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Wound up for Wounds Wound up (verb. To be excited) for Wounds (noun.

Injuries to living tissue)

Welcome to the February edition of Wound Up for Wounds.

I like to refer to Jan Rice as I work with you.

“An aspect of wound management often overlooked is

defining the wound itself. The guiding principles of wound

management have always been focused around defining the

wound, identifying any associated factors that may influence

the healing process, then selecting the appropriate wound

dressing or treatment device to meet the aim and aid the

healing process.

This structured approach is essential, as the most common

error in wound management is rushing in to select the wound

dressings without actually giving thought to wound aetiology,

tissue type and immediate aim” - Jan Rice RN, Australia

Canada is a leader in wound care methodology with the

Wound Bed Preparation paradigm which, if used, provides the

clinician with a solid wound assessment and treatment plan

including the dressing. At the risk of making some of the

readers ill with a picture of a wound, let us put this paradigm

to work on Page 2.

Enjoy the brighter days and the thoughts of spring.

Jane McSwiggan, MSc., OT Reg. (MB), IIWCC

In this issue:

Contact us:

Visit our public website: www.wrha.mb.ca

1 Wound up for Wounds

2-3 Wound Bed Preparation

4 Practice Corner

5 Upcoming Courses

6 Patient safety review

E: jmcswiggan@wrha.mb.ca

P: (204) 926-8013

F: (204) 947-9964

Wound up for Wounds

Issue 5 | February 2019

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Did you know?

In Manitoba, stages 3, 4 and unstageable pressure injuries are critical

incidents.

Please report using RL6 or call the Critical Incident Reporting and

Support Line (24 hours) at 204-788-8222.

Further information: http://www.wrha.mb.ca/quality/patient safety/

criticalincident/report.php

Wound Bed Preparation: Your Ticket to Success

Wound bed preparation has several steps which I will take you through in the assessment of the

wound shown on the next page. Try working through it and see where it takes you. Discuss with

your colleagues, come up with a plan. Next edition we will review the wound and give suggestions.

Person with a wound

Person-centered

concerns (pain) Identify/treat the cause

Moisture Balance Tissue(Debridement) Infection/Inflammation

Edge of the Wound

Determine Healability: Healable, Maintenance, Nonhealable/Palliative

Local Wound Care

Adapted from: Sibbald, R.G., Elliott, J.A., Ayello, E.A., & Somayaji, R. (2015)

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Is it possible to debride it? Remember vascular status.

Do not debride stable black eschar on heels and feet.

3. What tools are in your toolkit for debridement?

Mechanical (30cc syringe and 18 gauge needle or

blunt tip for 8-14 psi)

Autolytic (*hydrogel with hydrocolloid, dressing

cadexomer iodine, hydrophilic paste)

Consult advanced wound care clinician for opinion on

surgical or conservative sharp wound debridement

Infection/Inflammation

Look for signs of superficial (3 or more NERDS) or deep/

surrounding infection (3 or more STONEES)

N - Non-healing S - Size increasing

E - Exudate T - Temperature elevation

R - Red friable tissue O - Os (probes to bone)

D - Debris N - New areas of breakdown

S - Smell E - Exudate

E - Edema, Erythema

S - Smell

What tools are in your toolkit to treat infection?

Topical antimicrobial*, for superficial infection, which

should be used for 2 weeks. If there is no significant

improvement then stop use and consider an alternative

or identify other factors impeding healing1

“Don’t obtain swabs from superficial ulcers

for culture as they are prone to both false

positive and false negative results with

respect to the cause of the infection”

- Choosing Wisely Canada

Topical antimicrobial* and systemic antibiotic for deep/

surrounding infection. Swab clean wound tissue not

slough to direct antibiotic therapy.

Moisture Balance

Do you need to add or remove moisture to the wound?

Dry cells are dead cells and epithelium cannot migrate in

a wet environment. Choose a product that donates or

manages moisture.

Edge of Wound

Are the edges lacking new healthy tissue, is there

undermining at the wound edges, or are the edges rolled?

This indicates that wound healing is not progressing

normally. Dead space in undermined areas needs filling

and wound edges may need debridement if rolled or

unhealthy.

Identify and treat the cause

What caused the wound?

Consider co-morbid conditions, medications,

moisture, nutrition, and age. Improvement is

dependent upon removal of the sources of the

problem where possible.

Person-centered concerns

The goals and perspective of the recipient of

treatment are paramount.

Manage pain.

Are there risks to modify, is treatment

accessible?

Healable, maintenance (non-healing),

non healable

Is the wound going to heal or are there factors

such as the slough we see which will delay

healing?

Discuss with patient and team at rounds.

Assessment of the wound

Assessment of the wound seems to make everyone

nervous, but assessment can be made a lot less

daunting when we use the tools of wound bed

preparation.

Tissue/Debridement (healable or maintenance

wound)

1. Look at the wound & describe the tissue in the

wound bed indicating how much of each type by

percentage.

2. Is there tissue requiring debridement?

* Dressing categories not trade names are used, refer to local advanced wound care formulary

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Practice Corner: Dressing Change

Question: How often should a dressing be changed?

Answer? It depends on the wound and the type of

dressing.

Gauze has to be changed daily or more than once a

day. Advanced wound dressings such as foams,

alginates, hydrofibres and slow release iodine

dressings can be left in place longer. Change when

there is evidence of the dressing being at capacity from

exudate, or in the case of a dressing with iodine, that it

has been deposited into the wound bed.

Always date the dressing.

Become familiar with the properties of dressings

Learn your local wound care formulary, each site

and program has one.

Check in with your advanced wound care clinician

when you have completed a wound assessment, to

discuss your findings and plan.

Additional Information

Having trouble signing up for wound

care courses?

Staff with LMS access

Log into the Learning Management

System (LMS) from any computer or

device at https://manitoba-

ehealth.learnflex.net.

If needed, create a new account by

clicking “new User”.

Enter “WOUND CARE” in the global

search bar.

Level 1 is a bundle of 8 modules

available online;

Level 2 and other courses are

delivered in the classroom setting.

Staff without LMS access

Contact Cindy Hoff at

choff@wrha.mb.ca or 204-926-7047 to

register.

Have a question?

Contact Jane McSwiggan, Education

and Research Coordinator-Wound Care

at jmcswiggan@wrha.mb.ca.

Correction from November

2018 issue

Skin Tear Treatment if not Bleeding

Ensure dressing removal without tissue

trauma, use barrier film or barrier wipe

Please note that this applies to all

dressings except bordered silicone

foams (Mepilex® border foam on

WRHA formulary has silicone)

Wound Assessment

Identify/Treat the cause

Person-centred concerns & pain

Healable, Maintenance, Non-Healable?

T/D: Type of tissue?

Need for debridement?

I: Infection/Inflammation

NERDS or STONEES?

M: Moisture Balance, not too

wet, not too dry

E: Edge of wound & peri-

wound skin

NERDS

(≥3 antimicrobial dressing, no swab)

Non healing wound

Exudative wound

Red, friable granulation tissue

Debris (slough/eschar)

Smell or unpleasant odour

STONEES

(≥3 antimicrobial dressing, swab, abx)

Size is bigger

Temperature is Increased

Os (probes to bone)

New or satellite areas of breakdown

Exudate,

Erythema, edema

Smell or unpleasant odour

Lanyard card for wound assessment

(Print, cut out and laminate)

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Upcoming Wound Care Courses

Level 2 Adult Pressure Injuries

April 4, 2019 8:30 a.m. to 12:30 p.m. Victoria General Hospital

Level 2 Diabetic Foot Ulcers

March 21, 2019 8:30 a.m. to 12:30 p.m. Grace Hospital

Practice Days: Wound Assessment and Dressing Selection: four courses (each the same)

offered

March 14, 2019 8:30 a.m. to 10:30 a.m. Concordia Hospital

March 14, 2019 10:45 a.m. to 12:45 p.m. Concordia Hospital

May 2, 2019 10 a.m. to 12 p.m. St. Boniface Hospital

May 22, 2019 1 p.m. to 3 p.m. St. Boniface Hospital

Practice Days: ABCs of Leg Wounds and Compression Boot Camp

April 2, 2019 8:30 a.m. to 10:30 a.m. Victoria General Hospital

April 2, 2019 10:45 a.m. to 12:45 p.m. Victoria General Hospital

Musculoskeletal Injury Prevention in Wound Care

March 25, 2019 1 p.m. to 4 p.m. Health Sciences Centre

Level 2

Adult Pressure Injuries

1.Wounds UK (2013a) Best Practice Statement: The use of topical antimicrobial agents in wound

management. (3rd Ed). London, Wounds UK. Available to download from: www.wounds-uk.com

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October 2018

Safety Event

A recent critical incident review revealed a risk to

patients related to the monitoring of skin integrity

when a medical device was used.

What occurred?

A patient fractured their foot and required a cast

boot. Admission orders did not include care

instructions for the cast boot

The in-patient unit does not typically care for

these medical devices and resources were

unavailable to guide care.

There was hesitancy to remove the cast boot for

fear of harming the existing fracture.

An unstageable ulcer was discovered under the

cast boot a week later requiring emergent

debridement.

The wound initially improved after care but then

deteriorated. There were gaps in wound care

documentation and escalation to wound care

experts.

What was learned?

Resources and guidelines for management of

medical devices, such as cast boots, did not

exist within the site at the time of this event.

Recommendations

1. The regional wound care committee will develop

and implement a regional skin integrity and

medical device policy that will include but not be

limited to, the requirements for a physician order

(activity restrictions, frequency of removal) and a

skin assessment, when a medical device is

required.

2. The regional wound care committee will develop

and implement a regional product reference

guide for WRHA staff and physicians concerning

medical devices. The reference guide will

address the application, best fit, and risks

associated with the medical device and will

include a contact resource.

3. The Regional Physiotherapy Program will

develop and implement educational resources

for patients who require a medical device.

4. A medical device can be used to treat a

condition and can include braces, splints,

neck collars or devices such as oxygen

delivery systems.

Cast boot example

Medical Devices (e.g. brace, cast, splint)

This alert represents de-identified information from one or several patient safety reviews and is intended for

system-wide learning. If you have any questions, please contact the WRHA Patient Safety Team at

patientsafety@wrha.mb.ca or contact Client Relations at 204-926-7825.

To see additional Patient Safety Learning Advisories go to wrha.mb.ca/quality/event-learning.php