Practicing Smart Wound Care
By Ann Donovan, RN, MSN, CETN, and Charles E. Edmiston, Jr. PhD, CIC
The above patient had no visible clinical signs of a wound infection other than a non-healing wound. Quantitative biopsy revealed >105.
At a time of scarce healthcare dollars, practicing smart wound care is more important than ever. Smart wound care means finding solutions that will not compromise the quality of care while achieving financially viable positive outcomes.1 Presently, social and economic factors in the healthcare environment often act as barriers to providing quality care to patients with complex problems such as chronic wounds. Unfortunately in the future, these barriers also will play a greater role in health status than medical care.2 The goal of improving patient outcomes and optimizing the care for every patient with a chronic wound can only be achieved by practicing smart wound care.
The first smart wound care practice begins with defining the expected outcomes. The goal of patient outcomes is to focus on the recipient of care to achieve improved continuity, quality, operational efficiency, and cost.3 The outcome is healing. However, many factors influence the outcome measurement of a chronic wound, therefore, a comprehensive assessment is the sentinel starting point.
The patient's health history is the first critical indicator of one's intrinsic ability to heal. Disease processes such as peripheral arterial disease, pulmonary disease, diabetes, immune deficiencies, collagen vascular diseases, malignancies, and some mental illnesses are all known to impede wound healing. In addition, it is important to note that smart wound care requires the healthcare provider to identify those patients who have non-healing wounds. As the chronic wound population increases, healthcare providers need to understand that not all wounds will heal and that "forever after" wound care is not smart wound care.4
Despite advances in technology and research resulting in the availability of over 3000 wound care products, the outcome for some patients may require a long-term (possibly life-long) plan for wound management.5 For example, a positive patient outcome for a noncompliant patient may require keeping the wound free of infection, therefore, preventing frequent hospitalizations. In some patient populations, an outcome of healing may be an unrealistic goal.
Other important assessments to be obtained prior to establishing goals include wound history, care setting, financial situation, and the patient's expectations.6 Once an assessment is completed, a focused outcome can than be identified. It is at this time that the healthcare provider can establish that aggressive care may or may not be appropriate. When is aggressive wound care no longer appropriate? This is certainly true in terminal or end-stage disease processes as well as in patients who are noncompliant by choice. Practicing smart wound care requires that the practitioner be able to recognize (accept) that there are circumstances when despite all possible efforts, wound healing may not be an attainable objective.7
The outcomes for a patient presenting with a wound should be realistic, established early, and should serve as a guide for decision-making processes over the continuum of care for that patient. Having a clearly defined goal, which both the patient and healthcare provider understand and agree upon, can prevent wound management from becoming a frustrating process.8
Elimination or Control of Factors that Reduce Wound Healing
The second smart wound care practice begins with the recognition of causative factors when determining wound origin. Chronic wounds frequently have specific factors that relate to the etiology as well as secondary events that adversely influence or delay healing. Assessing the causality of the wound as well as identifying potential risk factors is important when developing an optimal wound management plan. In addition to evaluating risk factors, there are other specific indices that may reveal the origin or influence clinical outcomes. The characteristics of some common chronic wound factors are identified in Table 1.
Interventional strategies may be designed to try and ameliorate the influence of these factors in selected patients. For example, one can focus on providing systemic support to reduce existing risk factors. Examples of appropriate interventions may include:
- Reduce pressure--select appropriate pressure reduction support surface for both chair and bed.
- Minimize skin exposure to moisture from incontinence, perspiration, or wound drainage.
- Minimize environmental factors leading to drying of skin, such as exposure to cold.
Chronic Venous Insufficiency
- Surgical obliteration or ligation of veins
- Valvular repair
- Compression therapy
- Measures to improve tissue perfusion: surgical revascularization
- Hyperbaric oxygen
- Pharmacologic options
- Optimize nutrition/hydration
- Glucose control
- Measures to support tissue oxygenation
- Smoking cessation
Prioritize Smart Ulcer Management
Debridement of devitalized tissue is considered the most important component of wound care.9,10 The more necrotic tissue present in the wound bed, the more severe the insult to the tissue and the longer the time required to heal the wound.11 In addition, any open wound containing devitalized tissue will be colonized by a high level of bacteria.12 Necrotic tissue becomes an excellent breeding ground for microorganisms. The most effective way to decrease this level of bacteria within this environment is through debridement.
There are four main types of debridement: sharp, mechanical, enzymatic, and autolytic. Surgical or sharp debridement is the most efficient way to remove devitalized tissue.13 A patient who has a necrotic wound should be referred to a surgeon, wound care specialist, or other healthcare professional skilled in debridement. However, there are two contraindications to debridement: (a) pressure ulcers on the heel, in which a dry eschar covers the wound should not be debrided14 and (b) dry, stable, ischemic ulcers should not be debrided until perfusion to the extremity can be improved.15 However, if there are signs of infection, such as erythema, fluctuance, or drainage, debridement may be required. Dry eschars often act as "natures biologic dressing" in which case surgical debridement is not required.
A once-common mechanical debridement approach included wet-to- dry dressings and irrigation. Wet-to-dry dressings were performed by moistening one layer of wide mesh gauze with normal saline, applying it to the wound surface, and allowing it to dry before removing. By removing the dressing, dead tissue was lifted from the wound bed. Widely considered an out-of-date method by many, wet to dry dressings are used mainly on full thickness skin loss ulcers and can be used as the initial form of debridement while the patient awaits sharp debridement. If used, this nonselective and sometimes painful technique should be discontinued once the wound bed is pink.
Another method of mechanical debridement is irrigation. This is the removal of nonviable tissue using pressurized fluids. Irrigation of wounds with fluid delivered at 8-12 pounds per square inch (psi) such as with a 35 ml syringe and a 19-gauge angiocatheter is referred to as high-pressure irrigation.16 This procedure provides adequate force for removing debris without harming healthy tissues. The choice of fluid should not be toxic to the tissue. For the majority of patients, normal saline or water alone is an adequate irrigant. Smart wound care practitioners do not use toxic antiseptics that harm healthy tissue. Research has shown that antiseptics such as iodine, peroxide, and acetic acid harm cell populations active in the wound healing process.17 Wound irrigation can effectively decrease the bacterial burden.
Autolytic debridement refers to the breakdown or liquefaction of nonviable tissue by the body's own mechanisms. This process uses the patient's own enzymes to digest the dead tissue. Autolysis is a natural physiologic process that occurs in wounds kept moist by using moisture-retentive dressings (i.e., hydrocolloids, hydrogels, transparent films). The key point to remember when considering autolysis for debridement is that its effectiveness is reduced if the patient does not have adequate leukocyte function or neutrophil count.18 This form of debridement is also not efficient in the presence of a large amount of necrotic tissue.
Enzymatic debridement involves the use of selective enzymatic ointments to remove necrotic tissues. Enzymatic debridement is often used as an adjunct to sharp debridement. Several commercial enzymes products are available for topical treatment such as Panafil®. Accuzyme®, or Santyl®, which are applied daily to the wound. Wound debridement is sometimes considered a slow process when limited to topical treatments and whenever possible the more aggressive approach of sharp debridement should be considered.
All chronic wounds contain bacteria and will not heal optimally until the bacteria population is reduced or minimized. This often presents a significant obstacle to the chronic wound healing process. The goal of treatment is to kill the microorganisms while not damaging healthy tissue. Local treatment of the wound focuses on reduction of the bioburden. The bioburden is the metabolic load imposed by bacteria in the tissue. Bacteria compete with normal cells for oxygen and nutrients, their by-products are detrimental to healthy cells.19 Bacteria can impact upon the wound healing process through the production of inflammatory mediators, by increasing the incidence of thrombocytopenia, increasing platelet agglutination, and through the release of volatile short chain fatty acids that decrease chemotaxis and phagocytic cell function. In addition, a high bacterial bioburden and their metabolic byproducts will adversely impact upon epithelialization and wound contraction.20 An elevated tissue bioburden alone has been shown to have a more adverse effect on wound healing than the presence of diabetes, cardiopulmonary disease, malnutrition or anemia.21 Research reveals that wounds heal once the bioburden falls below <105 organisms/gram of tissue.22 Quantitative tissue biopsies have been the gold standard for the determination of tissue bioburden. However, many healthcare providers do not have the ability to perform or process a quantitative tissue biopsy.
The clinician must rely on his or her assessment skills. The wound must be observed for the signs and symptoms of infection which include: redness, swelling, increase in drainage, pain or tenderness, unusual odor, poor granulation tissue, warmth around the wound and sudden high glucose in patients with diabetes. However, it is important to note that at times an elevated bioburden may be present in patients who do not exhibit any of the overt classic signs of a wound infection. The only indicator of a chronic wound infection may be poor wound healing (Figure 1).
Some wound care providers may consider a clean wound infected if it does not show signs of healing after 2-4 weeks following optimal wound care. Because oral or parenteral antibiotics have been shown to penetrate poorly into chronic granulation tissue, failing to reduce the bacterial counts within the wound, a different strategy is warranted. Treatment often entails a 7 to 14-day course of topical (water-soluble) antimicrobial therapy. Examples of topical antimicrobials used for chronic wounds may include Nitrofurazone, Polysporin, Metronidazol, and Silver Sulfadiazine.23 The use of topical antimicrobials in the management of infected chronic wounds has been shown to be highly effective. However, once the infection is under control and the bioburden reduced, therapy should be discontinued since many topical formulations contain ingredients that will inhibit fibroblast activity.
A fundamental aspect of wound care is selection of an appropriate dressing. The wound care dressing must be able to absorb exudate yet provide a moist wound environment, provide thermal insulation, allow gaseous exchange, eliminate any dead spaces, reducing odor and pain. Table 2 lists the basic principles of effective wound care that must be considered when selecting an appropriate dressing.
There are many individual factors to consider when attempting to determine which dressing is best for a selected patient including not only cost, but also availability and accessibility.
Many challenges remain for healthcare professionals, interested and involved in wound healing. Smart wound care practices are fundamental to the management of chronic wounds and improving patient outcomes. Healthcare professionals must incorporate in their practice current professional standards, ensuring that each patient receives care that reflects quality and competence while being cognizant of effective resource management. Smart wound care should be judged by its overall effectiveness as measure by a series of positive events producing the desired optimal patient outcome.
Ann Donovan, RN, MSN, CETN, is a certified wound, ostomy and continence nurse and is the Associate Director of the Chronic Wound Care Clinic at the University of Virginia Health System in Charlotteville, Va.
Charles E. Edmiston, Jr, PhD, is an Associate Professor of Surgery, Director of the Surgical Mcrobiology Research Laboratory and the Hospital Epidemiologist at Froedtert Memorial Lutheran Hospital, the teaching affiliate institution for the Medical College of Wisconsin, Milwaukee, Wis.
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Table 1: Characteristics of common chronic wound factors
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Table 2: Points to ponder when selecting a wound dressing