CCE-CBD-223

EXAMINER ONLY INFORMATION

QUESTIONS

Q1. What is your assessment of this wound, and what are the risk factors for delayed healing?

• Prompt: Describe the wound characteristics that concern you.
• Prompt: What patient factors contribute to delayed healing?

Q2. What are your immediate steps in wound management?

• Prompt: What are the key steps in wound cleaning and dressing?
• Prompt: When would you consider antibiotics?

Q3. How would you educate the patient on wound care and prevention?

• Prompt: What key advice should be given?
• Prompt: How would you address smoking cessation and diabetes control?

Q4. What are the indications for referral to a specialist?

• Prompt: When would you refer to a vascular surgeon or wound clinic?
• Prompt: How would you coordinate ongoing care?

Q5. What preventive strategies can reduce the risk of chronic wounds?

• Prompt: What long-term measures should be considered?
• Prompt: How can primary care play a role in preventing chronic wounds?

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Q1: What is your assessment of this wound, and what are the risk factors for delayed healing?

This wound is a chronic, slow-healing lower leg ulcer with signs of infection, including purulent discharge, erythema, warmth, and mild oedema. The patient has systemic risk factors, such as type 2 diabetes mellitus, peripheral vascular disease (PVD), and smoking, all of which impair wound healing.

Key Features of Wound Assessment

• Wound characteristics: Chronicity (4 weeks), size (4cm x 3cm), presence of slough, and moderate exudate.
• Infection indicators: Purulent discharge, erythema, warmth, and systemic inflammation (CRP 28 mg/L).
• Vascular status: Ankle-Brachial Index (ABI) of 0.75, indicating moderate peripheral arterial disease.
• Diabetes impact: Elevated BGL (12.6 mmol/L), contributing to impaired immune response and poor wound healing.
• Lifestyle factors: Smoking impairs circulation and tissue oxygenation.

Q2: What are your immediate steps in wound management?

Immediate Wound Care Plan

1. Wound Cleaning and Dressing
   • Irrigation with saline or chlorhexidine to remove debris and reduce bacterial load.
   • Debridement (if necessary) to remove necrotic tissue and promote healing.
   • Appropriate dressing:
     • Hydrocolloid or foam dressings for moderate exudate.
     • Silver-impregnated dressings if signs of local infection.
2. Infection Control
   • Empirical oral antibiotics (e.g., flucloxacillin or cephalexin) if cellulitis present.
   • Consider MRSA coverage (e.g., doxycycline or trimethoprim-sulfamethoxazole) if patient has risk factors.
3. Metabolic and Vascular Optimisation
   • Tight glycaemic control with medication review.
   • Encourage smoking cessation to improve circulation.
4. Follow-up Plan
   • Review in 48-72 hours for wound progression.
   • Referral to vascular specialist if arterial supply is inadequate.

Q3: How would you educate the patient on wound care and prevention?

Patient Education on Wound Care

• Daily wound hygiene: Keep wound clean, dry, and change dressings as advised.
• Early signs of infection: Redness, swelling, pus, or increasing pain.
• Importance of follow-up: Regular wound reviews and dressing changes.

Addressing Risk Factors

• Diabetes management: Monitor blood glucose levels and adhere to medication.
• Smoking cessation: Provide brief intervention and referral to cessation programs.
• Foot care: Avoid trauma, wear protective footwear, and moisturise dry skin.

Q4: What are the indications for referral to a specialist?

Referral Criteria

• Wound not improving despite optimal care after 2-4 weeks.
• Signs of critical limb ischaemia (e.g., ABI <0.6, rest pain, non-healing ulcer).
• Deep infection or osteomyelitis suspected (e.g., worsening pain, bony involvement).
• Consider referral to a multidisciplinary wound care team, including vascular surgery, endocrinology, and podiatry.

Q5: What preventive strategies can reduce the risk of chronic wounds?

Long-Term Preventive Strategies

• Diabetes control: Optimise BGL, consider endocrinology review if poor glycaemic control.
• Vascular health: Regular ABI assessments, lifestyle modifications.
• Wound surveillance: Educate patient on early signs of deterioration.
• Footwear and skin care: Recommend well-fitting shoes and daily foot inspections.

---

SUMMARY OF A COMPETENT ANSWER

• Thorough wound assessment, considering infection, vascular status, and systemic risk factors.
• Appropriate wound cleaning and dressing choice, with infection control measures.
• Clear patient education on wound care, diabetes, and smoking cessation.
• Timely referral to specialists, particularly for vascular compromise or non-healing wounds.
• Comprehensive prevention strategy, including long-term metabolic and lifestyle management.

PITFALLS

• Failing to recognise chronicity and infection, leading to delayed intervention.
• Not considering vascular insufficiency, missing a critical component of healing.
• Inadequate debridement or dressing choice, impairing wound healing.
• Prescribing inappropriate antibiotics, particularly failing to cover MRSA in high-risk patients.
• Not addressing systemic risk factors, such as diabetes or smoking.

REFERENCES

• RACGP Guidelines on Wound Care in General Practice
• Diabetes Feet Australia on Diabetic Foot Ulcer Guidelines
• Better Health Channel on Foot Care for People with Diabetes
• Australian Wound Management Association on Best Practice Wound Care

---

MARKING

Each competency area is on the following scale from 0 to 3.

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Engages patient in discussion about wound management.
1.2 Provides clear and structured wound care education.

2. Clinical Information Gathering and Interpretation

2.1 Gathers detailed history of wound onset and risk factors.
2.2 Assesses wound characteristics effectively.

3. Diagnosis, Decision-Making and Reasoning

3.1 Identifies risk of wound infection or delayed healing.
3.2 Determines appropriate dressing and wound management plan.

4. Clinical Management and Therapeutic Reasoning

4.1 Provides wound care in line with best practice guidelines.
4.2 Implements appropriate antibiotic therapy if required.

5. Preventive and Population Health

5.1 Provides education on wound hygiene and infection prevention.

6. Professionalism

6.1 Ensures patient-centred and culturally appropriate communication.

7. General Practice Systems and Regulatory Requirements

7.1 Documents wound care plan and follow-up requirements.

8. Procedural Skills

8.1 Demonstrates correct wound cleaning and dressing application.

9. Managing Uncertainty

9.1 Recognises when referral to a wound specialist is necessary.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies patients at risk of chronic wounds (e.g., diabetes, vascular disease).

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD