The silent epidemic

In a recent report commissioned by the Smith and Nephew Foundation , skin breakdown and wounds in the UK were described as the ‘silent epidemic’. Up to £3.1billion , 3% of the NHS budget , is currently spent on wound care management. Yet there is little sound evidence to support this investment or to demonstrate the effectiveness of advances in wound care practice and management through new technologies.

Despite the significant cost to the NHS of skin and wound care , including a rising spend on a wide range of products , there is little insight into the nature or the numbers of patients with skin breakdown and wounds , their precise needs , or the quality of management outcomes. Not only is the NHS in the dark about needs and resource usage , the wound care industry is too. Knowledge transfer from the clinical to the industrial setting is hampered by an overarching reliance on the part of manufacturers’ market research techniques , as opposed to clinical audit and independent scientific research. Furthermore , the industrial test methods that specify the clinical performance of a given dressing are substantially guided by the demands of regulatory requirements for safety , sterility , storage and handling rather than by a clear idea of clinical and patient requirements for product design and performance. Companies use a range of different in-house test methods so that marketing claims for enhanced performance of company A’s dressing versus company B‘s on fluid handling , for example , are not credible. Independent , objective comparisons are, however, difficult to make because there are few universally accepted metrics for performance. Overall the NHS is investing substantially in wound management but , in the main , without evidence of the returns on that spend.

Woundcare Research for Appropriate Products or wrap, led by King’s College London , is an interdisciplinary collaboration between clinical , academic and industrial partners , with the express aim of addressing this lack of evidence in practical ways. Its focus is a shared , in depth understanding of the function and performance of wound care products designed t o meet the requirements of broken skin and wounds of varying aetiology , at different phases , inclusive of healing and non healing states.

WRAP started in 2001 with 12 partners from the wound care industry and now has 21 , including multinational companies , small to medium sized manufacturers , an independent tissue viability consultancy service , a specialist company for custom software and technical expertise for small businesses and healthcare, the trade association (Surgical Dressings Manufacturers’ Association - SDMA) , the leading NHS testing laboratory (Surgical Materials Testing Laboratory - SMTL) , and three clinical and academic centres in Birmingham , Bradford and London. WRAP secured two years of Engineering and Physical Sciences Research Council funding in support of a programme of research to transfer essential knowledge from patients and clinicians about their needs for dressing products together with ‘real life’ evidence of product performance , to the healthcare providers and industry.

Key outputs to date are:

inter-laboratory validation of an in vitro test rig which is beginning to be adopted as a cross-industry standard for evaluating dressing absorbency

3D imaging techniques for the investigation of skin deformation to inform dressing design and fixation from patient and clinician perspectives

a clinical note making system to evaluate dressing performance in the context of patient treatment and care.

The clinical note making system is the key to generating the vital evidence that the NHS and the industry currently do not have. It is a sophisticated analysis tool that routinely measures outcomes at a number of levels:

patient needs

effectiveness of care and dressing performance

organisational indices of effectiveness

In the UK the responsibility for assessing and managing wounds , planning treatment protocols and selecting dressings is substantially undertaken by nurses. It is well recognised that every organisation needs access to sound data if it is to succeed. It is also recognised that patient records , a critical source of data , fall short of the legal requirements of record keeping. At the point of wound care delivery a vast amount of information is lost because it is not recorded in a systematic format. WRAP focused on this shortfall and developed a note making system for routine wound care practice. The tool is available in paper and electronic versions. The system translates clinical information into robust data for clinical and managerial governance. The outcome indices can be readily imported into models of economic analysis to determine wound management costs.

The availability of reliable , quantitative data is essential if product innovation and assessments of effectiveness , safety and ‘value’ are to be driven by scientific principles based on observations and metrics that enjoy the confidence of all those who have a stake in successful woundcare.

Professor Lord Darzi’s vision for the next stage of NHS reform is a relentless focus on improving quality. The quality of information gathering for wound management could be transformed , relatively painlessly , if the NHS were to adopt this , or a similar clinical note making tool.

Patricia Grocott , King’s College London

Rob Cameron , Lattice Networks Limited

Carol Dealey , University Hospital Birmingham NHS Foundation Trust

Peter Vowden , Bradford Hospitals NHS Foundation Trust

Katherine Vowden , Bradford Hospitals NHS Foundation Trust

www.kcl.ac.uk

“the NHS is investing substantially in wound management but , in the main , without evidence of the returns on that spend”