Medical Honey for Wound Care

Barbara A. BischoffGrand Canyon University:

NUR-699 Making the Case for Evidence-Based Practice

15 October, 2014

Concept Model

Problem Description

•All wound types have the potential to become chronic•Pain is the greatest impairment with chronic wounds•3-6 million patients incur $5-$10 billion annually in

the United States• This study determined there is sufficient evidence to

propose a practice change to incorporate medical grade honey for improved pain management and wound healing in patients with chronic wounds.

(Rutterman et al, 2013; Werdin et al., 2009; Biglari et al., 2012)

Chronic Wounds

• A wound that fails to proceed through the normal temporal sequence of repair to produce anatomic functional integrity within 3 months.• Social, psychological, physical and economic cost • Consequences:• Severe impairment of quality of life• Restriction of daily activity• Emotional distress• Lengthy treatment• High treatment expense

(Frykberg, 2011; Werdin et al., 2009; Ruttermann et al.,2013)

Chronic diabetic foot ulcers (DFUs)

•Annual incidence – 2%• Lifetime risk – 15-25%•15% of DFUs lead to amputation•85% of lower extremity amputations preceded by DFU•Currently 24 million people in US with Diabetes•8% of Total Population• Foot complications most common reason for

hospitalization(Rogers, 2011)

Diabetes, Wounds and Mortality

• 68% mortality rate in five years after amputation• History of DFU significant predictor of mortality over age 65• 45% mortality rate in five years with a neuropathic ulcer

(Gethin & Cowman, 2009)

Healthcare Burden

• Lower extremity ulcers:• one of the most common complications of diabetes• leading cause for hospitalization of diabetic patients

•Risk factors:• neuropathy• deformity• high plantar pressure• poor glycemic control• long duration of diabetes• peripheral arterial disease• male gender

33% of cost to treat diabetes

complications spent on ulcer treatment

(Kamaratos et al., 2012)

Manuka Honey (Leptospermum scoparium)• Monofloral honey produced from bees feeding on

manuka plant• Endemic in Australia and New Zealand• Exhibits broad spectrum antibiotic activity against:• Staphylococcus aureus• Methicillin-Resistant Staphylococcus aureus (MRSA)• Pseudomonas aeruginosa• Vancomycin-sensitive • Vancomycinresistant enterococci (VRE)

(Kamaratos et al., 2012)

Manuka Honey Impregnated Dressing

•Provides moist environment with antimicrobial properties•Anti-inflammatory effects•Reduces edema and exudates•Promotes angiogenesis and granulation tissue formation• Induces wound contraction • Stimulates collagen synthesis • Facilitates debridement •Accelerates wound epithelialization

(Kamaratos et al., 2012)

Effect of Manuka honey-impregnated dressings (MHID) on

NDFU• Study size 62 type 2 diabetic patients• MHID [Group I ] vs conventional dressings (CD) [Group II]• Weekly follow-up, 16 week duration• Mean healing time 31 ± 4 days (GI) vs 43 ± 3 days (GII) = (P˂0.05)• GI 78.13% became sterile in 1 week vs 35.5% in GII• Weeks 2, 4, 6: 15.62% vs 38.7%, 6.25% vs 12.9% and 0% vs 12.9%• Percent ulcers healed were 97% (GI) vs 90% (GII).

(Kamaratos et al., 2012)

Microbiological Activity

•Dilution of honey produces hydrogen peroxide• Enzymatic activity of oxidases•H2O2 stimulates macrophage chemotaxis• Induces Vascular Endothelial Growth Factor (VEGF) •Promotes angiogenesis• Stimulates fibroblast proliferation• Possesses antioxidant action, protecting the local

wound milieu from oxidative stress.(Kamaratos et al., 2012)

Literature Support

• Ten patient study•Mean duration of chronic wound

prior to honey therapy 3.3 years• Seven wounds healed in ˂ 7 months•Perspective of effectiveness• Six month pilot study should provide

substantial clinical evidence of benefits.

Fig 1. Patient 3. Ulcer pathology before honey gel treatment.

Fig 2. Patient 3. Complete healing of the wound after 7 months of honey gel treatment.

(Tellechia, 2013)

Proposed Solution

• Introduce honey dressings into wound care program

• Provide information on medical honey to all stakeholders

• Train staff in accurate wound documentation processes

• Develop a mentor program headed by the wound care specialist

• Establish champion users to promote EBP techniques

• Conduct pilot study with honey dressings for DFU

• Evaluate study through analysis of carefully documented data(Al Saeed, et al., 2013; Bittman, et al., 2010, Kwakman et al., 2011; Dermasciences, n.d.)

Change Model•ARCC designed to:• utilize mentorship • build EBP relationships• sustain EBP

•Quality Management Services committee – evidence analysis•Clinical Resource Management committee – product

availability•Performance Improvement committee – mentor

development plan (Wallen, et al., 2010)

Budget Plan and Feasibility

•Principal Investigator =$3800.00.•Assessment Committee $3600.00.• Staff Education = $2050.00.•Presentation Materials = $200.00.•Print Cost for Handouts = $348.00.•Dressing Product = $28,800.00 • Total Budget: $297,998.00

(Rogers, 2010; Wallen et al., 2010)

Implementation

•Presentation to key stakeholders•Committee meetings•Mentor and staff education•Resource acquisition• Inform patients of evidence for use of alternative

dressing option•Carefully document all wound measurement and

qualitative data

Evaluation•Wound documentation•Patient and nursing satisfaction questionnaires• Software utilization to manage and control data•Data collection and analysis committee

Rate the following statements: Never RarelySome

timesOften Always

Staff were courteous and polite.

Staff understood my problem .

Staff explained care options clearly.

Staff treated me with dignity and respect.

Staff listened to what I had to say.

Staff gave me the opportunity to ask questions about my care.

Staff answered my questions clearly.

Staff involved me in decisions about my care.

Overall, I was happy with the outcome of the wound care.

(Adapted from Oxleas, n.d.)

Conclusion•Decreased pain• Increased wound healing•Better quality of life•Future patient populations will benefit from

medical honey treatment• Pediatrics• Acute wounds• Catheter prophylaxis

References

• Al Saeed, M. (2013). Therapeutic efficacy of conventional treatment combined with manuka honey in the treatment of patients with diabetic foot ulcers: A randomized controlled study. The Egyptian Journal of Hospital Medicine, 53(10), 1064– 1071.• Biglari, B., Moghadden, A., Santos, K., Blaser, G., Buchler, A., Jansen, G., Langler,

A., Graf, N. Weiler, U., Licht, /v., Strolin, A., Kack, B., Lauf, V., Bode, U., Swing, T., Hanano, R., Swatz, N.T. & Simon, A. (2012). Multicenter prospective observational study on professional wound care using honey (Medihoney). International Wound Care Journal. ISSN 1742-4801, 252-259.• Dermasciences Inc. (n.d.). MEDIHONEY Wound and Burn Dressing with Active

Leptospermum Honey. Princeton, NJ.

References (Cont)• Frykberg, R.G. (2011). The science of advanced wound care: What should you be

using in your office? Podiatry Today Supplement: Emerging evidence on advanced wound care for diabetic foot ulcerations. HMP Communications, LLC (HMP), 1-3, 8-15.• Gethin G, Cowman S (2009) Manuka honey vs. hydrogel – a prospective, open

label, multicentre, randomised controlled trial to compare desloughing efficacy and healing outcomes in venous ulcers. Journal of Clinical Nursing; Vol 18(3):466-474• Kamaratos, A. V., Tzirogiannis, K. N., Iraklianou, S. A., Panoutsopoulos, G. I.,

Kanellos, I. E. & Melidonis, A. I. (2012). Manuka honey-impregnated dressings in the treatment of neuropathic diabetic foot ulcers. International Wound Journal, 1-7. doi: 10.1111/j.1742-481X.2012.01082.x

References (Cont)• Kwakman, P.H.S, teVelde, A.A., deBoer, L., Vandenbroucke-Grauls, C.M.J.E. & Zaat,

S.A.J. (2011). Two major medicinal honeys have different mechanisms of bactericidal activity. PLoS One, 6(3) PMC3048876• Oxleas. (n.d.). Integrated complex wound care team patient satisfaction survey.

National Health Service. Retrieved from http://www.oxleas.nhs.uk/your-views/patient-experience-programme/who-are-our-patient-experience/adult-community-services/integrated-complex-wound-ca-1/ )• Rogers. (2011). Key concepts from the 2010 consensus statement on diabetic foot

ulcerations. Podiatry Today Supplement: Emerging evidence on advanced wound care for diabetic foot• Ruttermann M., Maier-Hasselmann, A., Nink-Grebe, B. & Burckhardt, M. (2013).

Clinical practice guideline: Local treatment of chronic wounds in patients with peripheral vascular disease, chronic venous insufficiency, and diabetes. Dtsch Arztebl Int; 110(3): 25–31. DOI: 10.3238/arztebl.2013.0025

References (Cont)

• Tellechea, O. (2013). Efficacy of honey gel in the treatment of chronic lower leg ulcers: A prospective study European Wound Management Association Journal 13(2), 35-39.• Wallen, G. R., Mitchell, S. A., Melnyk, B., Fineout-Overholt, E., Miller-Davis, C.,

Yates, J. & Hastings, C. (2010). Implementing evidence-based practice: effectiveness of a structured multifaceted mentorship program. Journal of Advanced Nursing 66(12), 2761–2771. doi: 10.1111/j.1365-2648.2010.05442.x• Werdin, F., Tennenhaus, M., Schaller, H.E. & Rennekampff, H.O. (2009).

Evidence-based Management Strategies for Treatment of Chronic Wounds. Open Access Journal of Plastic Surgery, 9(19), 169-179.