Reduction in wound healing times, cost of consumables and number of visits treated through the implementation of an electronic wound care system in rural Australia

Abstract

Globally, wound care costs the health care system 2–3% of the total expenditure on health, which equates to several billion dollars annually. To date, there are little data on the cost and healing rates of various wounds. This has been partly because of the difficulty in tracking wound management as the majority of wound care data has been focused on retrospective data from hospitals, general practice clinics and aged care facilities. This study reports on wound healing and cost of wounds collected from a larger project using the mobile wound care (MWC) electronic documentation system, which has been described elsewhere. The study involved 2350 clients from four health service districts in the Gippsland region in rural Australia who received treatments as part of the MWC research project (2010–2012), with a total of 3726 wounds identified (so an average of 1·6 wounds per client). By the end of the data collection period, 81% of these wounds had healed. A significant drop in healing time, cost of consumables and number of visits was found across the 3‐year period.

Background

Wound care costs the Australian Health system around $2·6 billion a year and affects almost 2% of the Australian population 1, 2. In the UK, the NHS costs of caring for patients with a chronic wound are conservatively estimated at £2·3–£3·1 billion per year (at 2005–2006 costs), which are around 3% of the total estimated out‐turn expenditure on health (£89·4 billion) for the same period 3, 4, 5. In the USA, a study reported a conservative estimate of more than $50 billion per year and that the prevalence of chronic non‐healing wounds is 2% of the general population 6, 7. These data indicate that wound healing is an ongoing major burden on the total health care system worldwide 8, 9, 10, 11.

To date, there are little data on the treatment costs and the healing rates of various wounds 11, 12, 13, 14. This has been partly because of the difficulty in tracking wound management as the majority of wound care data have been focused on retrospective data from hospitals, general practice clinics, community care services and residential aged care facilities. Most studies reporting on treatment costs and healing of wounds focus on either the effectiveness of a particular wound dressing or an intervention programme, often targeting a limited subset of the whole population and excluding palliative care patients or patients with anticipated amputations 15, 16, 17.

To obtain a more accurate idea of wound care costs and how treatment affects the overall expenditure, emphasis is currently placed on the speed at which healing occurs 17. By shortening the time taken to achieve complete healing, it is possible to terminate the need for ongoing interventions and reduce the expenditure 18, 19.

This study reports on wound prevalence, healing time, cost of care consumables and number of visits by district nurses providing treatment for wounds across four health service districts in the Gippsland Region, Victoria, Australia. The data were extracted from a larger project using the mobile wound care (MWC) electronic documentation system, which has been described elsewhere 20, 21.

Method

The current project was instigated by the Regional Clinical Nurse Consultant, Latrobe Community Health Service, in Gippsland and was funded by the Victorian Department of Health (DH) Strengthening Wound Management Practice initiative which was implemented across regional Victoria. The aim of the Wound management practice initiative was to target the management and treatment of chronic conditions and included the provision of extensive wound care training for district nursing staff in the region. The full methodology was published elsewhere 21. Briefly, de‐identified data were analysed using the MWC database between 12 April 2010 and 13 May 2012. Data were collected and recorded by district nurses from seven data collection sites across Gippsland in three main categories: patient, wound and treatment variables.

Comorbidities and factors affecting healing were collected separately. Nurses were able to enter the relevant comorbidities and factors affecting healing associated with the patients' medical history according to the list in the MWC database.

Statistical analysis

Data on the MWC healing time and costs were positively skewed – that is, numerous observations were many times larger than the average healing time and costs. These outliers were clinically significant but presented problems in terms of analysis. It was, therefore, inappropriate to analyse such skewed data using traditional methods (standard deviations and confidence intervals), which assume that the data were normally distributed. Bootstrapping is a technique that enables statistical analysis of our highly skewed data by producing a more appropriate (robust) measure of the confidence interval 22.

Bootstrapping for this data was calculated in two simple steps. Firstly, 1000 random samples were taken from within the data set and the average healing time for each of these samples was calculated. Secondly, using these 1000 samples, the 95% confidence interval was calculated with the upper and the lower limits of the confidence interval corresponding to the 2·5th and 97·5th percentile of the ordered 1000 sample results. Bootstrapped confidence intervals (BCa 95% CI) provide more stable (robust) results than alternative methods, and enable statistical comparisons between different subgroups (e.g. wound types, demographics, agencies) to be readily made. All the wound care data collected for analysis are shown in Figure 1.

Figure 1.

Data collected from the MWC database.

Results

There were 3726 wounds documented from 2350 clients, resulting in an average of 1·6 wounds per client. The majority of the wounds (56%) were acute wounds and were described as surgical, crush and trauma. Another 12·9% were associated with leg ulcers (venous, arterial, mixed and neuropathic), 9·4% were pressure ulcers (stage 1–4 according to guidelines at the time) and 7·5% were skin tears (categories 1–3). Other types of wounds caused by malignancy, fistula, skin disease, drain tube and irradiation totalled to 14%, as shown in Table 1.

Table 1.

Prevalence of wound aetiologies

Aetiology	No. of wounds	%
Acute – surgical/crush/trauma	2089	56·1
All leg ulcers	482	12·9
Arterial leg ulcer	43	1·2
Mixed leg ulcer	50	1·3
Neuropathic/diabetic	98	2·6
Undefined leg ulcer	176	4·7
Venous leg ulcer	115	3·1
All pressure ulcers	349	9·4
Pressure ulcer – stage 1	81	2·2
Pressure ulcer – stage 2	153	4·1
Pressure ulcer – stage 3	84	2·3
Pressure ulcer – stage 4	31	.8
All skin tears	281	7·5
Skin tear category 1a	86	2·3
Skin tear category 1b	52	1·4
Skin tear category 2a	43	1·2
Skin tear category 2b	43	1·2
Skin tear category 3	57	1·5
Other	190	5·1
Chronic – other than leg ulcers or p/u	131	3·5
Malignancy	75	2·0
Fistula/abscess/pilonidal sinus	73	2·0
Skin disease	27	.7
Drain tube	16	.4
Irradiation	13	.3
Total	3726	100·0

Of the total 3726 wounds, 3009 healed during the course of the project, which shows a healing rate of 81%. This analysis showed a consistent drop in the healing time of all wounds across the 3 years of the project, dropping from 75·5 days in year 1 to 58·3 days in year 2, and finally to 43·3 days in year 3 as shown in Table 2. The average healing times per aetiology is shown in Table 3. The highest healing times were reported for arterial leg ulcers with an average of 143 days and the lowest healing times were obtained from category 1a skin tears of 29 days. This improvement was also seen within individual aetiologies such as acute/surgical/trauma, all leg ulcers, all pressure ulcers, stage 2 pressure ulcers, skin tears and some chronic wounds as shown in Table 3.

Table 2.

Healing time by aetiology

Aetiology	n	Healing time		BCa 95% CI
		Mean	Standard deviation	Lower	Upper
Arterial leg ulcer	29	142·8	113·8	106·2	184·9
Chronic – other than leg ulcers or p/u	87	128·2	140·3	101·5	161·1
Malignancy	65	125·1	139·2	94·0	157·9
Mixed leg ulcer	37	107·9	94·8	81·9	138·4
Venous leg ulcer	94	106·5	104·4	87·3	125·7
Neuropathic/diabetic	77	100·8	86·7	83·7	120·8
Pressure ulcer – stage 4*	18	99·6	72·9	68·2	133·7
Pressure ulcer – stage 3	63	96·0	96·3	74·7	119·5
Pressure ulcer – stage 2	127	84·2	95·9	67·5	102·8
Undefined leg ulcer	133	78·4	81·7	65·9	92·4
Skin disease	20	74·4	86·9	46·5	106·5
Other	149	62·0	81·0	51·7	72·6
Pressure ulcer – stage 1	72	62·0	66·7	48·5	77·2
Fistula/abscess/pilonidal sinus	61	55·1	73·5	39·4	73·7
Acute – surgical/crush/trauma	1732	47·9	59·8	45·3	51·1
Skin tear category 2a	38	44·3	69·4	27·2	65·0
Skin tear category 2b	30	42·5	38·1	30·4	56·4
Skin tear category 3	45	41·7	39·0	32·2	53·8
Irradiation*	10	35·5	30·5	17·4	55·0
Drain tube*	14	34·1	39·9	18·4	60·0
Skin tear category 1b	41	31·2	29·9	23·1	40·7
Skin tear category 1a	67	29·2	26·2	23·3	35·5
Total healed wounds	3009	61·4	77·7	58·7	64·0

CI, confidence interval.

^*Indicates sample size is less than 20.

Table 3.

Progress over the study in healing time within aetiologies

	Acute/surgical/trauma			All leg ulcers			All pressure ulcers			Pressure ulcer stage 2			All skin tears			Chronic other than leg ulcers or pilonidal sinus
	n	Heal time (days)	Significant (2 tailed)	n	Heal time (days)	Significant (2 tailed)	n	Heal time (days)	Significant (2 tailed)	n	Heal time (days)	Significant (2 tailed)	n	Heal time (days)	Significant (2 tailed)	n	Heal time (days)	Significant (2 tailed)
All years	1732	47·9		370	98·2		280	82·1		127	84·2		221	36·5		87	128·2
Year 1	591	56·1	.000	171	108·2	.003	110	96·8	.013	48	121·7	.001	88	45·4	.025	41	160·5	.035
Year 2	686	47·2		126	104·2		113	81·9		58	69·7		93	28·8		29	124·4
Year 3	455	38·5		73	64·5		57	54·4		21	38·5		40	34·9		17	56·9

There were 57 cases where the cost of treatment consumables was not recorded, leaving out the data on 2952 of the 3009 wounds. These costs relate to any product, solution, instrument, tape or dressing used for wound healing. Costs ranged from $0 (i.e. no cost treatments, as it was provided by other systems) to $5318 (Table 4). Only 87 wounds (3%) were externally funded or self‐funded and the remaining wounds were funded by the organisations. Analysis of the cost of treatment consumables also showed an overall reduction, starting at $149 in year 1, rising slightly to $159 in year 2, before dropping sharply to $99 in the final year as shown in Table 5.

Table 4.

Cost of wounds progress through study period

Progress through project	n	Cost of treatment		BCa 95% CI		df	Significant
		Mean ($)	Standard deviation	Lower	Upper
Year 1	1129	148·79	297·05	132·73	167·98	2	.000
Year 2	1136	158·70	270·24	143·43	174·30
Year 3	687	98·91	157·87	87·52	111·15
Total healed wounds	2952	140·99	261·09	130·31	151·80

Table 5.

Cost of consumables by year of project

Grouped aetiology	Acute – surgical/crush/trauma	All leg ulcers	All pressure ulcers	All skin ulcers	Chronic – other than leg ulcers or p/u	Drain tube	Fistula/abscess/pilonidal sinus	Irradiation	Malignancy	Other	Skin disease
n	1697	361	277	218	82	14	61	10	65	148	19
Mean ($)	130·67	185·88	162·68	45·96	260·96	27·29	241·86	87·24	186·71	141·82	92·32
Non‐adherent dressings	159·55	270·00	204·27	66·88	524·63		106·44	118·49	327·70	186·76	102·61
Odour absorbent	842·41	556·01	964·50						305·20
Miscellaneous	410·38	466·79	320·85	74·66	533·17		824·95		251·92	509·80	53·61
Bandages	166·43	255·30	213·56	48·93	438·25		182·08		347·56	243·84	122·39
Cleanser	147·89	209·53	206·70	51·22	312·24	39·12	266·23	96·77	218·77	176·44	84·93
Creams	338·57	441·62	321·53	475·12	485·28		904·37		464·68	415·20	248·95
No cost dressings	170·82	223·96	199·22	73·71	333·58	18·83	278·03	97·74	223·95	206·68	101·65
Instruments	139·04	195·23	183·30	50·65	282·13	38·00	258·06	87·24	201·29	168·08	99·50
Tapes	199·88	228·31	208·00	78·20	412·66		360·68	95·81	350·13	236·62	133·14
TNPT	1763·59	238·70								177·36
Alginate/hydrofibres	232·44	410·07	485·02	72·63	740·81		386·47	146·67	417·80	350·43
Antimicrobial	263·62	296·96	324·98	104·39	518·98	86·63	505·72	238·99	407·54	276·98	151·30
Dry dressings	161·88	252·08	241·99	68·23	345·64	50·33	280·90	95·87	258·16	220·79	112·26
Films	178·22	243·48	215·85	55·06	460·83	41·05	159·59		202·88	229·13
Foams	173·00	219·97	178·58	53·04	274·70	37·82	148·40	143·60	260·84	208·84	84·94
Hydrocolloids honey	342·02	280·25	313·87	34·01	1092·33		129·92	238·99	530·59	900·77	83·85
Hydrogels	259·07	341·22	269·19	118·87	359·98		673·92	104·65	398·01	267·35	23·20
Hypertonic gauze	332·18	242·61	351·07	44·72	604·99		514·51	238·99	415·33	147·80
Island dressings	159·81	256·00	178·48	55·32	497·29	50·23	353·43	45·51	227·19	237·81	81·25
Wipes	298·40	293·98	273·10	27·66	587·52		481·74	238·99	422·41	290·09	153·46

TNPT, topical negative pressure therapy.

Analysis of the number of visits showed a similar pattern, starting at an average of 13 visits, rising slightly to 13·6 visits in year 2, and then dropping to 10·7 visits in year 3 as shown in Table 6.

Table 6.

Number of visits by aetiology

Aetiology	No. of visits			BCa 95% CI
	n	Mean	Standard deviation	Lower	Upper
Pressure ulcer – stage 4	18	27·5	34·6	14·6	27·1
Arterial leg ulcer	29	21·7	22·7	13·5	29·4
Malignancy	65	20·5	27·3	13·3	42·0
Fistula/abscess/pilonidal sinus	61	20·5	35·9	4·1	6·9
Pressure Ulcer – stage 3	63	18·9	20·4	4·0	5·4
Venous leg ulcer	94	18·2	24·5	10·7	16·4
Chronic – other than leg ulcers or p/u	87	18·1	25·5	14·1	23·1
Irradiation	10	15·0	9·5	7·5	13·5
Neuropathic/diabetic	77	13·7	12·0	6·0	10·6
Undefined leg ulcer	133	13·3	18·1	9·3	18·1
Mixed leg ulcer	37	13·2	13·3	13·6	23·5
Other	149	13·0	16·7	15·5	29·1
Pressure ulcer – stage 2	127	12·8	14·3	11·1	16·7
Acute – surgical/crush/trauma	1732	12·0	13·2	11·4	12·7
Skin disease	20	10·3	6·6	9·1	20·9
Skin tear category 2b	30	8·8	7·8	4·0	7·7
Pressure ulcer – stage 1	72	8·1	9·4	10·7	15·4
Skin tear category 3	45	6·9	6·5	4·7	9·0
Skin tear category 2a	38	6·6	7·4	5·2	9·0
Drain tube*	14	5·6	3·0	10·7	15·6
Skin tear category 1b	41	5·4	5·1	6·3	11·4
Skin tear category 1a	67	4·7	3·0	14·4	23·8
Total healed wounds	3009	12·7	16·1	12·2	13·3

^*Indicates sample size is less than 20.

Discussion

The information collected through the MWC system and outlined here in terms of wound prevalence, healing times and wounds costs for different treatment types provides the evidence base for future practice in the region and beyond.

This study reported on wound healing times and costs of different wound aetiologies collected using an electronic wound system. To our knowledge, this is the first Australian study to report on these outcomes. Prior to MWC, no data existed regionally, statewide or nationally as to the type or even numbers of wounds that were treated as part of the Home and Community Care services. The data from the first year of the MWC research project indicated that just over 80% of all wounds came from just four main aetiologies: skin tears, leg ulcers, pressure ulcers and acute wounds. This allowed the regional training to be specifically tailored to provide education around the management of these specific wound types. This has resulted in an overall decrease in healing times and costs associated with wounds over the 3‐year study period.

The slight increases in costs and number of visits in the second year are likely to be because of MWC‐based improvements in record keeping over time, leading to year 2 being a more accurate measure of costs and visits than the first year. In addition, the increased focus on wound care may have led to initial increases in costs and visits, which levelled off and then started to decline significantly by the final year of the project. A special attention was given to the ongoing training of the wound nurses beyond the life of the project to ensure appropriate wound assessment and management as per the organisations' guidelines. This will potentially ensure the sustainability of the benefits of the MWC project.

The MWC project resulted in considerable upskilling in terms of computer literacy, which varied widely across organisations at the commencement of the project. This was partly because of some organisations making data entry the responsibility of ward clerks or administrative personnel, often because of the limited access to information technology (IT) facilities referred to as a barrier above. In three sites, the MWC research commenced simultaneously or subsequently to the introduction of other data entry programmes used for funding and staff allocation. Ongoing IT support and follow up resulted in keeping all nurses involved in the project. Having nurses enter their own data reduces the likelihood of data error caused as a result of duplicate handling and transcription problems.

Another significant advantage of the early outcomes of access to these data was greater targeting of the wound management training being provided to the region as part of the wider Strengthening Wound Management Practice Regional Victoria initiative.

The limitation of this study includes the lack of involvement of general practice clients in the Gippsland areas as many clients consult their general practitioners for their wounds rather than going to hospitals or community health services. Another limitation was the additional time requirement of data entry demanded of nurses involved in research, the demand of learning to use a new IT tool and the reliance on the nurses to enter the data. Nonetheless, the large number of wounds collected in the database may have overcome this latter limitation.

Conclusion

The findings after 3 years of the MWC research project are clear, with significant decreases in healing time, costs of treatment and number of visits. In addition to the recorded outcomes, there were also major benefits to the participating organisations in terms of skill development and greater collaboration across the region.