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

This session will enable practioners to look at the impact of ‘high cost’ wound care therapies to a health economy. The cost of care maybe 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 a significant impact on quality of life for patients as well as reducing the cost of care for these complex patients. 

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.

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. 

New insights in pressure ulcer prevention:

Pressure, Shear, Friction and Microclimate in context

The overall goal of clinical practice is to restore or maintain health. Iatrogenic injuries, such as pressure ulcers, sometimes occur. Inappropriate care methods often remain in practice long after evidence has shown them to be harmful or ineffective. Education is critical in ensuring that all members of a clinical team act to prevent pressure ulcers according to the best evidence available.

Pressure has long been viewed as the most important extrinsic factor in pressure ulcer development. However, recent and ongoing research is revealing that shear, friction and microclimate also have important roles. For example, pressure and shear are closely linked, friction has a role in the development of shear, and microclimate influences the susceptibility of skin and soft tissues to the effects of pressure, shear and friction.
In addition to a direct effect, pressure also acts indirectly through the generation of shear stresses to produce pressure ulcers.

Clinical recommendations from the recent NPUAP and EPUAP guidelines that particularly relate to shear, friction and microclimate are reviewed in practice steps.
This scientific symposium will focus on new insight in pressure ulcer prevention and translate these in practice. But clinical judgement is always required for all who have the knowledge, skills and understanding to implement these new insights in their daily practice for effective and safe use.
Best clinical practice begins with identification of those at risk and ends with an evaluation of the impact, ie the effect on incidence and prevalence of pressure ulcers. 

Speakers: 

Michael Clark PhD
Welsh Wound Network
Cardiff, UK
Roles & memberships
Cardiff University
Cardiff University School of Medicine
Department of Dermatology & Wound Healing
Senior Research Fellow

Dr. Maarten Lubbers
Surgeon – intensivist
AMC – UvA, Amsterdam, Holland
1981: Surgeon
University of Amsterdam, Holland
1983: Chief Surgical Intensive Care Unit
University of Amsterdam, Holland
1983 - now: Academic Medical Center, Amsterdam
2007 also: Chief Hyperbaric Oxygen Unit AMC
Main interests:

- inflammation
- wounds
- transplantation
- infection
- sepsis
- MOF
Wounds: Healing, infection, dressings, tissue engineering;
antiseptics, evidence, health economics, guidelines.

Member

- ESCMID
- EPUAP
- EWMA
- ETRS
Author - more than 100 papers
- co-author several books
Lectures - more than 300

An international group of experts, who produced a consensus document on measuring the prevalence and incidence of pressure ulcers in 2009, recognised the need for an educational resource that takes a fresh approach to the extrinsic factors involved in pressure ulceration. The resultant consensus document – Pressure ulcer prevention: pressure, shear, friction and microclimate in context – consists of three papers: Pressure in context, Shear and friction in context, and Microclimate in context.

Each paper clearly defines and explains the science behind the extrinsic factor under examination and clarifies the synergistic links that exist between the factors. The papers build on the basic science to describe how the extrinsic factors contribute to pressure ulcer development, and discuss the types of and rationale for relevant clinical interventions that aim to prevent or ameliorate the effects of the extrinsic factor.

Biography speaker:

Prof. Keith Harding
Cardiff University, Cardiff, UK
Professor Keith Harding is currenty a Professor of Rehabilitation Medicine (Wound Healing) and the Director of the Wound Healing Research Unit at the University of Wales, College of Medicine.
He has worked in clinical research in Cardiff, and spent many years in General Practice. He has a long-standing interest in wound healing and has provided clinical supervision of a part-time outpatient clinic.
He also has a long-standing interest in continuing medical education and has acted in various capacities including GP CME Tutor for Wales and Postraduate Organiser for the University Hospital of Wales, as well as establishing further education courses in wound healing.
He is a member of the Royal College of Genral Practitioners and a Fellow of the Royal College of Surgeons, England.
Research interests include inflammatory cells in wound healing, aspects of measurement, the diabetic foot and quality of life evaluation. 

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.

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 focus will be upon the impact of bariatric patients and pressure ulcer care that is becoming more prevalent within health organisations with the increasing challenges of the obese patient. With the specialty of caring for the larger, heavier individuals evolves, it becomes increasingly important to recognise the need for adequate consideration for pressure ulcer prevention for these individuals with weight issues. When these two areas are combined it escalates what is already recognised as a major health challenge worldwide. It is now common knowledge that obesity has enormous detrimental consequences for health and the economy. The rise of obesity is widely accepted as a major public health problem and often perceived as resulting in considerable health system expenditure.
There are many implications both for health and for the moving and handling of patients, therefore risk assessment, adequate and suitable equipment provision, and training are essential in bariatric handling. The increased strain on the patient’s joints, cardiovascular system, range of movement and posture all make it more difficult for them to move and be moved. This potential from enforced immobility heightens susceptibility to pressure ulcer development; every organisation must strive to deliver the best service for their patients and in particular with this group prevention of pressure ulcers are of significant importance. 

What started as a treatment of wounds on various body parts, is now being put to much more sophisticated use. The development of these new techniques demands well trained specialists to guarantee a correct treatment. Our aim is to pass on the know-how of the training hospital, to provide a high standard in the outpatient care. We invented the “Luzern Model” in order to pass on our knowledge. Our goal of our teaching model is to have well educated wound managers and be there for them to answer their questions. Vacuum assisted closure therapy must be an option, which will only be carried out by well trained specialists. This is the only way we can guarantee a high standard of treatment with best results and avoid complications.
 

Method: This study describes the outcome of 61 patients treated from 1st November 2005 until 1st November 2006. AII types of patients were included: bolster after split skin grafting, traumatic infected wounds, dehisced wounds, venous ulcers, diabetic ulcers, decubital ulcers, wounds after amputations and sinus pilonidalis. Necrosis or the need for debridement were exclusion criteria for vacuum assisted closure therapy. The sponge-dressing changes took place in the outpatient-clinic and the home care setting.

Results: In total 29 of the patients were female (48%); average age was 54.8 years (range 9–89 years). In total 31 patients (51%) were classified as ASA III/IV, indicating high anesthesic risk. The most important negatively wound influencing factor were obesity (n=19), diabetes mellitus (n=12, 33%), smoking (n=9, 25%), peripheral arterial disease (n=6). Complications during the treatment were skin problems (n=7), pain (n=2), infection (n=5, 14%) thrombosis (n=2, 6%). Average duration of vacuum assisted closure therapy was 26 days.

Conclusion: 82.7% wounds are closed. Vacuum assisted closure therapy can be considered as a safe and effective therapy in the home care setting with a low rate of complications.

 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.
 

Analyses were based on data collected between 8/31/2001 and 11/24/2006 from 9,119 patients with 20,371 wounds involving 161,913 outpatient visits. From these data, 931 patients (~10%) received vacuum assisted closure therapy. AE surrogates such as infection, peri-wound complications, change or increase in exudate, wound cultures, pain and antibiotic medication prescriptions were used to determine whether the incidence of AEs differed between the treatment groups. Data were stratified by ICD-9 diagnosis code, wound size, and wound duration.

Patients with acute traumatic wounds (ATW) and pressure ulcers (PU) treated with vacuum assisted closure therapy experienced fewer presumed infections (p=0.006 and 0.005 respectively) than patients on moist wound care.
Amount and type of drainage were decreased for ATW (p<0.001), PU (p=0.004), and subacute flaps and grafts (p=0.034). Periwound complications were significantly less for ATW (p<0.001) and PU (p=0.014). Antibiotic prescription rates were reduced among chronic diabetic foot ulcers (p=0.036) and ATW (p=0.016), and no difference in the number of pain medication prescriptions were observed. There were no cases of hospitalization or deaths related to vacuum assisted closure therapy. A surprising 9.6% on vacuum assisted closure therapy were on heparin or Coumadin and none experienced bleeding.
Conclusions: Among 931 patients on vacuum assisted closure therapy, depending on wound type, there was either no statistical difference in the frequency of AE surrogates compared to patients on moist wound care, or patients on vacuum assisted closure therapy experienced significantly fewer AE surrogates. This study suggests that vacuum assisted closure therapy is safe for outpatient use in all wound types evaluated.