Wound Management

1. Wound Management Definition – Cut or break in the continuity of the skin Prevalence – 1.5% of the population (Gottrup 2004) Expenditure – 4% of total healthcare expenditure in UK Community nursing time – 67% in Ireland (HSE Guidelines 2009) 1. A wound is a break in the continuity of the skin. 2. It is estimated that 1.5-2% of the pop have a wound at any one time. This figure will increase in the context of increasing life expectancy and increase incidence of diabetes. 3. 4% of UK healthcare expenditure is spent on wound care 4. It is estimated that 67% of community nursing time involves the management of wounds. My experience as a Community Nurse would reflect this. Wound management involves interdisciplinary collaborative shared care between clinicians in primary care and the hospital.1. A wound is a break in the continuity of the skin. 2. It is estimated that 1.5-2% of the pop have a wound at any one time. This figure will increase in the context of increasing life expectancy and increase incidence of diabetes. 3. 4% of UK healthcare expenditure is spent on wound care 4. It is estimated that 67% of community nursing time involves the management of wounds. My experience as a Community Nurse would reflect this. Wound management involves interdisciplinary collaborative shared care between clinicians in primary care and the hospital.

2. Wound Assessment Guidelines – EUAP; Clearinghouse; HSE 2009 Assessment tools – Wound bed preparation; TIME; Colour classification; Applied wound management Continuum of healing – Pathology of the wound V Physiology of wound healing 1. Clinical guidelines for best practice in wound care give high priority to the accurate assessment of wounds. This assessment informs wound management decisions such as dressing choice or referral to a specialist. 2. Clinicians use assessment tools to assist them in describing the status of wounds 3. The focus of the visual assessment of the wound is to identify where the wound is on the continuum of healing. 1. Clinical guidelines for best practice in wound care give high priority to the accurate assessment of wounds. This assessment informs wound management decisions such as dressing choice or referral to a specialist. 2. Clinicians use assessment tools to assist them in describing the status of wounds 3. The focus of the visual assessment of the wound is to identify where the wound is on the continuum of healing.

3. Wound Terminology Pathology of wounds – Slough; necrosis Physiology of wound healing – Granulation; epithelialisation Controlled vocabulary – SNOMED CT; ICD-10; MeSh Wound assessment archetype - OpenEHR Wound ontology - NHS in Scotland The pathology of wounds uses clinical terms such as slough and necrosis The physiology of wound healing uses clinical terms such as granulation and epithelialisation. 2. The ability of this pathophysiological data to retain its integrity depends on the standards used to express these clinical terms and concepts. 3. A controlled vocabulary such as SNOMED CT facilitates standards and integration of computerised clinical information. 4. OpenEHR have developed a draft wound assessment archetype. 5. The NHS in Scotland has published a wound ontology. The pathology of wounds uses clinical terms such as slough and necrosis The physiology of wound healing uses clinical terms such as granulation and epithelialisation. 2. The ability of this pathophysiological data to retain its integrity depends on the standards used to express these clinical terms and concepts. 3. A controlled vocabulary such as SNOMED CT facilitates standards and integration of computerised clinical information. 4. OpenEHR have developed a draft wound assessment archetype. 5. The NHS in Scotland has published a wound ontology.

4. Wound Image Ontology Ontology – Machine readable terminology with reasoning capability Semantic interoperability (is_a) – Connected health between primary and secondary care Clinical decision support (if_then) – Support the primary care clinician Machine readable terminology, along with reasoning capability, is required for – Semantic interoperability - to communicate between primary care and the hospital CDS - to direct the primary care clinicians in the management of wounds. Wound image ontology is currently under construction (OWL Protégé). Imaging algorithms relating to wounds are soon to be published (Sven Van Poucke). Machine readable terminology, along with reasoning capability, is required for – Semantic interoperability - to communicate between primary care and the hospital CDS - to direct the primary care clinicians in the management of wounds. Wound image ontology is currently under construction (OWL Protégé). Imaging algorithms relating to wounds are soon to be published (Sven Van Poucke).

5. Wound Image Pre-processing For Evaluation Wound image – Artefact representation Colour calibration - Standardization Planimetry measurement - Surface area Region of interest (ROI) - the wound within the image 1. The wound image is an artefact representation of the wound To be useful to clinicians for evaluation, wound images require pre-processing 2. Colour calibration standardises images with different camera settings and differences in illumination 3. Planimetric measurement records the surface area of the wound 4. The region of interest (the wound within the image) needs to be identified 1. The wound image is an artefact representation of the wound To be useful to clinicians for evaluation, wound images require pre-processing 2. Colour calibration standardises images with different camera settings and differences in illumination 3. Planimetric measurement records the surface area of the wound 4. The region of interest (the wound within the image) needs to be identified

6. Gap In Literature There is no published study linking the description of the calibrated wound image with the clinical terminology used to describe wounds Planimetric studies using wound images have been published. There is no published study linking the description of the calibrated wound image with the clinical terminology used to describe wounds (Sven Van Poucke) Planimetric studies using wound images have been published. There is no published study linking the description of the calibrated wound image with the clinical terminology used to describe wounds (Sven Van Poucke)

7. Research Proposal Research Question – What is the correlation between wound terminology and wound image terminology? Research Objective – To link the terminology of the wound with the description of the wound image Research question Research objectiveResearch question Research objective

8. Methodology Patient selection Wound images pre-processing Clinician selection Procedure Data analysis With regard to methodology I will now discuss - Patient selection Image pre-processing Clinician selection Procedure Data analysisWith regard to methodology I will now discuss - Patient selection Image pre-processing Clinician selection Procedure Data analysis

9. Patient Selection Ethical approval AMNCH (Declaration of Helsinki 1975) Patient selection Written informed consent (n = 10) Patient confidentiality anonimised images I plan to conduct the study at AMNCH outpatient department’s wound clinic. I have received the support of Prof Sean Tierney Vascular Consultant. This is dependant on obtaining ethical approval at AMNCH, as well as approval from TCD ethical committee. Patient selection Patients with leg wounds will be selected and informed written consent obtained. Patient confidentiality will be preserved by anonimising the images with an identifier. There will be no recording of patient details other than the image I plan to conduct the study at AMNCH outpatient department’s wound clinic. I have received the support of Prof Sean Tierney Vascular Consultant. This is dependant on obtaining ethical approval at AMNCH, as well as approval from TCD ethical committee. Patient selection Patients with leg wounds will be selected and informed written consent obtained. Patient confidentiality will be preserved by anonimising the images with an identifier. There will be no recording of patient details other than the image

10. Wound Images Image recording >3 megapixel digital camera and Mac-Beth colour chart (n = 10) Image calibration Woundontology Consortium image server platform on www.colibrate.com Image Regions of interest Identified Image rotation 0*; 90*; 180* and 270* in random order (n = 40) Image recording Image calibration Image region of interest Image rotationImage recording Image calibration Image region of interest Image rotation

11. Clinician Selection Clinical wound analysis Domain Expert (n = 1) Wound image analysis Student (RCSI Students) (n = 4) Experienced (Community Nurses) (n = 4) Expert (Tissue viability Nurses) (n = 4) Professor Sean Tierney, Consultant Vascular Surgeon at AMNCH, will describe the wound at the time of imaging. Clinicians with varying levels of expertise will be recruited to evaluate the wound images – Student Nurses will be recruited from the Tissue Viability Course at RCSI Experienced Clinicians will be Community Registered Nurses (like myself) Expert Clinicians will be Tissue Viability Nurses Professor Sean Tierney, Consultant Vascular Surgeon at AMNCH, will describe the wound at the time of imaging. Clinicians with varying levels of expertise will be recruited to evaluate the wound images – Student Nurses will be recruited from the Tissue Viability Course at RCSI Experienced Clinicians will be Community Registered Nurses (like myself) Expert Clinicians will be Tissue Viability Nurses

12. Procedure Professor Tierney will evaluate the wounds at the time of imaging. Clinicians with varying levels of expertise will tag and describe what they see in the wound images It will be possible to assess intra rater reliability as well as inter rater reliabilityProfessor Tierney will evaluate the wounds at the time of imaging. Clinicians with varying levels of expertise will tag and describe what they see in the wound images It will be possible to assess intra rater reliability as well as inter rater reliability

13. Data Analysis 1 Data sets Wound data sets (n = 10) Wound image data sets (n </= 480) Quantitative statistical analysis Cohen’s Kappa statistic (J. Cohen 1960) Bland and Altman statistical method (Bland and Altman 1986) Qualitative analysis NUD*IST software (Begley 2004) A large volume of data sets will be generated in this study - a. 10 patients x 4 images x 12 Clinicians = 480 wound image data sets b. 10 patients x 1 Domain Expert = 10 wound data sets Statistical analysis will depend on the method employed to record the data - a. If Clinicians are asked to record numerical values for pathological and physiological descriptions, then quantitative statistical analysis will be employed. The kappa statistic and the Bland and Altman statistical technique will be used. Note that there is no absolute value to compare with. Consequently the correlation coefficient will not apply. b. If Clinicians are asked to comment without being given direction, then qualitative analysis will be used.A large volume of data sets will be generated in this study - a. 10 patients x 4 images x 12 Clinicians = 480 wound image data sets b. 10 patients x 1 Domain Expert = 10 wound data sets Statistical analysis will depend on the method employed to record the data - a. If Clinicians are asked to record numerical values for pathological and physiological descriptions, then quantitative statistical analysis will be employed. The kappa statistic and the Bland and Altman statistical technique will be used. Note that there is no absolute value to compare with. Consequently the correlation coefficient will not apply. b. If Clinicians are asked to comment without being given direction, then qualitative analysis will be used.

14. Data Analysis 2 Intra rater correlation – Describing different rotations of the same wound image Inter rater correlation – Describing the same wound image Inter rater correlation – Describing the wound compared to describing the wound image Intra rater correlation – within (rotations) Inter rater correlation – between (images) Inter rater correlation – between (images v wounds)Intra rater correlation – within (rotations) Inter rater correlation – between (images) Inter rater correlation – between (images v wounds)

15. Relevance Of This Research Wound documentation - Objective recording Wound management research - Enhanced medical knowledge Wound management CDS - Clinician support Wound management semantic interoperability - Connected health Wound management audit - Clinical outcomes and costs Wound documentation: accurate objective recording time stamped Wound research: If the language of wound image description is standardised wound management research is improved Wound CDS :Clinician support in clinical decision support can be developed Wound semantic interoperability : the shared care between primary and acute centres could result in remote image reporting Wound audit : the practical management of clinical outcomes for specific treatments like negative pressure dressings as well as the cost of service provision can be audited Wound documentation: accurate objective recording time stamped Wound research: If the language of wound image description is standardised wound management research is improved Wound CDS :Clinician support in clinical decision support can be developed Wound semantic interoperability : the shared care between primary and acute centres could result in remote image reporting Wound audit : the practical management of clinical outcomes for specific treatments like negative pressure dressings as well as the cost of service provision can be audited

16. My hope is that my research will be one piece that will help to complete the pictureMy hope is that my research will be one piece that will help to complete the picture