The impact of introducing a new foam dressing in community practice

An audit of resource use was undertaken in 35 patients treated by two ambulatory wound care providers in Germany (one medical practice and one outpatient wound clinic). A new wound dressingi was introduced with appropriate education and training in its use, and the frequency of dressing change and types of dressings used were recorded before and after adopting the new approach. Clinicians’ views on the performance of the dressing were also surveyed. After the introduction of the new wound dressing into routine community wound care practice, the mean frequency of dressing change was reduced by 1.3 times per week, from 4.6 to 3.3 times per week. The complexity and number of different dressing products decreased. The cost of dressings per change increased slightly, but the average cost of dressings per week was reduced by approximately 23%. Clinicians’ feedback on the new product was positive, with the overall performance rated as better than previous products for over 90% of wounds. INTRODUCTION Wounds are a growing health issue in Europe, and their treatment consumes a considerable quantity of resource1. Surveys in the UK have reported the population prevalence of wounds to be 3 to 4 people with one or more wounds per 1000 population.1,2, It has been estimated that there are as many as 1.0-1.4 million diabetic foot ulcers (DFUs) and 0.5-1.3 million leg ulcers at any one time in Europe, with 400,000-600,000 new DFUs per year and almost one million new venous leg ulcers (VLUs) presenting each year.3 The economic cost of managing these wounds is considerable, representing 2-4% of the total healthcare budget.4 As an example of the cost of treating individual wounds, the mean total cost of treating a chronic leg ulcer per year in Germany has been estimated to be over €9000.5,6 The demand for wound care will continue to grow because of an ageing European population and the growth of chronic long-term conditions, and as a consequence, the cost of treatment is likely to continue to rise.7 This is against a backdrop of competing resources from other areas of healthcare and increasing pressure on healthcare funding, and therefore efficiency gains will be necessary if providers are to continue to meet demand for wound care services. Much of the cost of wound care is driven by hospitalisation and nursing time, with materials and dressings making up a relatively small proportion.1,2 In the medical practice and outpatients setting, most of the resource utilisation is the time of healthcare professionals required to change wound dressings and undertake other activities such as cleansing, debridement and wound assessment.2 Hence one of the key ways to make wound care more efficient is to release some of this time. Previous studies have shown that the introduction of an advanced wound dressing combined with changes in practice can reduce unnecessary dressing changes and help to free up nurses’ time.8,9,10  Science, Practice and Education i ALLEVYNTM LIFE, Smith & Nephew, Hull, UK Efficiency in wound care: Contact [email protected] for more information. CE Mark Pending. ColActive is a registered trademark of Covalon Technologies Ltd. © 2016 Covalon Technologies Ltd. Mississauga, ON, Canada L4W 5S7. Chronic Wounds? The only advanced collagen dressing that contains EDTA for selective, permanent MMP inhibition with CMC and Alginate to maintain an optimal moist wound healing environment. Can Help. See you at The EWMA 2017 Conference. EWMA Journal 2017 COVALON Ad.indd 1 2016-09-07 1:09 PM EWMA Journal 2016 vol 16 no 2 7 One of these studies also showed a reduction in dressing costs as a result of adopting this approach.10 The dressing used in these studies includes a change indicator that is designed to indicate when the dressing needs to be changed, and a discretion / masking layer that reduces the staining of the dressing surface with exudate. This article describes the results of an audit of resource use undertaken by two ambulatory operating wound care providers in Germany. With regard to the treatment of chronic wounds, the relevant medical practice in Jena treats ulcus cruris patients (both venous and arterial aetiologies), secondly decubitus cases and in some cases diabetic foot cases. The practice is part of the wound network of Thuringia, which is a network of ambulatory medical practices focused on wounds, hospitals, medical suppliers, nursing services etc, enabling well-organised treatment of patients with chronic wounds. The Saalfeld centre primarily treats peripheral arterial occlusive diseases (level 4) with peripheral lesions as well as diabetic foot ulcers. The newii wound dressingiii was introduced with appropriate education and training in its use, and the frequency of dressing change and types of dressings used were recorded before and after adopting the new approach. Clinicians’ views on the performance of the dressing were also surveyed as part of the audit. METHODS Firstly, prior to the introduction of the new dressing, there was a training and education phase, during which staff were made aware of the new dressing and trained in how to use it. Clinicians in one of the two sites had previously been aware of the dressing, whereas in the other they were not. Particular attention was paid to making use of the exudate masking and visual indicators, which help patients and clinicians to recognise the most appropriate time to change the dressing. Secondly, staff (wound care nurses and homecare providers) at the two sites used the new dressing routinely in their practice for suitable patients with chronic wounds, based on the product’s indications for use. These decisions were based on clinical judgment and clinicians were able to modify their practice where appropriate (particularly dressing change frequency) to make use of the features of the new dressing. Anonymised data were collected using a paper audit form for each wound where the dressing was used, for a maximum of four dressing changes during January 2015 to April 2015. The data collected included details of wound characteristics, information about the dressings that were used and clinicians’ feedback on the performance of the new dressing. Wear times were recorded for previous dressings and for the new dressing (the latter being recorded for four dressing changes). These values were converted to frequency of dressing change for each wound using the equation: frequency (per week) = 7 / wear time (days). Dressing change frequency data were analysed on a per-patient basis, i.e. the frequency was first calculated for each patient and then the mean value was calculated across the group of patients. Wound area at the start of the evaluation was estimated from the maximum length and width of each wound using an ellipse formula.iv,11 Tables of results were prepared using SPSSTM v19.0. German national pharmacy prices were used to calculate the cost per dressing change and cost per week of the dressings that were used. In order to estimate costs where generic or non-specific dressing types were recorded, assumptions were made about which products were used. Details of dressing sizes were only recorded for the new dressing, so for previous dressings the nearest size which matched the size of the new dressing was assumed. In some cases, the secondary dressing or fixation was not recorded. In these cases, as a conservative approach, we did not assume any secondary dressing costs. RESULTS 35 patients with wounds who were being treated in the two different wound care providers in Germany (referred to above) were included in the audit. 34 patients had one wound and one patient had two wounds. For this latter patient, data relating to the larger of the two wounds were included. Therefore, in total, data from 35 wounds were included in the analysis. DEMOGRAPHICS AND WOUND CHARACTERISTICS Around three-quarters of patients were more than 60 years old, the most common age range being 71-80 years (Table 1). TABLE 1: PATIENT AGE Age category Number of Percentage (years) patients of patients 31-40 1 2.9% 41-50 0 0.0% 51-60 8 22.9% 61-70 5 14.3% 71-80 13 37.1% 81-90 8 22.9% Total 35 100% *Percentages may not add up to 100% due to rounding ii The term ‘new dressing’ refers to the newly-introduced dressing. iii ALLEVYN LIFE, Smith & Nephew, Hull, UK iv Area = length x width x ∏/4. EWMA Journal 2016 vol 16 no 1 8 Of the 35 wounds included in the audit, 20.0% (7/35) were diabetic foot ulcers (DFUs), 31.4% (11/35) were venous leg ulcers (VLUs), 28.6% (10/35) were pressure ulcers and the remaining 20.0% (7/35) were other wound types. Nine of the ten pressure ulcers were Category 2 ulcers and one was a Category 3 ulcer. Of the seven DFUs, one was classified as a Stage 1 DFU, four were classified as Stage 2 and two were “malum perforans” ulcers. Wound area was calculated for 33 wounds where length and width were available. Of these wounds, more than 75% of the wounds had a wound area of less than 10cm2, with only 6.1% (2/33 wounds) having an area of more than 40cm2 (Figure 1). FIGURE 1: WOUND AREA The most common exudate level was Moderate (15/34 wounds, 44.1%), with 10 wounds recorded as Low (29.4%), 1 wound Moderate to high (2.9%) and 8 wounds with a high level of exudate (23.5%). Of the 33 wounds where the type of exudate was recorded, 23 (69.7%) were recorded as having Fluid exudate, and 10 (30.3%) had Viscous exudate. Respondents were also asked to record the condition of the wound bed at the start of the evaluation. These categories were not mutually exclusive and therefore selection of more than one category was permitted. 45.7% of wounds (16/35) were epithelialised, 68.6% (24/35) had granulation tissue present, 5.7% (2/35) had necrotic tissue and 68.6% (24/35) had slough. The condition of the surrounding skin at the start of the evaluation was recorded (again with multiple selection permitted). 48.6% (17/35) had healthy skin, 31.4% (11/35) had reddened skin, 5.7% (2/35) had moist skin and 8.6% (3/35) had dry skin. DRESSING PRACTICE 3 of the 35 wounds were newly-presenting and therefore had no previous dressing use. For the remaining 32 wounds, the previous dressing products used prior to the introduction of the new dressing were recorded. Four of these wounds had multiple products used, whereas 28 wounds had a single product used. Where there was a previous product used, 65.6% (21/32) of these wounds had been treated with a foam dressing. Other dressings used pre-implementation included alginates, hydrocolloids and absorbent dressings (Table 2). After the changes, the new dressing was used on all 35 wounds. In some cases, other products were used in conjunction with the new dressing (Table 3). Science, Practice and Education