EUROPEAN  TISSUE  REPAIR  SOCIETY

Professor Finn Gottrup, from the University Centre of Wound Healing, Odense, Denmark, presented the next lecture:

Organisation of Wound Healing Services

Purpose
To improve prophylaxis and treatment of patients with all types of problem wounds. This is achieved during establishment of multi-disciplinary wound healing centre based on standardised treatment protocols, patients guidelines, basic and clinical research and education.

Methods
The health care system in Scandinavia is based on a socialised government paid health care system. The Copenhagen Wound Healing Center and The University Center of Wound Healing in Odense are established as a fully-integrated hospital unit in the socialised government health care system of Denmark. The Centers consists of outpatient clinics and in-patient wards with 20 and 11 beds only for patients with severe wounds of all ethnologies. The multi-disciplinary staff consists of medical doctors (surgeons, dermatologists), nurses (specialised), podiatrists, physiotherapists, researchers, etc. Continuous advisory visits by internal medicine- and microbiology doctors are established.

Results
The treatment strategy is both surgical and conservative orientated. However, the severe problem wounds treated in this type of centres will in most cases need a surgical intervention of a kind. The most modern wound care products and treatment techniques are used according to standardised treatment plans. Beside clinical work the Centres provide different types of educational services like congresses, meetings, courses and pre- and postgraduate educational programs for nurses and medical doctors. Basic and clinical research is done separately or in collaboration with national or international researchers. In- and outpatient functions for prevention and treatment of problem wounds have been established. The structure of a future national system for wound treatment and care has been prepared and is presently negotiated in the National Health Care System.

Conclusion
The optimal way for prophylaxis and treatment of all types of problem wounds is to establish Wound Healing Centres with both out- and in-facilities. These centres should be integrated as an accepted national expert function of wound healing. This concept, with minor adjustments, may be applicable for both industrialised and developing countries.

Dr Zbigniew Rybak and Professor Finn Gottrup, photo courtesy of EWMA

The next speaker Dr John Chen, from ConvaTec Global Development Center, Deeside, UK, presented a lecture entitled:

The Scientific Basis for Wound Care Practice and Product Innovation

The last forty years have seen a great increase in our understanding of the wound healing process in acute and chronic wounds. We have begun to dissect the biological processes that lead to fairly predictable acute wound healing, and we are beginning to understand why chronic ulcers form, are maintained and recur. We can explain why some products are more effective than others, why some practices are more effective than others, and why, for example, the risk of wound infection seems to be reduced under occlusion. Furthermore, we can unravel some of the interactions between the wound and its colonising microbes.

A moist wound environment is now regarded as the standard of care for surgical wounds, traumatic wounds, and chronic ulcers. It is now believed that the scab formed in unmanaged skin wounds is a sub-optimal solution to a threat to the integrity of the host organism. Unmanaged skin wounds are the only ones in humans that heal in a dry state. The moist environment is associated with accelerated epithelial resurfacing and enhanced angiogenesis. The risk of infection is reduced because of the activities of the natural host defences in the moist wound tissue under occlusive dressings. The moist environment is associated too with reduced wound pain, and autolytic debridement.

Our biological models for wounds explain why these observations are reported. For example, in the case of autolytic debridement, we now know that the natural enzymes produced by a wound are effective in the moist conditions. Epithelial cells are able to migrate in moist conditions, and hypoxia under occlusion in part enhances blood vessel growth.

In the case of chronic wounds, it is clear that ulcers form as a result of an internal disease process. We now understand some of the pathways that characterise the disease, and with this understanding we can devise specific treatments as well as understand why some practices are more effective than others. In venous ulcers, for example, we can explain the effectiveness of compression, and in neuropathic diabetic foot ulcers we can explain the effectiveness of offloading. We can explain too why some treatments do not work. Looking ahead we can also focus our development efforts more effectively because we can see how best to target the chronic wound pathology to improve outcomes.

Dr Wojciech Stras from ConvaTec Poland performed the last presentation entitled:

Granuflex™ – a modern wound healing product delivering cost-effective treatment of VLU in Poland

Modern dressings are common standard in managing both chronic and acute wounds in number of countries. There are many dressings on Polish market but Granuflex seems to be the most popular one. This product is also broadly used all over the world with a number of satisfied doctors and patients who underwent the treatment. Poland although faces problem of low popularity of modern wound management standards according to moist wound healing and occlusive dressings. As many studies show there is no need to fear of using modern dressings in term of increased number of infections or cost burden.

Medical professionals in Poland seemed to be afraid that using modern dressings increases the cost of therapy with no significant impact on wound progression. The relevant data show that modern dressing with example of Granuflex are both more clinically effective and cost effective. The reason for moderate willingness to use occlusive dressing in Poland may also rise from lack of experience with those products. They have been present in Poland for almost ten years, but the cost of therapy has been moved towards patients thus preventing doctors from prescribing them to elderly patients with leg ulcers necessitating long term treatment. Unfortunately, in Poland there is co-payment from patients towards the price of the dressing (around 50%). This seems to limit the number of prescriptions on modern dressings and excuses the use of cheap gauze. The problem also lays in the system of health care in Poland and diversification of expenses between hospital sector and outpatients clinics. Although the money comes from one budget the cost of the treatment is presumed as the cost of the drugs or medical devices used for patients during hospital stay. It prevents hospitals from the broad use of modern wound dressings and also has a negative impact on attitudes towards modern dressings among professionals in the community sector. Any way the situation in Poland is complex due to the transformation of health care system but the scientific and pharmaco-economic data apply to any systems for particular disease. As it was calculated for Polish condition the cost of twelve weeks treatment including cost of dressings, physicians and nursing time and the average percentage of wounds that close down under Granuflex or gauze showed that treatment with Granuflex is 40% cheaper in terms of pharmaco-economic evaluation. These data seem to be as clear as possible and the decision on type of wound management should be driven according to these facts as the total expenses taken on wound healing may decrease in that way.

Further information may be obtained from:
Dr W. Stras
E-mail: wojciech.stras@bms.com