Wound Management in Australia: Progress and Promise

Introduction Healthcare is currently experiencing a quiet revolution. Until recent times, it has been accepted that high quality healthcare emanates from the professionalism of clinical staff and that poor outcomes are the result of the vagaries of the disease processes. Thus, patients with chronic wound problems were resigned to accept that if the health professionals managing their wounds could not achieve wound healing, their wounds were thereby nonhealable. Times have changed. Community expectations now demand that evidence is provided to demonstrate optimized quality outcomes. Both at national and international levels, health facilities, services, and professionals are being challenged to develop integrated, multidisciplinary, organizational systems incorporating quality improvement. Governments, health departments, and health organizations increasingly require health facilities and services to have systems in place to develop, support, and report on quality improvement programs. The era of clinical governance has arrived. It is indisputable that the pace of clinical governance in some health facilities is far greater than in others. Indeed, it is apparent that in some health institutions, there is considerable rhetoric but little action in quality matters. However, clinical governance is neither a management accessory nor a clinical accessory to the normal working environment. It is an essential element for healthcare improvement. The community and governments will not accept the alternative: increasing adverse event rates and poor quality outcomes. The widely divergent healing rates for chronic wounds will no longer be excused as natural variations in the condition but will increasingly be taken as evidence of poor quality care. The extent of compliance with peer review and specific quality improvements within some health professional ranks has not been overwhelming. For example, the idea of being formally judged and held accountable other than by their own ideals and peer group is foreign to many in the medical profession. According to Arnold, doctors generally have difficulty accepting that it is possible to measure either the process or outcomes of clinical care in any meaningful way.[1] If a multidisciplinary approach to healthcare including wound management is to provide the appropriate synergies for optimal outcomes, then individual health professionals without exception require to engage in peer review and quality audits. In Australia as elsewhere, the health agenda has changed. The explosion of technological and therapeutic developments has not delivered the extent of health improvement anticipated from the substantial financial investment. Health expenditure has been featured as a concerning issue with successive federal governments particularly in the latter quarter of the century. The Productivity Commission annually assembles a framework of statistics on government services in Australia including health information. In 2002, the Commission reported that recurrent expenditure on public hospitals reached $14.4 billion in 2000, which represents a 2.6-percent increase in real terms since 1999.[2] Until recent years, patients’ demands for services were the main consideration, but now there is recognition that resources are finite and the quality and range of services to be provided have to fit within a budgetary framework. Rationing of services, whether implicit or overt, is gradually resulting. Such pressures on health service delivery are certainly viewed with great concern by many health professionals. The appropriateness of all aspects of healthcare is now a major consideration, and thus the effectiveness and efficiency of clinical interventions are of paramount importance. According to the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry, there is a growing focus on healthcare quality as a central function of health systems, not just an area of discretionary activity.[3] These interventions should include preventative action plans. Organizations have been described as a dynamic balance between the authority and the autonomy of the individual, the control that exists in formal structures, and the cooperation that occurs within and between teams.[4] Improving the quality of care in a health organization or system requires that the whole of the organization or system moves in the same direction and achieves change through the learning process. That learning process occurs at the level of the individual health professional as well as at an organizational systems level and all components in between.[5] This learning process is the essence of clinical governance. Clinical governance does not inherently take a macroscopic view of health organizations and systems. It is reliant on a mosaic of specific quality of care issues that reveal aspects of patient management relevant for the planning of quality improvement. One such quality of care issue particularly of relevance in patient care is wound management. This article will describe how this clinical challenge is currently being tackled in Australia and provide examples of two different types of wound problems that have acquired recent prominence internationally. Pressure Ulceration—New Beginnings Wound repair gradually slows as the body ages.[6] Optimal wound repair occurs in utero during early embryonic development and is characterized by nonscarring tissue replacement and healing. Unfortunately, this function is not evident post-natally. As the body ages, tissue repair declines, and increasingly, healing requires more specialized care and attention. In wound management, a major problem in the aged and immobile population is pressure ulceration. Pressure ulceration remains an insidious and distressing complication afflicting chair-bound or bed-ridden patients and one that is a significant cause of mortality in the hospitalized aged. Common precipitating factors that precede the development of pressure ulceration in elderly patients include acute illnesses, injuries or falls, anaesthetics and operations, acute confusional episodes, dehydration, sedation, and changes in the patients’ environments.[7] Some specific populations exhibit higher prevalence rates including quadriplegics, elderly patients with a fractured neck or femur, and patients in intensive care units. Pressure ulceration is not a new phenomenon. Its presence has even been discovered in Egyptian mummies, and the condition has been the subject of extensive research particularly over the past two or three decades. Such research has led to recognition of the role and biomechanisms of pressure in the genesis of the condition, and in turn, this has stimulated concerted efforts toward prevention, a keystone of pressure management. Many risk factors have been identified, and once risk assessment is determined for an individual, appropriate preventative management and care should then be planned and implemented. Prevention and management of pressure ulceration requires a multidisciplinary team approach and a robust system of care management. Failure to adhere to a preventative management plan will result in increased pressure ulcer rates and their associated costs. In many respects, the occurrence of pressure ulceration and efforts toward its prevention are significant exemplars of the strength of a health organization’s quality of care and risk management. How does Australia rate in terms of pressure ulcer prevention and management? Reported prevalence[8] and incidence[9] rates for pressure ulceration in the acute care setting and in the community[10] are relatively high. Importantly, the social and psychological costs endured by patients, their families, and their caregivers due to the presence of pressure ulceration are inestimable.[11] While the United States[12] and United Kingdom[13] have been experiencing litigation against healthcare facilities and individuals due to the occurrence of pressure ulceration, this has not been a feature in Australia. However, with the Australian public increasingly demonstrating their intolerance of the occurrence of pressure ulceration, successful litigation against Australian health facilities and individuals is on the rise.[14] Recognition of the pressure ulcer problem in Australia provided a significant stimulus for Australian health professionals to cooperatively take the opportunity to alter clinical systems practice and improve patient care. Through the auspices of the Australian Wound Management Association, clinical practice guidelines for the prediction and prevention of pressure ulcers were researched and published.[15] These guidelines offer comprehensive evidence-based information, recommendations, and consensus statements on pressure ulceration. While health professionals in Australia can avoid the potential for litigation by following these succinct clinical practice guidelines, patients can avoid the disastrous consequences of pressure ulcer genesis if health professionals adhere to these guidelines. The Australian Wound Management Association has also produced standards for wound management on the basis that documented standards form a model that guides quality outcomes and provides a measure that facilitates critical review of behaviors and practices by both individuals and professions.[16] These standards form a conceptual framework linking theoretical knowledge and clinical practice, and they represent robust risk management strategies as well as support improved quality of wound care regardless of the type of wound.[14] At the national level, there is a range of government and non-government activities and initiatives directed toward support of safety and quality of healthcare. However, the rapidly changing nature of the healthcare system presents significant implications for the delivery of safe, high quality care. As Buchan[17] notes, high quality care, however that is defined, will be difficult to deliver in any country where the various components of the healthcare system fail to interact in a mutually beneficial way. It is important that governments take a broad view across the continuum of care rather than pursue quality improvement in isolation within different sectors or settings of the health system. It is pertinent that not only does this reflect a trend toward more integrated care arrangements, but it also recognizes that many safety and quality issues occur at the boundaries between different parts of the healthcare system. Thus, governments have been eager to utilize quality of care indicators reflecting such integration of care delivery in their health facilities. The incidence and prevalence of pressure ulceration are seen as significant indicators of an integrated quality of patient care. Health facilities in New South Wales are now required to undertake regular pressure ulcer audits and report their outcomes to the government as well as their plans for improvement. Prevention of pressure ulceration has certainly moved to center stage in Australia. Burns—New Technologies On October 12, 2002, Australia awoke to a terrorist disaster on its doorstep. In Bali, a series of bombs were deliberately exploded in a nightclub and bar in order to cause maximum bloodshed among mainly foreign visitors enjoying late evening entertainment. A total of 202 people lost their lives in the tragedy including 88 Australians. A number of major trauma centers in Australia were immediately prepared to receive casualties from Bali, and it is a credit to their disaster planning and high quality care that so many lives were saved. Many patients suffered multiple injuries including shrapnel wounds, long bone fractures, limb loss, internal blast injuries, and major burns. An unprecedented collaborative effort by managers and clinicians ensured hospitals were quickly prepared and made ready to receive the victims. The Burns Centre in Royal Perth Hospital received 30 patients with burns ranging from 2- to 93-percent body surface area (BSA).[18] These patients also had other significant physical injuries as well as psychological trauma. The hospital’s operating theaters ran virtually non-stop for five days to complete the debridement of these patients’ burn injuries. The problems of immediate skin coverage for these large wounds and the consequent scar management were major challenges. Over the past few decades, the management of burns has progressed dramatically. In the 1960s, the survival of a patient with a burn covering 40-percent BSA was described by surgeons as a significant achievement, while in 2004, patients with burns covering most of the body can be saved. However, the problems of scarring and scar contracture often result in multiple operations for cosmetic and functional improvement even years after the initial injury. Technologies that can result in improved post-burn healing have been researched over many years. Early solutions to wound coverage included the use of synthetic materials, xenografts, and allografts. Although useful as temporary dressings, these types of grafts are quickly rejected by the body. Split-skin grafts certainly have assisted in covering large areas of the body following burn injuries, but there are significant limitations to their use. Experimental techniques showed skin cells could be taken from a patient and grown in the laboratory as thin sheets before being replanted to the injured parts.[19] Use of these cultured epithelial autografts rapidly gained acceptance as a treatment for severe burns. However, growth of these cells to a level when they could be used meant that their transplantation after three weeks of cell culture onto the burns site was occurring when scar formation was already in evidence. These autografts were also expensive to produce and difficult to handle. The breakthrough for the use of this technology was as a result of the pioneering work of Dr. Fiona Woods and her team in Perth, Australia. They had succeeded in making a suspension of cells from Day 5 culture well before scar formation became a problem. The cells in suspension can simply be sprayed onto the injured site. The cells can be grown from a small biopsy near the wound or from a small split-skin graft. The technology has enormous clinical potential and is not necessarily confined to burn injuries.[20] Twenty seven of the patients from the Bali tragedy who were treated in Royal Perth Hospital received split-skin grafts and epithelial autograft suspensions.[18] Three of these patients also required dermal reconstruction technology to heal their deep dermal burns. The cell suspension treatment reduced the wound healing time and will assist in improving scar quality over the forthcoming months and years. Conclusion Healthcare has all too often failed to deliver its full potential. In wound management, evidence-based knowledge of procedures and protocols for pressure ulcer prevention have been well described but are still not fully implemented. However, the community demands optimized health outcomes and will not accept anything less. Thus, governments, health departments, health organizations, and health professionals all require to have systems in place to develop, support, and report on quality improvement in healthcare delivery. When these multidisciplinary health groups cooperatively work together, their synergism can produce major benefits for the patient. In Australia, the heightened attention being paid to pressure ulcer prevention with the development of clinical wound standards and the cooperative organization of healthcare in the wake of the Bali tragedy are forceful examples of the rewards when health systems engage in seamless integration.