Implementing an evidence-based pathway to improve outcomes for non-healing wounds

ABSTRACT: In order to provide structured and equitable interventions in relation to identification and management of wound infection, an NHS Trust has implemented an evidence-based pathway for non-healing wounds. Following the introduction of the pathway there were reduced nurse visits for wound assessment, a reduction in wound area, a reduction in necrotic tissue and improved healing rates.

KEY WORDS

Case study

Evidence

Infection

Pathway

Silver dressing

UrgoClean Ag

Wound

ANITA KILROY-FINDLEY, Clinical Lead Tissue Viability, Leicestershire Partnership NHS Trust

KAREN OUSEY, PhD, Professor of Skin Integrity, Institute of Skin Integrity and Infection Prevention, University of Huddersfield

Frugal innovation in wound management within a low resource inpatient setting: a case series

Objective: This article highlights challenges of wound care in low resource settings, considering opportunities for frugal innovation and our experiences while creating virtual wound care clinics across two global communities. In addition, we will discuss four real cases presented within the virtual clinics. An adaptation of the widely accepted tissues, infection, moisture, edge, regeneration and repair of tissue, and social factors (TIMERS) wound assessment is also proposed with considerations for low-resource setttings. 

Method: From March to December 2021 the University of Salford engaged in a virtual wound clinic initiative with colleagues in Fort Portal Regional Referral Hospital.

Results: The clinics provided opportunities for professional and academic development of students on postgraduate tissue viability module in Salford, while empowering nurses and midwives in Uganda in taking their place at the centre of multidisciplinary teams in care delivery Furthermore, it created links between the university and clinicians in Uganda to develop the delivery of evidence-based wound management. Throughout this period, challenges associated with low resources were highlighted and, in some cases, innovative approaches to managing wound care were adopted to account for this.

Conclusions: The development and delivery of the virtual wound care clinics between the University of Salford and Fort Portal Regional Referral Hospital provided an opportunity for reflection on practice. This led to development of a Fit4purpose wound dressing, revision of evidence-based guidelines, deeper understanding of the scarcity of essential items and frugal practice, and examination of skin tone bias in the signs and symptoms of wound infection in patients with dark skin tones.

KEY WORDS

Case series

Dressings

Frugal innovation

Low resource

Uganda

Wounds

DR MELANIE STEPHENS

PhD, RGN, Senior Lecturer in Adult Nursing and Lead for Interprofessional Education, School of Health and Society, Mary Seacole Building, University of Salford, UK

MATTHEW WYNN,

MSc, RN Adult, Lecturer in Adult Nursing, School of Health and Society, Mary Seacole Building, University of Salford, UK

SHEBA PRADEEP

MSc, RN Adult, Lecturer in Adult Nursing, School of Health and Society, Mary Seacole Building, University of Salford, UK

LOUISE ACKERS

Chair in Global Social Justice, Director Knowledge, Health and Place Research

RACHEL NAMIRRO

Registered Midwife, Assistant Nursing Officer, Knowledge for Change, Fort Portal, Kabarole District, Uganda

BECKY MASKEW,

BSc Nursing (Adult), Staff nurse, Fairfield General Hospital, Northern Care Alliance, UK

SARAH SULEIMAN

Student Nurse CYP, School of Health and Society, Mary Seacole Building, University of Salford, UK

JANE BOARDMAN, BA Hons, Student Nurse, School of Health and Society, Mary Seacole Building, University of Salford, UK

DEREK BAHANDAGIRA, Registered Nurse, Assistant Nursing Officer, Surgical, Paediatrics, and Diabetes Clinic, Fort Portal Regional Referral Hospital, Uganda

ANGELA MUGUMBA,

Certificate of Registration Midwife, Assistant Nursing Officer, Knowledge for Change, Labour/Gynaecology Ward, Fort Portal Regional Referral Hospital, Uganda

KAYLEIGH THORNTON,

MA, Registered Midwife, Stockport Foundation Trust, UK AUGUSTINE SSEMUJJU, MMed (Obstetrics & Gynaecology), Specialist in Obstetrics and Gynaecology, Fort Portal Regional Referral Hospital, Uganda

YASMIN CAPEL, MBBS, Doctor, Knowledge for Change, Fort Portal Regional Referral Hospital, Uganda ODUR JOE, BSc, Pharmacist, Fort Portal Regional Referral Hospital, Pharmacy Stores

NALUKENGE PROSCOVIA,

Senior Theatre Assistant, Fort Portal Regional Referral Hospital, Uganda

HANNAH RANK, MBChB,

Doctor, Knowledge for Change, Fort Portal, Kabarole District, Uganda

AGNIESZKA SZYMKOWIAK,

MSc, CYP Nurse, Guy's and St Thomas NHS Trust, UK

National Wound Care Strategy update: pressure ulcer consultation

JACQUI FLETCHER OBE

Senior Clinical Advisor Stop the Pressure Programme/National Wound Care Strategy NHS England Clinical Implementation Manager

Complex wound healing with topical negative pressure wound therapy: a case study

Surgical wound dehiscence (SWD), a complication of surgery, can delay wound healing, increase the economic burden of the healthcare provider, and have a negative impact on the patient’s wellbeing. The fundamental goal for the treatment of SWD is wound closure. This article describes the use of Avance® Solo, a negative pressure wound therapy system, selected as a therapy for both the prevention and treatment of dehisced closed surgical incision wounds in a patient with complex and social needs.

KEY WORDS

Negative pressure wound therapy (NPWT)

Patient wellbeing

Surgical wound dehiscence

Wound healing

LISA SUTHERLAND

MSC RN LLB(HONS), Nurse Consultant for Wound Management and Tissue Viability, Norfolk anad Norwich University Hospital; Honorary Lecturer, University of East Anglia, Norwich, UK

What are the effects of Covid-19 on diabetes and foot complications associated with diabetes?

N Rezai

The Covid-19 pandemic, with its disruption of services and higher mortality risk has had far-reaching consequences for people with diabetes, contributing toward increased risk of rapid deterioration, ICU admissions and a worse prognosis. Covid-19 also affected access to diabetes related foot care and multidisciplinary services, with long-term implications for people who were unable to access care and attend clinic appointments during the pandemic. This review examines studies on the effect of Covid-19 on people with diabetes, foot complications associated with diabetes and service delivery.

Citation: Rezai N (2023) What are the effects of Covid-19 on diabetes and diabetic foot-related complications?. The Diabetic Foot Journal 26(1): 40–5

Key words

- Covid-19

- Foot care access

- Service provision

- Telemedicine

Article points

1. People with diabetes are more likely to be more unwell with Covid-19.

2. Foot care services were severely disrupted during the pandemic.

3. Lessons learned from the pandemic give avenues to investigate for footcare services in future.

Author

Miss Nealoofar Rezai, BSc (Hons) MRCPod, is Clinical Lead Podiatrist, Royal Free Hospital, London, UK

Treating obesity is no longer inSURMOUNTable

The SURMOUNT-2 trial was simultaneously presented at the ADA 2023 Scientific Sessions and published in the Lancet, and demonstrated that use of the dual GLP-1/GIP receptor agonist tirzepatide resulted in a mean body weight reduction of up to 14.7% after 72 weeks in people living with type 2 diabetes and comorbid obesity or excess weight. This level of weight loss has previously been associated with type 2 diabetes remission, and was also accompanied by clinically meaningful improvements in a number of cardiometabolic risk factors, including lipids, blood pressure and liver enzymes. With tirzepatide and semaglutide, we now have two compelling evidence-based pharmacological therapies with superior efficacy and safety profiles compared to previous obesity medications. However, there remains uncertainty about durability of effect and impact of withdrawal of treatment on weight loss maintenance. Amid calls to use percentage weight loss as a target biomarker in obesity (like HbA1c in diabetes, LDL-cholesterol in atherosclerotic cardiovascular disease and albuminuria in chronic kidney disease), a seismic shift in how we approach the management of obesity, with significant financial implications for healthcare systems globally, may be required.

Kevin Fernando

GP in North Berwick

Citation: Fernando K (2023) Diabetes Distilled: Treating obesity is no longer inSURMOUNTable. Diabetes & Primary Care 25: [early view publication]

      The SURMOUNT-2 trial was simultaneously presented at the ADA 2023 Scientific Sessions in San Diego and published in the Lancet. The trial demonstrated that use of the dual GLP-1 and GIP receptor agonist tirzepatide resulted in a mean body weight reduction of up to 14.7% after 72  weeks in people living with type 2 diabetes and comorbid obesity or excess weight.

      Moreover, around one third of participants lost over 20% of their baseline body weight. The average weight reduction with tirzepatide after 72 weeks was 14–16 kg, a level that has previously been associated with remission of type 2 diabetes (Lean et al, 2018).

      With respect to glucose-lowering efficacy (a  pre-specified key secondary endpoint of the trial), use of tirzepatide reduced HbA1c by 23  mmol/mol (2.1%) after 72  weeks. The mean HbA1c of trial participants at trial end was 41 mmol/mol (5.9%), reflecting, in other words, normalisation of glucose levels.

      Additional benefits observed included reductions in fasting glucose and insulin levels (indicating a significant increase in insulin sensitivity); improvements in lipid profile, particularly fasting triglyceride and non-HDL cholesterol levels; a reduction in systolic blood pressure of 6–7 mmHg; and reductions in liver enzymes (notably a 35% improvement in ALT) – all clinically meaningful improvements in cardiometabolic risk factors.

      SURMOUNT-2 also explored the safety profile of tirzepatide; reassuringly, the overall rate of serious adverse events was similar between the tirzepatide and placebo groups. Most treatment-emergent adverse effects with tirzepatide were, predictably, gastrointestinal in nature: most commonly nausea, diarrhoea and vomiting. However, these gastrointestinal adverse effects occurred primarily during the dose escalation period, were mostly mild to moderate in severity and decreased over time.

      Importantly, there was no imbalance observed with diabetic retinopathy events, liver and gallbladder events, malignancies (including pancreatic cancer and medullary thyroid cancer) and pancreatitis, which have previously shadowed certain incretin molecules. There were also no cases of severe hypoglycaemia detected, despite the potent glucose-lowering efficacy of tirzepatide. Mean pancreatic enzyme levels were increased but remained within the normal range, which is consistent with other incretin therapies used for obesity, such as semaglutide. Overall, mean pulse rate increased by 1 bpm over 72 weeks; there was an initial rise of 4 bpm observed, which subsequently decreased.

A seismic shift is required

      It is well known that people living with obesity and type 2 diabetes lose less weight than those living with obesity alone, so SURMOUNT-2 is a prodigious advance for the management of obesity and type 2 diabetes. The results of SURMOUNT-2 also surpass the compelling results with semaglutide 2.4 mg in the STEP-2 trial (Davies et al, 2021).

      Obesity is now recognised as a chronic disease with multiple pathophysiological aspects; it involves more than just an increase in body mass. Like other chronic diseases, obesity is relapsing in nature and can lead to a range of complications, including cardiometabolic disease and malignancy.

      Different complications require different amounts of weight loss for treatment; for example, in non-alcoholic fatty liver disease (NAFLD), 3–5% weight loss reduces hepatic steatosis, while ≥5–7% weight loss can lead to resolution of non-alcoholic steatophepatitis and ≥10% weight loss improves hepatic fibrosis (Hannah and Harrison, 2016). The 2022 ADA/EASD Consensus Report suggests that 5–10% weight loss confers metabolic improvement in type 2 diabetes, and weight loss of >10–15% can lead to remission of type 2 diabetes (Davies et al, 2022).

      Percentage weight loss should now be used as a target biomarker in obesity (like HbA1c in diabetes, LDL-cholesterol in atherosclerotic cardiovascular disease and albuminuria in chronic kidney disease) to mitigate the specific complications of obesity (Garvey, 2022).

      Much of current thinking for preventing and treating obesity centres around hedonic eating in combination with a sedentary lifestyle; “Eat  less, move more” is commonly delivered advice to people living with obesity. However, while these are contributing factors, it is well known that pathophysiological mechanisms affecting appetite and satiety are pivotal in the development of obesity. Optimising satiety needs to be addressed early in the management of obesity, as calorie restriction alone is unlikely to be a long-term solution if there is ongoing abnormal hunger.

      A seismic shift is required in how we approach the management of obesity, with increased access to weight management services and evidence based pharmacological therapies that directly impact appetite and satiety, such as semaglutide and tirzepatide.

Ongoing questions

      As with all good studies, SURMOUNT-2 raises more questions than answers. What is the durability of effect of tirzepatide after 72 weeks and, crucially, what is the effect of withdrawal of tirzepatide on weight loss maintenance? The STEP-4 weight maintenance trial and STEP-1 off-treatment extension study both demonstrated weight regain after discontinuation of semaglutide, suggesting that incretin therapy is required over the long term for sustained weight loss (Rubino et al, 2021; Wilding et al, 2022). This has significant financial implications for healthcare systems globally. One solution would be a phased approach to the management of obesity, with early phases using highly efficacious obesity drugs such as tirzepatide or semaglutide and then transitioning to lower-efficacy and cheaper obesity drugs for weight maintenance. Several such obesity maintenance drugs are in the early stages of development.

      This approach is analogous to the treatment of rheumatoid arthritis, where often potent targeted biological therapy is used early on to achieve remission of arthritis, followed by a switch to a conventional DMARD for maintenance therapy, for reasons of long-term safety and health economics. Using this approach for obesity management might help the sustainability of healthcare systems.

      Finally, what are the cardiovascular, renal and liver benefits of tirzepatide? These questions will hopefully be answered on completion of the SURPASS-CVOT, SURMOUNT-MMO and SYNERGY-NASH trials, which, unfortunately, are not due to report soon. However, positive results would facilitate targeted use of tirzepatide for people living with obesity and specific co-morbidities such as atherosclerotic cardiovascular disease, chronic kidney disease and NAFLD.

      In conclusion, treatment of obesity is no longer insurmountable, with two compelling evidence-based pharmacological therapies with superior efficacy and safety profiles compared to previous obesity medications. However, there remains uncertainty about durability of effect and impact of withdrawal of treatment on weight loss maintenance. Much-needed real-world data will help resolve some of this uncertainty.

References

1. Davies M, Færch L, Jeppesen OK et al; STEP 2 study group (2021) Semaglutide 2·4 mg once a week in adults with overweight or obesity, and type 2 diabetes (STEP 2): A randomised, doubleblind, double-dummy, placebo-controlled, phase 3 trial. Lancet 397: 971–84

2. Davies MJ, Aroda VR, Collins BS et al (2022) Management of hyperglycemia in type 2 diabetes, 2022. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 45: 2753–86

3. Garvey WT (2022) New horizons. A new paradigm for treating to target with second-generation obesity medications. J Clin Endocrinol Metab 107: e1339–47

4. Hannah WN Jr, Harrison SA (2016) Lifestyle and dietary interventions in the management of nonalcoholic fatty liver disease. Dig Dis Sci 61: 1365–74

5. Lean ME, Leslie WS, Barnes AC et al (2018) Primary care-led weight management for remission of type 2 diabetes (DiRECT): An open-label, cluster-randomised trial. Lancet 391: 541–51

6. Rubino D, Abrahamsson N, Davies M et al; STEP 4 investigators (2021) Effect of continued weekly subcutaneous semaglutide vs placebo on weight loss maintenance in adults with overweight or obesity: The STEP 4 randomized clinical trial. JAMA 325: 1414–25

7. Wilding JPH, Batterham RL, Davies M et al; STEP 1 study group (2022) Weight regain and cardiometabolic effects after withdrawal of semaglutide: The STEP 1 trial extension. Diabetes Obes Metab 24: 1553–64

This article is excerpted from the Diabetes & Primary Care Vol 25 No 4 2023 by Wound World.