Primary Care Report – Next-Generation Irrigating Solutions for Wound Bed Preparation by Global Business Media

SPECIAL REPORT

Next-Generation Irrigating Solutions for Wound Bed Preparation PuracynÂŽ Plus Professional Formula: A Next-Generation Wound Irrigation Solution for Optimal Wound Bed Preparation What is a Wound? Wound Care is Everything A Healing Process The Costs of Wounds

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Clear the way.

Expanding the Possibilities of Wound Care Better wound bed preparation begins with Puracyn Plus Professional Formula Wound Irrigation Solution Puracyn® Plus Professional Formula Wound Irrigation Solution is a nextgeneration wound irrigation and management solution designed to improve the most essential part of the wound treatment process: preparation of the wound bed. This advanced pH-balanced solution is used in conjunction with wound irrigation, debridement and dressing procedures, which set the stage for optimum healing conditions. Puracyn Plus Professional Formula Wound Irrigation Solution provides clinicians with a new alternative to commercial cleansers and solutions that may inhibit wound closure. CE Mark Pending For more information, or to order Puracyn® Plus Professional Formula Products, please visit puracynpro.com, or contact us: Brian Costigan - Vice President International – Human & Animal Health Office: +353 91 796896 briancostigan@innovacyn.com Customer Service: +001.866.318.3116 (8am - 5pm PST) Email/order: customerservice@innovacyn.com Fax/order: +001.909.428.1947 Address: 3456 N. Riverside Ave. Rialto, CA 92377, USA

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NEXT-GENERATION IRRIGATING SOLUTIONS FOR WOUND BED PREPARATION

SPECIAL REPORT

Next-Generation Irrigating Solutions for Wound Bed Preparation Puracyn® Plus Professional Formula: A Next-Generation Wound Irrigation Solution for Optimal Wound Bed Preparation

Contents

What is a Wound? Wound Care is Everything A Healing Process The Costs of Wounds

Foreword

John Hancock, Editor

Puracyn® Plus Professional Formula: 3 A Next-Generation Wound Irrigation Solution for Optimal Wound Bed Preparation Michelle Moore MSN, RN, CWCN, CLWCP, WCC, Innovacyn, Inc. Sponsored by

Published by Global Business Media

Published by Global Business Media Global Business Media Limited 62 The Street Ashtead Surrey KT21 1AT United Kingdom Switchboard: +44 (0)1737 850 939 Fax: +44 (0)1737 851 952 Email: info@globalbusinessmedia.org Website: www.globalbusinessmedia.org Publisher Kevin Bell Business Development Director Marie-Anne Brooks Editor John Hancock Senior Project Manager Steve Banks Advertising Executives Michael McCarthy Abigail Coombes Production Manager Paul Davies For further information visit: www.globalbusinessmedia.org

The opinions and views expressed in the editorial content in this publication are those of the authors alone and do not necessarily represent the views of any organisation with which they may be associated. Material in advertisements and promotional features may be considered to represent the views of the advertisers and promoters. The views and opinions expressed in this publication do not necessarily express the views of the Publishers or the Editor. While every care has been taken in the preparation of this publication, neither the Publishers nor the Editor are responsible for such opinions and views or for any inaccuracies in the articles. © 2016. The entire contents of this publication are protected by copyright. Full details are available from the Publishers. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form or by any means, electronic, mechanical photocopying, recording or otherwise, without the prior permission of the copyright owner.

Radical Change Happens at the Most Basic Level Advanced Indications for Use Technology for Jumpstarting the Healing Process Changing the Landscape of Wound Care Management The Economic Impact of Non-Healing Wounds: A Call for Streamlined Wound Care Protocols Streamlined Wound Bed Preparation Puracyn® Plus Professional Formula Wound Irrigation Solution in Wound Bed Preparation What Is Comprehensive Wound Treatment? Product Information

What is a Wound?

John Hancock, Editor

A Complex Set of Conditions A Range of Injuries and Conditions Different Wound Types Hard to Heal Wounds The Prevalence of Chronic and Hard to Heal Wounds

Wound Care is Everything

Camilla Slade, Staff Writer

The Human and Financial Cost of Wounds Better Treatment Means Better Outcomes Chronic Wounds

The Healing Process

Peter Dunwell, Medical Correspondent

When Natural Healing Isn’t Enough Wound Care – Elements in the Process

The Costs of Wounds

John Hancock, Editor

Wound-Related Complications Impact of Wounds on People Who Have Them Financial Impact of Wound Care on Healthcare Systems

References 16

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NEXT-GENERATION IRRIGATING SOLUTIONS FOR WOUND BED PREPARATION

Foreword W

OUNDS ARE quite common and for some

details of the treatment of chronic wounds through a

groups they are a regular occurrence.

comprehensive therapy which can be divided into a

Children, for instance, seem always to be grazing

corrective mode followed by a maintenance mode.

their knees and suffering scratches while some

The second piece sets out an overview of wounds;

manual workers such as those in the construction

a broad group of injuries from varied causes and with

sector see minor wounds as part of the job.

equally varied pathologies. It means that treatment

Rarely are these wounds threatening as long as

methods need also to be able to respond appropriately

they are quickly washed to remove debris, and

to the type of wound and the underlying state of the

covered to keep debris out. More seriously, those

patient for optimum outcome. Camilla Slade then

serving in the armed forces can suffer horrific

continues to drill further into wound care, its place in

wounds in the course of their duty and, here, the

healthcare and the importance of delivering the best

risk of complications is significant. There are also

quality care possible for each patient and each wound.

people whose underlying conditions make their

This is followed by an article by Peter Dunwell that

wounds slow to heal or even unlikely ever to heal.

gives an appraisal of wound healing, the risks that

Put together, it means that the management and

could follow if a wound does not heal properly and

effective treatment of wounds is a very important

how good management and processes can support

matter for any healthcare system.

healing and avoid poor outcomes. Finally, we look at

This Special Report opens with an article by

the costs of wounds. For those who have to live with

Michelle Moore of Innovacyn Inc., a family owned

wounds, for even a short time, the cost in degraded

and operated business dedicated to improving

quality of life can be high. For the systems that have

wound management outcomes across the world.

to treat wounds, the financial cost can be just as high

Since 2009, they have been the leader in creating

with some research equating the cost of wound care

innovative medical devices and solutions and

with the cost of obesity.

driving advancements in the human and animal health industries. The article goes on to describe the PuracynÂŽ Plus Family of Products and gives

John Hancock Editor

John Hancock has been Editor of Primary Care Reports since its launch. A journalist for more than 25 years, he has written and edited articles, papers and books on a range of medical, technology related, engineering and management topics. Healthcare subjects have included management of long-term conditions, elective and non-elective surgery, Schizophrenia, health risks of travel, local health management and NHS management and reforms.

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NEXT-GENERATION IRRIGATING SOLUTIONS FOR WOUND BED PREPARATION

Puracyn® Plus Professional Formula: A Next-Generation Wound Irrigation Solution for Optimal Wound Bed Preparation

Puracyn® Plus Professional Formula A next-generation irrigation solution for wound bed preparation.

Michelle Moore MSN, RN, CWCN, CLWCP, WCC, Innovacyn, Inc. Clearing the way for streamlined wound care protocols.

THE PURACYN PLUS FAMILY OF WOUND & SKIN CARE PRODUCTS

Radical Change Happens at the Most Basic Level

Technology for Jumpstarting the Healing Process

Puracyn® Plus Professional Formula is a nextgeneration wound irrigation and management solution designed to improve the most essential part of the wound treatment process: preparation of the wound bed.

The preservative in Puracyn Plus Professional Formula Wound Irrigation Solution (pH-balanced, stabilized hypochlorous acid in solution) has been shown to exhibit effective inhibition characteristics against microbial growth in vitro while remaining non-toxic to human tissues.

Advanced Indications for Use Puracyn Plus Professional Formula Wound Irrigation Solution is FDA-cleared (CE mark pending) for use by healthcare professionals on the following types of wounds: • Acute and chronic dermal lesions • Partial and full-thickness wounds • First and second-degree burns • Diabetic ulcers and stasis ulcers • Stage I-IV pressure injuries • Post-surgical wounds • Grafted and donor sites •M inor lacerations, abrasions, irritations, cuts, and burns • Trauma wounds

Changing the Landscape of Wound Care Management Part of a synergistic wound care management system, Puracyn Plus Professional Formula Wound Irrigation Solution provides an economical tool for all types of wound care while enhancing and streamlining wound care protocols.

The Economic Impact of Non-Healing Wounds: A Call for Streamlined Wound Care Protocols

RADICAL CHANGE HAPPENS AT THE MOST BASIC LEVEL CE MARK PENDING FOR MORE INFORMATION, CONTACT: Brian Costigan - Vice President International Human & Animal Health Office: +353 91 796896 briancostigan@innovacyn.com Customer Service: +001.866.318.3116 (8am - 5pm PST) Email/order: customerservice@innovacyn.com Fax/order: +001.909.428.1947 Address: 3456 N. Riverside Ave. Rialto, CA 92377, USA

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The impact of non-healing wounds exacts a human toll and places a financial burden on the

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NEXT-GENERATION IRRIGATING SOLUTIONS FOR WOUND BED PREPARATION

Part of a synergistic

SUMMARY OF MICROBIAL INHIBITION IN PRODUCT SOLUTION

wound care management system, Puracyn Plus Professional Formula Wound Irrigation Solution provides an economical tool for all types of wound care while enhancing and streamlining wound care protocols.

healthcare system. The staggering cost of caring for chronic wounds in home health settings and skilled nursing facilities is estimated to exceed $50 billion per year.1 Chronicity in wounds can lead to amputation and reduced quality of life, and thus dictate a need for wound care to establish a streamlined system of care that begins with the wound bed.

T.I.M.E. wound care and wound bed preparation standards require debridement in conjunction with a wound irrigation agent that does not impair the wound healing process, while providing ongoing moisture. Using irrigation and debridement on wounds creates a disruption to biofilm, and is in accordance with the T.I.M.E. standard of care practices.5

Streamlined Wound Bed Preparation

Debridement

The act of preparing the wound bed is essential to the efficacy of advanced modalities and treatments for both acute and chronic wounds. Effective wound bed preparation can also assist the fundamental healing process within the wound itself, while reducing woundrelated costs.2 Standardized, multidisciplinary protocols of care have been shown to reduce episode of care costs up to 35.3% per diem: $229.07 versus $354.26.3 The wound bed assessment tool developed by the International Advisory Board on Wound Bed Preparation, T.I.M.E., outlines the following target areas for effective wound management4: T= Tissue, non-viable or deficient I = Infection or inflammation M = Moisture imbalance E = Edge of wound, non-advancing or undermined 4 | WWW.PRIMARYCAREREPORTS.CO.UK

Puracyn Plus Professional Formula Wound Irrigation Solution can be used in tandem with advanced wound healing modalities such as negative-pressure wound therapy and lowfrequency ultrasound.

Moisture Puracyn Plus Professional Formula Wound Irrigation Solution is specifically indicated to moisten wound dressings and the wound bed surface, as well as assist in the removal of encrusted dressings.

Irrigation According to T.I.M.E., the ideal wound irrigation solution will remove debris without adversely affecting cellular activities crucial to the woundhealing process.5 Unlike saline solution or water, Puracyn Plus Professional Formula Wound Irrigation Solution expands the clinical applications of wound irrigation.

NEXT-GENERATION IRRIGATING SOLUTIONS FOR WOUND BED PREPARATION

Puracyn® Plus Professional Formula A next-generation irrigation solution for wound bed preparation.

WORLD CLASS MANUFACTURING CONFORMING TO ISO, FDA AND CE REGULATIONS

Wound bed preparation is an integral part of the standard of care for chronic and nonhealing wounds. Together with comprehensive treatment and the T.I.M.E. guidelines, wound bed preparation offers a protocol that can be an effective tool in wound management.

Puracyn® Plus Professional Formula Wound Irrigation Solution in Wound Bed Preparation Puracyn Plus Professional Formula Wound Irrigation Solution can be applied directly to the wound or poured onto absorbent gauze pads being used to cleanse the wound. It can also be used to support wound cleansing during sharp and mechanical debridement to remove exudate and inflammatory debris. The solution can also be used to saturate gauze pads which are placed directly onto the wound to soak. Because Puracyn Plus Professional Formula Wound Irrigation Solution is not irritating to the wound, it can be applied liberally and repeatedly until the wound is free of any debris in support of maintaining a clean wound bed. No rinsing is required after use. It should be left on the wound and not rinsed or wiped off. Puracyn Plus Professional Formula Wound Irrigation Solution does not damage healthy tissues. It is free of harsh chemicals and has passed all testing on tissue sensitivity and toxicity with no irritation reported. In fact, hypochlorous-based wound products have been documented to increase healthy granulation and reduce inflammation, thus accelerating the healing of many kinds of wounds or burns. Unlike other wound bed preparation solutions, hypochlorous does not interrupt fibroblast function or morphology.

HYPOCHLOROUS TECHNOLOGY, THE SCIENCE THAT DRIVES PURACYN PLUS PROFESSIONAL FORMULA

What Is Comprehensive Wound Treatment? Treatment of chronic wounds is done through a comprehensive therapy and can be divided into a corrective mode followed by a maintenance mode. The corrective mode entails: • Irrigating/cleansing the wound •R emoving necrotic or callous tissue (debriding) • Treating any edema • Treating any infection • Re-vascularizing, if poor blood flow exists • Creating a moist wound bed environment Maintenance mode involves: • Wound cleansing • Keeping the wound environment moist • Proper dressing management • Compressive bandage in venous stasis • Off-loading pressure from the wound •S upplemental debridement, as necessary to maintain the wound bed •S kin substitutes and other devices to support healing • Treating underlying medical condition(s) • Adequate nutrition to support healing • Prevention of infection

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NEXT-GENERATION IRRIGATING SOLUTIONS FOR WOUND BED PREPARATION

Wound bed preparation is an integral part of the standard of care for chronic and nonhealing wounds.

PURACYN PLUS PROFESSIONAL FORMULA DELIVERS BETTER OUTCOMES FOR PATIENTS AND PRACTITIONERS

Product Information Powered by hypochlorous technology, Puracyn Plus Professional Formula Wound Irrigation Solution provides clinicians with the following benefits: • Non-toxic and non-irritating • Contains no steroids or antibiotics • Contains no alcohol or iodine • Requires no mixing or diluting • Supports reduction of wound odor •E nvironmentally friendly – no special disposal required • Up to 24-month shelf life •C leanses and irrigates the wound without harming healthy tissue •S afe for irrigation in wound cavities, even with tunneling/undermining wounds • Non-corrosive • Non-flammable Puracyn® Plus Professional Formula can be used to: • Irrigate the wound bed • Flush away dirt and debris • Saturate dressings • Moisten encrusted dressings • Assist advanced healing modalities 6 | WWW.PRIMARYCAREREPORTS.CO.UK

Puracyn® Plus Professional Formula Wound Irrigation Solution Directions for Use •C leanse and irrigate the wound with Puracyn Plus Professional Formula Wound Irrigation Solution. •S aturate a gauze dressing and apply to wound bed. To help reduce wound odor and facilitate autolytic debridement, allow Puracyn Plus Wound Irrigation Solution to soak on the wound bed for 3-5 minutes. •P roceed to additional debridement protocols, if necessary. •R epeat the cleansing and irrigation of the wound bed. • I f needed, use appropriate wound filler and cover with dressing. •A ccording to the wound etiology, apply a final dressing that utilizes compression and/or offloading if needed.

NEXT-GENERATION IRRIGATING SOLUTIONS FOR WOUND BED PREPARATION

For more information, or to order Puracyn Plus Professional Formula Products, please visit puracynpro.com, or contact us:

Contact Innovacyn, Inc. 3546 N Riverside Ave., Rialto, CA 92377, USA, puracynpro.com

Puracyn® Plus Professional Formula A next-generation irrigation solution for wound bed preparation.

Brian Costigan – Vice President International – Human & Animal Health Office: +353 91 796896 briancostigan@innovacyn.com Customer Service: +001 866.318.3116 (8am PST - 5pm PST) Email/order: customerservice@innovacyn.com Fax/order: +001 909.428.1947 Address: 3456 N. Riverside Ave. Rialto, CA 92377 USA

References: Fife CE, Carter MJ, Walker D, Thomson B. Wound care outcomes and associated cost among patients treated in US outpatient wound centers: data from the US wound registry. Wounds. 2012;24(1):10–17.

Falanga V, Brem H, Ennis WJ, Wolcott R. Maintenance debridement in the treatment of difficult-to-heal chronic wounds. Ostomy Wound Management. 2008 Supplement: 1-15.

DaVanzo JE, El-Gamil AM, Dobson A, Sen N. A retrospective comparison of clinical outcomes and medicare expenditures in skilled nursing facility residents with chronic wounds. Ostomy Wound Management. 2010;56(9):32–42.

Schultz GS, Sibbald RG, Flanaga V, Ayello EA. Wound bed preparation: a systematic approach to wound management. Wound Rep Reg. 2003; 11: 1–28.

Dowsett C, Newton H. Wound bed preparation: TIME in practice. Clinical Practice Development. Wounds International. 2014; 5(3): 58-70.

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NEXT-GENERATION IRRIGATING SOLUTIONS FOR WOUND BED PREPARATION

What is a Wound? John Hancock, Editor

Examining underlying causes and conditions.

There are whole areas of practice to cater for both traumatic and surgical wound management but, in both cases, the prevention or management of infection is a key concern as this is what can pose an existential threat to either a limb or to the patient.

A Complex Set of Conditions Most wounds are little more than a part of everyday life: we all suffer from time to time and some more than others but the reality is that most wounds are of the minor kind (shaving cuts, paper cuts). However, some wounds for some people in particular circumstances are more serious (road accident, surgery) and/or chronic, taking a long time to heal and thus risking infection over and above what might have been the cause of the wound. But, whatever the type of wound, its proper treatment and, hopefully, restoration of the damaged tissue to full health, is a key branch of healthcare. In more technical and extensive terms from CliniMed1, “A wound by true definition is a breakdown in the protective function of the skin; the loss of continuity of epithelium, with or without loss of underlying connective tissue (i.e. muscle, bone, nerves) following injury to the skin or underlying tissues/ organs caused by surgery, a blow, a cut, chemicals, heat/ cold, friction/ shear force, pressure or as a result of disease, such as leg ulcers or carcinomas.”

A Range of Injuries and Conditions As stated above, not all wounds are the same. Wound Care Centers2 explains, “Most common wounds are superficial, limited to the outer skin layers. Some are deeper, reaching the underlying tissues and organs. Depending on the cause, site and depth, a wound can range from simple to life threatening.” The article continues, “Depending on the healing time of a wound, it can be classified as acute or chronic. Those classified as acute wounds heal uneventfully (with no complications) in the predicted amount of time. Those classified as chronic wounds take a longer time to heal and might have some complications.” There other factors that differentiate wounds: for instance, whether the wound is open (with tissue or even organs or bones exposed such as when a wound has been caused by a penetrating trauma) or closed, non-penetrating surface wounds. Also, while some wounds might be classified clean, others could be contaminated either from the wound cause itself 8 | WWW.PRIMARYCAREREPORTS.CO.UK

or from subsequent exposure. And some people are simply more at risk, usually as a result of an underlying condition. For instance, people with diabetes are more prone to wounds (a loss of nerve function can lead to abrasions not being noticed in sufficient time and circulatory problems can cause neuropathy leading to the loss of live tissue). Unfortunately, another side effect of their condition is healing problems and, if they have associated conditions such as obesity, that will put pressure on wound sites. As Wounds International explains in the paper ‘Best practice Guidelines: wound management in diabetic foot ulcers’3 considering just one type of wound, “In England, foot complications account for 20% of the total National Health Service spend on diabetes care, which equates to around £650 million per year (or £1 in every £150 [of total spend]). Of course, these figures do not take account of the indirect costs to patients, such as the effect on physical, psychological and social wellbeing and the fact that many patients are unable to work long term as a result of their wounds.”

Different Wound Types Additionally, there are many types of wound. Acute wounds occur when the skin is broken which can be either traumatic (from a minor cut to a stabbing, gunshot or accident related penetration) or surgical (cutting past the skin to access internal organs). There are whole areas of practice to cater for both traumatic and surgical wound management but, in both cases, the prevention or management of infection is a key concern as this is what can pose an existential threat to either a limb or to the patient. Some of the worst trauma wounds are Sharp Force Traumas which can be caused when any sharp object penetrates the skin. According to the depth to which a sharp force trauma penetrates, a wound can range from minor to serious to fatal – especially where a major organ is damaged during the sharp force entry, however caused. Blunt force trauma wounds are sometimes even worse because the damage is less localised and could involve broken bones which themselves can inflict wounds on surrounding tissue.

NEXT-GENERATION IRRIGATING SOLUTIONS FOR WOUND BED PREPARATION

Puracyn® Plus Professional Formula A next-generation irrigation solution for wound bed preparation.

Some wounds are symptoms of another condition: warts, for instance, “are caused by infection with the human papilloma virus (HPV), which can be passed on through skin-to-skin contact and sometimes through surfaces such as floors and towels.”4 And, particularly with older people, skin tears where the skin has thinned and dried, and lost its elasticity, are a more common wound type. Ulcers are an especially pernicious group of wounds to which people who are unable to get out of bed, unable to move or, say, confined to a wheelchair, will be prone as will diabetics and the obese. Skin grafts and donor site wounds are an unusual group well described by Wounds UK5, “Skin grafting is used for extensive wounds that are difficult to suture or for wounds that will produce prominent scars which could cause physical or psychological problems for the patient. Grafting involves the creation of another wound at the donor site that will also need nursing attention.”

Hard to Heal Wounds One group of wounds is described as ‘hard to heal’. Wounds International6 describes a hard to heal wound as, “one that fails to heal with standard therapy in an orderly and timely manner. This definition applies equally to both acute and chronic wounds and is independent of the wound type and aetiology.” Continuing to explain, “Many wounds, particularly those in an elderly population with significant comorbidities, prove challenging

to manage… Although delayed healing appears to be common, it is frequently not recognised early enough and can pose a major problem, increasing clinical workloads and cost.”

The Prevalence of Chronic and Hard to Heal Wounds Most wounds require no intervention by clinicians but will be simply dealt with by the sufferer or a colleague, family member, first aider with a thorough clean (usually under running water) and application of a sticking plaster. More serious trauma wounds will require an often brief but intense clinical intervention while chronic and non-healing wounds are likely to require a lengthy treatment programme. It is because of the cost of treating them that the prevalence of chronic and non-healing wounds has been the subject of many studies. . According to Nursing Times7, “Many attempts have been made to measure the frequency of occurrence of chronic wounds…” but it concludes that “collection of data related to the frequency of occurrence of any type of chronic wound is complex and fraught with complications.” BMJ Open8 offer some guidance based on the THIN (The Health Improvement Network) database in the UK and concludes; “… it was estimated [in 2013] that there were 2.2 million patients with a wound who matched the study protocol’s inclusion and exclusion criteria, equivalent to 4.5% of the adult population…”

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NEXT-GENERATION IRRIGATING SOLUTIONS FOR WOUND BED PREPARATION

Wound Care is Everything Camilla Slade, Staff Writer

Determining speed, costs, and influencing quality of life.

The better the care available at the outset, the more likely any wound is to heal successfully and within a reasonable time. So wound treatment is a very important matter. This is especially true for chronic and hard to heal wounds.

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The Human and Financial Cost of Wounds Wounds come with an array of associated conditions which have quite a significant impact on the costs of healthcare systems and, more importantly, on the patient. Aside from pain and discomfort associated with any wound, there can be lasting damage to the patient in the form of scars or disfigurement which, along with the circumstances in which a serious trauma wound occurs, can have a significant impact on a patient’s psychological and social wellbeing. It can also mean that the healthcare system has to meet the costs of scar removal, physical restructuring and, especially if a facial wound is involved, therapy or counselling. However, given a finite level of funding for any healthcare system, the cost is important to clinicians and managers – the time and resources allocated for wound care (chronic, non-healing or not). It isn’t just hospital or GP surgery time, but the additional resources required should a wound become hard to heal. Clinicians will need to be aware of all the treatments and healing devices available to avoid patients from falling into the above groups or, if they do, to manage their condition and hopefully, return them to health. Wounds International explains it in ‘Hard to heal Wounds made easy’9, “Reducing health costs is a recurring global issue. Wound management is a major area where there is a drive for improved cost-effectiveness. Costs are higher for hard-toheal and long duration wounds as the frequency of therapy, staff time and product use increases. Reducing costs while optimising quality of life for patients with delayed wound healing requires the following: • Early identification of hard-to-heal wounds; • Targeted use of advanced wound care products. “The latter must involve a plan to address specific issues within the wound, a defined goal and a timeline for use.” Nursing Times in ‘The Burden of Chronic Wounds in the UK’10 concludes, “UK cost estimates are subject to a wide margin of error, but are sufficiently accurate to indicate that wound care has a significant impact on NHS resources. Results from local audits of

wound-care practice in the UK and elsewhere highlight that a relatively high proportion of chronic wounds remain unhealed for long periods – almost certainly longer than necessary. Likely reasons for this include just treating the ulcer itself, rather than diagnosing and treating its underlying cause.”

Better Treatment Means Better Outcomes The better the care available at the outset, the more likely any wound is to heal successfully and within a reasonable time. So wound treatment is a very important matter. This is especially true for chronic and hard to heal wounds which are a condition in themselves with particular significance for some patients: understanding them is a key to treating them effectively. It’s important to know why some wounds don’t heal or are slow to heal. Wounds UK11 explains the problems that can result if a wound doesn’t heal when it should. “A hard-to-heal wound is defined as one that fails to heal with standard therapy in a timely fashion (Troxler et al, 2006). Normal wound healing starts with haemostasis, progresses through a destructive inflammatory phase and then a restorative phase. It finishes with remodelling of the wound. This process can be interrupted at any stage due to a number of intrinsic and extrinsic factors (Vowden, 2011). For patients in which healing is prolonged, clinicians face the dual challenge of managing the wound environment and the patient, whose wellbeing may be significantly compromised (EWMA, 2008)” Where an acute wound has been caused by a trauma, there might be a number of steps to be taken to repair the damage caused during the trauma. This could mean surgery to remove debris from the wound site. It will almost certainly involve cleaning the wound site and irrigating it to complete the cleaning process and assist with healing – irrigation is covered in a later article. Also, in the case of more severe wounds, it will usually mean closing the wound (once it is clean). Where the wound is of a longer-term nature, the process is necessarily more complex,

NEXT-GENERATION IRRIGATING SOLUTIONS FOR WOUND BED PREPARATION

Puracyn® Plus Professional Formula A next-generation irrigation solution for wound bed preparation.

to cover both healing (or management where healing is a less likely outcome) and long-term patient management.

Chronic Wounds If not properly managed, a chronic wound (something like a diabetic foot ulcer) can become a non-healing wound. The more common types of wound that fall into this category are venous ulcers, pressure ulcers, diabetic ulcers and arterial insufficiency ulcers. Also, not all wounds are brought about by accident, injury or infection. There are occasions when surgery will have a better outcome if the operation site is left open; abdominal surgery is a case in point where wound closure might be delayed to facilitate infection control and essential post-operative treatments. In these circumstances, proper management and dressing of the open wound is essential. Particular treatment processes are also called

for when a wound relates to conditions such as cancer or other terminal conditions. Wound management in palliative care is a specialist area of practice. Wounds UK’s ‘Wound Essentials’12 paper on the topic explains, “Wound care involving patients in palliative care requires a different approach to standard wound care with many of those encountered presenting with very compromised skin.” Clinicians have been concerned with the science of wound healing for a long time. In fact13, “One of the oldest medical manuscripts known to man is a clay tablet that dates back to 2200 BC. This tablet describes, perhaps for the first time, the ‘three healing gestures’ – washing the wounds, making the plasters, and bandaging the wound.” The ‘plasters’ referred to were what we today would call wound dressings to protect the wound, absorb exudate and apply healing herbs and plant extracts.

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NEXT-GENERATION IRRIGATING SOLUTIONS FOR WOUND BED PREPARATION

The Healing Process Peter Dunwell, Medical Correspondent

Wound irrigation is the steady flow of a solution across an open wound surface to achieve wound hydration, to remove deeper debris, and to assist with the visual examination.

OR ANY cause or type of a wound, the sooner remedial and healing treatment is started, the better the outcome is likely to be. With any wound requiring a period of treatment to aid recovery, but particularly with a chronic or hard-to-heal wound, it will be important initially to measure and record the size, depth and position plus rate its severity. This is usually accomplished using the University of Texas classification system, SINBAD (Site, Ischaemia, Neuropathy, Bacterial infection, Area and Depth).

When Natural Healing Isn’t Enough Hard-to-heal wounds are a particular problem that can result from a number of factors. Wounds International ‘Hard-to-heal wounds made easy’ explains14 “Wound aetiology, patient age and the presence of significant comorbidities all impact on the healing process, as do factors such as wound size and depth, location of the wound, wound duration and the presence of a heavy bioburden.” Fortunately, as Wounds International also explains in the paper ‘Wound bed preparation: TIME in practice’15, “The management of chronic wounds has progressed from merely assessing the status of the wound to understanding the underlying molecular and cellular abnormalities that prevent the wound from healing. The concept of wound bed preparation has simultaneously evolved to provide a systematic approach to removing the barriers to natural healing and enhancing the effects of advanced therapies. Wound bed preparation and the TIME framework are most likely to be successful when used alongside the wound bed preparation care cycle.” TIME To explain, and from the same paper, “The TIME table has been designed to help the clinician make a systematic interpretation of the observable characteristics of a wound and to decide on the most appropriate intervention: T– I– M– E–

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for Tissue: non-viable or deficient; for Infection/inflammation; for Moisture imbalance; for Edge, which is not advancing or undermining.”

Wound Care – Elements in the Process Today, wound care is as well researched as any other healthcare process and is designed not only to heal the wound (the ultimate objective in most cases) but also to avoid side-effects and associated conditions as much as possible. In its Best Practice Statement ‘Optimising Wound Care’16 Wounds UK states, “When a patient with a wound is managed inappropriately, they can suffer from failure to heal which results in the wound being present longer than is necessary and an increased risk of complications… ineffective management can result not only in prolonged patient suffering, but also increased cost to healthcare organisations.” Cleaning and irrigation Having established that the wound requires treatment, usually the first thing is to clean it – either the trauma that caused the wound and/or any infection that has caused or prolonged the wound will put debris or infected tissue into the wound site. In many cases, that plus dressing will be sufficient but sometimes, further treatment is necessary. “Wound irrigation is the steady flow of a solution across an open wound surface to achieve wound hydration, to remove deeper debris, and to assist with the visual examination. The irrigation solution is meant to remove cellular debris and surface pathogens contained in wound exudates or residue from topically applied wound care products. Compared to swabbing or bathing, wound irrigation is considered to be the most consistently effective method of wound cleansing.” That’s the conclusion of Medscape17, which continues, “Combined with debridement, irrigation is a critical step in facilitating progression from the inflammatory to proliferative phase of wound healing… The goal of irrigation is to clean the wound while avoiding trauma to [the] wound bed and minimizing risk of driving bacteria further into the wound bed.” Exudate control One serious issue with wounds is exudate, the continual ‘oozing’ of liquid from the wound site. Trudie Young, a Tissue Viability Nurse writing for Wounds UK18 explains, “Inappropriate management of exudate can lead to complexities

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including skin damage, pain and poor patient wellbeing. Healing is prolonged, placing a burden on patients and NHS resources. For example, poorly managed exudate leaking onto surrounding skin can cause periwound maceration, breaching the skin’s barrier against infection.” Debridement Debridement is usually little more than the removal of dead tissue or debris from the wound site which, in turn, will often be a natural process. But sometimes the healing process can be improved or accelerated if debridement can be enhanced and that will often be a surgical process. However, there are other options including a simple mechanical process and even the use of sterile larvae; but, however it is achieved, debridement will deal with the first element in the TIME table (see above), reduce the infection load on the body and support better healing. Preventing infection At any stage in wound healing, the prevention of wound infection is paramount. Not only

will infection slow the rate of healing or even reverse it, but also wound infections are among the most frequent hospital acquired infections making them a key contributor to unnecessary hospital deaths. Irrigation is an important contributor to infection control in removing dead tissue from the wound and thus removing the material on which infections can thrive. Most of the above fall into the general category of ‘wound bed preparation’ – a structured process for wound management and the achievement of better healing outcomes. Wound bed preparation involves optimising the state of the wound bed by application of the various procedures described above. Another matter in wound management is the assessing and management of pain which can cause a range of psychological as well as physical problems. Wounds are a serious condition and, as the next article will cover, they can have impacts beyond the effects on the patient – which are bad enough. There are also resource and cost implications if a wound is not well managed.

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The Costs of Wounds John Hancock, Editor

However they’re measured, suffering, discomfort, quality of life or financial cost, wounds are a burden.

The annual NHS cost of managing wounds was estimated to be £4.5£5.1 billion, two-thirds of which is incurred in the community and the rest in secondary care. This is comparable to the annual NHS cost of managing obesity which was estimated at £5.0 billion in 2013.

ETER DUNWELL’S article (previous) refers to Wounds UK’s statement, “When a patient with a wound is managed inappropriately, they can suffer from failure to heal which results in the wound being present longer than is necessary and an increased risk of complications… ineffective management can result not only in prolonged patient suffering, but also increased cost to healthcare organisations.” It is from that statement that we will conclude this paper. If any part of the body becomes infected, that can pose a threat to the whole body. This is especially true for long-term open and slow healing wounds. The best thing with a wound of any sort is to put in place a sound regime of wound care and management with a view to preventing it from becoming hard-toheal or further infected. But it’s not all doom and gloom. In a 2015 study for BMJ Open19, which followed a group of patients, it was found that, “Sixty one per cent of all wounds healed in the study year; 79% of acute wounds healed and 43% of chronic wounds. Binary logistic regression suggests that nutritional deficiency… and diabetes… were independent risk factors for non-healing during the study period. [Only], 4% of patients with a wound and 1% of control patients died in the study year.” As well as physical health issues, acute and chronic wounds can pose psychological problems such as stress, anxiety and mood disorders for patients. A 2012 PubMed survey for NCBI in the USA20 concluded that “increased awareness of the behavioural signs of stress, anxiety and mood problems among patients with wounds could help to improve the patient’s experience of wound care, as acknowledgement of mood problems could lead to the most appropriate form of treatment or help for individual patients.”

Wound-Related Complications According to Wound Care Centers21, “The most common wound complications are:

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• Infections: Wound infection presents with pus drainage, foul odour, fever, dull throbbing pain, mild swelling and heat at wound site. • I nflammation: Inflamed wounds are hot, red, painful, swollen and hard to move. • Scarring: Regenerated cells have different characteristics and fibrous tissue that can heal the wound, but may leave a scar behind. •L oss of function: Many wounds can be disabling and life threatening if a major organ, blood vessel or nerve was damaged. Either way, while the wound is still fresh or healing, the affected limb or area will lose its functionality until all lost or damaged tissue is repaired. All of the above are unpleasant but also threatening complications with the potential to adversely impact on the quality of life for any patient who suffers from them. Also, with the growing global trend towards antibiotic resistant infections, the number of weapons that a clinician can deploy against such complications is reducing every year. So more complex and lengthy treatments have to be considered and that means ‘more costly’ treatments. Infections such as sepsis might not be the stuff of common parlance but, along with resistant infections such as MRSA, they can pose an existential threat every bit as dangerous as conditions such as cancer. According to the UK National Health Service (NHS)22, people who “have just had surgery, or have wounds or injuries as a result of an accident” are among those more vulnerable to sepsis. At the least, sepsis can delay wound healing; at the worst it can be fatal.

Impact of Wounds on People Who Have Them We’ve already (above) touched upon the impact of any wound on quality of life; but “not all wounds will heal (such as those related to malignant disease) and so full healing might not be a realistic outcome for every patient.”23 That’s taken from Independent Nurse ‘Holistic assessment: the patient and wound’. This makes the proper assessment of both patient

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and wound all the more essential to ensure that every possible step is taken to minimise suffering for the patient.

Financial Impact of Wound Care on Healthcare Systems While nobody likes to talk about health care as an economic process, it is and, as well as the costs to patients highlighted above, there is another and financial cost to chronic wounds. Systagenix’s paper ‘Quantifying the economic value of diagnostics in wound care in the UK’24 opens with the statement that; “Chronic wounds present a significant financial and resource burden to the NHS. The annual cost of wound care in the UK has been estimated to be £2 million per 100,000 population [based on 2006-2007 prices].” Looking at those figures in more detail, the Systagenix paper continues to add that there are around 200,000 chronic wounds in the UK and they represent a significant burden to the patient and the NHS. Chronic wounds were estimated to cost the NHS around £2.3-3.1bn

at 2006 prices – 3% of NHS budget. However, with proper diagnosis and treatment, much of the disease burden can be avoided. This cost of chronic wounds is, of course, in addition to the costs of any wounds not only in the resources used for treatment but also in lost economic value from, say, somebody who needs to take a few days off work while a wound heals to someone who is unable to work at all but requires regular and expensive treatment. A BMJ research paper ‘Health economic burden that wounds impose on the National Health Service in the UK’,25 sums up the economic burden. “The health outcomes, resource implications and associated costs attributable to managing wounds in 2012/2013. After adjustment for comorbidities, the annual NHS cost of managing wounds was estimated to be £4.5–£5.1 billion, two-thirds of which is incurred in the community and the rest in secondary care. This is comparable to the annual NHS cost of managing obesity which was estimated at £5.0 billion in 2013.”

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NEXT-GENERATION IRRIGATING SOLUTIONS FOR WOUND BED PREPARATION

References:

CliniMed www.clinimed.co.uk/Wound-Care/Education/Wound-Essentials/What-is-a-Wound-.aspx

Wound Care Centers www.woundcarecenters.org/article/wound-basics/different-types-of-wounds

1 2

Wounds International, ‘Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers’ www.woundsinternational.com/media/issues/673/files/content_10803.pdf

NHS Choices www.nhs.uk/Livewell/skin/Pages/Commonconditions.aspx

Wounds UK www.wounds-uk.com/pdf/content_9409.pdf

Wounds International www.woundsinternational.com/media/issues/514/files/content_10140.pdf

Nursing Times www.nursingtimes.net/measuring-the-prevalence-and-incidence-of-chronic-wounds/200097.fullarticle

http://bmjopen.bmj.com/content/5/12/e009283.full

Wounds International http://www.woundsinternational.com/media/issues/514/files/content_10140.pdf

Nursing Times www.nursingtimes.net/Journals/2015/06/05/q/f/y/The-burden-of-chronic-wounds-in-the-UK.pdf

Wounds UK www.wounds-uk.com/made-easy/accel-heal-made-easy&print

Wounds UK www.wounds-uk.com/pdf/content_11701.pdf

NCBI www.ncbi.nlm.nih.gov/pmc/articles/PMC3601883/

Wounds International www.woundsinternational.com/media/issues/514/files/content_10140.pdf

Wounds International www.woundsinternational.com/media/issues/122/files/content_86.pdf

Wounds UK www.wounds-uk.com/best-practice-statements/best-practice-statement-optimising-wound-care

http://emedicine.medscape.com/article/1895071-overview

Wounds UK www.wounds-uk.com/pdf/content_10816.pdf

http://bmjopen.bmj.com/content/5/12/e009283.full

US National Library of Medicine www.ncbi.nlm.nih.gov/pubmed/22240932

Wound Care Centers www.woundcarecenters.org/article/wound-basics/different-types-of-wounds

NHS Choices www.nhs.uk/Conditions/Blood-poisoning/Pages/Causes.aspx

Independent Nurse www.independentnurse.co.uk/clinical-article/holistic-assessment-the-patient-and-wound/63468/

Systagenix, UK www.woundchek.com/uploads/downloads/posters_articles/Quantifying-the-economic-value-of-diagnostics-in-wound-care-in-the-UK.pdf 24

http://bmjopen.bmj.com/content/5/12/e009283.full

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