Chronic Wound Management Fundamentals and Best Practice
Gary discusses treating the whole person and not just the hole in the person
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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.
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.
Thank you, Ruth.
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?
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.
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?
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.
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?
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.
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?
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.
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.
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.
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?
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.
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.
Thank you very much, Ruth
Bye for now.
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.
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.
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
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.