Case study demonstrating cost effectiveness.

By Amanda Palmer, Wound Management Consultancy.

As presented at the Diabetic Foot Conference, April 2002

Introduction:

I was called to review a patient on one of the medical wards. A gentleman with Diabetes had been admitted on 18^th January with burnt feet.

Patients Name (pseudonym):

Sam Bloggs.

Age:

65

Past Medical History:

Type 2 Diabetic for 10 years,

Ischaemic Heart Disease,

Coronary Artery Bypass Graft 3 years ago,

Amputated 5th toe, right foot, 3 years ago,

Diabetic peripheral Neuropathy and Ischaemia.

Medication:

Metformin – 1g. tds

Aspirin 150mg – od

Atorvastatin - 20mg od

Frusemide - 40mg od

Insulin 40 units tds,

Allergies:

None known.

Social Situation:

Lives with wife and 4 teenage children.

Lives in own home,

Retired shop keeper,

Independent at home but will not wear anything on his feet in his house.

Non smoker, non-alcohol,

High fat diet. Appears to have poor understanding of a diabetic diet.

Health Assessment :

History:

Walked out onto his deck mid afternoon on 13^th January, was outside for a few minutes. His deck was in full sun and he consequently burnt his feet on the hot wood. Due to the neuropathy, he was unaware that this was occurring.

He developed large blisters that caused de-gloving of the entire sole of each foot. The district nursing service had seen him daily. They dressed his feet with Silver Sulpherdiazine Cream daily since 15^th January to admission.

The morning of 18^th January he woke with fever and chills and loss of appetite, and was admitted with ? Infection.

Current Condition:

On admission:-

Temp 39 degrees C,

Pulse 104,

Resps 16,

BP 118/80,

CG 13 mmol/l,

He felt unwell and appeared unwell.

The nursing staff commenced:-

Glucose, potassium and insulin infusion as per protocol,

Antibiotic Fucloxacillin IV was commenced,

Saline 120ml/hour.

The medical team felt that surgical debridement and grafting would be necessary. They called me to assess his feet and to recommend a dressing regime.

My Assessment:

Both feet had partial thickness burns. He had an intact blister on the underside of each toe. One large blister extended from the heel to the toes on both feet. This blister had burst and was debriding around the area of the metatarsal heads to the foot arch. The exposed area was painful, it was granulating, with a thin scanty layer of slough over the granulating area of the right foot only. It appeared that the SSD cream had been effective. There was no sign of infection, no malodour, moderate exudate, no erythema over the top of the foot.

Following a full assessment I discussed the plan with the surgeons who agreed that dressings would probably be sufficient to heal this wound.

Intervention:

The SSD cream had been effective, but requires daily application and reduces mobility because it is slippery and walking on it would simply squash it all out to the side of the foot. I therefore decided to trial Acticoat.

Acticoat is a Nanocrystalline Silver coated dressing. It looks like a multi layered piece of cloth, it is dry, and allows exudate to pass through to be absorbed by the padding of the secondary layer that is applied – i.e. combine dressing.

I removed the old dressing and soaked his feet in a bowl of warm water. I poured sterile water onto the dressing then laid it over the open granulating area. I loosely secured this with pieces of micropor tape then applied a combine dressing and secured it with a crepe bandage.

Mr Bloggs was kept on bed rest for the next 4 days. The combine pad was changed on the 3rd day as there were signs of strike through, but the Acticoat was not disturbed.

He continued to spike temperatures up to 39 degrees for which paracetamol was effective. The pyrexia were accompanied by increased pulse rate of 100bpm. Temperature averaged 38 degrees over the first 3 days, but settled back to 37 by the 4^th day, pulse 80bpm. GIK infusion kept his CG’s within a range of 4.3 – 11.1 mmol/l.

On day 5 the padding was removed and the acticaot came easily away from 90% of the wound but had adhered to the edges. I placed his feet in a bowl of warm water for 2 mins and the dressing came away easily and with no trauma. Mr Bloggs stated that the wound felt a lot more comfortable. The slough had gone completely, the blisters were re-adhering. The edges of the wound on the left foot and the edges and 80% of the wound bed on the right foot were epithelialising.

The medical team reviewed the wounds with me and were happy for this regime to continue. I discussed the progress with the surgical team who did not feel it necessary to see Mr Bloggs and were also happy for me to continue with the current dressing. The Acticoat was reapplied in the same way as before. He was now able to start mobilising gently with the physiotherapists. The dieticians reviewed and advised Mr. Bloggs on a recommended diabetic diet. He was discharged home the following day with a supply of Acticoat for the district nursing service to continue applying.

I re-reviewed the wound with the district nurses on 13^th February. This was one month after the initial burn. The improvement was significant. The dressing was being left intact for 7 days, with no change of padding in-between required. The left foot had fully epithelialised. The right foot had a 2cm diameter area of slough remaining on what was otherwise an epithelialising wound bed. There was no pain. The areas of blisters that had not broken down at the time of initial review had remained intact and had re-adhered to the sole of the foot.

The dressing on the left foot was discontinued and moisturising with aqueous cream tds was commenced.

Outcomes:

The use of SSD cream at home for 3 days prior to admission clearly assisted in keeping the wound clean and moist. The SSD assisted in wound bed preparation, therefore promoting healing. Changing to Acticoat dressing was more cost effective in terms of product cost and nursing time. It also allowed him to mobilise more easily. Its effect was significant in promoting epithelialisation, and reducing pain.

The ability to leave the product in situ for 5 - 7 days means being able to leave the wound bed undisturbed, leading to more efficient healing.

Table for cost comparison demonstrating cost effectiveness.

SSD Cream daily	Cost over 5 days	Acticoat every 5 days re-pad once in between.	Cost over 5 days
SSD Cream 500g tub x 1 Daily DN visit x 5 Dressing Pack x 5 Melolin x 10 Combine x 10 Sofban x 10 Crepe x 10 TOTAL	$85.00 $225.00 $4.60 $10.80 $5.60 $12.60 $14.00 $357.60	Acticoat 10 x 12.5 cm x 2 DN visit every 3rd day x 2 Dressing pack x 1 Combine x 4 Crepe x 4 TOTAL	$96.26 $90.00 $0.92 $2.24 $5.60 $195.02

(All costs are estimates for purpose of comparison only)