Site Assessments: Early Steps on the Journey Toward Outcomes

Abstract: Two volunteers who have continually dedicated time and effort to the Association for the Advancement of Wound Care (AAWC) and the Global Alliance and World Alliance for Wound and Lymphedema Care (WAWLC) describe perceptions of their life-changing overseas volunteer experiences. Learning and teaching became a two-way enrichment process, as volunteers and local healthcare leaders shared knowledge and practice pearls during lectures and hands-on workshops for managing wounds and lymphedema.

Address correspondence to: Terry Treadwell, MD, FACS Medical Director, Institute for Advanced Wound Care Baptist Medical Center South 2167 Normandie Dr. Montgomery, AL 36111 Phone: 334-286-3444 Email: tatread@aol.com

     While chronic wounds have become the new global epidemic in under-resourced countries, care for patients suffering with these wounds is lagging behind the current “state of the art.” What is the best way to approach providing evidence-based care for patients with chronic wounds in countries with limited resources? At first glance, one might suggest we could just charge into a country, tell them that they are doing everything wrong, tell them how we do it, and that this is the only way to get good results when treating wounds. Then, smugly return home patting ourselves on the back convinced that we have done a world-class job helping them solve their problems. Later we discover that they are still doing exactly what they were doing prior to our visit. Oh, well…what could we expect from such a backward country? If that is your attitude about helping underserved countries, you are destined for failure before you step on the airplane.      Under-resourced countries have challenges that we in the United States and other developed countries do not have to consider. Ms. Jan Rice, the wound education coordinator from La Trobe University in Australia, recently reported that the regional referral hospital in Honiara, Solomon Islands did not even have soap for the nurses to wash their hands (Rice J, personal communication, November 2009). We found that having clean water to wash hands and wounds can very well be a luxury. There are reports from Sudan that the bandages of those who have died are washed and reused.¹ There are problems with the lack of trained personnel to care for patients with wounds. Many local physicians view chronic wounds with disinterest and frustration and, when required, treat wounds with outdated and ineffective therapies or just pass the patients on to anyone who will manage the problem.² Obviously, there must be a change of attitude in addition to education.      What is the best way to interest people in caring for wound patients? How does one effectively provide the necessary information about the importance of wound care? One of the most important concepts is that the existing public health structure in the developing country must be used to spread new information. Everyone, including healthcare workers, public health officials, leaders of the country, and community leaders must understand how good wound care can improve the lives of the people and be aware of the fact that it will be economically advantageous to treat these people and return them to the workplace or at least to a productive, self-reliant life. The new information must be compatible with the social structure into which it is being sent. Educators must take into consideration the local politics of the people currently providing the care, evaluate carefully the ideas that may conflict with the current practices and values, consider the resources needed to implement the new ideas especially in resource-poor areas, and consider the educational and skill level of the people providing the care in all locations.³ Without a thorough knowledge of the impact the introduction of a new program will have on the local people and the healthcare providers, the program will be destined for failure.⁴      It is important to remove any perception of risk on the part of the person adopting the new information. This can be done by showing five positive characteristics of the new program, as described by Rogers.⁵ 1) The relative advantages of the new program for the current practitioner must be made known. 2) The compatibility of the new program with the current practices and beliefs must be stressed. 3) The simplicity of the new program must be apparent. 4) The persons adopting the new program must be able to try all or part of the program before committing to it completely. 5) The lack of hidden agendas and program difficulties must be apparent to the persons considering the program. Addressing these issues will increase the likelihood that the local citizens will embrace the program and its innovations, whether they are in the city or in the country. After presenting the educational information, we must be able to bring together teams of people to discuss the new programs and share ideas as to the best method of implementation in each area. Optimal results will result when we are able to recruit local leaders and healthcare workers to assist in formulating those plans and spreading the ideas and practices among both colleagues and patients.^4,6

Ghana Site Visits

     Several concepts guided our work in Ghana—identify the local needs, provide the evidence-based education appropriate for the situation, and follow-up to determine effectiveness of the program and provide further education. Our first trip in 2008 was a fact-finding and educational trip. Dr. Mary Jo Geyer, Dr. John Macdonald, and Dr. Terry Treadwell visited two large teaching hospitals—one in Accra, Ghana the other in Kumasi, Ghana—to observe how the referral hospitals were treating patients with wounds and lymphedema. The group also visited three smaller hospitals in Agroyesum, Agogo, and Amasaman, Ghana. The visits allowed us to discern what types of treatments were available to patients with wounds and lymphedema.      We returned home to develop a site-specific educational plan using the information we obtained, which would allow us to provide information that would be most useful to the sites we visited; it is fruitless to spend time talking about treatments and methods that will never be available to them.      In February 2009, Janice Young, RN, and Dr. Treadwell’s wife, Sheryl, accompanied the group in the return trip to Ghana to present the educational seminars based on what we had learned. We presented a 3-day seminar at each of the major teaching hospitals, one in Accra and one in Kumasi. The audience comprised nearly 40 physicians, nurses, and physical therapists, each of whom was invited to be a potential wound treatment leader in his or her area of expertise. Many in the audience had traveled 8 to 10 hours on very hostile roads to attend. This mixture of specialties allowed us to stress the importance of a multi-specialty “team” approach to wound and lymphedema care. The information we provided about the treatment of wound and lymphedema care involved what we considered to be the basic principles necessary to provide evidence-based care. These five principles are: 1) Comprehensive evaluation of the patient. 2) Debridement of the wound and infection control. 3) Moisture control of the wound. 4) Avoidance of physical and chemical trauma to the wound. 5) Control of the periwound edema and lymphedema. Understanding these five basic principles will allow anyone to begin to provide evidence-based wound and lymphedema care to patients regardless of the wound etiology. We were aware of the importance of teaching this approach utilizing locally available treatments and bandages. Visiting hospital supply rooms and local pharmacies provided us with the insight to make informed recommendations. This approach even provided us with the opportunity to teach how to use what supplies were available in order to meet the recommendations for modern wound care. It is critical to remember that programs and recommended care will not be sustainable if treatments and bandages are only accessible while we are there.      Since people learn in different ways, we believed it was important to provide hands-on learning (Figure 1) in addition to lectures (Figure 2). Allowing the practitioners the opportunity to learn the correct method of bandage application has proved to be invaluable. Dr. Paa Ekow Hoyte-Williams went to Tamale, the capital city of the Northern Region of Ghana (one of the three most under privileged regions in Ghana), to work soon after attending the conference. He encountered two patients that benefited from compression therapy by using short-stretch bandages we taught him how to make. He said that the treatment of these patients was, “...an opportunity to introduce limb bandaging in wound care to the local nursing staff. The good part of this was I met a colleague [Dr. Majeed] who also participated in the wound workshop and was keen on putting into practice what we learned. There was also a male nurse who showed keen interest in the procedure so we taught him how to go about it and he will be doing the subsequent bandaging in my absence” (Hoyte-Williams PE, personal communication, April 2009). The photos of him training his fellow practitioners on how to make and apply the short-stretch compression bandages followed by passing the information to others was most gratifying (Figures 3–5). This is how a sustainable, productive healthcare program is developed—teach one, and in turn, he will go on to teach others.

Uganda Site Visit

     In late June 2009, as part of the Global Initiative for Wound and Lymphedema Care (GIWLC), Dr. David Keast, Dr. Anna Towers, and Mrs. Patricia Coutts, a nurse and the President-Elect of the Canadian Association of Wound Care (CAWC), conducted a site visit to Uganda. The purpose was to evaluate the state of wound and lymphedema care to determine the possibility of developing education programs under the direction of Health Volunteers Overseas (HVO). The visit was sponsored by the Association for the Advancement of Wound Care Global Alliance. Reports were produced for both HVO and the World Alliance for Wound and Lymphedema Care (WAWLC), the successor to the GIWLC. The team visited the Mulago Hospital Complex Departments of Plastic and General Surgery in Kampala. The Mulago Hospital Complex is associated with Makerere University (Figure 6). At Mbarara University Hospital in Mbarara in western Uganda the team visited the Departments of Plastic and General Surgery as well as the Department of Dermatology. At each site the team met with doctors, nurses, and allied health personnel to observe ward rounds with the Uganda teams. The team provided education to the Department of Surgery in Mbarara at their regular Grand Rounds (Figure 7). The team also had an opportunity to meet with the Deputy Commissioner of Health Services for Mulago Hospital, the Principal of the Mulago School of Nursing and Midwifery, the Makerere University Medical School, Department of Pediatrics and Child Health, and the Director for Clinical and Health Services in the Ministry of Health. The team visited Kawempe Health Center in Kampala (Figure 8), a Level 4 Health Center. This center sees 600 to 800 patients per day. Two doctors staff the center, one of whom primarily provides dental care. Nurses and nurse’s aids provide the majority of care. The team conducted a total of 16 key informant interviews.      The population of Uganda at 33 million is roughly the same as Canada, and yet demographic data are radically different. In Uganda, 45% of the population is younger than 15 years old, there is an average of seven children per female, and 80% of the population lives in rural areas. The average life expectancy at birth is 50 years for both sexes. The maternal mortality ratio in 2005 was 550/100,000 live births, and infant mortality rate among both sexes was 78/1000 live births. Deaths due to HIV/AIDS in 2005 were 316/100,000.⁷ Contrarily, in Canada in 2005 the average life expectancy for males was 78 years and 82.7 for females, while the infant mortality rate for both sexes was 5.4/1000 live births.⁸      Public healthcare in Uganda is delivered through a system of Health Centers with increasing capabilities from Level 1 to Level 4. Only Level 4 Health Centers are staffed by a physician. The majority of care is provided by nurses, nurses’ aides, or clinical officers (nurses with additional training who are essentially primary care providers in a physician’s role). There are a series of District Hospitals serving small areas and approximately 100 health regions—some of which have a regional hospital. There is only one public tertiary care national referral hospital for medical conditions, the Mulago Hospital Complex. Mulago Hospital officially has 1500 beds, but Miriam Walusimbi, the Deputy Commissioner of Health Services for Mulago Hospital, estimated the actual occupancy to be 4500 patients. There is a system of faith-based hospitals in Uganda run by the various religious denominations as part of missionary outreach. We were unable to visit any of these facilities, but were told that they were often better resourced than the public system. Additionally, there is a facility called the International Hospital that is operated by the International Medical Group. We did not visit this facility but were informed that Ugandans of higher socioeconomic status, as well as visitors to Uganda, went to this facility. Again, this facility was reputed to be better resourced. More information can be obtained from the hospital’s website (www.img.co.ug). Few trained pharmacists are available to dispense medications. Allied healthcare professionals such as physiotherapists are available at the regional hospital level and higher, but not many.      In Uganda, given the relatively short life expectancy compared to developed nations, the most significant health problems affect the young. The burden of chronic diseases as seen in older, more developed populations such as heart disease, chronic obstructive lung disease, cancer, and diabetes is relatively low. For example, there are no prevalence data for diabetes available through WHO for Uganda, and the various persons we interviewed were aware of diabetes, but did not believe that it was a common problem. While cancer was acknowledged as a problem, we left with the impression that there are very few treatment programs other than the programs for breast and prostate cancer, and that even these programs focus primarily on surgical interventions. At the two centers we visited lymphedema was not recognized as a common problem, and filariasis-related lymphedema was seen as a problem affecting only the northern region of the country. The prevailing opinion of the clinicians interviewed was that lymphedema, because it was not painful, was under recognized. Lymphedema is usually well advanced before it is seen in the primary care centers, and by that point, the fatalistic view that nothing can be done is common among healthcare providers. Buruli ulcer and leprosy, while acknowledged to be present in the country, were not treated at either the National Referral Hospital or the Regional Hospital in Mbarara. The burden of chronic wounds related more to the following etiologies:      a. Burns both heat related and acid burns      b. Trauma specifically from motor vehicle accidents or from agriculture related problems      c. Postoperative (eg, dehisced C-section incisions)      d. Infection-related problems      e. HIV-related problems, such as Kaposi’s sarcoma      f. Skin malignancies.      The only dressings available are gauze based, which were produced and sterilized on site. The use of advanced dressings common in the developed world is unknown. Silver sulfadiazine is commonly used as a topical antibiotic and penicillin is given orally. Methicillin-resistant Staphylococcus aureus (MRSA) is not viewed as a problem. Compression therapy is rarely used and is considered too expensive.      There is a genuine need for education and training in wound and lymphedema care. Both perceived and unperceived needs exist at the national level. At the two hospitals the team visited, there is a perceived need to improve care for burns, trauma, and postoperative wounds. While it is recognized that other types of wounds exist (eg, diabetic foot ulcers, venous leg ulcers, Buruli ulcers, skin breakdown due to leprosy), these wound types are not seen routinely at this level. However, the Commissioner of Clinical and Health Services in the Ministry of Health does recognize the need for wound and lymphedema care in regional areas.      After visiting a number of facilities and interviewing clinicians in Uganda, the Canadian team recommended the creation of an initiative under the auspices of the WAWLC. The initiative would be based around an interprofessional “train the trainer” approach, starting at the national level and working down through the structure of the healthcare system to primary care delivery. To ensure its effectiveness and sustainability, the initiative needs to be seen as a partnership between both the Ministry of Education and Sport and the Ministry of Health, as both ministries have responsibilities in the training of clinicians. Wound- and lymphedema-care education should coincide.      The team identified the following factors that might facilitate such a program (ie, the “bridges” to promote the “Wound and Lymphedema Best Practice Pathway” [Figure 9]):      • Dedicated and well educated healthcare personnel      • Recognition at all levels of the need for improved care      • Desire at both sites to become centers of excellence      • Desire at all levels to increase capacity at the community level.      The following potential barriers were also identified and should be addressed to facilitate best practice and improve patient outcomes:      • Poor infrastructure      • Lack of human resources      • Modern wound care materials too expensive and not available      • Being able to free up clinicians from day to day work for education      • Remuneration issues      • Political issues      • Interdisciplinary care issues.

Conclusion

     The provision of evidence-based wound and lymphedema care around the world is just beginning, but fortunately it has taken a giant step forward. Provision of good care can be done with affordable medications and local treatments any healthcare provider can perform. The pathway to best practice must take into account local resources and preferences. It must identify barriers and bridges to best practice and help local clinicians to develop strategies consistent with their skills and resources (Figure 6). A giant step in that direction has recently been taken with the formation of the World Alliance of Wound and Lymphedema Care (WAWLC). This is a multi-national committee of wound care and other interested organizations working with the World Health Organization to provide modern wound and lymphedema care to the underserved areas of the world. The treatment of the new global epidemic—wounds and lymphedema—has now begun in earnest.