How MSF is Optimizing Pediatric Wound Care
How might we create a low cost, securing system that enables complicated pediatric wound dressings to remain in place? In the MSF context, we are faced with many different types of wounds - some of the most challenging being those of the pediatric cases we see. The wounds are often large and in awkward places and dressing are often not suitable. When the dressings slide off this causes an increased risk of infection in addition to the increased risk of pain for the child who is being treated.
This was the challenge that was posed by clinical field workers, specialist advisors and other key stakeholders when the SIU elicited insights on some of the greatest obstacles faced by the organization in the leadup to our inaugural Pediatric Hackathon. Following an intensive 2 days of ‘hacking’ with a multi-stakeholder group in Stockholm, we came to the conclusion that continuing to investigate innovative approaches to improving wound care and management processes in MSF field operations was imperative. With this realization, we continued to work with hackathon participants, and now Case Manager, CHRISTINA HUITFELDT.
Some Context on the LMIC Need for Optimized Wound Care
The graph below provides just a glimpse of the proportion of global trauma burden borne by low- and middle-income contexts. With all innovation, either process or product, the inception point must be true need - while treatment of resulting wounds and injuries is only one part of the puzzle it is clear that there is a need for effective wound care in the environments in which MSF is most active.
Reinforcing this need a 2015 STUDY FOUND THAT UPWARDS OF 1 MILLION DEATHS AND MORE THAN 52 MILLION DISABILITY ADJUSTED LIFE YEARS (DALYS) COULD HAVE BEEN PREVENTED IN ALL LOW AND MIDDLE INCOME COUNTRIES (LMICS) if a basic menu of surgical services were made universally available. This is a figure beyond true comprehension and naturally challenging to equate with standard interventions such as wound management.
A Real Need.
It’s estimated that upwards of 1 million deaths and more than 52 million Disability Adjusted Life Years (DALYs) could have been prevented in all Low and Middle income countries (LMICs) with a basic menu of surgical services including wound care offerings.
So what are we doing to address this need? Read on for further insight into how this Case has progressed since its hackathon inception:
How did you come to lead the wound case with the SIU?
During the Pediatric Hackathon I was invited to participate as a member in the wound care challenge group and was, later on, offered the role as a case manager for that challenge. My experience spans across innovation research, product and process development, analysis, organizational change, and design. I am grateful for the role and inspired by the SIU innovation process and I very much enjoy being part of the case manager community where we support and inspire each other.
Why is this case important? What challenges is this case tackling?
While exact figures supporting the importance of the case are currently are not easily accessible, past quantitative data and trends from a few of the MSF Operational Centers (OCs), as well as recent qualitative data from discussions and interviews, can be used as an indication and point towards the magnitude of the need: The surgical burn care study by Stewart et al. and among others the MSF Operations Center Brussels (OCB) 2008-2014 found that surgical burn care has increased from 8% of the general surgical operations in 2008 to 24% in 2014. The study also states that given the high volume of burn procedures performed at MSF - OCB projects and the resource-intense nature of burn management, requisite planning, and reliable funding are necessary to ensure the quality of burn care in humanitarian settings.
Burn Rates on the Rise
MSF Operations Center Brussels (OCB) 2008-2014 found that surgical burn care has increased from 8% of the general surgical operations in 2008 to 24% in 2014.
One of the general challenges within wound management can also be seen in the MSF Wound care protocol is the variety and complexity of the wound care situations and to achieve a wound care precision and continuity depending on wound type, severity, size, treatment stage, parts of the body involved, infection status and other parameters. Given the low-resource conditions where MSF operates there can be an increased risk of wound infections making some of the regular protocols and materials used for hospitalized patients living in developed countries not directly applicable. During the challenge investigations prior to the Hackathon, it was revealed that optimizations within pediatric wound care might have the potential to reduce the infection risk especially within burns and similarly complicated wounds. It was assessed that in pediatric wound care in the MSF context burns are treated in as much as about half of the patient cases and these have been identified as being especially challenging.
During the landscape mapping and feature analysis of a potential solution five main feature challenge areas have been identified to address what might need further refinement and exploration (beyond from the original idea of a bodysuit):
The stretchiness of the bodysuit/fabric used yet still covering the wound in a way not provided with a Net bandage (eg. TUBIFAST 2-WAY STRETCH BANDAGE) and applied in a way that does not lead to disturbances or additional pain when pulled over/applied or removed.
Design of the suit/3rd layer in a way so it still will be more cost-effective than relevant solutions on the market that are very costly such as garments.
Finding applications /solutions for fixating and/or tightening the third layer with minimum disturbances and pain other than with metal pins or knots (e.g. velcro or other applications that are safe, do not harm the skin and are not affected by dirt/humidity or can not be opened easily by a curious or mobile patient. Velcro as the main fixation principle in a potential bodysuit/one-piece protection layer needs to be further explored validated and approved or replaced by other solutions that are reliable yet still are not likely to harm the skin. We get indications from experienced field staff that Velcro is not easily kept clean, can lose its capacity and can also be played with by the child leading to unintended openings.
Finding a solution for the genital/perianal area when involved while keeping cost-effectiveness (eg. a diaper-like solution or even better sealing off the wound area from urine/faecal contamination with some kind of barrier such as CAVILON to mitigate the risk of contamination. (ex: CONVATEC PRODUCTS, the antimicrobial MEPILEX, TEGADERM combined with stool bags and alike)
Balancing water and dirt repellence with the breathability of the securing stretchable material (eg. would it be feasible to make off the shelf materials such as TUBIFAST more water and dirt repellent with coatings).
Briefly walk us through the case progression and key points in the timeline so far and what is expected?
The team is iteratively moving along the ideation and development phase according to the SIU innovation process. Qualitative data and landscape assessments have given us more directional information to validate the initial ideas from the Hackathon and to define feature challenge areas to explore.
The first phase of this project will end in January 2020. The objective at this stage was to generate dialogue, increased knowledge, inspiration and insights related to the wound care challenge. Any concept ideas considered worth exploring further in Phase 2 would be a step closer to solving the challenge but it could also potentially spark further elaborations based on having made the challenges, potential solutions and feature alternatives more visible and tangible. If we manage to raise awareness and discussion within MSF on the topic and this leads to any kind of concrete action to seek improvements this could be considered a great move forward.
In a wider sense the overarching aim was to support the treatment of children so they can experience less pain, better healing and quality of life as a direct or indirect result of this case effort. Likewise, if the project contributed to helping field workers to succeed with complicated wound care situations and lessen their burden such as fewer dressing changes for other than strictly medical reasons.
What are the greatest learnings you gained through the case development so far that may support future humanitarian innovations inside MSF and beyond? What worked and what didn't?
Striving for simplicity without being simplistic can be a challenge. Finding a few key features that can have the potential to carry the rest of the solution might help to combine a future oriented innovation outlook with a pragmatic approach. Sometimes the solution has to be divided into short-term development and long-term development.
What is next for this case?
Refinement of the concept visualizations as well as concept discussions with both MSF internal stakeholders and external contributors to the project are some of the next few steps to highlight now that potential solutions are made more tangible. This might lead to further iterations before finalizing documentation, reporting and presentation of insights and final outcome. During the course of the project we have established relations with the Karolinska Institute and an R&D group at Mölnlycke that will potentially serve as a partnering platform for later phases of the project and other SIU projects. We are also about to investigate opportunities to pretest draft mockups of the intervention here in Sweden and how to elaborate further versions for field tests.
READ MORE ON THE WOUND CARE CASE PAGE HERE
GET IN TOUCH WITH CASE MANAGER CHRISTINA HERE
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Stewart et al., 2017, Burn care Res. Author manuscript; available in PMC 2017 November 01, page 1-2
Wound care protocol - Operations Center Brussel, 2018, p 74
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