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Bandaging key to wound care

Researchers are making great improvements in treatment of hard-to-heal wounds, a problem that costs the nation up to $3bn a year. Amie Larter reports

Patients experiencing inflamed, weeping sores that are either reoccurring or fail to heal are typically suffering from a chronic or complex wound, says the head of a leading research group.

Stephen Prowse, the head of the Wound Management Innovation Co-operative Research Centre (CRC), believes these types of wounds are becoming a huge problem for the health system.

“We estimate that in Australia there are around 400,000 or so people at any one time with a complex difficult to heal wound,” Prowse explained. “That translates into a cost of around $2 billion to $3 billion a year, so we are talking about something like 2 per cent of the national health budget goes on the care and management of these difficult to heal wounds.”

Wound Management CRC is currently working with the Australian Wound Management Association to collect national data to ensure that it is recognised in a way that acknowledges the magnitude of the problem at hand.

Prowse believes that the economic cost is often hidden because much of the treatment is often conducted by a diverse range of service providers in a range of different settings including in the home, at local GPs or clinics or in hospitals.

“It is very hard to get an overall picture of what is really happening and what the overall cost genuinely is,” said Prowse. “A lot of the wound management is driven or conducted by nurses and other health professionals, which sometimes escapes the attention of the mainstream medical fraternity.”

Most frequently found in elderly patients or those suffering from obesity or diabetes, this excruciating medical condition is often caused by hard-to-heal wounds developing into ulcers – the most common of which is venous leg ulcers (VLUs). These are caused mostly by an underlying disease known as chronic venous insufficiency. This is where the veins in a patient’s leg lose the ability to pump oxygenated blood capably, and the effects become evident on the leg in the form of what can be an agonising wound.

The main treatment for VLUs is compression, with the Cochrane Systematic Review suggesting that it is the most important treatment to heal the wounds.

“If they do not have compression, not only will they not heal, but they will get worse,” said Dr Carolina Weller, from Monash University’s Department of Epidemiology and Preventative Medicine. “Best practice to heal people with a VLU is compression by applying a tight bandage on a lower limb from below the knees to the toes.”

According to Cochrane Database System review 2009, high compression bandaging (30-40 mmHg) is an effective treatment, healing over 70 per cent of uncomplicated VLUs in 3 months. Compression bandages are often successfully used by nurses and other medical professionals to aid the healing of the VLU. However, as Weller explains, there are problems that arise when using this form of treatment.

The first is due to the wide range of bandages available on the market. Due to the wide range of choice, there is evidence to suggest that nurses can often be confused with what to use and then how to apply. Nurses also need to be trained in application, which can be fairly expensive. This is on top of the compression bandages themselves, which can be quite costly.

If we lived in a world where cost and training was not an issue, one concern is still paramount – and that is the second problem: keeping the VLU compressed after the patient’s initial treatment.

“It is highly likely that once the patient goes home following compression application, because the bandage is uncomfortable – they take it off,” said Weller.

“So unless the patient comes back to the clinic, or the nurse is able to visit the patient at home to put it back on, it means the patient has no compression bandage on the limb – and as a result of that they will not be able to heal.”

The two types of compression used in Australia are the short-stretch single layer inelastic compression bandage and the three-layered elastic bandaging system. In an Australian first, Weller has lead a study to compare the effectiveness of the two in the treatment of VLUs.

Published in the international journal Wound Repair and Regeneration the research revealed that three-layer tubular bandaging significantly improved healing of VLUs and was more affordable and practical than single-layer bandages.

“Typically a single bandage would be used, which is inelastic and is quite difficult to apply unless nurses are trained,” Weller said. “The three-layer system is a tubular sock system that is open at the toes. Due to its simple way of application there is no confusion and it took nurses less time to apply.”

According to the study, which was conducted over 12 weeks in Victorian and Queensland hospital clinics, the costs for the three-layer bandage, including the price of the product and the time for the nurse to apply, was significantly less than that of a short-stretch system.

“We found that the cost of the three-layer system, including application time by a nurse, was almost halved in comparison to the more commonly used standard control compression bandage,” Weller explained.

In addition to cost, the three-layer bandage was much easier to apply and less time consuming.

Throughout the study, patients reported the three-layer bandage to be a comfortable alternative to standard compression bandages. Even though there was a firm system in place, the three-layer bandage conforms to the leg, making it a more comfortable option for patients.

“Patients kept the bandage on. If people keep the bandage on because it is comfortable enough then they have got a better chance of healing,” Weller said.

In terms of effectiveness of healing and reducing the wound, the study found that all compression, no matter what type of bandage used, was better than none. The portion of healed ulcers was larger in patients that were using the three-layer system, however, the study revealed no statistical difference between the treatment groups in reduction in ulcer size.

From the outset, it looks as though the introduction of early adoption of the three-layer system as best practice for general and community nurses could be more cost effective option that will increase healing. However, before this happens Weller believes that further funding and research is necessary to provide evidence at more of a population level surrounding patients that present with VLUs.

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