Trends in Wound Management Kevin Y. Woo, PhD, RN, FAPWCA
It is estimated that more than 400 million people worldwide have wounds of various etiologies.1 Chronic wounds, however, are often complex and recalcitrant to healing and may persist for months or years because of underlying disease processes or complications. With an aging population and increased prevalence of chronic diseases, the majority of wounds are becoming difficult to heal. This places a significant burden on the healthcare system and individual patients. The exact mechanisms that contribute to poor wound healing remain elusive but likely involve an interplay of systemic and local factors. In an effort to address the growing demand in wound care management that is evidence based and cost-effective, I would like to highlight several gaps in wound care management and their potential solutions. 1. Systematized and holistic approach to wound management. The healing of acute wounds follows a predictive sequence of overlapping phases including inflammatory, proliferative, reepithelialization, and remodeling stages.2 The complexity of healing depends on many intrinsic and extrinsic factors, which regulate the complex biochemical and cellular events that culminate in closure of a wound with fibrotic scar tissue. Unlike acute wounds, chronic wounds, such as pressure ulcers, venous leg ulcers, and diabetic foot ulcers, do not always follow predictable temporal overlapping phases of healing because of the disruption of 1 or more elements of the healing process.3 Treatment of chronic wounds requires a systematized approach under the tenets of ‘‘wound bed preparation,’’ which highlights the key individual components of wound care.4 Within this framework, it is important to treat the cause and address patientcentered concerns prior to local wound care. Best practices to prepare the wound bed for healing include debriding of unhealthy and nonviable tissue, controlling infection and bacterial bioburden, maintaining moisture balance, and addressing the unhealthy wound edges. Although complete healing may seem to be the logical goal for most patients and clinicians, some wounds do not have the potential to heal because of a number of factors, such as inadequate vasculature, coexisting medical conditions, and medications that prohibit the healing process.5 By determining the potential for healing, a proposed framework (Table 1) describes the primary focus of care and categorizes wounds into healable, maintenance, or nonhealable.6 Future study is required to describe the cost-effective and patient-centered approach to manage nonhealable wounds.6
2. Knowledge to improve nursing care in wound management. Nurses are fundamental to quality wound care. Yet, not all settings have provided adequate ongoing advanced education for nurses, as demonstrated by the level of knowledge toward prevention and management of wounds in some regions.7 Several studies from various countries have documented that measures to prevent pressure ulcers are not consistently applied by nurses across different healthcare settings, often because of the lack of time, poor knowledge, or perception of low priority in care. It is undisputable that knowledge and attitude could have a significant impact on the quality of wound-related care. Nurses who possess adequate knowledge and perceive wound care as rewarding are more likely to provide evidence-based care and lifestyle advice to their patients, compared with those who lacked knowledge and positive attitude.8 Patients (n = 88) who attended a diabetic foot care program that was led by nurses with advanced foot care training developed fewer fungal infections (P G .001) and calluses (P G .001) over 2 years.9 None of the patients who had a history of foot ulceration developed recurrence of callus-related foot ulcers. Ostrow et al10 documented a 40% reduction of amputation by providing specialized wound care training to an interprofessional team in Guyana. In a study that was funded by the Ministry of Health in Canada, Woo et al11 demonstrated that wound healing was improved by care provided by a nurse practitioner with advanced wound care training in the community. Clarke-Moloney et al12 provided training to 30 public health nurses in Ireland. The annual wound care audit indicated that the number of venous leg ulcers treated with high compression increased significantly by 16% (P G .0001). The frequency of dressing changes was reduced (P = .002) with an increase in once-weekly dressing changes by 10%, resulting in significant cost savings. 3. Emergence of diabetes and other chronic diseases. Diabetes is one of the most prevalent chronic diseases that has become a worldwide epidemic.13 According to the International Diabetes Federation, the number of people with diabetes internationally will increase from 246 million or 5.9% in 2007 to 380 million or 7.1% by 2025.11 Of persons with diabetes, 2% to 3% will develop a foot ulcer annually; whereas the lifetime risk of developing a foot ulcer is as high as 25% mainly because of neuropathy and potential coexisting vascular disease.14 In following patients with diabetes and neuropathy for 1 year, it was estimated that 7.2% of this population would develop a first-time
Kevin Y. Woo, PhD, RN, FAPWCA, is Assistant Professor, School of Nursing, Queen’s University, Kingston, Ontario, Canada.
ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 12
538
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table 1.
HEALABLE, MAINTENANCE, AND NONHEALABLE WOUNDS Proposed Criteria with Examples of Key Determinants
Wound Prognosis
Can the Cause Be Treated?
Healable
Yes, the cause has been corrected or compensated with treatment. For example, a patient underwent bypass surgery to improve arterial supply to promote healing of an arterial ulcer
Coexisting medical conditions and drugs that do not prevent healing
& Promote wound healing & For example, venous ulcers: 30% smaller by week 4 to heal by week 12
Maintenance
No, poor treatment adherence or lack appropriate resources. For example, a patient with venous stasis disease who does not wear compression (eg, stockings)
Coexisting medical conditions and drugs that may stall healing, eg, hyperglycemia
& Prevent further skin deterioration or breakdown, trauma, and wound infection & Promote patient adherence & Advocate for patients to acquire appropriate resources & Optimize pain and other symptom(s) management
Coexisting medical conditions that would prevent normal healing, such as advanced terminal diseases, malignant conditions, inadequate perfusion, malnutrition with low albumin (G20 mg/dL) or negative protein balance, significant anemia (hemoglobin G80 g/dL), or high-dose immunosuppressive drugs
& Prevent further skin deterioration or breakdown, trauma, and wound infection & Promote comfort & Optimize pain and other symptoms management
Nonhealable: palliative No, a cause that is not treatable. or malignant For example, there is widespread metastasis, including the skin, advanced stages of cutaneous malignant conditions, and chronic osteomyelitis
Goal/Objective
Figure 1. MULTI-LEVEL CHRONIC DISEASE SELF-MANAGEMENT MODEL
ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 12
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Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
foot ulcer.13 More than 80% of all nontraumatic amputations in diabetes are preceded by foot ulcers, which should be considered as one of the prognostic indicators for advanced diabetes.15 In most countries, the healthcare system costs of diabetic foot ulcers are exorbitant and include a high likelihood of hospitalizations. A comprehensive framework for diabetic foot care has been described involving multiple-level interventions, health policy revision, and healthcare organization remodeling.16 See Figure 1. 4. Primacy of self-management. Self-management and patient engagement are the cornerstone of chronic disease management. Self-management support is ‘‘the systematic provision of education and supportive interventions, by healthcare staff (and others), to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support. Traditional education has minimal effect on behavioral changes. A growing body of literature now validates various psychological interventions including the use of social support, problem-solving skills, contract setting, cognitive therapy, and self-monitoring of behaviors, to improve diabetic self-management.16 5. Delivery of psychosocial needs of people living with chronic wounds. People who are living with chronic wounds describe the experience as isolating, debilitating, depressing, and worrisome, which contributes to high levels of stress. People with chronic wounds have been shown to experience more mental health problems than people without wounds in the community and are less capable to marshal their resources and apply problem-focused strategies to cope with stressful events.14 In response to a web-based survey, healthcare practitioners (n = 908) acknowledged that mental health concerns are common in people with chronic wounds. More than 60% of the survey respondents indicated that between 25% and 50% of people with chronic wounds have mental disorders, such as anxiety and depression.18 A sense of urgency has emerged to move the practice paradigm toward a holistic approach that places equal emphasis on both physical and mental health concerns. Mental health problems have been shown to affect normal wound healing and self-care abilities contributing to increased morbidity and mortality. Despite the prevalence, Upton et al18 found that more than two-thirds of healthcare professionals believed either few (25%) or none (0%) of their chronic wound patients were receiving attention for their mental health problems. The unmet need for mental healthcare will likely continue to grow as a result of the aging population. Structured training is necessary for nurses to develop therapeutic alliance and counseling for their clients. Although nurses are often focused on completing a task, the new management paradigm should emphasize structured interventions that foster self-care and problem-solving skills among people with chronic wounds.
ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 12
Espousal of Interprofessionalism The optimal care of individuals with chronic wounds is complex and time-consuming and requires the support of an interprofessional team.19 Management of these ulcers involves a detailed examination and discussion with patients to adequately address their concerns. The management of a chronic wound may be further complicated by the fragmentation of communication and services between acute, chronic, and home care. An interprofessional team approach that draws on the required expertise from a number of healthcare professionals, including nursing, medicine, social work, infection control, chiropody, rehabilitation, and nutrition, is required to address the complexity of wound care.20
&
REFERENCES 1. Harding K, Queen D. Wound registriesVa new emerging evidence resource. Int Wound J 2011;268:325. 2. Woo K, Ayello EA, Sibbald RG. The edge effect: current therapeutic options to advance the wound edge. Adv Skin Wound Care 2007;2620:99-117. 3. Woo KY, Sibbald RG. Local wound care for malignant and palliative wounds. Adv Skin Wound Care 2010;2623:417-28. 4. Sibbald RG, Goodman L, Woo KY, et al. Special considerations in wound bed preparation 2011: an update. Adv Skin Wound Care 2011;2624:415-36. 5. Woo KY. Management of non healable or maintenance wounds with topical povidone iodine. Int Wound J 2013; January 4, 2013 [online]. 6. Woo KY, Abbott LK, Librach L. Evidence-based approach to manage persistent wound-related pain. Curr Opin Support Palliat Care 2013;267:86-94. 7. Demarre´ L, Vanderwee K, Defloor T, Verhaeghe S, Schoonhoven L, Beeckman D. Pressure ulcers: knowledge and attitude of nurses and nursing assistants in Belgian nursing homes. J Clin Nurs 2012;2621;1425-34. 8. Ameen J, Coll AM, Peters M. Impact of tele-advice on community nurses’ knowledge of venous leg ulcer care. J Adv Nurs 2005;2650:583-94. 9. Fujiwara Y, Kishida K, Terao M, et al. Beneficial effects of foot care nursing for people with diabetes mellitus: an uncontrolled before and after intervention study. J Adv Nurs 2011;2667:1952-62. 10. Ostrow B, Woo KY, Sibbald RG. The Guyana Diabetic Foot Project: reducing amputations and improving diabetes care in Guyana, South America. World Council Enterostomal Ther J 2010;263012(4):28. 11. Woo K, Alavi A, Botros M, et al. A transprofessional comprehensive assessment model for persons with lower extremity leg and foot ulcers. Wound Care Canada 2007; 26512(Suppl 1):s34-s47. 12. Clarke-Moloney M, Keane N, Kavanagh E. Changes in leg ulcer management practice following training in an Irish community setting. J Wound Care 2008;2617:116, 118-21. 13. Abbott C, Vileikyte L, Williamson S, Carrington A, Boulton A. Multicenter study of the incidence of and predictive risk factors for diabetic neuropathic foot ulceration. Diabetes Care 1998;2621:1071-5. 14. International Diabetes Federation. Diabetes Atlas. 3rd ed. Brussels, Belgium: International Diabetes Federation; 2006. 15. Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes. N Engl J Med 1994;26331:854-60. 16. Ministry of Health and Long-Term Care. Preventing and Managing Chronic Disease: Ontario’s Framework. http://www.health.gov.on.ca/en/pro/programs/cdpm/pdf/framework_full.pdf. Last accessed August 26, 2013. 17. Moffatt CJ, Franks PJ, Doherty DC, Smithdale R, Steptoe A. Psychological factors in leg ulceration: a case-control study. Br J Dermatol 2009;26161:750-6. 18. Upton D, Solowiej K, Woo KY. A multinational health professional perspective of the prevalence of mood disorders in patients with acute and chronic wounds [published online ahead of print January 4, 2013]. Int Wound J 2013. 19. Sibbald RG, Ayello EA, Alavi A, et al. Screening for the high-risk diabetic foot: a 60-second tool (2012). Adv Skin Wound Care 2012;2625:465-76. 20. Friman A, Klang B, Ebbeskog B. Wound care in primary health care: district nurses’ needs for co-operation and well-functioning organization. J Interprof Care 2010;262412(1):90-9.
542
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
It is estimated that more than 400 million people worldwide have wounds of various etiologies.1 Chronic wounds, however, are often complex and recalcitrant to healing and may persist for months or years because of underlying disease processes or complications. With an aging population and increased prevalence of chronic diseases, the majority of wounds are becoming difficult to heal. This places a significant burden on the healthcare system and individual patients. The exact mechanisms that contribute to poor wound healing remain elusive but likely involve an interplay of systemic and local factors. In an effort to address the growing demand in wound care management that is evidence based and cost-effective, I would like to highlight several gaps in wound care management and their potential solutions. 1. Systematized and holistic approach to wound management. The healing of acute wounds follows a predictive sequence of overlapping phases including inflammatory, proliferative, reepithelialization, and remodeling stages.2 The complexity of healing depends on many intrinsic and extrinsic factors, which regulate the complex biochemical and cellular events that culminate in closure of a wound with fibrotic scar tissue. Unlike acute wounds, chronic wounds, such as pressure ulcers, venous leg ulcers, and diabetic foot ulcers, do not always follow predictable temporal overlapping phases of healing because of the disruption of 1 or more elements of the healing process.3 Treatment of chronic wounds requires a systematized approach under the tenets of ‘‘wound bed preparation,’’ which highlights the key individual components of wound care.4 Within this framework, it is important to treat the cause and address patientcentered concerns prior to local wound care. Best practices to prepare the wound bed for healing include debriding of unhealthy and nonviable tissue, controlling infection and bacterial bioburden, maintaining moisture balance, and addressing the unhealthy wound edges. Although complete healing may seem to be the logical goal for most patients and clinicians, some wounds do not have the potential to heal because of a number of factors, such as inadequate vasculature, coexisting medical conditions, and medications that prohibit the healing process.5 By determining the potential for healing, a proposed framework (Table 1) describes the primary focus of care and categorizes wounds into healable, maintenance, or nonhealable.6 Future study is required to describe the cost-effective and patient-centered approach to manage nonhealable wounds.6
2. Knowledge to improve nursing care in wound management. Nurses are fundamental to quality wound care. Yet, not all settings have provided adequate ongoing advanced education for nurses, as demonstrated by the level of knowledge toward prevention and management of wounds in some regions.7 Several studies from various countries have documented that measures to prevent pressure ulcers are not consistently applied by nurses across different healthcare settings, often because of the lack of time, poor knowledge, or perception of low priority in care. It is undisputable that knowledge and attitude could have a significant impact on the quality of wound-related care. Nurses who possess adequate knowledge and perceive wound care as rewarding are more likely to provide evidence-based care and lifestyle advice to their patients, compared with those who lacked knowledge and positive attitude.8 Patients (n = 88) who attended a diabetic foot care program that was led by nurses with advanced foot care training developed fewer fungal infections (P G .001) and calluses (P G .001) over 2 years.9 None of the patients who had a history of foot ulceration developed recurrence of callus-related foot ulcers. Ostrow et al10 documented a 40% reduction of amputation by providing specialized wound care training to an interprofessional team in Guyana. In a study that was funded by the Ministry of Health in Canada, Woo et al11 demonstrated that wound healing was improved by care provided by a nurse practitioner with advanced wound care training in the community. Clarke-Moloney et al12 provided training to 30 public health nurses in Ireland. The annual wound care audit indicated that the number of venous leg ulcers treated with high compression increased significantly by 16% (P G .0001). The frequency of dressing changes was reduced (P = .002) with an increase in once-weekly dressing changes by 10%, resulting in significant cost savings. 3. Emergence of diabetes and other chronic diseases. Diabetes is one of the most prevalent chronic diseases that has become a worldwide epidemic.13 According to the International Diabetes Federation, the number of people with diabetes internationally will increase from 246 million or 5.9% in 2007 to 380 million or 7.1% by 2025.11 Of persons with diabetes, 2% to 3% will develop a foot ulcer annually; whereas the lifetime risk of developing a foot ulcer is as high as 25% mainly because of neuropathy and potential coexisting vascular disease.14 In following patients with diabetes and neuropathy for 1 year, it was estimated that 7.2% of this population would develop a first-time
Kevin Y. Woo, PhD, RN, FAPWCA, is Assistant Professor, School of Nursing, Queen’s University, Kingston, Ontario, Canada.
ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 12
538
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Table 1.
HEALABLE, MAINTENANCE, AND NONHEALABLE WOUNDS Proposed Criteria with Examples of Key Determinants
Wound Prognosis
Can the Cause Be Treated?
Healable
Yes, the cause has been corrected or compensated with treatment. For example, a patient underwent bypass surgery to improve arterial supply to promote healing of an arterial ulcer
Coexisting medical conditions and drugs that do not prevent healing
& Promote wound healing & For example, venous ulcers: 30% smaller by week 4 to heal by week 12
Maintenance
No, poor treatment adherence or lack appropriate resources. For example, a patient with venous stasis disease who does not wear compression (eg, stockings)
Coexisting medical conditions and drugs that may stall healing, eg, hyperglycemia
& Prevent further skin deterioration or breakdown, trauma, and wound infection & Promote patient adherence & Advocate for patients to acquire appropriate resources & Optimize pain and other symptom(s) management
Coexisting medical conditions that would prevent normal healing, such as advanced terminal diseases, malignant conditions, inadequate perfusion, malnutrition with low albumin (G20 mg/dL) or negative protein balance, significant anemia (hemoglobin G80 g/dL), or high-dose immunosuppressive drugs
& Prevent further skin deterioration or breakdown, trauma, and wound infection & Promote comfort & Optimize pain and other symptoms management
Nonhealable: palliative No, a cause that is not treatable. or malignant For example, there is widespread metastasis, including the skin, advanced stages of cutaneous malignant conditions, and chronic osteomyelitis
Goal/Objective
Figure 1. MULTI-LEVEL CHRONIC DISEASE SELF-MANAGEMENT MODEL
ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 12
540
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
foot ulcer.13 More than 80% of all nontraumatic amputations in diabetes are preceded by foot ulcers, which should be considered as one of the prognostic indicators for advanced diabetes.15 In most countries, the healthcare system costs of diabetic foot ulcers are exorbitant and include a high likelihood of hospitalizations. A comprehensive framework for diabetic foot care has been described involving multiple-level interventions, health policy revision, and healthcare organization remodeling.16 See Figure 1. 4. Primacy of self-management. Self-management and patient engagement are the cornerstone of chronic disease management. Self-management support is ‘‘the systematic provision of education and supportive interventions, by healthcare staff (and others), to increase patients’ skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support. Traditional education has minimal effect on behavioral changes. A growing body of literature now validates various psychological interventions including the use of social support, problem-solving skills, contract setting, cognitive therapy, and self-monitoring of behaviors, to improve diabetic self-management.16 5. Delivery of psychosocial needs of people living with chronic wounds. People who are living with chronic wounds describe the experience as isolating, debilitating, depressing, and worrisome, which contributes to high levels of stress. People with chronic wounds have been shown to experience more mental health problems than people without wounds in the community and are less capable to marshal their resources and apply problem-focused strategies to cope with stressful events.14 In response to a web-based survey, healthcare practitioners (n = 908) acknowledged that mental health concerns are common in people with chronic wounds. More than 60% of the survey respondents indicated that between 25% and 50% of people with chronic wounds have mental disorders, such as anxiety and depression.18 A sense of urgency has emerged to move the practice paradigm toward a holistic approach that places equal emphasis on both physical and mental health concerns. Mental health problems have been shown to affect normal wound healing and self-care abilities contributing to increased morbidity and mortality. Despite the prevalence, Upton et al18 found that more than two-thirds of healthcare professionals believed either few (25%) or none (0%) of their chronic wound patients were receiving attention for their mental health problems. The unmet need for mental healthcare will likely continue to grow as a result of the aging population. Structured training is necessary for nurses to develop therapeutic alliance and counseling for their clients. Although nurses are often focused on completing a task, the new management paradigm should emphasize structured interventions that foster self-care and problem-solving skills among people with chronic wounds.
ADVANCES IN SKIN & WOUND CARE & VOL. 26 NO. 12
Espousal of Interprofessionalism The optimal care of individuals with chronic wounds is complex and time-consuming and requires the support of an interprofessional team.19 Management of these ulcers involves a detailed examination and discussion with patients to adequately address their concerns. The management of a chronic wound may be further complicated by the fragmentation of communication and services between acute, chronic, and home care. An interprofessional team approach that draws on the required expertise from a number of healthcare professionals, including nursing, medicine, social work, infection control, chiropody, rehabilitation, and nutrition, is required to address the complexity of wound care.20
&
REFERENCES 1. Harding K, Queen D. Wound registriesVa new emerging evidence resource. Int Wound J 2011;268:325. 2. Woo K, Ayello EA, Sibbald RG. The edge effect: current therapeutic options to advance the wound edge. Adv Skin Wound Care 2007;2620:99-117. 3. Woo KY, Sibbald RG. Local wound care for malignant and palliative wounds. Adv Skin Wound Care 2010;2623:417-28. 4. Sibbald RG, Goodman L, Woo KY, et al. Special considerations in wound bed preparation 2011: an update. Adv Skin Wound Care 2011;2624:415-36. 5. Woo KY. Management of non healable or maintenance wounds with topical povidone iodine. Int Wound J 2013; January 4, 2013 [online]. 6. Woo KY, Abbott LK, Librach L. Evidence-based approach to manage persistent wound-related pain. Curr Opin Support Palliat Care 2013;267:86-94. 7. Demarre´ L, Vanderwee K, Defloor T, Verhaeghe S, Schoonhoven L, Beeckman D. Pressure ulcers: knowledge and attitude of nurses and nursing assistants in Belgian nursing homes. J Clin Nurs 2012;2621;1425-34. 8. Ameen J, Coll AM, Peters M. Impact of tele-advice on community nurses’ knowledge of venous leg ulcer care. J Adv Nurs 2005;2650:583-94. 9. Fujiwara Y, Kishida K, Terao M, et al. Beneficial effects of foot care nursing for people with diabetes mellitus: an uncontrolled before and after intervention study. J Adv Nurs 2011;2667:1952-62. 10. Ostrow B, Woo KY, Sibbald RG. The Guyana Diabetic Foot Project: reducing amputations and improving diabetes care in Guyana, South America. World Council Enterostomal Ther J 2010;263012(4):28. 11. Woo K, Alavi A, Botros M, et al. A transprofessional comprehensive assessment model for persons with lower extremity leg and foot ulcers. Wound Care Canada 2007; 26512(Suppl 1):s34-s47. 12. Clarke-Moloney M, Keane N, Kavanagh E. Changes in leg ulcer management practice following training in an Irish community setting. J Wound Care 2008;2617:116, 118-21. 13. Abbott C, Vileikyte L, Williamson S, Carrington A, Boulton A. Multicenter study of the incidence of and predictive risk factors for diabetic neuropathic foot ulceration. Diabetes Care 1998;2621:1071-5. 14. International Diabetes Federation. Diabetes Atlas. 3rd ed. Brussels, Belgium: International Diabetes Federation; 2006. 15. Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes. N Engl J Med 1994;26331:854-60. 16. Ministry of Health and Long-Term Care. Preventing and Managing Chronic Disease: Ontario’s Framework. http://www.health.gov.on.ca/en/pro/programs/cdpm/pdf/framework_full.pdf. Last accessed August 26, 2013. 17. Moffatt CJ, Franks PJ, Doherty DC, Smithdale R, Steptoe A. Psychological factors in leg ulceration: a case-control study. Br J Dermatol 2009;26161:750-6. 18. Upton D, Solowiej K, Woo KY. A multinational health professional perspective of the prevalence of mood disorders in patients with acute and chronic wounds [published online ahead of print January 4, 2013]. Int Wound J 2013. 19. Sibbald RG, Ayello EA, Alavi A, et al. Screening for the high-risk diabetic foot: a 60-second tool (2012). Adv Skin Wound Care 2012;2625:465-76. 20. Friman A, Klang B, Ebbeskog B. Wound care in primary health care: district nurses’ needs for co-operation and well-functioning organization. J Interprof Care 2010;262412(1):90-9.
542
WWW.WOUNDCAREJOURNAL.COM
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
