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.

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.

This literature review will discuss the clinical outcome of diabetic foot ulcers treated with vacuum assisted closure therapy, its implication in the transition from acute care to home care, factors that might influence clinical outcome in home care, and the quality of life aspects in these patients. Patient care for diabetic foot ulceration is complex and necessitates multidisciplinary collaboration to provide comprehensive wound care. It is critical for limb-preservation in this most high-risk population to have available a versatile, efficacious wound healing modality that can easily transition from acute care to home care. Finally, combining vacuum assisted closure therapy with other wound healing resources in a collaborative and synergistic fashion allows patients to continue with daily living activities, while receiving all the potential benefits of an advanced wound healing modality.

Methods: Eighteen outpatient wound centers in 11 U.S. States using the Intellicure electronic medical record (EMR) contributed to the Intellicure Research Consortium (IRC) database. 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.

Results: Compared to moist wound care patients treated with vacuum assisted wound closure therapy with acute traumatic wounds (ATW) and pressure ulcers (PU) experienced fewer presumed infections (p=0.006 and 0.005 respectively). 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 wound closure therapy. A surprising 9.6 % of patients on vacuum assisted wound closure therapy were on heparin or warfarin and none experienced bleeding.

Conclusions:Among 931 patients on vacuum assisted wound closure therapy, depending on wound type, there was either no statistical difference in the frequency of AE surrogates compared to patients on moist wound are, or patients on vacuum assisted wound closure experienced significantly fewer AE surrogates. This study suggests that vacuum assisted wound closure is safe for outpatient use in all wound
types evaluated.

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.