EWMA Council

The EWMA Journal 

ISSN number: 1609-2759 

Volume 7, No 2, May, 2007 

The Journal of the European 

Wound Management Association 

Published three times a year 

Editorial Board 

Carol Dealey, Editor 

Sue Bale 

Michelle Briggs 

Peter Franks 

Finn Gottrup 

E. Andrea Nelson 

Zbigniew Rybak 

Peter Vowden 

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October 2007. 

Prospective material for publication 

must be with the editors 

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EWMA Journal do not necessarily 

reflect the opinions of the Editors 

or the European Wound 

Management Association. 

Copyright of all published material 

and illustrations is the property of 

the European Wound Management 

Association. However, provided prior 

written consent for their reproduction 

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and printed, such permission will 

normally be readily granted. 

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should state where material is to 

be published, and, if it is abstracted, 

summarised, or abbreviated, then 

the proposed new text should be sent 

to the EWMA Journal Editor 

for final approval. 

Finn Gottrup 

Recorder 

Judit Daróczy 

Christina Lindholm 

EWMA Council 

Zbigniew Rybak Salla Seppänen Javier Soldevilla Carolyn Wyndham-White 

Panel Members 

Editorial Board Members 

Carol Dealey, UK (Editor) 

Sue Bale, UK 

Michelle Briggs, UK 

Peter Franks, UK 

Finn Gottrup, Denmark 

E. Andrea Nelson, UK 

Zbigniew Rybak, Poland 

Peter Vowden, UK 

Co-operating Organisations’ Board 

Rokas Bagdonas 

Pauline Beldon 

Claudia Caula 

Mark Collier 

Rodica Crutescu 

Bülent Erdogăn 

Milada Francu˚ 

Marie Gamlem 

Sheila Gilmartin 

Peter Hanga 

Mária Hok 

Lydia Jack 

Marco Romanelli 

President Elect 

Luc Gryson 

Treasurer 

Carol Dealey 

EWMA Journal Editor 

Christine Moffatt 

Position Document Editor 

Peter Franks 

President 

Aníbal Justiniano 

Aleksandra Kuspelo 

M.A. Lassing-Kroonenberg 

Martin Koschnik 

Guðbjörg Pálsdóttir 

Helena Peric 

Vivianne Schubert 

Maciej Sopata 

José Verdú Soriano 

Luc Tèot 

Deborah Thompson 

Gerald Zöch 

Peter Vowden 

Immediate Past President 

Zena Moore 

Secretary 

Katia Furtado 

Sue Bale 

Deborah Hofman 

E. Andrea Nelson Patricia Price 

Scientific Review Panel 

Caroline Amery, UK 

Mark Collier, UK 

Madeleine Flanagan, UK 

Milada Francu˚, Czech Republic 

Peter Franks, UK 

Luc Gryson, Belgium 

Deborah Hofman, UK 

Zena Moore, Ireland 

E. Andrea Nelson, UK 

Ralf-Uwe Peter, Germany 

Patricia Price, UK 

Rytis Rimdeika, Lithuania 

Marco Romanelli, Italy 

Salla Seppänen, Finland 

José verdu Soriano, Spain 

Carolyn Wyndham-White, Switzerland 

Gerald Zöch, Austria 

For contact information, 

see www.ewma.org 

EWMA Journal 2007 vol 7 no 2

3 Editorial 

Peter J Franks 

Scientific Articles 

7 Is it safe to use saline solution to clean wounds? 

João Carlos Gouveia, Christina Miguens 

15 The cost of pressure ulceration 


21 Epidemiology of wounds treated in 

Community Services in Portugal 

Elaine Pina 

29 Improving wound assessment through 

the provision of digital cameras across 

a Primary Care Trust 

Alison Hopkins 

Background Articles 

35 The use of telemedicine in wound care 

Rolf Jelnes 

39 Lord Joseph Lister: the rise of antiseptic 

surgery and the modern place of antiseptics 

in wound care 

David Leaper 

EBWM 

44 Abstracts of recent Cochrane Reviews 

Sally Bell-Syer 

EWMA 

48 EWMA Position Document 2007: 

Topical Negative Pressure in Wound 

Management 


50 EWMA Journal previous issues 

50 International Journals 

52 EWMA Corporate Sponsors contact data 

Conferences 

54 Conference calendar 

Organisations 

55 The XIth Finnish National Wound Management 

Conference, 1-2 February 2007 in Helsinki 

Salla Seppänen 

56 The SSiS is an association for registered nurses 

with a professional interest in wounds 


57 What’s new in Slovenia? 

Helena Kristina Peric 

58 Co-operating Organisations 

EWMA Journal 2007 vol 7 no 2 


is more than a conference 

As my time as president comes to a close I wish to reflect back on 

my time, to see where EWMA has come from and to look to the 

future of EWMA and its activities. 

For those who may not be familiar with the history of the organisation, 

EWMA was founded at a meeting in Cardiff in 1991, “to promote advancement 

of education and research into native epidemiology, pathology, 

diagnosis, prevention and management of wounds of all aetiologies”. For 

the first 10 years, it undertook an annual meeting held each year mainly 

in Harrogate, organised by Macmillan (then EMAP). However in 2000, 

we had the opportunity of developing our own way forward. The EWMA 

Council elected to work to develop their own meetings, and contracted 

Congress Consultants to organize our meetings, starting in Stockholm. 

While this was a time of great change, the model we now have has become 

so robust that other societies are adopting many of the innovations 

developed since that time. It is a great testimony to the past presidents, 

Council members and other supporters that EWMA is the organization 

it is today. 

It is difficult to identify all the innovations that have taken place, but one 

of the areas that deserve specific mention is the development of the Cooperating 

Organizations which currently number 38 national organizations 

in 29 countries. Indeed EWMA has been instrumental in helping to 

establish wound organizations in countries that previously did not have 

one. EWMA today is widely acknowledged as the umbrella organization 

that brings together these organizations and represents them on a European 

level. We will be seeking to develop this representation further with 

closer ties with Eucomed, an organization that represents the wound care 

industry in the EU. 

Other developments of note include the EWMA publications. The EWMA 

Journal is now in its seventh year, and provides an opportunity to present 

original research as well as reports from the national societies. It is a testament 

to Carol Dealey and her team that the journal is now indexed in 

CINAHL. Interest in EWMA journal has never been higher and we receive 

many approaches from companies, authors and even publishing houses, 

who are interested in publishing EWMA Journal. 

Our other voice is through the Position Documents. The original concept 

of Christine Moffatt, these papers have set a high standard and achieved 

�

international recognition as reference documents for key issues in wound 

management. We are particularly pleased that they are free to access through 

the EWMA website and are in five major European languages (English, 

French, Italian, Spanish & German). While budgetary issues prevent us 

from translating them into other languages we do allow all national societies 

the opportunity to translate them into their own languages for free 

(subject to permission). Please contact EWMA Business Office (ewma@ 

ewma.org) for more information. 

Another area of rapid development has been through the Educational 

Panel, originally led by Madeleine Flanagan and Finn Gottrup, now led by 

Zena Moore. There are many wound care courses undertaken throughout 

Europe, with a range of quality. The Educational Panel has developed 

EWMA curriculum frameworks by which these courses can be compared. 

Provided the courses fit the framework, EWMA can endorse the wound 

care course. Other innovations include the development of a University 

module to run in parallel with the EWMA meetings, and a Teach the 

Teacher project. 

For my part, I have developed an interest in supporting societies in developing 

evidence to support quality improvements in the care they can 

provide to patients. The Central and East European Leg Ulcer project 

aims to examine how models of implementation can be used to provide 

evidence that can justify the application of evidenced based care to patients. 

The study in Poland, the Czech Republic and Slovenia will give the much 

needed evidence to justify appropriate education, organization and access 

to modern wound care products that Governments require in order to justify 

their adoption. It is hoped that this could be a model for other wound 

aetiologies and countries to adopt to develop their services further. 

As I am about to hand over the presidency to Marco Romanelli, I hope that 

EWMA members feel that I have represented them fairly, and continued 

to work in the same spirit as previous presidents. I would like to thank all 

society members, our industry partners and others who have contributed 

so much to EWMA over the past 18 months. Standing down as President 

is hard, as one would like to have achieved more within the time given. I 

would have liked to attend more national wound care meetings, though 

when I have been unable to do so other Council members have been superb 

in representing the organization. EWMA is an amazingly dynamic 

organization. What is often forgotten is that the people who do much of 

the work do so without payment for their time. It is a great testament to 

all who are involved with EWMA that so much can be achieved with the 

good will of a small group of individuals committed to making life better 

for people in Europe and beyond. 


EWMA President 

www.ewma.org 


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Is it safe to use saline 

solution to clean wounds? 

INTRODUCTION 

The delivery of wound care has become increasingly 

technology based. However, some of the 

main problems related to impaired healing in 

wounds may be related to basic aspects such as 

cleansing, when it would be expected that, since 

enough evidence exists to indicate best practice 

in relation to the procedure (Blunt, 2001; Ellis, 

2004), healthcare professionals should have 

knowledge of this evidence. 

In primary health care in Portugal, wounds 

(chronic or acute) are usually cleansed with a sterile 

0.9 % (w/v) sodium chloride solution, usually 

termed physiological saline because it is isotonic 

for human cells (Flanagan, 1997) and innocuous 

and it is, therefore, generally the first choice solution 

for cleaning wounds (Davies, 1999). Isotonic 

sodium chloride solution is one of the best agents 

for cleaning open wounds because it removes debris 

and bacteria without cell destruction (Pina, 

1999, Cochrane, 2004). The major aim in wound 

cleaning is removal of organic and inorganic residues 

before application of the dressing thus maintaining 

an optimal environment at the wound site 

for healing (Morison et al., 1997). Other benefits 

of wound cleaning are: (i) to hydrate the wound 

surfaces and create a moist medium more favorable 

for healing; (ii) to preserve the surrounding 

skin, removing residues of glue and excess of 

humidity that can cause maceration, as well as 

erosion by action of enzymes of the exudates and 

toxic bacteria present on skin; (iii) to facilitate 

the visualization of the size and extension of the 

wound; (iv) to minimize the trauma of the wound 

due to the continuous use of adherent materials; 

(v) to reduce the risk of infection; and (vi) to 

promote the comfort of the ill person. (Morison 

et al., 1997; Agreda & Bou, 2004): 

The technique of wound cleansing has evolved 

through time. Thomlinson (1987) has demonstrated 

that the technique of rubbing the wounds 


(with a swab held on a forceps) from the clean 

area to the dirty area, up and down and from the 

center to the border, only resulted in distribution 

of bacteria upon the surface of the wound. Additionally, 

the use of the swab and vigorous rubbing 

can cause trauma, especially in epithelial cells, as 

well as leave residues (little filaments of the swabs) 

that could delay healing by acting as foreign bodies 

that could remain in the deep tissues and serve 

as a focus of infection (Wood, 1976). 

In conclusion, the best choice for wound cleansing 

is the irrigation technique. Irrigation consists 

of gently removing residues on the surface of the 

wound as well as other contaminants (Lawrence, 

1997-1998). This is achieved by using fluids at 

constant pressure or pulsated pressure (Cooper 

et al., 2003). 

The optimal pressure for irrigation is achieved 

using a 35 ml syringe with a 19 G caliber needle. 

The disadvantages of this method are mainly: 

- the detachment of the needle during irrigation 

with the risk of causing injury to the 

patient and/or the professional; 

- the production of aerosols that could contaminate 

the environment or the professionals. 

At present, the professionals of the Health Subregion 

of Coimbra perform the cleaning of wounds 

by irrigation, using flasks of sodium chloride solution 

of 100 cc, 500 cc or 1000 cc, with a transfer 

attached. The same flask with transfer is used in 

several patients with resulting risk of contamination. 

OBJECTIVES 

The present study was undertaken with the objective 

of evaluating the level of microbial contamination 

of physiological saline flasks used in health 

centers for wound cleaning and identifying those 

microorganisms found. 

� 

Scientific Article 

João Carlos Gouveia 

Christina Miguens 

C. S. Pampilhosa Serra, 

P. Serra., 

Portugal 

gouveia.miguens@sapo.pt

MATERIALS AND METHODS 

Samples 

From February to April of 2005, 44 saline solutions from 

22 health care centers localized in the health sub-region 

of Coimbra were collected. From each centre two flasks in 

use were randomly selected, one from the ER (Emergency 

Room) ward and the other from the outpatient clinic. A 

triple blind methodology for data analysis was used so 

that the professionals in the clinic were not aware at the 

time that the study was under way, the microbiologists 

did not know where the flasks came from and the person 

who analyzed the data also had no idea of the origin of 

the flasks. 

The samples were transported at 4ºC and maintained 

at this temperature until processing. 

Processing of samples 

At the time of sampling, the flasks of saline solutions were 

thoroughly mixed, and 5 ml fractions were removed by 

syringe and needle after disinfection of flask surfaces with 

Sodium Hypochlorite. The undiluted suspensions were 

seeded by the pour-plate technique. For this, 1.0 ml aliquots 

were deposited at the center of sterile empty Petri 

dishes, followed by 19.0 ml of plate count agar (PCA) 

(Biomérieux, France). After homogenization and solidification 

of the mixture, the plates, for all samples, were 

incubated at 28ºC and 37ºC for 48 hours. 

The saline solutions 0.1 ml fractions were evenly spread 

over the surface of Blood Agar (Biomérieux, France) and 

Sabouraud Chloramphenicol Agar (SAB CHL-D; Biomérieux, 

France) with individual sterile, bent-glass Lrods. 

We have also tested the transfer of the flasks of saline 

solutions for microbial contamination with a sterile cotton 

swab that was rubbed vigorously, with rotation, over the 

transfer surface. Swabs were immediately applied directly 

on Blood agar media by rubbing, with rotation, over the 

entire surface twice. These blood Agar plates were incubated 

at 37°C for 48 hours and the SAB CHL-D plates 

were incubated at 28ºC and 35ºC and examined daily 

for a period of 30 days before being declared as culture 

negative. 

The number of colony forming units (CFU) was determined 

in each plate after incubation and the CFU/ml 

of saline solutions was calculated by number of colonies 

x dilution factor. 

Isolation of bacteria 

The specimens with no bacterial growth were considered 

as negative. Bacterial colonies grown in PCA and Blood 

Agar media were selected by their morphological features, 

including all observed bacterial varieties. From each culture, 

the colonies were transferred to the original type 

of medium in the optimal incubation conditions. Every 

morphological type was observed using Gram’s stain for 

the definition of biochemical tests employed to identify 

bacterial species (or genera). Catalase and oxidase tests 

were then performed on the developed colonies, followed 

by biochemical genera and species identification 

tests which used four standardized micro-method systems: 

API Staph, API Strep, API 20 E and API Coryne strip test 

(BioMérieux, France). 

Isolation of Fungi 

Culture positive specimens were identified macroscopically 

by observation of morphological colonial characteristics 

such as texture and color and also microscopically by examination 

of conidial morphology. 

Amplification and sequencing 

When microbial identification was not conclusive when 

employing only conventional morphological and biochemical 

tests, additional 16S rRNA gene sequence determination 

and phylogenetic analysis were used for bacterial 

strains and in the case of moulds we performed the 

amplification and sequencing of ITS (Internal Transcriber 

Spacers) region of 5.8S gene. 

Statistical analysis 

Statistical analysis was performed with the use of SPSS 

11.0 (SPSS Inc., Chicago, USA) for parametric tests. We 

used the t Student for dependent samples; a P value of less 

than 0.05 was considered statistically significant. 

RESULTS 

Of the 44 saline solutions analyzed, 54.5% were contaminated. 

The saline solutions’ CFU/ml ranged between 1 

and 230. The relative distribution of contamination due 

to the transfer or the saline solution itself was diverse, corresponding 

50% to saline solution, 37.5% to the transfer 

and 12.5% to both sources. In terms of relation between 

types of ward/contamination, we realized that the flasks 

used in the ER were present in a ratio of 2:1 contaminated 

flasks to clean, when compared with the flasks collected 

in the outpatient clinic with a statistical difference 

(p= 0,01) [IC 95%: mean 0,363: 0,143]. A total of 38 

strains were isolated, 66% could be identified to species 

level using morphological and biochemical tests, the remaining 

34% were identified by gene amplification and 

sequencing. About 69.6% of the identified strains were 

Gram-positive cocci, the second dominant type of strains 

were Gram-positive bacilli (13%), and the third dominant 

type of strains were Gram-negative bacilli and moulds, 

both with 8.7%. 


The distributions of microbial taxa from saline solutions 

and transfers are shown in Figure 1. The figure shows 

that the number of different taxa in saline solutions was 

considerably higher than in transfers. 

The most frequent contaminants belonged to normal human 

flora (64%), namely Staphylococcus aureus (3 strains), 

Kytococcus sedentarius (3 strains), Staphylococcus epidermidis 

(2 strains), Enterococcus faecalis (2 strains), Klebsiella pneumoniae 

(2 strains), Micrococcus sp. (2 strains), Micrococcus 

luteus (1 strain), Staphylococcus haemolyticus (1 strain), 

Staphylococcus cohnii cohnii (1 strain), Staphylococcus 

lugdunensis (1 strain), Staphylococcus hominis (1 strain), 

Streptococcus salivarius (1 strain), Lactobacillus johnsonii 

(1 strain), Corynebacterium pseudodiphtheriticum (1 strain) 

and Corynebacterium striatum/amycolatum (1 strain). 

The second dominant group of microorganisms (36%) 

was saprophytes in nature such as, Bacillus sp. (2 strains), 

Ochrobactrum sp. (2 strains), Serratia marcescens (2 strains), 

Paenibacillus sp. (2 strains), Pantoea spp 3 (1 strain), Jeotgalicoccus 

sp. (1 strain), Massilia sp. (1 strain), Aspergillus 

fumigatus (1 strain), Aspergillus nidulans (1 strain), 

Cladosporium sp. (1 strain) and Penicillium sp. (1 strain). 

The number of microbial strains isolated from saline 

solutions and transfers are shown in Figure 2. Of the 38 

strains isolated, 26 were recovered from saline solutions 

and 12 from transfers. 

DISCUSSION 

In this study, it was observed that the majority of the saline 

solutions in use for cleaning wounds were contaminated. 

This is due, mainly, to the use of these saline solutions in 

multiple patients (through direct or indirect contact or 


Figure 1. 

Relative distribution of different microbial taxa in 

saline solutions and transfers. The Gram-positive 

cocci group included: Micrococcus, Staphylococcus, 

Enterococcus, Streptococcus, Kytococcus 

and Jeotgalicoccus. The Gram-positive bacilli 

group comprised: Bacillus, Corynebacterium, 

Paenibacillus and Lactobacillus. The Gramnegative 

bacilli group was represented by: 

Ochrobactrum, Massilia, Serratia, Klebsiella and 

Pantoae. Finally, the filamentous fungi group was 

constituted by: Aspergillus, Cladosporium and 

Penicillium. 

Figure 2. 

Number of strains isolated from saline solutions and transfers. 


droplets). This could constitute a major problem because 

the Healthcare Centers from which the samples were collected 

provide assistance to an average of 250000 patients 

and perform around 35000-50000 dressings annually, for 

either chronic or acute wounds. 

All the saline solutions collected were flasks of volume 

above 100 cc (500 cc or 1000 cc), which are used in consecutive 

patients, until the contents are exhausted. No 

statistical difference was found between the type of flasks 

and the contamination degree. Although the samples were 

�


Table 1. 

Microbial species identified from saline solutions and transfers. 

In total, 38 strains were independently isolated at 28, 35 and 

37ºC, and identified by morphological and biochemical tests, 

gene amplification and sequencing. 

a Identified by gene amplification and sequencing. 

b Represents probably a new species of Jeotgalicoccus, 

partial 16S gene sequence was most similar to 

Jeotgalicoccus pinnipedialis (95%, strain A/G14/99/10 T ). 

c Represents probably a new species of Massilia, 

16S gene sequence was most similar to Massilia timonae 

(97%, strain UR/MT95 T ). 

10 

collected in the clinic, the same procedure is adopted in 

home care and the flasks may remain in use for several 

days. 

After perforation of the saline solution flask by the 

transfer, it loses its sterility and so it is recommended that 

each saline solution flask should be of single-use. 

In order to re-use contents, the flasks are fitted with a 

transfer that remains attached and consequently there is 

additional loss of sterility. It also represents an entrance 

point for microorganisms present in the environment, increasing 

the probability of contamination. In this context, 

the manipulation of the transfer by health professionals 

represents an additional source of contamination. 

Our results show that, the contamination was mainly 

(50%) due to the saline solutions as well as the transfers 

(37.5%). Additionally, from some of the contaminated 

saline solutions we were able to isolate more than one 

� 


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bacterial species (data not shown) thus increasing the risk 

of wound contamination with multiple species. 

Trengove et al. (1996) demonstrated that the presence 

of several bacterial species (four or more) colonizing a 

wound significantly increases the probability of delayed 

healing. 

With respect to identification of microorganisms 

isolated, we observed that in most cases (64%) they belonged 

to the normal human flora, suggesting that the 

main source of contamination was human manipulation 

of the patient, while the other 36% were probably from 

the environment. 

It is disturbing to conclude that most of the wounds 

cleaned with these flasks, even if they were not colonised 

or infected before the treatment, have a higher risk of 

becoming infected after it, with all the associated costs 

both human and economic. We wished to change practice 

and looked for the evidence that the saline could be 

contaminated. Although we do not know infection rates 

in Portugal, it is logical to conclude that if we use contaminated 

solutions there will be a higher inoculum and 

therefore a greater risk of infection. 

CONCLUSION 

The false concept of economic benefits from multi-use 

products without taking into account other aspects such as 

effectiveness, has led to erratic practices with negative consequences 

for patients, namely: (i) increase in the period of 

time for the necessary treatments for wound healing; (ii) 

increase in the use of systemic antibiotic therapy for infections; 

(iii) increased possibility of nosocomial infections; 

(iv) increase of costs relative to the wound treatments; and 

(v) significant decreasing of quality life of patients (not 

published data). In summary, it is urgent that healthcare 

professionals adopt single use cleaning solutions in order 

to decrease or even eliminate a significant source of wound 

contamination. More than the flask size, the level of contamination 

will depend on the time it remains in use after 

being opened since it is known that each bacterium can 

divide in two in a period of just 20 minutes (one bacterium 

could yield one million bacteria in six hours) (Alfa 

& Sitter, 1991). 

It is important that those responsible for wound management 

should be alerted to the importance of avoiding 

in-use contamination of wound cleansing solutions, but 

1 

that is not all. Besides the standard precautions such as 

hand hygiene and appropriate use of gloves, it is important 

to consider that all materials in the proximity of the 

patient can become contaminated during wound cleansing 

through production of droplets and aerosol particles and 

that there is, therefore, also the risk of contamination via 

hands and gloves during the procedure. 

In relation to the use of transfers, our results suggest 

the need of adopting the use of single use saline solution 

flasks for wound cleaning, with a system of delivery that 

will permit wound irrigation without risk of manipulation. 

Although this study refers to saline solutions, the results 

should be extrapolated to all materials used in wound care 

which are in the proximity of the patient and are used for 

other patients (for example, hydrogel, swabs, ointments, 

and scissors). 

Finally, the results of this study were presented to head 

nurses from all the health centers in the region followed 

by an educational programme on prevention of cross contamination 

of infection during wound care. 

We hope that this study may lead to other more allinclusive 

studies, which can be lead in hospital wards, to 

examine and understand if these results may be extrapolated 

to all kind of healthcare services. m 

Bibliography 

Alfa MJ., Sitter DL. In hospital evaluation of contamination of duodenoscopes: a 

quantitative assessment of the effects of drying. J. Hospital Infection, 1991; 19: 

89-98. 

Agreda, J. & Bou, J. (2004). Atención integral de las heridas crónicas. Madrid, SPA, Sl. 

Blunt J (2002) Wound cleansing: ritualistic or research-based practice? Nursing Standard. 

16, 1, 33-36. 

Cooper, R. et al. (2003). Wound Infection & Microbiology. London, Medical 

ommunications, UK Ltd, Johnson & Johnson Medical. 

Davies, C. (1999). Wound care. Cleansing rites and wrongs. Nursing Times, 95 (43): 

71-72, 75. 

Ellis T. CPD: Understanding the act of contamination in wound dressing procedure, 

Collegian, Vol. 11, nº 3, 2004, p. 39-41 

Fernandez, R., Griffiths, R., Ussia, C. Water for wound cleansing, Cochrane database 

Syst Rev, 2002 (4) 

Flanagan, M. (1997). Wound Management. Edinburgh: Churchill Livingstone. 

Lawrence, H. (1997 Dec 17-1998 Jan 6). Nursing in 1998: on with the new? 

Nurs Stand, 12(13-5): 36-37. 

Morison, M. et al. (1997). A Colour Guide to the Nursing Management of Chronic 

Wounds. London, Mosby. 

Pina, E. (1999). Aplicação tópica de antimicrobianos no tratamento de feridas. In Nursing 

: formação contínua em enfermagem, 137: 31-34. 

Thomlinson, D. (1987). Journal of Infection Control Nursing. To clean or not to clean? 

Nursing Times, 83(9): 71-75. 

Trengove, N. J. et al. (1996). Qualitative bacteriology and leg ulcer healing. J Wound 

Care, 5(6): 277-280. 

Wood, R. A. (1976). Disintegration of cellulose dressings in open granulating wounds. 

British Medical Journal, 1(6023): 1444-1445. 


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a broad range of wound pathogens in the dressing including MRSA 5 

as demonstrated in in vitro testing 

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*AQUACEL ® dressing has the same composition and Hydrofiber ® Technology as AQUACEL ® Ag dressing. 

References: 1. Parsons D, Bowler PG, Myles V, Jones S. Silver antimicrobial dressings in wound management: a comparison of antibacterial, 

physical, and chemical characteristics. Wounds. 2005;17(8):222-232. 2. Walker M, Hobot JA, Newman GR, Bowler PG. Scanning electron 

microscopic examination of bacterial immobilisation in a carboxymethyl cellulose (AQUACEL ® ) and alginate dressings. Biomaterials. 2003;24:883-890. 

3. Bowler PG, Jones SA, Davies BJ, Coyle E. Infection control properties of some wound dressings. J Wound Care. 1999;8(10):499-502. 4. Walker 

M, Cochrane CA. Protease sequestration studies: a comparison between AQUACEL ® and PROMOGRAN ® in their ability to sequester proteolytic 

enzymes. WHRI 2494 WA139. May 27, 2003. Data on file, ConvaTec. 5. Jones SA, Bowler PG, Walker M, Parsons D. Controlling wound bioburden 

with a novel silver-containing Hydrofiber ® dressing. Wound Rep Reg. 2004;12:288-294. 

®/TM The following are trademarks of E.R. Squibb & Sons, L.L.C.: AQUACEL Ag and Hydrofiber. ConvaTec is an authorised user. 

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The cost of pressure ulceration 

INTRODUCTION 

Pressure ulcers are a major cause of morbidity in 

the population, yet it is largely an unseen problem. 

It is known that the treatment and prevention of 

pressure ulcers is costly to health services, but as 

yet there is still little information on precise costs. 

Moreover, there is a cost to patients of pressure ulceration, 

both in financial terms, but also in terms 

of their quality of life. This paper will review some 

of the key evidence in respect to both the costs to 

society and the costs to individual patients. 

MEASURING THE BURDEN OF 

PRESSURE ULCERATION ON RELATIVES 

AND CARERS 

It is important to examine both the costs of providing 

the health services to patients suffering from 

the disease in question, but also to determine the 

costs to patients and relatives since care falls increasingly 

outside the formal health services, and 

on to patients and their families. Indirect costs 

should be derived from estimates of lost production 

by the patient or family members caused by 

the disease, losses to society caused by the patient 

being unable to function to their potential, and 

quality of life issues, particularly problems associated 

with pain, poor mobility, discomfort and 

distress. Relatives and carers provide substantial 

support to health services, without which it is 

argued that health and social services would collapse 

under the burden if such informal care was 

not available. In is estimated that some 6.8 million 

people in the UK could be defined as carers 1 . 

These carers provide support and care to relatives 

and friends who are unable to care for themselves 

independently. In England the value of informal 

carers providing care in the community is estimated 

to be £57 billion per year 2 . 

THE FINANCIAL COSTS OF PRESSURE 

ULCERATION 

The costs of pressure ulcer care and prevention are 

largely unknown, perhaps due to the fact that it 

is a condition largely secondary to other diseases. 

However, there has been a long-standing interest 

in estimating the costs of pressure ulcers, sometimes 

using these costs to calculate which other 

services (surgery and bed stays) could instead be 

provided 3 . 

In 1993, the UK government commissioned 

accountants Touche Ross to provide them with 

an estimate of health service costs of pressure ulcers 

4 . They used existing research where available 

and expert opinion where necessary to provide a 

theoretical cost of prevention and treatment of 

pressure ulceration in an average 600 bedded hospital. 

Different models were proposed, depending 

on whether the hospital was high or low cost, and 

depending on whether there was an active prevention 

strategy with treatment, or treatment alone. 

The final estimates indicated that with a treatment 

strategy alone a low cost hospital would 

spend e 901,000 (£644,000) per year on pressure 

ulcers whilst a high cost hospital would spend 

in the region of e 1,614,000 per year in 1993. 

When including a prevention strategy into the 

care of patients the low cost hospitals used a similar 

budget (e 901,000), but the high cost hospitals 

used e 3,794,000. 

Most the excess cost associated with prevention 

was consumed by additional nursing time spent 

assessing and turning the patients. This report 

concluded that the cost of pressure prevention 

and treatment would cost the UK health service 

approximately 0.4-0.8% of the total annual 

budget. This analysis was limited in that it only 

estimated costs in the acute (hospital) services and 

was unable to estimate costs in the community. 

Moreover, there was no attempt to estimate indirect 

costs, costs to patients, nor any value placed 

on the patients’ quality of life. 

A more global investigation of cost of pressure 

ulceration was undertaken in the Netherlands, 

examining the costs in different care settings in- 

� 



Professor of 

Health Sciences 

& EWMA President 

Centre for Research & 

Implementation of 

Clinical Practice 

Faculty of Health & 

Human Sciences 

Thames Valley University 

32-38, Uxbridge Road, 

London W5 2BS 

Tel: 0208 280 5020 

Fax: 0208 280 5285 

peter.franks@tvu.ac.uk 

EWMA Journal 2007 vol 7 no 2 15


cluding home care; nursing homes; general hospitals and 

university hospitals 5 . Prevalence figures for different pressure 

ulcer stages were determined from estimates given 

by the Health Council for the Netherlands on Pressure 

Ulcers 6 . These data were combined with expert opinion 

(Dutch Society of Pressure Ulcer Experts) to determine 

personnel time, extra days of care, use of special beds and 

medical materials. Both low and high estimates were given 

to indicate the potential range of costs. Costs were dependent 

not only on ulcer stage, but were also highly dependent 

on where care took place. As an example of this mean low 

and high daily costs of stage II pressure ulcers were highest 

when treated in a university hospital (low e 71.6, high 

e 110.2) and lowest in the general hospital (low e 23.7, 

high e 25.1) with conversion factor e 1= $1.3. 

Home care was similar to University Hospital costs 

whereas nursing home care was similar to that of the general 

hospital costs. The authors estimated annual costs 

of pressure ulcer care to be in the range e 371 million to 

e 1,695 million per annum for a country with a population 

of just 16.5 million, or 1% of the Dutch health care 

budget. 

More recently, a model of costs of pressure ulcers has 

been developed in the UK, which adopted a more epidemiological 

approach 7 . It also looked at different health 

states for pressure ulcers, namely normal healing; critical 

colonisation, cellulitis and osteomyelitis. Each health state 

and pressure ulcer grade was ascribed a cost based on the 

research evidence and/or expert opinion. The average cost 

of healing the different pressure ulcer grades was estimated 

at e 1489 for a grade I, e 6,162 for grade II, e 10,238 for 

grade III and e 14,771 for grade IV. 

In the UK (population 60 million) annual incidence 

(new cases) was estimated at 140,000 for grade I, 170,000 

for grade II, 50,000 for grade III and 50,000 for grade IV 

based on available incidence data 8 . By combining average 

costs and number of cases the total cost of pressure 

ulcers was estimated at e 214 million (grade I), e 1047 

million (grade II), e 544 million (grade III) and e 670 

million (grade IV), giving a total cost of all pressure ulcers 

at e 2,473 million. This is equivalent of approximately 

2.6% of the total current NHS budget. 

As expected most cost (90%) was associated with nursing 

time, though in-patient stays accounted for 8% of 

overall costs and 30% for grades III and IV. Cost for antibiotics, 

dressings and pressure relieving equipment was 

all relatively low. 

Other studies have concentrated on specific costs of pressure 

ulceration. In Australia a study was undertaken to 

examine the bed days lost to pressure ulceration in 2001-2. 

It was estimated that a pressure ulcer led to an extra 4.31 

days per patient leading to 398,432 bed days lost and an 

16 

opportunity cost of AU$ 285 million (e 170.7 million) 

in a population of 20.3 million 9,10 . 

COSTS TO THE PATIENT: QUALITy OF LIFE 

Health related quality of life (HRQoL) is an important 

measure of the impact of a condition on the patient’s physical 

and mental well being and their ability to function 

socially. While most clinicians would accept that HRQoL 

is an important measure to determine the impact of disease 

on the patient relatively few studies have been undertaken 

to assess this. 

One influential qualitative study used a phenomenology 

approach to determine the impact of the condition 

on 8 subjects who mostly were suffering (or had suffered 

from) a stage IV pressure ulcer in the USA 11,12 . Key themes 

identified were: 

n Perceived aetiology of the ulcer 

n Life impact and changes 

n Psycho spiritual impact 

n Extreme painfulness associated with the PU 

n Need for knowledge and understanding 

n Grieving process 

The pressure ulcer had effects on the patients in terms 

of their physical, ability, their ability to function socially, 

their financial situation, changes in their perceived body 

image, and loss of independence and control of their own 

lives. Patients who had an ulcer for longer than six months 

experienced pessimism and a poorer adherence to treatment, 

which left them feeling depressed and frustrated. 

Coping with the pressure ulcer was difficult, and patients 

felt isolated, particularly when they were often left in a side 

room on their own. Patients felt humiliated that health 

care professionals were seeing parts of their body which 

were normally kept private. The odour from the pressure 

ulcer made them feel dirty and they often resorted to deodoriser 

to mask the smell. Financial costs were associated 

with having to miss work, for medical care, prescriptions 

and travel. The theme of living a restricted lifestyle was 

examined more recently, with more detail given for the 

impact on families 13 . 

Pain associated with the pressure ulcer appears to have 

a substantial impact on patients and their lives 13,14 . In 

the study by Szor 84% of patients with a grade II to IV 

experienced pain, even at rest, with 18% reporting this as 

excruciating 14 . In addition 88% reported pain at dressing 

change. Only 6% reported pain relief being prescribed, 

with nursing staff frequently denying the pain their patients’ 

experienced. 

A further study was undertaken using a generic quality 

of life tool (SF-36) in 60 patients in the community 15 . 

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1 Jørgensen B et al. Pain and quality of life for patients with venous leg ulcers: proof of concept of the effi cacy of 

Biatain - Ibu, a new pain reducing wound dressing. Wound Repair and Regeneration 2006, 14 (3), 233-239. 

2 Steffansen B et al. Novel wound models for characterizing the effects of exudate levels on the controlled release of 

ibuprofen from foam dressings. European Wound Management Association, Poster, May 2006, Prague, Czech Republic. 

3 Sibbald, RG et al. Decreased chronic (persistent) wound pain with a novel sustained-release ibuprofen foam dressing. 

European Wound Management Association, Poster, May 2006, Prague, Czech Republic. 

4 Flanagan M et al. Case series investigating the experience of pain in patients with chronic venous leg ulcers 

treated with a foam dressing releasing ibuprofen. WorldWideWounds April 2006. 

5 Gottrup F et al. Lower pain with Biatain - Ibu: Initial fi ndings from a randomised controlled double-blind clinical 

investigation on painful venous leg ulcers. International Wound Journal, Supplement 1, March 2007. 

Reclaim a life 

with less pain

17 TH CONFERENCE 

OF THE EUROPEAN 

WOUND MANAGEMENT 

ASSOCIATION 

Evidence, 

Consensus 

and Driving 

the Agenda 

forward 

EWMA2007 · GLASGOW 

2-4 MAY · 2007 

DOWNLOAD THE EWMA 2007 ABSTRACTS FROM 

WWW.EWMA.ORG/EWMA2007 

WWW.EWMA.ORG/EWMA2007 

Compared with the general population, patients with pressure 

ulcers experienced greater problems with physical and 

social functioning. At present no studies have examined 

utility scores of patients with pressure ulceration to determine 

the potential deficit associated with the condition 

and the potential cost in terms of QALYs (Quality adjusted 

life years). 

DISCUSSION 

In the area of pressure ulceration there has been some 

interest in the evaluation of outcomes of treatment, but 

very little attention to the overall cost of care, nor impact 

on the patients’ quality of life. Surprisingly, health services 

do not appear to be aware of the financial burden that 

pressure ulceration causes. As an example, the e 2.5 billion 

spent on pressure ulceration is equivalent to the cost of 

treating mental health in the UK or all community health 

services 7 . The cost estimates are highly dependent on the 

incidence of pressure ulcers, although few studies have 

been undertaken on a population basis to determine this 

important aspect of pressure ulcer evidence. The results 

from studies so far undertaken have shown that pressure 

ulcers lead to a clear deficit in quality of life, though again, 

these are based on small local studies of patients. 

There is a clear need for governments to understand that 

pressure ulceration causes a major financial burden on 

them and on patients’ lives. Until the magnitude is appreciated 

it is hard to push for cost effective treatments 

and prevention strategies on a national basis to rationalise 

the care of patients who suffer from this distressing condition. 

m 

References 

1. Maher, J., Green, H. (2000) Carers 2000. London, Office of National Statistics 

2. Carers UK (2002a) Without us carers. London, Carers UK. 

3. Hibbs, P. (1990) The Economics of Pressure Sore Prevention. In: Pressure Sores: 

Clinical Practice and Scientific Approach. Ed Bader, D. London, Macmillan Press 

Ltd. 

4. Touche Ross. ‘Pressure sores: a key quality indicator’. Department of Health, 

Heywood 1993 

5. Severens JL Habraken JM, Duivenvoorden S, Frederiks CMA. The cost of illness of 

pressure ulcers in the Netherlands. Adv Skin & Wound Care 2002; 15: 72-77. 

6. Health Council of the Netherlands. Pressure Ulcers. The Hague: 

Health Council of the Netherlands 1999 (In Dutch). 

7. Bennett G, Dealey C & Posnett J. The cost of pressure ulcers in the UK. 

Age & Ageing 2004; 33(3):230-5 

8. Clark M Watts S. The incidence of pressure sores within a national health service 

trust hospital during 1991. J Adv Nurs 1994: 20; 33-6 

9. Graves N, Birrell F, Whitby M. Effect of pressure ulcers on length of hospital stay. 

Infect Control Hosp Epidemiol 2005; 26(3): 293-7 

10. Graves N, Birrell FA Whitby M. Modelling the economic losses from pressure ulcers 

among hopsitalized patients in Australia. Wound Repair Regen 2005; 13 (5):462-7 

11. Langemo DK, Melland H, Hanson D, Olson B, Hunter S. The lived experience of 

having a pressure ulcer: a qualitative analysis. Adv. Skin Wound Care 2000; 13: 

225-35 

12. Langemo DK. Psychosocial aspects in wound care. Quality of life and pressure 

ulcers: what is the impact? Wounds 2005 17(1): 3-7. 

13. Hopkins A, Dealey C, Bale S, Defloor T, Worboys F. Patient stories of living with 

a pressure ulcer J Adv Nurs. 2006 56(4):345-53. 

14. Szor JK, Bourguignon C. Description of pressure ulcer pain at rest and at dressing 

change. J Wound Ostomy Continence Nurs. 1999; 26(3):115-20. 

15. Franks PJ, Winterberg H, Moffatt CJ. Health related quality of life and pressure 

ulceration: assessment in patients treated in the community. Wound Repair & 

Regeneration 2002; 10 (3): 133-140.

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EXTENDED ABSTRACT · PRAGUE 2006 

Epidemiology of wounds 

treated in Community Services 

in Portugal 

Abstract 

Aim: To characterize patients and types of wounds 

treated in community services and assess patients’ 

views with regard to wounds and care received. 

Materials and methods: Cross-sectional study of a 

sample of patients with wounds of duration longer 

than two weeks. A representative national sample 

was calculated taking into account regional 

dimensions, population density and urban/rural 

mix. Then 148 health centres were randomly selected 

and patient information was completed for 

a sample of patients in the clinics. 

Results: In all 1424 wounds in 1115 patients aged 

≥ 18 yrs were assessed. Of these 57.4% were treated 

in the clinic and 42.6% in the home. There 

was a predominance of female patients (57.7%) 

and the average age was 69.9 (clinic) and 77.1 

(home) years. Over 80% of patients were retired. 

Leg ulcers were the main type of wound followed 

by pressure ulcers. Average wound duration was 

7.4 months for pressure ulcers and 19.4 months 

for leg ulcers. Of 574 clinic patients a significant 

number complained of discomfort and pain but 

over 90% were satisfied with care received. 

Discussion: Patient population was characterized 

as elderly, low income and suffering from chronic 

underlying disease. Expectations regarding healing 

are low. An education / intervention project 

has been started to promote evidence-based practice. 

INTRODUCTION 

Chronic wounds are a major health care concern 

in the community. They cause substantial morbidity 

and their management is both time consuming 

and costly. Phillips 1 studied the aetiology and 

epidemiology of chronic cutaneous ulcers in the 

USA and found that pressure ulcers and leg ulcers 

were the most commonly encountered cutaneous 

ulcers. The Canadian Association of Wound Care 2 

combined data of significant studies surveying over 

14000 patients from 45 Health Care Institutions 

and found that 13-17% of pressure ulcers were 

found in community care. They found the prevalence 

of all types of wounds in persons receiving 

community care to be 34-37%. In Germany 3 , a 

study of chronic wounds in home care identified 

a prevalence of 4.1% for pressure ulcers, 2.7% for 

leg ulcers and 1% for diabetic foot ulcers. In India 

Gupta et al 4 conducted a prevalence study in an 

urban and a rural community and found a prevalence 

of 15.03 per 1000 with a predominance of 

untreated acute traumatic wounds. 

Graham et al 5 conducted a systematic review of 

prevalence studies in lower limb ulceration in the 

adult population. They identified 22 reports but 

differences in populations studied, study design, 

case identification procedures, and clinical validation 

of wounds prevented pooling of estimates. 

They recommend that future studies should include 

large numbers of subjects and total populations. 

Briggs and Closs 6 reviewed the literature on 

the prevalence of leg ulceration and encountered 

similar limitations. They therefore suggested that 

a combination of questionnaires to health professionals 

and a random sample of the population 

provide the best method of establishing the true 

prevalence. 

Until recently, wound management has been a 

low priority in Portugal and heavily dependent 

on hospital care (outpatient and inpatient). The 

approach is traditional, care is not evidence based, 

healing rates are low and very little information 

is available about the type of wounds treated in 

primary care. We conducted a study of leg ulceration 

in an urban area in Lisbon7 and identified a 

prevalence of 1.41 per 1000 population. The incidence 

of pressure ulcers has been studied in hospital 

populations in around 80 thousand patients8 for implementation of the Braden risk assessment 

scale but little is known about their burden in 

the community. Some aspects related to patients’ 

� 


Elaine Pina MD, 

Clinical Microbiologist 

Rua Professor Hernani 

Cidade 3-2A 

1600-630 Lisboa 

Portugal 

Tel: 351 217583027 

elainepina@netcabo.pt 



views regarding their wounds are also not known. As part 

of the leg ulcer study mentioned, a quality of life study 9 

reported that patients with leg ulcers showed significantly 

higher scores compared with Portuguese normative data 

for all domains of the Nottingham Health Profile. Education 

programmes are regularly held, many of them sponsored 

by industry, but do not seem to be reflected in the 

quality of care provided. 

This study was conducted in order to identify the burden 

of wounds on the individual and the community services 

in order to enable us to devise the most appropriate educational 

strategies to improve the quality of care in these 

patients. Because of the known limitations of definitions 

and denominators 5, 6, 10 , we did not attempt to calculate 

prevalence rates. We conducted case assessments of persons 

with wounds to determine the type of wounds treated in 

community services, their care and the patient’s perceptions 

related to their wounds and the care received. 

METHODS 

This was a cross sectional, multicentre, descriptive study 

of a sample of patients with wounds presenting at primary 

care services in Portugal. The sampling units were 

the health centres. After an initial calculation of the probable 

number of wounds treated in previous years it was 

estimated that to obtain a sample of 1000-1500 wounds in 

patients it would be necessary to visit around 120 Health 

Centres. The sampling method was undertaken in two 

phases. In the first phase the country was stratified by 

region (5 regions) taking into account dimensions and 

population density so as to obtain a representative national 

sample. In the next phase, regions were further subdivided 

into their sub-regions and councils in order to account for 

the urban/rural mix. Following this, 148 Health Centres 

were randomly selected as sampling units. Approval was 

obtained from the National Data Protection Committee. 

A pilot test was carried in one sub-region (16 health 

centres), during one month, involving 127 patients/219 

wounds. Only minor changes were made to the questionnaires. 

Data were collected between May 2004 and 

December 2005 (19 months). Twenty professional interviewers 

were trained with respect to the content of the 

questions and general characteristics of the wounds studied. 

They visited each health centre for a period of 1 to 2 

days, monitoring all patients with wounds treated at the 

clinic and in home care. The number of home care visits 

was determined based on the usual proportion of visits in 

relation to the patients seen in the clinic at each centre. 

All patients aged 18 or above, with wounds having a duration 

of more than two weeks, were included in the study. 

Informed consent was obtained for all participants. Since 

no validated tools were identified for this type of study, 

three data collections tools were devised for use during 

the study. They were based on the objectives of the study 

and guidelines of best practice. The first one was related 

to information provided by the nurse who cared for each 

patient and was related to clinical information and care 

given. A second questionnaire was directed to the patients 

in order to assess their views and satisfaction with the care 

received. A classification scale from 1 (minimum) to 5 

(maximum) was used to categorize the importance factor. 

Finally a third tool was used to assess the resources used in 

terms of nursing time and consumables. Statistical analysis 

was performed with the SPSS 13.0. A descriptive analysis 

of all variables with the absolute and relative frequencies 

for the categorical variables and average, standard deviation, 

maximum and minimum values for the continuous 

variables was obtained. This paper will report on the 

epidemiology of wounds treated and patients’ views with 

respect to their wounds and treatment received. 

RESULTS 

Of the 18 sub-regions in the country, 17 (144 health centres) 

participated in the study. A total of 1424 wounds 

from 1115 individuals (57.7% women and 42.3 men; 

national average 52% women) were studied. Of these, 

57.4% were seen in the clinic and 42.6% in the home. 

The majority of the patients was of low socio-economic 

status (only 3% graduated from secondary school). The 

average age of patients in the clinic was 69.9 (SD 13.6 

min 18 max 96) years (national average is 47 years) and 

in the home the average age was 77.1 (SD 10.7 min 22 

max 104). Over 80% were retired. 

Distribution of wounds by type is presented in table 1. 

Leg ulcers (35.6% venous, 2% arterial and 4.3% mixed) 

were predominant in the clinic and pressure ulcers in the 

home. Pressure ulcers were located predominantly in the 

hip (27.3%) sacrum (19.8%) and heel (19.6%). Of the 

traumatic wounds, 93% were in the lower limb. Chronic 

wounds (n = 981) were analysed in more detail. The median 

duration was of three months for pressure ulcers, 

12 months for leg ulcers and three months for diabetic 

foot ulcers. Because of the long duration of a number of 

wounds we established a cut-off of 100 months. Results 

showed that, for a cut-off of 100 months, the average 

duration was of 7.4 (SD 11.9) months for pressure ulcers 

and 19.4 (SD 23.8) months for venous leg ulcers (48 leg 

ulcers had a duration of over 8 years) and 9.8 (SD 15.3) 

months for diabetic foot ulcers. 

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Table 1-Distribution of wounds by type 

Because of the difficulties in the diagnosis of infection, 

we only collected information on the presence of related 

signs/symptoms. In 1108 patients, signs of inflammation 

or infection (oedema, erythema, pain, local warmth, exudate, 

odour) were present (Table 2). About 3% of pressure 

ulcers and leg ulcers showed all signs, and around 19% of 

ulcers referred showed at least three of them. 

Associated co-morbidities: 19.8% of patients with pressure 

ulcers and 16% of those with leg ulcers suffered from 

diabetes. Venous disease was present in 13.2% of patients 

with pressure ulcers and 10% of patients with diabetic foot 

ulcer. Of the pressure ulcer patients 9.2% had suffered a 

stroke and 3% suffered from hypertension. Other risk 

factors studied were malnutrition, smoking habits and alcohol 

intake. This was information reported by the health 

professionals (no definitions were supplied). Malnutrition 

was noted in 31.8% of pressure ulcer patients, in 4.5% of 

venous ulcers patients and in 8.2% of diabetic foot ulcer 

patients. Less then 4% of the patients referred smoking 

and alcohol intake was referred in about 6%. Around 20% 

of patients were on antibiotics. The most frequent medications 

are presented in table 3. 

Patients’ views: The questionnaire about patients’ views 

was completed for 574 patients who attended the clinic. 

Day-to-day discomfort due to the wound was referred to 

as being significant or very significant in more than 41.2%. 

Only 18% referred little discomfort. A high number of 

patients (70.9%) complained of pain, which ranged from 

little (7.5%) to significant or very significant (45%). Prolonged 

pain was referred by 57% of those referring pain. 

Twenty per cent complained of pain at dressing changes, 

Table 2. Signs of inflammation or infection 

Table 3. Most frequent medications prescribed 

15% of pain on movement and 8% at both; 45% used 

analgesic drugs. It is interesting to note that nurses only 

mentioned presence of pain in about 30% of the patients 

(Table 2). 

More than 90% of the patients were satisfied or very satisfied 

with the care received and only 7.5% had complaints. 

Disinfection of the wound (89.9%) and the dressing used 

were considered to be the most significant part of care followed 

by communication with the nurse (77.6%). 

One third of the patients came to the clinic on foot and 

37% used public transport. Others used a motorbike or 

family car and 6.8% were transported by ambulance or 

the health centre or day care centre transport. About 38% 

were accompanied by family or friends but, in most cases, 

this did not require absence from work. Waiting time for 

attendance was on average 21.4 minutes (SD19.0) with a 

minimum of 1 minute and a maximum of 2 hours. 

DISCUSSION 

This is the first study in the country to address the problem 

of wounds treated in community services. In this type of 

study in which the health professional supplies information 

on patients, some weaknesses can be expected, due to the 

high number of people involved, variable knowledge on 

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1. Leigh R, Barker S, Murray N, Hurel SJ. The Kerraboot ® : A novel wound dressing device for the management 

of leg and foot ulcers. Practical Diabetes Int 2004;21(1):27-30. 

2. Edmonds ME et al. Randomised study of Kerraboot ® vs standard wound care in the management of diabetic 

neuropathic foot ulcers. Wounds UK, 2006, Vol 2, No 1: 25-31. 

Kerraboot ® is a registered trademark of Ark Therapeutics Ltd 

© Copyright Ark Therapeutics Limited, 2006.

wound management and attention given to the 

questions asked. Discrepancies were identified 

in relation to wound categorization. However, 

because the method of data collection ensured 

confidentiality it was not possible to go back 

for clarification. Nevertheless, it was possible to 

characterize the population of patients treated in 

primary care in Portugal as aged, with a low socio-economic 

status and suffering from chronic 

underlying disease. Leg ulcers are the predominant 

wounds in the clinic and pressure ulcers are 

more frequent in the home. Wound duration 

is prolonged and healing rates are not known. 

However, we conclude that expectations with 

regard to healing are low not only in patients, 

since they are satisfied with the care received in 

spite of the discomfort and pain, but also in the 

health professionals. Analysis of the data related 

to care and costs (to be published) has also confirmed 

that there is a gap between actual practice 

and existing evidence that needs to be addressed 

in order to improve quality of care. In October 

2006 we started a project based on education/ 

intervention that will be implemented through 

2007 and early 2008. At the end of this period 

we will repeat the survey in order to assess the 

effectiveness of our intervention. m 

Acknowledgements 

This study was sponsored by Johnson & Johnson Wound Management a 

division of Ethicon- Johnson & Johnson Medical, Portugal. 

Data collection and statistical analysis was performed by Keypoint, 

Scientific Consultants (an independent company working in the field of 

clinical trials). 

References 

1. Phillips TJ. Chronic cutaneous ulcers: aetiology and epidemiology. 

J Invest Dermatology 1994 Jun; 102(6):38S-41S 

2. Woodbury G. and Houghton P. Canadian Association of Wound Care 

www.cawc.net/open/library/research/pandi/index.html accessed 

1-11-06 

3. Panfil EM, Mayer H et al Wound Management in patients with 

chronic wounds in ambulatory nursing – a pilot study. Pflege 2002 

Aug; 15(4): 169-176 (German, abstract in PubMed) 

4. Gupta N, Gupta SK et al An Indian community-based epidemiological 

study of wounds. J Wound Care, 2004 Sep; 13(8): 323-325 

5. Graham ID, Harrison MB et al Prevalence of lower-limb ulceration: 

A Systematic Review of Prevalence Studies Advances in Skin and 

Wound Care, Nov 2003 

findarticles.com/p/articles/mi_qa3977/is_200311/ai_n9342478 

Accessed on 25.10.2006 

6. Briggs M and Closs SJ The prevalence of leg ulceration: a review of 

the literature. EWMA Journal 2003; 3(2): 14-18 

7. Pina E. Furtado K. et al. Leg ulceration in Portugal: prevalence and 

clinical history. Eur J Vasc Endovasc Surg. 2005 May, 29(5):549-53 

8. Ferreira PL, Miguens C et al. Risco de desenvolvimento de úlceras 

de pressão Implementação nacional da Escala de Braden, 2006 

(in press) 

9. Furtado K. Pina E et al. Quality of life in patients with leg ulcers in 

Portugal. Rev Port Cir Cardiotorac Vasc. 2005 Jul-Sep;12(3):169-74. 

10. Fletcher J. Measuring the prevalence and incidence of chronic 

wounds. Mar 2003. Profession Nurse; 18(7) 384-388 


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EXTENDED ABSTRACT · PRAGUE 2006 

Short Paper 

Improving wound assessment 

through the provision of 

digital cameras across a 

Primary Care Trust 

Abstract 

This paper describes a Trust wide project initiated 

by the Tissue Viability service to improve wound 

care services and outcomes. Tower Hamlets is 

an inner city Primary Care Trust that has both 

Elderly Service in-patients plus District Nursing 

services. Project funding was secured to provide 

digital cameras across the Trust with the aim of: 

1. Reducing delay in diagnosis and referral for 

specialist review. 

2. Improving wound assessment and evaluation 

3. Promoting patient partnership 

4. Improving multidisciplinary collaboration 

within and across services 

Meeting the aims of the project was not difficult 

because the benefits of digital cameras are plain for 

both staff and patients, providing unambiguous 

discussion, facilitating patient and staff understanding, 

plus instant referral. Whilst the benefits 

for utilising this technology are clear, the issues 

surrounding the safe handling and storage of data 

were a challenge. Different protocols were required 

for the various Trust venues and were dependent 

on whether computer systems were networked or 

linked to GP software; the protocols required for 

secure archiving and the associated training will 

be presented. This paper also addresses the greatest 

challenge of the project, which has proved to be 

embedding camera use and the secure archiving of 

patient information across the wards and district 

nursing teams. 

INTRODUCTION 

Tower Hamlets Primary Care Trust (THPCT) 

has an urban population of 200,000 residents for 

whom the District Nursing service is managed 

across 17 teams. In addition there are 6 in-patient 

wards for Older Peoples services including 

four dedicated wound care beds. The Tissue Viability 

service works across the Trust and service 

boundaries and referrals for wound care advice 

and assessments are received by telephone from 


nursing, medical and allied health professionals. 

Guidelines are in place for management of all 

wound types and practitioners are expected to 

utilise the specific wound, leg ulcer or pressure 

ulcer assessment forms. 

PROJECT AIMS 

Several issues were identified that resulted in the 

process of referral, wound assessment and evaluation 

not being as robust as they could be, specifically 

that: 

n Phone referrals and descriptions of the 

wound bed could be ambiguous, causing 

either a delay in review or an inappropriate 

referral. 

n Digital cameras were only used by the Tissue 

Viability team; Polaroid cameras were used 

by some district nursing teams but obtaining 

the film was always problematic. 

n There was poor wound and surrounding 

skin assessment and evaluation. 

n There was incomplete wound information 

passed between community and rehabilitation 

services. 

n The patient’s General Practitioner and even 

some patients (due to its site) rarely saw the 

wounds thereby preventing partnership and 

valuable discussion. 

Thus the aims of the project were: 

1. To reduce delay in diagnosis and referral for 

specialist review through email referral and 

photography. 

2. To improve wound assessment and evaluation 

and enhance documentation and team 

discussion. 

3. To promote patient partnership 

4. To improve multidisciplinary collaboration 

across and within services 

Funding was secured for the provision of digital 

cameras and quality colour printers for each District 

Nursing team and ward. The aim was for 

nursing teams to photograph wounds and email 

� 



MSc, DN Cert, RGN. 

Clinical Nurse Specialist 

(Tissue Viability) 

Tower Hamlets Primary 

Care Trust 

Correspondence: 

Tissue Viability 

Primary Care 

Mile End Hospital 

Bancroft Road 

London E1 4DG 

alison.hopkins@ 

thpct.nhs.uk


them to the specialist team for advice and discussion. The 

next step was to ensure a correct process for data collection 

and storage. 

SECURE DATA COLLECTION AND STORAGE 

In order to ensure the safe use of digital images, a clear 

protocol for use needed to be developed. This was necessary 

to enable practitioners to follow a clear process for 

image production, storage/archiving and retrieval. This 

protocol was based on the THPCT’s guidelines ‘Consent 

to Examination and Treatment’ (see original source, Department 

of Health guide 1 ). Practitioners needed to be 

aware of the legal issues surrounding photographic consent 

and the use of the photograph outside patient records, such 

as education or publication. [See Box 1] 

Box 1 

Photographic consent issues 

• Informed consent (patient or their relative/carer) can 

be obtained through written or verbal means and documented. 

• Obtaining consent is a continuous process and not a one 

off event. 

• Information must be provided: why the photograph is 

required, how it will be used, who will see it and how 

often photographs may be taken. 

• Photographs can be used for education purposes 

if the patient cannot be identified. 

• Photographs must never be used for publication 

without written consent 

It is essential that the practitioners were aware that the 

photograph is part of the patient’s medical history and 

thus must be retrievable at any time. This requires good 

0 

Fig 1 

archiving and images must be saved without alteration. 

Records must be kept of the nurse specialist advice given 

by phone or email. Thus an email referral form was developed 

[Fig 1] that enabled attachment of the photograph 

and sections that addressed the assessment and concerns. 

The protocol made it explicit that NHS encrypted email 

addresses must be used. 

One of the problems identified when developing the 

protocol was that the IT systems varied across the trust; not 

all the nursing teams had access to the GP patient record 

systems and thus could not attach the photograph to the 

patient’s records. For those teams that were not networked, 

we had to ensure that the photographs were not stored on 

the computers (in case of theft) and thus had to be deleted 

after printing. These variations meant that the protocol 

had to be specific to each team’s requirements. However, 

this is now no longer an issue because the IT systems have 

been standardised across the trust. 

Email encryption was also an essential part of ensuring a 

secure process. For this reason only trust or NHS servers 

must be used. Referrals are usually received by phone in 

the specialist service thus it is incumbent on the team to 

regularly check emails for referrals. The referring teams 

have also been instructed to leave phone messages so that 

no delays are incurred. 

Two practitioners from each ward or team were trained 

in the use of the camera and printer, archiving of photographs 

and use and storage of the referral documents. 

PROJECT OUTCOMES 

The development of protocols and training has enabled 

the project aims to be met: 


1. To reduce delay in diagnosis and 

referral for specialist review through 

email referral and photography: 

With a photograph on the monitor 

the ensuing discussion is now based 

on what is seen and not imagined! 

This has enabled the prompt commencement 

of treatment and prioritising 

of specialist assessments. 

2. To improve wound assessment and 

evaluation and enhance documentation 

and team discussion: there is 

now a clear link to assessment and 

evaluation. There is clear evidence of 

progress and efficacy of treatment or 

deterioration of the wound bed and 

surrounding skin. Photographs have 

added clarity to team discussions 

and aided education. 

3. To promote patient partnership: patients 

are not always able to see their 

wounds, thus digital photography 

has promoted understanding, education 

and partnership. This outcome 

has been of particular benefit as the 

immediacy of the image can give 

hope and encouragement; patients 

like to have their own prints often in 

sequence! 

4. To improve multidisciplinary collaboration 

across and within services: 

on discharge or transfer across 

services, photography has helped to 

improve communication. 

DISCUSSION 

This project has had successful outcomes 

and the tissue viability service has provided 

digital cameras and a framework 

for their use across the trust. However, 

like any new initiative there have been 

some challenges that we are still working 

on. The greatest challenge to the project, 

despite piloting and refining the process, 

has been to get some teams to use the 

cameras and email referral forms.When 

discussing the diffusion of innovation, 

Rogers 2 states succinctly that ‘Getting a 

new idea adopted, even when it has obvious 

advantages, is often very difficult’. 

Here, many innovations thus require a 

lengthy period before they become widely 

adopted. Rogers’ model describes an innovation 

curve that separates people into 

innovators, early adopters, early majority, 

late majority and laggards. Identifying 

why we have had so many ‘late majorities’ 

and laggards can probably be explained 

by the poor use of email and computers 

by practitioners whose key role is clinical. 

This has been identified as a problem 

for the trust and is therefore is being 

addressed. Despite the enthusiasm for 

the cameras and the opportunities this 

would bring, it is still another thing for 

the clinical staff to do and in a world of 

competing priorities camera use is low 

in some teams. Thus, the encouragement 

and team training continues. 

It is worth noting why the trust has 

not used camera phones as these are now 

in common use and would therefore be 

an easier technology to adopt. Firstly, the 

cameras were purchased before camera 

phones were of a high enough quality. 

Secondly, there is the issue of secure archiving 

of photographic images; photographs 

will be easy to take but not necessarily 

downloaded appropriately or the 

advice/discussion provided will not be 

recorded. The lack of encryption is also 

a concern. Given due consideration, cameras 

give the trust more control over the 

images and so more security. 

This paper has presented the development 

of a framework that enables digital 

images to be recorded within a secure system. 

The outcomes have been successful 

but, despite the enthusiasm, some practitioners 

have been very slow to adopt the 

new technology. It is essential that patients 

have access to the same assessment, 

wound evaluation and referral process 

wherever they are in the borough thus 

adoption of this new process needs to be 

pursued. m 

References 

1. Department of Health. Good Practice in consent implementation 

guide: consent to examination or treatment. 

Department of Health. 2001. http://www.dh.gov.uk/ 

PublicationsAndStatistics/Publications/PublicationsPolicyAndGuidance/PublicationsPolicyAndGuidanceArticle/fs/ 

en?CONTENT_ID=4005762&chk=7ENk2Q (1.12.06) 

2. Rogers EM. Diffusion of Innovations. Simon and Schuster 

International. 5th Edition. (2003) Page 1 


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1 Münter K-C et al. Effect of a sustained silver-releasing dressing on ulcers 

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2 Jørgensen B et al. The silver-releasing foam dressing, Contreet Foam, 

promotes faster healing of critically colonised venous leg ulcers: a 

randomised, controlled trial. International Wound Journal 2005, 2(1), 64-73. 

3 Rayman et al. Sustained silver-releasing dressing in the treatment of 

diabetic foot ulcers. British Journal of Nursing 2005, 14(2), 109-114. 

4 Ip M et al. Antimicrobial activities of silver dressings: an in vitro comparison. 

Journal of Medical Microbiology 2006, 55, 59-63 

5 Scanlon E et al. Cost-effective faster wound healing with a sustained 

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Faster wound healing 

by reducing the barriers 

to wound healing

The use of telemedicine 

in wound care 

Most patients suffering from chronic 

wounds are attended to by local district 

nurses and may geographically be 

far away from specialist centres. A need for specialist 

advice may, however, turn up often resulting 

in a tedious process for the patient. A remission 

note is forwarded to the hospital and the patient is 

allocated an appointment, perhaps days or weeks 

later in the outpatient clinic. During the waiting 

time the wound may have worsened and become 

more resistant to treatment. 

To deal with this, we have introduced telemedicine 

in Soenderjylland, Denmark, as a tool to 

communicate, in a fast way, between the wound 

care nurses in the local communities and the hospitals. 

This concept we have named “Saar-I-Syd” 

(“Wounds-in-the South”). 

We applied the experiences, from two PhD 

projects based in the Department of Endocrinology 

M, Aarhus Universityhospital and Centre 

for Pervasive Health Care, Alexandra Instituttet, 

ISIS Katrinebjerg, Aarhus. In these studies the 

technology was developed and tested 1 . In the sec- 

Fig 1. 

The set-up, diagram 

ond study 2 local district nurses in Aarhus participated 

in the development of a real-time on-line 

teleconsultation, which was proven to be fully 

exchangeable to a standard in-hospital consultation. 

In “Saar-I-Syd” the web-based database was 

adapted to our needs through collaboration with 

the software company Dansk Telemedicin A/S. 

Telemedical consulations are now used in Soenderjylland 

(220.000 inhab.) as an interdisciplinary 

tool to remit patients with venous leg ulcers, arterial 

ulcers, diabetic foot ulcers, pressure sores 

and inflammatory ulcers to the specialists in the 

hospitals, to communicate between the different 

sectors, thus avoiding visits to the outpatient 

clinic, to control quality of the treatment given 

and to support the district nurses in their handling 

of the patients with chronic wounds. 

HOW IS THIS DONE? 

When the district nurse sees a patient with a 

chronic wound, the patient is registered in our 

web-based electronic database. Only healthcare 

� 

Background Article 

Rolf Jelnes, MD1 

Niels Ejskjaer, MD 2 

1 Saar-I-Syd, 

Department of 

Vascular Surgery, 

Sygehus Soenderjylland, 

Aabenraa, 

Denmark 

2 Diabetic Foot Centre, 

Department of Medicine M, 

Aarhus University Hospital, 

Denmark 

rolf.jelnes@get2net.dk 



Fig 2. Screendisplay – part of Wound Assessment table Fig 3. Reduction in wound area over time – quality control 

professionals, chosen from the list in the database, have access 

to the data and the patients give informed consent. 

The following data are submitted: personal identification, 

medication, concurrent disease, allergy, duration of 

wound and a description of the wound. Ankle pressure 

and ABI is measured, investigations for neuropathy such 

as monofilament and tip term are performed and data 

on hgb1ac and swabs are entered and other parameters 

relevant for that particular wound. 

The district nurse uses a mobile phone to take a photo 

of the wound and sends this photo electronically to the 

web-based database. We use the N73 with 3.2 megapixels, 

giving us photos of outstanding quality. At the same time 

data on the treatment of the wound is recorded – wound 

status, wound size, the surrounding skin, pain at change 

of bandage and during the day – type and VAS. The type 

of treatment is entered – debridement – product-compression-pressure 

relief etc. All this can be done in the home of 

the patients using the mobile telephone and an electronic 

pen. A preliminary diagnosis is made. 

Finally, the district nurse decides to whom information 

is to be submitted. A choice has to be made weather it is 

routine or calling for an urgent answer. 

The specialists get the information by an sms on their 

mobile telephone, indicating that new information has 

been entered the database. This means, that advice can be 

given, in case of an urgent problem if e.g. the specialist is 

attending a conference in South Africa. The only need is 

access to the web. 

By looking at the data, compression therapy can be prescribed 

and, if necessary, a future appointment to the 

outpatient’s clinic can be forwarded on the same day, 

– typically for duplex scanning of the veins, toe pressure 

measurement or a consultation at a chiropodist. Further 

medical advice such as glycaemia control is submitted at 

the same time. 

6 

We have now worked with this system for 12 months. 270 

patients are now registered in our database. Our personal 

experience, working with telemedicine, is as follows: 

n A proper diagnosis is made at an early stage 

n Adequate treatment – conservative and surgical 

– can be started much earlier than previously, thus 

shortening the wound treatment period. 

n In cases of wound deterioration the patients can 

be seen on the same day and an evaluation can be 

made. 

n Fewer visits to the outpatient’s clinic, as we do not 

need to see those patients, which heal according to 

our standard. 

n Much less troublesome for the patients, as they can 

stay in their own surroundings 

n Specialist support to the districts nurses, thus improving 

their skills – education. 

Once the wound is healed, a decision is made on when to 

follow up on the recommendations given. This is done by 

a notification from the database to the mobile telephone 

to the district nurse 14 days prior to the decided followup 

time. 

We are still working on improving our set-up – i. e.: communication 

systems to the GP’s, district nurses records as 

well as healthcare economic expenses. 

In conclusion, our set-up based on an electronic webbased 

wound care record, to which all medical staff have 

access, is simple to work with and reliable. We are aware, 

that our statements concerning our experiences are undocumented. 

Documentation will follow at a later stage. 

m 

References 

1. Larsen SB, Clemensen J, Ejskjaer N. UMTS and telemedicine: a feasibility study. 

Accepted for publication oct 2006 J Telem Telecare 

2. Clemensen J, Larsen SB, Ejskjaer N. Telemedical treatment at home of diabetic 

foot ulcers. J Telem Telecare. 2005;11 Suppl 2:S14-6. 


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Lord Joseph Lister: 

the rise of antiseptic surgery and 

the modern place of antiseptics 

in wound care 

Evidence, Consensus and Driving the Agenda forward 

EWMA Glasgow 2-4 May 2007 

David leaper gives us his views on 

Lord Lister and the role of antiseptics 

in current surgical practice. 

INTRODUCTION 

It is appropriate to remember Lord Joseph Lister 

as the European Wound Management Association 

comes to Glasgow for its annual meeting in 

May of 2007. It was here in Glasgow that the 

world witnessed the birth of antiseptic surgery 

which was introduced by Lister in the 1860s. 

Although antiseptic surgery was superseded by 

aseptic surgery, because of its toxicity to operating 

theatre personnel as well as the patients’ tissues, 

it was a major breakthrough in infection control 

at the time. All forms of surgery, but particularly 

trauma surgery which Lister specialised in, were 

prone to high morbidity and mortality in relation 

to surgical site infection 1 . Nevertheless, there is 

a still a major role for the use of antiseptics in 

wound care, which will have to be reconsidered on 

a more widespread basis, as the overuse of antibiotic 

therapy is threatening to produce increasing 

numbers of resistant and emerging bacteria. There 

is some evidence that any microbial resistance has 

developed against antiseptics but this is limited, 

probably as their action is so general and multifaceted 

on bacteria, fungi and viruses as well as 

spores. 

LORD LISTER 

Joseph Lister was born in Essex in 1827 and later 

entered University College London as a medical 

student where he qualified in 1852. He almost 

certainly saw Robert Liston undertake one of the 

first amputations there under ether anaesthesia. 


For the first time such operations could be undertaken 

without the need for excessive speed 

with a patient held down by several burly theatre 

attendants, and allowed time for a more careful 

procedure! 1 

After qualification Lister went to Edinburgh 

where he was apprenticed to the famous surgeon 

James Syme, who was obviously another surgeon 

adept at amputation as he has an eponymous operation 

named after him for amputation of the 

foot. It is clear that Lister made a good impression 

as he was appointed to the Regius Chair of 

Surgery in Glasgow in 1860 where he laid down 

his foundations of antiseptic surgery. His ability 

to impress continued and he was subsequently 

appointed as Professor of Clinical Surgery in Edinburgh 

in 1869 and ended his clinical career in 

the Chair of Surgery at Kings College Hospital in 

London 1 . Throughout his life his clinical practice 

was really that of an orthopaedic/trauma surgeon 

(see figure 1). He contributed to surgical education 

and for a time was a member of Council of 

the Royal College of Surgeons of England. 

Lister was honoured further with the award of 

a Baronetcy in 1883; he became a Lord in 1897 

and was awarded the Order of Merit. He died in 

1912 and has a superb public monument left to 

his memory in Portland Place in London 2 . 

It is interesting to speculate how he devised the 

concept of antiseptic surgery. At the time postoperative 

infection was rife after the increasingly 

ambitious elective surgery, and particularly after 

trauma, and was attended by a high complication 

rate and mortality. Apparently the public 

engineers of Carlisle had taken up the concept, 

presumably from their contemporaries in Paris, 

� 


David Leaper 

Professor 

Wound Healing 

Research Unit 

University of Wales 

College of Medicine 

Cardiff 

Wales 

profdavidleaper@ 

doctors.org.uk


Figure 1. Lord Lister on a ward round 

of treating stinking sewage with phenol. Lister became 

aware of this and visited Carlisle 2 . One wonders whether 

he subsequently may have had some similar thoughts 

when walking along the Clyde, which would have been a 

similarly unpleasant experience in those days. He was also 

aware of the contemporary work of Louis Pasteur; only 

a Frenchman would have made the connection between 

the spoiling of wine to vinegar because of the recently 

recognised, offending bacteria and not simply exposure 

to air as was generally thought 2 . Whatever the train of 

thought was he brilliantly realised that the destruction of 

bacteria, rather than their exclusion which was to come 

later as aseptic surgery, from an operative or traumatic 

site might reduce the risk of infection. His hypothesis 

proved correct. 

Lister’s next patient was a boy of 11 years who had suffered 

a compound fracture of his left leg. He was treated with 

undiluted “carbolic” to all parts of the wound of the leg, 

which was simply splinted. The wound was treated with 

similar dressings and splits and the patient walked out of 

the hospital some six weeks later. A second 32 year old 

male patient with a compound fracture of the thigh was 

similarly and successfully treated. 3 Before too long the 

operating theatre in Glasgow was witnessing the introduction 

of 1:20 carbolic hand washing, skin preparation and 

of course the famous carbolic spray which can still be seen 

at the Royal College of Surgeons of England in London. 

The operating theatre environment could not have been 

pleasant and certainly would not have impressed modern 

theatre managers and health and safety committees. 

0 

The success of these measures was nevertheless spectacular. 

Between 1864-1866 there had been 16 deaths after 

35 amputations (a 46% mortality) and between 1867- 

1870, after introduction of antiseptic surgery, there were 

6 deaths after 40 operations (a 15% mortality). (I make 

that statistically significant; Yates’ X 2 , p

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Alcoholic hand rubs have largely replaced antiseptic solutions 

for the infection control process against MRSA. 

However, they are no substitute for hand washing in soap 

and water, or an aqueous antiseptic solution, with adequate 

hand drying during an epidemic of Clostridium difficile 

enteritis, when patients are in isolation. 

It is difficult to understand why dilute aqueous antiseptics 

have fallen out of favour for lavage in surgery, 

for example as a peritoneal lavage for faecal peritonitis. 

It is probably related to a perceived impression of local 

and systemic toxicity, particularly with regard to povidone 

iodine. In fact allergy is rare and the reports of thyroid 

dysfunction sporadic and probably unjustified. It must be 

remembered that antiseptics have had little, if any proven, 

resistance shown following their use. With the rise of antibiotic 

resistance and emergence then a whole rethink 

about antiseptic use may have to be made. 

Antibiotic impregnation of surgically-implanted, prosthetic 

devices and intravascular catheters may also have to 

be reconsidered for these same reasons of antibiotic resistance. 

Nevertheless some type of antimicrobial prophylaxis 

must be used as infection of a vascular or orthopaedic 

prosthesis can be a disaster. The recent introduction of 

a widely used and safe antiseptic, triclosan, into sutures 

for widespread surgical practice, for example, holds great 

promise for the prevention of postoperative infection. The 

incidence of surgical site infection (SSI) has been found to 

be high, with attendant increased healthcare costs, when 

appropriate post discharge surveillance is undertaken 6 . A 

move away from antibiotic prophylaxis, particularly in 

clean surgery where its use is unclear anyway, or for inappropriate 

treatment of SSIs has to be welcomed. However, 

there is unquestioned value with level I evidence, 

of antibiotic prophylaxis in the clean-contaminated and 

contaminated categories of surgical operations and this 

should not be discarded 7 . 

In chronic wound care the use of antiseptics has been 

and continues to be controversial. There was a time when 

hypochlorite solutions were widely used in open wound 

management, including acute wounds such as abscess cavities, 

and chronic wounds such as pressure sores and leg 

ulcers. Their use for debridement, and preparation of a 

recipient wound bed for split thickness grafting, still has 

their advocates. However, it is widely held that these agents 

should not be used in routine wound management at all 

and reserved for their unquestioned role as disinfectants 

for clinical surfaces and lavatory seats, and sterilising babies’ 

bottles 8 . 

The emergence of antibiotic resistance is a reason to turn 

back to the safe use of the aqueous antiseptics, such as povidone 

iodine and chlorhexidine, for wound cleansing and 

the reduction of bacterial colonisation of open wounds. 

These antiseptics have a role as prophylactics against critical 

colonisation and invasive infection. Thereby antibiotic 

use may be avoided altogether or be reserved for their use 

in treating spreading infection, particularly when there are 

systemic signs and the patient needs admission to hospital. 

There are entirely adequate and more effective alternatives 

to disinfectants such as the hypochlorites for debridement, 

and a wider use of topical antiseptics is inevitable if antibiotics 

are to be used less. 9 

One of the difficulties of antiseptic-impregnated surgical 

dressings relates to the fact that most antiseptics are 

rapidly inactivated on contact with body fluids, exudate 

and necrotic tissue. Slow-release povidone iodine dressings 

are already available and their effectiveness is being 

improved and, together with the recent introduction of 

silver-containing dressings, overcome this disadvantage. 

These dressings also offer a barrier to transmission of resistant 

of resistant organisms 10 . 

Lord Lister would probably be pleased to know that antiseptics 

not only have a continued role in modern clinical 

practice, but also that their contribution, particularly in 

surgery and wound management, is likely to increase. 

m 

References 

1. Fisher RB. Joseph Lister 1827-1912. Macdonald and James, London. 1977 

2. Ellis H. The first antiseptic operations (1867). In: Surgical Case Histories of the Past. 

Royal Society of Medicine Press, London. 1994 

3. Lister J. On a new method of treating compound fracture, abscess, etc, with observations 

on the conditions of suppuration. Lancet 1867; 1: 326 

4. de Lalla F. Surgical prophylaxis in practice. J Hosp Infect 2002; 50(Suppl A): S9 

- S12. Edwards P S, Lipp A, Holmes A. Preoperative skin antiseptics for preventing 

surgical wound infections after clean surgery. Cochrane Database Syst Rev. 2004 

(3):CD003949. 

6. Leaper DJ, van Goor H, Reilly J, Petrosillo N, Geiss HK, Torres AJ, Berger A. Surgical 

site infection – a European perspective of incidence and economic burden. International 

Wound Journal 2004; 1: 247-273 

7. Wong PF, Gilliam AD, Kumar S, Shenfine J, O’Dair GN, Leaper DJ. Antibiotic 

regimens for secondary peritonitis of gastrointestinal origin in adults. Cochrane 

Database of Systematic Reviews 2005; 2: CD004539 

8. Leaper DJ. Eusol. Editorial. British Medical Journal 1992; 304:930-931 

9. Teot L, Coessens B, Cooper R, Flour M, Gryson L, Henry F, Lachapelle J-M, Lamme 

E, Leaper DJ, Lubbers M, Magliaro A, Meaume S, Monstrey S, Pierard GE, Scuderi 

N, Van den Bulck R, Vermassen F, Vranckx JJ. Wound Management. Changing 

ideas on antiseptics. De Coker Belgium 2004 

10. Leaper DJ. Silver dressings; their role in wound management International wound 

Journal 2006; 3: 282-294 


�� 

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EBWM 

Sally Bell-Syer, MSc 

Review Group Co-ordinator 

Cochrane Wounds Group 

Department of 

Health Sciences 

Area 4 

Seebohm Rowntree 

Building 

University of York 

York, 

United Kingdom 

sembs1@york.ac.uk 

ABSTRACTS OF RECENT 

COCHRANE REVIEWS 

Topical agents and dressings for 

fungating wounds [Review] 

Adderley U, Smith R 

The Cochrane Database of Systematic Reviews 

Copyright © 2005 The Cochrane Collaboration. 

Published by John Wiley & Sons, Ltd.2007 Issue2. 

ABSTRACT 

Background: Fungating wounds arise from primary, 

secondary or recurrent malignant disease and are 

associated with advanced cancer. A small proportion of 

patients may achieve healing following surgical excision 

but treatment is usually palliative. Fungating 

wound management usually aims to slow disease 

progression and optimise quality of life by alleviating 

physical symptoms, such as copious exudate, malodour, 

pain and the risk of haemorrhage, through 

appropriate dressing and topical agent selection. 

Objectives: To conduct a systematic review of the 

evidence of the effects of dressings and topical agents 

on quality of life and symptoms that impact on quality 

of life in people with fungating malignant wounds. 

Search strategy: We searched the Cochrane Central 

Register of Controlled Trials (CENTRAL) and the 

Wounds Group Specialised Register in August 2006. 

The Cochrane Breast Cancer Group and the Pain and 

Palliative Care Group were contacted for relevant 

studies. The Allied and Complementary Medicine 

(AMED) database was searched in January 2007. 

There was no restriction on language or date of publication. 

Selection criteria: Randomised controlled trials (RCTs) 

or, in their absence, controlled clinical trials (CCTs) 

with a concurrent control group, both published and 

unpublished, and written in any language, were eligible 

for inclusion. 

Data collection and analysis: Data extraction was 

undertaken by one author and checked for accuracy 

by a second author. Two review authors independently 

assessed trial quality. 

Main results: Two trials involving 63 people were 

included. One RCT in women with superficial breast 

lesions compared 6% miltefosine solution with placebo 

and found that miltefosine delayed tumour progression. 

However, this trial had methodological limitations. 

A second trial compared topical metronidazole with 

placebo and found that metronidazole reduced 

malodour. However, this trial also had methodological 

limitations and was underpowered. 

Authors’ conclusions: There is weak evidence from one 

small trial that 6% miltefosine solution applied topically 

to people with superficial fungating breast lesions 

(smaller than 1cm) who have received either previous 

radiotherapy, surgery, hormonal therapy or chemotherapy 

for their breast cancer may slow disease 

progression. There is insufficient evidence in this review 

to give a clear direction for practice with regard to 

improving quality of life or managing wound symptoms 

associated with fungating wounds. More research is 

needed. 

Synopsis 

Fungating wounds sometimes occur in people with 

advanced cancer. Care usually aims to slow down 

disease progression and improve quality of life by 

relieving physical symptoms using appropriate dressings 

and other applied treatments. 

There is weak evidence to suggest that patients with 

superficial fungating breast lesions (smaller than 1cm) 

who have received either previous radiotherapy, surgery, 

hormone therapy or chemotherapy for their breast 

cancer may extend the time to disease progression by 

receiving topical 6% miltefosine solution. There is 

insufficient evidence to direct practice with regard to 

improving quality of life or managing other wound 

symptoms associated with fungating wounds. 

Preoperative bathing or showering with 

skin antiseptics to prevent surgical site 

infection [Review] 

Webster J, Osborne S 




ABSTRACT 

Background: Surgical site infections (SSIs) are wound 

infections that occur after invasive (surgical) procedures. 

Preoperative bathing or showering with an antiseptic 

skin wash product is a well-accepted procedure for 

reducing skin bacteria (microflora). It is less clear 

whether reducing skin microflora leads to a lower 

incidence of surgical site infection. 

Objectives: To review the evidence for preoperative 

bathing or showering with antiseptics for the prevention 

of hospital-acquired (nosocomial) surgical site infection. 

Search strategy: We searched the Cochrane Wounds 

Group Specialised Register (December 2005), 

the Cochrane Central Register of Controlled Trials 

(The Cochrane Library Issue 4, 2005), 

MEDLINE (January 1966 to December 2005) and 

reference lists of articles. 

� 


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Selection criteria: Randomised controlled trials comparing any 

antiseptic preparation used for preoperative full-body bathing or 

showering with non-antiseptic preparations in patients undergoing 

surgery. 

Data collection and analysis: Two authors independently 

assessed studies for selection, trial quality and extracted data. 

Study authors were contacted for additional information. 

Main results: Six trials involving a total of 10,007 participants 

were included. Three of the included trials had three comparison 

groups. The antiseptic used in all trials was 4% chlorhexidine 

gluconate (Hibiscrub). Three trials involving 7691 participants 

compared chlorhexidine with a placebo. Bathing with chlorhexidine 

compared with a placebo did not result in a statistically 

significant reduction in SSIs; the relative risk of SSI (RR) was 

0.91 (95% confidence interval (CI) 0.80 to 1.04). When only 

trials of high quality were included in this comparison, the RR of 

SSI was 0.95 (95%CI 0.82 to 1.10). Three trials of 1443 participants 

compared bar soap with chlorhexidine; when combined 

there was no difference in the risk of SSIs (RR 1.02, 95% CI 0.57 

to 1.84). Two trials of 1092 patients compared bathing with 

chlorhexidine with no washing, one large study found a statistically 

significant difference in favour of bathing with chlorhexidine 

(RR 0.36, 95%CI 0.17 to 0.79). The second smaller study 

found no difference between patients who washed with chlorhexidine 

and those who did not wash preoperatively. 

Authors’ conclusions: This review provides no clear evidence of 

benefit for preoperative showering or bathing with chlorhexidine 

over other wash products, to reduce surgical site infection. 

Efforts to reduce the incidence of nosocomial surgical site infection 

should focus on interventions where effect has been demonstrated. 

Synopsis 

It is unclear whether using chlorhexidine for preoperative 

bathing or showering prevents surgical site infection. 

Surgical site infection is a serious complication of surgery and 

may be associated with increased length of hospital stay for the 

patient and higher hospital costs. The use of an antiseptic solution 

for pre-operative bathing or showering is widely practiced 

in the belief that it will help to prevent surgical site infection. 

However, the review found six trials that included over 10,000 

patients that did not show clear evidence of benefit for the use 

of chlorhexidine solution over other wash products. 

Skin grafting for venous leg ulcers [Review] 

Jones JE, Nelson EA 




ABSTRACT 

Background: Venous leg ulceration is a recurrent, chronic, 

disabling condition. It affects up to one in 100 adults at some 

time. Standard treatments are simple dressings and compression 

bandages or stockings. Sometimes, despite treatment, ulcers 

remain open for months or years. Sometimes skin grafts are 

used to stimulate healing. These may be taken, or grown into a 

dressing, from the patient’s own uninjured skin (autografts), or 

6 

EBWM 

applied as a sheet of bioengineered skin grown from donor cells 

(allograft). Preserved skin from other animals, such as pigs, has 

also been used (xenografts). 

Objectives: To assess the effect of skin grafts for treating venous 

leg ulcers. 

Search strategy: We searched the Cochrane Wounds Group 

Specialised Register (February 2006) and the Cochrane Central 

Register of Controlled Trials (The Cochrane Library, Issue 1, 

2006). 

Selection criteria: Randomised controlled trials (RCTs) of skin 

grafts in the treatment of venous leg ulcers. 

Data collection and analysis: 

Two reviewers independently undertook data extraction and 

assessment of study quality. 

Main results 

We identified 15 trials – generally of poor methodological quality 

– involving 768 participants. In 11 trials participants also 

received compression bandaging. One trial (31 participants) 

compared a dressing with an autograft. Three trials (74 participants) 

compared frozen allografts with dressings, and three trials 

(47 participants) compared fresh allografts with dressings. Two 

trials (345 participants) compared tissue-engineered skin (bilayer 

artificial skin) with a dressing. In two trials (71 participants) a 

single-layer dermal replacement was compared with standard 

care. Four trials compared skin grafting techniques: one trial 

(92 participants) compared autografts with frozen allograft, a 

second (51 participants) compared a pinch graft (autograft) 

with a porcine dermis (xenograft), the third (seven participants, 

12 ulcers) compared tissue-engineered skin with a split-thickness 

graft, the fourth (10 participants) compared a fresh allograft 

with a frozen allograft. 

The trials comparing bilayer artificial skin with a dressing 

reported a significantly higher proportion of ulcers healing with 

artificial skin. There was not enough evidence from the other 

trials to determine whether other types of skin grafting increased 

the healing of venous ulcers. 

Authors’ conclusions: 

Bilayer artificial skin, used in conjunction with compression 

bandaging, increases the chance of healing a venous ulcer 

compared with compression and a simple dressing. Further 

research is needed to assess whether other forms of skin grafts 

increase ulcer healing. 

Synopsis 

Applying bilayered tissue-engineered skin under compression 

improves healing of venous leg ulcers compared with simple 

dressings and compression, but the effect of other types of graft 

is not clear. 

Approximately 1% of people in industrialised countries have a 

leg ulcer at some time, mainly caused by poor blood flow back 

from the legs towards the heart. Skin grafts, either using the 

patient’s own skin or donor skin/cells, have been evaluated to 

see whether they improve the healing of ulcers. The review of 

trials found evidence that tissue-engineered skin composed of 

two layers increases the chance of healing. There was not 

enough evidence to recommend any other type of graft, and 

further research is required. 


Prof. Christine Moffatt 

EWMA Position 

Document Editor 

Director, 

Centre for Research 

and Implementation 

of Clinical Practice 

Christine.Moffatt@ 

exchange.tvu.ac.uk 

Correspondence to: 

Kathy Day 

MEP Ltd, 

53 Hargrave Road, 

London N19 5SH 

kday@mepltd.co.uk 

EWMA Position Document 2007: 

Topical Negative Pressure 

in Wound Management 

More than a decade after pioneering 

researchers experimented with crude 

suction apparatus to promote wound 

healing, topical negative pressure (TNP) therapy 

has revolutionised the field of wound management. 

TNP therapy substantially broadens the 

scope of treatment and has rapidly become a 

first-line intervention for a wide range of complex 

wounds. This important development in wound 

care is being shown in a growing number of randomised 

controlled trials, as well as case studies, 

to produce dramatic improvements in clinical 

outcomes such as healing rates, hospitalisations 

and, in the case of mediastinitis and the open abdomen, 

mortality. 

The indications and advantages of TNP therapy 

have been reviewed extensively (Box 1), however 

there remains a crucial need for a better understanding 

of when and how to effectively integrate 

this therapy into clinical practice. 

Box 1 

Studies using TNP therapy in various wound types 

n Burn wounds 1 

n Chronic leg ulcers 2 

n Diabetic foot ulcers 3 

n Open abdomen including 

management of fistulae 4 

n Pressure ulcers 5 

n Securing a skin graft 6 

n Sternal wound infections 7 

n Surgical, non-healing wounds 8 

n Trauma 9 

With these issues in mind, the 2007 EWMA position 

document – Topical negative pressure in 

wound management – presents a European perspective 

on the pathophysiological effects and the 

technical and practical issues involved in using 

TNP therapy. The aim is to provide insights into 

the use of the intervention in the clinical setting, 

and to enable healthcare professionals to select 

and apply therapy safely. The document is published 

in five languages (Figure 1) and is available 

online at: www.ewma.org. 

It should be noted that most clinical trials of TNP 

therapy have used the vacuum assisted closure 

(V.A.C. ® Therapy) system and therefore it is this 

specific device that is described throughout the 

document. 

In the first of the four papers presented, Gustafsson, 

Sjögren and Ingemansson set the scene 

by outlining the historical development of TNP 

therapy and describing the key components of 

the VAC system. 

Although TNP therapy has obvious clinical advantages, 

it is often considered expensive compared 

with alternative options and this may have been 

a barrier to its use, particularly in community set- 

Figure 1. The 2007 EWMA position document is available 

in five languages. 


Figure 2. Patient and wound specific issues and the role of TNP therapy 

tings. Trueman therefore puts forward an economic case 

for the intervention in the second paper of the document. 

He proposes that we consider the factors listed in Box 2 

when analysing the true cost of dressings. He shows that 

these may often be sufficient to offset the higher acquisition 

costs of the VAC dressings. 

Box 2 

Factors affecting the cost of wound treatment 

The cost of managing chronic wounds 

can be influenced by: 

n Frequency of dressing changes and 

associated nurse time 

n Healing rates 

n Impact on hospitalisations and adverse events 

In the third paper Vowden, Téot and Vowden present a 

general therapeutic strategy (using the concept of wound 

bed preparation) that can be applied to many different 

wound types to help clinicians identify when to use TNP 

therapy and how to integrate the technique into overall 

wound management (Figure 2). In doing so they stress that 

if selected it must be introduced with defined treatment 

objectives and clinical endpoints. 

For treatment to be safe and effective, however, it is important 

to understand how the specific requirements of 

individual wound types may affect the application of TNP 

therapy. In the final paper, Wild uses the management 

of the open abdomen to demonstrate this point. TNP 

therapy in this context is effective because it offers the 

advantages of the traditional open abdomen technique 

while preventing many of the complications. 



This EWMA position document is published at a time 

when treatment initiatives in wound care are extremely 

common and the requirements of healthcare professionals 

and patients are equally challenging. The information 

provides a sound overview of TNP therapy, which – in the 

hands of clinicians with appropriate, up-to-date knowledge 

and practical skills – is producing impressive results 

in a variety of wound types. The task now is to ensure that 

all suitable patients benefit maximally from its use, both in 

the hospital and community setting. m 

References 

1. Kamolz LP, Andel H, Haslik W, et al. Use of subatmospheric pressure therapy to prevent 

burn wound progression in human: first experiences. Burns 2004; 30(3): 253-58. 

2. Vuerstaek JD, Vainas T, Wuite J, et al. State-of-the-art treatment of chronic leg ulcers: 

a randomized controlled trial comparing vacuum-assisted closure (V.A.C.) 

with modern wound dressing. J Vasc Surg 2006; 44(5): 1029-37. 

3. Armstrong DG, Lavery LA; Diabetic Foot Consortium. Negative pressure wound 

therapy after partial diabetic foot amputation: a multicentre, randomised controlled 

trial. Lancet 2005; 366(9498): 1704-10. 

4. Wild T, Stortecky S, Stremitzer S, et al. [Abdominal dressing – a new standard in 

therapy of the open abdomen following secondary peritonitis?] Zentralbl Chir 2006; 

131(Suppl 1): S111-14. 

5. Ford CN, Reinhard ER, Yeh D, et al. Interim analysis of a prospective, randomized 

trial of vacuum-assisted closure versus the Healthpoint system in the management of 

pressure ulcers. Ann Plast Surg 2002; 49(1): 55-61; discussion: 61. 

6. Jeschke MG, Rose C, Angele P, et al. Development of new reconstructive techniques: 

use of Integra in combination with fibrin glue and negative-pressure therapy for reconstruction 

of acute and chronic wounds. Plast Reconstr Surg 2004; 113(2): 525-30. 

7. Sjögren J, Gustafsson R, Nilsson J, et al. Clinical outcome after poststernotomy mediastinitis: 

vacuum-assisted closure versus conventional therapy. Ann Thorac Surg 2005; 

79(6): 2049-55. 

8. Moues CM, Vos MC, van den Bemd GJ, et al. Bacterial load in relation to vacuum-assisted 

closure wound therapy: a prospective randomized trial. Wound Repair Regen 

2004; 12(1): 11-17. 

9 Stannard JP, Robinson JT, Anderson ER, et al. Negative pressure wound therapy 

to treat hematomas and surgical incisions following high-energy trauma. J Trauma 

2006; 60(6): 1301-06.

EWMA Journal 

Previous Issues 

Volume 6, no 2, Fall 2006 

The number of leg ulcers increases – a 20-year-questionnaire 

study in Pirkanmaa Health Care in Finland 

Anna L Hjerppe 

An ex-vivo model to evaluate dressings & drugs for wound healing 

Johanna M. Brandner, Pia Houdek, Thomas Quitschau, 

Ute Siemann-Harms, Ulrich Ohnemus, Ingo Willhardt, Ingrid Moll 

Compression therapy of venous ulcers 

Hugo Partsch 

Seasonal variation of onset of venous leg ulcers 

Marian Simka 

Determinants and estimation of wound healing achievement after 

minor amputation in patients with diabetic foot 

Robert Bém, A. Jirkovská, V. Fejfarová, J. Skibová, B. Sixta, P. Herdegen 

Leg ulcer prevalence in the Czech Republic: 

Omnibus survey results 2006 

Zdenek Kucera 

Volume 6, no 1, Spring 2006 

Focus on silver 

Jean-Yves Maillard, Stephen P Denyer 

Factors that influence the frequency of rebandaging 

Una Adderley 

Microengineered hydrogel as a vehicle for grafting 

human skin cells 

Stephen Britland, Annie Smith 

Wound Care in Anatolia 

Ali Barutcu 

Implementation of a Leg Ulcer Strategy in Central & Eastern Europe 

Peter J. Franks 

Post Graduate Wound Healing Course Modena, Italy 

Deborah Hofman 

From The Laboratory to the Patient: Future Organisation and 

Care of Problem Wounds. A New Experience 

Finn Gottrup 

Volume 5, no 2, Fall 2005 

Retrospective analysis of topical application of 

factor XIII in patients with chronic leg ulcers 

Mirjana Ziemer, Claudia Scheumann, Martin Kaatz, Johannes Norgauer 

An overview of surgical site infections: 

aetiology, incidence and risk factors 

Finn Gottrup, Andrew Melling, Dirk A. Hollander 

Regulating research and associated activity in the UK 

Sue Bale 

Article Review – The effectiveness of a hyperoxygenated fatty 

acid compound in preventing pressure ulcers 

Joan-Enric Torra i Bou, T. Segovia Gómez, J. Verdú Soriano, 

A. Nolasco Bonmatí, J. Rueda López, M. Arboix i Perejamo 

Article Review – Extended commentary on a trial 

E. Andrea Nelson 

UK Lymphoedema Framework Project 

Philip A. Morgan, Christine J. Moffatt, Debra C. Doherty, Peter J. Franks 

German Wound Surgeons 1450-1750 

Carol Dealey 

The EWMA Journals can be downloaded free of charge from www.ewma.org 

50 

Volume 7, no 2, January 2007 

Self-care activities of venous leg ulcer patients in Finland 


Smoking is not contra-indicated in maggot debridement 

therapy in the chronic wound 

Pascal Steenvoorde 

Effectiveness of non-alcohol film forming skin protector 

on the skins isles inside the ulcers and the healing rate of 

venous leg ulcers 

Tanja Planinsek Rucigaj 

Wound measurement: the contribution to practice 

Georgina T. Gethin 

Improving education in wound care: crossing 

the boundaries of interprofessional learning 

Caroline McIntosh 

Waterjet debridement of deep and indeterminate depth 

thermal injuries 

Mayer Tenenhaus 

International Journals 

The section on International Journals is part of 

EWMA’s attempt to exchange information on 

wound healing in a broad perspective. 

Italian 

English 

Finnish 

Acta Vulnologica, vol. 4, no 4, 2006 

www.aiuc.it 

A Proposal for a bill of rights in wound care 

Brambilla R., Coppi C. 

Diabetes mellitus and pressure sores: interactions 

and strategies 

Gallo M., Furlini S., Somà K. 

Ulcers induced during therapy with hydroxyurea 

in patients with myeloproliferative disorders 

Venturi C., Pandolfi R., Motolese A. 

Advances in Skin & Wound Care, vol. 20, april 2007 

www.aswcjournal.com 

Pressure Ulcers in Neonates and Children: 

An NPUAP White Paper 

Mona Mylene Baharestani, Catherine R. Ratliff 

Treatment of Ischemic Wounds with Noncontact, 

Low-Frequency Ultrasound: The Mayo Clinic 

Experience, 2004-2006 

Steven J. Kavros, Jenny L. Miller, Steven W. Hanna 

The Treatment of Diabetic Foot Ulcers: 

Reviewing the Literature and a Surgical Algorithm 

Steven R. Kravitz, James B. McGuire, Sid Sharma 

Haava, vol. no 1, 2007 

www.suomenhaavanhoitoyhdistys.fi 

How MD can utilize the microbiological tests 

Sakari Vuorinen 

Drains, wound suction an their treatment 

Ansa Iivanainen, Helvi Hietanen 

Planning of wound treatment 

Marja Nidkasaari 

Treatment of bullet wounds 

Lauri Handolin 

Polyurethane foams and amputation wounds 

Sirpa Arvonen 

Silver in the treatment of burns 

Helena Asikainen, Juha M. Venäläinen 

The mystery of green net 

Jaana Ruohoaho 

Vacuum assisted closure in wound management 

Tiina Pukki 

Honey in the treatment of lec ulcers 

Maria Nevalainen 

Wound management in intensive care unit 

Ritva Sipinen 

Developing documentation in wound management 

Jonna Saarela, Satu Tuovinen 

Tissue viability nurse in communities – a project work 

Eija Luotola 

Developing infection controlling models for practise 

of wound care 

Kirsi Terho, Tiina Kurvoien, Marianne Routamaa 

Quality of care of diabetic foot 

Senja Torvinen 

Living with scars 

Virpi Hämeen-Anttila 


Spanish 

English 

English 

Helcos 2007, vol 18, no 1 

Efficiency of the products for pressure ulcers treatment: 

a systematic review with meta-analysis 

García Fernández F.P., Pancorbo Hidalgo P.L., 

Verdú Soriano J., Soldevilla Agreda J.J., Rodríguez Palma M., 

Gago Fornells M., Martínez Cuervo F., Rueda López J. 

Clinical judgement or assessment scales to identify 

patients at risk of developing pressure ulcers? 

Rodríguez Torres Mª. del C., Soldevilla Agreda J.J. 

International Wound Journal, Mar. 2007, vol. 4, Issue 1 

www.blackwellpublishing.com 

OASIS ® wound matrix versus Hyaloskin ® in the treatment of 

difficult-to-heal wounds of mixed arterial/venous aetiology 

M Romanelli, V Dini, M Bertone, S Barbanera, C Brilli 

Successful management of deep facial burns in a patient with 

extensive third-degree burns: the role of a nanocrystalline silver 

dressing in facilitating resurfacing 

M Marazzi, A De Angelis, A Ravizza, MN Ordanini, L Falcone, 

A Chiaratti, F Crovato, D Calò, S Veronese, V Rapisarda 

Paediatric partial-thickness scald burns 

– is Biobrane the best treatment available? 

A Mandal 

Wound bed preparation of difficult wounds: 

an evolution of the principles of TIME 

C Ligresti, F Bo 

Clinical predictors of treatment failure for diabetic foot 

infections: data from a prospective trial 

BA Lipsky, P Sheehan, DG Armstrong, AD Tice, AB Polis, 

MA Abramson 

The role of vascular endothelial growth inhibitor in 

wound healing 

KP Conway, P Price, KG Harding, WG Jiang 

Randomised clinical trial of Hydrofiber dressing with silver 

versus povidone-iodine gauze in the management of open 

surgical and traumatic wounds 

F Jurczak, T Dugré, A Johnstone, T Offori, Z Vujovic, D Hollander 

Negative pressure wound therapy via vacuum-assisted 

closure following partial foot amputation: 

what is the role of wound chronicity? 

DG Armstrong, LA Lavery, AJM Boulton 

Negative pressure wound therapy: 

treating a venomous insect bite 

MS Miller, M Ortagon, C McDaniel 

The International Journal of Lower Extremity 

Wounds 

vol. 6, no 1, 2007 

http://ijlew.sagepub.com 

Wound Healing at the Crossroads 

Raj Mani 

Developing guidelines in the absence of 

traditional research evidence: an example from 

the lymphoedema framework project 

Peter J. Franks, Philip A. Morgan 

Growth factors: the promise and the problems 

Jeffrey M. Davidson 

The development and application of diabetic 

foot protocol in Chiang Mai University Hospital 

with an aim to reduce lower extremity amputation 

in thai population: a preliminary pommunication 

K. Rerkasem, N. Kosachunhanun, S. Tongprasert, 

K. Khwanngern, A. Matanasarawoot, 

C. Thongchai, K. Chimplee, S. Buranapin, 

S. Chaisrisawadisuk, A. Manklabruks 

An evaluation of the value of group education in 

recently diagnosed diabetes mellitus 

G. S. Ooi, C. Rodrigo, W. K. Cheong, R. L. Mehta, 

G. Bowen, C. P. Shearman 

The diabetic foot: perspectives from Chennai, 

South India 

Vijay Viswanathan 

Growth Factors in the Treatment of Diabetic 

Foot Ulcers: New Technologies, Any Promises? 

N. Papanas and E. Maltezos 

English 

Scandinavian 

German 


Journal of Wound Care, April issue, vol. 16, no 4, 2007 

www.journalofwoundcare.com; jwc@emap.com 

Use of polarised light as a method of pressure ulcer 

prevention in an adult intensive care unit 

J. Verbelen 

Can translocated bacteria reduce wound infection? 

V.I. Nikitenko 

Venous leg ulcer treatment and practice – part 4: 

surgery and pharmaceutical therapies 

S. Rajendran, A.J. Rigby, S.C. Anand 

Management of bioburden with a burn gel that 

targets nociceptors 

L. Martineau, H-M. Dosch 

Can cycloidal vibration plus standard treatment reduce 

lower limb cellulitis treatment times? 

S. Johnson, K. Leak, S. Singh, P. Tan, W. Pillay, 

R.J. Cuschieri, E. Mostyn 

Bacterial profiling using skin grafting, standard culture 

and molecular bacteriological methods 

A. Andersen, K.E. Hill, P. Stephens, D.W. Thomas, 

B. Jorgensen, K.A. Krogfelt 

A prospective observational study of the efficacy of a 

novel hydroactive impregnated dressing 

F. Meuleneire, P. Zoellner, M. Swerev, O. Holfeld, J. Effing, 

S. Bapt, N. Tholon, E. Felder, B. Streit, H. Kapp, H. Smola 

Wounds (SÅR) vol. 15, no 1, 2007 

www.saar.dk 

Care and treatment of people with cancer wounds 

Betina Lund-Nielsen 

Compression therapy of venous leg ulcers 

– how can we make it more cost-effective? 

Rie Nygaard, Susan F. Jørgensen 

Terra Sigillata – a pharmaceutical product used for more 

than 2000 years 

Annette Frölich 

Lymphoedema clinic at Copenhagen Wound Healing Centre 

– much-needed developments for patients where no 

treatment is possible 

Jens Fonnesbech 

Higher level and a stronger scientific foundation: 

New diploma in wound management 

Jens Fonnesbech 

Prevention and treatment of diabetic foot ulcers 

– commenting on the debate in the Norwegian Parliament 

Stortinget 

Kirsti Espeseth 

Wund Management Issue 2, 2007 

Overview 

Incidence of Ulcus cruris in Germany: 

Data of the German Federal Health Monitoring 

K. Kröger 

Standards in the Treatment of Wounds 

Obsolete products and methods in the treatment 

of chronic wounds 

W. Sellmer 


Corporate A 

Coloplast 

Holtedam 1-3 

DK-3050 Humlebæk 

Denmark 

Tel: +45 49 11 15 88 

Fax: +45 49 11 15 80 

www.coloplast.com 

ConvaTec Europe 

Harrington House 

Milton Road 

Ickenham, Uxbridge 

UB10 8PU 


Tel: +44 (0) 1895 62 8300 

Fax: +44 (0) 1895 62 8362 

www.convatec.com 

Ethicon GmbH 

Johnson & Johnson Wound Management 

Oststraße 1 

22844 Norderstedt 

Germany 

Tel: +49 40 52207 230 

Fax: +49 40 52207 823 

www.jnjgateway.com 

KCI Europe Holding B.V. 

Parktoren, 6th floor 

van Heuven Goedhartlaan 11 

1181 LE Amstelveen 

The Netherlands. 

Tel: +31 (0) 20 426 0000 

Fax: +31 (0)20 426 0097 

www.kci-medical.com 

5 

EWMA Corporate Sponsor Contact Data 

Lohmann & Rauscher 

P.O. BOX 23 43 Neuwied 

D-56513 

Germany 

Tel: +49 (0) 2634 99-6205 

Fax: +49 (0) 2634 99-1205 

www.lohmann-rauscher.com 

Mölnlycke Health Care Ab 

Box 13080 

402 52 Göteborg, 

Sweden 

Tel: +46 31 722 30 00 

Fax: +46 31 722 34 08 

www.molnlycke.com 

Smith & Nephew 

Po Box 81, Hessle Road 

HU3 2BN Hull, 


Tel: +44 (0) 1482 225 181 

Fax: +44 (0) 1482 328 326 

www.smith-nephew.com 

Tyco Healthcare 

154, Fareham Road 

PO13 0AS Gosport 


Tel: +44 1329 224479 

Fax: +44 1329 224107 

www.tycohealthcare.com 

Corporate B 

3M Health Care 

Morley Street, Loughborough 

LE11 1EP Leicestershire 


Tel: +44 1509 260 869 

Fax: +44 1 509 613326 

www.mmm.com 

Activa Healthcare Ltd 

1 Lancaster Park 

Newborough Road 

Needwood 

Burton on Trent 

Staffordshire 

DE13 9PD 

Tel: +44 (0) 8450 606 707 

Fax: +44 (0) 1283 576808 

www.activahealthcare.co.uk 

B. Braun Medical 

204 avenue du Maréchal Juin 

92107 Boulogne Billancourt 

France 

Tel: +33 1 41 10 75 66 

Fax: +33 1 41 10 75 69 

www.bbraun.com 

Comvita UK Ltd 

Unit 3, 55-57 Park Royal Road 

London NW10 7LP 


Tel: +44 208 961 4410 

Fax: +44 208 961 9420 

www.comvita.co.uk 


Ferris Mfg. Corp. 

16W300 83rd Street 

Burr Ridge, 

Illinois 60527-5848 U.S.A. 

Tel: +1 (630) 887-9797 

Toll-Free: +1 (630) 800 765-9636 

Fax: +1 (630) 887-1008 

www.polymem.com 

Paul Hartmann AG 

Paul-Hartmann-Strasse 

D-89522 Heidenheim 

Germany 

Tel: +49 (0) 7321 / 36-0 

Fax: +49 (0) 7321 / 36-3636 

www.hartmann.info 

Sorbion AG 

Hobackestraße 91 

D-45899 Gelsenkirchen 

Tel: +49 (0)2 09-95 71 88-0 

Fax: +49 (0)2 09-95 71 88-20 

www.sorbion.com 

Laboratoires Urgo 

42 rue de Longvic 

B.P. 157 

21300 Chenôve 

France 

Tel: (+33) 3 80 44 70 00 

Fax: (+33) 3 80 44 71 30 

www.urgo.com 

Use 

the EWMA Journal 

to profile your company 

Deadline for advertising in the 

next issue is 1 August 2007 


EWMA Position Document 2007 

Topical Negative Pressure 

in Wound Management 

Editor: Christine Moffatt 

The document is available in English, French, 

German, Italian and Spanish, and can be 

downloaded from www.ewma.org 

Previous Position Documents: 

For further details contact 

MEP Ltd, 53 Hargrave Road, 

London N19 5SH. 

www.mepltd.co.uk 

or 

EWMA Business Office, 

Congress Consultants, 

Martensens Allé 8, 

1828 Frederiksberg, 

Denmark 

Tel: +45 7020 0305 

Fax: +45 7020 0315 

ewma@ewma.org 


Conferences 

Conference Calendar 

Conference Theme 

SAWC & WHS 2007 (National) Apr/May 28-1 Tampa, Florida USA 

17th Conference of the European Wound 

Management Association (EWMA 2007) 

5th international symposium on the 

Diabetic Foot 

For web link please visit www.ewma.org 

Evidence, Consensus and Driving the 

Agenda forward 

EADV 16th Congress European Dermatology and Venereology 

– Strong Past, Stronger Future 

May 2-4 Glasgow Scotland 

May 9-12 Noordwijkerhout The Netherlands 

May 16-20 Vienna Austria 

SAfW 4th Congress (National) May 24 Morges Switzerland 

11th Symposium of modern Woundhealing 

(National) 

Jun 1-2 Bregenz Switzerland 

12th Congress of the ESDaP (National) Jun 14-17 Wroclaw Poland 

Wounds UK Summerconference (National) Jun 22 Warwickshire UK 

Tissue Viability and Wound Care Management 

(National) 

Improving Practise on the Wards Jul 3 London UK 

EPUAP 10th European Meeting Ten years of progress, the present and 

the future in Pressure Ulcer Prevention and 

Management 

Aug/Sep 30-01 Oxford UK 

VI Congresso Nazionale AIUC Alla scoperta dell’ulcera cutanea cronica Sep 12-15 Genova Italy 

SSiS National Congress Sep 24 Sweden 

ETRS 17th Annual Meeting Measurements in wound healing 

– the conduit between the laboratory and 

the clinic 

Sep 26-28 Southampton UK 

ILDS 21st World Congress of Dermatology Global Dermatology for a globalized world Oct 1-5 Buenos Aires Argentina 

APTFeridas 2007 National Congress Nov 7-9 Porto Portugal 

Wounds UK 2007 (National) Nov 12-14 Harrogate UK 

VII Nacional Congress GNEAUPP Nov Spain 

National Meeting DSFS Cancer Wounds Nov 16-17 Nyborg Denmark 

XIIth National Wound Management Conference Jan/Feb 31-1 Helsinki Finland 

NIFS National Conference Pressure Ulcers Feb 14-15 Bergen Norway 

SAWC & WHS 2008 (National) Apr USA 

18th Conference of the European Wound 

Management Association (EWMA 2008) 

Wound Healing · Wound Management 

– Responsibility and Actions 

WUWHS – 3rd Congress Wound Care Efficacy, 

Effectiveness & Efficiency 

Oxford – European Wound Healing 

Summer School 

7th Scientific Meeting of the Diabetic Foot Study 

Group (DFSG) of the EASD 

5 

Different aspects of patient wound 

management based on therapy innovation 

and clinical research 

2008 

May 14-16 Lisbon Portugal 

Jun 4-8 Toronto Canada 

Jul Oxford UK 

Sep 11-13 Pisa Italy 


FWCS 

Finnish 

Wound Care Society 

Salla Seppänen, RGN, 

Specialist in Medical- 

Surgical Nursing, MNSc, 

Principal Lecturer, 

Oulu University of Applied 

Sciences, 

Oulainen Department of 

Health Care 

Finland 

salla.seppanen@pp.inet.fi 


The XIth Finnish 

National Wound Management Conference 

1-2 February 2007 in Helsinki 

The Finnish Wound Care Society organised its 

annual wound management conference for 

2007 on the theme of “Special Issues in 

Wound Management”. 

The programme included sessions 

discussing lower limb amputation, wound 

infection, costs of wound care, seamless 

services in wound care and wound patients’ 

quality of life, which focused on pain, nutrition 

and living habits. 

EWMA organised the conference keynote 

speaker Professor John Posnett from the UK. 

He presented a lecture on the costs and effectiveness 

of wound care in which he estimated 

that the average cost of chronic wounds in 

Finland is now at least 194 billion euros per 

year. This presents the Finnish Wound Care 

Society with the challenge to develop 

evidence-based wound management, which 

covers the whole care path of the patient. 

The national conference collected together 

about 700 health professionals from all over 

Finland. 

Organisations 

The feedback of participants was positive 

and encouraging; 75.4% of participants 

assessed the conference as good and 21.7% 

assessed it as excellent. Most of the participants 

(73.4%) stated that they felt that the 

conference was useful for their work. 

According to the conference feedback, the 

content of sessions was relevant, interesting 

and professional providing useful tips for 

clinical practice. 

The conference also attracted corporate 

healthcare professionals with 26 corporate 

members participating in the conference 

exhibition. 

The XIIth National Wound Management 

Conference will be held on 31/1-1/2.2008 in 

Helsinki on the theme of “Modern Wound 

Management”. 


SSiS 

Sårsjuksköterskor i 

Sverige 

Tissue Viability 

Nureses in Sweden 


President 

christina.lindholm@hv.hkr.se 

56 

www.sarsjukskoterskor.se 

The SSiS is an association for 

registered nurses with a professional 

interest in wounds 

Wound healing is an important field, in which 

nursing competence must improve and 

become more visible. 

Sårsjuksköterskor i Sverige (SSiS)/ Tissue 

Viability Nurses in Sweden is a part/section of 

the Swedish Society of Nursing (SSF) and also 

a Co-operating Organisation within EWMA 

since 2006. 

The SSiS is an association for registered 

nurses with a professional interest in wounds. 

The main purpose of the SSiS is to address 

nation wide, strategic issues in wound 

management, in close co-operation with politicians, 

other national societies and EWMA. 

We aim to 

– promote evidence-based medical and 

nursing practice in agreement with laws 

and regulations in order to increase quality 

of care for persons with wounds or at risk 

of developing wounds 

– become a meeting place for co-operation 

and exchange of knowledge between 

interest groups from various specialist 

areas in wound healing 

– cover, disseminate and promote research, 

development and education in wound 

healing 

– strengthen and clarify the nurse’s role 

in wound healing 

– improve the wound patients’ physical, 

practical and emotional situation 

Membership in the SSiS includes free issues 

of the EWMA Journal and the Danish SÅR 

journal, reduced subscription fees for the new 

Swedish journal Sår and reduced registration 

fees for SSiS and EWMA conferences. 

Since being established in late 2005, the SSiS 

has recruited around 350 members, arranged 

two conferences, set up working teams, 

established co-operation with the companies, 

started a website, www.sarsjukskoterskor.se, 

and acted as a point of reference to the 

authorities in different wound-related 

subjects. 

Conferences 

Two conferences have been held, both at 

the Karolinska University Hospital. They have 

attracted more than 400 participants. 

International speakers include Tom Defloor, 

Mark Collier and Keith Harding. The next 

conference on the theme Wound management 

– practical aspects and ethical issues – 

an interactive session will be held September 

24. The Annual General Meeting has been 

held on March 26, combined with a meeting 

for representatives from the companies. 

At present our main efforts are directed 

towards expanding the website, planning the 

next conference, preparing problem inventories 

in the wound healing area, drawing up 

competency standards for Swedish nurses 

specialising in wound healing and recruiting 

more members. 


WMAS 

Slovenian Wound 

Management 

Association 


Slovenian 

Wound Management Association 

Cankarjeva 8 

1236 Trzin 

Slovenia 

helena.peric@siol.net 

What’s new in Slovenia? 

Slovenian Wound Management Association 

(WMAS) has been very active in the past 

couple of years. As a very young association it 

still suffers from some “childhood” problems 

but we are overcoming them more and more. 

WMAS is run by professor Zoran M. Arnež. 

Vice-presidents are Vanja Vilar and Zdenka 

Kramar. The executive board consists of 

different professions- doctors of various 

specializations, nurses, pharmacists… 

As Slovenia is a small country (population less 

then 2 million) we always struggle with man 

power, so last year we decided to hire a part 

time secretary to assist us with administration. 

This proved to be a good decision as our plan 

of activities is always ambitious enough to 

keep us busy. 

Some of the major achievements of the association 

in the last 2 years are: 

n publishing Recommendations for prevention 

and treatment of pressure ulcers, Recommendations 

for treatment of venous leg ulcers, 

Recommendations for treatment of diabetic 

foot ulcers and Recommendations for treatment 

of malignant wounds. The Recommendations 

are very appreciated by health care 

professionals. Of course we are aware that this 

is just the first step out of many required to 

bring wound care in Slovenia to the level 

where all patients will be treated adequately 

and equally. We would like to expand these 

recommendations into detailed guidelines but 

what is even more important, we need to find 

a way to assist health care professionals to 

implement them in practice as much as 

possible. In order to do so, some changes 

have to be made at macro level (health care 

organization, reimbursement…) and some 

changes have to be made at micro level 

(health care professionals interest and attitude 

towards wound care…) 

n organization of many educational events 

on prevention and treatment of chronic 

wounds, including workshops and discussion 

forums. Over the past 2 years, more than 

thousand people attended these activities. 

We also support activities organized by other 

institutions who serve as wound care centers 

of excellence. 

n influencing health care politics to 

improve wound care services in Slovenia. 

Representatives of WMAS wrote many letters 

and paid many visits to Reimbursement 

agency, Ministry of health, Health council 

etc. Members of WMAS also cooperated with 

articles and interviews on the radio, TV and 

in the printed media in order to raise awareness 

of wound care problematic. 

n cooperating with European Wound Care 

Association: we maintain regular cooperation 

with EWMA. Last year we started a joint 

project “Implementing leg ulcer strategy in 

Eastern Europe” under the leadership of 

Peter Franks. We are hoping that this project 

will provide evidence which can be used in 

our efforts to improve wound care services in 

Slovenia. It is one of our major activities for 

2007. 

This year we are planning similar activities as 

in previous years. We have an ambitious plan 

we hope to fulfill with EWMA support. We 

are also looking forward to have some of our 

representatives visiting EWMA conference as 

this is an excellent opportunity to exchange 

experience, refresh knowledge and gain new 

ideas. 

Warm regards from Slovenia on behalf of 

WMAS executive board! 

Organisations 


5 

Co-operating Organisations 

Danish Wound 

Healing Society 

ABISCEP 

Wound Management 

Association in Belgium 

AISLeC 

Associazione Infermieristica 

per lo Studio Lesioni Cutanee 

Italian Nurse Association for 

the Study of Cutaneous 

Wounds 

www.aislec.it 

AIUC 

Associazione Italiana 

Ulcere Cutanee. 

Italian Association for 

Cutaneous Ulcers 

www.aiuc.it 

APTFeridas 

Portuguese Wound 

Management Association 

www.aptferidas.com 

AWA 

Austrian Wound Association 

www.a-w-a.at 

CNC/BFW 


Organisation 

www.befewo.org 

www.wondzorg.be 

CSLR 

Czech Wound Management 

Society 

www.cslr.cz 

CWMA 

Croatian Wound 


DGfW 

Deutsche Gesellschaft für 

Wundheilung 

www.dgfw.de 

DWHS 

Danish Wound Healing 

Society 

www.dsfs.org 

FWCS 

Finnish Wound Care Society 


GAIF 

Grupo Associativo de 

Investigacão em Feridas 

www.gaif.net 

GNEAUPP 

Grupo Nacional para el 

Estudio y Asesoramiente en 

Ulceras por Presión y Heridas 

Crónicas 

www.gneaupp.org 

GWMA 

Greek Wound Management 

Association 

HWMS/MSKT 

Hungarian Lymphoedema 

and Wound Managing 

Society 

ICW 

Initiative Chronische Wunden 

IWHS 

Iceland Wound Healing 

Society 

www.sums-is.org 

LBAA 

Latvian Wound Treating 

Organisation 

LF 

Lymphoedema Framework 

www.lymphoedemaframework.org 

LSN 

The Lymphoedema Support 

Network 

www.lymphoedema.org/lsn 

LUF 

The Leg Ulcer Forum 

www.legulcerforum.org 


LWMS 

Lithuanian Wound 

Management Society 

NATVNS 

National Association of 

Viability Nurse Specialists 

(Scotland) 

www.natvns.com 

NIFS 

Norwegian Wound Healing 

Association 

www.nifs-saar.no 

NOVW 

Dutch Organisation of 

Wound Care Nurses 

www.novw.org 

PWMA 

Polish Wound Management 

Association 

ROWMA 

Romanian Wound 


SAfW 

Swiss Association for 

Wound Care 

www.safw.ch 

SEBINKO 

Hungarian Association for 

the Improvement of Care of 

Chronic Wounds and 

Incontinentia 

www.sebinko.hu 

SFFPC 

La Société Française et 

Francophone de Plaies et 

Cicatrisations 

www.sffpc.org 

SISS 

Swedish Wound Care Nurses 

Association 

www.sarsjukskoterskor.se 

SWHS 

Svenskt Sårläkningssällskap 

www.sarlakning.com 

SWMA 

Serbian Wound Management 

Association 

TVNA 

Tissue Viability Nurses 

Association 

www.tvna.org 

TVS 

Tissue Viability Society 

www.tvs.org.uk 

WMAI 


Association of Ireland 

www.wmaoi.org 

WMAS 

Slovenian Wound 


WMAT 


Association Turkey 

Present your national 

wound management 

organisation 

or write a report about 

your organisation’s 

latest meeting. 

ewma@ewma.org 

Deadline 

for incoming material for 

the next issue is 

15 July 2007 

Organisations 


3 Editorial 


Scientific Articles 

7 Is it safe to use saline solution to clean wounds? 

João Carlos Gouveia, Christina Miguens 

15 The cost of pressure ulceration 


21 Epidemiology of wounds treated in 

Community Services in Portugal 

Elaine Pina 

29 Improving wound assessment through 

the provision of digital cameras across 

a Primary Care Trust 


Background Articles 

35 The use of telemedicine in wound care 

Rolf Jelnes 

39 Lord Joseph Lister: the rise of antiseptic 

surgery and the modern place of antiseptics 

in wound care 

David Leaper 

EBWM 

44 Abstracts of recent Cochrane Reviews 

Sally Bell-Syer 


48 EWMA Position Document 2007: 

Topical Negative Pressure in Wound 

Management 


50 EWMA Journal previous issues 

50 International Journals 

52 EWMA Corporate Sponsors contact data 

Conferences 

54 Conference calendar 

Organisations 

55 The XIth Finnish National Wound Management 

Conference, 1-2 February 2007 in Helsinki 


56 The SSiS is an association for registered nurses 

with a professional interest in wounds 


57 What’s new in Slovenia? 


58 Co-operating Organisations

EWMA Council

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