Clinical and economic consequences of discharge from hospital with on-going TNP therapy: A pilot study

Plan de egreso: herramienta del cuidado - diada con enfermedad crónica

Introducción: La OMS reporta incremento de las enfermedades crónicas no trasmisibles, dada su complejidad, los pacientes presentan constantes hospitalizaciones, por lo cual es necesario fortalecer la competencia del cuidado de la enfermedad tanto del paciente como del cuidador en el hogar a través del programa plan de egreso. Objetivo: determinar el cambio en la competencia para el cuidado posterior a la implementación de herramienta plan de egreso para el cuidado en el hogar de la diada persona-cuidador familiar en situación de cronicidad en una institución de segundo nivel de atención. Materiales y métodos: Estudio de abordaje cuantitativo, seudo-experimental, con diseño de pruebas pre-test y pos-test, aplicando los instrumentos de “caracterización diada paciente-cuidador” y “Cuidar”. La población correspondió a 62 diadas. Muestreo no probabilístico a conveniencia. Se calculó del delta pre-post y se utilizó t-Student pareada para comparar. Resultados: el programa plan de egreso aumentó en el paciente las dimensiones de Conocimiento con un delta de 3.2 y Unicidad de 3,0 y competencia de cuidado global en 10,3; mientras que las competencias del cuidador familiar mejoraron en las dimensiones de Conocimiento con un delta de 3.34, Unicidad con delta 1.5, la dimensión de Disfrute con 1.7 y la de Reciprocidad –Relación con un delta de 1.61 para un total en la competencia de 9.2. Discusión y conclusiones: Estos hallazgos sugieren fortalecer el programa plan de egreso, durante la hospitalización y alta con el propósito de mejorar la competencia para cuidar en el hogar tanto del paciente como su cuidador familiar en situación de cronicidad.

Consensus on the health education of home-based negative pressure wound therapy for patients with chronic wounds: a modified Delphi study

Background

The study aimed to develop consensus on the components of health education of home-based negative pressure wound therapy (NPWT) for patients with chronic wounds.

Methods

A Delphi method was used to achieve consensus on the components of health education and 75% agreement and coefficient of variation (CV) <0.25 were used as cutoff. Sixteen experts were recruited purposefully to finish this study.

Results

Two rounds of consultation were implemented. Consensus was achieved on 36 of the 42 statements. The final agreed list of statements represented three domains: health education before carrying out home-based NPWT, health education for the treatment day of NPWT at hospital and health education for NPWT at home.

Conclusions

This study was the first attempt to develop consensus on the comprehensive components of health education of home-based NPWT for patients with chronic wounds. According to the established framework and components of health education, wound professionals can safely and effectively implement health education of home-based NPWT for patients with chronic wounds and improve their self-care ability and treatment experience at home.

EWMA Document: Negative Pressure Wound Therapy

1. Introduction Since its introduction in clinical practice in the early 1990's negative pressure wounds therapy (NPWT) has become widely used in the management of complex wounds in both inpatient and outpatient care.¹ NPWT has been described as a effective treatment for wounds of many different aetiologies^2,3 and suggested as a gold standard for treatment of wounds such as open abdominal wounds,^4-6 dehisced sternal wounds following cardiac surgery^7,8 and as a valuable agent in complex non-healing wounds.^9,10 Increasingly, NPWT is being applied in the primary and home-care setting, where it is described as having the potential to improve the efficacy of wound management and help reduce the reliance on hospital-based care.¹¹ While the potential of NPWT is promising and the clinical use of the treatment is widespread, highlevel evidence of its effectiveness and economic benefits remain sparse.^12-14 The ongoing controversy regarding high-level evidence in wound care in general is well known. There is a consensus that clinical practice should be evidence-based, which can be difficult to achieve due to confusion about the value of the various approaches to wound management; however, we have to rely on the best available evidence. The need to review wound strategies and treatments in order to reduce the burden of care in an efficient way is urgent. If patients at risk of delayed wound healing are identified earlier and aggressive interventions are taken before the wound deteriorates and complications occur, both patient morbidity and health-care costs can be significantly reduced. There is further a fundamental confusion over the best way to evaluate the effectiveness of interventions in this complex patient population. This is illustrated by reviews of the value of various treatment strategies for non-healing wounds, which have highlighted methodological inconsistencies in primary research. This situation is confounded by differences in the advice given by regulatory and reimbursement bodies in various countries regarding both study design and the ways in which results are interpreted. In response to this confusion, the European Wound Management Association (EWMA) has been publishing a number of interdisciplinary documents^15-19 with the intention of highlighting: The nature and extent of the problem for wound management: from the clinical perspective as well as that of care givers and the patients Evidence-based practice as an integration of clinical expertise with the best available clinical evidence from systematic research The nature and extent of the problem for wound management: from the policy maker and healthcare system perspectives The controversy regarding the value of various approaches to wound management and care is illustrated by the case of NPWT, synonymous with topical negative pressure or vacuum therapy and cited as branded VAC (vacuum-assisted closure) therapy. This is a mode of therapy used to encourage wound healing. It is used as a primary treatment of chronic wounds, in complex acute wounds and as an adjunct for temporary closure and wound bed preparation preceding surgical procedures such as skin grafts and flap surgery. Aim An increasing number of papers on the effect of NPWT are being published. However, due to the low evidence level the treatment remains controversial from the policy maker and health-care system's points of view-particularly with regard to evidence-based medicine. In response EWMA has established an interdisciplinary working group to describe the present knowledge with regard to NPWT and provide overview of its implications for organisation of care, documentation, communication, patient safety, and health economic aspects. These goals will be achieved by the following: Present the rational and scientific support for each delivered statement Uncover controversies and issues related to the use of NPWT in wound management Implications of implementing NPWT as a treatment strategy in the health-care system Provide information and offer perspectives of NPWT from the viewpoints of health-care staff, policy makers, politicians, industry, patients and hospital administrators who are indirectly or directly involved in wound management.

Clinical evidences, personal experiences, recent applications

Management of difficult wounds can be a complex, challenging and expensive task, especially for wounds showing a slow healing process. Topical negative pressure (TNP) therapy has greatly improved difficult wounds treatment. It allows to treat patient on an outpatient management, to reduce the complication rate with shorter hospital stay, to avoid frequent dressings with expensive advanced materials and allow a lower commitment of health professionals. Vacuum Assisted Closure^® (VAC^®) system is a therapeutic device based on the administration of a controlled TNP introduced by Morykwas and Argenta in 1997. It is indicated in different kinds of wound, but clinical evidences are present only for few of them. In this work we summarize indications and recommendations for VAC^® therapy and we analyze the actual better choice of treatment based on evidences and personal experience in order to stimulate further studies. Finally we introduce recent applications of VAC^® system such as Prevena^®, VAC Instill^® and VAC Via^®. Prevena^® is a system based on TNP indicated in the management of closed wounds that present risk factors for dehiscence. VAC Instill^® is a system that allows to associate TNP and topical administration of solutions, such as antibiotics or disinfectants, to treat specific type of wounds. VAC Via^® is a device based on TNP, characterized by little dimension and a preset system that allow the treatment of little wounds for 7 d, with no impairment for the patient. The aim of our paper is to describe a report of VAC^® therapy use in order to stimulate further studies and to define the level of evidence of VAC^® therapy.