Chronic Wound Management Fundamentals and Best Practice

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Gary discusses treating the whole person and not just the hole in the person

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 SPEAKER:

Welcome to Smith & Nephews, Closer to Zero podcast. Bi-monthly podcast  with leading experts in wound care hosted by Smith & Nephew. Helping  health care professionals in reducing the human and economic cost of wounds.

00:00:03

RUTH  TIMMINS:
Hello, I'm Ruth Timmins from Smith & Nephew and welcome to today's  podcast. Today, we have a very special guest, Gary Bain, otherwise known as  the Wound Guy. To discuss the topic of chronic wounds and some key principles and considerations. Gary's a nurse educator and wound care consultant, and he  led the launch and implementation of the Wound Management Service at the  Sydney Adventist Hospital, and directed the nurse-led outpatient Wound Clinic  for 25 years.

Currently,  he's in private practice and also provides clinical support to patients and  their clinicians in the aged care, primary care and community sectors. With  his present role as educator, nurse consultant in wound management at the Mt  Wilga Private Hospital. And he's also a lecturer at Macquarie University's  Australian Lymphoedema Education Research and Treatment. So welcome, Gary,  and thank you for joining us today.

00:00:20

GARY  BAIN:
Thank you, Ruth.

00:01:13

RUTH  TIMMINS:
So, on the topic of discussing chronic wounds, we often hear the statement,  you know, ‘treat the whole person not just the hole in the person.' So what  is your take on this advisory? And can you comment on its application in your practice?

00:01:14

GARY  BAIN:
Sure I think one of the big mistakes that health professionals make when we have somebody in front of us who has a wound, and we educate our patients to  kind of think the same way too, which is an error. And that is we kind of put wounds as if they are an entity all of their own. We kind of talk about the wound. We talk about the dressing on the wound and maybe getting if it had  the right dressing, then the wound would be fine. But we always talk about the wound as if it was almost something separate to who the individual is.

And  the idea of treat the whole person, not just the hole in the person. I like  that concept, because when we come to really try and understand, why is it  that a wound which should heal, we are designed to heal and we do all of our life until we arrive at a time when we don't. Well, why not? Why now all of a  sudden, something I could have got better, why now can I not get it better?  What is it that has made this hard to heal or made it chronic? And I think  the link that I like to try and help people realise is that the skin is  actually an organ. This organ is part of a system called the integumentary  system. And all systems within the body have a relationship with one another.  They all influence one another.

So  if a wound which would have healed normally now is struggling to do so, then  there's always gonna be a reason why things are in struggle street. And  invariably it means finding what other systems are in this person's body, which may also require attention or fixing. You know, maybe we got to get  better nutrition, maybe that the blood supply to the wound is not ideal and  the vein needs to be decongested, or the artery needs to deliver more blood. Now maybe it's something as simple as the fact that we've got a swollen leg,  and we need to try and get rid of some of that fluid in the leg for the wound  to start to heal.

So,  the concept that when we do see somebody with a wound, and this wound has now  been present for weeks or months, means we can't just look at the hole. We've  got to consider the individual in their entirety. And sometimes that means  their social circumstances as well. You know, what's happening within their  larger environment around what they can financially afford. What are they  eating? What's their level of activity? Do they have social support? Do they  have experiences with anxiety and depression? All of these things ultimately  are connected and have a response to and from the wound.

00:01:29

RUTH  TIMMINS:
And so, I know you've mentioned before in previous webinars and so on about  having a diagnosis. So, you know, in your experience, is that often a problem  that the wound hasn't been properly diagnosed?

00:04:05

GARY  BAIN:
Yes. Yeah. Now, look, that's a lovely question Ruth, because there is been  work done by Professor Julian Guest in the UK. And what he's mentioned there,  I think is very applicable for Australia as well. And that is that people  when they have wounds which are on struggle street, they are hard to resolve.  That one in three, certainly one in two, may progress for their entire time  of trying to deal with their wound and not know the reasons for it to be  chronic - actually not have a label as to why it's so hard for this thing to  proceed to get better.

So  the absence of diagnosis is a major problem and that applies to whether  people are within the home care environment, within the aged care environment  or in the more acute care setting. But giving a chronic wound a name or a label, a reason to exist is a challenge. And that's actually one of our  greatest responsibilities as wound care clinicians, is to help people arrive  at a point where they can be given a diagnosis to their presentation.

00:04:19

RUTH  TIMMINS:
Cause I expect, obviously, once you've diagnosed the wound, that's then how  you can decide the appropriate treatment, and perhaps that leads into my next  question. Which would be, you know, so how do you decide upon what dressings  and therapies you want to use?

00:05:24

GARY BAIN:
Yeah, again, people will kind of assume that a dressing or when you get the  right dressing, that there's some way there a magic bullet. One of the things  that is so often done is the ad hoc nature of dressing wounds. And when one doesn't seem to be doing its job, you switch over to something else and see  if something else can do what the other one didn't.

But one of the biggest problems  we have, when you're dealing with folks with long term wounds, is the absence  of data. Having an understanding of what's gone on, what do we think might be  happening? If we are going to come up with an intervention, then what are our  goals? What are we hoping to achieve? Is it the issue of getting rid of  slough on a wound, reducing the amount of pain in a wound, maybe dealing with  the amount of exudate? In this goal-setting, it's not just the clinician  either. It should be the patient saying what do they want us to achieve if  we're looking after their wound?

And is there something that they  are looking at from a dressing perspective? Particularly around things like  dealing with smell, or containing the exudate that might be a continuing  problem for them. But when it comes to choosing dressings we need to be goal  centred, and we should be measuring wounds so that we know what their size  is, what the kind of tissue content is like in the wound. Is there slough  there? Is there granulation tissue? Is there brand new skin forming? And what  is the level of exudate? Because ideally when a wound is showing signs of  getting better, it should be a cleaner, healthier colour. The level of  exudate should be dropping away and then the size of the wound should be  getting smaller.

When it comes to your dressing  choice, if you're instigating a dressing for a goal and a purpose, you want  to see that it's actually achieving what you're aiming to set out to do. And  your three pillars of quantification are a part of that assessment. And you  combine that with decent photography and examining from the patient  perspective. What is their pain from zero to ten? What's their pain like when  you began? What's their pain like now? Do the same with odour and so forth.  Our interventions, which primarily consist of dressings, need to mean  something. You want to achieve something. And it also brings us to the point  that what we haven't said yet about some chronic wounds.

People assume that if we do the  right thing, that wounds will get better, the majority of wounds will get  better. But as we begin to label wounds with a diagnosis and bring those two  things together, there are times when wounds are hard to heal, but to bring  them to closure is not realistic. The most common one might be that person  who's got a malignant wound for instance, or someone who may actually have  leg swelling but they're in their 80s now. They live alone. They don't have  the dexterity to put their compression stocking on. So we'll have to live  with the fact that their wound will be an entity that they will struggle to  close.

So, whether we have a healable  wound or a non-healable wound, the nature of the diagnosis and work class or  category we put them in, then help us to elucidate the goals that are  required for what we wanna do with dressings. But if dressings are goal  orientated and measurable and then they can be evaluated, then they can be  the best tools and they're the necessary tools we need to choose the right  dressing for the right wound at the right time.

00:05:39

RUTH  TIMMINS:
That's so important isn’t it?. I know that we've recently concluded the Lymphoedema  Awareness Month and that you work in a lymphoedema unit or with a lymphoedema  unit, I should say. So what message do you have for individuals or clinicians  about managing limb swelling, you know, and how does, you know, oedema affect  wound healing?

00:09:02

GARY  BAIN:
Yeah, this is something that is not really well taught. So the awareness of  it within our health care sector is not yet ideal. So to have had months like  Lymphoedema Awareness Month, is a lovely shot in the arm to set a bit of momentum about this. It's not normal to have swollen legs and arms. You know,  it can happen for many reasons that one, or two, or more limbs can swell. And  sometimes it's a disease state like cancer, or could be medications, or could  be a result of trauma or surgery. The thing about if they've got a swollen  arm or a leg, it's a bit like that chronic wound. There will be a reason for  it.

And  at some point in time, people deserve to know that their swelling is there  because of something. Like with the chronic wound, many will be fixable, some  will not. And with lymphoedema, this is the same. Many forms of lymphoedema  can be ameliorated and contained and managed, not necessarily all. So, we  need to know a reason as to why swelling is present. Because when it is  present, the skin is under duress. This magnificent organ which is responsible for your health, is actually negatively impacted by swelling and  the tissue tends to become hypoxic or depleted of oxygen.

And  chronic oedema or swelling puts people into a profound inflammatory phase,  which is very difficult to progress from. And should they get a wound or a  skin break within the swollen arm or leg, that then makes the repair of this wound exceptionally unlikely, unless that oedema can be resolved or reduced.  Meaning people then move out of that inflammatory state and away from that  hypoxic environment.

So  it's interesting here that this is really where when we start to talk about  dressings and devices like compression stockings, or bandagings, or wrap  systems, or intermittent pneumatic compression pumps, there's a really important interplay between dressings and your compression device. Because,  invariably when you've got the swollen leg, you've got a heavily discharging  wound and it's often very full of protein, very high risk of secondary infection. But whatever you use to absorb the forms of fluid that are coming  out, that dressing also needs to be compatible with a compression device of  some form.

So  you've actually got to think carefully about the dressings you use, as to  what type that's absorbent capacity, and to also be aware that as you do  reduce the volume of the limb, that that heavy previous amount of exudate  will drop off considerably, and you can go within a matter of days from a heavy  discharging wound to a very dry wound. So you need to be prepared to be a  little bit dynamic with your dressing choices, as you proceed to treat a  swollen limb with whichever device that you may be using.

And  a lot of this will come back to as to, when you are talking about a  compression device, whether it be the stocking, whether it be the Tubigrip™,  whether it be the pump. What can people afford, what can they manage? Who, is there somebody home alone with poor dexterity has a big influence on what we  do.Whereas somebody who may have a competent carer who is physically able to  assist gives them another set of possibilities, which you can't do with the  old granny with rheumatoid arthritis who can't manage the pump at home.

So once again, lymphoedema is just like the chronic wound. We've got to look at  it through the prism of who is that we're caring for and where is the person  in this particular presentation.

00:09:23

RUTH  TIMMINS:
Yes, really interesting, Gary. And I was just wondering where you see  advanced therapies fitting in, such as single-use negative pressure like PICO  for example, in managing chronic wounds.

00:13:05

GARY  BAIN:
Yeah, advanced therapies have a very important role to play because we often  talk about the TIME mnemonic and with the clinical support tool that Smith  & Nephew have, they bring us through the range of considering the tissue types, whether we're dealing with infection yes or no, what the inflammation  may be like in a wound, it's exudate volume. But getting a wound to close and  have a sustainable covering and have edges which can approximate or move towards a wound centre, sometimes this can be really challenging to achieve,  particularly in wounds which have been present for weeks or months.

So there is a lot of evidence now and has been building for decades around the  use of negative pressure, at being able to supply a better of volume of  blood, a better drainage of lymphatic fluid, a physical force to bring  margins together. So there are definitely times when negative pressure is the  tool to be using to assist to bring wounds to closure. Particularly if  already got to a point now that wounds are being debrided or devitalized  tissue and infection is controlled. So it's a major tool that people need to be  prepared to avail themselves of.

00:13:17

RUTH  TIMMINS:
When you reflect upon all your years of treating people with chronic wounds,  if you were to have a key message or a few key messages for people today to  go home with what would that be?

00:14:34

GARY  BAIN:
Well, my key message as I reflect on that very decent question, Ruth. Is in  32 years of looking after people with chronic wounds, I've actually realised  the more I've learned, the less I know. And that being the case, that for me  to look after somebody with a chronic wound, it's usually a disservice if I'm  the only one doing that, because I now realise that people with chronic  wounds, deservedly so, need a team around them. This is they themselves,  their family members, those who are socially significant to them. But it also  means their medical officer, their nursing personnel, dietitians,  podiatrists, their physiotherapist, their lymphoedema therapists.

As we begin to understand better the aetiologies of wounds and understand that  behind that is an individual who needs our support and our care. Really,  people need a coherent, goal-oriented team around them who are prepared to communicate and work with one another. And Ruth, this is where I'd have to  tell you that I'm actually in love with the place that I work. Because in a  rehab environment, I actually see teamwork done to its optimum best.

And the difference that can make to a people sense of worth and well-being and  the improvement to their quality of life is quite profound. Because it's all  of us for them, not just one or two. So the value of a team I now fervently believe in as being the ultimate gold standard of how you help people with  chronic wounds to progress.

00:14:46

RUTH  TIMMINS:
That's so true, isn't it? Well, that's all we've got time for today, really,  Gary. So we really appreciate your time, sharing your knowledge and expertise  with us on this very you know, relevant topic on managing chronic wounds. And  so don't forget to tune in for our next podcast. And there will be some  resources available for you to access after this podcast. Thanks again, Gary,  and we look forward to seeing you soon.

00:16:22

GARY  BAIN:
Thank you very much, Ruth

00:16:48

RUTH  TIMMINS:
Bye for now.

00:16:49

SPEAKER:
The use of the TIME Clinical Decision Support Tool has been shown to provide  a structured approach to wound management, reduce variation in practice and  enhance nurse confidence with decision making.(1) The clinical impact of the TIME CDST tool is demonstrated by a number of successful real-world examples,  which has been recently published as a case series.(2-6) For details of the  case series and various tools and resources to support your clinical practice. Please contact your local Smith & Nephew representative or  email us at ProfEd.ANZ@smith-nephew.com.

00:16:53

SPEAKER:
Helping you get closer to zero inaccuracy in wound assessment. The  information presented in this podcast is for educational purposes only. It is  not intended to serve as medical advice. Products listed, outline of care are  examples only. Product selection and management should always be based on  comprehensive clinical assessment. For detailed products information  including indications for use, contraindications, precautions and warnings.  Please consult the products applicable instructions for use, prior to use.

00:17:36

References.

1. World Union of Wound HealingSocieties (WUWHS) (2020) Strategies to reduce practice variation in wound assessment and management: The TIME Clinical Decision Support Tool. London:Wounds International

2.Swanson T, Duynhoven K, Johnstone D. Using the new TIMEClinical Decision Support Tool to promote consistent holistic wound management and eliminate variation in practice at the Cambourne Medical Clinic, Australia:Part 1. Wounds International 2019; 10(1): 38-47

3. Jelnes R, Halim AA, Mujakovic A et al. Using the new TIME Clinical Decision Support Tool to promote consistent holistic wound management and eliminate variation in practice: Part 2 at the Sygehus Sonderjylland Hospital, Sonderborg, Denmark. Wounds International 2019;10(2): 38-45

4. Woo K. Using the new TIME Clinical Decision Support Tool to promote consistent holistic wound management and eliminate variation in practice: Part 3 at the West Park Healthcare Centre, Chronic Care and Rehabilitation Hospital, Canada. Wounds International 2019;10(3): 48-55

5.. Walters S, Snowball G, Westmorland Let al. Using the new TIME Clinical Decision Support Tool to promote consistent holistic wound management and eliminate variation in practice: Part 4 at SilverChain, Australia. Wounds International 2019; 10(4): 32–9

6.BlackburnJ, Ousey K, Stephenson J. Using the new TIME Clinical Decision Support Tool to promote consistent holistic wound management and eliminate variation in practice: Part 5, survey feedback from non-specialists. Wounds International2019; 10(4): 40–9

 

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Speakers

Gary Bain

RN MClinEd BN DipApSc MACN

Principal at The Wound Guy & Leg Club Associate Partner

Currently in private practice as ‘The Wound Guy’, Gary Bain provides education to medical, nursing, allied-health and product-industry personnel. He also provides clinical support to patients and their clinicians in the aged care, primary care and community sectors. The Wound Guy entity’s purpose is to enhance the well-being of individuals who experience a wound and to empower those who care for them.

Gary conducts his clinical practice at Mt Wilga Private Hospital (Rehabilitation), NSW and is a lecturer at Macquarie Univeristy’s Australian Lymphoedema Education, Research and Treatment (ALERT).

Gary completed his undergraduate training at Avondale College, obtaining a Diploma of Applied Science (Nursing). He obtained a Bachelor of Nursing through the University of Technology Sydney, combining this with a Burns and Plastics Nursing Certificate from the Royal North Shore & Concord Hospitals, completing his tertiary studies at the School of Medicine, University of NSW with a Masters Degree in ClinicalEducation.

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