How To Build Solid Foundations to Support the Treatment and Management of Chronic Wounds by woundmasterclass

December 2023

How To Build Solid Foundations to Support the Treatment and Management of Chronic Wounds: A Clinician's Guide Editorial Summary Expanding upon the well-established TIME wound bed preparation protocol, M.O.I.S.T., an enhanced educational model designed by Wund-DACH researchers empowers healthcare practitioners to make well-informed and balanced decisions in the topical treatment of chronic wounds. Serving as a reference tool, the model advocates for a systematic and harmonized approach to wound care, thereby bolstering the practitioners' confidence in their treatment choices. Comprising 5 essential factors (Moisture, Oxygen, Infection, Support, and Tissue), the model offers a comprehensive framework that allows practitioners to adapt to the individual patient's requirements, elevating wound care practices to new levels of effectiveness and patient-centered care.

Introduction

ound care is a complex therapy area, with many variables impacting on the process of wound healing. Often, patients present with multiple co-morbidities that can directly or indirectly affect wound healing. Chronic wounds are, by their nature, wounds which take a longer time to heal. These include diabetic foot ulcers (DFUs), pressure ulcers/injuries (PI/Us), leg ulcers of different etiologies, and burns. These wounds are open areas or lesions which may present with significant tissue loss and contain a range of tissue types, spanning from healthy appearing granulation tissue to necrotic tissue and slough. Additionally these wounds frequently produce excessive levels of exudate which can negatively affect the wound and the surrounding skin. Chronic wounds can also be painful, malodorous, debilitating, and are often responsible for directly affecting the quality of life of the patient. This is not only a burden for the patient, but also for their families and carers.

Mr John Timmons International Medical Director, Mölnlycke Glasgow, United Kingdom

The financial burden of wounds within many health care systems may go relatively unrecognised due to the complex nature of the problem, lack of a unified approach, and the associated comorbidities.1

Assoc Prof Matthew Malone

Prof Dr Joachim Dissemond

Principle Scientist, R&D Bioactives and Wound Biology & Conjoint A. Professor Infectious Diseases and Microbiology, School of Medicine, Western Sydney University

Clinic for Dermatology, University Hospital Essen Essen, Germany

Macclesfield, United Kingdom

Wound Masterclass - Vol 2 - December 2023

A leading health economist in the United Kingdom has managed to successfully model the true financial cost of wound care in the National Health Service (NHS) and has found that the cost of wound care continues to grow despite advances in wound care knowledge and available technology. Some would argue that this technology has not yet made a significant impact on the delivery of care. In one of the latest of these studies, Guest et al. (2017) suggest that wound care is often within a non-specialist environment and that this can in some cases lead to extended healing times with care episodes not being optimized. There is also significant pressure in many markets related to the cost of wound dressings despite little proof that the price of dressings is the root cause of care expense. In fact, Guest et al. have calculated that the cost of wound dressings is

How To Build Solid Foundations to Support the Treatment and Management of Chronic Wounds: A Clinician's Guide Figure 1: HEIDI

MOIST

Outcome measures

History, Examination, Investigation, Diagnosis and Implementation

Moisture Oxygen Infection Support Tissue

Patient reported PROMS Clinical outcomes Economic outcomes

Holistic

Contents

Social or Environmental Patient experience

Using M.O.I.S.T. concept to enhance wound care and improve healing outcomes

only 6% of the cost of wound care. Most wound care costs incurred are associated with the costs of time for the clinician, clinic visits, and overheads for the facility where the patient is being treated.2 Professor Joachim Dissemond, Dermatology and Venerology Consultant with the additional discipline of Allergology, has practised at the Dermatology Clinic, Essen University Hospital, since 1999, initially as an Assistant Physician and then as a Senior Physician since 2003. A Wound Outpatient Clinic was set up at Essen University Hospital on Professor Dissemond’s initiative. The Dermatology Clinic is nowadays recognized as an interdisciplinary wound center.

Common Wound Etiologies Where M.O.I.S.T. May Be Applicable Chronic wounds can have many different causes. They are often characterised by their extended healing times, presence of sloughy tissue, excessive bioburden, and high levels of exudate.3 Coupled with underlying disease processes such as in the case of foot ulcers in diabetes, leg ulcers in patients with chronic venous insufficiency, and pressure ulcers in patients with restricted mobility, there are often many facets to the non-healing wound. Wound chronicity can be characterized in different ways. The cause of chronicity may be time driven, meaning the longer a wound is open, the environment will change. Exposure to

bacteria in and around the wound will increase the bioburden and promote the development of bacterial biofilm and promotion of a persistently inflamed state. This hostile environment will lead to an increase in matrix and bacterial proteases which lead to off target destruction of host proteins, cellular senescence, and delayed healing. One may also think of a chronic wound as one that is found on a chronic patient, with comorbid conditions which may be the source of the wound (e.g., venous and/ or arterial insufficiency, diabetes) or a strong contributing factor (e.g., immobility, renal or pulmonary disease, cancer, autoimmune diseases) or drugs that can slow healing, in addition to chemotherapeutic agents, such as cytotoxic antineoplastic and immunosuppressive agents; corticosteroids, nonsteroidal anti-inflamatory drugs (NSAIDs), anticoagulants mTOR inhibitors (rapamycin), and hydroxyurea or tyrosine kinase inhibitors such as imatinib. Therefore, it is not only important to address the immediate issues on the wound bed itself but also the underlying pathology which contributes to wound chronicity.

Why Adopt M.O.I.S.T. ? In the absence of a consistent methodology, there have been many attempts to simplify approaches to the non-healing wound in order to make the assessment and management easier to understand and implement. One of the more successful of these was the TIME concept.4 The TIME concept was created by a group of expert clinicians to summarize the main steps of wound bed preparation. In short, the TIME acronym looked at T for tissue management, I for infection or inflammation, M for moisture management, and E for wound edge. In 2016, a group of clinicians brought together by WundDACH, the umbrella organization of German speaking wound healing societies, discussed the need to further develop the TIME concept to include some other aspects that should be considered in wound care today.5 This alternative approach appeared necessary because, after 15 years, new therapeutic options have emerged that could not be represented in the TIME concept, which focused primarily on wound bed preparation. The acronym for this new approach is known as M.O.I.S.T. The letters in this acronym stand for

Wound Masterclass - Vol 2 - December 2023

How To Build Solid Foundations to Support the Treatment and Management of Chronic Wounds: A Clinician's Guide

“A good nutritional status is also an essential part of the care of patients with wounds in order to promote healing, and the management of pain should also be considered in the patients’ care.”

Moisture balance, Oxygen balance, Infection control, Supporting therapies, and Tissue management.5 This new acronym was not designed to be used in order but rather an aide memoire for the clinician who manages patients with chronic wounds.

Figure 2: How M.O.I.S.T. should be included in the overall patient assessment.

Supporting Therapies

Local Wound Treatment

Patient Assessment and the Use of M.O.I.S.T. As a Clinical Decision Aid In this article we will examine each of the letters of M.O.I.S.T. and how they may be used to support practice and aid in creating the appropriate treatment approach for the patient. As with all wound care treatment and assessment systems, it is important to use a holistic framework in order to address all the needs of the patient. Therefore, the M.O.I.S.T. concept should be used in the context of the overall care of the patient. This will include full assessment of the patient, including all medical history and concurrent conditions, and a full assessment of the wound including duration, size and etiology; assuring that with the other supporting therapies, for example in patients with underlying venous and lymphatic disease, the patient will undergo a vascular evaluation, leading to appropriate compression therapy, as well as appropriate skin care. For patients with diabetes related foot ulcers, full assessment of neuropathy and potential ischemia will be necessary and off-loading devices will be used to support the overall approach to wound care. A good nutritional status is also an essential part of the care of patients with wounds in order to promote healing, and the management of pain should also be considered in the patients’ care. Figure 2 illustrates how M.O.I.S.T. should be included in the overall patient assessment.

Patient & Wound

O. I. S.

for wound healing, with early studies showing that achieving the correct moisture balance will promote healing.6 Wounds which are dry are likely to take a longer time to heal as a scab can form over the wound, and in turn the new cells have to burrow underneath in order to continue healing. In the meantime, the benefit has also been well proven scientifically, so that moist wound therapy is now recommended in most expert recommendations and guidelines.7,8 Exudate is an essential component of wound healing and provides an environment conducive to new tissue growth, enabling the presence of appropriate inflammatory mediators and growth factors into the wound bed and to act as a medium for migration of cells such as keratinocytes across the wound bed.9 Wound exudate also contains essential nutrients which are needed for cell metabolism. In addition to this, the presence of exudate supports the removal of dead tissue through autolysis.

M = Moisture Balance The creation of a moist wound environment has long been accepted as the gold standard

Wound Masterclass - Vol 2 - December 2023

In chronic wounds, the wound environment can be complicated with the presence of excessive exudate levels caused by a prolonged

How To Build Solid Foundations to Support the Treatment and Management of Chronic Wounds: A Clinician's Guide

“Many wound dressings now exist which can help to support the optimal moisture balance within the wound bed, some of which contain a silicon wound contact layer which not only promotes healing but facilitates pain reduction on dressing removal.”

inflammation. Chronic wound exudate has been shown to contain excessive levels of inflammatory mediators such as matrix metalloproteases (MMPs). When these exist in high amounts they can start to degrade the new extracellular matrix and the new tissue, which will prolong the inflammatory phase and therefore wound healing (Figure 3). It is also worth noting that most chronic wounds will also have an excessive bioburden, potentially as planktonic bacteria or bacteria encased in a biofilm, which in itself triggers the body's inflammatory response, leading to greater exudate production creating a cycle of continuous inflammation. Excessive moisture levels are not only detrimental to healing in the wound bed, but if not managed appropriately Figure 3: Pressure ulcer with poor exudate management. Note the damage to the surrounding skin caused by toxic contact dermatitis.

they can lead to maceration of the surrounding skin and ultimately, skin breakdown.9 When selecting a wound dressing, the goal should be achieving the optimal balance of moisture supporting a moist wound bed whilst absorbing and handling excessive exudate in order to promote wound healing and prevent maceration of the surrounding

skin.10 The dressing should also be able to adequately retain or move the exudate into a secondary dressing when external pressure is applied, in order to prevent the exudate from pooling on the wound bed and surrounding tissues, as in patients receiving compression therapy or those with foot ulcers who have a total contact cast in situ. Many wound dressings now exist which can help to support the optimal moisture balance within the wound bed, some of which contain a silicon wound contact layer which not only promotes healing but facilitates pain reduction on dressing removal.

O = Oxygen Balance Oxygen is an essential component for many physiological processes and also has a direct impact on wound healing. Many problems with wound healing begin and end with an issue relating to oxygen levels in the wound and surrounding tissues. Oxygen is a vital requirement for every step in the wound healing process, including angiogenesis, revascularization, synthesis of connective tissue, and resistance to infection.11 Oxygen availability is a clear predictor for wound healing outcome; just 3% of wounds with an extremely low oxygen concentration heal, compared to 95% of wounds with a normal oxygen concentration.12 Hypoxia is often the case in lower limb wounds where arterial disease results in decreased blood supply and even in venous disease where there is reduced oxygen due to vascular inefficiency secondary to edema in the surrounding tissue. Without oxygen, many cellular functions cannot be supported and in chronic wounds this can result in slow healing. Interventions that can help to improve tissue oxygenation include reperfusion/ revascularization surgery to help re-establish the arterial blood supply, which would then support oxygen transport to the wound site.

Wound Masterclass - Vol 2 - December 2023

How To Build Solid Foundations to Support the Treatment and Management of Chronic Wounds: A Clinician's Guide

“The majority of chronic wounds will contain bacteria in the form of planktonic bacteria, and also biofilm. The presence of high levels of bacteria, and often the compromised immunity of the patient or host, can lead to systemic infection.”

Compression therapy in the case of venous leg ulcers (VLUs) is an essential part of the treatment which helps to reduce edema in the limb, improving overall vascular efficacy by reducing distance diffusion of oxygen; over time wound healing should improve.13 More recently, products and therapies which supply oxygen directly or indirectly to the wound bed have been introduced, which facilitate the delivery of oxygen directly to the wound bed.14 This encourages wound healing by increasing the amount of available oxygen. Arenberger et al. conducted a small randomized controlled trial (RCT) in 2011 of a haemoglobin spray on chronic ulcers of various types, which showed 93% healing at 6 months with haemoglobin spray compared with 7% healing without haemoglobin spray. There was a 93% success rate of healing (n = 42) with the haemoglobin spray group versus the control.15

I = Infection Control Infection is one of the biggest challenges for patients with wounds and for health care services. By their nature, chronic wounds are open skin defects which have been present for long periods of time.16 The wound bed is often complex, with many tissue types present, including slough, fibrin, and necrotic tissue. The majority of chronic wounds will contain bacteria in the form of planktonic bacteria, and also biofilm. The presence of high levels of bacteria, and often the compromised immunity of the patient or host, can lead to systemic infection.16 Wounds are an ideal growth environment for bacteria due to the warm temperature, the presence of a food source (the wound tissue and sloughy tissue present), oxygen from the environment is readily available, and in many patients with co-morbidities immunity can be reduced, which makes them more susceptible to infection (Figure 4).

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Figure 4: Spreading infection and cellulitis as a result of VLU.

In recent years it has also been identified that open chronic wounds are likely to contain biofilm which cause chronic infections and delayed wound healing.17 Biofilms form when bacteria aggregate (meaning forming a clump of cells), attach to a surface, change the way they behave and produce a protective matrix. This contributes to enhanced tolerance to many therapeutics and the host immune system. When assessing a wound that is infected, there are usually visible signs associated with infection and excessive bacterial proliferation. These signs include but are not limited to: local redness, local heat, swelling/ edema, increasing pain, and loss of function. Other signs include excessive exudate and/ or a change in the type of exudate being produced; that is, the exudate may be thicker or more purulent in nature.16 The TILI score, a therapeutic index, designed by Dissemond et al., aims to help health professionals, in particular those not specialists in would care management, in the early identification of patients with locally infected wounds. It assesses 6 clinical criteria for local wound infection, including erythema of the surrounding skin; localised heat; edema, induration or swelling; spontaneous pain or pressure pain; stalled

How To Build Solid Foundations to Support the Treatment and Management of Chronic Wounds: A Clinician's Guide

“It is important to note that patients with diabetes or autoimmune disorders may not exhibit the traditional signs of infection, making detection difficult; with these patient groups it is therefore important to proceed with caution, and the use of antimicrobials and antibiotics may be necessary for longer periods of time.”

wound healing; and increase and/ or change in colour or smell of exudate. If the wound meets 5 of the criteria, then antimicrobial treatment can be commenced.18 Depending on the results of the clinical evaluation to be performed, this score could provide the basis for early intervention with a selective and time-limited use of localized wound therapy in patients with infected wounds. When faced with a wound infection, it is important to act quickly to reduce the levels of bacteria and to prevent spread locally and systemically. This is best achieved by physical removal of non-viable or infected tissue such as debridement, and effective and repeated cleansing of the wound and periwound skin using a safe cleansing solution (for example, polihexanide or hypochlorous acid). Further extended antimicrobial activity can be achieved through the use of topical antimicrobial agents and dressings. It is important to note that patients with diabetes or autoimmune disorders may not exhibit the traditional signs of infection, making detection difficult; with these patient groups it is therefore important to proceed with caution, and the use of antimicrobials and antibiotics may be necessary for longer periods of time.

S = Support the Wound Bed When it comes to the treatment of problematic wounds that do not heal as expected, there are various strategies available to help rebalance the environment inside the wound bed and facilitate the healing process. These strategies aim to address specific factors that may be impeding the healing progress and promote a more favorable environment for wound healing. One approach is to control and bind excessive MMPs within the wound bed. MMPs are enzymes that play a crucial role in the breakdown of extracellular matrix components;

however, when their activity becomes excessive, it can lead to the degradation of healthy tissue and hinder wound healing. By utilizing therapies or dressings that effectively inhibit or bind these MMPs, the excessive proteolytic activity can be controlled, allowing for a more balanced healing process. Optimizing the pH conditions within the wound bed is another important aspect of promoting wound healing. An optimal pH range is necessary for the activation of enzymes involved in various stages of the healing process. Deviations from the normal pH range can impair enzyme activity and delay healing. Therefore, treatments that focus on maintaining the appropriate pH levels within the wound bed can help create an environment conducive to healing. There has not been a consensus of evidence supporting the optimal pH for wound healing. Protecting growth factors is another strategy employed to facilitate wound healing. Growth factors are signaling molecules that regulate cellular activities and play a vital role in wound repair; however, they can be easily degraded or inactivated within the wound environment, which can hinder their effectiveness. Various techniques, such as the use of growth factor delivery systems or dressings that protect and release growth factors in a controlled manner, can help ensure their sustained presence and activity within the wound bed. Controlling pro-inflammatory mediators is also crucial for successful wound healing. While inflammation is a natural part of the healing process, an excessive or prolonged inflammatory response can impede healing and contribute to chronic wound formation. Therapies that target specific pro-inflammatory mediators or modulate the inflammatory cascade can help regulate the inflammatory response and create a more favorable environment for

Wound Masterclass - Vol 2 - December 2023

How To Build Solid Foundations to Support the Treatment and Management of Chronic Wounds: A Clinician's Guide

“A healthy wound bed is crucial for effective wound healing; in order to create an optimal environment for healing, it is necessary to clean and prepare the wound bed by removing any dead cells and tissue.”

healing.

Biosurgical debridement

In addition to these strategies, the use of collagen dressings can be beneficial for wound healing. Collagen, a major component of the extracellular matrix, provides structural support and promotes cell migration and proliferation. Collagen dressings can help facilitate the formation of granulation tissue, aid in wound contraction, and provide a moist wound environment, which is conducive to healing.

This method involves the application of sterile maggots to the wound. Maggots secrete enzymes that selectively break down necrotic tissue, while leaving healthy tissue intact. This method has been used for centuries and has shown efficacy in promoting wound healing.

Overall, these therapeutic and treatment choices, such as controlling MMPs, optimizing pH conditions, protecting growth factors, controlling pro-inflammatory mediators, and utilizing collagen dressings, work together to rebalance the wound environment and promote the healing process. By addressing specific factors that may be inhibiting healing, these strategies can help get the healing of problematic wounds back on track and improve overall patient outcomes.

T = Tissue Management A healthy wound bed is crucial for effective wound healing; in order to create an optimal environment for healing, it is necessary to clean and prepare the wound bed by removing any dead cells and tissue. This process, known as debridement, can be achieved through various methods depending on the nature and condition of the wound. Autolytic debridement This method involves the use of moistureretentive dressings that promote the body’s natural enzymatic processes to break down and remove necrotic or non-viable tissue. By maintaining a moist environment, autolytic debridement allows the body’s own enzymes to selectively degrade the dead tissue, while preserving healthy tissue.

Wound Masterclass - Vol 2 - December 2023

Surgical debridement As the name suggests, this method involves the removal of necrotic or non-viable tissue through a surgical procedure. Sharp surgical debridement is often used in cases where extensive debridement is required, such as in deep wounds, or wounds with significant infection. It allows for precise removal of unhealthy tissue and enables a clean wound bed for subsequent healing. Enzymatic debridement This method of debridement involves the use of topical enzymes that selectively break down necrotic tissue. These enzymes are applied to the wound bed and left for a specific duration, after which the wound is cleansed. Enzymatic debridement is particularly useful in wounds with thick or adherent necrotic tissue. Mechanical debridement These methods involve physically removing necrotic tissue through techniques such as wetto-dry dressings, wound irrigation, or the use of specialized instruments. Wet-to-dry dressings involve applying a moist dressing to the wound, which is allowed to dry and adhere to the necrotic tissue; upon removal, the dressing lifts away the dead tissue. Wound irrigation utilizes a gentle stream of fluid to flush away debris and necrotic tissue. Specialized instruments, such as curettes or forceps, may be used to mechanically remove non-viable tissue.

How To Build Solid Foundations to Support the Treatment and Management of Chronic Wounds: A Clinician's Guide In addition to debridement, certain treatment options can enhance its effects and promote wound healing. Negative pressure wound therapy (NPWT) involves the application of a vacuum system to the wound bed, which helps remove excess fluid, stimulate blood flow, and promote granulation tissue formation. Electrical stimulation and ultrasound therapy are physical therapies that can also enhance debridement by promoting cell growth, increasing blood flow, and reducing inflammation in the wound bed.

with eschar, is normally black in colour, is dry and leathery in appearance, and can be difficult to remove. This tissue will be a physical impediment to healing so must be removed to allow wound healing to take place. The quickest way to achieve this would be sharp debridement, however, this may not be suitable for all patients. Some autolytic gel products can be used to help soften the necrosis, but this may take significant time (Figure 5a). Sloughy Tissue

Overall, a combination of cleansing the wound bed with appropriate solutions, employing different debridement methods such as autolytic, biosurgical, surgical, enzymatic, or mechanical techniques, and utilizing adjunctive therapies like NPWT, electrical stimulation, or ultrasound can help prepare the wound bed for optimal healing and improve outcomes for patients. In most chronic wounds, debridement focuses on specific targets depending on the stage of wound healing. These targets encompass various aspects, including necrosis, slough, eschar, impaired tissue, sources of inflammation, sources of infection, exudate, serocrusts, hyperkeratosis, pus, hematomas, foreign bodies, debris, bone fragments, and other types of bioburden or barriers to healing. Effective debridement aims to remove these elements and promote a cleaner wound bed, allowing for improved healing and optimal wound management.

Types of Tissue Necrotic Tissue

This often looks yellow, grey and/ or white in appearance. This tissue consists of white blood cells, dead tissue, bacteria and debris. This is also a physical barrier to wound healing and as stated above, can act as a reservoir for bacteria. As with necrotic tissue, slough should be removed with sharp debridement where possible, and gelling fibre products or hydrogels can be used in between debridement episodes to support autolytic debridement, depending on exudate levels (Figure 5b, 5c). Granulation Tissue Granulation tissue is the name given to the new tissue which is forming in the wound bed, due to its granular or bumpy appearance. Normal, healthy granulation tissue should be red in colour, not dark or grey which could indicate infection. Granulation tissue is a good sign that the wound is progressing towards healing. This tissue needs to be protected and prevented from drying out. Products used should maintain optimal moisture balance and may include wound contact layers, foam dressings and if necessary gelling fibre products when exudate levels are high (Figure 5d).

Necrotic tissue is when the wound is covered

Figure 5a: This pressure ulcer in an elderly female is covered with hard eschar. Figure 5b: The majority of this wound is covered with sloughy tissue, not also the exudate on the wound surface. 5a

Wound Masterclass - Vol 2 - December 2023

How To Build Solid Foundations to Support the Treatment and Management of Chronic Wounds: A Clinician's Guide

“Once the wound has been cleansed and debrided, there is a small window (<24 hours) during which biofilm can reform or may be more sensitive to antimicrobials; therefore, one strategy to help reduce or prevent biofilm reformation is to use topical antimicrobial products on the wound surface at this time.”

Epithelial Tissue Epithelial tissue is the tissue that grows over the top of the wound once granulation is complete. This should be pink in colour and often is seen beginning to form at the wound edges and also on the wound surface where hair follicles may be present. These are often seen as ‘islands’ of epithelial tissue. As with granulation tissue, epithelial tissue should be protected from physical damage and from drying out, as this will allow the new cells to migrate across the wound surface. Dressings may include wound contact layers and silicone foam dressings.

Biofilm Most chronic wounds not responding to standard of care have been shown to contain biofilm.19 Biofilm is the term used when microorganisms demonstrate altered behaviours; growth, metabolism, virulence, communication, and production of a protective matrix. Biofilms may form with the same species of microorganisms or as complex polymicrobial communities, however the principle function of biofilm is to protect the microbes from attack by therapeutics and the host immune system. Importantly, biofilms are not visible to the eye and the microorganisms are often spread heterogeneously within wound tissue; biofilms do not just form evenly over the surface of a wound, but may exist as small aggregates of cells deeper in wound tissue. Biofilms cause chronic infections as the host immune system struggles to clear them from the tissue, and many therapeutics do not work as efficiently. Ultimately, the downstream effects of chronic infection are the continuous induction of host inflammatory mediators, which damages host tissue.20 The result is that wound healing can be stalled or slowed down and exudate levels may increase. Biofilms can re-form very quickly (within hours to days) and reach full maturity within 3 days. Most of the

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literature agrees that wounds with mature biofilm are much more tolerant to therapies, thus are harder to heal than those with young, less mature biofilms present. The most effective way to remove biofilm is through physical removal, such as regular sharp and mechanical debridement. However, debridement alone does not remove all biofilm because clinicians cannot see where they are exactly located within a wound. Consensus guidelines therefore propose that following debridement there is value in utilizing cleansing agents (e.g., hypochlorous acid) and/ or the application of topical antimicrobial dressings to ‘mop up' or reduce any residual microorganisms in the wound. Once the wound has been cleansed and debrided, there is a small window (<24 hours) during which biofilm can reform or may be more sensitive to antimicrobials; therefore, one strategy to help reduce or prevent biofilm reformation is to use topical antimicrobial products on the wound surface at this time. More frequent debridement may also be needed in order to tip the scales of reducing the biofilm before it quickly reforms.

Using M.O.I.S.T. To Help Support Clinical Practice

72-year-old male •

1-week duration diabetes-related foot ulcer (DFU) with associated acute infection

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Depression, Hypertension,Type 2 Diabetes Mellitus, Dyslipidaemia, and Peripheral Neuropathy

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DFU extends from the plantar 4th metatarsal head to the dorsal 4th interdigital space

•

Measured 1.5 cm2 (area) with a depth ranging from 0 to 3 cm

How To Build Solid Foundations to Support the Treatment and Management of Chronic Wounds: A Clinician's Guide •

The DFU was interconnected from the plantar 4th metatarsal head to the dorsal 4th interdigital space of the left foot; it measured 1.5 cm2 (area) with a depth ranging from 0 to 3 cm

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Tissue management: The wound bed was composed of 14% sloughy and 86% granulating tissue

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Infection control: The ulcer was associated with a moderate skin and soft tissue infection with cellulitis requiring outpatient based intravenous antibiotic therapy for 2 weeks

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Tissue management: Curettage sharp debridement of the wound bed was only required at the baseline and initial study assessment

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Infection control: The wound was cleansed with Granudacyn® (wound irrigation solution containing hypochlorous acid, Mölnlycke, Gothenburg, Sweden) at all dressing changes until the final study assessment when normal saline was used

•

At baseline, the wound was dressed (primary dressing) with Exufiber® Ag+ (silver-containing gelling fibre dressing, Mölnlycke, Gothenburg, Sweden) and Mepilex® (secondary dressing) (foam dressing, Mölnlycke, Gothenburg, Sweden))

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Moisture management: Exudate levels were moderate, viscous, and purulent in appearance

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The peri-wound skin was macerated (Figure 6a)

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After 27 days of treatment, only Mepilex® was required

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The ulcer had previously been treated with Inadine® (povidone-iodine impregnated dressing. 3M™, Maplewood, MN, United States) and Allevyn® Foam (foam dressing, Smith & Nephew, London, United Kingdom)

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Throughout the study, Mefix® (adhesive dressing, Mölnlycke, Gothenburg, Sweden) was used for dressing fixation, and a CAM walker was used for offloading

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The patient experienced no pain prior to and during dressing removal, during wound irrigation, and upon application of the study dressings

Dressings were changed at each study assessment and in between these visits the patient changed the dressings every 3 days, as per clinician directions

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Follow-up assessments: After 27 days of treatment, the wound area was almost healed (Figure 6c)

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Tissue management: The composition of the wound bed tissue steadily improved over the study period, and at the final

•

Treatment Regime A detailed wound evaluation was completed at a baseline assessment and 2 further scheduled study visits over a period of 27 days (Figure 6b).

Figure 6a: Start of evaluation (day 1). A 2-month-old foot ulcer with moderate levels of purulent, viscous exudate. The wound bed tissue was 14% sloughy and 86% granulating tissue. The peri-wound was macerated. Figure 6b: After 16 days of treatment, exudation was low, viscous, and clear/serous in appearance. The wound bed tissue was 5% sloughy and 95% granulating. Figure 6c: End of evaluation (day 27) At the final follow-up visit, the wound was almost healed. The wound bed was composed of 100% granulating tissue. 6a

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How To Build Solid Foundations to Support the Treatment and Management of Chronic Wounds: A Clinician's Guide study assessment was composed of 100% granulation tissue •

Infection control: All clinical signs of wound infection were resolved after 27 days of treatment

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Moisture management: After 16 days of treatment, wound exudate levels were low and clear/ serous in appearance but remained viscous; at the final study assessment it was non-viscous

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Throughout the study, the peri-wound skin was healthy. The patient remained painfree during all dressing change procedures throughout the study

as indicated by the classic signs of inflammation, warmth, and erythema. Oral antibiotics were prescribed •

Moisture balance: Exudate levels were high; viscous and yellow/ green in appearance, with wound malodor. The peri-wound skin was hyperkeratotic. The wound had previously been cleansed using normal saline, and dressed with Inadine® (povidone-iodine impregnated dressing, 3M™, Maplewood, MN, United States) and Zetuvit® (absorbent dressing, Hartmann, Heidenheim, Germany)

•

The patient was pain-free prior to and during dressing removal, during wound irrigation, and upon application of the study dressings due to loss of protective sensation (peripheral neuropathy)

Clinical Outcome At the final evaluation, the wound had almost healed and was no longer probing to bone.

Treatment regime •

A detailed wound evaluation was completed at a baseline assessment and at 4 further scheduled study visits over a treatment period of 53 days

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Tissue management: A mix of debridement methods were utilized. Sharp curettage of the ulcer bed with a ring curette (baseline, follow-up visits 1 - 3) and sharp debridement (follow-up visits 2 and 3) of the peri-wound were performed; at the final assessment debridement was not required (Figure 7)

52-year-old male •

Acutely infected diabetes-related foot ulcer (DFU), secondary to peripheral neuropathy and poor footwear

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Ex-intravenous drug user, on Methadone program

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Type I Diabetes Mellitus, Hypertension, and Ischaemic Heart Disease, Peripheral Arterial Disease and Peripheral Neuropathy

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12 months prior to presentation, the patient had undergone amputation of the right fourth toe

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The DFU, located on the plantar 1st metatarsal head on the left foot, measured 7.8 cm2 (area) with a depth ranging from 0 to 0.2 cm. The ulcer duration at presentation was 4 weeks

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Tissue management: The wound bed was composed of 9% slough and 91% hypergranulating tissue (as per 3D wound imaging software)

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Infection control: There were clinical signs of a mild skin and soft tissue infection

Wound Masterclass - Vol 2 - December 2023

Figure 7a: Start of evaluation (day 1). A 4-week-old diabetic foot ulcer with high levels of yellow/ green, viscous exudate. The peri-wound skin was hyperkeratotic and callus was visible. Figure 7b: Treatment day 20. After 20 days of treatment, the wound area had reduced by 30.8% to 5.4 cm2, with an average depth of 0.1 cm. Exudation had reduced to moderate. Figure 7c: Treatment day 27. After 27 days of treatment, the wound area measured 3.5 cm2 (a 55.1% reduction) with no wound depth. The wound bed was composed of 99% granulating tissue and 1% slough. 7a

How To Build Solid Foundations to Support the Treatment and Management of Chronic Wounds: A Clinician's Guide

Figure 7d: Treatment day 42. Wound area measured 1.9 cm2, a 75.6% reduction from baseline. Wound exudate remained moderate but was clear/ serous and non-viscous in appearance. Figure 7e: End of evaluation (day 53). At the final follow-up visit, the area of the wound had reduced by 83.3% to 1.3 cm2. 7d

treatment, only mild wound malodor remained. At the final assessment, the wound was free from clinical infection and on a healing trajectory •

Moisture management: After 20 days of treatment, the level of wound exudate decreased to a moderate amount. Over the next 22 days and until the end of the study, the exudate transformed into a non-viscous and clear/ serous appearance. At the final assessment, the exudation was minimal. Throughout the study, the skin surrounding the wound remained healthy. Additionally, the patient did not experience any pain during dressing changes throughout the entire duration of the study

•

Clinical outcome: The primary management approach for this patient focused on source control. This involved debridement to physically eliminate infected tissues, along with the use of topical antimicrobial therapy as an additional measure to reduce overall bioburden. Adequate fluid management was necessary due to the high exudate level. At the final assessment, the wound showed significant improvement and was progressing towards healing, indicating successful achievement of source control

•

At all dressing changes, the wound was cleansed with Granudacyn® (wound irrigation solution containing hypochlorous acid) Infection control: At baseline, the wound was dressed with Exufiber® Ag+ (silvercontaining gelling fibre dressing; primary dressing) and Mextra® Superabsorbent (superabsorbent; secondary dressing (Mölnlycke, Gothenburg, Sweden)). After 20 days, as wound exudation had reduced, the secondary dressing was replaced with Mepilex® Border Flex (foam dressing). Throughout the study, Mefix® (adhesive dressing) was used for dressing fixation, 2-layer Tubigrip® E (elasticated tubular bandage, Mölnlycke, Gothenburg, Sweden) provided compression therapy and a CAM walker was used for offloading Dressings were changed at each study assessment and, in between these visits, the patient changed the dressings as per clinician request

•

Follow-up assessments: After 53 days of treatment, the wound area had reduced by 83.3% to 1.3 cm2, with no depth

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Tissue management: The composition of the wound bed tissue gradually improved over the study period, and after 42 days of treatment, was composed of 100% granulation tissue

Conclusion M.O.I.S.T. offers clinicians a framework to help support them in making good clinical decisions when managing patients with wounds. The real benefits of M.O.I.S.T. are more easily explained when the model is used in clinical practice. The case studies above illustrate the benefits of using a platform such as M.O.I.S.T. to help with the assessment and treatment of patients with chronic wounds. By providing a methodical walk through the patient journey, M.O.I.S.T. can be used to help identify problem areas and encourage clinicians to consider the main wound related issues, and combined with holistic patient assessment it can provide a useful platform for the promotion of wound healing.

References •

Infection control: The clinical signs of wound infection had resolved following 3 weeks of antibiotic therapy and local wound management. After 42 days of

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