Debridement as a Component of Wound Bed Preparation-Autolytic, Enzymatic, Mechanical and Sharp Debridement
We're going to start with autolytic enzymatic and biosurgery the little surgeons. Dot mentioned the DIMES and the TIME acronym, so Im going to go through these very briefly very quickly. Our goal is a functional wound bed. Not only is it a functional wound bed, it is a sustained functional wound bed. So we start with debridement. That is our D. Infection and inflammatory control that is our I. M is moisture regulation. You dont want the wound too wet or too dry and desiccated. Wound edges Dot has mentioned this several times you want those edges migrating, and I added one other component: S, for the periwound skin. Officially, the periwound is 4cm from the edge of the wound, but often we see damage even further beyond that, and so were going to talk a little bit about that today.
Were going to start with autolytic debridement, which is the natural degradation using the endogenous enzymes from within the body to, and to achieve this we usually use either moisture donating or moisture absorbing dressings, depending on what were trying to do. If you have dry, hard eschar, and debridement is your goal, then cross hatching is going to help to facilitate that process. So when we look at moist wound healing and autolytic debridement, they work synergistically together, to create this autolytic debridement process. So were using our moisture retentive or moisture donating dressings that are going to help retain the endogenous enzymes, and this is where the endogenous enzymes are functional. Remember with our older adults, oftentimes the endogenous enzymes are not working the way they need to. So the eschar and slough are going to be liquefied by this process.
Autolytic debridement is appropriate for all wounds with necrotic tissue, and it is beneficial for wounds covered with eschar if you do your cross hatching with your sharp instrument. Its also known as scoring. There are contraindications to autolytic debridement including gangrenous wounds. We dont want to open wounds when we have no blood flow, cause all we do is create a bigger hole, and we dont have blood flow to close the wound, to facilitate the wound healing process. No blood flow, no wound healing. Very, very simple, from that perspective. And you do need to have a vascular consult.
So autolytic debridement is the safest type of debridement. It does not disrupt the healthy tissue. It can be used in conjunction with other types of debridement. It is painless. It is easy to perform. It is caregiver friendly, but it does have some disadvantages. You do have to have a person with a functional immune system for autolytic debridement to be able to work. If its going over 30 days as you look and you see 3 to 30 days, if the debridement has not taken place within 30 days, then your patient probably doesnt have the enzymes to be as functional as they need to be. There is the potential for bacterial growth, cause we are covering the wound over, and we cant have maceration to the periwound area. And injury to the periwound area its very important that you take care of the periwound area. And this is an important note: please note that autolytic debridement is contraindicated in the presence of an infection, unless this is the caveat unless youre addressing the infection, either systemically or locally.
So when we look at our autolytic debridement decision tree, dressings, drive, dressings, excuse me, drainage, drive, dressing, decisions. Is it minimal, is it moderate, is it copious
drainage? So youre going to think about that. You're think about which dressing youre going to pick, youre going to look at the amount of drainage coming out of that wound. Youre going to look at the periwound condition, cause you want to take care of the periwound area. And think about the frequency of change, because ladies and gentlemen, in general, were messing with our wounds too much. There needs to be a very good reason to change that dressing more than once a day very good reason. I cant think of too many reasons not too many, very few to change a dressing more than once a day. Every time you cool that wound bed down, you take the saline and you clean that wound bed, you chill it down the cells become chilled and they go Brrrrr! Im cold! And Im not going to move until it warms up around this place! And it takes hours for it to thermoregulate again and for the wound bed to warm up. So unless you have a really good reason to do VID or three times a day dressing changes, at the most you should be doing once a day. And please use a skin sealant, especially with our older individuals who already have fragile skin. As you look at this photograph you can see the area where the skin sealant has been applied around the periwound area. And when you put the skin sealant on, it is critical that skin sealant is dry before you put the dressing adhesive on the skin. The skin sealant when its in place and its dry, the dressing adhesive adheres to the sealant and not to this persons skin, and helps prevent maceration and also stripping when you take the dressing off.
So these are our different types of dressings. Were going to go fly through these really, really quickly. These are the dressings that contribute to autolytic debridement. Gauze is at the bottom, because thats where all this dressing mess started gauze. And then we recognized that gauze wasnt working very well. But there are some reasons for gauze. You might use it for scrubbing, for, using for wet to dry as a debridement option, which is really the only reason you should be using gauze unless, unless youre delivering some type of solution into the wound bed, if youre using the gauze as a delivery mechanism. Otherwise, its simply a wet to dry debridement process. Its mechanical debridement.
There are several reasons not to use gauze. Now, show me in the audience: who must use gauze? Cause thats all you have. Anybody in the audience have to use gauze? All right. So we all have some smart dressings. But there are reasons not to use it. They evaporate, the wound bed dries out; there is a higher infection rate with gauze; they have been shown that you have bacteria that get through up to 64 layers of gauze. How many of you are putting on 65 layers? Youre not?! There is, its not selective debridement. It doesnt know viable tissue from nonviable tissue. There is decreased temperature. I told you that the wound needs to warm up. The cells like to move in a nice warm environment. It doesnt, the wound stays chilled whenever you use gauze. It is labour intensive. We have studies that show that it takes more nursing time to use gauze than to use some of the other products that we have available to us. Its also can be painful to the patient, its more expensive over time, and there is aerosolization of bacteria, which means, when you take that gauze off of this wound, bacteria spray into the air, and stays there for up to 30 minutes. You breathe it, the next nurse, physician, therapist that walks in behind you breathes it, and the patients breathe it. So youre going to be very, very careful when this happens.
Transparent films what we call thin films is one of the dressing categories that we use that works beautifully for autolytic debridement. Now, look at this photograph. On the bottom youll see this ooey, gooey stuff. Well, some people think thats what when they see it? Pus, thats right. But its not. Its the autolytic debridement process taking place.
Thats good stuff. But sometimes we have to tell the family and even sometimes clinicians that thats good stuff. And we do need to think about how were going to apply the thin film. Cynthia talked about the hydrocolloids that came along as our second smart dressing that we have, that has the hydrophilic colloid particles that are on this polyurethane foam or film. And it forms a gel, and it is a little bit on the stinky side when you take the hydrocolloid off, but it is impermeable to bacteria. So nothing in, nothing out, which is good and can be bad. If you have an anaerobe growing under there, then it is a bad things.
Hydrogels how many of you are using hydrogels? Show me your hands if you are using hydrogels. Why are you using hydrogels? Why is this important to you? To add moisture to the wound bed. So this is for non to scant draining wounds. It hydrates the wound bed. Sometimes there are things that are added, if you look at this list, youll see alginates, sometimes, for viscosity, collagen, hyaluronic acid, for performance, silver, it comes in sheets, it comes in an amorphous form. If youre going to use a sheet, please, most of them need to be cut to fit inside the wound margin. Anybody ever see a square on the outside of the wound margin when somebody put a hydrogel on and didnt cut it to fit inside the wound margin? Its very important that we fit inside the wound margins.
Next category: calcium alginates. Seaweed. It is seaweed. And it comes in ropes or sheets. You can put it in and conform it into many, many different types of wound conformations. It is not suitable for dry wounds however. Hydrofiber, it will absorb up to 30% more than an alginate, and one of the things about alginates, let me go back for just a moment, thats really wonderful, its biocompatible with the body. If you leave a piece of gauze in there youve got a problem. You leave some alginate in there, its okay. Its biocompatible with the body. If it comes out dry, you put that alginate in there, it comes out dry, that means that you need to back off to a different type of dressing the alginate is no longer appropriate.
Foams wonderful dressings. Wonderful categories. Theres polyurethane open cell configuration, it can be single or multilayer. Theres all types of forms. Sometimes they have, they are adherent where they have the border adhesive around it, and they are indicated from moderate to highly draining wound moderate to highly draining.
Enzymatic debridement, which is wonderful, for instance if in your older adults, autolytic isnt working, you might go to enzymatic immediately. This is the use of some topically applied chemical agent to help break down the necrotic tissue, and the only one we have that is FDA approved at this time, is collagenase. So collagenase, as you look at this photograph, collagenase breaks the strands, the necrotic strands. It is specific for necrotic collagen, and it breaks the collagen strands at the bottom of the wound base. So you put your collagenase on about a nickel thickness, as you see in this photograph, and itll go down the sides of the wound, down to where the collagen fibers are, the strands are anchoring the necrotic tissue into the wound bed; breaks it, and then that, the necrotic tissue will dissolve and go away. The problem is, some of you are into instant gratification. I am. Im into instant gratification. And we dont always see the collagenase is working. It just seem like, oh, its sitting there, its sitting there, its sitting there, and then all of a sudden, youll see what its done, because its been working at the bottom of the wound this whole time. So be patient with collagenase.
Its derived from the bacteria they take the bacteria, Clostridium histolyticum, they change the DNA, and then it is identical to your collagenase, the human collagenase. So its engineered, bioengineered.
Enzymatic debridement requires that you do it daily. This is one of the reasons to do a daily dressing change. If you have very thick eschar, you might want to do a BID, and you do, again, you want to look at the cross hatching, such as this. This might be a good reason to do BID collagenase, cause theres a lot of thick eschar there. Application: you put it on about a nickels thickness, and you can put it on the dressing, you can put it on directly into the wound bed if you like, and this is just showing a photograph of how well collagenase did in this particular wound.
Biosurgery the little surgeons. Look at how cute they are! Isnt that precious? Look at this guy with his little buggy eyes and his little fangy things! I just think theyre so precious. They are wonderful. How many of you are intentionally using, intentional, yes, how many of you are intentionally using the larva to help with how, how many of you, how many of you have used it unintentionally? Yeah? And when you used it, what did your wound bed look like? It was beautiful, wasnt it? Yes, they work wonderfully. They also secrete collagenase thats one of the, one of the secretions thats in their secretions. They, the crawling, they think of the crawling and the fact that they use their little fangies to hook on and then pull themselves along, also help to loosen the necrotic tissue. The three reported actions are debridement of the necrotic tissue, disinfection, and theyre not a picky eater. They like bacteria also. So they kill the bacteria actually in their alimentary canal, and also promote wound healing.
They are good for all types of wound. Doesnt matter what the wound type is. And here they come from California this is what they look like when theyre delivered to you. And theyre used a lot in Europe. And this is another photograph of using, when you look at the top, top left, and then you look at the bottom right, you can see how well the maggots have done.
All right. So thats our first one. Im ready for a second one. Any questions on that? Okay, good.
All right, thank you. So, now were going to get into wound bed preparation, debridement as a component of wound bed preparation, Part 2, and were going to talk about mechanical and sharp debridement. When we look at mechanical debridement, this is the application of some outside force to dislodge necrotic tissue. So we might use wound scrubbing. How many of you have taken your gauze and kind of scrubbed around in your wound? You know, whats go, whats going on in here? Let me scrub around in here and see whats going on. Almost all of us have used the gauze at some time. If youre going to use gauze, you can scrub them, the center of the wound, out. Why do I want to go from the center out? Right, I dont want to bring anything into the wound bed. And be careful with your periwound area, your wound margins, excuse me, your wound margins, when you scrub in to out. Scrub two to three minutes; be careful that you dont scrub granulation tissue.
Wet to dry dressings is appropriate for debridement. However, look at this photograph. Is wet to dry appropriate for this particular wound? Absolutely not. We are tearing out the granulation tissue. It is non selective. It cannot tell the difference between viable and nonviable tissue. It can be traumatic to the patient and to the wound. Its painful if the
person is sensate. However, you have a wound completely covered with necrotic tissue. Is it okay for you to do wet to dry? Sure it is. Your job is to call the physician. I have a physician in Dallas. Loves wet to dry. Dr S. Im going to call him Dr S. So Dr S. loves wet to dry. Good. Many times its appropriate. Its my job to, cause I have to ass it and do them wet to dry, whos doing the wet to dry? The nurses and the therapists, thats right.
So I call Dr S., say Dr S, wet to dry did great. You know, stroke him, you know, little ego thing going here. Did great, got a lot of that necrotic tissue out. How about if we change to, cause I think its time change I think I see a tendon, and were getting some granulation tissue so how about if I change to and I let Dr S. know what my equipment is, my supplies, my skill set. I dont get emotional; its all objective. Because if I say to Dr S, Ive said, I see a tendon, I see some granulation tissue what do you want me to do? I just told him that it was working really great. So whats Dr S. going to do, say? Keep doing wet to dry. So I have to let him know, or her know, why I want to change it, and Ive never had a physician say no when Ive approached it in this manner.
Stop when you see granulation tissue in the wound bed you dont want to damage it - when the patient is experiencing pain and when theres a potential to damage structures such as tendons.
Hydrotherapy. How many of you have ever done whirlpools? This is where the profession of physical therapy in general started wound care in the hydro room. The nastiest of the nastiest wounds came down to my hydro room. Now, sometimes the nurses wanted me to bathe their patients, and I did have to draw the line. My hubbard is not your bathtub. But we still remained friends, I have to tell you that. So when we think about whirlpool, it is going away. There are people around the country that have taken whirlpools out of their departments cause they cant get people to stop referring for it. Okay, we take it out. Cant refer any more. There are some things that it does. It increases circulation, which could be good, could be bad. However, it can cause skin maceration of course, increases edema, disrupts new cells. I dont know how many pounds per square inch, PSIs, coming out of that jet. I dont know how many PSI is coming out of there.
Contraindications: venous insufficiency is now a documented contraindication for whirlpool. So if youre still giving orders for this, and if you want to put that venous insufficiency leg ulcer in there for a five minutes in tepid water, because its truly truly nasty, thats fine, but its just like Cynthia said all youre doing is giving it a little bit of a bath without anything going on. Youre just rinsing it off. Doesnt help very much. Compromised cardiovascular pulmonary function should not be in a whirlpool, especially a full body whirlpool. Renal function, dry gangrene, has no business in a whirlpool. Acute phlebitis, ischemic wounds or neuropathic foot ulcers, patients with impaired cognitive function, or lethargy and unresponsiveness, and it is not effective for adherent necrosis or eschar or fibrinous tissue.
Wound irrigation how many of our nurses have ever done wound irrigation? Quite a few of you have. Wonderful. Its been around for a long time and its actually from the nursing profession that we learned to do this better. So these are some prefabricated wound irrigation systems, you want to do your wound irrigation and the other things Im going to show you in just a few minutes you want to have some pressure. The pressure is important. Anywhere from eight to fifteen pounds per square inch of pressure.
Now pulse lavage with suction is one of those places that changed my career in wound care. Got out of the whirlpool, hydro room, and now I can take the pulse lavage with suction unit to my patient. How many of you are still doing pulse lavage with suction? Anyone? Its still a very effective modality.
This is a colleague of mine, Dr Harriet Loane, who is the queen of pulse lavage with suction, using it on a pain patient, excuse me, a burn patient. However, with burns, you do have to be careful of pain and you may have to do some type of topical and/or oral analgesic when you do it. Low frequency ultrasound Ive used ultrasound my entire career for well over 30 years. High frequency ultrasound is what I would use for strains and sprains. Most of you will know ultrasound related to imaging of some type. Low frequency ultrasound is fairly new, that takes the ultrasound sound wave, slows it down, and we have a whole new area of wound care using this energy. We have non contact low frequency ultrasound which youre seeing here, where were putting out the sound energy through a solution, and are actually changing some things thats happening in the wound bed. And then there is contact low frequency ultrasound so theres non contact and contact low frequency ultrasound, which is appropriate and wonderful for some of the things we want to do in wound care. And we think that the, the theory is that were having microcavitations that also destroy the bacteria. We actually blow up the bacteria walls, and so you decrease your bioburden when you use this particular energy.
Now, we do have physicians in the room, and Im talking to you also, but I want to talk about instrument debridement for non physicians. Sharp debridement, as opposed to surgical debridement only physicians can do surgical debridement which implies viable and nonviable tissue. Sharp debridement can be done by physicians, podiatrists, which is a physician also, physical therapists, physical therapists assistants; in some states, nurses, nurse practitioners, physician assistants, occupational therapists. So I just mentioned surgical versus sharp. Surgical is viable and/or nonviable tissue; sharp is selective and implicit for nonviable tissue only. The advantages of surgical debridement, however, is sometimes you need to get all of that stuff out as fast as possible because youre afraid your patient is going systemic. Or it already becoming, all right, or it already is a systemic infection. Then get your physician involved. And get that stuff out of there, that dead tissue out, as fast as you can.
Maintenance debridement you go ongoing sharp debridement, ongoing enzymatic debridement, ongoing autolytic debridement. You keep debriding this wound until you have a sustainable functional wound bed. Very, very important that you keep doing this.
Where do you find your legal standards? State practice act. Ladies and gentlemen, even though you work for the VA, you still have a state practice act, right? You have to get your contact hours, your state practice act is not a suggestion, it is the law. What does your state practice act say about sharp debridement? Are your rules in your state in my state of Texas, sharp debridement is mentioned in my state practice act as something that I am allowed by law to do. What does your state practice act do, say? What about policies and procedures related to sharp debridement. How many of you have policies and procedures in place for sharp debridement? One person. How many of you are doing sharp debridement? Several of you are. Please, have a policy and procedure in place and then follow it. If you want a policy and procedure, email me and Ill send you a template that you can use to write up your own.
You look at your national professional standards of practice. You look at your guidelines. The WOCN, the Wound Ostomy Continence Nurses Society, has guidelines on sharp debridement. The American Physical Therapy Association has guidelines on sharp debridement. Physicians orders absolutely. Get a physician to order. It is necessary. Its nice to have a protocol in place also not necessary, but its nice. Each wound site needs to be mentioned. You get a new wound site, you get a new order. It doesnt cover the one that you were working on. You get a new wound site, get a new order. You might need PRN orders.
This is what the WOCN recommends. Look at this. Conservative sharp debridement of soft necrotic tissue is what is recommended. I have a caveat for that, and my recommendation is, for a sample order, selective sharp debridement of necrotic tissue, PRN, as needed, of, and then you mention the location of where youre going to do that sharp debridement.
Indications, extensive devitalized tissue, advancing cellulitis, presence of a thick eschar, in combination with other methods, but there are contraindications. Remember, no blood flow, no sharp debridement. Gangrene. Stable heel ulcers. In general, people tell you not to remove eschar from a stable, from a heel that is stable. Youre going to have to make a decision. If you decide that youre going to remove eschar from a heel, you have stable eschar, youre going to remove it, be sure you document why youre taking that stable eschar off. And there are reasons to do it, but be sure you say why youre doing it.
Unidentifiable structures, the key word is a structure. Its a tendon. I dont know which tendon it is, but I know its tendon. Id better think about it before I take it out. Terminally ill there may be times when you want to do sharp debridement, but there are many times when youre not going to do sharp debridement, because were into palliative care or maybe hospice care. Anticoagulation therapy is a relative contraindication. I was in a lawsuit one time where the patient bled out, because the physical therapy team did sharp debridement and they didnt look at the medication sheet, and the person was on Plavix, Coumadin and Aspirin, and no one, including the physician, look at the INR, and the person was five times anticoagulated on Coumadin alone. And the patient bled out and died, and I had to find two of my colleagues grossly negligent according to the, our state practice act, in the State of Texas, and it broke my heart to do that. But thats what I had to do. And it was because they didnt look at the medication sheet before they did sharp debridement.
Blood clotting disorders such as hemophilia be very, very careful.
How many of you have used disposable sharp debridement tools? Okay. How many of you use reusable sharp debridement tools? Both are wonderful. Were not doing microvascular surgery here. So disposable instruments work just fine. So, and there are different, you can use different types of scalpels, different types of scissors, curettes, bottom right, look at this photograph and youll see the curette. I know several nurses, one of whom is in the room, that loves this particular type of curette, and its great for scraping out that fibrin or slough does it very, very nicely.
You want to get ready to debride you get all of your supplies in place make sure you have adequate lighting thats very important that you, especially if you are over 40, that you have adequate lighting. My friend Karen Lou Kennedy has one of those headlights that she wears when shes doing some of her wound care and doing her assessments. Very,
very important. Prepare for bleeding. I am an assertive debrider. I go to that line of demarcation whenever possible between viable and nonviable tissue. And when I get to that line of demarcation, sometimes I get a little bit of bleeding. Im not going after the viable tissue. Thats outside my practice act. But Im going to the viable tissue. So, I need to be ready for bleeding.
Plan for the pain. Work with your nursing staff. I cannot pass medications. Its against the law. So I have to partner very closely with the physicians and the nurses to get my patients medicated.
Reasons to stop debridement. Clinician fatigue or patient fatigue. The patient is bleeding. If youre bleeding Im going to question your technique. Pain. You get to viable tissue. Location of a fascial plane. High anxiety of the clinician. How many of you have had a gut feeling in your life? Whos had a gut feeling in their life? All right. Your gut, that intuition, will never lie to you. This will lie to you, over and over. Your head will lie to you. Your gut will never lie.
Do you get a bad feeling in your gut, and you have sharp instruments in your hands? Put them down, write something in the chart, something that is honest and is appropriate, but stop the debridement process.
Set a time limit and stay within the time limit. Holes? Dont go there with a sharp instrument. You have to be able to see the tip of your instruments. Very, very important.
Extensive undermining you cant see? Dont go there with a sharp instrument. You see gross purulence that you didnt expect, such as you see in this bottom wound? Stop. Get the patient to the physician. Get the physician involved.
Pressure will stop most bleeding. Its important to have a method for stopping bleeding pressure. If your patient is on anticoagulants, youre going to have to hold pressure on longer. So you have to, again, look at the medication sheet.
Elevation you can do that if you have a lot of bleeding, then youre maybe going to have to have a suture, and again, Im going to, I would have to have my physician involved.
Some of the topical agents work very nicely, as you look at this list thrombin, surgicel, gel foam there are silver nitrate sticks. You want to make sure your patient has stopped bleeding before you dress the wound and you send them out. Very important, especially in the presence of anticoagulation therapy.
Get the physician back involved if your patient is febrile on a downhill course where theres been no wound improvement over several sessions. New cellulitis, unexpected gross purulence. You know your anatomy, you know your physiology, you know that youre getting ready to expose the bone or a tendon. Get the physician back involved, major abscesses, major structures such as vessels, the ephemeral artery, I think I need to get my physician back involved. Very important.
Remember, we want to continue to do debridement. Its not a onetime event. The aggressiveness of the debridement is going to depend on the load of the tissue. Is it devitalized tissue versus how much healthy tissue? The patients tolerance to being still.
You need a patient that will be still while you have a sharp instrument in your hand. You, there can be time constraints for the practitioner. You need to have help available often times. How many of you go in there and debride by yourself? Who debrides by yourself? Oh, so several, oh, you debride by yourselves? All right. Sometimes you need help, especially if you have to help, need help to hold that patient in a position, in the same position for extended period of time, especially in long term care.
Anatomy is going to be the key to comfort for doing sharp debridement. You want to be able to recognize what is normal, avoid trouble, identify what youre about to remove. Please have a policy and procedure in place. You do need one.
This is a particular patient who was on the operating table for an eight hour period, so she had gross, she ended up with this necrotic wound, three days, three or four days later. Now, they didnt put the betadine on the wound. They did it around the wound and they did a sharp debridement process. Then they, and they also put the enzyme on. Then they repeated sharp debridement, then they started pulse lavage with suction, and put the enzyme on. Then they did enzymatic debridement, and I happen to know it was collagenase. They continued with collagenase, and for all intents and purposes its closed. So this is what happens: you combine your debridement options to get the best outcome of a clean and functional wound bed.
So in summary, debridement is integral to creating a functional wound bed. It transforms this hostile environment of a chronic wound into a more receptive milieu. It is fundamental to facilitate the wound closure and create that functional wound bed. It creates an optimal wound bed for the application of advanced wound products such as skin substitutes or growth factors. It can be accomplished by several different methods, or alone, in combination or alone, and youre going to choose, the method is going to be dependent on the unique characteristics of your patient and of your wound.
Thank you very much.
|Goals and Objectives|
After participating in this activity, the viewer should be better able to:
1. Review the rationale behind correct debridement procedures.
2. Propose an acceptable set of practice protocols in relation to debridement
3. List acceptable protocols for safe and effective debridement
4. Identify legal issues in relation to debridement
Estimated time to complete this activity is 32 minutes.
Nurses, Therapist, and other health care professionals who care for patients with wounds, ostomies, and incontinence.
Complete the 4 steps to earn CE/CME credit:
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My CV (Curriculum Vitae): On our web site, we offer an online data based profiling tool in which you supply information that is part of your curriculum vitae or professional resume. This tool stores the information that you provide on our servers. The information is accessible by other members and the public, and is designed to advertise you to the online community and allow other's to find you based on the information that you provide. We will always make it clear to you when information you provide to us through a tool will be saved.
Member Lookup: On our website, other members will be able to look you up and send you messages. If you opt not to be listed (blocked), no other members will be able to look you up.
In addition, we gather information about you that is automatically collected by our Web server, such as your IP address and domain name. We will use this information to personalize its offerings and presentations to you, facilitate your movements throughout our Web sites, provide personalized services, and to communicate with you individually.
Continuing Medical Education
When you register for a Continuing Medical Education ("CME") or a Continuing Education ("CE") activity through our web site, we collect certain personally identifiable information from you such as your name, email address and mailing address. We require that you provide the state in which you are licensed and your license number. In addition to personally identifiable information, we collect aggregated non-personally identifiable information about the activities undertaken by our users. We use the information that we collect through CME/CE activities in several ways:
(i) We are accredited by the Accreditation Council for Continuing Medical Education ("ACCME") to provide continuing medical education for physicians, through a sponsorship agreement with the Mount Sinai School of Medicine. As an ACCME accredited entity, we are required periodically to submit aggregated data about CME participants and the CME activities we certify. We also provide personally identifiable information to other accredited CME/CE providers who certify CME/CE activities posted on our Web sites, as required by the ACCME and other accrediting bodies. These reports may include personally identifiable information about you and credits issued to you, for the purpose of maintaining records that you can request from the accredited provider for up to six (6) years;
(ii) Commercial supporters of CME/CE activities on our Web site will receive only a data about CME/CE activities that are relevant to their interests and/or the courses they support;
Uses We Make of Information
We collect data about visitors to our Web sites for product development and improvement activities. We also use it for market analysis. We may provide information from our Web sites in aggregate form, with identifying information removed, to third parties. For example, we may tell a health care partner what percentage of our registered users are of a particular medical specialty or have certain credentials. Any third party that receives our data must agree not to attempt to re-identify the people it belongs to. For example, we may provide information to a potential advertiser of a product that would appeal to a diabetes patient about what percentage of our users have diabetes. Depending on our agreement with the third parties, we may or may not charge for this information.
Marketing and Advertising
We may target our advertising or marketing depending on information we have about you. For example, a user that is a healthcare professional who treats diabetes may receive advertising for new diabetes therapies (although in neither case will the advertiser have access to any individually identifiable information about you). We may also personalize our Web site based on your interests. For example, you may see different articles in different places on our Web site based on information you have shared with us, or information we have gained by observing your previous behavior, or information we may have gained from your interactions with a third party that shares information with us. We use information for our own internal marketing, research, and related purposes. Third Parties In addition to aggregate information (discussed previously), we may share some kinds of personally identifiable information with third parties as described below.
Other Companies: We have strategic relationships with other companies who offer products and services on our Web sites. When you are interacting with those companies, different rules and privacy policies may apply. We do not control the collection or use of information you provide to these companies, but we do require that those companies clearly state their policies so you can decide whether to give them any information.
Promotional Offers: Sometimes we send offers to selected groups of customers on behalf of other businesses. When we do this, we do not give that business your name and address. We provide a variety of mechanisms for you to tell us you do not want to receive such promotional offers. For example, we may provide an opt-in box for consumers to receive an email from another business, and we make clear that by opting in you are submitting your data to a third party.
Protection of Information
We have implemented technology and security policies, rules and other measures to protect the personal data that we have under our control from unauthorized access, improper use, alteration, unlawful or accidental destruction, and accidental loss. We also protect your information by requiring that all our employees and others who have access to or are associated with the processing of your data respect your confidentiality. We use security methods to determine the identity of its registered users, so that appropriate rights and restrictions can be enforced for that user. Reliable verification of user identity is called authentication. We use both passwords and usernames, as well as double opt-n verification, to authenticate users. Users are responsible for maintaining their own passwords.
Access to Information and Choices
Correction of Information We Have About You
If you believe that registration information collected by our Web site(s) is in error, you may edit your personal profile any time that you like. You can directly edit most of your user profile on the Web site on which you initially registered. Information that you can not edit may only be changed by contacting Web Customer Support (see CONTACTS). Requests for deletion of your record may result in your removal from the registry, but we may keep certain demographic information about you for product improvement purposes. You may contact Web Customer Support and ask for the changes that you would like to make.
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