Paper cut?

A call for a moratorium on first aid regulations for businesses is unlikely to be matched by a stay on clinical guidance, as a wide array of new wound care technologies emerge

Mention of the general election may not be something you expect to see in an article on wound care and minor injuries. However, St John Ambulance has created the opportunity by issuing a ‘first aid manifesto’.

The first aid charity has been urging the political parties to include first aid in their election plans, placing a particular focus on schools. It has set out a five-point plan to increase the number of first aiders, especially young people, and calls for more people to be trained in paediatric first aid.

Of perhaps most interest to independent pharmacies, though, is the manifesto pledge it wants politicians to adopt: “Fix health and safety regulations for five years (unless new evidence emerges), to help smaller organisations stay on top of them.”

To support this aim, St John Ambulance believes that health and safety regulations should be left as they are, unless there is new evidence which indicates a need to change the current policy. “Our research shows that smaller and medium-sized enterprises (SMEs) back health and safety regulations and feel that the balance is just right. However, there is a cost to SMEs in learning new regulations wherever they change,” it says. “Therefore, we are calling for a moratorium on new regulations or  for the life of this Parliament, or unless dramatic new evidence emerges. This period of policy stability would best support SMEs.”

Keeping NICE and busy

While business health and safety regulation changes could tentatively be facing a hiatus, research around developments in therapeutic approaches to wound care and first aid means organisations like NICE will be kept busy. Earlier this year it issued a Key Therapeutic Topic (KTT 14) document on wound care products.

St John Ambulance believes that health and safety regulations should be left as they are

Although there is some evidence that modern or advanced dressings (for example, hydrocolloids, alginates and hydrofibre dressings) are more clinically effective than conventional dressings (such as paraffin gauze) for treating wounds, there is insufficient evidence to distinguish between them,” it says. “There is at present no robust clinical or cost- effectiveness evidence to support the use of antimicrobial dressings (for example, silver, iodine or honey) over non-medicated dressings for preventing or treating chronic wounds.”

Its advice, then, is about preventing problems: “Indiscriminate use should be discouraged because of concerns over bacterial resistance and toxicity. Antimicrobial dressings may be considered to help reduce bacterial numbers in wounds, but should be avoided unless the wound is infected or there is a clinical risk of the wound becoming infected.”

Taking honey as an example, Cochrane recently updated its evidence on its role as a topical treatment for acute and chronic wounds. While over 630 research papers have been published on honey and wounds, according to PubMed, the Cochrane authors were only able to include 26 studies.

Assessing the data involves trying to compare a wide range of patient populations and comparators, making it difficult to draw overall conclusions, they say. The authors also had to downgrade a lot of the data over concerns about bias and imprecision. As a consequence, “any evidence for differences in the effects of honey and other treatment types is of low or very low quality and does not form a robust basis for decision making.”

Show me the honey

However, Cochrane has been able to make some positive endorsements, saying there is “high quality evidence that honey heals partial thickness burns around four to five days more quickly than conventional dressings” – this includes polyurethane film, paraffin gauze, soframycin- impregnated gauze, sterile linen and leaving the burns exposed. And also that there is “moderate quality evidence that honey is more effective than antiseptic followed by gauze for healing wounds infected after surgical operations.”

From a patient perspective, the interest in honey appeals to those who like to use natural remedies, as pharmacist and wellness practitioner Neeta Devalia recognises (www.wellnesswithneeta.com). “As a pharmacist, I am often asked for dressings to treat minor injuries such as burns, cuts and wounds,” she says.

“It is preferable to see the injury but this is not always the case. When treating wounds, the choice of dressing will depend on the type of wound and the stage of healing – in my experience it is mainly the  nurses who decide which dressings to use. “However, I am aware that honey is known for its anti-bacterial properties and can facilitate the body’s natural healing process. I often tell people about the benefits of Manuka honey. I also inform them that sterile honey dressings and honey wound gels are available and treatment should be discussed with their nurse or GP.”

NICE and not saying no

More examples of recent wound care updates come from NICE. Among its output is ‘medical technology guidance’ (MTG). This addresses specific technologies notified to NICE by sponsors. The ‘case for adoption’ is based on the claimed advantages of introducing the specific technology compared with current management of the condition. This case is reviewed against the evidence submitted and expert advice.

MTG21 looked at the ReCell Spray-On Skin System in terms of treating skin loss, scarring and depigmentation after burn injury. The ReCell system uses a small piece of the patient’s skin to create a solution containing a suspension of skin cell components which is then sprayed on to the site of the burn. The cells in the suspension then multiply quickly and embed themselves in the base of the wound. The regenerative nature of these skin cells is intended to encourage the growth of healthy skin so that the burn wound can heal rapidly.

NICE has recommended further research, but points out that its recommendation “is not intended to preclude the use of the technology in the NHS but to identify further evidence which, after evaluation, could support a recommendation for wider adoption.”

Similarly, in MTG20, looking at Parafricta Bootees and Undergarments to reduce skin breakdown in people with or at risk of pressure ulcers, NICE again says that further research is recommended, but the product could be used within the NHS. The Parafricta products are made from a fabric designed to reduce the shear stress and friction between the fabric and skin. As less force is exerted on the skin by the fabric, this reduces the risk of the skin being damaged, which in turn reduces the risk of pressure ulcers.

Potential benefits

As around 12,000 people each year have burns wounds requiring hospital admission, which sometimes involve long hospital stays, and 200,000 patients in the UK have a chronic wound, there are a large number of people who may benefit from innovative devices to manage these conditions, says Professor Carole Longson, director of the NICE centre for health technology evaluation

“It’s essential to note that these recommendations for further research don’t mean that these promising technologies should not be used, as it’s important that more data can be generated to help inform further considerations on their clinical utility. NICE will update both pieces of guidance if and when substantive new evidence becomes available.”

Pressure ulcers have been the subject of international guidelines updated last year and now being promoted, as a result of a collaborative effort among the National Pressure Ulcer Advisory Panel (NPUAP), European Pressure Ulcer Advisory Panel (EPUAP) and Pan Pacific Pressure Injury Alliance (PPPIA).

They include 575 explicit recommendations and research summaries, with the updating needed to add sections on a range of emerging fields of interest. These include the prevention and treatment of biofilms, prophylactic dressings, microclimate control, medical device-related pressure ulcers, prevention and management of heel pressure ulcers, and low friction fabrics.

It certainly looks like NICE has plenty of work ahead on the wound care front.

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