December 2023
MasterSeries 60 Minutes Interactive All Roads Lead to Healing: Mastering Wound Bed Preparation
from providing services to those not likely to
Global expert
benefit – avoiding under use and misuse
Ms Terry Swanson Vice Chair, International Wound Infection Institute
•
Patient centered: Providing care that is respectful of
Victoria, Australia
and
responsive
to
individual
patients’
preferences, needs and values and ensuring that patient values guide all clinical decisions
Global expert Prof Georgina Gethin
•
Professor of Nursing, Head of School of Nursing and Midwifery, University of Galway
Timely: Reducing wait and sometimes harmful delays for both those who receive and those who give care
Galway, Ireland
•
Person Centeredness and Combining It With Wound Bed Care
Efficient: Avoiding waste, including waste of equipment, supplies, energy, and ideas
• What Is Quality in Healthcare?
Equitable: Providing care that does not vary in quality because of personal characteristics such as gender, ethnicity, geographic location, and
In the US, the agency for healthcare research and
socioeconomic status
quality identifies six domains that are considered 1
to be indicators of health care quality. With the application of this with wound care, patients can
•
The key symptoms and experiences associated with a chronic wound
experience high quality and consistent treatment, aiding to their satisfaction and wellbeing during the
This can be divided up into three categories: physical
process of their care.
impact, social impact, and psychological impact. These are all integrated within the person-centred
Care being provided should be:
Supported by
•
Safe: Avoiding harm to patients from the care that is intended to help them
•
Effective: Providing services based on scientific knowledge to all who could benefit, and refrain
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MasterSeries 60 Minute Interactive: All Roads Lead to Healing: Mastering Wound Bed Preparation
“The notion of person-centred care offers a vital perspective that patients should be at the centre of decisions made, rather than on the periphery. Clinicians with such wider perspectives will enhance the quality of care for their patients.”
•
Figure 1: interconnected themes of patient impact.
Adherence: Decision to accept, reject or modify their treatment
•
Concordance: Agreement between a clinician and patient on the treatment plan
In comparison to other concepts, such as compliance adherence and concordance, person centred care holds 8 principles, as identified by the Picker Institute at Harvard Medical school. Although not defined as an academic research or set out as policy, the principles had been defined via consultation with the public. These include: •
Continuity and transition
•
Access to care
•
Information and education
•
Respect of patient’s preferences
•
Physical comfort
The notion of person-centred care offers a vital
•
Involvement of family and friends
perspective that patients should be at the centre
•
Emotional support
of decisions made, rather than on the periphery.
•
Co-ordination and integration of care
Clinicians with such wider perspectives will enhance The examination of these decided principles in relation
the quality of care for their patients.
to wound care is important for better treatment and The World Health Organisation (2015) described
care. In regard to access to care, it can be considered
person-centred care as “a paradigm shift toward
for patients with recurrent wounds - such as venous
an approach where people have the education and
leg ulcers or hidradenitis suppurativa - as they know
support, they need to make decisions and participate
when a wound is about to break out, or the early signs
in their own care”.
of it about to, they may become more impatient with the idea of being added to a waiting list, wanting more
Support may consist of social, health service or financial
support.
This
description
from
prompt access the care they require at that time.
WHO
emphasises that it is based on people’s needs and
Information and education in an appropriate format
expectations, rather than a focus on diseases. The
which patients can understand and access freely
approaches and practices that consider the person
is equally important. Evidence shows that current
as a whole, with many levels of needs and goals,
resources for wound care are not widespread and
with these needs coming from their own personal
readily available. The European Wound Management
social determinates of health. Whilst this is a very
Association are contributing to this by providing more
thorough and tasking approach, clinicians can use
patient education.
this approach to improve the wellbeing and results for their patients.
Co-ordination and integration of care can look to the analysis of medical records, for example. It is
•
Compliance: Willingness to follow or consent to
possible for there to be separate medical records
the wishes of another
depending on departments such as dermatology, GP practice, hospital practices, etc. This may include
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MasterSeries 60 Minute Interactive: All Roads Lead to Healing: Mastering Wound Bed Preparation
“A wound can be thought of as like an island. An island is affected by what is surrounding it, and under it.”
the continuity of care and transition arrangements.
•
In each study, it was identified that patients
A various set of notes requires coordination and for
with chronic wounds had poorer mental health
it to be integrated properly for the patient. Wound
than their age/ gender counterparts. This was
care practitioners must also be aware of the sensitive nature of analysing these notes - a patient can find
achieved with different measuring scales •
looking at such material to be distressing as they are
99% could walk unaided, serving to be beneficial as mobility and exercise is a factor to promote
not used to seeing it like an experienced clinician is.
healing
Involvement of family and friends regards emotional
•
53% have hypertension (EU)
support,
•
16-20% have diabetes3
but
may
also
include
educational,
appointment arrangements. Physical comfort may be achieved with beds, appliances, and suitable
A group of patients with chronic wounds and the topic
compression wear.
of wound assessment heavily regards looking at a group of individuals with complex health care needs.
European Wound Management Association have
Fit and healthy people do not get chronic wounds;
further evidence for person centred care for chronic
there is one fundamental underlying comorbidity, and
wounds.
at least one underlying factor that is affecting healing. Furthermore, prescribed medications, environmental
Also, impact of patient health and lifestyle factors on
factors, and age, etc.
wound healing: The Island Paradigm •
Stress
•
Sleep
A wound can be thought of as like an island. An island
•
Smoking
is affected by what is surrounding it, and under it.
•
Alcohol
When looking at wound assessment, it can be broken
•
Common medication and illicit drug use
down into further parts:
•
Physical activity
•
Nutrition Figure 2: Holistic approach to wound assessment.
These are the most prevalent risk factors. The Profile of Patients With Venous Leg Ulcers: A Systemic Review and Global Perspective Evidence taken from multiple sources of data produced these key findings on patients with venous leg ulcers complied into a picture of the population we are dealing with: •
Age 47 (Asia)
•
Age 69 (EU)
•
Ulcer size is on average 25.7cm^2 (EU)
•
To 30.95cm^2 (South America)
•
Mean ulcer duration = 13.8 months (EU)
•
To 65.5 months (South America) - Longer, arguably due to various different resources and the structure of services
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MasterSeries 60 Minute Interactive: All Roads Lead to Healing: Mastering Wound Bed Preparation
“Many clinicians now begin consultations in a different way, ensuring that patient centred concerns are emphasised. This is expressed via questions asking the patient of their concerns, specific care requests, and establishes a focus on what the patient would like to assess, rather than creating one sided medical goals from a practitioner.”
All of these factors will influence what the wound
6. Assess for treatment infection.
looks like, as well as altering the rates of healing and the risk of further deterioration.
7. Moisture management.
Preparing the Wound to Heal
8. Evaluate rate of healing.
This approach4 looks at wound bed preparation in
9. Edge effect:
terms of updated recommendations. It is shown to be effective as it begins with a person with a chronic
Regards looking at the edge of the wound to indicate
wound, focusing on the patient immediately with
wound status.
this person-centred care approach. Secondly, it looks to identify/ treat the cause of the wound and
10. Organisational support.
identify the patient and family’s centre of concern. Thirdly, determine the ability to heal, before moving
Wound assessment helps to plan treatment, monitor,
on to looking at local wound care. This may include
and evaluate, justify interventions, and in terms of
debridement, inflammation/ local infection, and
enhanced communication.
moisture balance. Wound bed assessment is fraught with a longThe approach suggests ten recommendations for
standing difficulty of it being primarily subjective.
clinicians to instil in their practices:
This is due to the fact it consists of visual inspection and relying on descriptors to help clinicians identify a
1. Treatment of cause:
wound. There are very few objective methods. More of the interventions in wound assessments require
It is important to identify the cause and to treat
technology, and this requires more finance and
it. This may be pressure, moisture associated skin
resources that may not be accessible to everyone.
damage, medical device related injuries, or venous hypertension.
The triangle of wound assessment5 involves analysing three aspects of the wound:
2. Patient centred concerns: •
Wound bed
Many clinicians now begin consultations in a different
Tissue type
way, ensuring that patient centred concerns are
Exudate
emphasised. This is expressed via questions asking the patient of their concerns, specific care requests,
Infection •
Wound edge
and establishes a focus on what the patient would
Maceration
like to assess, rather than creating one sided medical
Dehydration
goals from a practitioner.
Undermining Rolled
3. Determine ability to heal:
•
Periwound skin Macerating
This aspect questions whether is it possible for a
Excoriation
wound to heal or not.
Dry skin Hyperkeratosis
4. Local wound care
Callus Eczema
5. Debride when indicated
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MasterSeries 60 Minute Interactive: All Roads Lead to Healing: Mastering Wound Bed Preparation
“Wound bed assessment is fraught with a long-standing difficulty of it being primarily subjective. This is due to the fact it consists of visual inspection and relying on descriptors to help clinicians identify a wound.”
Figure 3:
Figure 4:
Figure 5:
Figure 6:
Figure 7:
Figure 8:
With the wound blocked out in Figure 3, the
By contrast, Figure 5 shows a heel wound from a
surrounding of it can be made clearer. Doing so will
patient with diabetes and history of stroke. There
improve judgement of what the wound is likely to be.
are no areas of surrounding erythema, no signs of infection despite the build-up of thick tenacious
There is dry flaky skin build up, varicose eczema and
slough. The wound presents a well-defined edge,
dryness from prolonged bandaging. There is also
alongside healthy tissue that is merging into the
a fragile periwound area, combined with satellite
wound.
lesions and varicosities. This patient has venous hypertension, long-standing venous leg ulceration.
In a case like Figure 5, the treatment should aim to protect the good tissue that is there via the form of
Figure 4 reveals the wound. In looking into this and
granulation tissue around the top. Removal of slough
assessing the edge of the wound, the potential of
is not recommended at this point. As this patient has
healing can be decided. The edge blending into the
severe peripheral arterial disease, removing slough
wound and lack of definition, alongside the wound
via a scalpel would cause a new wound to open up,
bed itself showing fibrous and bright red friable
causing a rebound necrosis. The primary aim with
tissue, shows there is potential for healing, however
this wound would be to manage the exudate, protect
it requires a renewed approach. A healing wound
underlying tissue, and monitor any signs of infection.
would hold a more defined edge, with areas showing epithelial edge advancement. This is not evident in
Figure 6 presents a different kind of wound edge.
this particular wound.
It holds a purple hue on its surroundings, with a dark dull red. The issue of colour is shown here as a bright red indicates a good red granulation tissue;
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MasterSeries 60 Minute Interactive: All Roads Lead to Healing: Mastering Wound Bed Preparation
“Adequate wound cleansing is vital for all wound cases. Utilisation of a good irrigation fluid to cleanse the wound, and potentially drinkable regular tap water, will aid in the healing process.”
Figure 9: Periwound assessment.
take a long time. In this patient, the likelihood of healing is very small, primarily due to many social circumstances, but due to multiple underlying comorbidities. The wound edge shows a highly fragile and friable state. Underneath it, there is a delicate and inflamed tissue, beside areas of epithelial that are popping up indicating that healing is occurring. However, there is a large build-up of pseudemonas, maceration and inflammation. There is copious exudate from the wound that is pouring down and gathering around the ankle.
description can become problematic. Figure 6 is red, however as it is a dull red it is a poor indication. The
Treatment would be to treat underlying infection,
entire wound is covered in fibrous tissue, but it is not
irrigation to reduce bacterial burden, as well as extra
slough. The edge is ragged and also very thin.
moisture absorbing dressings around the ankle with protection of the periwound area. Regular wound
This patient has rheumatoid arthritis. With flare
dressings would also be required. Changing absorbent
ups, the wound would become enlarged. Here, the
pads to soak up exudate would be beneficial. The
deterioration is due to rheumatoid arthritis and drug
patient in Figure 8 refuses compression therapy
therapy the patient was undergoing.
despite being eligible for it.
The wound is a healable wound and can be managed
Wound edge assessment in Figure 8 shows a very
by managing exudate from the wound, managing
varied result. This evidence supports the fact that
inflammation around the wound, and managing local
a challenge in wound care includes the fact that a
wound infection.
wound is not a uniformed island and is different depending on the focus point of the wound.
Figure 7 presents a patient with a common kind of venous leg ulcer. There are no signs of infection or
Figure 9 clearly illustrates an infected wound, with a
inflammation around the wound. The wound bed
large maceration of periwound skin due to excessive
itself presents bubbly like granulation tissue – ideal
moisture from the wound. There is also a build-up
tissue accompanied with a well-defined wound edge
of slough, surrounded by a friable edge that is not
that is not inflamed nor slopping into the wound itself.
defined but inflamed.
There is some fibrous tissue, however no build-up of slough. Management of a simple dressing to protect
In this case, gentle irrigation to clean the wound
the tissue combined with a management of wound
bed and reduce the bacterial burden, high quality
exudate would be ideal.
protection of the periwound skin, and adequate moisture control would be sufficient for management.
Adequate wound cleansing is vital for all wound cases.
Compression therapy should be held off until the
Utilisation of a good irrigation fluid to cleanse the
infection has been resolved.
wound, and potentially drinkable regular tap water, will aid in the healing process. Figure 8 presents a highly extensive venous leg ulceration. It is a healable wound; however, it may
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MasterSeries 60 Minute Interactive: All Roads Lead to Healing: Mastering Wound Bed Preparation In regard to protecting the peri wound area it is
The human microbiome is a complex system. On some
important to:
occasions the microbiome works together to reduce pathogenic bacteria - not all biofilms are necessarily
• •
Protect it from Moisture Associated Skin Damage
bad. This is only the case when it becomes pathogenic
(MASD)
and subsequently forming hyperinflammation leading
Cleanse
with
hypoallergenic
non
irritating
to a chronic and recant wound healing process.
products •
Avoid
products
containing
preservatives,
This shows an imbalance where there are too many
quinoline, PVP iodine
negative components that are not conducive to
•
Tepid water only if used
wound healing, and such destructive enzymes and
•
Opt for the utilisation of no rinse products
toxics can worsen the wound condition. It causes
•
Gently dry the skin
for the wound to change from being host centric -
•
Carefully consider wound dressings
controlled by the body’s physiological processes - to
•
Use skin protectant products
now more bacteria centric. This imbalance decreases the amount of growth factors. Additionally, the
To conclude, wound bed preparation involves
destructive lytic enzymes and free radicals affect cell
patient assessment, assessment of the aetiology
proliferation and wound healing capability.
of the wound, healing assessment, and wound bed assessment.
The
nutrient
rich
exudate
from
persistent
inflammation assists in the bacterial cause and makes
Wound Bed Preparation
that environment more hostile, therefore affecting immune recognition and the healing process.
Principles of Biofilm Management Biofilm Consensus Group 2017 findings Planktonic is not the normal state for bacteria. It is considered as non-attached, free floating and
In a consensus group from 2017, signs and symptoms
replicating. It goes into great density/ virulence and
were established:
becomes an acute infection. Antibiotics are effective for planktonic because they are replicating.
•
Failure of appropriate antibiotic treatment
•
Recalcitrance
themselves, to the dressing, or below the wound
to
appropriate
antimicrobial
treatment
Biofilm is when they attach; they can attach to •
Antibiotics do not function on non-replicating bacteria. Biofilm decreases myotic activity
surface. When they become attached, they can aggregate. Aggregation can enable communication known as quorum sensing.
•
When they begin to mature, they become more
•
Recurrence of delayed healing on cessation of antibiotic treatment Patients with local infection or biofilm infection
tolerant to most antimicrobial agents. The host
are often on a 10-week cycle, in which once the
defences’ efficacy becomes reduced due to the
antibiotic treatment has stopped, symptoms
protection of the extracellular matrix because the
come back rapidly
centre of a mature biofilm may be slightly hypoxic, and the myotic activity – replicating – has decreased.
•
Delayed
healing
despite
optimal
wound
management and health support
Therefore, antibiotics would not become effective. •
Describes when a patient has a healable wound
The body recognises that the biofilm is there, and
but delayed healing despite optimal treatment –
therefore it promotes a chronic inflammation.
diagnosis and targeted therapy
Evidence shows that it can be over 1000x more tolerant to antibiotics. Biofilms have primitive
•
Increased exudate/ moisture
circulatory systems that facilitate uptake of nutrients
(when) doing weekly assessments, an increase in
and removal of metabolic products. These nutrients
moisture is a negative indicator
can be from edema and fluids, hence why moisture
94
management is vital. This causes an increase of
•
Low-level chronic inflammation
exudate when there is a biofilm.
•
Low-level erythema
•
Patients
may
sometimes
be
prescribed
There can also be gene transfer of microbes within
antibiotics despite it being an inflammation
the biofilm, and this may be polymicrobial.
instead of an infection
Wound Masterclass - Vol 2 - December 2023
MasterSeries 60 Minute Interactive: All Roads Lead to Healing: Mastering Wound Bed Preparation •
Poor granulation/friable/hyper granulation
•
Secondary signs of infection
Figure 10:
Figure 10 shows an updated version of biofilm based wound care. It upholds consistent instructions of the disruption of the biofilm and the prevention of recolonisation. With this scheme, the signs of persistent inflammation must be monitored. Presence of slough and necrosis may not necessarily be relevant to biofilm, as it may be a result of other things such as circulation (for necrosis) and moisture balance (for slough). Management of Biofilm: Common Ingredients •
Knowing aetiology
•
Standard of care for that aetiology
The International Wound Infection Institute (IWII)
•
Wound and periwound cleansing.
coined the term ‘wound hygiene’. It was expanded
•
Debridement of wound, edges and periwound
and explored on within the document, providing a
•
Once the wound is prepared then proactive
consensus of what wound hygiene entails. It involves
management to prevent microbial attachment
an anti-biofilm strategy: what to look out for, and how to handle the intensity of those interventions.
Consistency in the recommendations of biofilm: Outline of Wound Hygiene •
WBP – Wound Bed Preparation, since 1990s.
•
Time –since early 2000
1.
Cleanse the wound and periwound skin
•
BBWC - Biofilm based wound care
2.
Debridement
•
Step-down step-up paradigm – published 2017
3.
Refashion the wound edge
•
Wound Hygiene – published 2019
4.
Dress the wound
These documents provide a synthesis of the latest
The wound hygiene concept has continued to evolve;
research and evidence. They are also patient
it began with the wound itself and continued to
centered, and when adapted locally they can provide
expand. The wound healing framework includes
cultural sensitivity and awareness.
assessment, management of the wound via the four steps of wound hygiene, and monitoring to ensure
As they are reviewed and authored by clinicians
the cycle of healing continues.
for clinicians the majority are free for download or feature a low fee requirement to increase
The
accessibility. Additionally, they can be translated into
contamination,
many different languages.
spreading infection and systemic. Due to the usage
wound
infection
continuum
colonization,
consists
localised
of
infection,
of the term ‘critical colonization’ in 2008, localised has Using evidence-based practices in documents can
become asterisked.
be highly beneficial due to the issues presented by disparity in how people are managing wound
The continuum became updated in 2016 via rigorous
bed cleansing globally. As there is varied practice
methodology. Figure 11 displays this version, with
throughout the world, these documents detailing best
terminology about increasing microbial virulence in
practice and guidelines provide a helpful framework
green, and there is also a biofilm arrow included at
for people to be apply to their own clinical practices.
the top.
They may also be used to update policies and
The intervention strategy developed with changes to
procedures; accrediting the clinic with higher quality
reserve topical anti-microbials for when there is a local
references and data as the latest evidence is being
infection, as well as saving systemic antimicrobials.
implemented.
The term critical colonization had been removed, saving
systemic
antimicrobials
for
spreading/
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MasterSeries 60 Minute Interactive: All Roads Lead to Healing: Mastering Wound Bed Preparation Figure 11:
Figure 12:
Figure 13: Evaluation of an infected wound.
systemic infection. This enables good stewardship of antiseptics and antimicrobials. The wound infection continuum became updated further in 2022 (Figure 12), again via rigorous methodology.
This
edition
features
signs
and
symptoms under the relevant terminology. Local Infection: Infection Contained within the Wound Bed Covert, also known as Secondary S&S infection: •
Delayed healing or increased size of wound
•
Unhealthy granulation tissue
•
Increased Exudate
•
Suspected Biofilm
Overt, Classic S&S infection:
Spreading Infection, the invasion of surrounding and deeper tissue by ineffective organisms:
•
Erythema within 2 cm
•
Purulent exudate
•
Increasing pain
•
Local warmth and oedema
•
Erythema becomes greater than 2 cm, as shown in Figure 13
•
Cellulitis
•
Lymphangitis
•
Enlargement of the wound and/or satellite ulcers
Covert is aligned with the biofilm and the secondary signs of infection such as delayed healing, increased
Treatment would not solely consist of therapeutic
wound size, and unhealthy granulation tissue.
cleansing and topical antimicrobials, but also includes systemic antibiotics.
Overt are the classic signs of infection, including increased pain, oedema, and there may be some exudate. It is important to note that this is still contained within the wound bed. Treatment is proactive as it involves therapeutic cleansing and consideration of topical antimicrobials.
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MasterSeries 60 Minute Interactive: All Roads Lead to Healing: Mastering Wound Bed Preparation Figure 14: Determining infection vs induration of a wound.
edges to prevent the microbes that are on the periwound surface returning to contaminate the wound. The intensity depends on the healing phase and condition the wound is in. The importance of wound cleansing: •
Decreased antibiotics prescribing
•
Alteration of wound environment
•
Disruption of biofilm
•
Improved efficacy of topical treatments
•
Prevention of escalating from local infection to spreading of infection (when conducted in early phases of wounding)
•
Maybe saving a limb or life
It is vital to ensure that when doing therapeutic irrigation that there are the correct pounds per square inch of 4-15 psi. With loose or necrotic tissues, a higher psi would be required, and it may be lowered once it is clean or healing. Therapeutic irrigation must be carried out with personal protection.7,8 Options for cleaning the periwound and skin: •
Portable water and wash cloths
•
Commercial wipes - often used in podiatry
A challenge presented in wound care is the confusion
department due to its smaller body surface
between infection and inflammation. Figure 14
•
Glove fingers
presents an inflamed wound that may be caused
•
Forceps
from contact with the dressing and a reaction, or it
-
often
used
for
scraping
off
hyperkeratotic tissue
may be the wound fluid that is now interacting with
•
Sponges
the skin in a negative way causing contact dermatitis.
•
Utilisations of cleaning agents – provides
By understanding the cause, the difference can be
synergistic effects that are highly beneficial6
made better. Tips for Practice When cleansing wounds, it is effective to adopt a thorough and comprehensive approach. It is possible
•
to remove non-viable tissue and clean it up to enable the dressings to directly contact the wound surface
the periwound •
and perform better. Once the biofilm and micro
Don’t contaminate the water. If using a bowl of warm water, do not put the cloth that touched
environment has been disrupted, the dressings have better access.
You can be soaking the wound while you clean
the skin back into the water •
You can apply pH neutral/ antiseptic skin cleanser on gloved hands, massaging it in and
Helpful Tips for Therapeutic Wound Cleansing
then washing with potable water •
The patient can shower but the limb should be
When deciding what to cleanse with, it ultimately
bagged first, and then cleaned. This allows for
depends on what is there available, as well as the
the limb to be protected from the contaminates
type of wound – such as healing or infected. Infected
and microbes from the upper body
wounds can use antiseptics as its design is for this purpose. Cleaning occurs with each dressing change,
In the event the patient has a very dry scaly leg, it may
and anywhere there has been a dressing. This area
be the case that the leg has dried up after removing
should be cleansed about 20 cm from the wound
the compression wrap.
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MasterSeries 60 Minute Interactive: All Roads Lead to Healing: Mastering Wound Bed Preparation A good method to handle dry scaly wounds is as
its full potential of healing by being cleansed.
follows: A common misconception is that there is a difference • •
Create a soak by pouring solution on the wound,
between mechanical cleansing and debridement.
this provides it with contact time
However, they are essentially the same thing; both
Using gloves and with a combination of a pH skin
methods achieve the same goal. The components
cleanser, massaging the wound helps soften the
illustrated here may also be sued to be applied to
skin
negative pressure wound therapy.
Prevention is highly important in wound care to
Figure 15: Types of wound exudate.
ensure the wound does not become worse. Wound cleansing should also be combined with protecting limb skin health. The Management of Hyperkeratosis of provides easy strategies for cleansing and providing emollients. Hyperkeratosis is essentially a breeding ground for microbes and the goal is to reduce this to
Serous
Seroanguineous
Sanguineous
Seropurulent
Fibrinous
Purulent
Haemopurulent
Haemorrhagic
prevent infection. Rinsing, cleaning, or scrubbing a wound: It is important to clean a wound, and if it is an infection it would need to be scrubbed. In order for this to happen the synergistic effect and combination of an agent and mechanical device would be needed. •
Sterile water and normal saline have limited ability to manage microbes. If this is the only resource available, it is important to combine
•
•
•
•
this with more aggressive mechanical action
Figure 15 displays the different types of exudate. In
Antiseptic solutions assist in making the cleaning
regard to the viscosity, understanding the viscosity/
more effective. They can kill and or disrupt the
consistency can influence the effectiveness of
bacteria in the wound
dressings.
Surfactants make the job easier and more effective due to the fact it breaks surface tension
It is also beneficial to inspect the old dressings and find
and makes removing debris more effective
out when it was last changed. A dressing saturated in
Using mechanical aids improves the goal of
a matter of hours will not last for three days. This can
the activity. Using gauze is acceptable but
help decide the frequency of wound dressing change,
multiple would need to be used to prevent cross
or the absorbency of the dressing. Moisture needs to
contamination
be balanced, and the type of fluid and dressing used
Therapeutic cleansing is rigorous cleansing of
will aid in wound assessment.
wounds and periwound to remove: Assessing the Wound Exudate • •
Excess exudate, debris, remnant dressing, nonviable tissue
•
Inspect the used dressing for any leakage
Improve assessment, as components of the
•
Determine the amount of wound exudate in
wound are defined more clearly •
Disrupt and remove microorganisms
•
Wound cleansing should be done with each
both wound and dressing •
Assess the colour, viscosity, and odour of wound exudate
dressing change When managing and treating infection, it is important During this process it is important to be aware of the
to be mindful about prescribing antibiotics due to
fact that some cultures do not advocate cleansing.
antimicrobial wounds. It is still necessary to carry out
Due to the importance of cleansing, it is imperative
wound preparation even when prescribing antibiotics.
to teach the patients why it is needed and to have
The five-step guide to wound healing suggests key
cultural sensitivity. This can be done by proving the
warning signs including:
evidence and conveying how the wound needs to have
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Wound Masterclass - Vol 2 - December 2023
MasterSeries 60 Minute Interactive: All Roads Lead to Healing: Mastering Wound Bed Preparation •
A healable wound is not healing
delayed by external clinicians until the wound has
•
Changes to the patient’s overall health or
significantly worsened:
wellbeing (fever, etc.) •
Increased amounts of exudate, discoloration,
•
odour
Incorrect
diagnosis,
and
requirement
for
specialised clinics
•
Deterioration of wound edge or periwound skin
•
Requirement for advanced therapy
•
Hyper-granulation - discolouration of the wound
•
Growth factors
bed, granulation tissue, fragile wound bed tissue •
Biofilm should be suspected if a local infection
When wounds are not healing, or it is being
is
significantly delayed, clinicians can act as a facilitator
non-responsive
to
topical
antimicrobial
treatment
of advanced care, and work with other specialists to achieve the end goal. This may involve dieticians,
The classification system from the IWGDFU can be
podiatrists, and vascular surgeons. Sharing the
mirrored with the IWII classification system to portray
workload and collaborating will ensure the patient
consistent information and resources. This evidence
is provided with well-rounded specialised care for
shows how accurate resources and information are
optimal results. Moving towards a multidisciplinary
highly important to ensure clinicians follow a well-
clinic can provide high benefits for patients appearing
established routine.
with non healing wounds.
Why are wounds therapeutically cleansed?
As the healing trajectory becomes closer, more gentle methods can be adopted, and the need for sharp
•
To disrupt the biofilm
•
To cleanse excess exudate from the wound
•
To prepare the wound bed for cultures and/or
This biofilm suppression process, as established by
the wound dressing
Stephen Percival (2022), provides a process of how
•
To assist in wound assessment
to remove biofilms, similar to the existing concept
•
Removing debris, foreign bodies, remnant
therefore showing the great consistency between
dressing, and loose non-viable tissue
resources to enable high quality care over different
To decrease the bioburden
clinics.
•
selective reduce.
The ‘Step Down Step Up’ biofilm based wound care
It is important to note that sharp debridement
strategy places importance on the requirement to be
alone cannot solely achieve biofilm suppression.
less tolerant of non-healing wounds.
Cleansing is still necessary, as well as a repetition of debridement- depending on the depth of the biofilm
It is important to understand what the diagnosis is. If
below the surface level.9
this is unclear it is necessary to carry out a referral or use a clinicians that can provide this diagnosis.
Antimicrobial
Aggressive debridement and empirical treatment, as
Antimicrobial is an umbrella term used for antibiotics,
well as a standard of care should be implemented. In
antiseptics, and disinfectants.
doing so, the first week should enable an improved quality of living for the patient, such as decreased
•
Antibiotics
are
selective
agents
against
exudate and decreased odour. Whilst wound healing
replicating bacteria to kill or reduce them. It can
may not necessarily occur yet, a healing trajectory
be administered systemically or topically. With
should be established within the first month.
biofilms, there is a decreased activity of this, hence why they are not effective
With an expected healing timeline formed, the choice
•
Antiseptics are chemical agents that can be
to step them down to standard care could be made,
applied topically to a skin or wound. The new
or potentially step them up for more advanced
generation of antiseptics have low cytotoxicity
therapy options, as shown in the graph. With early
and selectivity. They are designed to inhibit and
intervention, this process is made possible.
kill the multiplication of microorganisms •
Disinfectants are not used on human wounds as
In cases where a wound does not benefit from this
they are toxic to human cells. However, they are
process or early intervention, it must be reassessed.
used to surfaces prior to putting equipment on
This also involves cases in which the diagnosis was
top. They are relatively non-selective agents with
Wound Masterclass - Vol 2 - December 2023
99
MasterSeries 60 Minute Interactive: All Roads Lead to Healing: Mastering Wound Bed Preparation multiple sites of actions that kill a wide range of
•
Semi-controlled environment
microorganisms •
Wound cleansing in a residential facility
Dressing Types, Indicators and Application: • • •
Medicated: such as honey, silver, antiseptic, and
Option for a shower would require same instructions as acute care settings
iodine
•
Assess risk factors
Non-medicated: work via actions, such as
•
Share or individual shower area
microbe binding, sequestering, osmotic or hypertonic which include rinsing, moisture
•
Wound cleansing in the home environment
donating, or absorbing if it is wet •
Passive: drying with gauze or non-adherent
•
Assess risk factors
•
Negative Pressure Wound Therapy (NPWT):
•
Health status
such as dressing, without cannister, disposable,
•
Repeated infections
instillation, and incision
•
Capability of doing the task independently
•
Cellular and tissue-based products: matrix and
or requires assisted care
scaffolding and growth factors Wound cleansing considerations:
•
Cleanliness of the home
•
Potable water
•
Equipment available and condition
•
Same instructions as previous environments
•
If cleaning wound and periwound once
•
Patient’s health related factors
•
Wound characteristics
shower completed options are in the
•
Availability of products/ equipment
shower or using a container
•
Complexity of the wound dressing procedure
•
Environment of where the wound dressing
Showers are encouraged for patients, however if
procedure will occur – such as unpredictable
there are repeated infections it is advised to keep the
home settings, or the controlled clean hospital
wound covered, irrespective of if it gets wet, as this
setting
can be changed after the shower.
•
Local policies and procedures
•
Wound cleansing in an acute hospital inpatient
thought should be evident in practice to ensure
setting:
cleanliness is achieved.
When wound cleansing in a home setting, care and
•
If
having
a
shower
(based
on
risk
Choices of Aseptic Technique
•
Cover the wounds during general hygiene.
Aseptic technique is based on:
•
After general hygiene patient removed
assessment)
•
from shower area if in shared shower
•
Sequencing
arrangement, remove the dressings and
•
Environmental control
cleanse the wound and periwound.
•
Hand hygiene
If single shower and minimal risk factors
•
Maintenance of aseptic fields
after general hygiene remove dressing
•
Equipment requirements
in the shower and cleanse (complete the
•
PPE
dressing application elsewhere) •
Use clean or disposable cloths to pat dry the area
•
Wound cleansing in a clinic or GP •
Option to remove their bandages/ dressings at home and cleanse prior to coming in (check risk factors and home environment)
•
Same principles for cleaning the wound and periwound, cover wound in shower
•
Either bring in the old dressing, take a photo or describe how the old dressing looked
100
Wound Masterclass - Vol 2 - December 2023
MasterSeries 60 Minute Interactive: All Roads Lead to Healing: Mastering Wound Bed Preparation Figure 16: Value-based healthcare.
The Standard Aseptic Technique
impact over an inexpensive option will prove itself to be the better option. This is due to the way in which
The concept of standardizing care for wounds in
an inexpensive option can add up, as opposed to the
different environments and patients has many
lower frequent costs of better value options.
challenges and is not seen to be suitable for clinicians wanting to hold a patient centric approach in their
Wound Hygiene and Health Economics
clinics. There are many risk factors, for example if the patient is severely immunocompromised, greater
When the recommended antiseptics and treatment
precautions are necessary. Similarly, in a home
programs are used, then the antibiotic antimicrobial
environment or controlled environment, there are
usage is reduced, as well as the length of treatment
different precautions and factors to consider. This
therefore providing more wound free days. This
also includes access to resources and equipment
results to an overall reduced price of therapy.
such as complex stainless-steel trolleys or dressing
Evidence in trials, product evaluation and case studies
trays. Following a patient centred approach would
all indicate that wound bed preparation provides
enable consistent quality of wound care depending
good health economics.10
on the circumstance, over standardizing and creating a rigid approach that will not be beneficial nor
Wound Bed Preparation for What You Can and Can’t
optimise results.
See.
Value Based Healthcare
Figure 17 is an augmented assessment using a fluorescent device. This helps to improve cleansing. In
When looking at the costs of wound care, it is very
a study showing the benefits of improved cleansing,
important to see the value in the option. Figure 32
there was:
portrays option B being cheaper, but causing to be more cost ineffective as it causes more later issues.
•
33% decrease in antimicrobial prescriptions
The value outweighs the initial cost point of the
•
49% decrease in prescription of antimicrobial
option.
dressings •
The frequency may also shift which option is cost effective. A high value product that can have a better
23% increase in wound healing rates within 12 weeks
•
2% decrease in amputation rate
Wound Masterclass - Vol 2 - December 2023
101
MasterSeries 60 Minute Interactive: All Roads Lead to Healing: Mastering Wound Bed Preparation This evidence shows the drastic benefits of
Figure 18: Immunofluorescence aiding in evaluation of a wound.
improving cleansing and conducting wound bed preparation in one year. Key Points To conclude, it is important to note that: •
Every wound dressing procedure matters
•
What you do or don’t do may affect the outcome of wound healing in the short term or long term
•
Assessment and diagnosis are key to providing appropriate and targeted therapy
Invest in healing by investing the time to: •
Provide aseptic technique or subscribe to the local wound infection and prevention protocols
•
Thorough
assessment
of
the
wound
and
wound/
periwound •
Therapeutic
periwound
cleansing/ debriding and cleansing •
Appropriate
wound
dressing
based
wound
goals
on
and
selection patient
preferences •
Monitoring
progress
and
making
appropriate referrals
References 1. Six Domains of Health Care Quality. Content last reviewed November 2018. Agency for Healthcare Research and Quality, Rockville, MD. - https://www.ahrq.gov/ talkingquality/measures/six-domains.htm 2. Naomi Fearns et al., 2017, Placing the patient at the centre of chronic wound care: A qualitative evidence synthesis. Journal of Tissue Viability, 26, 4, 254-259 3. Gethin, G., Vellinga, A., Tawfick, W., O’Loughlin, A., McIntosh, C., Mac Gilchrist, C., Murphy, L., Ejiugwo, M., O’Regan, M., Cameron, A., & Ivory, J. D. (2021). The profile of patients with venous leg ulcers: A systematic review and global perspective. Journal of tissue viability, 30(1), 78–88. https://doi.org/10.1016/j.jtv.2020.08.003 4. Sibbald et al., 2021, Wound Healing Southern Africa, 14 (2), 52-60 5. Dowsett C Et Al Triangle Of Wound Assessment Made Easy Wounds International 2015 6. Wounds International 2019 | Vol 10 Issue 4 | Wounds International 2019 7. Rodeheaver GT, Ratliff CR (2007) Wound Cleansing, Wound Irrigation, Wound Disinfection. In: Rodeheaver GT, Krasner DI, Sibbald RG eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. HMP Communications, Malvern, P.A. 8. White W & Asimus M (2014) Assessment and management of non-viable tissue. In: Wound Management for the Advanced Practitioner Edited by Swanson T, Asimus M and McGuiness B. IP Communications 9. Murphy, C., Atkin, L., Dissemond, J., Hurlow, J., Tan, Y. K., Apelqvist, J., James, G., Salles, N., Wu, J., Tachi, M., & Wolcott, R. (2019). Defying hard-to-heal wounds with an early antibiofilm intervention strategy: ‘wound hygiene’. Journal of wound care, 28(12), 818–822. https://doi.org/10.12968/jowc.2019.28.12.818 10. Queen, D. and Harding, K. (2023), What’s the true costs of wounds faced by different healthcare systems around the world? Int Wound J, 20: 3935-3938. https:// doi.org/10.1111/iwj.14491 11. Dunk, A.M. et al. (2023) A ‘quick guide’ to Pressure Injury Management, Wounds International. Available at: https://woundsinternational.com/supplements/a-quickguide-to-pressure-injury-management/ 12. The wound care pathway - corporate - coloplast. Available at: https://www. coloplast.com/products/wound/the-wound-care-pathway/ (Accessed: 16 December 2023). 13. Swanson, T., Ousey, K., Haesler, E., Bjarnsholt, T., Carville, K., Idensohn, P., Kalan, L., Keast, D. H., Larsen, D., Percival, S., Schultz, G., Sussman, G., Waters, N., & Weir, D. (2022). IWII Wound Infection in Clinical Practice consensus document: 2022 update. Journal of wound care, 31(Sup12), S10–S21. https://doi.org/10.12968/jowc.2022.31. Sup12.S10 14. Schaper, N. C., van Netten, J. J., Apelqvist, J., Bus, S. A., Fitridge, R., Game, F., Monteiro-Soares, M., Senneville, E., & IWGDF Editorial Board (2023). Practical guidelines on the prevention and management of diabetes-related foot disease (IWGDF 2023 update). Diabetes/metabolism research and reviews, e3657. Advance online publication. https://doi.org/10.1002/dmrr.3657
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Wound Masterclass - Vol 2 - December 2023
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