: a systematic review. Diabetes
Metab Res Rev. 2015 Sep 7 [Epub ahead of print].
20. Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter
Y, Alonso-Coello P, et al. GRADE: An emerging
consensus on rating quality of evidence and strength
of recommendations. BMJ 2008 Apr
26;336(7650):924-926.
21. Putting Feet First. Available at: http://www.Diabetes.
org.uk/putting-feet-first. Last accessed 8 September
2015.
22. Doggen K, Van Acker K, Beele H, Dumont I, Félix P,
Lauwers P, et al. Implementation of a quality improvement initiative in Belgian diabetic foot clinics:
feasibility and initial results. Diabetes Metab Res Rev.
2014 Jul;30(5):435-43.
23 Morbach S, Kersken J, Lobmann R, Nobels F,
Doggen K, Van Acker K. The German and Belgian
Accreditation Models for Diabetic Foot Services.
Diabetes Metab Res Rev. 2015, in press.
24. Step-by-Step. Available at: http://iwgdf.org/step-bystep/. Last accessed 8 September 2015.
20. Game F, Apelqvist J, Attinger C, Hartemann A,
Hinchliffe RJ, Löndahl M, et al. Effectiveness of
interventions to enhance healing of chronic ulcers of
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THERAPIES. HAND IN HAND.
Science, Practice and Education
Clinical challenges of
differentiating skin tears
from pressure ulcers
ABSTRACT
Background
Skin tears can have a profound impact on the
health and well-being of an individual, the consequences of which are often underestimated. Those
affected report that skin tears both increase pain
and compromise overall quality of life. Persons at
the extremes of age and the critically/chronically
ill represent the populations most at risk for skin
tears and ensuing complications, such as wound
infections, impaired mobility, and social isolation.
For individuals with health conditions, such as malnutrition, peripheral vascular disease, and/or compromised immunity, a skin tear can develop into a
chronic, non-healing wound that leads to increased
health care expenditures.1 The International Skin
Tear Advisory Panel (ISTAP) and previous studies
have documented that pressure ulcers and skin tears
share many common risk factors. Recent publications have also highlighted the clinical challenges
of differentiating skin tears from pressure ulcers,
as well as the importance of correctly diagnosing
each as a distinct wound type.2 In addition, there
have been recent changes to the pressure ulcer
staging system, removing friction as a descriptor
for pressure ulcer development. Conversely, friction
is one of the many risk factors for skin tears. This
article will explore, using case studies, the clinical
challenges of differentiating skin tears from pressure ulcers.
Method
Three case studies were used to review the relationship between pressure ulcers and skin tears using
demographic factors, co-morbidities, predisposing
factors, cause of wound, description of the evolution
of the wound, and other variables.
Results
These cases highlight the challenges of differentiating between skin tears and pressure ulcers.
EWMA Journal 2016 vol 16 no 1
Kimberly LeBlanc1-4
In all three cases, skin tears were misdiagnosed as
pressure ulcers, and these misdiagnoses resulted
in delayed implementation of skin tear prevention
strategies.
Tarik Alam3,5
Conclusion
Skin tears and pressure ulcers share certain risk
factors and clinical characteristics. Identifying
and classifying these wounds as distinct, separate wound types can pose a clinical challenge to
health care professionals. The National Pressure
Ulcer Advisory Panel (NPUAP), European Pressure
Ulcer Advisory Panel (EPUAP), Pan Pacific Pressure Injury Alliance (PPPIA), and ISTAP, maintain
that despite the similarities in wound appearances
and challenges in diagnosis, it is critical that pressure ulcers and skin tears are properly diagnosed.
By differentiating these wounds, the most effective
prevention and wound management strategies can
be implemented.1,3
INTRODUCTION:
The skin, which is the largest organ in the body,
is a vital organ that is critical for the maintenance
of health and well-being. Although there are many
different aetiological factors that can compromise
skin integrity, it is accepted that any disruption
in skin integrity can potentially lead to infection,
persistent pain, immobility, mental anguish, and
may have a negative impact on quality of life.4,5
With growing concerns for patient safety, quality
of care, and health care resources, there is a need to
reduce the incidence of skin breakdown and implement early treatment strategies to prevent progression of superficial skin damage to deep tissue
traumas within a cost-effectiveness framework.6
Skin tears and pressure ulcers represent the most
common wounds affecting older individuals, and
these constitute a significant disease burden to
healthcare systems.2,7,8 In nursing, both wound
Diane Langemo6
Sharon Baranoski7
Karen Campbell3
Kevin Woo1
1 Queen’s
University,
Kingston Ontario, Canada
2 KDS Professional
Consulting, Ottawa Ontario,
Canada
3 Faculty
of Health Sciences,
School of Physical Therapy,
University of Western
Ontario, Canada
4 International
Skin Tear
Advisory Panel
5 Hollister
Limited
6 University
of North Dakota,
Grand Forks, North Dakota
USA.
7 Wound
Care Dynamics,
Inc. Shorewood, Illinois USA
Correspondence:
kimleblanc@rogers.com
Conflicts of interest: None

17
aetiologies are considered as nursing-sensitive outcome
measures and bench markers for quality of care. It has
been hypothesised, and recent literature reports, that these
wound types appear to share many common risk factors.1,8,9 However, their clinical presentation and wound
healing expectations may be markedly different.2,10 In the
recently updated International Pressure Ulcer Guidelines,
the need to differentiate between pressure ulcers and skin
tears has been highlighted.2 In order to optimise the prevention and treatment of skin tears and pressure ulcers,
one must be able to accurately differentiate and diagnose
these wounds according to their aetiology and clinical
presentation. This will allow for the implementation of
interventions that target each specific wound type. The
purpose of this article, through case study format, is to
highlight the challenges of differentiating between these
two wound types and to initiate a global discussion on how
a bundled approach to care can be used for the prevention
and management of these wounds.
DIFFERENTIATING SKIN TEARS
FROM PRESSURE ULCERS
It has been reported that skin tears, deep tissue injuries,
and stage two pressure ulcers often mimic one another, and
misdiagnoses may occur.2,8 This can result in inappropriate
and/or poorly timed prevention strategies, potentially resulting in re-injury. What is known is that all of these skin
injuries have the potential, if pressure is present, to evolve
into painful, and costly, full thickness tissue ulceration.2
SKIN TEARS
A skin tear is defined as “a traumatic wound occurring
principally on the extremities of older adults, as a result
of friction alone or shearing and friction forces which
separate the epidermis from the dermis (partial thickness wound) or which separates both the epidermis and
the dermis from the underlying structures (full thickness
wound).”9 Without appropriate management, skin tears
have a high likelihood of evolving into chronic wounds,
Figure 1
ISTAP Skin Tear Classification System
18
Type 1: No Skin Loss
Type 2: Partial Flap Loss
Type 3: Total Flap Loss
Figure 1a, 1b
Figure 1c
Figure 1d
Linear flap tear, which
Partial flap loss, Total flap loss,
can be repositioned to which cannot be
exposing the entire
cover the wound bed
repositioned to cover
wound bed
wound bed
Figure 1a
Figure 1b
Figure 1c
Figure 1d
EWMA Journal 2016 vol 16 no 1
Science, Practice and Education
imposing a significant health burden both to individuals
and the healthcare system.1,7 According to existing literature, intrinsic and extrinsic risk factors for skin tears may
include falls, poor nutrition, impaired mobility, cognitive
impairment, and dry, fragile skin. These wounds are commonly observed in the extremes of age and in the critically
or chronically ill. Although often under-reported, they
are hypothesised to be highly prevalent and particularly
troublesome for the elderly population.9
Individuals suffering from skin tears report increased
pain and compromised quality of life. In addition, because the populations at the highest risk for skin tears
often include those at extremes of age and the critically
or chronically ill, these individuals are at a higher risk
for developing secondary wound infections and for having co-morbidities, which can contribute to skin tears
evolving from acute to chronic, complex wounds.1 The
consequences of skin tears are often underestimated, and
misclassification can impede the implementation of appropriate interventions and further preventative strategies.
ISTAP SKIN TEAR CLASSIFICATION
The International Skin Tear Advisory Panel (ISTAP) developed and validated the ISTAP Skin Tear Classification
system, with the goals of raising the global healthcare community’s awareness of skin tears and simplifying the identification and classification of these wounds. It is envisioned
that the acceptance and utilisation of a common language
and classification system for skin tears will facilitate best
practices and research in this area. Skin tears are classified
as type 1 (no tissue loss), type 2 (partial tissue loss), and
type 3 (complete tissue loss).11 (Figure 1)
PRESSURE ULCERS
The NPUAP, EPUAP, and PPPIA define a pressure ulcer
as a localised injury to the skin and/or underlying tissue,
usually over a bony prominence, resulting either from
pressure alone or in combination with shear. A number
of contributing or confounding factors are also associated
with pressure ulcers; however, the significance of these
factors has yet to be elucidated. The PPPIA modified the
definition of a pressure ulcer in 2014, to state, “Some of
these factors include mobility limitations, perfusion and
oxygenation, poor nutritional status, and increased skin
moisture”.3 An international standardised classification
system is used to describe and categorise pressure ulcers
according to the type of visible tissue damage that is present. In this system, pressure ulcers are assigned a stage or
category once the wound being assessed is diagnosed or
determined aetiologically to be a pressure ulcer. Critically,
this classification system was not designed for use in any
other wound type. Assignment of a pressure ulcer stage
is based on visual inspection to determine level of tissue
involvement and wound depth, and staging requires an
EWMA Journal 2016 vol 16 no 1
understanding of the anatomy of the skin and underlying
tissues.
Pressure ulcers most commonly occur over areas of bony
prominence. When they form elsewhere on the body, an
external source of frequent, constant pressure must be present. This external pressure source may be the patient’s
own limb, as in the case of contractures or orthopaedic
abnormalities.12 At other times, the external pressure may
come from the patient’s environment, such as broken or
ill-fitting wheelchair parts, bed frames, or chairs. Tight
or ill-fitting clothing, shoes, bra straps, and orthopaedic
splints can also be sources of external pressure. An ulcer
appearing on a body part that does not have a source of
frequent, constant pressure is probably not a pressure ulcer,
but rather, is a condition with another aetiology, such as
a skin tear.7,12 Deep tissue injury pressure ulcers are often
misdiagnosed as superficial skin injuries, such as skin tears,
incontinence-associated dermatitis, or stage II pressure
ulcers.2 A Suspected Deep Tissue Injury (SDTI) pressure
ulcer can initially appear as a purplish or maroon-coloured
area of intact skin or even as a blood-filled blister. The
purplish and/or maroon colour can also be apparent in a
skin tear, but the differentiating factor would be that the
skin tear would not have intact skin and the discolouration
would be found beneath the tear. Critically, the evolution
of an SDTI can involve a thin blister, which eventually
may peel, leading some clinicians who see it for the first
time to question if it is actually a skin tear. Again, this
highlights the point that the aetiology and evolution of
the lesion provide important discriminating factors for the
clinician’s diagnosis.
INTERNATIONAL NPUAP/EPUAP PRESSURE
ULCER CLASSIFICATION SYSTEM
Category/Stage I: Nonblanchable Erythema. Intact skin
with non-blanchable redness of a localised area, usually
over a bony prominence. Darkly pigmented skin may
not have visible blanching; its colour may differ from the
surrounding area. The area may be painful, firm, soft, or
warmer or cooler, as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with
dark skin tones. May indicate “at risk” individuals (a heralding sign of risk). (Figure 2)
Category/Stage II: Partial Thickness Skin Loss. Partial
thickness loss of dermis, presenting as a shallow open ulcer
with a red-pink wound bed, without slough. May also
appear as an intact or open/ruptured serum-filled blister.
Presents as a shiny or dry shallow ulcer without slough or
bruising (bruising indicates SDTI). This Category/Stage
should not be used to describe skin tears, tape burns, perineal dermatitis, maceration, or excoriation. (Figure 3)

19
Figure 2
Category/Stage III: Full Thickness Skin Loss. Subcutaneous fat
may be visible, but bone, tendon, and muscle are not exposed.
Slough may be present but does not obscure the depth of tissue
loss. May include undermining and tunnelling. The depth of a
Category/Stage III pressure ulcer varies by anatomical location.
The bridge of the nose, ear, occiput, and malleolus do not have
subcutaneous tissue, and Category/Stage III ulcers in these locations can be shallow. In contrast, areas of significant adiposity can
develop extremely deep Category/Stage III pressure ulcers. Bone/
tendon is not visible or directly palpable. (Figure 4)
Figure 3
Category/Stage IV: Full Thickness Tissue Loss. Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar
may be present on some parts of the wound bed. Often includes
undermining and tunnelling. The depth of a Category/Stage IV
pressure ulcer varies by anatomical location. The bridge of the nose,
ear, occiput, and malleolus do not have subcutaneous tissue, and
ulcers here can be shallow. Category/Stage IV ulcers can extend
into muscle and/or supporting structures (e.g., fascia, tendon, or
joint capsule) making osteomyelitis possible. Exposed bone/tendon
is visible or directly palpable. (Figure 5)
Figure 4
Unstageable: Depth Unknown. Full thickness tissue loss, in which
the base of the ulcer is covered by slough (yellow, tan, grey, green, or
brown) and/or eschar (tan, brown, or black). Until enough slough
and/or eschar is removed to expose the base of the wound, the true
depth, and therefore Category/Stage, cannot be determined. Dry,
adherent and intact eschar, without erythema on the heels should
not be removed as this serves as “the body’s natural (biological)
dressing. (Figure 6)
Figure 5
Suspected Deep Tissue Injury (sDTI): Depth Unknown. Purple
or maroon localised area of discoloured intact skin or blood-filled
blister due to damage of underlying soft tissue from pressure and/
or shear. The area may be preceded by tissue that is painful, firm,
mushy, boggy, or warmer or cooler, as compared to adjacent tissue.
Deep tissue injury may be difficult to detect in individuals with
dark skin tones. Evolution may include a thin blister over a dark
wound bed. The wound may further evolve and become covered
by thin eschar. Evolution may be rapid, exposing additional layers
of tissue, even with optimal treatment. (Figure 7)
Figure 6
PREVALENCE RATES
The prevalence of pressure ulcers in North American long-term
care (LTC) settings has been reported to be between 2.4–28%.13 A
systematic review of skin tear prevalence and associated risk factors
revealed occurrence rates varying between 3.9–22%.14
A general wound audit of four Canadian LTC facilities identified
prevalence rates of 14.7% and 15.8% for skin tears and pressure
ulcers, respectively, and uncovered a possible association among risk
factors attributed to pressure ulcers and skin tears.10 What is unknown regarding that study are the numbers of pressure ulcers and
20
Figure 7
EWMA Journal 2016 vol 16 no 1
Science, Practice and Education
skin tears per individual, and another unknown factor is whether
or not any of the skin tears led to a pressure ulcer.
While research on pressure ulcers in LTC spans over 30 years,
skin tear studies are still in their infancy. Skin tears and pressure
ulcers are often compared in the literature, as they frequently affect the elderly population, appear to have some associated factors
in common, can result in costly and painful wounds, and create
added strain on the healthcare system.7,8
Because skin tears and pressure ulcers share certain risk factors
and clinical characteristics, identifying and classifying these wounds
as distinct, separate wound types can pose a clinical challenge to
health care professionals. The National Pressure Ulcer Advisory
Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP), Pan Pacific Pressure Injury Alliance (PPPIA), and ISTAP
maintain that despite the similarities in wound appearances and
challenges in diagnosis, it is critical that pressure ulcers and skin
tears must be properly diagnosed. By differentiating these wounds,
the most effective prevention and wound management strategies
can be implemented.1,3
The following three cases highlight the challenges of differentiating between skin tears and pressure ulcers. In all three instances,
skin tears were misdiagnosed as pressure ulcers, and this resulted in
delayed implementation of skin tear prevention strategies.
CASE STUDIES
Case Study 1
65-year-old female residing in LTC for greater than 2 years. Past
medical history includes obesity, multiple sclerosis, wheel chair
dependence, and history of multiple skin tears. Due to her obesity,
the dietician follows her closely, and she is on a weight loss program
that is high in protein. She developed multiple type 3 skin tears to
her bilateral trochanter regions, extending to bilateral upper thighs,
all secondary to unsuitable equipment for a bariatric patient. These
wounds were misdiagnosed as Stage II pressure ulcers and became
complex wounds secondary to anatomical location, obesity, immobility, external pressure to the area, and repeat trauma as the cause
(inappropriate equipment leading to skin tears was not removed
in a timely fashion). (Figure 8)
Figure 8
Figure 9
Figure 10
Figure 11
Figure 12
Case Study 2
75-year-old female residing in LTC for approximately
6 months. Past medical history of stroke with left side weakness,
multiple sclerosis, incontinence of urine and stool, and wheel chair
dependence. She had no history of previous pressure ulcers or skin
tears. As a relatively new admission to the LTC facility, the dietician was following her to ensure optimal nutritional intake. She
developed a type 3 skin tear over the left trochanter, secondary to
ill-fitting incontinence briefs. The wound deteriorated and was
subsequently misclassified as a Stage III pressure ulcer. Wound
healing was delayed due to pressure, the patient’s general poor
health status, and the failure to change the incontinence product
for well-fitted briefs in a timely fashion. (Figure 9-10)

EWMA Journal 2016 vol 16 no 1
21
Case Study 3
52-year-old male with a history of brain injury and complete immobility. He had a past history of stage II pressure
ulcers to his coccyx area. It was noted by the registered
staff that nutritional intake was an issue and that it had
not improved, despite involvement of a dietician in his
care. He was treated with antibiotics for a urinary tract
infection and developed diarrhoea. The skin was damaged
with chemical irritation from faecal matter and mechanical
irritation from frequent cleansing. Small discrete skin tears,
due to frictional force from the washcloth, were noticed
in the injured area, as evidenced by partial skin loss. The
area continued to deteriorate within a week and acquired a
dark, purplish appearance with evidence of tissue necrosis
and deep tissue injury. The standard hospital mattress was
replaced with a low air loss mattress, and the patient was
frequently turned to provide pressure redistribution and
minimise shearing forces. (Figure 11-12)
DISCUSSION
These cases highlight the challenges of differentiating between skin tears and pressure ulcers. In all three instances,
skin tears were misdiagnosed as pressure ulcers, and this
misdiagnosis resulted in delayed implementation of skin
tear prevention strategies.
It is a clinical challenge for healthcare professionals to
identify and classify skin tears when they occur in areas
of the body where pressure ulcers also typically occur,
such as over bony prominences. In addition, skin tears
that develop over areas exposed to constant/unrelieved
pressure may deteriorate rapidly and, thus, can be subsequently identified as pressure ulcers, especially as a stage II
or SDTI pressure ulcer.2 When skin tears occur over bony
prominences, added pressure can result in additional tissue
damage, which may manifest as a pressure related injury;
however, this association has yet to be explored.
Bundled approaches to care allow healthcare professionals to prevent and manage several potential wound
aetiologies (pressure related injuries, moisture associated
injuries, and skin tears) with one prevention program,
which can potentially save money and time, but more
importantly, also enhances patient comfort. It should be
cautioned, however, that healthcare professionals must
be cognizant of the fact that these programs need to be
flexible to allow for specific and individualised prevention
programs. The cases above illustrate that there are shared
risk factors among skin tears, deep tissue injury, and stage
two pressure ulcers. However, skin tears have the added
component of friction and trauma that may not be present with pressure related injuries.8 It is imperative that
skin tears be differentiated from pressure ulcers, in order
to facilitate appropriate prevention strategies, such as the
removal of the cause of trauma or friction.
22
CONCLUSION
The three cases discussed here highlight the challenges a
healthcare professional may encounter when skin tears occur in areas of the body where pressure ulcers are commonly identified. The updated International Pressure Ulcer
Classification System documents that skin tears should not
be classified as pressure ulcers. Therefore, proper identification and classification of skin tears, and the implementation of interventions aimed at preventing these wounds
from occurring, are essential. Further research is needed to
identify risk factors that are associated with skin tears, in
order to facilitate the correct diagnose this wound type. n
KEY TAKE AWAY POINTS:
1. The prevalence of skin tears is reported to be equal
to, or greater than, that of pressures in the aging population.
2. Skin tears are acute wounds, which have a high
risk of becoming chronic and more complex.
3. Clinicians must be aware of the importance of
differentiating between skin tears and pressure ulcers to ensure the use of prevention and manage ment strategies that are appropriate for the given
wound aetiology.
4. There is a possible link between the risk factors
associated with pressure ulcer development and
those associated with skin tear development.
Further research is required to establish if such a link exists and if a bundled approach to prevention
and management is best practice.
EWMA Journal 2016 vol 16 no 1
Science, Practice and Education
REFERENCES
1. LeBlanc K, Baranoski S. Skin tears: The forgotten
wound. J Nurs Manag, 2014; 45(12): 36-46.
2. Black J, Brindle C, Honaker J. Differential diagnosis
of suspected deep tissue injury. Int Wound J, 2015
Jun 1.
3. Haesler, E. Prevention and treatment of pressure
ulcers: Clinical practice guideline [guideline]. National
Pressure Ulcer Advisory Panel, European Pressure
Ulcer Advisory Panel and Pan Pacific Pressure Injury
Alliance. Perth, AU: Cambridge Media; 2014.
4. Garcia E. Skin tears: Assessment and management.
Joanna Briggs Institute; 2013.
5. Krasner DL, Rodeheaver G T, Sibbald RG, Woo KY.
International interprofessional wound caring. In:
Krasner DL, Rodeheaver GT, Sibbald RG, Woo KY,
editors. Chronic wound care: A clinical source book
for healthcare professionals. 5th Ed. Malvern, PA:
HMP Communications; 2012. p. 3-12.
6. Baranoski S, Ayello E, Tomic-Canic M, Levine J. Skin:
An essential organ. In: Baranoski S, Ayello E, editors.
Wound care essentials: Practice principles. 3rd Ed.
Philadelphia, PA: Wolters Kluwer, Lippincott Williams
and Wilkins; 2012. p. 57.
7. Carville K, Leslie G, Osseiran-Moisson R, Newall N,
Lewin G. The effectiveness of a twice-daily skinmoisturizing regimen for reducing the incidence of
skin tears. Int Wound J. 2014; 11(4): 446-453.
8. LeBlanc K. Baranoski S. Christensen D. Langemo D.
Sammon M. Edwards K. Regan, M. International skin
tear advisory panel: A tool kit to aid in the prevention,
assessment, and treatment of skin tears using a
simplified classification system. Adv Skin Wound
Care. 2013; 26(10): 459-476.
9. LeBlanc K, Baranoski S, Christensen D, Langemo D,
Sammon M, Edwards K, Regan M. State of the
science: Consensus statements for the prevention,
prediction, assessment, and treatment of skin tears.
Adv Skin Wound Care. 2011; 24(9): 2.
12. Flacker JM. Skin integrity and pressure ulcers:
Assessment and management. In: Williams MV,
Flanders SA, Whitcomb W, Cohn S, Michota F,
Holman R, Merli G, editors. Comprehensive hospital
medicine. 1st ed. Philadelphia, PA: Saunders Elsevier;
2007. p. 200.
13. Woodbury G, Houghton P. Prevalence of pressure
ulcers in Canadian healthcare settings. Ostomy
Wound Manag. 2004; 50(10): 22-38.
14. Strazzieri-Pulido KC, Peres G, Campanili T, Conceição de Gouveia Santos V. Skin tear prevalence and
associated factors: a systematic review. Rev Esc
Enferm USP. 2015; 49(4): 668-674.
10. Woo KY, LeBlanc K. Prevalence of skin tears among
the elderly living in Canadian long-term care facilities.
2014. Unpublished Manuscript.
11. LeBlanc K, Baranoski S, Holloway S, Langemo D.
Validation of a new classification system for skin
tears. Adv Skin Wound Care. 2013; 26(6): 263-265.
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Science, Practice and Education
LONDON · UK
EWMA n LONDON 2015
Submitted to EWMA
Journal based on
presentation given in
the free session Pressure
Ulcer 1
Primary Care Patient
Safety (PISA) Research
Group - Identifying
priorities for pressure
ulcer prevention in
primary care
BACKGROUND
Pressure ulcers are harmful and largely
avoidable. They cause needless pain and
suffering for patients1,2 as well as increased morbidity, mortality and length
of hospital stay.3,4 As a result, pressure
ulcer prevention is a priority area for patient safety in healthcare organisations
internationally.5-7 The majority of efforts
have focused on improving pressure ulcer
prevention and treatment in secondary
care, but an opportunity exists to advance
pressure ulcer prevention in primary care.
Patient safety incident reports contain
free text descriptions of unsafe or poor
quality care that are written by frontline
healthcare professionals when any untoward event resulted in, or could have
resulted in, harm to a patient.8,9 Such
reports contain information, which can
be used to model the sequence of events
leading up to harmful outcomes, as well
as the related contributory and contextual factors.10,11 In England and Wales,
a National Reporting and Learning Service (NRLS) was established in 2003 as
a repository to enable the generation of
learning from safety incident reports.12
The Primary Care Patient Safety (PISA)
Research Group led by Dr Andrew Carson-Stevens at the School of Medicine,
Cardiff University, aims to advance the
quality and safety of primary care through
identifying learning from data like patient safety incident reports to support
organisations and their teams to empirically design/ redesign their systems and
to develop, test, implement and evaluate
Raymond Samuriwo1,2,3,4
Huw Prosser Evans1
changes in practice. The PISA Group was formed
in January 2013 with funding from the National
Institute for Health Research (NIHR) in order to
characterise the largest sample of patient safety incident reports from general practice worldwide.13
To date, the PISA group has undertaken analyses
of safety incident reports describing problems
in care for patients during the transfer between
secondary and primary care,14 vaccine safety in
children,15 vulnerable children in primary care10,
16 and safety incidents experienced by children in
the general practice setting.17,18
In collaboration with international experts from
the Australian Institute for Healthcare Innovation (Hibbert and Makeham), the PISA group is
examining free-text patient safety incident reports
describing pressure ulcers written by frontline
healthcare professionals with a view to identifying priority issues for pressure ulcer prevention
in primary care and supporting the development
of interventions.
Andrew Carson-Stevens1,6,7,8
Philippa Rees1
Peter Hibbert5
Meredith Makeham5
Huw Williams1
on behalf of the Primary Care Patient
Safety (PISA) Research Group
1 Primary
Care Patient Safety (PISA)
Research Group, Division of Population
Medicine, School of Medicine, Cardiff
University, UK
2
School of Healthcare Sciences,
Cardiff University, UK
3 Cardiff
Institute for Tissue Engineering
and Repair (CITER), Cardiff University,
UK
4 School
METHODS
The PISA Group uses a three-stage mixed methods process to generate learning from a sample
of reports received by the NRLS over a decade
(2003-2013):
Stage 1: Familiarisation and data coding – reading free-text and applying codes to represent the
incident type, potential contributory factors, level
and type of harm described in the safety incident
report.
n
Stage 2: Generation of data summaries – descriptive statistical analysis to identify the most
frequent and harmful incident types.
n
of Healthcare, University of
Leeds, UK
5 Australian
Institute for Healthcare
Innovation, Macquarie University,
Sydney, Australia
6 Primary & Emergency Care Research
(PRIME) Centre Wales, Cardiff
University, UK
7 Department
of Family Practice,
University of British Columbia, Canada
8 Honorary Professor, Institute of
Healthcare Policy and Practice,
University of the West of Scotland, UK
Correspondence:
carson-stevensap@cardiff.ac.uk
Conflicts of interest: None

EWMA Journal 2016 vol 16 no 1
25
Science, Practice and Education
Stage 3: Interpretation of themes and learning – thematic analysis to understand the most common safety contributory themes, and consideration of the contexts within
which they occurred. Clinicians and patient safety experts
review the analyses to identify key areas for improvement
in pressure ulcer prevention in primary care.
The method is described in more detail in a recently published study protocol.13
n
CONCLUSION
This study will be the first national-level (England and
Wales) analysis of patient safety incident reports from primary care about pressure ulcers. It will empirically iden-
tify concepts to inform a quality improvement agenda
for pressure ulcer prevention in primary care. When this
study is completed in Spring 2016, its findings should
be interpreted in conjunction with existing research and
development efforts in the field of pressure ulcer prevention in primary care.
ACKNOWLEDGEMENTS
This project was funded by the National Institute for
Health Research HS&DR (project number 12/64/118).
However, the views and opinions expressed therein are
those of the authors and do not necessarily reflect those of
the HS&DR, NIHR, NHS or the Department of Health.
n
REFERENCES
1. Grey JE, Harding KG, Enoch S. Pressure ulcers. BMJ.
2006;332(7539):472-5.
2. Briggs M, Collinson M, Wilson L, Rivers C, McGinnis
E, Dealey C, et al. The prevalence of pain at pressure
areas and pressure ulcers in hospitalised patients.
BMC Nursing. 2013;12(1):19.
3. Berlowitz D. Incidence and Prevalence of Pressure
Ulcers. In: Thomas MDDR, Compton MDGA, editors.
Pressure Ulcers in the Aging Population. Aging
Medicine. 1: Humana Press; 2014. p. 19-26.
4. Dealey C, Posnett J, Walker A. The cost of pressure
ulcers in the United Kingdom. Journal of Wound
Care. 2012;21(6):261-4.
5. Dubois CA, D’Amour D, Tchouaket E, Clarke S,
Rivard M, Blais R. Associations of patient safety
outcomes with models of nursing care organization at
unit level in hospitals. Int J Qual Health Care.
2013;25(2):110-7.
6. Sales AE, Schalm C, Baylon MAB, Fraser KD. Data
for improvement and clinical excellence: report of an
interrupted time series trial of feedback in long-term
care. Implementation Science : IS. 2014;9:161.
7. Unbeck M, Sterner E, Elg M, Fossum B, Thor J, Pukk
Härenstam K. Design, application and impact of
quality improvement ‘theme months’ in orthopaedic
nursing: A mixed method case study on pressure ulcer
prevention. International Journal of Nursing Studies.
2013;50(4):527-35.
26
8. Reznek MA, Barton BA. Improved incident reporting
following the implementation of a standardized
emergency department peer review process.
International Journal for Quality in Health Care.
2014;26(3):278-86.
14. Williams H, Edwards A, Hibbert P, Rees P, Prosser
Evans H, Panesar S, et al. Harms from discharge to
primary care: mixed methods analysis of incident
reports. British Journal of General Practice.
2015;65(641):e829-e37.
9. Mitchell I, Schuster A, Smith K, Pronovost P, Wu A.
Patient safety incident reporting: a qualitative study of
thoughts and perceptions of experts 15 years after ‘To
Err is Human’. BMJ Quality & Safety. 2015; Article In
Press.
15. Rees P, Edwards A, Powell C, Evans HP, Carter B,
Hibbert P, et al. Pediatric immunization-related safety
incidents in primary care: A mixed methods analysis
of a national database. Vaccine. 2015;33(32):387380.
10. Rees P, Carson-Stevens A, Williams H, Panesar S,
Edwards A. Quality improvement informed by a
reporting and learning system. Archives of Disease in
Childhood. 2014;99(7):702-3.
16. Omar A, Rees P, Evans HP, Williams H, Cooper A,
Bannerjee S, et al. Vulnerable children and their care
quality issues: a descriptive analysis of a national
database. BMJ Quality & Safety. 2015;24(11):732-3.
11. Carson-Stevens A, Edwards A, Panesar S, Parry G,
Rees P, Sheikh A, et al. Reducing the burden of
iatrogenic harm in children. The Lancet.
2015;385(9978):1593-4.
17. Rees P, Edwards A, Panesar S, Powell C, Carter B,
Williams H, et al. Safety Incidents in the Primary Care
Office Setting. Pediatrics. 2015.
12. Howell A-M, Burns EM, Bouras G, Donaldson LJ,
Athanasiou T, Darzi A. Can Patient Safety Incident
Reports Be Used to Compare Hospital Safety? Results
from a Quantitative Analysis of the English National
Reporting and Learning System Data. PLoS ONE.
2015;10(12):e0144107.
18. Rees P, Edwards A, Powell C, Williams H, Hibbert P,
Makeham M, et al. Identifying priorities for improved
child healthcare: A mixed methods analysis of safety
incident reports. BMJ Quality & Safety.
2015;24(11):730-1.
13. Carson-Stevens A, Hibbert P, Avery A, Butlin A, Carter
B, Cooper A, et al. A cross-sectional mixed methods
study protocol to generate learning from patient
safety incidents reported from general practice. BMJ
Open. 2015;5(12).
EWMA Journal 2016 vol 16 no 1
The Spirit of Innovation.
L&R offers one-stop treatment solutions: innovative
products for debridement as well as a complete
range of products for phase-oriented moist wound
management and compression. Apart from the production and distribution of products as well as own
research activities, L&R provides valuable, practical assistance via centralized and decentralized
training programs for healthcare professionals.
At the EWMA conference 2016, visitors will benefit
from healthcare professionals’ hands-on expertise
at the L&R symposia and L&R workshops, e.g.:
Modern Wound Management:
What are our challenges, what are our
solutions? – About biofilm, debridement
and highly exuding wounds.
Symposium
11th May 2016
3:30 – 4:30 p.m.
Session room 2
German/English
3:30 – 4:00 p.m.: Werner Sellmer (Hamburg, Germany)
“Does biofilm represent a challenge for the local therapy of wounds?”
4:00 – 4:15 p.m.: Dr Carsten Glockemann (Hannover-Oststadt, Germany)
“How to implement modern wound management into daily practice of a physician?”
4:15 – 4:30 p.m.: Björn Jäger (Lingen, Germany)
“Nursing – a crucial partner in wound management”
Experience our innovation-driven spirit in
hall 5, booth no. 5 I 50 or at our virtual booth
www.Lohmann-Rauscher.com/EWMA!
www.Lohmann-Rauscher.com
European Wound Management Association
(EWMA), 11th–13th May 2016
Smith & Nephew Wound Management
at EWMA 2016, Bremen
Smith & Nephew is proud to support healthcare professionals in their daily
efforts to improve the lives of patients, by helping them to deliver better
outcomes for patients and healthcare systems.
At EWMA congress this year, we look forward to welcoming you at our exhibition
booth stand 5 - J 52 at the Bremen Congress centre, where some of the products that could
help you deliver such outcomes will be on display, including ALLEVYN™ LIFE wound dressing,
ACTICOAT™ Antimicrobial Silver Dressing, as well as Negative Pressure Wound Therapy (NPWT)
devices (PICO™ and RENASYS™). A number of international key opinion leaders will also be present
at our stand.
Join us at our symposia on Wednesday 11th May at 15:30 – 16:30 (German language only) and
Thursday 12th May at 13:15 – 14:15 (with simultaneous English translation) to learn more about
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Supporting healthcare professionals for over 150 years
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70756
Science, Practice and Education
Challenges faced by
healthcare professionals in
the provision of compression
hosiery to enhance compliance
in the prevention of venous
leg ulceration
ABSTRACT
Venous leg ulceration affects 1 in 500 people in
the United Kingdom1 resulting in a detrimental
effect on the patient’s quality of life. Prevalence
increases with age, and venous leg ulcers have
high recurrence rates.1 Compression hosiery is the
mainstay of treatment and prevention, although
hosiery efficacy is hindered by non-concordance.2
AIM
To enhance the current delivery and management
of compression hosiery in a local National Health
Service (NHS) Trust.
METHOD
A pilot questionnaire was administered to 26
healthcare professionals to explore the current information provided to patients and to understand
the professional’s knowledge about and opinions
on patient compliance with compression hosiery.
RESULTS
Application difficulties and discomfort were the
main reasons healthcare professionals provided for
patient non-compliance. 79% of patients experienced difficulties with hosiery application. 90%
of professionals provided verbal advice when prescribing hosiery, and 46% provided written information. Healthcare professionals felt that patients
did not understand the importance of compression hosiery. These data suggest inconsistencies in
the information provided to patients.
INTRODUCTION
Compression hosiery is the mainstay of treatment
and prevention of venous leg ulceration and reduction in venous hypertension symptoms.3,4
EWMA Journal 2016 vol 16 no 1
Reference sources used in the literature search
were CINAHL, Medline, Academic Search Complete, and Sciencedirect. The following search
terms were used: “ulcers and recurrence,” “venous ulcer and hosiery,” “compression stockings/
hosiery,” “compliance/adherence/concordance,”
and “ulcers and prevention”. From the literature
review, the reasons given by participants for not
using compression hosiery include cost, application difficulties, discomfort, health promotion,
and self-efficacy.5-15
Difficulty with the application of compression
hosiery was found to be the most common reason
provided for non-compliance. The literature highlighted that ill-fitting compression hosiery is associated with the skills, training, and competence
of clinicians carrying out the assessment. 16-18
Compression hosiery measurement should be
carried out by a healthcare professional who has
knowledge of the underlying causes of venous
ulceration, compression hosiery treatment, and
the effect of different types of hosiery knit (flat
or circular).3,4,18-20 This is imperative not only
for successful, cost-effective treatment outcomes,
but also and more importantly for convincing patients that the hosiery will improve and manage
their symptoms and, thus, reduce the impact of
leg ulcers on their quality of life.3,4,17,20
The therapeutic relationship between the nurse
and the patient and the role that relationship
plays in leg ulcer aftercare is rarely discussed in
the literature, although its significance to health
promotion appears to be underestimated. Nurses
are at the forefront of leg ulcer management, and
the standard of care they provide plays a significant role in influencing a patient’s concordance
Suzanne F Tandler, TVN
Worcestershire Health and
Care NHS Trust, Worcester,
UK
Correspondence:
suzywalker83@gmail.com
Conflicts of interest: None

29
with treatment.25,26 Therefore, an effective nurse-patient
relationship is imperative to achieve successful treatment
outcomes through the adoption of a holistic assessment,
recognising that the patient is an expert in his/her own
condition.27,28
Solutions to issues experienced by patients and healthcare
professionals are highlighted in the literature; these include
a staged introduction to compression hosiery,28 effective
use of compression hosiery application aids,29 and clear
and consistent health promotion using verbal and written
information,30 such as lifestyle advice that incorporates
the facilitation of self-efficacy improvement techniques.31
These solutions aim to facilitate patient concordance with
compression hosiery and leg ulcer aftercare. Ultimately,
this could result in improvements in quality-of-life outcomes and a reduction in the financial burden faced by
the National Health Service.32
METHODS
A self-report questionnaire was distributed to a purposive
sample of 26 registered healthcare professionals who are
members of a County Tissue Viability Team. The aim of
the questionnaire was to determine whether respondents
considered non-compliance to be an issue in treatment
with compression hosiery. In addition, questions were
included to discover what information is commonly provided to patients when they are prescribed hosiery. Respondents were asked to identify the reasons they thought
caused non-compliance and what they felt could be done
to address compliance.
Ethical approval was sought from the local Trust, the
study was deemed a service evaluation, and permission
for the study was granted.
Figure 3 highlights that 4% of respondents provided no
advice, 46% provided a compression hosiery advice leaflet,
and 60% provided a skin care leaflet. The respondents
considered non-concordance as an issue in 25-50% of
patients.
Figure 4 signifies that 96% of respondents considered
patients to be non-concordant with compression hosiery
due to application difficulties.
Following the recommendation/prescription for treatment with compression hosiery, 72% of respondents were
contacted by patients with concerns about their treatment.
When respondents were asked whether they thought patients understood the importance of compression hosiery,
opinion was split at 50%. However, 72% of respondents
believed patients did not take sufficient responsibility for
their own compression hosiery application and care.
Figure 5 indicates the view of respondents on what could
be done to improve compliance. 77% of respondents considered that initiating a hosiery fitting service would improve compliance. It is the view of 32% that Non-payment
of hosiery on FP10. An FP10 is a form which doctors
and nurses with in the NHS use to prescribe a particular
treatment or medicine, the patient then pays a charge for
each item which is currently £8.40 per item or £16.80
per pair of hosiery.33
When asked how often and when respondents followed
up with patients prescribed compression hosiery, respondents provided varying answers. Only 25% reviewed treatment before 12 weeks, 50% reviewed between 12-24
weeks, and 25% reviewed after 24 weeks.
RESULTS
As shown in Figure 1, the majority of respondents were
community nurses. As shown in Figure 2, 62% of respondents completed an accredited leg ulcer management
course.
DISCUSSION
Sixty percent of respondents thought patients were supplied with sufficient information when prescribed compression hosiery, information which consisted of verbal advice in 90% of responses. Similar findings were highlighted
in the literature; clinicians, therefore, may not be providing
adequate information and support. 48% of respondents
thought better information on compression therapy would
FIGURE 1
CURRENT PROFESSION
OF RESPONDENTS
FIGURE 2
NUMBER OF RESPONDENTS WHO HAVE
COMPLETED AN ACCREDITED LEG ULCER COURSE
YES
42%
31%
NO
COMMUNITY STAFF
NURSE
DISTRICT NURCE
39%
61%
PRATICE NURCE
PODIATRIST
23%
OTHER
4%
30
EWMA Journal 2016 vol 16 no 1
Science, Practice and Education
FIGURE 3
ADVICE GIVEN TO PATIENTS WHEN PRESCRIBED COMPRESSION HOSIERY
NONE
COMPRESSION THERAPY
VERBAL ADVICE
SKIN CARE LEAFLET
0%
10%
20%
30%
40%
50%
60%
70%
80% 90% 100%
80% 90% 100%
FIGURE 4
MAIN REASONS THAT RESPONDENTS THOUGHT PATIENTS
WERE NON-CONCORDANT WITH COMPRESSION HOSIERY
NONE
APPLICATION DIFFICULTIES
POOR PAITENT INFORMATION REGARDING
HOSIERY APPLICATION
POOR PATIENT INFORMATION, RE: SKIN CARE
POOR FIT
DISCOMFORT
0%
10%
20%
30%
40%
50%
60%
70%
FIGURE 5
WHAT RESPONDENTS CONSIDERED COULD BE DONE TO IMPROVE COMPLIANCE
BETTER INFORMATION ON COMPRESSION HOISERY
BETTER INFORMATION ON SKIN CARE
HOSIERY FITTING SERVICE
GREATER CHOICE OF PRESCRIBABLE HOSIERY
NON-PAYMENT FOR HOSIERY ON FP10
MORE APPLICATION AIDS ON FP10
0%
10%
20%
30%
40%
50%
60%
70%
80% 90% 100%

EWMA Journal 2016 vol 16 no 1
31
improve compliance. The literature recognises that noncompliance with treatment is positively associated with the
patient’s lack of knowledge and understanding of his/her
condition and the role of treatment with compression hosiery. The healthcare professional is responsible for ensuring that patients are supplied with sufficient information
in an appropriate format17 to enable the patient to make an
informed decision on whether to comply with treatment.
Consistent with findings in the literature, responses to
the questionnaire in this study revealed that application
difficulties were the single most common reason for noncompliance with compression hosiery. Although the use of
application aids is recommended and a selection is available on FP10 prescription, their usage has not been established. 64 % respondents felt that a wider variety would
enhance compliance. Such a service might be difficult to
deliver and would be means-tested to determine whether
an individual may be eligible for government assistance
based upon whether the individual has the means to fund
this without assistance. This is due to the £20bn efficiency
savings needed by the NHS, as highlighted by the NHS
Improvement Service.34
Poor application technique or inaccurate sizing of compression hosiery is related to low use by patients. Similarly, 77% of respondents reported discomfort and 19%
reported poor fit as reasons for patients’ non-compliance
with compression hosiery. The accurate measurement
and selection of the appropriate type of compression
hosiery with regard to flat or circular knit garments are
key to ensure that a patient’s comfort is promoted at all
times.3,4,17,18,20,22,23
The majority of respondents in this study, 62%, had
taken an accredited leg ulcer course. The Medical Education Partnership (2006)19 maintains that health professionals involved in the provision of compression hosiery
should be competent to do so. The knowledge, skill, and
experience of the registered nurse in providing leg ulcer
care and aftercare is paramount and is positively related
to the quality of care provided and success of preventa-
IMPLICATIONS FOR PRACTICE
It is vital that the assessment, measurement, and selection process by which
hosiery is prescribed is holistic, ensuring
that patients are involved and play an
active part in their care to promote
compliance.
32
tive treatment.12 Reasons for the gap in the knowledge
and skill of the registered nurse have been highlighted by
respondents to be attributable to a number of reasons,
including funding to complete training and motivation
to develop the required skills. Nurses are accountable for
their practice and, therefore, need to ensure that they not
only are competent to provide the care needed,31 but also
work towards a patient-centred approach that delivers
evidence-based outcomes.35,36
Patients should be encouraged to take control of their
health by playing an active role in their treatment through
the utilisation of the nurse-patient therapeutic relationship, which is based upon trust, empathy, and empowerment.17,25,29,36
73% of respondents in this study felt that patients did
not take sufficient responsibility for their own application
of hosiery and care; therefore, consideration must be given
as to what can facilitate this in practice.
CONCLUSION
Twenty-six healthcare professionals who are members of
a County Tissue Viability Team took part in a small-scale
survey providing a representative sample. The questionnaire explored the challenges faced by healthcare professionals and patients in enhancing compliance with the use
of compression hosiery. The main findings concur with the
literature: application difficulties and discomfort are the
most common reasons for patient non-compliance with
compression hosiery.
The knowledge and skill of the registered nurse is related
to the quality and success of treatment provided. To improve patient concordance, nurses need to be supported
in their pursuit of training to develop their knowledge and
skills in this area. Additionally, healthcare professionals
must ensure that the selection process by which hosiery is
prescribed is holistic and engages patients in a therapeutic
nurse-patient relationship to empower patients to have an
active part in their care. n
FUTURE RESEARCH
Future research is required to understand
the frequency of the use of application
aids, patient’s perceived consistency of
health promotion advice, and the role of
self-efficacy in the prevention of venous
leg ulcer recurrence.
EWMA Journal 2016 vol 16 no 1
Science, Practice and Education
REFERENCES
1. Scottish Intercollegiate Guidelines Network.
Management of chronic venous leg ulcers [national
clinical guideline]. Edinburgh: SIGN; 2010.
13. Van Hecke A, Grypdonck M, Defloor T. A review of
why patients with leg ulcers do not adhere to
treatment. J Clin Nurs. 2009;18(3):337-349.
26. World Union of Wound Healing Society. Principle of
best practice: compression in venous leg ulcers. A
consensus document. London: MEP Ltd; 2008.
2. Royal College of Nursing. The nursing management
of patients with venous leg ulcers. [clinical practice
guideline]. London: Royal College of Nursing; 2006.
14. Finlayson K. Edwards H. Courtney M. The impact of
psychosocial factors on adherence to compression
therapy to prevent recurrence of venous leg ulcers. J
Clin Nurs. 2010; 19(9-10):1289-1297.
27. Williams A. Issues affecting concordance with leg
ulcer care and quality of life. Nurs Stan. 24(45):5156.
3. Posnett J, Franks PJ. The burden of chronic wounds in
the UK. Nurs Times. 2008; 104( 3):44–45.
4. Department of health. Care in local communities: A
new vision and model for district nursing. [document]
London: Department of Health; 2013.
5. Nelson AE, Harper DR, Prescott RJ, Gibson B, Brown
D, Ruckley CV. Prevention of recurrence of venous
ulceration: Randomised controlled trial of class 2 and
class 3 elastic compression. J Vasc Surg. 2006 Oct
31; 44(4):803-8.
6. Franks PJ, Oldroyd MI, Dickson D, Sharp EJ, Moffatt
CJ. Risk factors for leg ulcer recurrence: a randomised
trial of two types of compression stocking. Age and
Ageing. 1995; 24(6):490-494.
7. Samson RH, Schowalter DP. Stockings and the
prevention of recurrent venous ulcers, J Dermatol
Surg Oncol.1996; 22(4):373-376.
8. Peters J. A review of the factors influencing nonrecurrence of venous leg ulcers. J Clin Nurs.1998;
7(1):3-9.
9. Flanagan M, Rotchell L, Fletcher J, Schofield J.
Community nurses’, home carers’ and patients’
perceptions of factors affecting venous leg ulcer
recurrence and management of services. J Nurs
Manag. 2001; 9(3):153-159.
10. Raju S, Hollis K, Neglen P. Use of compression
stockings in chronic venous disease. Phlebolymphology. 2007; 21:790-795.
11. Finlayson K, Edwards H, Courtney M. Factors
associated with recurrence of venous leg ulcers: A
survey and retrospective chart review. Int J Nurs Stud.
2009; 46(8):1071-1078. HERTIL
12. Moffatt C, Kommala D, Dourdin N, Choe Y. Venous
leg ulcers: patient concordance with compression
therapy and its impact on healing and prevention of
recurrence. Int Wound J. 2009; 6(5):386-393.
EWMA Journal 2016 vol 16 no 1
15. Ziaja D, Kocełak P, Chudek J, Ziaja K. Compliance
with compression stockings in patients with chronic
venous disorders. Phlebology. 2011; 26(8):353-360.
16. Worcestershire NHS Acute Hospitals Trust. Annual
Plan 2013/14. Worcester, UK: Worcestershire NHS
Acute Hospitals Trust; 2012.
17. Moffatt C. Martin R. Smithdale R. Leg ulcer
management. Vol 10. Oxford, UK: Blackwell
Publishing Ltd; 2007.
18. Martin F, Duffy A . Assessment and management of
venous leg ulceration in the community: a review. Br J
Community Nurs. 2011 Dec 2.
19. Medical Education Department. Best practice for the
management of lymphoedema: International
consensus. London: MEP Ltd; 2006.
20. Stephen-Haynes J. An overview of compression
therapy in leg ulceration. Nurs Stan. 2006 Apr 19;
20(32):68-76.
21. Stephen-Haynes J, Sykes R. Audit of the use of
compression hosiery in two NHS Trusts, Wounds UK.
2013: 9(1):16-20.
22. Murphy, S. (2008) The nurse-patient relationship and
the successful use of compression therapy. Wound
Essential. 2008; 3:72-74.
23. Furlong W. Venous disease treatment and compliance: the nursing role. Br J Nurs. 2001; 10(11):1822.
28. Johnson S. Compression hosiery in the prevention and
treatment of venous leg ulcers. J Tissue Viability.
2002;12,(2):67-74.
29. Bandura A. Self-efficacy: Towards a unifying theory of
behavioural change. Psychol Rev. 1977; 84(2):191215.
30. Gray D. Achieving compression therapy concordance
in the new NHS: a challenge for clinicians. J
Community Nurs. 2013; 27(4):107-111.
31. Nursing and Midwifery Council (NMC). The code:
Professional standards of practice and behaviour for
nurses and midwives. London, UK: NMC; 2015.
32. Dowsett C, Elson D. Meeting the challenges of
delivering leg ulcer services. Wounds UK. 2013;
9(1):90–5.
33. National Health Service. [Internet] NHS help your
health choices. Help with your prescription costs. UK:
NHS; 2016 [Accessed on 2016 March 3]. Available
from: http://www.nhs.uk/NHSEngland/Healthcosts/
Pages/Prescriptioncosts.aspx.
34. NHS Improvement System. NHS improvement now
closed. UK: NHS; 2013 [Accessed 2013 Nov 16]
Available from: www.improvement.nhs.uk/Default.
aspx?alias=improvement.nhs.uk/qipp.
35. Department of Health. Guidance of patient reported
outcome measures [document]. London: DH; 2009.
36. Yarwood-Ross L, Haigh C. A case of compression
therapy, Br J Nurs. 2012; (21):26.
24. Anderson I. (2013), How to…Ten top tips on
compliance, concordance, and adherence. Wounds
International. 2013; 4(2):9-12.
25. Tattersall J. The expert patient: a new approach to
chronic disease management for the 21st century.
London: Department of Health; 2001.
33
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Science, Practice and Education
LONDON · UK
EWMA n LONDON 2015
Submitted to EWMA
Journal based on
presentation given in
the free session Pressure
Ulcer 1
Pressure Ulcer Incidence:
Do patients
retain
information?
Kathrin Vowden1,2
Victoria Warner1
INTRODUCTION
Many service commissioners are demanding a
reduction in pressure ulcer prevalence and regard pressure ulceration as a key indicator of
care quality. Within our area of practice, local
commissioners have indicated that all health care
providers in the district should work together to
reduce pressure ulceration across the local health
care economy. Health care professionals clearly
have a critical role to play in patient assessment,
risk categorisation, care planning and equipment
provision. However, this alone will not be sufficient to achieve the reduction targets which will
involve effective patient engagement.
National and International guidelines all recognise the importance of patient education in care
and recognise the significance of patient involvement in personalised care planning and service
provision.1, 2 Hartigan et al have demonstrated the
value of education leaflets in supporting pressure
ulcer prevention in an elderly population.3 Patient
support applications running on mobile phones
and tablets are also available to assist in pressure
ulcer prevention and patient education4 but are
not widely used in a hospital setting. This study
examines how effective standard verbal and written information is at delivering patient education
for pressure ulcer prevention.
Local hospital policy is that all patients identified as being at risk of developing pressure ulceration are provided with information on what
a pressure ulcer is, what constitutes risk and how
to assist staff in pressure ulcer prevention. The
policy includes patient and carer involvement in
care planning, and encouragement to report skin
changes and pain to staff.
EWMA Journal 2016 vol 16 no 1
METHOD
Hospital policy is that patients are provided with
both printed information based on the criteria in
National Institute for Clinical Excellence (NICE)
guidance1 and European Pressure Ulcer Advisory
Panel (EPUAP) documents2 and reinforced by
verbal discussion in relation to pressure ulcer
prevention. To audit the effectiveness of the current information provided by ward staff to “high
risk” patients, a questionnaire was designed by
the Wound Healing Unit (WHU) to allow both
assessment of the current “education” and to
provide WHU staff with the opportunity to give
patients further information when deficiencies in
their knowledge or understanding relating to pressure ulcer prevention were identified.
Fifty patients, from both medical and surgical
wards, at high risk of pressure ulceration were
identified. Following consent, patients were approached and questioned by the WHU staff. A
proportion of patients (1 in 5) were randomly
selected (9) to undergo a further assessment by
WHU staff using the same questionnaire. The
second assessment occurred on the following day
and was designed to assess their retention and
understanding of any additional information provided during the first questionnaire session.
RESULTS
Following provision of information by the ward
staff, 38 of 50 patients knew what a pressure ulcer
was. 6 patients thought that moisture lesions and
bedsores were the same thing. 26 patients recognised that pressure ulcers could occur at several
body sites including the sacrum and heel, 20 felt
Jane Collins2
1 Bradford
Teaching
Hospitals NHS Foundation
Trust, Bradford UK
2 University of Bradford,
Bradford UK
Correspondence:
krv3@me.com
Conflicts of interest: None

35
Science, Practice and Education
that pressure ulcers only occurred on the sacrum and 4
were unsure where they occurred.
When asked how staff recognised that they were at risk
of pressure ulceration, only 3 knew that staff had a risk
assessment sheet, 26 did not know and 15 said they know
these things because they were nurses. The remaining 7 felt
that everyone in hospital may get a “bed sore”.
33 patients recognised that they were having regular skin
assessment and knew why, in addition 9 patients knew to
report skin soreness. The remainder did not equate skin
assessment with pressure ulcer prevention. 29 patients were
aware that the nurses had told them that they were at risk
of developing a pressure ulcer, 10 patients expressed concern about developing a bedsore. 38 patients recognised
that poor mobility was a risk factor and understood the
need for repositioning. 7 patients understood that poor
nutrition contributed to risk. 9 patients did not know
about factors that increased risk.
Despite all patients being on a profiling bed and a minimum of a high density foam mattress, 16 felt that they
were not provided with pressure relieving equipment, 4
of these were actually on an alternating pressure mattress.
Re-questioning of the sub-group of 9 patients after further information provision by the WHU staff during the
initial questionnaire session showed an improvement in
understanding, but one patient still lacked understanding
and two did not know that pressure ulcers could occur
anywhere on the body.
DISCUSSION
Patients’ understanding of the information provided in relation to pressure ulcer prevention may not be as complete
as we assume. Even after specialist staff provided additional
information, some patients still do not understand why
and how pressure ulcers occur. Patient engagement in pressure ulcer prevention is a key component in the overall
prevention strategy, and a lack of patient and family understanding often contributes to complaints and litigation.
CONCLUSION
This small survey indicates that we should all revisit this
aspect of care and work to raise public awareness of their
role in pressure ulceration prevention. n
REFERENCES
1. National Institute for Clinical Excellence (NICE).
Clinical guidelines CG179: Pressure ulcers: prevention
and management of pressure ulcers. 2014.
2. 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. Haesler E,
editor. Osborne Park, Western Australia: Cambridge
Media; 2014.
36
3. Hartigan I, Murphy S, Hickey M. Older adults’
knowledge of pressure ulcer prevention: a prospective
quasi-experimental study. Int J Older People Nurs.
2012;7(3):208-18.
4. Hudgell L, Dalphinis J, Blunt C, Zonouzi M, Procter S.
Engaging patients in pressure ulcer prevention. Nurs
Stand. 2015;29(36):64-70.
EWMA Journal 2016 vol 16 no 1
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1. Armstrong DG, et al. Off-loading the diabetic foot wound. Diabetes Care 24:1019-1022, 2001 2. Bloomgarden ZT: American Diabetes Association 60th Scienti c Sessions, 2000. Diabetes Care 24:946-951, 2001. 3. American Diabetes Association: Consensus
Development Conference on Diabetic Foot Wound Care. Diabetes Care 22:1354–1360, 1999 4. Coleman W, Brand PW, Birke JA: The total contact cast, a therapy for plantar ulceration on insensitive feet. J Am Podiatr Med Assoc 74:548 –552, 1984 5. Helm PA, Walker
SC, Pulliam G: Total contact casting in diabetic patients with neuropathic foot ulcerations. Arch Phys Med Rehabil 65:691– 693, 1984 6. Baker RE: Total contact casting. J Am Podiatr Med Assoc 85:172–176, 1995 7. Sinacore DR, Mueller MJ, Diamond JE: Diabetic
plantar ulcers treated by total contact casting. Phys Ther 67:1543–1547,1987 8. Myerson M, Papa J, Eaton K, Wilson K: The total contact cast for management of neuropathic plantar ulceration of the foot. J Bone Joint Surg 74A:261–269, 1992 9. Walker SC, Helm PA,
Pulliam G: Chronic diabetic neuropathic foot ulcerations and total contact casting: healing effectiveness and outcome probability (Abstract). Arch Phys Med Rehabil 66:574, 1985 10. Mueller MJ, Diamond JE, Sinacore DR, Delitto A, Blair VPD, Drury DA, Rose SJ: Total
contact casting in treatment of diabetic plantar ulcers: controlled clinical trial. Diabetes Care 12:384 –388, 1989 11. Liang PW, Cogley DI, Klenerman L: Neuropathic ulcers treated by total contact casts. J Bone Joint Surg 74B:133–136, 1991 12. Walker SC, Helm PA,
Pulliam G: Total contact casting and chronic diabetic neuropathic foot ulcerations: healing rates by wound location. Arch Phys Med Rehabil 68:217–221, 1987 13. Armstrong DG, Lavery LA, Bushman TR: Peak foot pressures in uence the healing time of diabetic foot
ulcers treated with total contact casts. J Rehabil Res Dev 35: 1–5, 1998 14. Lavery LA, Vela SA, Lavery DC, Quebedeaux TL: Reducing dynamic foot pressures in high-risk diabetic subjects with foot ulcerations: a comparison of treatments. Diabetes Care 19:818–821,
1996 15. Lavery LA, Armstrong DG, Walker SC: Healing rates of diabetic foot ulcers associated with midfoot fracture due to Charcot’s arthropathy. Diabet Med 14:46–49, 1997 16. Lavery LA, Vela SA, Lavery DC, Quebedeaux TL: Total contact casts: pressure reduction
at ulcer sites and the effect on the contralateral foot. Arch Phys Med Rehabil 78:1268–1271, 1997 17. Fife CE; Carter MJ, Walker D: Why is it so hard to do the right thing in wound care? Wound Rep Reg 18: 154–158, 2010. 18. Jensen J, Jaakola E, Gillin B, et al: TCC-EZ
–Total Contact Casting System Overcomingthe Barriers to Utilizing a Proven Gold Standard Treatment. DF Con. 2008.
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4. Marburger M, Andersen MB. In vitro test of eight wound dressings with silicone adhesive: Fluid handling capacity and absorption under compression, Presented at Wounds UK 2013
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The Coloplast logo is a registered trademark of Coloplast A/S. © 2016-04. All rights reserved Coloplast A/S, 3050 Humlebaek, Denmark.
Science, Practice and Education
Wound management
in epidermolysis bullosa
INTRODUCTION
Epidermolysis Bullosa (EB) is the generic term for
a large complex group of inherited blistering and
skin fragility disorders. There are 4 main types of
EB and many additional subtypes. The common
factor is fragility of the skin and mucous membranes with a tendency for blisters and wounds
to develop following minimal everyday friction
and trauma. Fragility results from reduced or absent vital proteins, which give the skin its tensile
strength. EB can be inherited either dominantly
or recessively, with the recessive types generally
being more severe.
The 4 main types of EB are EB simplex; junctional EB; dystrophic EB and Kindler syndrome.
Whilst experienced clinicians may be able to make
a provisional diagnosis, this is difficult in the presentation of affected new-borns and diagnosis must
be made from analysis of a skin biopsy using the
key diagnostic tools of positive immunofluorescence, antigen mapping and electron microscopy.
Re-categorisation in 2014 removed many of the
eponyms and included more variants.1
The severity of the condition varies between
painful blistering of the hands and feet in EB simplex localised, to death in early infancy resulting
from laryngeal disease and faltering growth in
those with generalised severe junctional EB.
Scarring in those with severe forms of dystrophic
EB leads to development of contractures, microstomia, oesophageal strictures and pseudosyndactyly.2
PRINCIPLES OF WOUND CARE
Wound healing is compromised by the underlying
genetic defect, poor nutritional status, anaemia
(both resulting from chronic disease and iron
deficiency), pain and pruritus. The general guidance of selection of the correct dressing, protecting the peri-wound skin, avoiding skin stripping,
EWMA Journal 2016 vol 16 no 1
lancing blisters to limit their spread, addressing
the bio-burden and exudate management apply.
In addition, the type of EB further dictates skin
and wound care. Whilst this article will briefly
describe these categories and recommendations,
more detailed information is available in Best
Practice Guidelines for Skin and Wound Care in
Epidermolysis Bullosa.3
Although there is a plethora of wound care products available, the selection suitable for those with
fragile skin is more limited. Adhesive dressings
and even those coated with soft silicone may result
in skin stripping in the most fragile patients. Using a Silicone Medical Adhesive Remover (SMAR)
can eliminate this risk. SMARs are also essential
in removing adhesive products such as fixation
for cannulas and essential monitoring devices.4
Due to the increase in antibiotic resistant organisms, oral or intravenous antibiotics are reserved
for systemic infection with a preference to use
topical antimicrobial therapies as first line treatment.5
NUTRITIONAL SUPPORT
Oral blistering and dysphagia compromise intake
in severe forms of EB. Long term enteral feeding
is often necessary to increase nutritional requirements and aid wound healing.6
CARE OF THE NEWBORN
WITH SEVERE EB
Severely affected infants often present with widespread skin loss resulting from inter-uterine movements and compounded by the trauma of delivery.
In addition to complex wound management, all
screening and handling procedures require modification to reduce additional damage to the fragile
skin and mucosa.7
Jackie Denyer
Correspondence:
jackiedenyer1@gmail.com
Conflicts of interest: None

39
Skin stripping following removal of adhesive tape
Birth damage in a severely affected new born infant
Figure 1: Foot and lower leg dressing template
Remove cord clamp and replace with a ligature
Nurse in cot/bassinette unless incubator required for reasons
such as prematurity
Give regular analgesia and additional pre-procedure doses
using a validated neonatal pain score for adjustment
Lance all blisters with a hypodermic needle
To protect peri-umbilical skin
Heat and humidity may exacerbate blistering
To provide adequate pain relief
Blisters are not self- limited and left unchecked will spread,
resulting in pain and further tissue damage
Leave the blister roof in situ
Cover open wounds with a non- adherent absorbent foam
dressing e.g. polymeric membrane
Use a template to pre-cut dressing shapes. Cover entire limb,
overlap dressing and secure by taping to itself
Dress digits individually
Cleanse napkin area with 50% liquid paraffin, 50% white soft
paraffin in ointment or aerosol form
Line napkin with soft material such as commercial liner
Protect intact skin with a barrier product
Cover wounds and blister sites with hydrogel impregnated
gauze dressings
Nurse on neonatal mattress
Avoid bathing until inter-uterine and birth damage have
healed
Dress in front fastening baby suit
Always use a Silicone Medical Adhesive Remover
to safely take off adherent dressings, adhesive tapes or
adherent clothing
40
The roof will act as a protective dressing and reduce pain
and tissue damage
To provide an optimal wound healing environment, continual cleansing of the wound and management of exudate
To reduce duration of dressing changes
To avoid skin stripping from adhesive tapes and to protect
undamaged skin from normal baby movements
To avoid early pseudosyndactyly
Water may cause stinging to open wounds and blister sites
To reduce trauma from the edges of the napkin
To promote skin integrity
To provide a moist wound environment and protect from
faecal contamination
To protect skin, offer comfort and for ease of handling
To avoid further trauma from handling
For ease of handling and for added protection from normal
baby movements
To avoid skin stripping
EWMA Journal 2016 vol 16 no 1
Science, Practice and Education
Template for lower leg
Template for Heel / Boot
Template for Hand / Fingers
PolyMen
Wrist
Cut slits
Slits Hand
Slits
Heel
Slits Fingers
Toes
WOUND MANAGEMENT SPECIFIC TO
THE TYPE OF EB
EB SIMPLEX (EBS)
Most forms of EBS are dominantly inherited and result
from a disorder of keratin proteins, which provide scaffolding for basal epidermal cells. Defects of keratin result in
blisters forming following minimal friction and trauma.8
With the exception of neonates with generalised severe EB simplex who are frequently born with extensive
wounds, the localised and generalised types of EB simplex
are characterised by blistering caused by friction. EB simplex is affected by heat and humidity, with blistering being
much worse in the summer months.
Management of EBS is by lancing blisters, reducing
friction and use of measures to keep cool such as using
socks containing silver thread, cooling insoles and shoes
offering ventilation.9
Suitable dressings offer comfort, reduce heat and promote healing of blister sites. Appropriate dressings include
sheet hydrogels, bi-stretch silicone dressings and bordered
soft silicone dressings. However, many affected individuals
prefer not to use any dressings at all.
Care must be taken to ensure blistering does not result
from trauma caused by the edges of dressings. This can
be minimised by rounding off the dressings and padding
Over granulation tissue in a child with junctional EB
EWMA Journal 2016 vol 16 no 1
beneath the edges with dressings such as lipidocolloid or
hydrofiber.
JUNCTIONAL EB (JEB)
JEB is a recessively inherited condition. Blistering occurs
within the lamina lucida. Mechanical integrity of the
hemi-desmosomes or anchoring fibrils is compromised
by gene mutations.
In its most severe form, generalised severe junctional EB
infants rarely survive beyond the first two years of life.10
Less severe forms of junctional EB (JEB Intermediate)
predispose to the development of chronic wounds, alopecia and with an increased risk of squamous cell carcinoma
in mid life.
Over-granulation tissue features in wounds of all types of
severe EB, but it is most common in those with junctional
EB. Measures to deter this florid tissue include selecting a primary dressing with a very fine mesh such as a
lipidocolloid, or using hydrogel impregnated gauze dressings. Hypergranulation is most troublesome on the face
of longer-term survivors, causing chronic wounding, pain
and disfigurement. Treatment with a very potent topical
steroid in combination with an antimicrobial agent destroys the over- granulation tissue and encourages healing
to take place.
DYSTROPHIC EB (DEB)
Dystrophic EB can be inherited either dominantly or recessively. In DEB, collagen VII is reduced and, in severe
recessive forms, completely absent.
Collagen VII forms the basis of anchoring fibrils, which
attach the epidermis to the dermis leading to formation
of traumatic wounds following minimal shearing forces.
Those with markedly reduced or absent collagen VII heal
with atrophic scarring leading to development of progressively disabling contractures.
Wound management in dystrophic EB is complex, with
a need to protect from trauma, manage the bio-burden and

41
exudate, and attempt to delay formation of contractures
and pseudosyndactyly.
There is a high risk of development of aggressive forms
of squamous cell carcinoma in young adults with severe
dystrophic EB.11 Patients and carers need to be made
aware of the signs and encouraged to report any change
in appearance of a chronic wound, an abnormal sensation
or increase in pain or exuberant tissue growth within an
existing wound.
Suitable dressings in the management of dystrophic EB
are plentiful and can be selected according to need, such
as exudate management, critical colonisation, infection,
odour or protection. Recommended dressings include soft
silicone, lipidocolloid, foams, honeys, enzymatic gels and
super-absorbers.
KINDLER SYNDROME
Kindler syndrome is recessively inherited and results from
mutations in the gene FERMT1.12
This is a rare type of EB, which is difficult to diagnose
as it may demonstrate features of other types of EB due to
the unique feature of variable level of cleavage with blister
formation occurring within the epidermis, lamina lucida
or sub lamina densa.
Neonatal skin loss and blisters are common but reduce
during infancy. Later changes include photosensitivity
requiring sun protection, atrophic and pigmentary skin
changes.
Dressing selection is indicated by level of blister formation with epidermal blistering following recommendation
for those with EB simplex and sub lamina densa that of
dystrophic EB.
CHRONIC WOUNDS
Those with severe forms of EB are predisposed to the development of chronic wounds. Common causes include
infection and critical levels of colonisation, poorly controlled exudate, presence of slough and necrotic material
and destruction from scratching to relieve the discomfort
resulting from pruritus.
Management of these wounds is complex, and due to
the underlying gene defect and multiple co-morbidities,
not always successful.13
Appropriate management of exudate is crucial if attempts are to be made to protect the peri-wound skin
from maceration.
Bathing may be difficult for individuals who have multiple wounds and contractures due to pain, risk of damage
from handling and duration of a full dressing change.14
In the absence of bathing, wound cleansing with an antiseptic agent is encouraged as is removal of slough and
dried exudate using debridement cloths and pads. Medical
42
grade honey preparations, hydrogels, enzymatic and larval
debridement have also been successfully employed.
Advanced therapies for management of chronic wounds
using bioengineered skin grafts, protease modulators, collagen and keratin dressings should be considered if regular
recommended dressings are unsuccessful.
INFECTED WOUNDS
Infected wounds should be managed using topical antimicrobial products unless the patient is systemically unwell.
Recommended products include medical grade honey, enzyme alginogel, polymeric membrane, polyhexamethylene
biguanide and silver dressings. Silver products should be
used with caution in infants under one year. When used
in large areas there is a potential risk of raised plasma silver
levels, so restrict usage to 14 days.
MANAGEMENT OF FUNGATING WOUNDS
Patients with severe forms of EB, in particular those with
generalised severe dystrophic EB, have a very high risk of
developing squamous cell carcinoma. Towards the end
of life these may result in an inoperable tumour, which
develops into a fungating wound. Careful management
to address pain, exudate, bleeding and odour may require
multiple layers of dressings. Dressing changes should be
kept to a minimum in order to reduce the risk of bleeding
and additional pain.15
PRURITUS
Pruritus is a challenge for affected individuals, carers and
health professionals. Scratching leads to extensive skin
damage and wounding. Additionally intense pruritus
forms part of the pain spectrum and can result in depression and insomnia.16
Management of pruritus is by simple measures such as
applying emollients or products containing menthol to
cool the skin, avoiding warm environments if possible or
using air conditioning or non–buffeting fans to circulate
the air.
Loose cotton clothing or specialised silk garments have
anti-pruritic properties and can be helpful.
MANAGEMENT OF PAIN
Pain in severe EB is multi-factorial and requires input from
a specialised pain team with an age-appropriate validated
pain tool used at each dressing change in order to achieve
optimal pain management.
Management of wound pain must consider the presence of both nociceptive and neuropathic pain and may
require regular and procedural opioid treatment together
with agents such as gabapentin and pregabalin. Topical
agents including morphine gels and dressings containing
ibuprofen are helpful for individual painful wounds.
EWMA Journal 2016 vol 16 no 1
Science, Practice and Education
Non-pharmacological treatments such as guided imagery and psychotherapy are used in conjunction with
pharmacological treatments.17
CONCLUSION
Wound management in EB is complex as it is influenced
by multiple co morbidities and the fragility of the skin.
Dressing management is specific to the type of EB, pres-
ence of infection or critical colonisation, levels of exudate,
availability of products and personal preference. Families
with a long history of EB, such as those with EB simplex
localised, may shun modern technologies and prefer to
use less suitable products as dictated by family members,
which is frustrating for the professional attempting to
help. n
REFERENCES
1. Fine JD, Bruckner Tuderman L, Eady RA et al.
Inherited epidermolysis bullosa: updates recommendations on diagnosis and classification. J Am Acad
Dermatol 2014: Jun, 70(6): 1103-26
2. Formsa SA, Maathuis CBG, Robinson PH et al.
Postoperative hand treatment in children with
recessive dystrophic epidermolysis bullosa. J Hand
Ther 2008:2(1): 80-84
3. Denyer J, Pillay E. Best practice guidelines for skin
and wound care in epidermolysis bullosa. International Consensus. DEBRA 2012
4. Denyer J. Reducing pain during the removal of
adhesive and adherent products. Br j Nurs 2011;
20(15): S28-S30-5
5. Mellerio JE. Infection and colonization in epidermolysis bullosa. Dermatol Clin 2010; 28(2): 267-9
6. Hubbard L, Haynes L, Skylar M, et al. The challenges
of meeting nutritional requirements in children and
adults with epidermolysis bullosa; proceedings of a
multi-disciplinary team study day. Clin Exp Dermatol
2011; 36(6) 579-83
7. Denyer J. Management of the infant with epidermolysis bullosa. Infant 2009; 5(6): 170
14. Arbuckle HA. Bathing for individuals with epidermolysis bullosa. Dermatol Clin 2010; 28(2):256-6
8. Uitto J, Richard G, McGrath JA. Diseases of
epidermal keratins and their linker proteins. Exp Cell
Res 2007; 313(10) 1995-2009,
15. Grocott P. The palliative management of fungating
wounds. J Wound Care 2000; 9(1): 4-9
9. Mather C, Graham-King P. Silver fibre sock can make
a difference in managing EB simplex. Poster
presentation. Wounds UK, 2008, Harrogate
10. Fine JD. Premature death in EB. In: Fine JD, Hintner
H, Eds, Life with Epidermolysis Bullosa (EB):
Aetiology, Diagnosis, Multidisciplinary Care and
Therapy. Wein-New York: Springer, 2008;197-203
16. Denyer J, Pillay E. Best practice Guidelines for skin
and wound care in epidermolysis bullosa. International Consensus. DEBRA 2012 (10)
17. Moss K. Contact at the borderline: psychoanalytic
psychotherapy with EB patients. Br J Nurs 2008;
17(7): 449-55
11. Fine JD, Bauer A, McQuire J, et al. Cancer and
inherited epidermolysis bullosa. In: Epidermolysis
Bullosa, 1999; John Hopkins University Press,
Baltimore, MA:175-92
12. Ashton GH. Kindler Syndrome. Clin Exp Dermatol
2004:29; 116-21
13. Abercrombie EM, Mather CA, Hon J, et al. Recessive
dystrophic epidermolysis bullosa. Part 2: care of the
adult patient. Br J Nurs 2008; 17(6)
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2016 vol 16 no 1
43
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Science, Practice and Education
LONDON · UK
EWMA n LONDON 2015
Submitted to EWMA
Journal based on
presentation given in the
key session Wound Care
& Geriatrics / Dementia in
Wound Care.
Skin aging:
a global health
challenge
INTRODUCTION
Aging is a universal concern. Linked to aging are a
series of physiological and pathological processes,
among them changes in skin turnover, quality,
and regenerative potential. Skin aging has long
been viewed as more of an aesthetic problem than
as a real functional health problem.
Nowadays, more people are reaching “old” age,
resulting in an increase in both the proportion of
the population that is of advanced age and in absolute global number of persons of advanced age.1,
2, 3 Skin aging must be thought of as a health issue
that should be integrated into the global aging
field, in which we know that each organ insufficiency can add to another and produce those difficult to treat co-morbid states well known by the
geriatrician. Therefore, we must adopt a broader
view of aging skin health than just concern over
the skin or wound itself.
World demographics show us that, in all countries, the proportions and absolute numbers of
those aged 65 and over and, among them, those
aged 85 and over are steadily growing.1, 2, 3 This
is the positive result of improved global health
conditions, but this outcome leads to new challenges associated with aging. Among these challenges is skin aging and, more globally, coping
with multiple aging organs and illnesses resulting
in polymorbidities.
Recently, the concept of dermatoporosis has
been developed, in which skin aging is compared
to bone aging (osteoporosis), which includes both
bone density and microarchitectural changes leading to osteoporotic fractures. On this background,
skin aging, which has been characterised previously as an aesthetic phenomenon, is now clearly
identified as an organ insufficiency to be considered parallel to renal or heart insufficiency, for
example.4, 5, 6
EWMA Journal 2016 vol 16 no 1
CONTRIBUTING FACTORS
Skin aging is the result of both intrinsic and extrinsic factors. Intrinsic factors are those that are
genetically determined, lead to what some call
chronologic aging, and include sex hormones
levels and inner oxidative stress. Among other
outcomes, fine wrinkles, skin thinning, laxity,
and loss of elasticity are caused by chronologic
aging.7-12
Extrinsic factors are all factors that, from the
outside, enhance intrinsic skin aging and lead to
profound wrinkles, pigmentary defect, and skin
cancers. Photoaging, linked to sun exposure, is
considered a major contributor to overall skin aging. Grossly, ultraviolet A radiation is responsible
for skin aging and ultraviolent B radiation for
skin cancers, which increase in incidence with age.
Medications such as corticosteroids, immunosuppressants, and chemotherapeutic agents directly
impact the skin. Other factors, such as tobacco,
alcohol consumption, and air pollutants, certainly
play important roles as well.13, 14
Intrinsic factors can play a role in the extrinsic
skin aging pathway; for example, skin pigmentation, which is genetically determined, plays a major role in the phototoxicity of sunrays. As a result,
less pigmented skin exposed to sun will become
thinner and weaker and have a lessened defensive role and capacity to rejuvenate than more
pigmented skin that is similarly exposed to sun.
Extrinsic and intrinsic factors lead to skin weakness that translates into skin tears, deep dissecting hematomas, and wound-healing difficulties,
which in turn can lead to lengthened hospital
stays.
However, we should adopt a broader view on the
global aging process and look at its consequences
on other functions that can have direct or indirect

Hubert Vuagnat
University Hospitals of
Geneva Department of
Rehabilitation and
Palliative Care Medical
Rehabilitation
Division,
Bernex, Switzerland
Correspondance:
hubert.vuagnat@hcuge.ch
Conflicts of interest: None
45
Figure 1. Forearm and hand, typical thin skin with cutaneous
hematoma and scars.
Figure 3. Deep dissecting hematoma.
Figure 2. Skin tears.
Figure 4. Dermatoporosis with multiple old and recent lesions.
effects on skin health. Among these aging consequences
are sensitivity losses which will place the skin at risk from
undetected injuries, other neurological deficits resulting in
falls in which the skin tears and/or bleeds easily, and renal
insufficiency or malnutrition, which are common in the
elderly and result in further insults to the skin. With age,
the number of diagnoses that can negatively impact skin
integrity and/or repair capacity increases. These diagnoses include diabetes, conditions requiring anticoagulants,
edema from cardiac insufficiency, peripheral arterial disease, and chronic venous insufficiency.
potentially dangerous everyday objects, such as a wheelchair.
Skin protection efforts can also involve carefully applying treatments of non-age-related skin problems in patients of advanced age. For example, in the case of perineal
dermatitis, treatment must be rapidly applied following
strict protocols.16
Special attention must be paid to smokers. Tobacco has
both long-term and short-term effects on skin health.
Quitting cigarettes proves very useful for wound healing and reducing postoperative problems, such as suture
dehiscence and infection.17, 18
PREVENTIVE MEASURES
Protection of the skin is very important, and simple
measures such as skin washing and systematic daily use
of emollients have proven effective.15 However expensive,
some retinoid based creams with hyaluronic acid have also
proven effective.6
Skin protection efforts can extend beyond the skin itself.
Such efforts may include establishing a safe environment
to reduce falls and impacts and padding of limbs and
46
WOUND TREATMENT
In aged skin, all stages of wound healing may be impaired,
including
-Inflammation, with early increase in neutrophils, delayed monocyte infiltration, impaired macrophage function (reduced phagocytic capacity), increased secretion
of proinflammatory mediators, and decreased vascularendothelial-growth-factor production.
EWMA Journal 2016 vol 16 no 1
Science, Practice and Education
-Proliferation, with reduced response to hypoxia, delayed angiogenesis, and delayed collagen deposition with
reduced fibroblast proliferation and migration. Delayed
re-epithelialisation and reduced keratinocytes proliferation
and migration will occur.
-Remodelling, with reduced collagen turnover, resulting
in increased fibroblast senescence. This decreased activity
usually leads to visually accelerated maturation and less
visible scars.19
For this reason, special attention must be paid to wound
care in the aging population. If wounds or skin tears appear, state-of-the-art treatments must be applied timely to
optimise healing without further damage to the skin. Low
adherence, moisture-maintaining dressings play an important role in this treatment.20, 21 For both prevention and
treatment, an interdisciplinary approach will be crucial.
CONCLUSIONS
Our fragile and vital skin will age, and its protective and
regenerative roles will diminish over time. Due to the evergrowing number of elderly and the fact that skin aging is
a real health problem that complicates and is complicated
by other co-morbidities, aging skin status must readily be
assessed. Skin protection by emollients can ease the effects
of aging on the skin. Minimising the impact of extrinsic
factors in childhood by, for example, using sunscreen regularly and throughout life as well as avoiding tobacco, can
also help optimise the health of aging skin.
Current wound-healing evidence has been based largely
on either animal models or younger human skin models.
Further research must now focus on how best to maintain
skin health in the aging population. n
REFERENCES
1. United Nations, Department of Economic and Social
Affairs, Population Division (2013). World Population
Ageing 2013. ST/ESA/SER.A/348. http://www.un.org/
en/development/desa/population/publications/pdf/
ageing/WorldPopulationAgeing2013.pdf
2. United Nations, Department of Economic and Social
Affairs, Population Division (2015). World Population
Prospects: The 2015 Revision, Key Findings and
Advance Tables. Working Paper No. ESA/P/WP.241.
http://esa.un.org/unpd/wpp/publications/files/key_findings_wpp_2015.pdf
3. Jamison D. T., Summers L. H. et al. Global health
2035: a world converging within a generation. Lancet
2013; 382: 1898–955.
4. Kaya G., Saurat J.-H. Dermatoporosis: A chronic
cutaneous insufficiency/fragility syndrome. Dermatology 2007; 215:284-94.
5. Kaya G. Dermatoporose : un syndrome émergent.
Rev Med Suisse 2008 ; 4 : 1078-82
6. Kaya G. New therapeutic targets in dermatoporosis. J
Nutr Health Aging. 2012 Apr; 16: 285-288.
7. Farage M. A. et al. Intrinsic and extrinsic factors in
skin ageing: a review. Int J Cosmet Sci. 2008; 30:
87-95.
15. Kottner J., et al., Maintaining Skin Integrity in the
Aged: A Systematic Review. The British Journal of
Dermatology. 2013; 169: 528-542.
8. Farage M.A., Miller K.W., Maibach H.I. Textbook of
Aging Skin. 2010, https://books.google.ch/
books?id=9-ALWZhXomAC&pg=PA37&hl=fr&sourc
e=gbs_
toc_r&cad=3%20-%20v=onepage&q&f=false#v=on
epage&q&f=false
16. Skin dermatitis http://www.hug-ge.ch/procedures-desoins/prevention-des-dermites-du-siege-chez-ladulte
9. Kammeyer A. et al. Oxidation events and skin aging.
Ageing and skin research reviews. 2015; 21: 16-29.
18. McDaniel JC, Browning KK. Smoking, Chronic Wound
Healing, and Implications for Evidence-Based
Practice. Journal of wound, ostomy, and continence
nursing 2014; 41: 415-E2.
10. Kottner J, EWMA Journal 2015; 2: 11-13 http://
ewma.org/ongoing/EWMA%20JOURNAL/EWMA%20
Journal%20Oct%202015%20web.pdf
11. Oh D.M. ET AL. Sex hormones and woundhealing.
Wounds 2006; 18 : 8-18.
12. Rinnerthaler M. et al., Oxidative stress in aging
human skin. Biomolecules. 2015; 21: 545-89.
13. Krutmann J. et al. Pollution and skin: From epidemiological and mechanistic studies to clinical implication.
J. Dermatol. Sci., 2014; 76: 163-168.
17. Sorensen LT, Karlsmark T, Gottrup F. Abstinence
From Smoking Reduces Incisional Wound Infection: A
Randomized Controlled Trial. Annals of Surgery.
2003; 238: 1-5.
19. Gould L., Chronic wound repair and healing in older
adults: current status and future research. Wound
Repair Regen. 2015; 23: 1-13.
20. LeBlanc K. et al. Pratiques recommandées pour la
prévention et le traitement des déchirures cutanées
http://cawc.net/images/uploads/wcc/6-1-leblanc-f.pdf
21. Xiaoti Xu BS et al. The current management of skin
tears. Am J Emerg Med (2009) 27, 729–733.
14. Wlaschek M. Solar UV irradiation and dermal
photoaging. Photochem. Photobiol. 2001; 63; 41-51.
EWMA Journal 2016 vol 16 no 1
47
Flaminal
®
Simplicity in treatment
U
the Enzyme
Alginogel®
for each wound type
X
works continuously on the 4 T.I.M.E.-principles
voor elk type wond
Beele et al. Expert consensus on a new enzyme alginogel. Wounds International 2012; vol 8 N°1:64-73.
www.flenpharma.com | info@flenpharma.com
Cochrane Reviews
ABSTRACTS OF RECENT
­COCHRANE REVIEWS
of NPWT with alternative treatments or different types
of NPWT in the treatment of leg ulcers.
July 2015:
Negative pressure wound therapy for
treating leg ulcers
Jo C Dumville, Lucy Land, Debra Evans, Frank Peinemann
Citation: Dumville JC, Land L, Evans D, Peinemann F.
Negative pressure wound therapy for treating leg
ulcers. Cochrane Database of Systematic Reviews
2015, Issue 7. Art. No.: CD011354. DOI:
10.1002/14651858.CD011354.pub2
ABSTRACT
Background: Leg ulcers are open skin wounds that
occur between the ankle and the knee that can last
weeks, months or even years and are a consequence of
arterial or venous valvular insufficiency. Negative pressure wound therapy (NPWT) is a technology that is
currently used widely in wound care and is promoted
for use on wounds. NPWT involves the application of a
wound dressing to the wound, to which a machine is
attached. The machine applies a carefully controlled
negative pressure (or vacuum), which sucks any wound
and tissue fluid away from the treated area into a canister.
Objectives: To assess the effects of negative pressure
wound therapy (NPWT) for treating leg ulcers in any
care setting.
Search methods: For this review, in May 2015 we
searched the following databases: the Cochrane
Wounds Group Specialised Register (searched 21 May
2015); the Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library 2015, Issue 4);
Ovid MEDLINE (1946 to 20 May 2015); Ovid MEDLINE (In-Process & Other Non-Indexed Citations 20
May 2015); Ovid EMBASE (1974 to 20 May 2015);
EBSCO CINAHL (1982 to 21 May 2015). There were
no restrictions based on language or date of publication.
Selection criteria: Published or unpublished randomized controlled trials (RCTs) comparing the effects
Data collection and analysis: Two review authors independently performed study selection, risk of bias
assessment and data extraction.
Main results: We included one study with 60 randomized participants in the review. The study population
had a range of ulcer types that were venous arteriolosclerotic and venous/arterial in origin. Study participants had recalcitrant ulcers that had not healed after
treatment over a six-month period. Participants allocated to NPWT received continuous negative pressure
until they achieved 100% granulation (wound preparation stage). A punch skin-graft transplantation was
conducted and the wound then exposed to further
NPWT for four days followed by standard care. Participants allocated to the control arm received standard
care with dressings and compression until 100% granulation was achieved. These participants also received a
punch skin-graft transplant and then further treatment
with standard care. All participants were treated as inpatients until healing occurred.
There was low quality evidence of a difference in
time to healing that favoured the NPWT group: the
study reported an adjusted hazard ratio of 3.2, with
95% confidence intervals (CI) 1.7 to 6.2. The follow-up
period of the study was a minimum of 12 months.
There was no evidence of a difference in the total number of ulcers healed (29/30 in each group) over the follow-up period; this finding was also low quality evidence.
There was low quality evidence of a difference in
time to wound preparation for surgery that favoured
NPWT (hazard ratio 2.4, 95% CI 1.2 to 4.7).
Limited data on adverse events were collected: these
provided low quality evidence of no difference in pain
scores and Euroqol (EQ-5D) scores at eight weeks after
surgery.
Authors’ conclusions: There is limited rigorous RCT
evidence available concerning the clinical effectiveness
of NPWT in the treatment of leg ulcers. There is some
evidence that the treatment may reduce time to healing as part of a treatment that includes a punch skin
graft transplant, however, the applicability of this find-
Gill Rizzello
Managing editor
Cochrane Wounds,
School of Nursing,
Midwifery and Social Work,
University of Manchester
Correspondence:
gill.rizzello@manchester.ac.uk
More information:
www.wounds.cochrane.org
Conflicts of interest: None

EWMA Journal 2016 vol 16 no 1
49
ing may be limited by the very specific context in which NPWT
was evaluated. There is no RCT evidence on the effectiveness of
NPWT as a primary treatment for leg ulcers.
Plain language summary
Negative pressure wound therapy for treating leg ulcers
Background: Leg ulcers are wounds that occur between the
ankle and the knee as a result of poor blood flow in the legs.
These wounds are relatively common, often affecting older people. There are several different treatments for these ulcers and
the underlying problems that cause them. Negative pressure
wound therapy (NPWT) is a treatment currently being used for
wounds including leg ulcers. NPWT involves the application to
the wound of a dressing to which a machine is attached. The
machine then applies a carefully controlled negative pressure (or
vacuum), and sucks any wound and tissue fluid away from the
treated area into a canister.
What we found: After extensive searching up to May 2015 to
find all relevant medical studies that might provide evidence
about whether NPWT is an effective treatment for leg ulcers, we
found only one randomized controlled trial (RCT) that was eligible for this review. (RCTs provide more robust results than most
other trial types.) The study was small with 60 participants who
had hard-to-heal ulcers. The average age of these participants
was 73 years, and 77% of them were women. The study was
funded by the manufacturer of the NPWT machine. The study
explored the use of NPWT in preparing leg ulcers for a skin
graft. In the study, the ulcers were treated with NPWT or with
normal (standard) care until the wounds were considered ready
to have a skin graft applied. The study’s results are not relevant
for leg ulcers that are not being prepared for skin grafts. Participants remained in hospitals during treatment and until their
wounds healed.
There was low evidence from this study that ulcers treated
with NPWT healed more quickly than those treated with standard care (dressings and compression). There was also evidence
that ulcers treated with NPWT became ready for skin grafting
more quickly than those treated with standard care. There were
very limited results for other outcomes such as adverse events
(harms) and it was not clear how information about adverse
effects was collected. Twelve ulcers recurred (broke out again) in
the NPWT group and 10 recurred in the standard care group.
The evidence for the effectiveness of NPWT in treating leg
ulcers is very limited, and at present consists of only one study
with 60 participants. This study provided evidence that NPWT
may reduce time to healing as part of a treatment that includes
a skin graft. At present, no RCTs have investigated the effectiveness of NPWT as a main treatment for leg ulcers.
This plain language summary is up-to-date as of May 2015.
July 2015:
Dressings for treating foot ulcers in people with
diabetes: an overview of systematic reviews
Lihua Wu, Gill Norman, Jo C Dumville, Susan O’Meara, Sally
EM Bell-Syer
50
Citation example: Wu L, Norman G, Dumville JC, O’Meara S,
Bell-Syer SEM. Dressings for treating foot ulcers in people with
diabetes: an overview of systematic reviews. Cochrane Database
of Systematic Reviews 2015, Issue 7. Art. No.: CD010471. DOI:
10.1002/14651858.CD010471.pub2.
ABSTRACT
Background: Foot ulcers in people with diabetes mellitus are a
common and serious global health issue. Dressings form a key
part of ulcer treatment, with clinicians and patients having many
different types to choose from. A clear and current overview of
current evidence is required to facilitate decision-making regarding dressing use.
Objectives: To summarize data from systematic reviews of randomised controlled trial evidence on the effectiveness of dressings for healing foot ulcers in people with diabetes mellitus
(DM).
Methods: We searched the following databases for relevant systematic reviews and associated analyses: the Cochrane Central
Register of Controlled Trials (CENTRAL; The Cochrane Library
2015, Issue 2); Database of Abstracts of Reviews of Effects
(DARE; The Cochrane Library 2015, Issue 1); Ovid MEDLINE
(In-Process & Other Non-Indexed Citations, 14 April 2015); Ovid
EMBASE (1980 to 14 April 2015). We also handsearched the
Cochrane Wounds Group list of reviews. Two review authors
independently performed study selection, risk of bias assessment
and data extraction. Complete wound healing was the primary
outcome assessed; secondary outcomes included health-related
quality of life, adverse events, resource use and dressing performance.
Main results: We found 13 eligible systematic reviews relevant
to this overview that contained a total of 17 relevant RCTs. One
review reported the results of a network meta-analysis and so
presented information on indirect, as well as direct, treatment
effects. Collectively the reviews reported findings for 11 different
comparisons supported by direct data and 26 comparisons supported by indirect data only. Only four comparisons informed by
direct data found evidence of a difference in wound healing
between dressing types, but the evidence was assessed as being
of low or very low quality (in one case data could not be located
and checked). There was also no robust evidence of a difference
between dressing types for any secondary outcomes assessed.
Authors’ conclusions: There is currently no robust evidence for
differences between wound dressings for any outcome in foot
ulcers in people with diabetes (treated in any setting). Practitioners may want to consider the unit cost of dressings, their management properties and patient preference when choosing
dressings.
Plain language summary
Dressings to treat foot ulcers in people with diabetes
Background: Diabetes mellitus (generally known as ‘diabetes’),
when untreated, causes a rise in the sugar (glucose) levels in the
blood. It is a serious health issue that affects millions of people
around the world (e.g., almost two million people in the UK and
24 million people in the USA). Foot ulcers are a common problem for people with diabetes; at least 15% of people with diabeEWMA Journal 2016 vol 16 no 1
Cochrane Reviews
tes have foot ulcers at some time during their lives. Wound
dressings are used extensively in the care of these ulcers. There
are many different types of dressings available, from basic
wound contact dressings to more advanced gels, films, and specialist dressings that may be saturated with ingredients that
exhibit particular properties (e.g. antimicrobial activity). Given
this wide choice, a clear and up-to-date overview of the available
research evidence is needed to help clinicians/practitioners to
decide which type of dressing to use.
Review question: What is the evidence that the type of wound
dressing used for foot ulcers in people with diabetes affects healing?
What we found: This overview drew together and summarised
evidence from 13 systematic reviews that contained 17 relevant
randomised controlled trials (the best type of study for this type
of question) published up to 2013. Collectively, these trials compared 10 different types of wound dressings against each other,
making a total of 37 separate comparisons. The different ways
in which dressing types were compared made it difficult to combine and analyse the results. Only four of the comparisons
informed by direct data found evidence of a difference in ulcer
healing between dressings, but these results were classed as low
quality evidence.
There was no clear evidence that any of the ‘advanced’
wound dressings types were any better than basic wound contact
dressings for healing foot ulcers. The overview findings were
restricted by the small amount of information available (a limited
number of trials involving small numbers of participants).
Until there is a clear answer about which type of dressing performs best for healing foot ulcers in people with diabetes, other
factors, such as clinical management of the wound, cost, and
patient preference and comfort, should influence the choice of
dressing.
This plain language summary is up-to-date as of April 2015.
August 2015:
Debridement for venous leg ulcers
Georgina Gethin, Seamus Cowman, Dinanda N Kolbach
Citation example: Gethin G, Cowman S, Kolbach DN. Debridement for venous leg ulcers. Cochrane Database of Systematic
Reviews 2015, Issue 8. Art. No.: CD008599. DOI:
10.1002/14651858.CD008599.pub2.
ABSTRACT
Background: Venous ulcers (also known as varicose or venous
stasis ulcers) are a chronic, recurring and debilitating condition
that affects up to 1% of the population. Best practice documents
and expert opinion suggests that the removal of devitalised tissue from venous ulcers (debridement) by any one of six methods
helps to promote healing. However, to date there has been no
review of the evidence from randomised controlled trials (RCTs)
to support this.
Objectives: To determine the effects of different debriding methods or debridement versus no debridement, on the rate of
EWMA Journal 2016 vol 16 no 1
debridement and wound healing in venous leg ulcers.
Search methods: In February 2015 we searched: The Cochrane
Wounds Group 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. There were no restrictions with
respect to language, date of publication or study setting. In addition we handsearched conference proceedings, journals not
cited in MEDLINE, and the bibliographies of all retrieved publications to identify potential studies. We made contact with the
pharmaceutical industry to enquire about any completed studies.
Selection criteria: We included RCTs, either published or
unpublished, which compared two methods of debridement or
compared debridement with no debridement. We presented
study results in a narrative form, as meta-analysis was not possible.
Data collection and analysis: Independently, two review authors
completed all study selection, data extraction and assessment of
trial quality; resolution of disagreements was completed by a
third review author.
Main results: We identified 10 RCTs involving 715 participants.
Eight RCTs evaluated autolytic debridement and included the
following agents or dressings: biocellulose wound dressing
(BWD), non-adherent dressing, honey gel, hydrogel (gel formula), hydrofibre dressing, hydrocolloid dressings, dextranomer
beads, Edinburgh University Solution of Lime (EUSOL) and paraffin gauze. Two RCTs evaluated enzymatic preparations and
one evaluated biosurgical debridement. No RCTs evaluated surgical, sharp or mechanical methods of debridement, or debridement versus no debridement. Most trials were at a high risk of
bias.
Three RCTs assessed the number of wounds completely
debrided. All three of these trials compared two different methods of autolytic debridement (234 participants), with two studies
reporting statistically significant results: one study (100 participants) reported that 40/50 (80%) ulcers treated with dextranomer beads and 7/50 (14%) treated with EUSOL achieved complete debridement (RR 5.71, 95% CI 2.84 to 11.52); while the
other trial (86 participants) reported the number of ulcers completely debrided as 31/46 (76%) for hydrogel versus 18/40 (45%)
for paraffin gauze (RR 0.67, 95% CI 0.45 to 0.99). One study
(48 participants) reported that by 12 weeks, 15/18 (84%) ulcers
treated with BWD had achieved a 75% to 100% clean, granulating wound bed versus 4/15 (26%) treated with non-adherent
petrolatum emulsion-impregnated gauze.
Four trials assessed the mean time to achieve debridement:
one (86 participants) compared two autolytic debridement
methods, two compared autolytic methods with enzymatic
debridement (71 participants), and the last (12 participants)
compared autolytic with biosurgical debridement; none of the
results achieved statistical significance.
Two trials that assessed autolytic debridement methods
reported the number of wounds healed at 12 weeks. One trial
(108 participants) reported that 24/54 (44%) ulcers treated with
honey healed versus 18/54 (33%) treated with hydrogel (RR
(adjusted for baseline wound diameter) 1.38, 95% CI 1.02 to
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51
1.88; P value 0.037). The second trial (48 participants) reported
that 7/25 (28%) ulcers treated with BWD healed versus 7/23
(30%) treated with non-adherent dressing.
Reduction in wound size was assessed in five trials (444 participants) in which two autolytic methods were compared. Results
were statistically significant in one three-armed trial (153 participants) when cadexomer iodine was compared to paraffin gauze
(mean difference 24.9 cm², 95% CI 7.27 to 42.53, P value
0.006) and hydrocolloid compared to paraffin gauze (mean difference 23.8 cm², 95% CI 5.48 to 42.12, P value 0.01). A second trial that assessed reduction in wound size based its results
on median differences and, at four weeks, produced a statistically significantly result that favoured honey over hydrogel (P
value < 0.001). The other three trials reported no statistically
significant results for reduction in wound size, although one trial
reported that the mean percentage reduction in wound area was
greater at six and 12 weeks for BWD versus a non-adherent
dressing (44% versus 24% week 6; 74% versus 54% week 12).
Pain was assessed in six trials (544 participants) that compared
two autolytic debridement methods, but the results were not statistically significant. No serious adverse events were reported in
any trial.
Authors’ conclusions: There is limited evidence to suggest that
actively debriding a venous leg ulcer has a clinically significant
impact on healing. The overall small number of participants, low
number of studies and lack of meta-analysis in this review precludes any strong conclusions of benefit. Comparisons of different autolytic agents (hydrogel versus paraffin gauze; Dextranomer beads versus EUSOL and BWD versus non-adherent dressings) and Larvae versus hydrogel all showed statistically significant results for numbers of wounds debrided. Larger trials with
follow up to healing are required.
Plain language summary
Debridement for venous leg ulcers
Background: Venous leg ulcers are a common type of leg
wound. They can cause pain, stress, social isolation and depression. These ulcers take approximately 12 weeks to heal and the
best and first treatment to try is compression bandages. In an
attempt to improve the healing process it is thought that removing dead or dying tissue (debridement) from the surface of the
wound can speed up healing. Six different methods can be used
to achieve debridement: use of an instrument such as a scalpel
(with or without anaesthesia - surgical debridement and sharp
debridement, respectively); washing solutions and dressings
(mechanical debridement); enzymes that break down the
affected tissue (enzymatic debridement); moist dressings or natural agents, or both, to promote the wound’s own healing processes (autolytic debridement); or maggots (biosurgical debridement).
Objectives: We assessed evidence from medical research to try
to determine how effective these different methods of debridement are in debriding wounds. We also wanted to understand
what effect, if any, debridement has on the healing of venous
ulcers, and whether any method of debridement is better than
no debridement when it comes to wound healing.
Search methods: We searched a wide range of electronic databases and also reports from conferences up to 10 February
52
2015. We included studies written in any language that included
men and women of any age, cared for in any setting, from any
country, and we did not set a limit on the years in which studies
were published. We were only interested in robust research, and
so restricted our search to randomised controlled trials (in which
people are randomly allocated to the methods being tested). All
trial participants were required to have a venous ulcer with dead
tissue (slough) present in the wound.
Results: We found ten studies that included a total of 715 participants. These were conducted in a range of countries and
care settings. Participants had an average age of 68 years, and
there were more women than men. Most of the studies were
small, with half of them having fewer than 67 participants. The
trials tested a range of debridement methods including: autolytic
methods such as non-adherent dressings; very small beads;
biocellulose dressings; honey; gels; gauze and methods using
enzymes. Autolytic methods of debridement, were the most frequently tested. We identified no studies that tested surgical,
sharp or mechanical methods of debridement and no studies
that tested debridement against no debridement.
It was not possible to say whether any of the methods evaluated performed better than the rest. There was some evidence
to suggest that sloughy ulcers that had more than 50% of slough
removed after four weeks were more likely to heal by 12 weeks;
and some evidence to suggest that ulcers debrided using honey
were more likely to heal by 12 weeks than ulcers debrided with
hydrogel. What remains uncertain at this time is whether
debridement itself, or any particular form of debridement is beneficial in the treatment of venous ulcers.
The overall quality of the evidence we identified was low, as
studies were small in size, and most were of short duration.
There were differences between them in terms of the amount of
slough in the wound bed of the ulcers at the start of the trial, in
treatment regimes, the duration of treatments, and the methods
used to assess how well the debridement treatments had
worked. In six trials, the people assessing the wounds were
aware of the type of treatment each patient was receiving, which
may have affected the impartiality of their evaluations. Five studies did not provide information on all the results (outcomes) in
their trials, and this missing information on important benefits or
harms of the debridement method being evaluated meant that
those trials were at a high risk of bias and of producing unreliable results. Only two studies reported side effects due to the
treatment; these included maceration (or wetness) of the skin
around the ulcers, infection and skin inflammation.
September 2015:
Systemic antibiotics for treating diabetic
foot infections
Anna Selva Olid, Ivan Solà, Leticia A Barajas-Nava, Oscar D
Gianneo, Xavier Bonfill Cosp, Benjamin A Lipsky
Citation example: Selva Olid A, Solà I, Barajas-Nava LA, Gianneo OD, Bonfill Cosp X, Lipsky BA. Systemic antibiotics for treating diabetic foot infections. Cochrane Database of Systematic
EWMA Journal 2016 vol 16 no 1
Cochrane Reviews
Reviews 2015, Issue 9. Art. No.: CD009061. DOI:
10.1002/14651858.CD009061.pub2.
ABSTRACT
Background: Foot infection is the most common cause of nontraumatic amputation in people with diabetes. Most diabetic
foot infections (DFIs) require systemic antibiotic therapy and the
initial choice is usually empirical. Although there are many antibiotics available, uncertainty exists about which is the best for
treating DFIs.
Objectives: To determine the effects and safety of systemic antibiotics in the treatment of DFIs compared with other systemic
antibiotics, topical foot care or placebo.
Search methods: In April 2015 we searched the Cochrane
Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library);
Ovid MEDLINE, Ovid MEDLINE (In-Process & Other NonIndexed Citations); Ovid EMBASE, and EBSCO CINAHL. We
also searched in the Database of Abstracts of Reviews of Effects
(DARE; The Cochrane Library), the Health Technology Assessment database (HTA; The Cochrane Library), the National
Health Service Economic Evaluation Database (NHS-EED; The
Cochrane Library), unpublished literature in OpenSIGLE and
ProQuest Dissertations and on-going trials registers.
Selection criteria: Randomised controlled trials (RCTs) evaluating the effects of systemic antibiotics (oral or parenteral) in people with a DFI. Primary outcomes were clinical resolution of the
infection, time to its resolution, complications and adverse
effects.
Data collection and analysis: Two review authors independently
selected studies, assessed the risk of bias, and extracted data.
Risk ratios (RR) were estimated for dichotomous data and, when
sufficient numbers of comparable trials were available, trials
were pooled in a meta-analysis.
Main results: We included 20 trials with 3791 participants. Studies were heterogenous in study design, population, antibiotic
regimens, and outcomes. We grouped the sixteen different antibiotic agents studied into six categories: 1) anti-pseudomonal
penicillins (three trials); 2) broad-spectrum penicillins (one trial);
3) cephalosporins (two trials); 4) carbapenems (four trials); 5)
fluoroquinolones (six trials); 6) other antibiotics (four trials).
Only 9 of the 20 trials protected against detection bias with
blinded outcome assessment. Only one-third of the trials provided enough information to enable a judgement about whether
the randomisation sequence was adequately concealed. Eighteen out of 20 trials received funding from pharmaceutical industry-sponsors.
The included studies reported the following findings for clinical resolution of infection: there is evidence from one large trial
at low risk of bias that patients receiving ertapenem with or without vancomycin are more likely to have resolution of their foot
infection than those receiving tigecycline (RR 0.92, 95% confidence interval (CI) 0.85 to 0.99; 955 participants). It is unclear if
there is a difference in rates of clinical resolution of infection
between: 1) two alternative anti-pseudomonal penicillins (one
trial); 2) an anti-pseudomonal penicillin and a broad-spectrum
EWMA Journal 2016 vol 16 no 1
penicillin (one trial) or a carbapenem (one trial); 3) a broadspectrum penicillin and a second-generation cephalosporin (one
trial); 4) cephalosporins and other beta-lactam antibiotics (two
trials); 5) carbapenems and anti-pseudomonal penicillins or
broad-spectrum penicillins (four trials); 6) fluoroquinolones and
anti-pseudomonal penicillins (four trials) or broad-spectrum penicillins (two trials); 7) daptomycin and vancomycin (one trial); 8)
linezolid and a combination of aminopenicillins and beta-lactamase inhibitors (one trial); and 9) clindamycin and cephalexin
(one trial).
Carbapenems combined with anti-pseudomonal agents produced fewer adverse effects than anti-pseudomonal penicillins
(RR 0.27, 95% CI 0.09 to 0.84; 1 trial). An additional trial did
not find significant differences in the rate of adverse events
between a carbapenem alone and an anti-pseudomonal penicillin, but the rate of diarrhoea was lower for participants treated
with a carbapenem (RR 0.58, 95% CI 0.36 to 0.93; 1 trial).
Daptomycin produced fewer adverse effects than vancomycin or
other semi-synthetic penicillins (RR 0.61, 95%CI 0.39 to 0.94; 1
trial). Linezolid produced more adverse effects than ampicillinsulbactam (RR 2.66; 95% CI 1.49 to 4.73; 1 trial), as did tigecycline compared to ertapenem with or without vancomycin (RR
1.47, 95% CI 1.34 to 1.60; 1 trial). There was no evidence of a
difference in safety for the other comparisons.
Authors’ conclusions: The evidence for the relative effects of different systemic antibiotics for the treatment of foot infections in
diabetes is very heterogeneous and generally at unclear or high
risk of bias. Consequently it is not clear if any one systemic antibiotic treatment is better than others in resolving infection or in
terms of safety. One non-inferiority trial suggested that ertapenem with or without vancomycin is more effective in achieving
clinical resolution of infection than tigecycline. Otherwise the relative effects of different antibiotics are unclear. The quality of
the evidence is low due to limitations in the design of the
included trials and important differences between them in terms
of the diversity of antibiotics assessed, duration of treatments,
and time points at which outcomes were assessed. Any further
studies in this area should have a blinded assessment of outcomes, use standardised criteria to classify severity of infection,
define clear outcome measures, and establish the duration of
treatment.
Plain language summary
Antibiotics to treat foot infections in people with diabetes
Review question: We reviewed the effects on resolution of infection and safety of antibiotics given orally or intravenously
(directly into the blood system) in people with diabetes that have
a foot infection.
Background: One of the most frequent complications of people
with diabetes is foot disorders, specially foot ulcers or wounds.
These wounds can easily become infected, and are known as a
diabetic foot infections (DFIs). If they are not treated, the infection can progress rapidly, involving deeper tissues and threatening survival of the limb. Sometimes these infections conclude
with the affected limb needing to be amputated.
Most DFIs require treatment with systemic antibiotics, that is,
antibiotics that are taken orally, or are inserted straight into the
bloodstream (intravenously), and affect the whole body. The
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53
choice of the initial antibiotic treatment depends on several factors such as the severity of the infection, whether the patient has
received another antibiotic treatment for it, or whether the infection has been caused by a micro-organism that is known to be
resistant to usual antibiotics (e.g. methicillin-resistant Staphylococcus aureus - better known as MRSA). The objective of antibiotic therapy is to stop the infection and ensure it does not
spread.
There are many antibiotics available, but it is not known
whether one particular antibiotic - or type of antibiotic - is better
than the others for treatment of DFIs.
The investigation: We searched through the medical literature
up to March 2015 looking for randomised controlled trials
(which produce the most reliable results) that compared different systemic antibiotics against each other, or against antibiotics
applied only to the infected area (topical application), or against
a fake medicine (placebo) in the treatment of DFIs.
Study characteristics: We identified 20 relevant randomised
controlled trials, with a total of 3791 participants. Eighteen of
the 20 studies were funded by pharmaceutical companies. All
trials compared systemic antibiotics with other systemic antibiotics.
Key results: It is unclear whether any particular antibiotic is better than any another for curing infection or avoiding amputation.
One trial suggested that ertapenem (an antibiotic) with or without vancomycin (another antibiotic) is more effective than tigecycline (another antibiotic) for resolving DFI. It is also generally
unclear whether different antibiotics are associated with more or
fewer adverse effects. The following differences were identified:
1. carbapenems (a class of antibiotic) combined with anti-pseudomonal agents (antibiotics that kill Pseudomonas bacteria)
produced fewer adverse effects than anti-pseudomonal penicillins (another class of antibiotic);
2. daptomycin (an antibiotic) caused fewer adverse effects than
vancomycin or other semi-synthetic penicillins (a class of antibiotic);
3. linezolid (an antibiotic) caused more harm than ampicillin-sulbactam (a combination of antibiotics);
4. tigecycline produced more adverse effects than the combination of ertapenem with or without vancomycin.
Quality of the evidence: There were important differences
between the trials in terms of the diversity of antibiotics assessed,
the duration of treatments, and the point at which the results
were measured. The included studies had limitations in the way
they were designed or performed, as a result of these differences
and design limitations, our confidence in the findings of this
review is low.
54
September 2015:
Support surfaces for pressure ulcer prevention
Elizabeth McInnes, Asmara Jammali-Blasi, Sally EM Bell-Syer, Jo
C Dumville, Victoria Middleton, Nicky Cullum
Citation: McInnes E, Jammali-Blasi A, Bell-Syer SEM, Dumville
JC, Middleton V, Cullum N. Support surfaces for pressure ulcer
prevention. Cochrane Database of Systematic Reviews 2015,
Issue 9. Art. No.: CD001735. DOI: 10.1002/14651858.
CD001735.pub5.
ABSTRACT
Background: Pressure ulcers (i.e. bedsores, pressure sores, pressure injuries, decubitus ulcers) are areas of localised damage to
the skin and underlying tissue. They are common in the elderly
and immobile, and costly in financial and human terms. Pressure-relieving support surfaces (i.e. beds, mattresses, seat cushions etc) are used to help prevent ulcer development.
Objectives: This systematic review seeks to establish:
(1) the extent to which pressure-relieving support surfaces
reduce the incidence of pressure ulcers compared with standard
support surfaces, and,
(2) their comparative effectiveness in ulcer prevention.
Search methods: In April 2015, for this fourth update we
searched The Cochrane Wounds Group Specialised Register
(searched 15 April 2015) which includes the results of regular
searches of MEDLINE, EMBASE and CINAHL and The
Cochrane Central Register of Controlled Trials (CENTRAL) (The
Cochrane Library 2015, Issue 3).
Selection criteria: Randomised controlled trials (RCTs) and
quasi-randomised trials, published or unpublished, that assessed
the effects of any support surface for prevention of pressure
ulcers, in any patient group or setting which measured pressure
ulcer incidence. Trials reporting only proxy outcomes (e.g. interface pressure) were excluded. Two review authors independently
selected trials.
Data collection and analysis: Data were extracted by one review
author and checked by another. Where appropriate, estimates
from similar trials were pooled for meta-analysis.
Main results: For this fourth update six new trials were included,
bringing the total of included trials to 59.
Foam alternatives to standard hospital foam mattresses
reduce the incidence of pressure ulcers in people at risk (RR
0.40 95% CI 0.21 to 0.74). The relative merits of alternating
and constant low-pressure devices are unclear. One high-quality
trial suggested that alternating-pressure mattresses may be
more cost effective than alternating-pressure overlays in a UK
context.
Pressure-relieving overlays on the operating table reduce postoperative pressure ulcer incidence, although two trials indicated
that foam overlays caused adverse skin changes. Meta-analysis
of three trials suggest that Australian standard medical sheepskins prevent pressure ulcers (RR 0.56 95% CI 0.32 to 0.97).
EWMA Journal 2016 vol 16 no 1
Cochrane Reviews
Authors’ conclusions: People at high risk of developing pressure
ulcers should use higher-specification foam mattresses rather
than standard hospital foam mattresses. The relative merits of
higher-specification constant low-pressure and alternating-pressure support surfaces for preventing pressure ulcers are unclear,
but alternating-pressure mattresses may be more cost effective
than alternating-pressure overlays in a UK context. Medical
grade sheepskins are associated with a decrease in pressure
ulcer development. Organisations might consider the use of
some forms of pressure relief for high risk patients in the operating theatre.
Plain language summary
Can pressure ulcers be prevented by using different support
surfaces?
Pressure ulcers (also called bed sores, pressure sores and pressure injuries) are ulcers on the skin caused by pressure or rubbing at the weight-bearing, bony points of immobilised people
(such as hips, heels and elbows). Different support surfaces (e.g.
beds, mattresses, mattress overlays and cushions) aim to relieve
pressure, and are used to cushion vulnerable parts of the body
and distribute the surface pressure more evenly. The review
found that people lying on ordinary foam mattresses are more
likely to get pressure ulcers than those lying on a higher-specification foam mattress. In addition the review also found that
people who used sheepskin overlays on their mattress developed
fewer pressure ulcers. While alternating-pressure mattresses may
be more cost effective than alternating-pressure overlays, the
evidence base regarding the merits of higher-specification constant low-pressure and alternating-pressure support surfaces for
preventing pressure ulcers is unclear. Rigorous research comparing different support surfaces is needed.
February 2016:
Skin grafting and tissue replacement for treating
foot ulcers in people with diabetes
Trientje B Santema, Paul PC Poyck, Dirk T Ubbink
Citation example: Santema TB, Poyck PPC, Ubbink DT. Skin
grafting and tissue replacement for treating foot ulcers in people
with diabetes. Cochrane Database of Systematic Reviews 2016,
Issue 2. Art. No.: CD011255. DOI: 10.1002/14651858.
CD011255.pub2.
ABSTRACT
Background: Foot ulceration is a major problem in people with
diabetes and is the leading cause of hospitalisation and limb
amputations. Skin grafts and tissue replacements can be used to
reconstruct skin defects for people with diabetic foot ulcers in
addition to providing them with standard care. Skin substitutes
can consist of bioengineered or artificial skin, autografts (taken
from the patient), allografts (taken from another person) or xenografts (taken from animals).
Objectives: To determine the benefits and harms of skin grafting
and tissue replacement for treating foot ulcers in people with
diabetes.
Search methods: In April 2015 we searched: The Cochrane
Wounds Specialised Register; the Cochrane Central Register of
Controlled Trials (CENTRAL) (The Cochrane Library); Ovid
MEDLINE; Ovid MEDLINE (In-Process & Other Non-Indexed
Citations); Ovid EMBASE and EBSCO CINAHL. We also
searched clinical trial registries to identify ongoing studies. We
did not apply restrictions to language, date of publication or
study setting.
Selection criteria: Randomised clinical trials (RCTs) of skin
grafts or tissue replacements for treating foot ulcers in people
with diabetes.
Data collection and analysis: Two review authors independently
extracted data and assessed the quality of the included studies.
Main results: We included seventeen studies with a total of
1655 randomised participants in this review. Risk of bias was
variable among studies. Blinding of participants, personnel and
outcome assessment was not possible in most trials because of
obvious differences between the treatments. The lack of a
blinded outcome assessor may have caused detection bias when
ulcer healing was assessed. However, possible detection bias is
hard to prevent due to the nature of the skin replacement products we assessed, and the fact that they are easily recognisable.
Strikingly, nearly all studies (15/17) reported industry involvement; at least one of the authors was connected to a commercial organisation or the study was funded by a commercial
organisation. In addition, the funnel plot for assessing risk of
bias appeared to be asymmetrical; suggesting that small studies
with ‘negative’ results are less likely to be published.
Thirteen of the studies included in this review compared a skin
graft or tissue replacement with standard care. Four studies
compared two grafts or tissue replacements with each other.
When we pooled the results of all the individual studies, the skin
grafts and tissue replacement products that were used in the trials increased the healing rate of foot ulcers in patients with diabetes compared to standard care (risk ratio (RR) 1.55, 95% confidence interval (CI) 1.30 to 1.85, low quality of evidence). However, the strength of effect was variable depending on the specific product that was used (e.g. EpiFix® RR 11.08, 95% CI 1.69
to 72.82 and OrCel® RR 1.75, 95% CI 0.61 to 5.05). Based on
the four included studies that directly compared two products,
no specific type of skin graft or tissue replacement showed a
superior effect on ulcer healing over another type of skin graft or
tissue replacement.
Sixteen of the included studies reported on adverse events in
various ways. No study reported a statistically significant difference in the occurrence of adverse events between the intervention and the control group.
Only two of the included studies reported on total incidence of
lower limb amputations. We found fewer amputations in the
experimental group compared with the standard care group
when we pooled the results of these two studies, although the
absolute risk reduction for amputation was small (RR 0.43, 95%
CI 0.23 to 0.81; risk difference (RD) -0.06, 95% CI -0.10 to
-0.01, very low quality of evidence).
Authors’ conclusions: Based on the studies included in this
review, the overall therapeutic effect of skin grafts and tissue

EWMA Journal 2016 vol 16 no 1
55
replacements used in conjunction with standard care shows an
increase in the healing rate of foot ulcers and slightly fewer
amputations in people with diabetes compared with standard
care alone. However, the data available to us was insufficient for
us to draw conclusions on the effectiveness of different types of
skin grafts or tissue replacement therapies. In addition, evidence
of long term effectiveness is lacking and cost-effectiveness is
uncertain.
Plain language summary
Skin grafting and tissue replacement for treating foot ulcers in
people with diabetes
Background: Foot ulceration is a major problem in people with
diabetes and is the leading cause of hospital admissions and
limb amputations. Despite the current variety of strategies available for the treatment of foot ulcers in people with diabetes, not
all ulcers heal completely. Additional treatments with skin grafts
and tissue replacement products have been developed to help
complete wound closure.
Review question: What are the benefits and harms of skin grafting and tissue replacement for treating foot ulcers in people with
diabetes?
What we found: We included thirteen randomised studies that
compared two types of skin grafts or tissue replacements with
standard care and four randomised studies that compared two
grafts or tissue replacements with each other. In total 1655
patients were randomised in these seventeen trials. Risk of bias
was variable among studies. The biggest drawbacks were the
lack of blinding (i.e. patients and investigators were aware who
was receiving the experimental therapy and who was receiving
the standard therapy), industry involvement and the possibility
that small studies were less likely to be published if they reported
‘negative’ results. Adverse advent rates (harm due to the treatment) varied widely.
Conclusion: Based on the seventeen studies included in this
review, skin grafts and tissue replacements, used in conjunction
with standard care, increase the healing rate of foot ulcers and
lead to slightly fewer amputations in people with diabetes compared with standard care alone. However, evidence of long term
effectiveness is lacking and cost-effectiveness is uncertain. There
was not enough evidence for us to be able to recommend a specific type of skin graft or tissue replacement.
This plain language summary is up-to-date as of 9 April 2015. n
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EWMA Journal
Previous Issues
Volume 15, no 2, October 2015
Of youth and Age - What are the Differences regarding skin
structure and function ?
Kottner J
The Development and Benefits of 10 year ́s Experience with
an Electronic Monitoring Tool (PUNT) in a UK Hospital Trust.
Collier M
Preparing student Nurses for the future of Wound Management: Telemedicine in a simulated Learning Environment.
Christiansen S, Rethmeier A
The Psychological Effect of Malignant fungating Wounds on
the Patient.
Reynolds H, Gethin G
The Pressure Ulcer Guidance (PUG) Tool.
Barnard J, Copson D
Other journals
EWMA wishes to facilitate the exchange of
information on wound healing in a broad perspective with
this section on International Journals.
Italian
Application of Ortodermina ointment (lidocaine 5%) when
preparing ulcers for ultrasonic debridement
Giacinto F., Germano M., Giacinto E., et al
Retrospective study on the use of negative pressure
wound therapy in the treatment of pilonidal cysts (sinus
pilonidalis) opera-ted on using an open technique or
complicated by dehiscence of the surgery site through
sepsis
Carnali M., Ronchi R., Finocchi L., et al
Epidemiology of antibiotic resistance and MBL genes
among Pseudomonas aeruginosa and Acinetobacter
baumannii clinical strains isolated from burnt patients in
Iran: a systematic review
Hashemi A., Tarashi S., Erfanimanesh S.
Volume 15, no 1, April 2015
Efficacy of magnetic resonance imaging in deciding the appropriate surgical margin in diabetic foot osteomyelitis.
Fujii M, Armstrong DG, Terashi H
Ex vivo platelet activation with extended duration pulse electric
fields for autologous platelet gel applications - A new, potential
clinical standard for platelet activation and perspectives for a
more widespread adoption and improved wound healing with
platelet gels.
Neculaes VB, Torres A, Morton C, Larriera A, Klopman S, Conway
K, Garner AL
Pressure ulcer reduction: the role of unregistered healthcare
support workers in validation and prevention.
Ellis MB, Price J
Measuring change in limb volume to evaluate lymphoedema
treatment outcome.
Williams AF, Whitaker J
Volume 14
Number 2
October 2014
Published by
European
Wound Management
Association
WOUND CARE
– SHAPING THE FUTURE
Rf
dC
A PATIENT,
PROFESSIONAL,
PROVIDER
AND PAYER
PERSPECTIVE
English
Advances in Skin & Wound Care, vol. 29, no 4, 2016
www.aswcjournal.com
A Multimodality Imaging and Software System for
Combining an Anatomical and Physiological Assessment
of Skin and Underlying Tissue Conditions
Diane Langemo, and James G. Spahn
The Use of a Novel Canister-free Negative-Pressure
Device in Chronic Wounds: A Retrospective Analysis
Thomas E. Serena, and John S. Buan
Effects of Lidocaine, Bupivacaine, and Ropivacaine on
Calcitonin Gene-Related Peptide and Substance P Levels
in the Incised Rat Skin
Guilherme A. F. Lapin, Bernardo Hochman, Jessica R. Maximino et al
Risk Factors for Pressure Ulcers Including Suspected Deep
Tissue Injury in Nursing Home Facility Residents: Analysis
of National Minimum Data Set 3.0
Hyochol Ahn, Linda Cowan, Cynthia Garvan, et al
Volume 14, no 2, October 2014
Economic outcomes of a new chronic wound treatment system
in Poland
Grzegorz Krasowski, Robert Wajda, Małgorzata Olejniczak-Nowakowska
Dressings for split thickness skin graft donor sites
Dorte P. Barrit, Hanne Birke-Sorensen
The utility of pulse volume waveforms in the identification of
lower limb arterial insufficiency
Jane H Davies, Jane E A Lewis, E Mark Williams
The importance of using a nutritional risk analysis scale in
patients admitted to continued care
Jose M Corrales, Nuria P Gayo, Mª del Carmen P Águila,
Almudena M Martín, Ana Ribeiro
Neonatal facial pressure ulcers related to non-invasive ventilation
Laura Bonell-Pons, Pablo García-Molina, Evelin Balaguer-López,
Mª Ángeles Montal, María C Rodríguez
Acta Vulnologica, vol. 14, no 1, 2016
www.vulnologia.it
Finnish
Haava, no. 2, 2015
www.shhy.fi
Multiprofessional co-operation – Wound Care Path in City
of Helsinki
Lepäntalo M.
National Guideline for Prevention of Transmission of
Multiresistent Microbes
Kavola H.
Skin Problems Related to Ostomy
Isoherranen K.
Wound Infection Related to Treatment
Arifulla D.
Volume 14, no 1, May 2014
Prevalence of pressure ulcers in hospitalized patients in
Germany
Heidi Heinhold, Andreas Westerfellhaus, Knut Kröger
Excess use of antibiotics in patients with non-healing ulcers
Marcus Gürgen
Regenerative medicine in burn wound healing: Aiming for the
perfect skin
Magda MW Ulrich
Promising effects of arginine-enriched oral nutritional supplements on wound healing
Jos M.G.A. Schols
Efficacy of platelet-rich ­plasma for the treatment of chronic
wounds
Vladimir N. Obolenskiy, Darya A. Ermolova, Leonid A. Laberko,
Tatiana V. Semenova.
Spanish
Helcos, vol. 26, no. 1, 2016
New National Guidelines for Nutrition
Ursula Schwab
Good care requires recognition of malnutrition
Kaisa Pulkkinen
Nutritional supplements in care of patients with wound Ildikó Hytönen
Challenges for good nutrition in care of patient with
serious burn injuries
Matti Vänni
The EWMA Journals can be downloaded free of charge from www.ewma.org
58
EWMA Journal 2016 vol 16 no 1
EWMA
English
Journal of Tissue Viability, vol. 25, no 1, 2016
www.journaloftissueviability.com
Scandinavian
Wounds (SÅR) no 4, 2015
www.saar.dk
Annual General Meeting 2015
Summary
Jens Fonnesbech
Paracelsus - A doctor ahead of his time
Adam Bencard
Can You Seek Advice On Acute Wounds In Pharmacies?
Susan Bermark
Travel Journal
St. Elisabeth Hospital in Tanzania
Gro Møller Chistoffersen and Ninna Drivsholm
Scandinavian
SÅRmagasinet no 1, 2016
www.s
Malignant wounds- diagnosis, care, quality of life
Pressure Ulcer and Wounds Reporting in NHS Hospitals in
England Part 1: Audit of Monitoring Systems
I.L. Smith , J. Nixon , S. Brown, et al
Pressure Ulcer and Wounds Reporting in NHS Hospitals in
England Part 2: Survey of Monitoring Systems
S. Coleman , I.L. Smith , J. Nixon, et al
Features of Lymphatic Dysfunction in Compressed Skin
Tissues - Implications in Pressure Ulcer Aetiology
R.J. Gray , D. Voegeli , D.L. Bader
English
Journal of Wound Care, vol. 25, no 3, 2016
www.journalofwoundcare.com
Well-being in wounds inventory (WOWI): development of a
valid and reliable measure of well-being in patients with
wounds D. Upton, P. Upton, R. Alexander
Negative pressure wound therapy versus standard wound
care on quality of life: a systematic review
A.H.J. Janssen, E.H.H. Mommers, J. Notter et al
The importance of hydration in wound healing: reinvigorating the clinical perspective
K. Ousey, K.F. Cutting, A.A. Rogers, et al
Effect of a wound cleansing solution on wound bed preparation and inflammation in chronic wounds: a single-blind
RCT
A. Bellingeri, F. Falciani, P. Traspedini et al
Polish
Lietuvos chirurgija, vol. 14, no 4, 2015
www.chirurgija.lt
Thoracic outlet syndrome
Jasinskas M, Minderis M.
Head trauma in children
Sapagovaite I, Ravinskiene J.
Reasons of shunt revision surgery for hydrocephalus
Sustickas G, Rimsiene J.
Adult intussusception – a rare cause of intestinal obstruction in adults
Poskus T, Grisin E.
German
Sepsis and wounds
Treatment of basal cell carcinoma
English
Wound Repair and Regeneration, vol. 24, no. 1, 2016
Analysis of the chronic wound microbiota of 2,963
patients
by 16S rDNA pyrosequencing
Randall D. Wolcott, John D. Hanson, Eric J. Rees, et al
Rapid Identification of slow healing wounds
Kenneth Jung, Scott Covington, Chandan K. Sen, et al
Exacerbated and prolonged inflammation impairs wound
healing and increases scarring
Li-Wu Qian, Andrea B. Fourcaudot, Kazuyoshi Yamane, et
al
Guidelines (collectively)
Leczenie Ran vol. 12, no 4, 2015
www.journalofwoundcare.com
The role of angiopoetic factors in wound healing among
patients with diabetes treated with negative-pressure
wound therapy
Mrozikiewicz-Rakowska B, Kania J, Bucior E et al.
Prevention and treatment of decubitus ulcers in the practice of neurology nurses in relation to the recommendations issued by the Polish Wound Management Association. Preliminary report
Bazalinski D, Fafara A, Zabek P et al.
Effect of silver-releasing foam dressing in hydrofiber®
technology on healing of diabetic foot ulcers
Kucharzewski M, Wilemska-Kucharzewska K, Sopata M et
al.
Lithuanian
Wound infections: Antibiotic resistance, MRSA and ESBL
German
Wund Management, no 1, 2016
Therapeutic Local Oxygen Supply for Wundhealing
K. Kröger, P. Engels, J. Dissemond
How to treat this type of wound? B. Jäger, K. Kröger, C. Schwarzkopf
A multicentre clinical evaluation of Cuticell Contact silicone wound contact layer in daily practice
A. Süß-Burghart, K. Zomer, D. Schwanke
Phlebologie, vol.1, 2016
www.schattauer.de
LYR study: Influence of a web-based
application on the systematic chronological and effectiveness of networkguided patient management processes in
lymphological care
S. Hahn; J. Berger; V. Rahms et.al.
Long-term observational study on outpatient treatment of
venous diseases with medical compression
stockings in Germany
C. Schwahn-Schreiber; M. Marshall; R. Murena-Schmidt et.
al.
Anomaly of the inferior vena cava
and lactose malabsorption
W. J. Schnedl; P. Kalmar; S. J. Wallner-Liebmann et.al.
EWMA Journal 2016 vol 16 no 1
59
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EWMA anniversary
MILESTONES IN EWMA’S HISTORY
EWMA would like to use the opportunity of our 25th Anniversary
to thank all previous members of the EWMA Council
for their great contributions to the development of the organisation with their
visions and ideas, as well as their hard work.
2000
First independent EWMA
Conference held in Stockholm
EWMA
MILESTONES
2001
EWMA secretariat established in
Copenhagen (CAP Partner,
previously Congress Consultants).
1991
EWMA founded. First EWMA conference held in Cardiff, Wales.
Arranged by the Publishing House
Macmillan Magazines Ltd.
2001
First issue of the EWMA Journal
published. Now approx. 12.000
copies are distributed to clinicians
throughout Europe.
EWMA Presidents 1991-2001
1991-1993
Terrence Turner
62
1993-1995
Carol Dealey
1995-1996
David Leaper
1996-1997
Chris Lawrence
1997-1998
George Cherry
1998-1999
Finn Gottrup
1999-2001
Christine Moffatt
EWMA Journal 2016 vol 16 no 1
EWMA
2008
EWMA course endorsement
programme established.
2008
Collaboration with Eucomed
Advanced Wound Care Sector
Group on defining the “burden of
illness” associated with chronic
wounds in Europe.
2003
First EWMA Wound Education
Curriculum developed.
2001
First EWMA position document
published. Since then, various
aspects of wound management
have been covered.
2001
The EWMA Educational
development Project was initiated
(Later placed under the EWMA
Education Committee)
2008
EWMA Patient Outcome Group
established. The initial objective was
to examine the challenges related to
acquiring high quality evidence in
wound care.
2007
EWMA University Conference Model
pilot. The EWMA conference is now
an integrated part of wound
management education for post
graduate students in a number of
educational institurions throughout
Europe.
2009
EWMA started an international
partner programme, to formalise
and further develop knowledge
sharing and collaboration with
like-minded associations in other
parts of the world.
2001
EWMA cooperating organisation
model established. This network
now includes 53 organisations
in 36 countries.
EWMA Presidents 2001-2009
2001-2005
Peter Vowden
EWMA Journal 2016 vol 16 no 1
2005-2007
Peter Franks
2007-2009
Marco Romanelli
63
2010
First deliverable of the
EWMA Patient Outcome Group:
Publication of the Outcomes in
controlled and comparative studies
on non-healing wounds –
Recommendations to improve
the quality of evidence in wound
EWMA
management.
MILESTONES
2010
EWMA started working actively to
create awareness about non healing
wounds in the European
Parliament. This led to a series of
advocacy activities targeting
European level policy makers, in
particular related to the European
Commission supported EU Joint
Action on patient safety (PASQ)
2012
EWMA became part of the
EU supported ‘SWAN-iCare’ project
(EU FP7) and the ‘United4Health‘
project (ICT PSP).
2012
First meeting of the EWMA Teacher
Network established to strengthen
collaborationbetween European
educators working with wound care
and EWMA.
2013
EWMA Patient panel
established. Increased focus on
wound patient rights and development of patient information.
2013
EWMA President, Jan Apelqvist,
became member of the board of
the Association for Advancement of
Wound Care (AAWC, US)
2013
EWMA confirmed as collaborating partner of the EU supported
Joint Action on chronic disease
management (CHRODIS-JA) with
focus on improving the prevention
and management of diabetic foot
ulcers across Europe.
EWMA Presidents 2009-2015
2009-2011
Zena Moore
64
2011-2013
Jan Apelqvist
2013-2015
Salla Seppänen
EWMA Journal 2016 vol 16 no 1
EWMA
2014
First joint position document, written
in collaboration with international
partners AAWC and Wounds
Australia: Managing Wounds as a
Team: Exploring the concept of a
team approach to wound care
2014
The EWMA antimicrobial stewardship programme was initiated. This
originated from the publication of
the EWMA Document:
Antimicrobials and Non-healing
Wounds (published in 2013).
The stewardship programme led
to a close collaboration with the
British Society for Antimicrobial
Chemotherapy (BSAC).
2015
Development of a EWMA
wound centre endorsement
programme and pilot endorsements
in China and Brazil.
2016
First National Wound Care
Round Table, held in collaboration
with a EWMA Cooperating
Organisation organised by the
Lithuanian Wound Management
Association, in Kaunas,
Lithuania.
2015
EWMA welcomed a
representative from the
international partner organisations
AAWC (US) and Wounds Australia
as co-opted members of the
EWMA Council.
EWMA President
2015-2017
Severin Läuchli
EWMA Journal 2016 vol 16 no 1
65
EWMA anniversary
25 years of EWMA conferences
During the previous 25 years, EWMA has visited many great cities and
countries with our annual (and in some years bi-annual) conference. The majority
of these have been held in collaboration with national wound management
associations, many of which became cooperating organisations of EWMA in 2001
when this formalised collaboration was initiated.
Below is an overview of the previous EWMA conferences and their visual design.
We look forward to visiting new cities in future years.
Upcoming are EWMA 2017 in Amsterdam and EWMA 2018 in Poland.
66
1991
1992
1993
1994
1995
1996
EWMA Journal 2016 vol 16 no 1
EWMA
EWMA Journal 1997
1998
1998
2000
2001
2002
2003
2005
2006
2007
2008
2009
2016 vol 16 no 1
67
68
2010
2011
2012
2013
2014
2015
EWMA Journal 2016 vol 16 no 1
EWMA
The EWMA conference
– 25 years of successful
development
Total number of participants
Since the year 2000, EWMA has continuously
worked on developing the annual conference to
include all the different aspects of wound management. We have also extended the collaboration
with many of our partner organisations to include
exchanges of knowledge during the EWMA Conference and vice versa. At the same time we have
experienced an increasing interest from partici-
Development in the number of participants at the EWMA
Conferences (2000-2015).
pants as well as exhibitors in using the EWMA
conference as a hub for knowledge exchange
and networking. This increase is illustrated in the
Scientific presentations
graphs below:
Development in the number of scientific presentations at the EWMA
Conferences (2000-2015).
Exhibiting companies
Growth of EWMA exhibition in total number of exhibitors
over the last 7 years (2009 -2015)
EWMA Journal 2016 vol 16 no 1
Countries represented
Development in the number of countries represented by participants
at the EWMA Conferences (2001-2015).
69
EWMA 25th Anniversary celebration
MAKING A DIFFERENCE IN WOUND CARE
Professor Sue Bale
OBE, PhD, FRCN, RGN, NDN, RHV. R&D Director, Aneurin Bevan University Health Board, Wales, UK.
Finn Gottrup
MD, DMSci., Professor of Surgery, University of Southern Denmark, Copenhagen Wound Healing Center,
Christina Lindholm
PhD, Senior Professor at Sophiahemmet University
Christine Moffatt
CBE, FRCN, RGN, Professor of Clinical Nursing Research, University of Nottingham
Deborah Glover
MBE, BSc (Joint Hons), RN, Independent Nurse Consultant/Medical Editor
EWMA Council 1993-1994
Twenty-five years; that’s a quarter of a century, a generation. Children have been born, grown up and probably
have children of their own; it’s quite a long time! The
European Wound Management Association is 25 years
old in 2016. That represents quite an achievement, particularly when one considers the heterogeneous nature of
its members and the disparate countries they hail from.
The authors most of whom were among the founding
members of EWMA, were of course, bright young things
back in 1991. Today they may have a grey hair or two,
but are still as passionate about wound care as they were
then. This article outlines the EWMA story.
Pop EWMA into an internet search engine and aside
from the European Wound Management Association, one
can find something called the ‘exponentially weighted
moving average’. This is used to monitor the output of
a business by tracking either the moving average of the
70
output or average of performance over the lifetime of the
process. The EWMA is constantly re-calculated while the
process is in operation, giving greater weight to recent
measurements to show the effect of process improvements.
Perhaps this can be used as an analogy for the work of
‘your’ EWMA. Let’s ask a question:
How many wound management/tissue viability societies
across Europe does the European Wound Management
Association (EWMA) represent?
A) I DON’T KNOW
B) QUITE A FEW
C) 53, ACROSS 36 COUNTRIES
ANSWER – YES, IT’S C.
EWMA is both an umbrella organisation linking wound
management associations across Europe, and a multiEWMA Journal 2016 vol 16 no 1
EWMA
Conference Planning meeting before the EWMA meeting in Granada, Spain, 2002.
disciplinary group bringing together individuals and organisations interested in wound management. It works
to promote the advancement of education and research
into native epidemiology, pathology, diagnosis, prevention and management of wounds of all aetiologies. If we
consider the outputs of each individual society in relation
to wound care, for example, venous leg ulcer healing rates,
we may see small improvements over say, ten years. If
however, we pool outcomes, we would see a bigger trend
to improvement – the improvements in years 1 and 2
are considered, but the outcomes in year 9 would carry
greater weight and show greater improvements. In effect,
this is what the EWMA does – it re-calculates the ‘average’
output (clinical approaches) and brings them together as
a whole to demonstrate how collective data and sharing
of information can improve the ‘business’ of wound care.
TABULA RASA
EWMA was founded in 1991. Sue Bale, one of the founding members, recollects that given the success of the Advances in Wound Care Symposium and its Association
in the USA, a posse of wound management professionals
came together to consider whether a similar European
society would be possible or feasible, given the multiple
health care systems and languages across Europe. Fortunately, the general consensus was that they were all willing
EWMA Journal 2016 vol 16 no 1
and ready to give a European version of the Association
for Advances in Wound Care a try.
Accordingly, Terence Turner was elected as President and
the Council was established. As Christina says;
“…I remember the pride when asked to be a EWMA board
member in the very early days. To come together in constructive work with all the giants – the Welsh group, Keith Harding, Sue Bale and Mike Clark, the Oxford-group, Terence
Ryan and his co-workers, Finn Gottrup who was already
working on the establishment of a wound healing centre in
Copenhagen, Christine Moffat with her groundbreaking research in leg ulcer epidemiology and nursing care, and Carol
Dealey with her work in pressure ulcers! We who were early
on board remember the unexplored fields of research - a true
tabula rasa. We were all scientific entrepreneurs, and breakers of new
Conference Planning meeting before the EWMA meeting in
Granada, Spain, 2002 clinical ground for wound management.
FOUNDING PRINCIPLES
One of the founding principles was that EWMA would
be all inclusive across the professions and countries. Sue
recollects:
“We recognised that there might be challenges but we were

71
EWMA s 3rd conference, Harrogate, UK, 1993.
determined to acknowledge the input that every professional
group could bring. We were also cognisant of the value, expertise and diversity of each country within Europe and how
we could learn from each other”.
Another principle was that we would seek to provide
education, promote research and inform clinical practice
across the broad range of wound aetiologies. Finn concurs:
“… to promote the advancement of education and research
into native epidemiology, pathology, diagnosis, prevention and
management of wounds of all aetiologies. In general it was
to establish better knowledge, education and organisation of
the wound area”.
The important issue was perhaps ‘native’ epidemiology.
The organisation had to somehow find a way of ensuring
that education and any policy directives took into account
the issues affecting individual countries.
Based on these principles, EWMA’s original mission statement included an ambition to provide support for patients
and carers and lay people, with the focus on improving
wound care for all.
EARLY DAYS
Existing associations and societies at the time generally
were focussed on one country, health care system or wound
aetiology. While they provide a valuable resource for pa72
tients and clinical staff working in that specialty, they
are by their nature limiting. EWMA therefore actively
sought to emulate the American Association for Advances
in Wound care (AAWC) and their symposium.
However, up until 1994 EWMA’s activity was largely centred on the UK; only Finn, and a little later Christina,
represented Europe. As Finn says:
“…For this reason it was… a little difficult to call EWMA
a European organisation!”
In its infancy, EWMA was supported by the Journal of
Wound Care (Emap Ltd) and its activities largely centred
on the annual conference. Mostly these were held in the
UK, but Copenhagen, Milan and Madrid also hosted.
From extra-curricula meetings at the conferences, various
position and consensus documents were produced and
clinical studies were coordinated and shared. Christina
recalls:
“I personally remember the first four clinical studies in the
world with hydrocolloid on leg ulcers. … peri-stomal ulceration had been healed with the first hydrocolloid, Stomahesive,
so we studied the effect of a more flexible wafer on leg ulcers
- with quite an effect. From these results, the first interactive
wound dressing was born”.
By 1999 during Finn’s Presidency, it was clear that formal
administrative support was required and that EWMA was
EWMA Journal 2016 vol 16 no 1
EWMA
ready to be a stand-alone, independent organisation, and
that the conference should be hosted by member countries,
working with national wound care organisations. Accordingly, in 2000, with Christine Moffatt as President, the
administrative function was taken over by Henrik Nielsen
and the CAP Partner (formerly Congress Consultants)
team. Chris recalls that this enabled her, the new Council
and the team to formulate and implement a strategic plan;
sub sections within the plan included the organisational
aspects of EWMA becoming a stand-alone entity, the education and publishing aspects (position documents, consensus documents, best practice documents, etc), working
with industry, and working with associate organisations.
Today, the team continues to drive EWMA forward, and
is according to Finn,
“…one of the most important reasons for EWMA’s size and
position in Europe and the rest of the world today”.
Christina recollects the conference in Stockholm she
helped to organise:
“For me, the first independent EWMA conference in Stockholm in 2000 of course played a very special role. I was
responsible for the conference as local organiser, and with my
small team from Uppsala we tried to handle all the practical issues. This was also my first acquaintance with Henrik
Nielsen; we worked together well and what a success the conference became! One small nightmare occurred when one of
the excursion boats with all the Finnish delegates on board
was stranded – I still shiver at the memory!
I think this conference was a major step forward for EWMA.
It was also the first European Conference where EWMA
joined forces with veterinarians, who were lyrical about this
initiative (but a bit undisciplined to work with!)
Having become a truly European organisation, the annual conferences have been held in places such as Helsinki,
Prague, Grenada, Brussels and Vienna to name but a few.
As Sue remarks:
“Holding the… conference in different countries enables the
clinical population of that country to attend…, which might
not be possible in years where it is held elsewhere”.
Many delegates play the ‘how many conferences have you
been to?’ game each year. It is for many members, a source
of pride that they belong to an organisation that has a
twenty-five year history, and that is so truly multi-national
and so dynamic.
OUR UNIQUE SELLING POINT
While other international groups exist, each with largely
similar aims and objectives, the EWMA’s driving ideal is to
improve wound care across all health economies. EWMA
achieves this through three main principles:
n Advocacy - EWMA works continuously to improve
European wound patients’ quality of life by
EWMA Journal 2016 vol 16 no 1
identifying and advocating the highest quality
treatment available and assessing its cost effectiveness
from a multidisciplinary point of view. Recent past
presidents and the EWMA office have been politically
active, drawing attention to the numbers of patients
with chronic wounds and the associated costs. This
has been achieved through targeting policy makers and
key opinion leaders in the European Union and
national governments. EWMA is also focusing on
patient pathways and the value and role of multi
disciplinary teams
n Education
– EWMA strives to work from common
ground; EWMA has produced a wide selection of
position documents and papers, many of which are
translated and disseminated. All such documents are
written by subject experts and have included topics
such as compression, new technologies, different wound
aetiologies and home care. Each explores the underlying
theory, together with best practice and the evidence
base, so providing the reader with a rounded perspective
n Collaboration
- The partner organisations of EWMA
are divided into three partnership categories;
cooperating organisations, international partner
organisations and EWMA associated organisations.
The widest-ranging level of collaboration exists with
the cooperating organisations (53 to date) which,
through the annual cooperating organisation’s board
meeting, are entitled to present and elect members of
the EWMA Council as well as to other specific benefits.
In addition, as an umbrella organisation EWMA
recognises and benefits from the experiences of other
wound healing associations and societies across Europe
and beyond. This reduces duplication of effort and
facilitates the sharing of best practice in terms of
education, research and practice development.
It also provides a repository of information and evidence
for those associations and societies that as newly formed or
those that have not yet established wide networks (the exponentially weighted moving average principle!). EWMA
connects associations and societies so that they too can
continue to grow and flourish.
ACHIEVEMENTS SO FAR
It has been a busy few years; EWMA has grown and
thrived, morphing from a single entity to an umbrella
association, thereby creating networking opportunities
and a venue for the sharing of experiences across associations and societies. It has changed and adapted to suit the
needs of patients, carers and the public as well as health
care professionals.

73
Leaving Council members celebration, EWMA Conference Lisbon
2008, Zbigniew Rybak, Deborah Hofmann, Christina Lindholm.
Members of the EWMA Council, from the EWMA 2008 Conference
in Lisbon 2008.
EWMA’s Patient Outcome Group (POG) has been influential in informing the design and conduct of high
quality research. The initial focus of this group was to
highlight the importance of acknowledging which outcome is defined as the primary endpoint of a study, and
to support the general recognition of alternative outcome
measures to complete healing in the evaluation of healing interventions. This work has changed the mind set
of many researchers. Their work has been much debated,
critiqued and published.
the European commission on patient safety and
antibiotic resistance.
Other significant activities include:
n Standardising education with EWMA module outlines
n To be the overarching ‘umbrella’ organisation under
which European wound healing associations collaborate
n The introduction of a specific programme for students
at the EWMA conferences (The EWMA University
Conference Model, UCM)
n To support patients to play a key role in prevention and
their own treatment as a central member of the multi disciplinary treatment team
n Raising
political awareness for politicians and policy
makers across Europe
n To
provide highly accessible educational resources for
citizens, patients and professionals
n Collaborating with industry to develop new evidence- based technologies and initiating new developments in
the organisation of, and research into, wound healing
n To promote wounds as one of the major challenges for
the quality of life of citizens as well as a major
contributor to the economic burden of European health
care systems
n The
cooperation of European practitioners has
resulted in more consistency in understanding,
education and treatment in the discipline. Internationally, educational programs and wound centre e
ndorsements has been undertaken in China, Singapore,
Brazil and many other places
STATE OF THE ASSOCIATION AT 25 YEARS OLD
EWMA continues to improve European wound patients’
quality of life by identifying, pursuing and advocating the
highest quality, cost-effective multi-disciplinary treatment.
EWMA’s goals remain fluid and responsive to its membership and patients – new ones replace those achieved. At
present, these are:
n Council
74
members have met with Members of the
European Parliament (MEPs) and relevant patient
organisations. The aim of these meetings was to create
awareness among members of the European Parliament
about the challenges related providing high quality
wound management, as well as the importance of
paying attention to health economics and patient
quality of life. Among other things, EWMA has
contributed actively to initiatives supported by
n To actively promote to governments and other decision
makers that wounds are preventable by implementation
of adequate prevention measures
n To
promote the delivery of cost-effective, evidence based best practice wound prevention and wound
treatment
n To promote a multidisciplinary approach to the
prevention and treatment of wounds.
EWMA works towards the fulfilment of these goals
through:
n EWMA documents on epidemiology, pathology,
diagnosis, prevention and management of wounds of
EWMA Journal 2016 vol 16 no 1
EWMA
effective service for patients with wounds across Europe
n Continuing support for cooperating organisations, in
particular increasing focus on how dialogue and sharing
of knowledge can be increased across local, national
and European levels
First Co-operating organisations Board meeting, held in Dublin,
Ireland, 2001.
all aetiologies
n Hosting of multidisciplinary wound conferences and
training courses in Europe
n Maintaining and updating EWMA documents, and
ensuring that we select new document topics based on
the greatest need of our membership, patients and their
carers
n Continuing to develop a constructive and balanced
dialogue with all stakeholders, including industry
supporters
n Encouraging increased demonstration of the outcomes
of wound care services
n Creation
of forums for networking and sharing of
experiences for individuals and organisations actively
involved in wound management
n Advocacy activities targeting policy-makers and
key-opinion leaders in national governments and the
European Union
n Providing
THE NEXT QUARTER CENTURY - PLAIN SAILING?
Setting up and developing such an organisation is not
without its challenges - the first 24 years are the worst…!
While the organisation has gone through its ‘storming,
forming and norming’ phases, much is left to achieve.
Further goals include:
n Raising the profile of wounds across Europe so that
policy makers better understand the implications of
poor wound care and the value of appropriate wound
care
n Anticipating
types of wounds that will be the most
challenging in terms of clinical management and health
care costs in all European countries – diabetic foot
ulcers and cellulitis for example. Consideration must
also be given to the effects that the ageing population
has on the European health care systems
n Standardising and setting standards for multi discipli nary teams in wound care, and to ensure a safe and
EWMA Journal n Continuing to advocate for improved clinical practices
while also taking into consideration the overall need
of society for cost-effective solutions Clearly, there is
still much to do!
guidance for practice
Thus, EWMA strives to be the organisation that citizens,
patients, professionals, Governments, Health Services and
educational institutes come to for advice, expertise and
opinion in Europe.
n Ensuring equal levels of knowledge across all countries
(for example, on use of compression)
2016 vol 16 no 1
However, EWMA council believes that with the support
of its members and the structures they have in place, these
will be achieved before the gold anniversary.
CONCLUSION
EWMA now has an extended collaboration with AAWC
and Wounds Australia (previously the Australian Wound
Management Association, AWMA), including an exchange
of seats in the respective councils of the associations. This
extended collaboration represents a further strengthening
and formalisation if EWMA’s long standing collaboration
and knowledge sharing with these international partners.
More importantly, it ‘squares the circle’; the founding
members asked if EWMA could replicate the AAWC
model could be across Europe – 25 years later, the answer
is ‘yes’.
We’ll leave the closing remarks to Christina Lindholm:
“EWMA started its early conferences- and a new world opened
up for us. The position documents and other consensus documents were developed, and I personally think that these have
been the most important assets of EWMA, parallel to the
conferences.
I personally would like to wish EWMA- and all the people
working for it, a successful celebration of its 25 years. The
early pioneership and deep friendship we developed over the
years is a true source of joy for me personally”. n
75
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EWMA 2016 Conference in Bremen, Germany
PATIENTS · WOUNDS · RIGHTS
The 26th conference of European Wound Management
Association, the 10th Deutscher Wundkongress and 2nd
WundD·A·CH Kongress 2016 will be a great event in
many ways. The scientific programme has expanded significantly and will consist of various key sessions, workshops, lectures, full-day streams, and satellite symposia. It
will involve scientists from Europe and other countries in
the world. The 2016 conference is organised in cooperation with the Initiative Chronische Wunden e.V.(ICW) and
the collaboration of German-speaking wound associations
WundD·A·CH.
The conference offers more than 1,000 scientific presentations by international key speakers, free paper presenters, poster presenters, workshop facilitators, and satellite
symposium speakers. A very large number of participants
are expected, and the exhibition is the largest in the history of EWMA.
The conference theme is:
PATIENTS · WOUNDS · RIGHTS
The patient is more than a person with a wound. He/
she is a human being with needs and requirements; and
rights! According to the international declaration of hu-
Arriving at the EWMA 2015 conference in London.
78
man rights, everyone has the right to health, implying that
prevention and treatment of non-healing wounds must be
available to everyone. Thus, securing patients’ Quality of
Life is a political responsibility as well as a clinical one.
Patients’ access to wound care requires the collaboration
of patients, professionals and policy makers. It is a corner
stone of good practice in wound management and a fundamental objective of the interdisciplinary team approach.
The 2016 programme will offer guest sessions from several organisations that are active in thematic issues related to wound healing and management. The organisations include Dystrophic Epidermolysis Bullosa Research
Association(DEBRA), European Burns Association(EBA), The
European Council of Enterostomal Therapy(ECET), European Federation of National Associations of Orthopaedics
and Traumatology(EFORT), European Pressure Ulcer Advisory Panel(EPUAP), The European Society for Clinical Nutrition and Metabolism(ESPEN), European Society of Plastic,
Reconstructive and Aesthetic Surgery(ESPRAS), European
Society for Vascular Surgery(ESVS), European Tissue Repair Society (ETRS), International Compression Club(ICC),
International Lymphoedema Framework(ILF) and World
Alliance for Wound & Lymphedema Care(WAWLC).
Fully booked EWMA 2015 session.
EWMA Journal 2016 vol 16 no 1
EWMA
An International Partner Session will be hosted by
‘EWMA’s Australian partner, Wounds Australia.
EWMA AND GERMAN WOUND CONGRESS
ANNIVERSARIES
At this year’s EWMA conference we celebrate EWMA’s
25th anniversary as well as the 10th anniversary of the
German Wound Congress. EWMA’s anniversary will be
celebrated throughout the year, and in particular at the
conference in Bremen with a number of activities highlighting important milestones of EWMA.
Workshops
EWMA 2016 will also run a variety of interactive workshops, giving participants an opportunity to address and
elaborate on particular aspects of the session themes.
WORKSHOPS INCLUDE:
n Wound assessment
n Diabetic foot: assessments, offloading and footwear
n Clinical trials: are they worth performing in the diabetic
foot? What is the recent evidence?
n Skin care in leg ulcers
PROGRAMME HIGHLIGHTS
Key sessions
The topics highlighted at EWMA 2016 cover the advancement of research in relation to epidemiology, pathology,
diagnosis, prevention and wound management. Additional
guest sessions will be held to discuss wound healing and
management, and promote cooperation and networking.
n Pros and cons of in-vitro and in-vivo model systems to
study biofilm infections
n Debridement
n Military wounds
n Electrostimulation
n Pain management in patients with wounds
n Cochrane
n Wound centres and wound centre endorsements
n Economic downsizing: the importance of organisation
KEY SESSIONS INCLUDE:
to ensure adequate care for chronic wound patients
n Patients. Wounds. Rights. (Opening plenary key
n How we do that: practical approach to clinical practice
session)
n How to write an abstract and how to make an e-poster
n New technologies in wound care
n Getting published
n Migration, culture and ethnic skin
n Cooperating organisations
n Adipositas and wounds
n Biofilm: From laboratory to clinical practice
n Evidence and outcome
n Opportunities for tissue engineering in wound care
n Management of patients with venous leg ulcers:
current best practice
n Use of oxygen therapies in wound care
EWMA focus sessions – on phlebology, revascularisation,
diabetic foot and antimicrobial stewardship – foster more
in-depth discussions than the workshops allow. A number
of abstracts will also be presented in high-level free paper
sessions, and as e-posters on display throughout the event.
n Health-related quality of life: the patient’s perspective
n Negative pressure wound therapy
n Networking structures in wound care
n Individualised wound diagnostics
n Local wound infection
n Compression therapy
EWMA 2015 E-poster session.
EWMA Journal 2016 vol 16 no 1
Stay informed by visiting the conference website,
www.ewma2016.org
to see registration opportunities or obtain further
information about the programme. You can also get
your updates on EWMA’s social media platforms.
The EWMA 2015 exhibitors welcome the participants.
79
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EWMA
DOCUMENT SUMMARY:
MANAGEMENT OF PATIENTS WITH
VENOUS LEG ULCERS: CHALLENGES
AND CURRENT BEST PRACTICE
Peter J Franks1
(Editor), PhD, Professor of
Health Sciences and Director, Document editor
In 2014 EWMA decided to define leg ulcer management as a key focus area, due to
significant challenges and variations in the assessment and management of venous
leg ulcers in Europe and other parts of the world. This has resulted in the publication
of a consensus document in April 2016 on Management of patients with venous leg
ulcers: challenges and current practice. This article introduces and summarises key
points from the full document.
INTRODUCTION & AIM OF
THE DOCUMENT
It is well documented that the prevalence of venous leg ulcers (VLUs) is increasing, coinciding
with an age-ing population. Accurate global prevalence of venous leg ulcers is difficult to estimate
due to the range of methodologies used in studies
and accuracy of reporting.1 Venous ulceration is
the most common type of leg ulceration and a significant health problem, affecting approximately
1% of the population and 3% of people over 80
years of age2 in westernised countries. Moreover,
the global prevalence of VLUs is predicted to escalate dramatically, as people are living longer, often
with multiple comorbidities.
Despite the fact that an abundance of guidelines
for management of patients with venous leg ulcers (VLUs) are available and regularly updated,
there is still variation and quality in the services
offered to patients with a VLU. There are also
variations in the evidence and some recommendations contradict each other, often causing confusion and a barrier to implementation.3 Finally,
the difference in health care organisational structures, management support and the responsibility
of VLU management can vary across count-ries,
often causing confusion and a barrier to seeking
treatment. These factors complicate the guideline
implementation process which is generally known
to be a challenge with many diseases.4
EWMA and Wounds Australia have developed
a consensus document, with the aim to highlight
some of the barriers and facilitators related to implementation of VLU guidelines as well as providing clinical practice statements to overcome these
and “fill the gaps” currently not covered by the
majority of available guide-lines.
Judith Barker2
(Co-editor), RN, NP, STN,
BHlth Sci (Nurs); MN(NP),
Document co-editor
1 Centre for Research & Implementation of Clinical
Practice, 128 Hill House,
210 Upper Richmond RoadLondon SW15 6NP, United
Kingdom
2 Wounds
Australia
On behalf of the author
group:
Mark Collier, Georgina
Gethin, Emily Haesler,
Arkadiusz Jawien, Severin
Laeuchli, Giovanni Mosti,
Sebastian Probst, Carolina
Weller.
METHODOLOGY
The development of the document includes:
n Recommendations
reviewed from eight
clinical practice guidelines (CPGs) published
since 2010 which were compared for the
purpose of this document. These are listed
in table 1.
The full document is published as an online
supplement in the Journal of Wound Care, April
2016. The document can be downloaded free of
charge from the Journal of Wound Care website.
EWMA Journal 2016 vol 16 no 1

Correspondence:
ewma@ewma.org
81
Table 1: Overview of the compared guidelines (sorted by publication year)
No Title
Organisation
Published
/updated
Country/
international
collaboration
1
Association for the Advancement of Wound Association for the Advancement
Care (AAWC) venous ulcer guideline5
of Wound Care
(2005) 2010
USA
2
3
4
5
6
7
8
Management of chronic venous leg ulcers (SIGN CPG 120) (6)
SIGN (GB) - Scottish Intercollegiate
Guidelines Network
2010
Scotland
Varicose ulcer (M16) [Varicose ulcer (NL: Ulcus cruris venosum)]7
NHG (NL) - Dutch College of
General Practitioners
2010
The Netherlands
Australian and New Zealand Clinical Practice Guideline for Prevention and Management of Venous Leg Ulcers1
Australian Wound Management
2011
Association and the New Zealand
Wound Care Society
Australia &
New Zealand
Guideline for management of wounds in patients with lower-extremity venous disease8
Wound, Ostomy, and Continence
Nurses Society - Professional
Association
(2005) 2011
USA
Guideline for Diagnostics and Treatment of Venous Leg Ulcers9
European Dermatology Forum
(2006) 2014
Europe
Management of venous leg ulcers: Clinical practice guidelines of the Society for Vascular Surgery and the American
Venous Forum10
The Society for Vascular Surgery
2014
and the American Venous Forum
Management of Chronic Venous Disease, European Society for Vascular
Clinical Practice Guidelines of the European Surgery
Society for Vascular Surgery (ESVS)11
n A
study of relevant background literature on
guideline implementation as well as different
aspects of VLU assessment, diagnosis and
management. A systematic review of the
identified litterature is outside the scope of this
document.
n The
opinion of the expert working committee.
CLINICAL ADHERENCE TO GUIDELINES - BARRIERS AND FACILITATORS
Many approaches have been published offering potential
solutions to barriers to guideline implementation, mostly
in areas other than wound care. Substantial evidence suggests that behaviour change is possible, but this change
generally requires comprehensive approaches at different
levels (doctor, team practice, hospital, and health system
environment), tailored to specific settings and target
groups. Plans for change should be based on characteristics of the evidence or guideline itself and barriers and
facilitators to change.12,13
82
2015
USA &
Europe
Europe
A section of the document is dedicated to an outline of
the potential barriers and facilitators for clinical practice
guideline implementation related to the various players:
The healthcare system/organisation, health care professionals and patients.
The barriers and facilitators identified include both for
CPG implementation and those specifically related to leg
ulcer management guidelines.
CURRENT BEST PRACTICE LEG ULCER MANAGEMENT - CLINICAL PRACTICE STATEMENTS
The main focus of the document is to provide an overview
for high quality service provision, with a key focus on
the “good patient journey”. This section is divided into 5
chapters focusing on key elements of the patient journey:
n Assessment
and differential diagnosis
n Treatment delivery: Compression therapy,
dressings and invasive treatments
n Monitoring
outcome
EWMA Journal 2016 vol 16 no 1
EWMA
n Referral
structures
n Secondary
prevention
Each chapter concludes with a set of key clinical practice
statements, which refer back to the comparison of evidence
based VLU guidelines and the opinion of the expert committee (See Table 1). The clinical practice statements are
provided in this summary. They are presented in their full
context in the document.
ASSESSMENT AND DIFFERENTIAL DIAGNOSIS
Clinical Practice Statements:
Statement A: All patients presenting with lower leg ulceration must receive a comprehen-sive assessment.
Comments: This must include medical/surgical history; vascular assessment; laboratory investigations; leg ulcer history
and symptoms; pain; mobility and function; psychosocial status; quality of life and examination of the leg and ulcer.1 A
comprehensive clinical assessment and treatment plan must
be developed and documented.
Basic assessment before initiation of treatment should include clinical assessment of the ulcer and leg as well as ruling
out arterial disease by performing ABPI measurements.
Statement B: Patient assessment must be conducted by a
health professional with appro-priate clinical knowledge
and skills who has the required qualifications, registration and licensing for the health system in which they
practice .1, 6
Statement C: Following a comprehensive assessment, a
recognised classification system (for example the CEAP
Classification System) should be used to classify the extent
of venous disease.
Statement D: A patient must be reassessed if the ulcer does
not heal on the expected trajectory or when the patient’s
clinical or social status change.
Comments: Further assessment to exclude other underlying
diseases must be performed after 3 months or if there is cause
for concern prior to this.
Patients with a non-healing or atypical leg ulcer must be
referred to a health professional trained and competent in the
management of leg ulcers for further assessment and consideration of biopsy.1
Statement E: Bacterial swabs should not be taken routinely unless clinical signs of infection are present.1, 6,14
EWMA Journal 2016 vol 16 no 1
TREATMENT DELIVERY
Compression therapy
Clinical Practice Statements:
Statement A: Compression therapy is recommended over
no compression in patients with a venous leg ulcer to
promote venous leg ulcer healing1, 5-11
Comment: we have a great number of studies comparing
compression with no compression therapy and confirming that
VLUs heal more quickly with compression therapy.15-18
Statement B: In patients with a venous leg ulcer strong
compression pressure over low compression pressure is
recommended to increase venous leg ulcer healing.1, 6, 8, 9
Comment: there is evidence that a strong compression (higher
that 40 mm Hg) is more effective than a Iow compression
pressure (≤ 20 mm Hg) in promoting ulcer healing.15,19-22
Compression should be applied by means of a multicomponent system, which increases pres-sure and stiffness rather
than single component bandages.23-25 Adjustable Velcro®
com-pression devices or elastic kits may be considered effective
alternatives especially when trained personnel are unavailable.5, 21,26
Statement C: In patients with venous leg ulcers we suggest
using intermittent pneumatic compression (IPC) when
other compression options are not available or cannot be
used. When possible we suggest using IPC in addition to
standard compression.9,10,27
Comment: there is evidence that compared with no compression, IPC is able to increase the VLU healing rate.28, 29 There
is also limited evidence that IPC might improve healing of venous ulcers when used in addition to standard compression.30
Statement D: In patients with venous leg ulcers and arterial impairment (mixed ulcers) we suggest applying a
modified compression in patients with less severe arterial disease: ankle brachial pressure index [ABPI] >0.5 or
absolute ankle pressure >60 mmHg.10 This should only
be applied by a trained HCP in mixed ulcer management
and where the patient can be monitored. We have enough
data that in patients with arterial impairment compression
may be applied with reduced pressure provided arterial
impairment is not severe.31-36 When ar-terial impairment
is moderate (ABPI > 0.5) a modified, reduced compression
pressure does not impede the arterial inflow37,38 and may
favour ulcer healing.39 Compression must be avoided in
severe, critical, limb ischemia.10,40

83
Statement E: In patients with a healed venous leg ulcer,
compression therapy is recom-mended to decrease the risk
of ulcer recurrence.10
Comment: even if available trials have some flaws, the evidence regarding the effectiveness of compression by stockings
in ulcer recurrence prevention is strong. Some evidence is
in favour of the strongest possible compression, which seems
directly related to the effectiveness in ulcer recurrence prevention.41-43 A recent paper underlines the compliance of the
patients wearing elastic stockings, which seems even more
important than pressure itself.44
THE ROLE OF DRESSINGS IN
VLU MANAGEMENT
Clinical Practice Statements
Statement F: No specific dressing product is superior for
reducing healing times in VLUs.1 Simple non-adherent
dressings are recommended in the management of VLUs.6
This applies to the majority of small and non complicated
VLUs.
Dressings are selected based on assessment of the stage
of the ulcer bed, cost, access to dressing and patient and
HCP preference.1, 8,10
Comment: If the VLU is exudating heavily, select a dressing
that has a high absorptive capacity that can also protect the
periwound from maceration.
Statement G: Concerning management of the surrounding skin, the HCP can consider us-ing topical barrier preparations to reduce erythema and maceration from VLUs.
Venous ec-zema can be treated with short term topical
steroids, zinc impregnated bandages, or other dermatological preparations.6,1
Statement H: Concerning use of wound dressings in the
case of clinical infection, a com-prehensive assessment of
the patient and their VLU is required to determine the
severity of the infection and appropriate treatment implemented. Antimicrobial therapy such as silver, honey and
cadexomer iodine dressings can be prescribed when a VLU
exhibits signs of infection.1,8-10
Comment: The use of topical antimicrobials should not be
used in the standard care of VLUs with no clinical signs of
infection.1, 8-10
Statement I: Concerning wound dressings and cost saving, the standard care of treating VLUs reduce the cost of
ulcer management.1,8
84
Comment: we have sufficient evidence to support that ulcer
dressings are effective in exudate management, in controlling
ulcer infection and in allowing cost saving of ulcer management.45-51
Statement J: Ulcers characterised by an adequate wound
bed but absent or slow healing may need a maintenance
debridement of wound bed and peri-wound skin.52
INVASIVE TREATMENTS
Clinical Practice Statements
Statement I: To improve ulcer healing in patients with
VLU and incompetent superficial veins, surgery (high ligation/stripping) or alternatively any new ablation techniques should be suggested in addition to standard compression therapy.10,27
Comment: Traditional surgery has slightly higher level of evidence than new ablative techniques, probably because they
have not been sufficiently studied for this purpose. 53,54
Statement J: To prevent ulcer recurrence in patients with
active or healed VLU and in-competent superficial veins,
the surgery (high ligation/stripping) of incompetent veins
in ad-dition to standard compression therapy is recommended.10,11,27
Statement K: To prevent ulcer recurrence in patients with
active or healed VLU and in-competent superficial veins,
ablation technique in addition to standard compression
therapy is suggested.6,9,10,27
Comment: Open surgery for prevention of ulcer recurrence
when superficial veins are involved is the only well documented treatment.54-56
New ablation techniques still require more studies so this is
why the evidence of using them is much lower.57,58
Statement L: To improve ulcer healing and to prevent recurrence in patients with VLU and incompetent superficial
veins with pathologic perforating veins and with or without deep venous disease, surgery or ablation of superficial
and perforating veins is suggested in addi-tion to standard
compression therapy.10,27
Comment: Every treatment of perforating veins is controversial, because of lack of well-designed RCTs and uncertainties
whether abolition of axial reflux or closure of insufficient
perforator is more beneficial for improving healing of leg ulcer.59-61
Statement M: To improve ulcer healing and to prevent
recurrence in patients with active or healed VLU and isoEWMA Journal 2016 vol 16 no 1
EWMA
lated pathologic perforating veins, surgery or alternative
ablation technique of perforating veins is suggested in case
of failure of standard compression therapy.10,27
amongst other things changing of dressings and compression
band-ages/hosiery/wraps. The HCP should support the patient
to enhance selfcare activities.
Statement N: To close the pathologic perforator veins in
patients with VLU, percutaneous techniques, which do
not need incisions in the areas of compromised skin are
recommended over open venous perforator surgery.10,27
Statement B: Specialised leg ulcer clinics are recommended as the optimal service for treatment of VLU in the
community (primary care) setting.6
Comment: Avoidance of any incision within a region of compromised skin is crucial, so this is why the minimally invasive
techniques, from a ultrasound-guided foam sclerotherapy to
SEPS should be taken into consideration when the treatment
is planned.27
Statement O: In patients with infra-inguinal deep venous
reflux and active or healed VLU the recommendation is
against deep vein ligation of the femoral or popliteal veins
as a routine treatment.10,27
Comment: This is an old surgical procedure which fortunately
currently is rarely performed.62,63
Statement P: To improve ulcer healing and to prevent recurrence in patients with total occlusion or severe stenosis
of inferior vena cava and/or iliac veins, venous angioplasty
and stenting is recommended in addition to compression
therapy.10,27
Statement Q: No specific debridement method has been
documented to be optimal for treatment of venous leg
ulcers.8
Comment: The most commonly used methods of debridement
are surgical (sharp), conserva-tive sharp, autolytic, larval,
enzymatic and mechanical. Surgical debridement is rapid,
although it requires either general or local anaesthetic and can
be painful. Conservative sharp debridement is the removal of
loose avascular tissue without pain or bleeding.1
Statement R: Mechanical debridement methods, such as
ultrasound, high-pressure irriga-tion or wet to dry dressings, may be useful for reducing non-viable tissue, bacterial
burden and inflammation.1
REFERRAL STRUCTURES
Clinical Practice Statements:
Statement A: Leg ulcer management must be undertaken
by trained or specialised HCP.1,6-8
Statement C: In rural areas, where specialised HCPs may
not be available, telemedicine can offer an opportunity to
provide specialised assistance for assessment, diagnosis and
treatment of a VLU patient.64
SECONDARY PREVENTION
Statement A: When a VLU has healed, the patient requires
lifelong medical grade com-pression hosiery providing 18
– 40mmHg to reduce the long term effects of venous
disease.1,6
Statement B: The patient must be assessed by a trained
health professional for suitability and strength of compression.1,6
Statement C: The patient should consider replacing compression hosiery every six – twelve months and/or per
manufacturer’s recommendation.1
Statement D: The benefit of a daily skin care programme
promotes the health of legs and reduces the risk of VLU
recurrence.1,6
Statement E: Exercise and movement has a positive benefit for the patient and enhances calf muscle pump.1, 65
Progressive resistance exercise has been shown to promote
calf muscle function
Statement F: Elevation of the limbs when sitting and
avoidance of standing for prolonged periods assists in controlling lower leg oedema.1,6
Statement G: Consider monitoring the patient for six twelve months after the VLU has healed
MONITORING OUTCOME
This document chapter highlights the need to continuously audit the outcomes of VLU patient care. It is stated
that study outcomes should apply to a single or small
number of clearly defined objectives, including:
n A precise statement of the degree of benefit expected from the intervention, and its duration;
n Clear
Comment: Individual patients and carers can, however, play
a proactive role in self-care ulcer management including
EWMA Journal 2016 vol 16 no 1
statements on the time frame of the study
(especially in relation to how quickly the benefits
might start);

85
n A definition of the patients for whom the benefit
is sought.66
Wide variations in endpoints of trials of VLU have been
reported together with a lack of endpoints related to QoL
or patient identified endpoints.67
CONCLUSION
It is well established that VLU prevalence is on the increase, more often in older adults, which will escalate the
cost to the patient and healthcare organisations in the coming decades. More than ever there is a sub-stantial need for
international consensus on prevention and management
strategies of these chronic wounds, which is cost effective,
with positive outcomes for the patient. There is a need
for a multidisciplinary team approach of all healthcare
professionals across different health sectors to work collaboratively in the future to reduce the development and
recurrence of these wounds.
EWMA and Wounds Australia as expert bodies can lead
the way in providing education and evidence-based publications on VLU management and ensure this chronic, debilitating, often slow-healing wound is kept on the agenda
as an international health priority. n
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90
EWMA Journal 2016 vol 16 no 1
NEW SPONSORS
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EWMA Journal 2016 vol 16 no 1
EWMA DOCUMENT:
USE OF OXYGEN THERAPIES IN WOUND CARE
Work on this document is now in progress. The author group chaired by Prof. Finn Gottrup and
co-chaired by Prof. Joachim Dissemond met in Copenhagen on 1 March 2016 with the purpose
of elaborating guiding principles for the document, as well as an overall outline of its content.
Publication of the document is planned for Spring 2017.
This initiative is covered in a key session at the EWMA 2016 Conference, to be held Friday
13 May from 13.45-15.15.
The document is supported by unrestricted grants from AOTI, Inotec AMD and Sastomed.
It is still possible for additional companies to support the document. Please contact the EWMA
secretariat at jnk@ewma.org for further information.
EWMA OUTLOOK DOCUMENT:
ADVANCED THERAPIES IN WOUND MANAGEMENT
The EWMA Council has decided to publish a document that will investigate and provide an
outlook on the barriers and possibilities of advanced therapies in next generation wound management. Cellular therapies, tissue engineering and tissue substitutes are all techniques associated
with the clinical discipline of regenerative medicine and will be covered here. Moreover, a focus
on physical therapies and the potential of sensors and software will be included.
The document will include literature review and expert opinion on where the opportunities
lie ahead and call for research in recommended areas.
AUTHOR GROUP
EWMA Council member prof Alberto Piaggesi and EWMA President Dr Sevein Läuchli will
be chairing and co-chairing the project. Other contributing authors will be confirmed soon.
The work on this document will be initiated in 2016. Publication is planned for Spring 2018.
For information about this project and opportunities to support it, please contact the EWMA
secretariat at NFB@ewma.org.
EWMA DOCUMENT:
SURGICAL SITE INFECTION
The EWMA Council has decided to publish a document on the topic of surgical site infections
(SSI). The document will address SSI in the hospital setting, and, in particular, in the home
care and community care setting. This feeds into EWMA’s previous work on various aspects
of wound-related patient safety, and links up with other recent and ongoing EWMA focus
areas such as the antimicrobial stewardship programme, the NPWT document (planned for
publication in Summer 2016), and the Home Care Wound Care document published in 2014.
EWMA aims to gather a broad interdisciplinary expert working committee to take responsibility for the development of this document.
The work on this document is planned to be initiated before the end of 2016. Publication
is planned for Spring 2018.
For information about this project and opportunities to support it, please contact the EWMA
secretariat at jnk@ewma.org.
92
EWMA Journal 2016 vol 16 no 1
EWMA NEWS
EWMA WOUND CENTRE ENDORSEMENTS
In autumn of 2015, EWMA carried out two pilot endorsements of wounds centres:
• The Wound Centre of the Peking University First Hospital in Beijing which is a
hospital based centre.
• The Wound Clinic of the Sesc Health Center of Excellence, Belo Horizonte, Brazil which
is a clinic based outside of a hospital setting.
Based on these experiences, EWMA will work toward developing an international wound centre
endorsement programme in collaboration with its partner organisations.
To learn more about EWMA’s endorsement programme and these experiences with the establishment of wound centres, join the EWMA 2016 workshop in Bremen, Thursday 12 May
2016 at 10.00-11.00.
The development of the wound centre endorsement programme was supported by an unrestricted grant from the Coloplast Access to Health Careprogramme.
NEW PATIENT RESOURCES SECTION AT WWW.EWMA.ORG
The EWMA Patient Panel has developed a resource section for patients with non-healing
wounds and their relatives or private carers. These pages include a Questions & Answers
section with basic information about wound causes and diagnosis, life style issues, treatment
and prevention. The section also includes a glossary of words typically related to non- healing
wounds and wound management and links to patient material developed and provided by
other organisations.
EWMA hopes that cooperating organisations of EWMA that do not currently provide patient
information will make use of this opportunity to translate and disseminate this online patient
information developed by EWMA.
EWMA would be pleased to receive any kind of feedback on this patient resources section.
Visit the new section at: www.ewma.org/resources/for-patients-and-relatives/
EWMA & COOPERATING ORGANISATIONS
1ST ROUNDTABLE, KAUNAS, LITHUANIA, 15 APRIL 2016
In 2015, EWMA launched a new collaborative activity: “National wound care roundtables”. This
initiative aims to support the organisation of a number of meetings on a national level, focusing
on a previous or current EWMA focus topic. These meetings will be arranged in collaboration
with the Cooperating Organisations of EWMA that wish to host a “wound care roundtable”.
The 1st Roundtable was organised by the Lithuanian Wound Management Association
(LWMA), and chaired by former EWMA Council member Prof. Rytis Rimdeika. This took
place in the Lithuanian city of Kaunas on 15 April 2016. The key topic of the meeting and
debate was “Organisation of Negative Pressure Wound Therapy (NPWT)”.
The EWMA Council was represented by Prof. Sue Bale and Dr. Edward Jude.
An article about this very first roundtable will be published in the October 2016 issue of the
EWMA Journal. Meanwhile, all Cooperating Organisations are encouraged to express their
interest in hosting a roundtable during 2017 and beyond.
EWMA Journal 2016 vol 16 no 1
93
EWMA NEWS
THE NEW EWMA WEBSITE
EWMA’s website www.ewma.org has undergone a full make-over to improve the users’ online
experience when looking for wound information and resources. New features are available for
both professionals and non-professionals.
EWMA has just launched its new website. The address
www.ewma.org remains the same, but behind the URL is
a whole new experience when it comes to finding woundrelated content, whether you are a health professional or
a citizen.
The new www.ewma.org is more than just a digital facelift.
A lot of effort has gone into making the navigation on the
site easier by re-arranging content, using more illustrations
and adding new features. Also, the design is now responsive, which is a vast improvement for users of tablets and
smartphones.
For visitors of EWMA Conferences, there is also change
underway. Starting with the EWMA 2017 Conference in
Amsterdam, the Conference’s website will be incorporated
into www.ewma.org, making the website the sole access
point for all information concerning EWMA.
A brand new feature is a section for patients and relatives. Here, citizens with interest in wound care can find
out about their rights as a wound patient, and find answers to many of their questions and explanations to the
terms often used in wound management. This initiative
is introduced by EWMA’s ‘Patient Panel’, which works
to enhance EWMA’s engagement in patient rights and
patient empowerment.
94
Educators in wound management will be pleased to have
free access to EWMA’s education modules on the website.
The education modules constitute a curricular framework
for developing education programmes in various areas of
wound management. Though the information is available
without charge, it is strongly advised that the use of the
education modules is followed by a review by EWMA’s
Education Committee with the aim to obtain an endorsement of the education programme.
The website is continuously developing, and amongst other things EWMA aims to make more audio-visual content
available to our users in the future. To support this, the site
will soon include a new platform, the EWMA Conference
knowledge centre, which will be the entrance point to all
types of materials related to previous EWMA Conferences,
such as abstracts, posters and recorded sessions. We hope
that this will ensure the continued availability of all the
important knowledge sharing that takes place during the
EWMA conferences.
Should you have any recommendations for improvement
or other feedback to the site, we will be very happy to hear
from you. Send an e-mail to ewma@ewma.org
EWMA Journal 2016 vol 16 no 1
EPUAP2017
The 19th Annual Meeting of the
European Pressure Ulcer Advisory Panel
20 – 22 September 2017
Belfast, Northern Ireland
www.epuap2017.org
One Voice for
Pressure Ulcer
Prevention
and Treatment
Challenges
and Opportunities
for Practice, Research
and Education
EPUAP Business Office
office@epuap.org
Tel.: +420 251 019 379
Conference venue
BELFAST WATERFRONT
Abstract submission deadline:
15 APRIL 2017
Review notification deadline:
15 MAY 2017
Early registration deadline:
15 JUNE 2017
EPUAP 2017 will be organised by the European Pressure
Ulcer Advisory Panel in partnership with the Tissue Viability
Nurse Network (Northern Ireland) and the Wound
Management Association of Ireland.
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IN
F
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EXUD
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*As demonstrated in vitro
1. Newman GR, Walker M, Hobot JA, Bowler PG, 2006. Visualisation of bacterial sequestration and bacterial activity within hydrating Hydrober™
wound dressings. Biomaterials; 27: 1129-1139. 2. Walker M, Hobot JA, Newman GR, Bowler PG, 2003. Scanning electron microscopic examination
of bacterial immobilization in a carboxymethyl cellulose (AQUACEL™) and alginate dressing. Biomaterials; 24: 883-890. 3. Bowler PG, Jones SA,
Davies BJ, Coyle E, 1999. Infection control properties of some wound dressings. J. Wound Care; 8: 499-502. 4. Walker M, Bowler PG, Cochrane CA,
2007. In vitro studies to show sequestration of matrix metalloproteinases by silver-containing wound care products. Ostomy/Wound Management.
2007; 53: 18-25. 5. Assessment of the in vitro Physical Properties of AQUACEL EXTRA, AQUACEL Ag EXTRA and AQUACEL Ag+ EXTRA dressings.
Scientific background report. WHRIA3817 TA297, 2013, Data on file, ConvaTec Inc. 6. Antimicrobial activity and prevention of biofilm reformation
by AQUACEL™ Ag+ EXTRA dressing. Scientific Background Report. WHRI3857 MA236, 2013, Data on file, ConvaTec Inc. 7. Antimicrobial activity
against CA-MRSA and prevention of biofilm reformation by AQUACEL™ Ag+ EXTRA dressing. Scientific Background Report. WHRI3875 MA239,
2013, Data on file, ConvaTec Inc. 8. Physical Disruption of Biofilm by AQUACEL™ Ag+ Wound Dressing. Scientific Background Report. WHRI3850
MA232, 2013, Data on file, ConvaTec Inc.
AQUACEL, AQUACEL Extra, ConvaTec, the ConvaTec logo, Hydrofiber and the Hydrofiber logo are trademarks of ConvaTec Inc.
All other trademarks are the property of their respective owners. © 2016 ConvaTec Inc. AP-016136-GB
T
IO
N
EWMA NEWS
EWMA Publications
New publications in 2016
New document by EWMA and Wounds Australia:
Management of patients with venous leg ulcers – Challenges and best practice.
Published April 2016
This document provides clinical practice statements addressing key aspects to consider when developing an evidence-based leg ulcer service that enhances the patient journey. The document also identifies barriers and facilitators in the implementation of best practice in the management of a VLU.
The document will be launched in a key session during the EWMA 2016 Conference:
Wednesday 11 May 16.45-18.00
New EWMA document:
Negative pressure wound therapy – Overview, challenges and perspectives
Will be published July 2016
This document provides an overview of the evidence base for the use of negative pressure wound
therapy (NPWT) in wound treatment and covers all three types of NPWT: On open wounds, with
instillation and over closed incisions. The document also focuses on the organisational and health
economical aspects of NPWT.
The document will be launched in a key session during the EWMA 2016 Conference:
Friday 13 May 8.00-9.30
Antimicrobial stewardship in wound management:
A BSAC/EWMA Position Paper
Expected publication: Summer 2016
The aim of this position paper is to provide clinicians with an understanding of the importance of Antimicrobial stewardship (AMS) in the management of patients with infected wounds. The paper will also
address who should be involved in AMS and how to conduct AMS in wound management.
The paper was initiated and developed in collaboration with the British Society for Antimicrobial
Chemotherapy (BSAC).
The manuscript is currently in peer review.
The project will be presented in the BSAC/EWMA Symposium at the EWMA 2016 Conference
Wednesday 11 May 2016, 13.45– 16.40
Document on the use of oxygen therapies in wound healing
Publications currently planned for 2017
In 2016-2017, EWMA will work on a document aiming to provide practice-oriented guidance on the
use of various forms of oxygen therapies for wound treatment. This document will include an overview
of treatment options available and an assessment of the best available evidence for use. In addition,
the document will detail specific aspects and current discussions connected with the use of oxygen in
wound healing.
Expected publication: Spring 2017
The topic and initiative is covered in a key session during the EWMA 2016 Conference:
Friday 13 May 13.45-15.15
EWMA Journal 2016 vol 16 no 1
97
WOUNDS AUSTRALIA NEWS
Wound
Australia
Australian Wound Management Association
becomes Wounds Australia
The Australian Wound Management Association (AWMA) undertook a move to change by member resolution in 2015 from an association of geographically based wound management organisations to a single
national peak body (Wounds Australia) representing all members of the previous associations. We are
pleased to announce that Wounds Australia came into action in November 2015.
With the nationalisation of AWMA into a new entity, Wounds Australia has a new logo as well as a new
look to our website. Wounds Australia is poised to provide more benefits to its members, and act as the
peak organisation in Australia for wound management.
Helen McGreogor
President
of Wounds Australia
www.awma.com.au
Wounds Australia has inducted a Board of Directors who are busy developing a new organisational structure and strategic direction. In the medium term, Wounds Australia will also be seeking to strengthen its
strategic operations and business functions through the recruitment of a CEO. We are re-shaping our
education, research and membership committees into national portfolios and engaging members to participate in developing member-driven strategic direction through these portfolios.
The Wounds Australia board has identified that increasing the number of education scholarships/grants
available to members is an early member benefit action it can undertake. This gives members the opportunity to access more education and training in wound management than previously offered.
Wounds Australia continues with a range of projects underway either in development, completion or
review phases. International projects, in conjunction with our project partners, include the Pressure Injury
and the Venous Leg Ulcer Guidelines. Nationally, projects include the Aseptic Technique Guidelines and
our major health promotion project “Wounds Awareness Week” in collaboration with the Wound Management Innovation CRC. Local branches of Wounds Australia continue to hold education events and
host webinars on wound practice upskilling.
The Australian Journal of Wound Management “Wound Practice and Research” continues to be produced and published by Wounds Australia four times a year along with the newsletter ‘DeepesTissues’
and these are valuable resources for evidence based practice.
We have an exciting year ahead of us, as it is national conference year for Wounds Australia. The conference is being held in Melbourne 9-12th November. Registration is open and filling quickly. We look forward to welcoming any EWMA members who are attending.
OBITUARY NOTICE
EWMA international
Partner Organisation
Sandy Dean, Fellow of Wounds Australia, Past National Wounds Australia Nursing Representative
and Past President of Wounds Australia, Victoria.
On the 22nd April 2015 Wounds Australia lost one of our vibrant long term members who was
largely recognised for making a difference in wound management and ultimately for people that suffered wounds.
She was an Australian leader in establishing one of the first multidisciplinary wound clinics - the
Caulfield Wound Clinic -which she ran for close to 30 years. One of Sandy’s legacies is her incredible
work in pressure injury prevention. She was recognised as expert in hospital mattresses and changed
practice in hospitals nationally.
She will be profoundly missed and always fondly remembered. Her knowledge and commitment
to improving wound management practice will live on through all those that she has taught, touched
and inspired over her many years in our specialty.
www.awma.com.au
98
EWMA Journal 2016 vol 16 no 1
Organisations
AAWC NEWS
AAWC
Association for
the Advancement
of Wound Care
Dear
EWMA Colleagues,
Reflecting over my two-year term as AAWC President, I feel honoured to update EWMA about the
accomplishments of our diverse, professional association! As the leading interdisciplinary association
for wound healing in the United States, we have
had tremendous success; therefore, I proudly step
into the revered Past President position while taking
with me many triumphant memories and plan to
stay heavily involved.
Vickie R. Driver
President of AAWC
ABOUT AAWC
As the leading interpro­
fessional organisation in
the United States dedicated to advancing the care
of ­people with and at risk
for wounds, AAWC
provides a whole year of
valuable benefits! Be sure
to join us for near daily
updates and alerts on
Facebook and LinkedIn.
AAWC’s latest accomplishments are a testament to
the progressive approach of dedicated members
and include the launch of a state-of-the-art AAWC
website and Career Center, release of popular educational brochures, and enhancement of the
revered Education for the Generalist program.
Giving back to members is of paramount importance at AAWC. Our programmes offer exclusive
membership benefits; provide travel grant support
to those who volunteer overseas; award scholarships to members for teaching, learning and
exchange programmes; and reward those who contribute our organisation.
Of great importance, AAWC brings a united voice
to United States government and public policy
issues. For example, AAWC remains the host society, along with Wound Healing Society, as co-host
for an initiative entitled, “Wound-care Experts/FDA
– Clinical Endpoints Project (WEF-CEP)”. Since
complete closure is the only endpoint the FDA recognises in determining device and drug approvals,
our teams are developing clinical endpoints that are
meaningful to our patients. WEF-CEP aims to
define scientifically rigorous, yet achievable, clinical
endpoints in wound healing for consideration by the
FDA. We have more to do; however, we are steadily
headed to the finish line of this truly remarkable
journey.
AAWC collaborates with national and international
societies, such as with the consolidation of clinical
guidelines. While each wound care association
involved continues to advance its own mission for
our field, I have the vision that one day there will be
one set of resources supported by tens of thousands
of multidisciplinary, collaborative, professional
organisation members.
With a focus on education, AAWC is an integral
part of SAWC Spring and SAWC Fall - the premier
wound care conferences in the United States. In the
spring, AAWC hosts a clinical practice track that
provides evidence-based, patient-centred, interdisciplinary, practical information that can easily be
shared with decision makers and colleagues soon
after the conference. AAWC heavily participates in
SAWC Fall planning and hosts several events at
that venue annually as well.
In summary, I am proud of the cohesiveness and
success of AAWC. Together, we have fought for
positive change in the wound healing community.
As I “pass the gavel” to incoming AAWC President
Dr. Greg Bohn, I am honoured to have represented
AAWC by advocating for and being a needed voice
for improving patient care. An astute leader, Dr.
Bohn will continue to reinforce AAWC’s position in
the world.
Join AAWC and our mission to advance the care of
people with and at risk for wounds. Please contact
any board member or the office at any time; we are
always happy to hear your suggestions. Visit our
website to learn more about getting involved:
http://aawconline.org.
Yours truly,
Dr. Vickie R. Driver
President, AAWC
EWMA international
Partner Organisation
www.aawconline.org
EWMA Journal 2016 vol 16 no 1
99
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WAWLC
NEWS
Dr. David Keast
President of WAWLC
Dr. Hubert Vuagnat
Treasurer of WAWLC
World Alliance for
Wound and Lymphedema
Care (WAWLC) Update
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.
www.debra-international.org
The World Alliance for Wound and Lymphoedema Care (WAWLC) celebrated its annual general
meeting in Geneva 13-14 November 2015. For a
general update on WAWLC activities to advance
sustainable prevention and care of wounds & lymphoedema resource-limited settings please refer
to the overview published in the EWMA Journal
Vol.15 No 2 October 2015.
At the EWMA 2016 conference 11-13 May in
Bremen, Germany WAWLC will host a session on
Thursday 12 May 8.00-9.30 with the following
tentative agenda:
Title: Update on principal WAWLC activities in
resource-limited settings
Chairs: David Keast, Hubert Vuagnat
Presentations:
n Presentation of the Burden of Illness-study in
Brazil, China, India (Hubert Vuagnat)
n Report on the test of the WAWLC standard
wound kit for use in resource-poor settings
(Eric Comte)
n Reflections on lessons learned from wound
care training and education in Cameroon
(Dr. Franck Wanda, Cameroon)
n Update of other WAWLC activities.
n Questions and debate
ABOUT WAWLC
WAWLC started as a working group in 2007 and
was officially launched as a global partnership in
2009. Read more about WAWLC and current projects on the website: www.wawlc.org.
EWMA international
Partner Organisation
www.wawlc.org
EWMA Journal 2016 vol 16 no 1
International.
Croatian Wound
Association
CWA President
Nastja Kucisec-Tepes,
MD, PhD
Review of the 8th Symposium on
Chronic Wound organised by the
Croatian Wound Association (CWA)
The above event was held in accordance with the
basic aims of the CWA which are: education of
medical personnel in the multidisciplinary approach
to the prevention of the chronic wound, targeted
treatment and care, improvement and standardisation
of methods and procedures and promotion of up-todate knowledge about the chronic wound.
a properly educated family physician is the pillar of
healthcare and treatment, including the treatment of
patients with chronic wounds, we gave special attention to this subject.
In order to reach our determined goals we decided
to carry out education by means of symposia which
are regularly held every year since the founding of the
Association in 2007 until the present day.
The first topic was lymphoedema which was covered
by key experts from Slovenia and Croatia. Special
attention was roused by the presentation on lymphoedema following breast cancer surgery, which was
concluded with practical guidelines for women. We
also had a lively discussion on the topic of lymph
drainage in positive primary loci.
Along with the above, we regularly update our website
with practical instructions for clinical practice, procedures, standard methods, novelties. The website is
accessible to all who are interested in issues related
to the chronic wound. These are primarily the members of the CWA, followed by medical personnel of
varied profile and, last but not least – the patients
themselves.
In striving to promote knowledge about chronic
wounds, an optional subject was introduced into the
curricula of the Medical High School and institutions
of higher education. For this purpose a handbook
“Chronic Wounds” (in Croatian) written by D. Huljev,
MD, PhD was published.
In the structure of our symposia we always have one
main topic, so that we systematically cover the issues
related to chronic wounds with a special stress on
clinical practice or family medicine. Therefore, the
history of our symposia covers the following topics:
decubitus, lower leg ulcer, diabetic foot, atypical
wounds, chronic wounds – local treatment – a challenge for the clinicians, chronic wounds – accents in
prevention and treatment, chronic wounds between
theory and practice.
EWMA
Cooperating Organisation
www.huzr.hr
102
In 2015 we organised the 8th Symposium with international participation, entitled: Chronic Wounds –
Management in Primary Health Care. The Symposium was held in the Tuhelj Spa on 22nd and 23rd
October 2015. The main goal of this Symposium was
to bring together physicians from primary health care,
because we noticed a large gap in the knowledge and
handling of chronic wounds. Considering the fact that
The Symposium consisted of several major and several minor topics.
The second topic, under the title “Chronic wound in
practice” consisted of case presentations and results
of follow-up. For the first time we heard the results of
monitoring the duration of treatment of chronic
wounds on the level of family medicine in Zagreb. On
the basis of well analysed epidemiological data, the
authors of this presentation pointed out clearly defined
problems, among which a correct and timely application of compression therapy is predominant. The
second presentation dealt with the results of monitoring of the application of compression therapy by
family physicians with the conclusion that compression therapy must be carried out also as prophylaxis,
the precondition being a precise diagnosis of lower
leg ulcer. The authors concluded that ulcus cruris is
not a diagnosis of disease.
We heard a very interesting presentation about the
analysis of initial knowledge of nurses about chronic
wounds which showed a mediocre theoretical knowledge and an insufficient practical one. We also heard
interesting presentations about the problems of treating chronic wounds from the perspective of family
physicians, surgical treatment of avulsion wound of
the lower leg, the patient’s knowledge about foot,
skin and nail care.
The conclusion was that more effort should be
directed at collecting relevant data at family medicine
level, which would point out the outstanding issues
and enable their relevant solutions.
EWMA Journal 2016 vol 16 no 1
Organisations
In addition, the need was seen for more printed material in the
form of guidelines, algorithms and recommendations applicable in day-to-day clinical practice.
a final version, accepted by consensus, and present it to a
broader medical audience for endorsement.
In response to the needs, we are working intensively on the
drafting of guidelines about the prevention and treatment of
decubitus, which would be accepted by consensus as national
guidelines. This work is co-ordinated by the CWA.
The 8th Symposium “Chronic Wounds – Management in Primary Health Care” gathered 230 participants and 32 lecturers
and it fully justified the aims intended by the organisers. All the
lectures were printed in the journal AMC 2015; 69 (Suppl. 1):
1 – 136 and they represent a permanent theoretical source of
knowledge on this subject.
The third block of presentations consisted of invited lectures of
leading experts from Croatia and Serbia on the following topics:
pathophysiology of wound healing, pain and suppression of
pain, antiseptics – facts and errors, skin substitutes, possibilities
of debridement in the family physician’s clinic, the value of
carboxytherapy, the problem of peripheral ischaemia in primary medicine, along with a skin doctor’s review of the treatment of chronic wound in a community setting.
There was a lively debate and a number of proposals were put
forth. We concluded that work with patients suffering from
chronic wounds must be intensified, made more professional
and that outpatient and hospital sectors must be more closely
related in the area of chronic wound management.
The fourth block consisted of workshops on compression
therapy. The participants at the Symposium stated that workshops were the most useful form of education from the point
of view of everyday clinical practice. They appealed to the
organisers to increase the number of hours dedicated to practical work in the next symposium. It is interesting to note that
nearly all participants took part in the workshops, both participants and lecturers. The exchange of knowledge and experience
yielded high quality education and provided many practical
answers.
The chapter on lymphoedema showed that there are a number
of theoretical subjects which deserve further attention, and
examples from clinical practice pointed to a number of problems
that can be resolved, as well as connecting the primary and
tertiary healthcare in a more effective way in the area of
chronic wound management.
The workshops proved once again the necessity of a targeted
and supervised clinical practice, which can be carried out only
by educated professionals in this field.
Theoretical lectures provided us with a number of novelties and
changes, and informed us of studies that were carried out in
the past ten-year period, which changed the clinical practice.
This primarily relates to the issues of disinfectants and biofilm,
substitutes and alternative forms of treatment of skin defects,
suppression of pain and the value of new supportive therapeutic procedures. n
The last block of lectures was allocated to representatives of
companies in order to give them the opportunity to present
novelties in their production in front of a relevant body of participants. They were encouraged to present these novelties in
the management of chronic wounds without advertising slogans
and adjectives such as “the best”, “of highest quality”, “unique”
and the like, which is usually the case in commercial presentation of products.
The guidelines on prevention and treatment of decubitus
drafted by the Croatian Wound Association were distributed to
a certain number of healthcare professionals in order to
gather their feedback. This is necessary in order to formulate
EWMA Journal 2016 vol 16 no 1
103
The Next Generation of Wound Care:
Grafix ® Cryopreserved Placental Membrane
• Designed for application directly to
acute and chronic wounds, including but
not limited to, Diabetic Foot Ulcers and
Venous Leg Ulcers
• Flexible, conforming and adheres to
complex anatomies
• Available in multiple sizes
Randomised multi-centre trial
comparing Grafix vs. conventional
care in 97 patients with Diabetic
Foot Ulcers1
• Median time to closure was 42 days
compared to 70 days for the control
group (n =97, p =0.019)
• 50% fewer infections occurred in the
Grafix group than control (18% vs.
36%, p = 0.044)
a Relative improvement 3x greater than other wound therapies that have
been used in multi-center randomised controlled trials.
Control (standard care) included surgical debridement, off-loading, and
non-adherent dressings.
7015 Albert Einstein Drive
Columbia, MD 21046, USA
+1-888-OSIRIS 1
www.Osiris.com
GR 16005/REV00
1. Lavery LA, Fulmer J, Shebetka KA, Regulski M, Vayser D, Fried D, et al. The
efficacy and safety of Grafix for the treatment of chronic diabetic foot ulcers:
results of a multi-centre, controlled, randomised, blinded, clinical trial. Int
Wound J. 2014;11(5):554-560
Organisations
EBA
European Burns
Association
New impulses
for the care of
burn patients
Attracting more than 880 participants, the 16th “European Burns Association Congress” in Hannover has
been a big success. The international congress was
organised by the “European Burns Association” (EBA)
in cooperation with the German Society for Burn
Medicine (DGV).
Peter M. Vogt
Hannover Medical School
Department of Plastic, Hand
and Reconstructive Surgery
President of the EBA and
Congress President 2015
For four days, renowned experts from European and
Intercontinental countries exchanged latest information in the treatment of burns.
Besides current issues in practice, the conference’s
focal points were on practice guideline-based therapy,
quality assurance and the accreditation of burn
injury centres in Germany and Europe.
A special highlight of the congress was the lecture of
the Italian plastic surgeon and burn specialist Prof.
Dr. Michele Masellis from Palermo, Italy who has been
honoured with the Rudi Hermans Lecture.
For more than 30 years he has been working to
improve burn medicine in southern Europe and the
Orient, doing important work for the therapy, especially in the Mediterranean region and in developing
countries. By establishing modern standards at conferences, seminars and in surgical operations, he had a
major impact improving the care of patients affected
by severe burn injuries.
methods that preserve the epidermis through cell
sprays and achieve significant improvements were
presented at the congress. Particularly impressive were
the microsurgical plastic restoration techniques and
the results of face transplant which were presented
from Prof. Juan Barret from Barcelona, one of the
leading global experts.
An important focus were infections in burns, scars
and paediatric burns - still the leading cause of death
despite advanced medical facilities, despite the maintaining of highest hygienic standards and the targeted use of antibiotics. Another focus was on the
progress in the treatment of scars - by microneedle
therapy, laser and mechanical processes. “These
advances are important especially for kids as they are
hampered in growth by scars and have to live their
whole life with physical and mental consequences,”
said Professor Vogt.
All information can be found under www.eba2015.
de.
The 17th “European Burns Association Congress” will
take place from 6 - 9 September 2017 in Barcelona.
“The EBA maintains a close collaboration with the
Euro-Mediterranean Burn Council, founded by Professor Masellis“ says congress president Prof. Dr. Peter
M. Vogt, chairman of the EBA, director of the Clinic
for Plastic, Aesthetic, Hand and Reconstructive Surgery at the Medical University of Hannover and director of the Severe Burn Injuries Centre Lower Saxony.
“Europe has grown closer together, also on a burn
medicine point of view.“
Correspondence:
eba@congresscare.com
www.euroburn.org
EWMA Journal In the area of acute care, a focus was on the new
method of so-called enzymatic debridement, a
removal of eschar by an enzyme that is applied from
the outside on the wound and that favourably influences the healing process at an early stage. In addition, skin replacements with biomaterials and new
2016 vol 16 no 1
105
Manchester - a centre of
excellence in wounds research
INTRODUCTION:
Ljubisa Paden
University of Ljubljana,
Department of Nursing,
Ljubljana, Slovenia
In February 2015, Mr. Ljubisa Paden (RN, Slovenia)
was awarded a EWMA Travel Grant by the EWMA
Executive Committee. The following report is his
account of the impressions and learning outcomes
from his visit to The School of Nursing, Midwifery
and Social Work at The University of Manchester.
EWMA provides travel grants to young practitioners who wish to develop their skills within wound
care and wound management abroad. The travel
grants will primarily be given for educational purposes or clinical experiences outside the applicants’
own countries.
You can find more information about the EWMA
Travel Grant and how to apply at www.ewma.org.
Correspondence: ljubisa.
paden@zf.uni-lj.si
In September 2015 I visited The School of Nursing, Midwifery and Social Work at The University of Manchester, where I had the opportunity to be part of the Wounds Research Group.
The School of Nursing, Midwifery and Social
Work runs several different research projects in
wound care, and also houses the Editorial Unit
of Cochrane Wounds (one of the review groups
of the Cochrane Collaboration). This enabled me
to encounter many different types of research,
clinical practice and networking opportunities.
The main learning objectives were to improve
my research skills and therefore I was engaged
with various research tasks. I strengthened my
knowledge and skills in research design, especially
in designing prevalence studies and qualitative
studies related to wound research. I improved my
skills in critical appraisal and evidence synthesis.
Another important focus of my visit was oriented
towards exploring ethical issues related to wound
research. I had the opportunity to discuss my
PhD project with several researchers. The project
will explore the prevalence and lived experience of
people with surgical wounds healing by secondary intention. Furthermore this travel was also
oriented toward improving my personal effectiveness and therefore I have improved my language
skills, presentation skills and communication
with different stakeholders. Moreover I had an
opportunity to be present at many meetings of
106
different wound-related research projects groups
where I had chance to observe how the projects
are lead, time management of projects, and how
to manage different tasks in research projects.
During this study tour I also visited three clinical placements in order to become acquainted
with the management of complex wounds in the
United Kingdom. Two of the clinical settings
were in the community, and I also visited a university hospital. In the leg ulcer clinics I gained an
insight into the organisational aspect of nurse-led
clinics, and furthermore I observed tissue viability
nurses and district nurses in a wound management context. I was impressed by their broad
knowledge and professional competencies in decision making, which differ quite significantly
from those in Slovenia. I also visited the Tissue
Viability/Infection Control Services at Central
Manchester University Hospitals NHS Foundation Trust, where I became acquainted with the
specialist tissue viability services which are provided in hospital wards and in out-patient clinics.
I had many opportunities to discuss wound care
with various healthcare professionals who provide
direct or indirect wound care, such as staff nurses,
ward managers, advanced nurse practitioners,
nursing specialists, cardio-thoracic surgeons and
microbiologists. All these professionals briefly
described how they are connected with wound
care and wound research. Furthermore they were
all happy to answer my questions related to my
research project.
This study tour has also widened my professional network, as I had many opportunities to
connect with practitioners and researchers in
wound care across academia and health care services, specifically the NHS.
This travel grant will help me translate and
introduce new theoretical knowledge, good
practices and research methods not only to my
teaching colleagues in Slovenia but also to students, researchers and professionals in clinical
practice. Furthermore I hope that this training
will eventually have an important impact on the
development of higher quality wounds research
and improve the translation of research evidence
EWMA Journal 2016 vol 16 no 1
Organisations
The School of Nursing, Midwifery and Social Work at The University of Manchester, UK
into clinical practice in Slovenia and beyond.
I would like to express my thanks to EWMA,
who awarded me a travel grant; to the Department
of Nursing, Faculty of Health Sciences, University
of Ljubljana, who supported this travel; to Profes-
sor Dame Nicky Cullum who hosted me at the
School of Nursing, Midwifery and Social Work,
The University of Manchester, and to all the practitioners and researchers who were involved in my
training. n
2nd International Congress Fellows in Science
and the10th National Croatian Congress of plastic,
reconstructive and aesthetic surgery
Dubrovnik, Croatia, was the venue of the 2nd International Congress Fellows in Science and the 10th
National Croatian Congress of plastic, reconstructive
and aesthetic surgery from 1- 4 October 2015. The
conference was recognised and appointed by the European Society of plastic, reconstructive and aesthetic
surgery (ESPRAS) with whom EWMA has an agreement of exchange of presentations at our respective
conferences.
Fellows in Science is a place of gathering of experts
in the field of plastic, reconstructive and cosmetic
surgery, as well as other specialists, who exchange
experiences, skills and knowledge.
The Congress was attended by the most respected experts from Croatia and 40 highly distinguished speakers from Europe, USA and Asia. Conference topics
covered all areas of plastic surgery from cosmetic
surgery, microvascular and reconstructive surgery of
the breast, body and extremities, hand surgery, surgery
of melanoma to the modern treatment of burns and
contemporary approach to the treatment of chronic
wounds. The Congress programme was implemented
through 14 professional sections, two satellite symposia, 5 workshops, a number of distinguished speakers
addressing lectures and final roundtable.
EWMA Journal 2016 vol 16 no 1
EWMA offered a separate guest session attended by
30 - 40 participants including:
n Introductory lecture about EWMA activities by
Dubravko Huljev. All participants were already
familiar with EWMA activities, and showed great
interest in the presented activities, and the importance of promoting the managing of patients with
wounds including education, adoption of consensus and guidelines, and connections between
national associations and individuals involved
in treating patients with wounds.
n Main lecture by Rose Cooper about the EWMA
document “Antimicrobials and non-healing
wounds: evidence, controversies and suggestions”.
n Main lecture by Dubravko Huljev about the EWMA
Dubravko Huljev
Former EWMA
Secretary
Rose Cooper
Co-author of he EWMA
document “Antimicrobials
and non-healing
wounds: evidence,
controversies and
suggestions
document “Managing wounds as a team”.
During the lectures, and later in the discussion, we
clarified the basic concepts of interdisciplinary, multidisciplinary and transdisciplinary approach to treating
patients, particularly patients with chronic wounds.
The participants showed great interest in this subject,
and provided their own examples from everyday work,
and their experiences and difficulties in implementing
this approach to treating patients. After discussion,
everyone agreed that the team approach is indispensable if we want to achieve the best results in the
treatment of patients with chronic wounds. n
www.espras.org
107
35th annual meeting of the European
Bone and Joint Infection Society
Save the date:
1-3 September 2016
Oxford, United Kingdom
Early registration
deadline
1 August 2016
www.ebjis2016.org
The new face of
Dermatology
• New Editor-in-Chief:
G.B.E. Jemec
• New section ‘Skin Cancer’
edited by C. Ulrich
• New section ‘Tattoo and Body Art’
edited by J. Serup and N. Kluger
• New section ‘International
Dermatology Outcome Measures’
edited by A. Garg
• New Editorial Board
• Reduced color charges
• Free access and no page charges
for all review papers
www.karger.com/drm
KI16310
S. Karger
Medical and Scientific Publishers
Basel . Freiburg . Paris .
London . New York . Chennai .
New Delhi . Bangkok . Beijing .
Shanghai . Tokyo . Kuala Lumpur .
Singapore . Sydney
Corporate Sponsors
Corporate A
ConvaTec Europe
www.convatec.com
acelity
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Flen Pharma NV
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BSN medical GmbH
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PAUL HARTMANN AG
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Coloplast
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Lohmann & Rauscher
www.lohmann-rauscher.com
Mölnlycke Health Care Ab
www.molnlycke.com
Ferris Mfg. Corp.
www.PolyMem.eu
Wound Management
Smith & Nephew Medical Ltd
www.smith-nephew.com/wound
Wacker Chemie AG
www.wacker.com
Corporate B
Nutricia Advanced
Medical Nutrition
www.nutricia.com
Laboratoires Urgo
www.urgo.com
DryMax
www.absorbest.se/
drymax-woundcare
SastoMed
www.sastomed.com
Vancive Medical
Technologies
vancive.averydennison.com
Freudenberg Vliesstoffe SE
& Co. KG
www.freudenberg-pm.com
SOFAR S.p.A.
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KLOX Technologies Inc
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Söring Gmb
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3M Health Care
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Covalon Technologies Ltd
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ABIGO Medical AB
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Boyd Technologies
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B. Braun Medical
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Chemviron
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110
Medi GmbH & Co. KG
www.medi.de
Welcare Industries SPA
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Stryker
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EWMA Journal 2016 vol 16 no 1
Exclusive offer for
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Visit www.magsubscriptions.com/jwc or call +44 (0)1722 716997
Conference Calendar 2016/17
Conferences 2016
Theme
Month
Days
EWMA+DeWu+Wunddach
Patients·Wounds·Rights
May
11-13Bremen
Germany
16th Malvern Diabetic Foot Conference
May
18-20
Oxfordshire
United Kingdom
13th EADV Spring Symposium
May
19-22
Athens
Greece
May
26-28
Darwin
Australia
International Lymphoedema Framework
Asia Pacific Lymphology
Conference
City
Country
EFORT 17th EFORT Congress
June
1-3
Geneva
Switzerland
SAfW Romande
June
2
Morges
Switzerland
AEEVH28th
National Congress of
Vascular Nursing and Wounds
June 9-10
Barcelona
Spain
DGfW
1st DGfW Academy-Day
June
17
Giessen
Germany
3rd international Course on the Neuropathic Osteoarthropatic Foot (Charcot Foot Course)
June
23-25
Rheine
Germany
35th Annual meeting of the European Bone and Joint Infection Society
September
1-3
Oxford
United Kingdom
A-DFS2nd Conference of the September
8-9
Stuttgart
Association for Diabetic Foot
Surgeons
Germany
DFSG+EASD13th meeting of the Diabetic Foot Study Group and the
European Association for the
Study of Diabetes
September
9-11
Stuttgart
Germany
SAfW
18th Symposium for Wound Care September
15
Zürich
Switzerland
The Lindsay Leg Club Foundation
16th Annual Conference
September
21-22
Worcester
UK
DEBRA
International Conference
September
22-25
Zagreb
Croatia
September
25-29
Florence
Italy
September
26-27
Birmingham
UK
EADV25th EADV Congress
Sept-Oct
28-2
Vienna Austria
NDF
Nordic Diabetic Foot Symposium 2016
October
5-6
Copenhagen
Denmark
SAWC Fall Symposium
October
7-9
Las Vegas
Nevada, US
October
12-15
Pisa
Italy
WUWHS5th congress of the WUWHS
European Burns Association
1st
EBA Educational Course
Pisa International Diabetic Foot Course
The annual conference of the Canadian Association of Wound Care
22nd annual conference
November
3-6
Niagara Falls
Canada
Wounds Australia
State of Play
November
9-12
Melbourne
Australia
Interdisciplinary Wound Congress
November
24
Köln
Germany
Annual Meeting of the Danish Wound Healing Society
November
26
Billund Danmark
Conferences 2017
Month
Days
City
Country
European Pressure Ulcer Advisory Panel Focus meeting
April
4-6
Berlin
Germany
SAWC Spring Symposium
April 5-9
San Diego, CA
USA
EWMA 2017
Annual Conference
May
3-5
Amsterdam
The Netherlands
Theme
For web addresses please visit www.ewma.org
112
EWMA Journal 2016 vol 16 no 1
26-27 SEPTEMBER 2016
ICC | BIRMINGHAM – UNITED KINGDOM
TOP FACULTY ON THE FOLLOWING TOPICS:
• Patients assessment
• Scar assessment
• Principles of reconstruction
• How can Science improves outcomes?
• Facial reconstruction
• Novel Anti-scarring Strategies
• Breast reconstruction
• Reconstruction in Resource-Limited environments
• Outcomes
• Scalp reconstruction
• Contractures
• Transplants
• Hand and upper limb reconstruction
• Post burn reconstructive surgery with dermal equivalents
surgical steps
• Neck Reconstruction
• Microsurgery
• Axillae and Chest
• Tissue expansion
• Lower limb reconstruction
• Future Therapies
• Hypertrophic scarring; molecular overview
• Stem Cell Therapy
• Microneedling
• Hair transplant
• An overview of the future of skin substitutes
1
ST
EUROPEAN
EBA BURNS
ASSOCIATION
EDUCATIONAL
COURSE
26-27 SEPTEMBER 2016
ICC | BIRMINGHAM – UNITED KINGDOM
WWW.EBA2016.ORG
Congress & Exhibition Organiser | Congress Care - EBA Society Office
Congress Care, P.O. Box 440, 5201 AK ’s-Hertogenbosch, The Netherlands
Tel. +31 (0)73 690 14 15, Fax.+31 (0)73 690 14 17
info@congresscare.com, www.congresscare.com
509185_CC_EBA_Adv210x142.indd 1
04-03-16 09:33
medi Wound Care
Effective therapy chain for treating venous leg ulcer together.
• Effective products for guideline-compliant care
• Shorter treatment times and higher patient adherence
“I’m totally convinced by medi’s
wound concept – my treatment
is guideline-compliant and
economical, but still individual”.
• Economic use of staff and materials
Bremen:
See you in
1
Booth 5J2
Step
3
Step
2
© medi: the person shown is a model.
Prevention of
recurrence
Compression therapy
in the maintenance
phase –reliable and
Therapy of the
attractive.
Step
underlying disease
• mediven plus
Compression therapy
• mediven 550 leg
in the acute phase –
• circaid juxtalite
effective and
Wound debridement
self-managing.
Cleansing of the wound
• circaid juxtacures
in the acute phase.
• mediven ulcer kit
• UCS Debridement
1
Discover the medi World of Compression.
Cooperating
Organisations
AEEVH
Spanish Association of Vascular
Nursing and Wounds
www.aeevh.es
AFIScep.be
French Nurses’ Association
in Stoma Therapy, Wound
Healing and Wounds
www.afiscep.be
AISLeC
Italian Nurses’ Cutaneous
Wounds ­Association
www.aislec.it
AIUC
Italian Association for the
study of Cutaneous Ulcers
www.aiuc.it
AMP Romania
Wound Management
Association Romania
www.ampromania.ro
APTFeridas
Portuguese Association for the
Treatment of Wounds
www.aptferidas.com
AWTVNF
All Wales Tissue Viability
Nurse Forum
www.welshwoundnetwork.org
AWA
Austrian Wound Association
www.a-w-a.at
BEFEWO
Belgian Federation of
Woundcare
www.befewo.org
BWA
Portuguese Wound Society
www.sociedadeferidas.pt
FWCS
Finnish Wound Care Society
www.shhy.fi
GAIF
Associated Group of Research
in Wounds
www.gaif.net
GNEAUPP
National Advisory Group for the
Study of P
­ ressure Ulcers and
Chronic Wounds
www.gneaupp.org
HSWH
Hellenic Society of Wound
Healing and Chronic Ulcers
www.hswh.gr
ICW
Chronic Wounds Initiative
www.ic-wunden.de
LBAA
Latvian Wound Treating
­Organisation
LUF
The Leg Ulcer Forum
www.legulcerforum.org
LWMA
Lithuanian Wound Management Association
www.lzga.lt
MASC
Macedonian Wound
Management Association
National Association of Tissue
Viability Nurses, S
­ cotland
NIFS
Hungarian Association for the
Improvement in Care of Chronic
Wounds and Incontinentia
www.sebinko.hu
SEHER
The Spanish Society of Wounds
www.sociedadespanolaheridas.
es
SFFPC
The French and Francophone
Society f Wounds and Wound
Healing
www.sffpc.org
SSiS
Swedish Wound Care Nurses
Association
www.sarsjukskoterskor.se
SSOOR
Slovak Wound Care Association
www.ssoor.sk
SSPLR
The Slovak Wound Healing
Society
www.ssplr.sk/en
STW Belarus
Icelandic Wound Healing
­Society
www.sums.is
SWHS
Serbian Wound Healing Society
www.lecenjerana.com
SWHS
Swedish Wound Healing Society
www.sarlakning.se
TVS
NOVW
URuBiH
Croatian Wound Association
www.huzr.hr
DGfW
PWMA
German Wound Healing
Society
www.dgfw.de
Polish Wound Management
Association
www.ptlr.org.pl
DSFS
SAfW
Danish Wound Healing
Society
www.saar.dk
SEBINKO
Norwegian Wound Healing
Association
www.nifs-saar.no
Dutch Organisation of Wound
Care Nurses
www.novw.org
D A N I S H WO U N D
HEALING S O C I E T Y
Serbian Advanced Wound
Management Association
www.lecenjerana.com
SUMS
Hungarian Wound Care Society
www.euuzlet.hu/mskt/
NATVNS
CWA
SAWMA
MSKT
CNC
Czech Wound Management
Society
www.cslr.cz
Swiss Association for Wound
Care (French section)
www.safw-romande.ch
Society for the Treatment of
Wounds
(Gomel, Belarus)
www.burnplast.gomel.by
MWMA
CSLR
SAfW
Maltese Association of Skin
and Wound Care
www.mwcf.madv.org.mt/
Bulgarian Wound
Association
www.woundbulgaria.org
Clinical Nursing Consulting –
Wondzorg
www.wondzorg.be
114
ELCOS
Tissue Viability Society
www.tvs.org.uk
Association for Wound
Management of Bosnia and
Herzegovina
www.urubih.ba
UWTO
Ukrainian Wound Treatment
Organisation
www.uwto.org.ua
Swiss Association for Wound
Care (German section)
www.safw.ch
EWMA Journal 2016 vol 16 no 1
Organisations
Cooperating
Organisations (cont.)
V&VN
Decubitus and Wound Consultants, ­Netherlands
www.venvn.nl
WCS
Knowledge Center
Woundcare
www.wcs.nl
WMAI
Wound Management
­Association of Ireland
www.wmai.ie
WMAK
Wound Management
Association of Kosova
WMAS
Wound Management Association Slovenia
www.dors.si
ILF
International Lymphoedema
­Framework
www.lympho.org
KWMS
Korean Wound Management
Society
www.woundcare.or.kr/eng
NZWCS
New Zealand Wound Care
Society
www.nzwcs.org.nz
SILAUHE
Iberolatinoamerican Society of
Ulcers and Wounds
www.silauhe.org
SOBENFeE
Brazilian Wound M
­ anagement
­Association
www.sobenfee.org.br
World Alliance for Wound and
Lymphedema Care
www.wawlc.org
Other Collaborators
Diabetic Foot Study Group
www.dfsg.org
AAWC
Association for the
Advancement of Wound Care
www.aawconline.org
Wounds Australia
Wounds
Australia
www.awma.com.au
CAWC
Canadian Association of
Wound Care
www.cawc.net
Debra International
Dystrophic Epidermolysis
Bullosa Research Association
www.debra.org.uk
EFORT
European Federation of
National Associations of
­Orthopaedics and
Traumatology
www.efort.org
CTRS
(Chinese Tissue Repair Society)
www.chinese-trs.com/en
IWII
Int. Wound Infection Institute
www.woundinfection-institute.
com
EWMA Journal 2016 vol 16 no 1
HomeCare Europe
www.homecareeurope.org
ICC
International Compression Club
www.icc-compressionclub.com
MSF
Médecins Sans Frontières
www.msf.org
WUWHS
The World Union of Wound
Healing Societies
www.wuwhs.org
Associated
Organisations
Leg Club
DFSG
International
Partner Organisations
Eucomed Advanced Wound
Care Sector Group
www.eucomed.org
WAWLC
WMAT
Wound Management
­Association Turkey
www.yaradernegi.net
Eucomed
Lindsay Leg Club Foundation
www.legclub.org
LSN
The Lymphoedema
Support Network
www.lymphoedema.org/lsn
EADV
European Academy of Dermatology and Venereology
www.eadv.org
EBA
European Burns Association
www.euroburn.org
ECET
European Council of Enterostomal Therapy
www.ecet-stomacare.eu
ESPEN
The European Society for Clinical Nutrition and Metabolism
www.espen.org
Media Partner
JWC
Journal of Wound Care
www.magonlinelibrary.com
For more information about
EWMA’s Cooperating Organisations
please visit www.ewma.org
ESPRAS
European Society of Plastic,
Reconstructive and Aesthetic
Surgery
www.espras.org
ESVS
European Society for Vascular
Surgery
www.esvs.org
EPUAP
European Pressure Ulcer Advisory Panel
www.epuap.org
ETRS
European Tissue Repair Society
www.etrs.org
115
7 Editorial. Läuchli S
Science, Practice and Education
11 Development of an evidence-based global consensus for diabetic
foot disease: The 2015 guidance of the International Working
Group on the Diabetic Foot. Van Netten JJ, Bakker K, Apelqvist J,
Lipsky BA, Schaper NC,
17 Clinical challenges of differentiating skin tears from pressure ulcers.
LeBlanc K, Alam T, Langemo D, Baranoski S, Campbell K, Woo K
25 Primary Care Patient Safety (PISA) Research Group - Identifying
priorities for pressure ulcer prevention in primary care. Samuriwo R,
Evans HP, Carson-Stevens A, Rees P, Hibbert P, Makeham M, Williams H
29 Challenges faced by healthcare professionals in the provision of
compression hosiery to enhance compliance in the prevention of
venous leg ulceration. Tandler SF
35 Pressure Ulcer Incidence: Do patients retain information?
Vowden K, Warner V, Collins J
39 Wound management in epidermolysis bullosa, Denyer J
45 Skin aging: a global health challenge. Vuagnat H
Cochrane Reviews
49 Abstracts of recent Cochrane reviews. Rizello G
Celebration of EWMA’s 25 year anniversary
62 Milestones in EWMA’s history
66 25 years of EWMA conferences
70 Making a difference in wound care
EWMA
78 EWMA 2016 Conference in Bremen, Germany
81 Document summary: Management of patients with venous leg ulcers:
challenges and current best practice. Franks PJ, Barker J
90 New corporate sponsors
92 EWMA News
Organisations
98 Wounds Australia News. McGreogor H
99 AAWC News. Driver VR
101 WAWLC News. Keast D, Vuagnat H
102 Review of the 8th Symposium on Chronic Wound organised by CWA.
Kucisec-Tepes N
105 New impulses for the care of burn patients. Vogt PM
106 Manchester - a centre of excellence in wounds research. Paden L
107 2nd International Congress Fellows in Science and the 10th National
Croatian Congress of plastic, reconstructive and aesthetic surgery
110 Corporate Sponsors
112 Conference Calendar
114 Cooperating Organisations, International Partners and Other
Collaborators; an overview