Europe takes on wound-care challenges

Non-healing wounds are a significant problem for healthcare systems worldwide, reportedly accounting for 2-4% of healthcare budgets - a figure expected to rise in conjunction with increases in elderly and diabetic populations - and yet, efficient structures for wound management are still not in place in many countries throughout Europe. Severin Läuchli, president of the European Wound Management Association, explains how the organisation works to address the challenges to the implementation of high-quality and cost-effective wound management.

Due to the often complex aetiology of chronic wounds, and the various medical problems of individuals suffering from them, the challenges related to inefficient wound management have been an area of focus for many years. The European Wound Management Association (EWMA) links wound-management associations across Europe, bringing multidisciplinary individuals and organisations together to improve patients' quality of life across Europe. It has introduced several initiatives recently to support this goal.

Independent speciality and multidisciplinary teams

Chronic wounds need careful diagnostic evaluation, which often requires input from different specialities. Treatment addresses a variety of underlying factors and usually involves the expertise of different medical professions such as physicians, nurses and physiotherapists. The benefit of multidisciplinary interventions for many chronic diseases, including wound care, is well proven; but actually establishing a multidisciplinary approach to wound care within all relevant clinical settings remains a challenge throughout Europe.

Wound care is primarily not defined as an independent speciality for physicians or nurses, meaning there is no standard level of education among the healthcare professionals responsible for providing treatment and care. Due to this, the wound-care domain suffers from variation in the interest and involvement of relevant medical specialities, leading to confusion as to who is responsible for different aspects of wound management. Difficulties related to implementing appropriate referral routes also present an obstacle. EWMA has taken a number of actions to specifically address these issues.

In 2014, EWMA published Managing Wounds as a Team, proposing a universal model for a team approach to wound management. The need to ensure multidisciplinary collaboration is also highlighted in wound-type-specific pieces such as a new EWMA document on leg ulcer management, which will be published in the coming months.

To address the variations in the educational level of healthcare professionals specialising within relevant medical specialties (such as dermatologists, endocrinologists, and orthopaedic and plastic surgeons), EWMA developed a wound-healing curriculum for physicians that was adopted by the European Union of Medical Specialists (UEMS) in April 2015. EWMA is initiating similar activities, to support a common European curriculum for the undergraduate and postgraduate education of nurses.

In 2015, EWMA initiated a wound centre endorsement programme, aiming to define standards for multidisciplinary wound centres in Europe and internationally. This will happen in collaboration with international partner organisations of EWMA. Based on this, EWMA will work towards establishing a network of wound centres, enabling the sharing of knowledge and continued development of a best-practice wound centre model.

Transfer of services from hospitals to community care

Healthcare services are increasingly moving from hospitals to community care - the objective of this being to reduce healthcare sector costs and improve patient quality of life by providing care within the home environment. This has further stressed the need to establish clear treatment pathways for wound patients. It is also vital to ensure that healthcare staff in community care settings attain the minimum skills required to deliver effective wound care, and that they have easy access to communication with wound specialists in clinics.

EWMA published a document on wound care in the home care setting, Home Care - Wound Care, in 2014, describing these challenges and providing recommendations for how to meet them.

In addition, reports on the use of eHealth services in wound management support the increased evaluation of opportunities for telemedicine and telehealth services, such as remote consultations between community care staff and wound-care specialists. The implementation of these technologies could enhance the role of the patient in their own care, and provide greater involvement of general practitioners and informal carers in the patient's home.

Inconsistent guideline implementation

The available European and national evidence-based guidelines that exist for the primary types of chronic
wound management (such as diabetic foot ulcers, pressure ulcers and venous leg ulcers) are not systematically implemented into clinical practice around Europe. Typical barriers to the implementation of these guidelines include:

• lack of management recognition of the value of evidence-based guideline adoption within the given domain
• the mix or level of skills available in healthcare staff members not matching recommendations
• lack of systematic training programmes
• lack of awareness that the guideline exists, or lack of human or financial resources to invest in the reorganisation of healthcare services.

To address these challenges, EWMA is collaborating with other societies, such as the International Working Group on the Diabetic Foot and the European Pressure Ulcer Advisory Panel, to actively support large-scale implementation of the European guidelines published by these two organisations.

It also published a new document on the management of venous leg ulcers in 2015, providing a review of the existing guidelines and extracting the evidence-based or best-practice recommendations for a full overview of how to design and implement high-quality leg ulcer management.

Patient safety: the wound management perspective

Pressure ulcers are a preventable yet common problem. International prevalence rates vary between 8.8 and 53.2%, while incidence rates vary from 7.0 to 71.6%. The prevention of pressure ulcers constitutes a significant patient safety issue and, potentially, significant resource savings if the appropriate prevention measures are effectively implemented.

Other areas that have potential for great improvements to patient care and resource savings are nosocomial infections and surgical site infections (SSIs). The incidence of SSIs in orthopaedic and trauma surgery varies with the level of risk associated with types of procedures. SSIs are generally reported to occur in less than 1% of low-risk patients (such as joint-replacement procedures), while SSIs may develop in up to 15% of high-risk patients undergoing contaminated procedures, which are primarily encountered in emergency trauma surgery.

Even though the focus on patient safety has increased in recent years - owing, among other things, to the focus on the topic in the EU Commission - there remains a long way to go in the prevention of pressure ulcers and SSIs. In the case of pressure ulcers, insufficient prevention measures relate back to the failure to adopt evidence-based guidelines, including appropriate risk assessment tools. Concerning SSIs, it is, among other factors, a challenge to ensure the proper monitoring of patients that have undergone surgery following their discharge from hospital.

To raise awareness of these patient-safety related challenges, EWMA highlights pressure ulcers as a significant issue of patient safety, thereby promoting the adoption of evidence-based guidelines for pressure ulcer management on a national level as well as within the communications of the EU Commission. EWMA is also planning the publication of a focus document on the prevention and management of SSIs in home care, targeting community nurses, to be initiated in late 2016.

Antimicrobial stewardship in wound management

Challenges related to the management of infections are also present in the prevailing debate about the need to reduce the use of antimicrobial agents in general healthcare.

Wounds are predisposed to infection, as the exposure of subcutaneous tissue following a loss of skin integrity provides a moist, warm and nutrient-rich environment conducive to microbial colonisation and proliferation. The use of antimicrobial agents is therefore clearly important in wound management. Inappropriate use of antimicrobials, however, creates an environment for resistance against the currently available antimicrobial products. This in part supports not using such products in situations where antimicrobials could support the more efficient treatment of the infection, and decrease the risk of complications and death. On the other hand, overuse of antimicrobial agents is a well-known problem contributing to the development of antimicrobial resistance, and is an ineffective use of healthcare resources.

At present, there is not a consistent approach to defining, evaluating and measuring the appropriate use of antimicrobials locally in wound management. EWMA has decided to take a leading role in the efforts to reduce the inappropriate and inadequate use of antimicrobials, having published an overview document, Antimicrobials and Non-Healing Wounds, outlining the available evidence, controversies and possible ways forward in this domain.

It has also launched a European Antimicrobial Stewardship Programme, promoting, facilitating and teaching good antimicrobial practice in wound management. EWMA additionally collaborates with relevant organisations engaged in the question, such as the British Society for Antimicrobial Chemotherapy, to reach common goals.

Opportunities from advanced therapies

New options to treat chronic wounds (such as cellular therapies, engineered tissues and substitutes, physical therapies, and sensors and software), are regularly introduced in the field of wound management. In most cases, however, these do not reach a substantial evidence base, and thus healthcare professionals are not able to properly evaluate them for use in clinical practice. This may result in lost opportunities to improve wound management.

To counter this, EWMA is currently planning a document that provides an overview of the opportunities in the multifaceted and complex field of new advanced therapies. This work also aims to include a review and discussion about clinical experiences and the evidence beyond them, as well as discussing barriers and facilitators for the adoption of advanced therapies in wound management.

The long game

Non-healing wounds are one of the most prevalent problems in healthcare across Europe, concerning a large number of medical specialties and professions. To a large extent, the solutions to the problems are present, but efforts to implement current best practice for wound management and prevention, and to continue investigating new opportunities for treatments and organisation of care, are needed. A key starting point is the establishment of a multidisciplinary team, comprising the right expertise to evaluate all aspects of these complex patient conditions.