Dr Karen Ousey, Reader in Advancing Clinical Practice, School of Human and Health Sciences, University of Huddersfield

The Department of Health (DH) (2009a; b; 2010a; b) has clearly identified the importance of maintaining and developing a quality service to all health and social care users. The QIPP agenda; Quality, Innovation, Productivity and Prevention relates well to the specialities of tissue viability and wound care. Integral to maintaining and developing quality is the ethos ‘No decision about me without me’ promoted in Equity and Excellence: Liberating the NHS (DH, 2010a) that suggests patients should be involved in the decision-making process alongside practitioners. Indeed, patients will be in charge of making decisions about their care and will be able to choose which consultant-led team, general practitioner and treatment they have. The patients’ experience and satisfaction will be analysed through the use of Patient Reported Outcomes Measures (PROMs) and the amount of complaints received by healthcare users.

The importance of being able to ensure that care administered to patients is based on the best available evidence, and is cost effective has never been more significant, with the DH (2010a) identifying that the NHS must make efficiency savings of between £15-£20 billion by the end of 2013/14. In relation to tissue viability, Posnett and Franks (2008) had calculated that 200 000 people in the UK have a chronic wound with an estimated cost of treatment being £2.3–£3.1billion per year, these numbers will no doubt rise over the next few years as the ageing population increases.

The cost of preventing and treating pressure ulcers in a 600-bed acute trust has been estimated as being between £600 000 and £3 million a year (Touche, 1993). In 2010 the DH (2010b), estimated the cost of a category 3 pressure ulcer as being between £363 000 to £543 000 and a category 4 pressure ulcer as costing between £447 000 and £668 000. They identified that a reduction of 25% in pressure ulcers would mean 88 fewer pressure ulcers and a potential cost saving of £510 000 in health care per year, per NHS trust. Many pressure ulcers are preventable through risk assessment and the implementation of pressure-relieving measures with the DH promising that there would be ‘safer care for patients, who can be confident that they will be protected from avoidable harm’ (DH, 2009a:29). This can only happen if health professionals are provided with evidence that supports the use of wound dressings; education to develop their own knowledge and the skills to evaluate and understand the results of audit; reliability and validity of evidence and research presented to justify the use of wound care products.

ActivHeal® Hydrocolloid

Horkan et al (2009) explored whether or not systematic reviews, undertaken during the period 1998-2008, focusing on the issue of standard advanced wound dressings, added to the body of knowledge in wound dressings. They identified 13 systematic reviews and meta-analysis studies concluding that ‘it appears that consistent evidence that any one moist wound healing dressing is better than another in terms of wound healing is still lacking’ (Horkan et al, 2009: 304). Nelson and Bradley’s (2007) review of the Cochrane database exploring dressings and topical agents for arterial leg ulcers, identified that there was no evidence to allow any recommendations to be made on the choice of dressing type or topical agent.

A 3-month ‘in-use’ trial of the ActivHeal® dressings was undertaken by Lewis (2009) to ascertain the amount of money that could be saved if the Trusts’ current choice of wound dressings were replaced by those from the ActivHeal® range. ActivHeal® dressings were evaluated on care of older people, surgical, orthopaedic and neurology wards replacing the current foam, alginate, gel and hydrocolloid dressings on the chosen wards. At each dressing change, the nurse was required to fill out an evaluation form, at the end of one calendar month the completed evaluation forms were collected and each product was given an evaluation result as being either ‘worse than’, ‘equivalent to’, or ‘better than’ the previously used dressing. In terms of dressing performance, there was no obvious difference between the original ‘branded’ dressings and the replacement ActivHeal® range. The ActivHeal® dressings were rated as ‘equivalent to’ or ‘better than’ original dressings in almost all cases. The nursing staff registered no complaints about the change to the ActivHeal® range of dressings.

Following completion of the trial Lewis estimated that the annual cost saving on foam dressings alone was in excess of £41 000. The annual spend on wound dressings, prior to using ActivHeal®, was £103 029, the equivalent of 3 month spend, when using ActivHeal® range was £11 952 which equated to an annual spend of £47 808. Lewis acknowledges that this trial was only run over a limited period of time and therefore the findings may not be as accurate as a longer trial.

This supplement presents a series of case studies using the ActivHeal® range of products; foam non-adhesive; foam adhesive; alginate; aquafiber; hydrocolloid and hydrogel dressings. The methodology and patient sample will be expanded in the methodology section. The case studies highlight and discuss the use of the product range and the results that were experienced by the practitioners and patients. A variety of wounds were used to evaluate the product range with results showing that the products worked effectively; were cost effective; comfortable to the patient; easy to use and caused little discomfort on removal.

In the current health economic climate, cost savings are essential for each health professional and commissioner, without reducing the quality of care offered to each patient. The case studies presented in this booklet discuss, highlight and present a range of dressings that can provide a cost-effective dressing range that are evaluated by practitioners and patients positively.

The overall aim of the series of case studies is to provide clinical information on the usability, acceptability and clinical performance of the ActivHeal® range of products, when used in the management of chronic wounds of various aetiologies.

It is the aim of this series of evaluations to show progression of healing in all cases, irrespective of the healing variables and the setting of care.

Patient progress was monitored and photos and assessments were taken at each dressing change to illustrate how the wounds had progressed using the ActivHeal® Foam.

The 11 patients comprised of six males and five females, the exudate levels of the wounds were assessed between low to medium levels of exudate. On average the dressings were changed every 3-4 days. In all 11 cases the ActivHeal® Foam was used as a primary dressing. The case study presents a male admitted with a dog bite wound that was initially treated with a hydrogel and foam. However, on week two the hydrogel was discontinued and the ActivHeal® foam dressing used as a primary dressing and was not included in the initial evaluations. The data was analysed and is shown in Figure 7.

The evaluation of the data showed that in the case of ActivHeal® Foam’s ability to manage exudate, 90% of the respondents were very satisfied, 8% satisfied and only 2% dissatisfied.

In maintaining a moist environment 93% were very satisfied, 5% satisfied and only 2% dissatisfied. It was documented that one patient (representing the 2% dissatisfied) noted their skin had become slightly macerated owing to a sudden increase in exudate leading to an increase in dressing changes until exudate levels subsided.

When asked about ActivHeal® Foam’s conformability, 71% were very satisfied and 29% satisfied. The product was also assessed for ease of use where 98% were very satisfied and 2% dissatisfied.

CASE STUDY: USING ACTIVHEAL® FOAM TO MANAGE EXUDATE AS A SECONDARY DRESSING

Mr P was a 56-year-old male with a history of a previous deep vein thrombosis and a non-insulin-dependent diabetic of 4 years. The patient had presented to Accident and Emergency with chest pain. On admission it was noted that the patient had a wound to his right thigh. The cause of the wound was a dog bite 4 months previously that he was self-treating with an antiseptic cream and dry dressing (Figure 8).

INITIAL PRESENTATION

At the initial examination the wound presented as an area of adherent slough with little exudate. The peri-wound area seemed fragile with some oedema. There was also evidence of some healed tissue. The priority for this wound was to debride the devitalised tissue through rehydration and the facilitation of autolytic debridement. ActivHeal® Hydrogel was chosen to assist in the rehydration of the wound, to remove the devitalised tissue and facilitate autolysis. The secondary dressing that was used was ActivHeal® Foam Adhesive which was chosen to ensure the hydrogel remained in place, while maintaining a moist wound environment. The ActivHeal® Foam Adhesive also provided a bacterial barrier to prevent infection and contamination but also enabled the patient to wash and shower as the dressing is waterproof. The ActivHeal® Foam has a range of features which ensure that excess exudate is absorbed away from the wound bed, and a moist healing environment maintained to create a wound healing environment.

Dressing changes took place every 2-3 days. The wound continued to debride autolytically with the application of the ActivHeal® Hydrogel and ActivHeal® Foam Adhesive dressings. Following a week of this dressing regime, which accounted for two dressings changes, the ActivHeal® Hydrogel was discontinued as all of the devitalised tissue had been removed and the exudate levels had increased. At this point the wound was reassessed and ActivHeal® Foam Adhesive was chosen to effectively absorb and retain the exudate, maintain a moist environment, facilitate moist wound healing and prevent contamination.

The wound continued to progress through the healing continuum, and at all times the peri-wound area remained intact with no signs of maceration which demonstrated that the ActivHeal® Foam Adhesive was managing the levels of exudate well. The patient was discharged home to the care of the district nurses (Figure 9).

To conclude, the main challenge was to effectively rehydrate the sloughy tissue and maintain a moist wound healing environment. Both the ActivHeal® Hydrogel, ActivHeal® Foam Adhesive along with ActivHeal® Foam Non Adhesive allowed the wound to progress. The products demonstrated good clinical outcomes while allowing easy dressing usage without causing pain and trauma to the patient on removal.

Patient progress was monitored and photos and assessments were taken at each dressing change to illustrate how the wounds had progressed using ActivHeal® Hydrogel.

The 11 patients comprised of six males and five females, the exudate levels of the wounds were assessed between dry to low levels of exudate. On average the dressings were changed either every day or on alternate days. In all 11 cases the ActivHeal® Hydrogel was used as a primary dressings and ActivHeal® Foam dressing was used as a secondary dressing. The data was analysed and is shown in Figure 14.

In maintaining a moist environment 71% were very satisfied, 25% satisfied and only 4% dissatisfied. In regards to ActivHeal® Hydrogel’s conformability, 75% were very satisfied and 25% satisfied. All respondents were very satisfied with the product’s ease of use. It was also documented on the assessment forms that ActivHeal® Hydrogel had a high viscosity, was easy to apply and did not cause any underlying trauma to either the surrounding skin of the wound or through maceration to the peri-wound area.

Anecdotally, the nurses also reported that the dressings were able to effectively rehydrate and remove devitalised tissue of both necrosis and slough and that on three occasions only one application of the ActivHeal® Hydrogel was necessary. The nurses also reported that there was minimal residue left on the wound prior to reapplication of the gel, suggesting that the absorption of the product had occurred and a degree of rehydration had been achieved.

An overall rating of 79% of the respondents were very satisfied and 21% satisfied with the product, which supports that the product is acceptable for wounds that have been assessed to remove devitalised tissue with dry to low exudate levels. All of the wounds assessed and evaluated progressed through the healing continuum, with devitalised tissue being removed.

CASE STUDY

Mrs B was a 94-year-old female with a past medical history of diabetes and hypotension. The patient was admitted following a fall with reduced mobility and was generally unwell. On admission the patient was fully assessed and an area on her right buttock was discoloured with areas of necrosis (Figure 15) and the patient was referred to the tissue viability team.

INITIAL PRESENTATION

At the initial examination the wound presented as an area of necrosis with little exudate. The cause of the wound was pressure and moisture as the patient was incontinent of both faeces and urine. The patient was also non-concordant and refused to be turned or tilted. However, she did agree to be nursed on a pressure-relieving mattress.

It was difficult to assess the depth of the tissue involvement in this lesion as necrotic eschar was present and therefore it was decided debridement was required to facilitate a diagnosis of depth. The European Pressue Ulcer Advisory Panel (EPUAP) classification system has attempted to address the difficulty of categorising a necrotic lesion by using an unclassified/unstageable classification. This descriptive definition discusses it as full thickness tissue loss in which the actual depth of the ulcer is completely obscured by slough and/or eschar in the wound bed. Until enough slough/eschar is removed to expose the base of the wound, the true depth cannot be determined (EPUAP, 2009).

The priority for this wound was debridement, this was achieved using a rehydration method that facilitated autolytic debridement. ActivHeal® Hydrogel was chosen to assist in the rehydration of the wound, to remove the devitalised tissue and facilitate autolysis. The ActivHeal® Hydrogel contains 85% water and a collection of polymer chains that are water insoluble and is indicated for the management of necrotic and sloughy wounds with nil to low exudate including pressure ulcers, cavity wounds, leg ulcers, skin donor sites and diabetic foot ulcers. Hydrogels donate moisture to provide a moist environment, this encourages and facilitates autolysis or debridement of devitalised tissue from the wound bed (Morris, 2006).

Despite experiencing increasing demand for care and services, in the context of a diminishing income and economic crisis, the NHS has been asked to find £15-20 billion of savings over 4 years (Foster and Bolger, 2010) which is to be reinvested so that the burgeoning care deficit can be addressed. Nurses are well placed to be innovative by examining process and cutting out duplication and waste. It is imperative that we benchmark practices that align to the ideals of a quality, cost-effective and productive service which focuses on safety, effectiveness and patient experience. In relation to the quality agenda there is a need to ensure that wound care products are able to assist the health professional in the management of wounds. Every dressing change will have an impact on the patient experience; therefore, evidence outlining the effectiveness of wound care products can support health professionals in their roles to select quality products that assist in wound management.

The case study evaluations present excellent patient outcomes, demonstrating the ActivHeal® wound care products’ ability to manage exudate; maintain a moist wound environment; conformability to the wound and ease of use for practitioners.

Choosing the correct and appropriate dressing to manage a wound is essential, with practitioners ensuring that their choice of product is based on the best available evidence while ensuring cost effectiveness. This supplement has presented case study and assessment evidence which supports the ActivHeal® range in providing practitioners with products that manage the complexities of promoting moist wound healing in a cost-effective manner.