PICO 14 Single Use Negative Pressure Wound Therapy - Skin Tear Case study
Join us to hear about a skin tear case study highlighting the positive outcomes of using PICO 14
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Welcome to Smith & Nephew's Closer To Zero podcast. Bi-monthly podcasts with leading experts, wound care, hosted by Smith and Nephew, helping healthcare professionals in reducing the human and economic cost of wounds.
Hello, I'm Ruth Timmins from Smith & Nephew. And welcome to today's podcast focused on skin tears and using PICO single-use negative pressure wound therapy. Today we have a special guest, Thomas Leong who is the clinical nurse consultant for skin integrity at the Royal Prince Alfred Hospital in Sydney. Thomas has been in his current role since 2011, and he's the chair of a number of wound and pressure injury committees. He has many years of experience in areas of wound management, including burns and ICU, and is involved in research projects and publications. So, thank you, Tom, for joining us today.
Thank you so much Ruth for having me.
So today we're focusing on skin tears So, I was just wondering how big an issue this is and, you know, in your day to day work?
It's a good question. I have a look at lot of skin tears and of varying degrees of severity. And one of the big problems we have in our hospital I guess, is monitoring these and counting these. And we do have a system which is called the IIM system, and incident information management system. And that tracks a lot of our hospital acquired complications and of course, skin tear is one of them. In the past however, we had an older system and that's been superseded now, but it was very difficult to actually differentiate the different types of hospital acquired complications relating to skin injuries, such as pressure injuries and skin tears, because there was no category for skin tears, but now that's changed. And so, in terms of the numbers of skin tears we have, I can't give you that, we don't actually have a good monitoring of that at the moment. But as of this year, we've been able to do that. And we do see a lot of them, and the problem is getting our staff to actually report them as well, because there hasn't been that culture of doing it. It's something we need to build up again. That being said, in the elderly, we know statistically it is a significant problem. And anything we can do to mitigate those problems is a welcome thing. And of course, if skin tears occur, then we need to try and rectify them as quickly as possible. And I think negative pressure wound therapy is definitely one of those answers for this problem.
So what are the challenges in looking after these types of wounds then, Tom?
Well, I think one of the biggest problems is, it usually happens in the elderly and even without their sort of numerous co-morbidities that they have, they are increased in risk of injury. And not only that they have an increased risk of inability to heal because of the changes as a result of ageing, things like drier skin, thinner skin, loss of skin turgor, and less collagen and less subcutaneous tissue attaching to that basal layer, makes it very difficult to manage sometimes. And often there's also a lack of education around managing skin tears. So, when patients damage their skin at home, they tend to think, Oh, that skin flap, I'll just tear it off and put a bit of
gauze over it and that's their solution. And often, the skin flap is then gone when they come in, when they've already have an infection or some other complication. And so, yeah, these are a few of the little battles we have with the elderly and the skin tears.
Yeah. So, I know you mentioned about using PICO single-use negative wound pressure therapy on skin tear. So perhaps you could give an overview of one of the cases you use PICO 14 on.
Yeah, I guess with negative pressure wound therapy, as I mentioned, it, we use it for a lot of things. And I know PICO has been around for quite a number of years now, probably almost ten years, nine years or so? I think it's been around.
This is the ten year anniversary actually, Tom. Yes you're right.
OK. 10 years or maybe nine years in Australia or was it yeah, 10 year anniversary. But yeah, it's been around for a while and there's some things about it, which I find very good. I mean, that being said, there's a lot of competition out there and I think that the 14 is another step in the evolution of the PICO. It has improved and I think competition just pushes improvements along. And, that's why it's here I believe. I mean the patient that I chose to use it on, was an 87-year-old lady, just right in that demographic. And she had a skin tear, which happened a week prior to me seeing her and was seen by her GP. She was on antibiotics. It was worsening. She was not getting any pain relief in terms of the dressings that she was receiving. And yeah, it was a big problem for her. Now, for me, she actually came to the hospital through the emergency department, and then was admitted and given IV antibiotics. But I was only called, on the, I had a referral putting it online for me to see her on her last day of admission. And so I missed her. And so she actually went home and it didn't improve. Or the dressing regime that she had, I say from the GP was not effective and had adhered to her wound. And so she came back to see us again and in the emergency department and she was referred to hospital in the home. Now, hospital home sounds like a bit of a misnomer, because I see her in the hospital, but in wound care wise, we do see patients in the hospital under that banner, whereas they treated other people with antibiotics and that sort of thing at home, so it sounds a bit funny having hospital in the home, in the hospital, that being said I saw the wound, it was a nasty skin tear. It was actually down, beyond the fat layer and she had a lot of necrotic tissue on top. And so it was a bit of a challenge to treat this. And I think part of the problem was again, her age, but also the fact that she had ongoing infection, which caused some tissue necrosis. So in terms of my initial treatment, though, for her, it wasn't the PICO. It was to help get rid of that necrotic burden that was on the wound, so that involved softening the tissue, using a hydrofiber dressing and a Silicon dressing on top of that for the first few dressing changes. And that then allowed me to debride it, with a scalpel or a pair of scissors. And then once I had a clean wound bed, I was able to apply the PICO. Now, one of the things I do like about the PICO is that, it is a silicon-based dressing and that works so well on all these elderly patients. It is gentle on their peri-wound skin. The fact that it has quite a few layers in there and then absorptive layer to draw that moisture away from the top of the skin is another essential ingredient, which will prevent the wound from, or the peri-wound skin from macerating, if there's a high amount of exudate. And so, I thought PICO was a good choice. And the fact that, the PICO 14 has 14 days, I think that's a much, much better option than what was previously available. You know, in the end I always want more, but 14 is a good number. So once I put it on, the patient was really happy. She found that her leg was comfortable. It absorbed the moisture and the exudate really well, one problem I guess she did have was just recurrent infection. Unfortunately, it did, there was a surface infection maybe, not what we call, classify as cellulitis or a clinical infection at the time, but there was definitely a critical colonisation on the wound, which caused more cell death, or skin necrosis and or tissue necrosis. So in that time, we had to restart her on antibiotics. I did use some Durafiber Ag as well under the PICO. And that's another good thing about the PICO, we can add layers there to help with exudate absorption as well as this case, providing an anti-microbial element to dressing. So after two weeks after the 14 days, we used an application called tissue analytics to measure her wounds. So, we had a nice objective measure, and it was reduced by roughly 10 centimetres squared in those two weeks. So that was a really positive result. And, so we decided to continue with PICO 14 again, but unfortunately, after those two weeks, we didn't have it available to us. So we just continue with Durafiber and the Silicone bordered foam for another week until we had another PICO 14 available. And we continue again for another, another two weeks with that. So after 38 days, we were able to change over to just a, more conservative, again, dressing back to the Durafiber Ag, Silicone foam and just change it weekly. And yeah, it just made it much more comfortable for the patient and less traumatic in terms of dressing changes.
Sounds like it was a really good outcome. Were there any other benefits for using PICO 14?
I think one of the challenges with any of these disposable negative pressure devices is getting a good seal. And even though it's on a leg and it's not a highly multi curved surface, occasionally these types of dressings can end up with the leak, especially if you leave them for a while and outpatients, it's difficult because we can't keep an eye on them 24/7, but with the PICO, I find it's stayed on very nicely. There were no leaks. The only thing is sometimes, occasionally the wound did macerate a little bit on the wound edges, but that's because of just the amount of exudate she had and the infection that was reoccurring in her. I think that's just one of those things we had to watch out for.
Do you have any other tips and tricks when using PICO 14?
Yeah. Well, I think with all sorts of dressings, nurses always find that they have, they're in a hurry and they, have a lot of work to do and trying to get things finished. But I think with this, we need to take our time and put it on smoothly, ensure there are no wrinkles and that will then set you up for a dressing that's going to be trouble-free and with the PICO it works really well. If, the other tip, I guess, is to always ensure that you have a seal before you put the reinforcing strips around it, always choose your patients carefully of course, if there are other wounds in the peri-wound area, like small superficial wounds, just ensure that you have something underneath the border to absorb the minute exudate, they may come from those little more superficial wounds in the peri-wound. And this happens a lot with the elderly. They have lots of dry, flaky skin. And sometimes when you clean off that skin, you have little micro fishes or micro skin loss that will exude small amount of exudate. If that's under the border of your dressing, whether it be a PICO or anything else, it will cause maceration. And if that happens, then I would apply something like a hydrofibre under the border. And the PICO seems to seal that very well, but I don't have any issue with that. I mean, with this lady, we had a fantastic result, of roughly 80% reduction in a wound over those, that month. And, that all comes down to, I think, putting things down carefully, choosing your dressing carefully and choosing your patient carefully.
OK. Thank you. And so, what would be some key takeaway messages today?
I think with, any disposable negative pressure device, we need to choose our patients carefully, the PICO 14 does provide a good range of, or breadth could I say, of the wound choices that we have, because it's able to accommodate for deeper wounds (1) up to seven centimetres deep, as well as the more superficial wounds, but anybody who has, is of concern, anyone who has fragile skin, anyone who has a compromised circulation, anyone who's diabetic. I think anyone with those sorts of co-morbidities, will benefit from negative pressure wound therapy. And I think if we use it sooner rather than later, we can probably provide our patients with less pain and avoid complications. And I think yeah, the PICO 14 is definitely a great addition to negative pressure quiver, especially the disposable side of things. It's a, yeah, definitely a great choice.
OK. Well, thank you, Tom, for you know, sharing with us today. That's really good that there was a positive outcome there and you know, just a good example of, how, you know, single-use negative pressure wound therapy, such as PICO can be a benefit. So thank you very much.
Yeah. Thank you again for having me and I hope yeah, people can benefit from my experience.
Yeah, I'm sure it's been really valuable and there will be some resources attached to this podcast as well. So please have a look at those, and don't forget to join us for our next podcast, and we hope to see you soon. So, thanks again, Tom and bye for now.
At Smith & Nephew, we are proud to provide you with continued innovations in negative pressure wound therapy. Our latest technology, the PICO 14 single-use negative pressure wound therapy system with airlock technology, has been designed with a pump duration of up to 14 days and is aimed for hard to heal and deep wounds. Early intervention with PICO has shown a 94% success rate in healing versus standard dressings.(1) For more information on how PICO can kick start the healing trajectory of your chronic wounds, contact your local Smith & Nephew representative, or email us at ProfEd.ANZ@smith-nephew.com.
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. It's detailed product information, including indications for use, contraindications, precautions and warnings, please consult the products applicable instructions for use prior to use. Helping you get close to zero human and economic consequence of wounds.
Dowsett C, et al. Use of PICO◊ to improve clinical and economic outcomes in hard-to-heal wounds. Wounds International. 2017;8:53–58
Clinical Nurse Consultant, Royal Prince Alfred
Thomas is the Clinical Nurse Consultant for Skin Integrity at Royal Prince Alfred Hospital (RPAH) an 800 bed quaternary hospital. Thomas has been in his current role at RPAH since 2011. He is the Chair of a number of Wound and Pressure Injury Committees at RPAH.
Thomas has been involved in various research projects at RPAH and SLHD to improve patient care in relation to skin integrity and wound care. These include ‘Use of Cultured Epithelial Autograft for Donor Site Wound Healing’, ‘Use of Silicone dressings’. Most recently, he was an associate investigator on the ‘Getting to the Bottom of Hospital-acquired Pressure Injury: Translating Knowledge into Practice Study’ across Sydney Local Health District Study. This study was awarded the ‘Peoples Choice Award’ at the NSW Research Nursing Symposium in September 2017 and the ‘SLHD Patient Safety Quality Award’ in November 2017. He was also an associate investigator on a recently published study to reduce occipital pressure injuries in 2018 in the intensive care unit at RPAH, which led to an 87.7% reduction in occipital pressure injuries.
Thomas’ experience is encompassed in his nursing career spanning almost three decades. He has worked nationally and internationally, Raxaul Mission Hospital, India, Charing Cross and Chelsea and Westminster Hospitals, London in the skin integrity field. His tertiary qualifications include a Master of Clinical Nursing, The University of Sydney specialising in Burns and Wound Management. Currently, Thomas is an Associate Investigator of a number of controlled trial studies at RPAH on the best practice for managing incontinence associated dermatitis, the use of heel offloading boots in the intensive care unit, and the use of an artificial intelligent application to measure, track and document wound progression. Thomas has presented his research at various national conferences including the Wounds Australia, and Australian and New Zealand Burns Association Conference. Thomas is a member of the state-wide the Electronic Medical Record Wound Documentation Committee comprising 13 districts, which is working on developing a solution to address the current gaps in wound documentation.