This system allows these fluids to stay for a predefined period in contact with the wound and are taken out due to the activity of the vacuum system. In our clinic we gained experience with saline solution as instillation solution. It showed up that application of this system we could successfully treat complex infected pressure ulcers.
Based on the experiences in infected wounds we were interested to see if the V.A.C. Instill® System also could be effective for treatment in contaminated but not infected wounds. We decided not only to look to clinical results like wound healing efficacy but also to immunohistochemical parameters for: neoangiogenesis, growth factors and a reduction in the presence of macrophages, like CD34, ACTINA, EGFR and CD68.
Unfortunately we were able to treat only 5 patients at this moment so the results are very preliminary. However we see more neoangiogenesis activity and a more effective reduction of macrophage activity. Also clinically we saw satisfying results.
Conclusion: V.A.C. Instill® Therapy can be an effective treatment for infected wounds but also for contaminated wounds. As the amount of collected data in non-infected wounds at this moment is too small for final conclusions it can be stated this therapy is very promising. More research however is necessary. 

Dr. Manlio Ottonello, MD
Plastic Surgeon,
Pietra Ligure, Italy

Education
1987 Graduation in Medicine and General Surgery University of Genoa,
Italy
1994 Specialization in Plastic and Reconstructive Surgery University of
Genoa, Italy
2000 Specialization in Hand Surgery and Surgery of the Upper
Extremities, University Pierre e Marie Curie, Medical Faculty Saint
Antoine, Paris, France

Working Experience and Positions

Held 1985/1987 internship General Surgery Department and Department of Hand
Surgery San Paolo Hospital Savona, Prof. Renzo Mantero
1988/1989 official Head of the Medical Department of the Marine Military,
specialized and qualified for the care regarding the Hyperbaric
Chamber at Military Hospital and Military Arsenal, La Spezia, Italy
1989/1991 Specialist in internal medicine at the Department of Plastic Surgery
Santa Corona Hospital, Pietra Ligure, Italy
1991/1999 Assistant physician (resident) at the Department of Plastic and
Reconstructive Surgery, Santa Corona Hospital, Pietra Ligure, Italy
Full time responsibility regarding general surgery, emergency room
and wards
Apr-Sep1999 Resident at the “Institut de la Main”, Prof. A. Gilbert, Paris, France
Oct 1999 - Head of the Department (first level) for Plastic and Reconstructive
Dec 2000 Surgery of the Spinal Cord Unit, Santa Corona Hospital, Pietra
Ligure, Italy
Jan 2001 Head of the Department for Plastic, Reconstructive and
present Rehabilitation Surgery
Responsible physician of the ambulatory for “difficult wounds”

Dr. Ottonello is a member of various societies and associations in the field of plastic, aesthetic and hand surgery and EPUAP and Wound Infection Institute. He has further presented at various national and international conferences regarding Plastic and Reconstructive Surgery, Hand Surgery and Wound healing as well as has given numerous lectures at a.o. the Nurse’s Training School.

Main principle of infection surgery has always been radical debridement. “Ubi pus, ibi evacua”, often cited by surgeons is not enough. All necrotic and infected tissue should be resected in case of limb or life threatening infections. Surgical and sharp debridement has become the gold standard, especially in complicated skin and soft tissue infections, whereas in chronic wounds alternative techniques (mechanical, enzymatic, autolytic and biological debridement, honey) may be more appropriate.

Wound irrigation can be helpful, but has no effect on remaining pathogens. HPPL may be deleterious by causing bacterial penetration into depth of tissues, while instillation of antiseptic fluids into a wound has an ongoing effect, when it´s used for a longer time, and when the antiseptic agent remains in the wound for at least 20 minutes. For more than seventeen years the V.A.C.® Therapy System has been used succesfully in treating wound infections. Preparing wounds for closure means to clean wounds, to achieve wound retraction and minimize following surgical procedures.

When infection is under control, the wound should be closed at the earliest time possible. Sometimes a simple split-thickness skin graft may be suitable for wound closure. In case of exposed bone, orthopaedic hardware, the use of local, pedicled and free flaps including microsurgical procedures is essential not only for wound closure but also for infection control. Well perfused tissue of the flap serves as carrier of systemic antimicrobial agents, which are absolutely necessary to kill remaining pathogens at the site of infection. Infection control can be difficult or even impossible in case of insufficient debridement, persistence of bacteria, and insufficiency of antimicrobial agents in case of multidrug-resistant (MDR) bacteria like MRSA and Acinetobacter Baumannii. Instillation technology is able to combine and optimize the effects of permanent elimination of bacteria by NPWT and to kill and wash out pathogens by cyclic instillation of antiseptic fluids.

The V.A.C. Instill® System enables a 3 stage-working cycle. Vacuum therapy / instillation of antiseptic fluids / hold time. Our experiences of treatment of infected wounds include chronic wounds with local infection, acute infections originating from chronic wounds as well as limb- and lifethreatening infections caused by MDR bacteria. In some patients NPWT and Instillation Technology were used as a salvage procedure following failure of multiple plastic surgical procedures. One thing was equal in all patients. Debridement and subsequent plastic surgical procedure seemed to be insufficient for infection control, or time to closure seemed to be to early. We have always been using Polyhexanid (Lavasorb®) for instillation. Instillation time directly depended on wound size. Time of therapy lasted at least 4 days, at most 18 days.

Dressing changes were performed every two to four days. Surgical closure was performed by direct secondary suture, skin grafting or flap surgery. In all cases infection control and complete healing were achieved, despite of incomplete debridement and leaving Prolene-Mesh® in situ in two cases. We believe the V.A.C. Instill® Wound Therapy System to be a useful tool for infection control in difficult anatomical regions (e.g. open wrist and talocrural joint), in case of impossibility of total debridement and MDR bacteria.

Prof. Dr. Michael Schintler
Department of Plastic and Reconstructive Surgery
University Clinic Medical School Graz, Austria

Qualifications
2008-date Head of Burns Team, University Clinic of Surgery,
Department for Plastic and Reconstructive Surgery
2000 to date Head of Outpatient Clinic for Diabetic Foot Patients
University Clinic of Surgery,
Department for Plastic and Reconstructive Surgery
2000-2001 Consultant for Trauma Surgery
1995-2000 Consultant for Plastic and Reconstructive Surgery
Clinical Department for Plastic Surgery
Medical University Graz, Austria
1988-1992 General Practitioner, District Hospital Klagenfurt, Austria
1981-1988 M.D., Medical University Graz, Austria

Employment History
Jan 1998-date Staff Surgeon, Department of Plastic and
Reconstructive Surgery, Medical University Graz
Jan 1995-Dec 1997 Surgical Residency
Department of General Surgery, Medical University Graz
1992-1995 Surgical Residency , Department of Trauma Surgery,
Regional Hospital Hermagor
1988-1992 General Practitioner Training, District Hospital Klagenfurt
Teaching
1998-2007 Courses and Seminars; Certified Woundmanager, Austria,
Germany, Switzerland; Kammerlander Consulting.
2003-date AO- Courses, University Clinic of Trauma Surgery,
Flap – Courses with Cadaver dissections, Institute of Anatomy,
Medical University Graz
2000-to date Theoretical, practical and clinical teaching to the
postgraduate students at the University Clinic of Surgery

The Expert Working Group who put the document together comes from a variety of countries from across the world. They are a mixture of nurses, doctors and bioengineers, all with a special interest in pressure ulcers. Some have considerable practical experience which is reflected in the text. The authors have also been able to take advantage of information in the International Pressure Ulcer Guidelines recently published by the European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel.

Dr Carol Dealey PhD MA BSc (Hons) RN RCNT
University Hospital Birmingham NHS Trust,
University of Birmingham
Carol Dealey is Senior Research Fellow at University Hospital Birmingham NHS Trust, Birmingham, UK
and University of Birmingham, UK.
Carol has worked and researched in the field of Tissue Viability for over 20 years and was one of the first Clinical Nurse Specialists in Tissue Viability (1987-97). Carol has undertaken a considerable body of research in the subject and has presented at national and international conferences as well as having numerous publications. The 4th edition of her textbook the Care of Wounds is in preparation.
She is Immediate Past President of the European Pressure Ulcer Advisory Panel and was one of their representatives on a joint working party with the USA National Pressure Ulcer Advisory Panel to develop international pressure ulcer guidelines. She was President of the European Wound Management Association 1993/4 and is currently a Council member. She was also Chairman of the Tissue Viability Society from 1996-98. Carol is Editor of the EWMA Journal and on the editorial boards of the Journal of Tissue Viability and International Wound Journal.

This paper will discuss implementation of the information provided in the document into everyday practice. For example, repositioning and the use of pressure redistributing devices are widely used across Europe for the prevention of pressure ulcers. The link between the theoretical information on pressure and the practical application in practice will be discussed for these strategies and for others used in the document. 

Clinicians need to be empowered to understand not only their budgets but those of the healthcare system around them. They will need to audit their clinical activity and demonstrate savings that can be made in terms of bed days and admission avoidance. A new technology should enable good clinical outcome measures, a reduction in overall spend and an increase in capacity or turnover of patients. A business case that demonstrates these outcomes allows clinicians and managers to work to achieve the same goal and is hard not to approve.
This session will consider how these business cases can be developed.  

Ms Stella Vig
Consultant General and Vascular Surgeon
Mayday University Hospital, Croydon
Stella Vig is a Consultant General and Vascular Surgeon
at Mayday University Hospital, Croydon appointed in 2006.
She qualified from the University of Wales Medical School in 1991, with an intercalated BSc in Biochemistry (1988) and gained FRCS in 1994. She completed her MCh under Professor John Dormandy at St Georges Hospital in 2004.
Her research and vascular interests include carotid disease, peripheral vascular disease, management of diabetic foot complications, thrombophilia, wound care and risk factor management.
She is Clinical Lead for General Surgery, Trauma/Orthopaedics and Urology. This has consolidated her interest in service improvement with cost effective care to the benefit of both patients and Trust/PCT.
She is also Foundation and Training Programme Director with an interest in training both at undergraduate and post graduate levels.

Methods
From November 2001 to December 2009, 330 patients (age range from 10 days to 86 years) received a vacuum assisted closure system for the treatment of sternal wound infection.
Treatment consisted of opening of the entire wound with removal of all sternal wires, surgical debridement and implantation of a V.A.C.® Therapy System with a black foam or a silver-coated foam use trademarked and registered marks for Granufoam and Silver foam. Thereafter, the patients underwent a dressing change every third day until the swabs were negative and the inflammation parameters were in the normal range or when requested by treating physician..

Results
In 65%, cases there was a deep infection with involvement of the sternal bone and mediastinitis; 35% had a superficial infection. Secondary sternal closure after V.A.C.® Therapy was possible in 76% of the patients, whereas 24% proceeded to plastic surgery reconstruction with muscle flaps due to destruction of the sternal bone. In those cases where sternal closure was possible, we used three techniques of sternal closure, depending on the quality of the sternal bone: normal sternal wires, the sternal talon system or plate osteosynthesis. In all patients, Triclosan-coated sutures were used for secondary infection prevention.

Discussion
The key to successful management of sternal wound infection is with early recognition, enabling preservation of the sternal bone and facilitating secondary sternal closure, which in turn reduces hospital stay and costs. As we have gained a wide experience in using NPWT therapy, we developed certain guidelines for the treatment of sternal wound infections in order to ensure the best outcome.reference to those guidelines here.

For more than seventeen years the V.A.C.® Therapy System has been used successfully in treating wound infections. Preparing wounds for closure means to clean wounds, to achieve wound retraction and minimize following surgical procedures. When infection is under control, the wound should be closed at the earliest time possible. Sometimes a simple split-thickness skin graft may be suitable for wound closure. In case of exposed bone, orthopaedic harware the use of local, pedicled and free flaps including microsurgical procedures is essential not only for wound closure but also for infection control. Well perfused tissue of the flap serves as carrier of systemic antimicrobial agents, which are absolutely necessary to kill remaining pathogens at the site of infection. Infection control can be difficult or even impossible in case of insufficient debridement, persistence of bacteria, and insufficiency of antimicrobial agents in case of multidrug-resistant (MDR) bacteria like MRSA and Acinetobacter Baumannii.

Instillation technology is able to combine and optimize the effects of permanent elimination of bacteria by NPWT and to kill and wash out pathogens by cyclic instillation of antiseptic fluids. The V.A.C.-instill® System enables a 3 stage-working cycle. Vacuum therapy / instillation of antiseptic fluids / hold time. Our experiences of treatment of infected wounds include chronic wounds with local infection, acute infections originating from chronic wounds as well as limb- and lifethreatening infections caused by MDR bacteria. In some patients NPWT and Instillation Technology were used as a salvage procedure following failure of multiple plastic surgical procedures. One thing was equal in all patients. Debridement and subsequent plastic surgical procedure seemed to be insufficient for infection control, or time to closure seemed to be to early. We have always been using Polyhexanid (Lavasorb®) for instillation. Instillation time directly depended on wound size. Time of therapy lasted at least 4 days, at most 18 days. Dressing changes were performed every two to four days. Surgical closure was performed by direct secondary suture, skin grafting or flap surgery. In all cases infection control and complete healing were achieved, despite of incomplete debridement and leaving prolene mesh® in situ in two cases. We believe the VAC-instill® Wound Therapy System to be a useful tool for infection control in difficult anatomical regions, (e.g. open wrist and talocrural joint) in case of impossibility of totally debridement and MDR bacteria.

Material and Methods: The V.A.C. Instill® enables a 3 stage-working cycle. Vacuum therapy / instillation of antiseptic fluids / hold time. We have always been using Polyhexanid (Lavasorb®) for instillation. 15 patients with severe diabetic foot infections were treated with V.A.C. Instill®. All patients presented with limb or even life-threatening infections. Debridement and following plastic surgical procedure seemed to be insufficient for infection control, or time to closure seemed to be to early. Instillation time directly depended on wound size. Time of therapy lasted at least 6 days, at most 12 days. Dressing changes were performed every two to four days. Surgical closure was performed by direct secondary suture, skin grafting or flap surgery.

Results: In all cases infection control and complete healing was achieved, despite of incomplete debridement and even long lasting open Charcot joints.

Conclusion: We believe the V.A.C. Instill® to be a useful tool for infection control and limb salvage in severe diabetic foot infections and in case of impossibility of totally debridement. Early defect coverage and hospital discharge could be cost-effective.

The St Vincent Declaration (1989) agreed to reduce worldwide diabetic amputation rates by half and a Hi-Lo amputation ratio was suggested as an additional quality measure (High Amputation was defined as an amputation above the ankle).

This session will enable practioners to look at the impact of ‘high cost’ wound care therapies to a health economy. The cost of care is changed with savings realised but masked in differing budgets.
It will provide evidence for further local discussions and will allow you to look at your own data for quality indicators to see whether this can also have an significant impact on quality of life for patients as well as reduce cost of care and amputation rates.

In 2007 the Federal Center for Medicare and Medicaid Services (ref 3) announced that it would no longer reimburse US hospitals for NPUAP stage 3 and 4 hospital-acquired PUs. Hospitals in the US therefore need to develop a prevention model that uses proven interventions. This presentation describes how implementation of one such model resulted in zero prevalence of hospital-acquired PUs. Central to its success is that the programme was a management priority.

3 Center for Medicare and Medicaid Services, 2008

Isabel Bales, RN, MSN, CWON, AGNP
694 West Fort Street • Farmington, Illinois 61531 • USA 

Professional Objective:
To practice as an adult/geriatric nurse practitioner to provide care,
especially to those afflicted with wounds, diabetes, and patients in need of palliative care.
To conduct research that will result in the improvement of patient care.

Credentials:
Professional Registered Nurse       
Certified Wound and Ostomy Nurse  

Certifications:
Wound Care
Ostomy Care

Education:
MSN, University of Illinois at Chicago, May 2009
BSN, Southern Illinois University at Edwardsville, December 2000

Research:
Reaching for the Moon: Achieving Zero Pressure Ulcer Prevalence, 2009
The Development of a Computer-Based Ostomy Care Training Resource for Staff Nurses, 2008
A Comparison Between the use of  Intravenous Bags and the Heelift Suspension Boot to Prevent Pressure Ulcers – 2007

Publications:
Reaching for the Moon: Achieving Zero Pressure Ulcer Prevalence, Journal of Wound Care, 18(4), April 2009
The Development of a Computer-Based Ostomy Care Training Resource for Staff Nurses, 2008,
Publication Pending on the Ostomy and Wound Management Journal

Professional Experience:

2003-Present
WOUND AND OSTOMY NURSE, Methodist Medical Center of Illinois.
• Clinical resource for the acute and rehabilitative care of patients with  selected disorders
of the gastrointestinal, genitourinary, and integumentary systems,  such as complex draining wounds,
ostomies, fistulae, dermal ulcers, tubes, and  incontinence.  Main wound care educator for the nursing
staff.  Primary wound care and ostomy care patient educator. Participate in the development and
implementation of procedures and  protocols.  Recommend standards for cost-effective supplies/equipment
related to wound, ostomy, and incontinence care to be utilized in the hospital through product evaluation.
Chairperson of the wound committee.

 
2002-2003
STAFF NURSE, Methodist Medical Center of Illinois, Transitional Care Unit.
•Assessment of patients, medication administration, treat wounds, implement interventions  following
hospital protocols.  Preceptor and mentor for the unit’s new staff.  Member of  QI committee.  Functioned
as the charge nurse when assigned.

2000-2002
ASSISTANT DIRECTOR OF NURSING, HCR-Manor Care, Canton, Illinois

1998-2000
ASSISTANT DIRECTOR OF NURSING, HCR-Manor Care At Riverview, East Peoria, Illinois

1996-1998
STAFF NURSE, Graham Hospital, Canton, Illinois

Methods: A BIM was developed to investigate the use of different hospital surfaces; standard foam, constant low pressure and alternating pressure surfaces. The model summarizes the cost of PU treatment for patients with existing ulcers and demonstrates whether prevention strategies using pressure relieving surfaces can save hospitals money as a result of preventing PUs in the ‘at risk’ population. The model also provides information on the optimal way in which to adopt appropriate surfaces.  A hypothetical scenario is presented for a typical medium-sized hospital, with more patients placed on pressure relieving surfaces than on standard foam surfaces as previously was the case.

Results: The findings from the hypothetical scenario indicate that when more pressure relieving devices were adopted, there was a reduction in PU development. The associated PU treatment costs reduced substantially, which offset the increased outlay for the surfaces themselves, resulting in substantial cost savings.

Conclusions/Discussion: Our model demonstrates that the implementation of pressure relieving surfaces will reduce the incidence of PUs and generate cost savings. Hence, in order to reduce the strain on hospital budgets that PUs can cause, adopting a planned approach to PU prevention and treatment using pressure relie¬ving surfaces is vitally important.

Method: A BIM was developed to investigate the use of different hospital surfaces; standard foam, constant low pressure and alternating pressure surfaces. The model summarises the cost of PU treatment for patients with existing ulcers and demonstrates whether prevention strategies using pressure relieving surfaces can save hospitals money as a result of preventing PUs in the ”at risk“ population. The model also provides information on the optimal way in which to adopt appropriate surfaces. A hypothetical scenario is presented for a typical medium-sized hospital, with more patients placed on pressure relieving surfaces than on standard foam surfaces as previously was the case.

Results: The findings from the hypothetical scenario indicate that when more pressure relieving devices were adopted, there was a reduction in PU development. The associated PU treatment costs reduced substantially, which offset the increased outlay for the surfaces themselves, resulting in substantial cost savings.

Conclusions: Our model demonstrates that the implementation of pressure relieving surfaces will reduce the incidence of PUs and generate cost savings. Hence, in order to reduce the strain on hospital budgets that PUs can cause, adopting a planned approach to PU prevention and treatment using pressure relieving surfaces is vitally important.

The document draws on the significant clinical research evidence available and the consensus opinion of the expert working group. Many of these experts met in February 2008 to examine the role of epidemiological studies in the development and evaluation of pressure ulcer prevention programmes. Following this meeting, consensus recommendations were developed to provide guidance on performing prevalence and incidence studies and how to use the data collected to improve standards of care for pressure ulcers. In particular it outlines a systematic approach to evaluating, interpreting and comparing studies. In this presentation, Dr Nils Lahmann will outline the key sections of the document, using his clinical experience in Germany to highlight the issues surrounding prevalence and incidence and how implemen-tation of effective PU prevention strategies can help to reduce PU occurrence.

The strategy developed was:
• specialistic units can activate vacuum assisted closure therapy only after Plastic Surgery consultancy (best possible therapy in difficult wound healing)
• the Health Technologies Evaluation Unit approves the request only after Plastic Surgery consultancy  (centralized control)
• vacuum assisted closure therapy is activated at the requesting clinic, and continues in low-cost clinics if discharge is not possible
• end of vacuum assisted closure therapy and definitive wound closure strategy are decided after Plastic Surgery consultancy.

The need of well trained medical and nursing staff was answered through:
• selection of dedicated professionals to be trained in vacuum assisted closure therapy
• workshops for demonstration of vacuum assisted closure therapy use and efficacy.

The overall cost-effectiveness optimi-zation was completed with the acti-vation of an early discharge strategy to home care with specifically vacuum assisted closure therapy trained nursing staff for patients living at <60 km from the hospital, or transfer to low-cost clinics of patients living at >60 km.

Our results were:
• optimization of cost-effectiveness
• increasing good opinion of vacuum assisted closure therapy clinical efficacy
• well trained staff
• in/out patients ratio inversion.

In this presentation I will highlight how a seamless transition of care can be achieved, (specifically for patients receiving vacuum assisted closure therapy) between wards, hospitals and the patient’s home. I will describe how the development of a managed service and cross disciplinary working can facilitate these benefits to patients receiving vacuum assisted closure therapy and how many common obstacles to this process can be approached and hopefully overcome. I will show how working with various separate factions can facilitate the development of a seamless service. I will demonstrate the importance of setting up robust and sustainable systems and how they help to achieve an efficient service that is both cost effective as well as being patient focused. I will share specific documentation templates and established processes which are designed to eliminate waste and prevent this impacting upon the patient’s treatment. I will briefly cover topics such as effective business cases, key personnel, systems options for differing organisations, efficiency savings for both primary and secondary care organisations and of course patient satisfaction and successful outcomes.

The need for pressure ulcer prevention strategies is well recognised in clinical guidelines. The appropriate use of pressure-relieving surfaces during hospitalisations is central to the prevention of pressure ulcers. Pressure-relieving surfaces fall into three broad categories: standard foam surfaces, continuous low-pressure surfaces and alternating pressure surfaces. The costs of these surfaces differ substantially. As such, it is vital that healthcare planners and providers ensure that patients are allocated to appropriate surfaces to ensure that prevention strategies are effective and healthcare resources are allocated efficiently. By following best practice guidelines on the appropriate use of pressure-relieving surfaces, hospitals can reduce the pressure ulcer prevalence, while saving money as a result of more efficient use of surfaces and reduced treatment costs.

1 Kaltenhaler, E., Whitfield, M.D., Walters, S.J., Akehurst, R.L., Paisley, S. UK, USA and Canada: How Do Their Pressure Ulcer Prevalence and Incidence Data
Compare. Journal of Wound Care. Jan 2001; 10(1): 530-5.

The measurement and interpretation of pressure ulcer occurrence data has long been problematic in pressure ulcer research, with different definitions of pressure ulceration, differing clinical populations and different data collection methods among some of the challenges faced. This presentation will consider the measurement of pressure ulcer occurrence given that this is a key foundation to achieving evidence of the implementation of successful pressure ulcer prevention strategies. The evidence for changes in pressure ulcer occurrence following the introduction of pressure ulcer preventive strategies will be reviewed. In this section, the focus will be placed upon the impact of the introduction of pressure-redistributing support surfaces as a common tactic to reduce pressure ulcer occurrence. The problems that can arise when attempting to uncover the value of any single tactic used to prevent pressure ulcers will be highlighted and related back to the challenge of correctly measuring pressure ulcer occurrence. The presentation will conclude with recommendations for future pressure ulcer occurrence data collection that should help standardise data allowing more meaningful comparisons between health care providers and trends in pressure ulcer occurrence over time to be made.

A number of published studies have considered the economic and clinical outcomes associated with the use of vacuum assisted closure therapy in home health settings in the United States. However, uptake in home health settings outside of the United States remains relatively limited, largely on financial grounds. Barriers to uptake include limitations in the evidence base, difficulties associated with the virement of funds across care settings and perverse incentives introduced by reimbursement and coverage procedures. Healthcare planners are encouraged to consider how each of these barriers can be addressed to improve the efficiency of wound management.

The following presentation will use the model of hard-to-heal DFUs, in which the most significant factors related to high cost have been identified as number of surgical procedures, in-patient hospital stay and time to healing as well as the consequences of amputation. The estimated cost of treating a DFU in the USA is up to US $20,000 and a major limb amputation costs about US $70,000. Recent estimates reveal that DFUs and
amputations alone cost the USA healthcare system about US $30 billion yearly. Lower extremity complications account for approximately 15–40% of the total cost of diabetes in most countries.
Resource utilization and economic cost in DFU were analyzed based on people with diabetes with post amputation ulcers (up to the Tran metatarsal level) enrolled into a sixteen-week, randomized clinical trial. Patients randomized to vacuum assisted closure therapy received therapy with dressing changes every 48 h. Control patients received standard MWT according to consensus guidelines. Resource utilization and procedures were analyzed using a standardized protocol.
Treatment of diabetic wounds using vacuum assisted closure therapy compared to MWT was associated with substantially lower resource utilization with regard to out-patient visits, dressing changes, surgical procedures and antibiotics. Overall direct treatment costs were also substantially different between the two groups, where
treatment with vacuum assisted closure therapy  was on average $8,800 less than with MWT.
In summary, this study revealed that treatment with vacuum assisted closure therapy  resulted in healing at a lower overall cost of care and further illustrates the challenges in doing health economic studies in wound care. 

 Vacuum assisted closure therapy has been demonstrated to be a cost effective way of managing complex chronic wounds, particularly pressure ulcers and diabetic foot wounds (Trueman, 2007). These cost benefits can only be realised if the transition from hospital to community care is both efficiently and effectively managed.
We have developed a robust communication and funding system that allows early discharge of patients to the community. This is based around the availability of trained community staff, a detailed communication process, a multidisciplinary care package and a prior managerial funding agreement allowing the smooth transition of care between the different funding centres.

The key questions before discharge are:
Is the wound suitable for management in the community?
Is the patient otherwise fit for discharge?
Are the home environment and social circumstances suitable for discharge?

Once these issues have been addressed more specific questions relating to the provision of vacuum assisted closure therapy in a home environment are addressed. Only when these issues have been resolved is discharge with vacuum assisted closure therapy considered appropriate.

References
1. Posnett, J., Franks, P. (2008) The burden of chronic wounds in the UK.Nursing Times 104: 3, 44–45.

2. Trueman, P. (2007) Health economics and topical negative pressure therapy. European Wound Management Association
(EWMA) Position Document: Topical Negative Pressure in Wound Management. London MEP Ltd.

Specific evidence for commencing, managing, and terminating vacuum assisted closure therapy has been consolidated into an active treatment matrix. This lecture shall answer key questions about this modality, and present the algorithm developed to assist clinicians in making decisions about using vacuum assisted closure therapy appropriately in patients with Stage III and Stage IV pressure ulcers. A case series representing various pathways along the algorithm of vacuum assisted closure therapy in pressure ulcers shall be presented. Specific advantages for transitioning these difficult cases to the home care setting shall be highlighted.