Mending the Wounded

The incidence of chronic wounds in the United States is approximately 5 million to 7 million per year, and the annual cost associated with management of these wounds is more than $20 billion, according to the Agency for Healthcare Research and Quality (AHRQ).¹ AHRQ also notes that chronic wounds are a significant source of morbidity, lead to considerable disability, and are associated with increased mortality. Consequently, they have a substantial impact on public health and the expenditure of healthcare resources.

There are many factors that can adversely affect wound healing, several of which are represented in the mnemonic DIDNT HEAL:²

D = Diabetes: The long-term effects of diabetes impair wound healing by diminishing sensation and blood flow. Acute loss of diabetic control can also impact wound healing negatively by causing reduced cardiac output and poor peripheral perfusion.
I = Infection: Infection promotes collagen lysis. Bacterial contamination is a necessary condition but is not sufficient for wound infection. A susceptible host and wound environment are also required.
D = Drugs: Steroids, for example, obstruct the proliferation of fibroblasts and collagen synthesis.
N = Nutritional problems: Malnutrition and deficiencies of vitamins A, C, and zinc impair the wound-healing process.
T = Tissue necrosis: This impairs wound healing.
H = Hypoxia: Inadequate tissue oxygenation due to local vasoconstriction can occur because of blood volume deficit, unrelieved pain, or hypothermia, especially involving the extremities.
E = Excessive tension on wound edges: This can lead to local tissue ischemia and necrosis.
A = Another wound: Competition between several healing areas for the substrates required for wound healing impairs wound healing at all sites.
L = Low temperature: The relatively low tissue temperature in the distal aspects of the extremities can lead to slower healing of wounds at these sites.

In the acute-care environment, healthcare workers (HCWs) must contend with a multitude of challenges with regard to promoting wound healing, not the least of which is the potential presence of multi-drug resistant organisms.

Handwashing is still a big problem and the reason for approximately 80 percent of hospital-acquired infections, according to the Centers for Disease Control and Prevention (CDC), says Cynthia A. Fleck, MBA, BSN, RN, ET/WOCN, CWS, DNC, DAPWCA, FCCWS, a certified wound specialist and an advanced practice nurse in dermatology. Fleck is the vice president of clinical marketing for Medline Industries, Inc.s Advanced Skin and Wound Care division and serves on the boards of the Association for the Advancement of Wound Care (AAWC) and the American Professional Wound Care Association (APWCA). She is also secretary/treasurer of the American Academy of Wound Management (AAWM).

We also know that hands are the most common culprit in the transmission of methicillin-resistant Staphylococcus aureus (MRSA), Fleck continues. Good hand-hygiene programs cannot be stressed enough before and after every client, and gloves do not replace hand hygiene. Alcohol hand rinses are now considered the preferred method. Newer hand rinses have little to no detrimental impact on the skin, but a big influence on bacteria. For example, products like Sterillium Rub, with its high concentration of ethanol (80 percent by weight), ensure rapid, but also extensive and thorough effect. It penetrates into the skin layers of the stratum corneum deeply and rapidly.

That way the number of organisms with the resident flora is reduced as far as possible within two minutes. This guarantees a long-lasting effectiveness against the organisms of the resident and temporarily resident hand flora.

For the perpetuation of a natural barrier, Fleck points out that skin needs to be soft, hydrated, and pliable. Prolonged washing times, and in particular the use of brushes, destroy the protective function of the stratum corneum.

Once the skin is affected, it is more vulnerable to the colonization of infectious agents. Frequent hand antisepsis with the modern skin-friendly products like Sterillium Rub without washing has a far less aggressive effect on the skin. It ensures a low rate of scaling and has skin-smoothing properties, even with intensive long-term use.

In terms of promoting wound healing and preventing infection, Kristen Comstock, marketing manager for 3M Skin Health, notes that receiving proper training and education that complement effective product solutions for optimal wound healing can be hard for HCWs. The turnover rate is high in this industry, and expertise in the wound-care specialty is fairly rare, she says. As a result, ensuring that healthcare workers receive the right training and education is difficult.

Comstock also cites the challenges that complex wounds and comorbidities present. Patients often have complex wounds that need to be treated, and/or comorbidities that healthcare workers need to be aware of when treating and dressing wounds. These complications make for a much more challenging environment to provide proper wound healing care.

Carl Liebert, group product manager, infection control, Smith & Nephew Wound Management, points to the prevalence of infection in hospitals. There are many community-acquired bacteria that are being brought into the acute care setting by patients, healthcare workers, and visitors, he says. MRSA is one of the more significant threats. Transmission of MRSA to an unprotected wound can be very simple, and thats what makes these bacteria so challenging.

Wound Care Strategies and Technologies

Fleck says the use of silver dressings continues to gain popularity in terms of their use on problematic wounds, and for the safe, broadspectrum prophylaxis of infection. She contends that the use of ionic silver is one of the safest and easiest ways for clinicians to fight bioburden.

By applying a topical antimicrobial barrier, one is preventing bacteria from entering the wound or incision site, Liebert explains. There are many different ways to combat these bacteria in the acute care setting, all of which cost some money. Deciding how to do this with limited funds is a significant challenge. Institutions must decide whether to focus on the short-term or long-term costs. For example, each dressing has an acquisition cost which is straightforwardly understood; however, if no barrier or a limited-effect barrier is applied and a patients wound becomes infected, the hospital could get into significant expenses with prolonged hospital stays, antibiotic treatment, and so on. We like to think of our products as preventive measures to bacterial transmission and potential cross-contamination. Liebert points to Smith & Nephews Acticoat® product as a potent antimicrobial dressing. Alternative (silver) dressings may have some antimicrobial properties, but they wont necessarily protect against multiple MRSA strains, and they may not last as long.

Fleck suggests that facilities consider silver dressings that deliver sustained-release ionic silver for three days to seven days or longer. Since silver has little chance of developing clinically significant resistance, evokes very limited sensitivity, and is available over-the-counter, it makes a wonderful dressing for the acute-care provider. She also recommends versatile silver dressings, as they are designed to handle a variety of wounds and their changing needs.

For example, silver amorphous hydrogels, silver powders, silver alginate/CMC combinations, and silver site dressings that provide protection from catheter-related bloodstream infections and other infections that may arise from the use of percutaneous tubes and openings such as feeding tubes. These products are safe for use in all populations, non-toxic, non-irritating, have a low-profile design, and are see-through. Products containing CHG (chlorhexidine gluconate) may cause irritation, can cause hypersensitivity, are opaque (not allowing visualization), have no effect on pseudomonas, and are not recommended in patients less than 16 years of age.

Liebert stresses the importance of potency in a silver dressing. Potency means that multiple pathogens are being killed. The measure of potency is a parts-per-million (PPM) measurement of how much silver is released from the dressing. The importance of a high PPM count is that there are significant amounts of organic and inorganic substances, notably chloride ions, present in the wound. When a silver dressing is applied, the active material in these silver dressings (Ag+) binds to chloride ions (Cl-) for example. A high dose of silver is required to overcome the neutralization of the silver from the wound. By having a high PPM (70 to 100 for example), enough silver is present so that once it interacts with chloride ions, theres still silver left to fight infection, maintaining a bactericidal effect. With the lower-potency dressings (one PPM, for example) the silver is used more quickly, leaving little to protect the wound. This makes it a less effective antimicrobial barrier.

In terms of the fast-acting aspect, Acticoat has been shown in vitro to reduce the bacteria count by a factor of three logarithms within 30 minutes, Liebert continues. Thats important today, because resistance to antibiotics is a prominent issue. If its an antimicrobial barrier dressing thats very potent and fast-acting, that gives the bugs much less chance to develop some sort of resistant properties to silver.

The ability of a silver dressing to last for a long period of time is also vital, Liebert notes. In addition to Ag+, Acticoat offers an extra silver element to our dressing thats called Ag0. This element is neutral, so it does not bond readily with chloride ions and other organic material. The Ag0 remains present, and after all of the Ag+ gets used up, the chloride ions attack the Ag0, freeing it to become Ag+, which then in turn kills more bacteria. The Ag0 is unique to Acticoat, and it allows the barrier to be long lasting and bactericidal the entire time.

Fleck points to ultrasonic debridement as a novel way for clinicians to prepare the wound bed. Ultrasonic debridement allows HCWs to control amplitude (and thus the amount of pain experienced by the patient), which increases the level of precision and has an antimicrobial effect sub-dermally. She says this method will change the way bedside debridement is performed. Prudent and timely wound bed preparation, including debridement as the cornerstone, is still the best bet for rapid wound healing.

One study explored the use of low-frequency ultrasonic debridement (LFUD) for debridement and bacterial biofilm destruction in chronic wounds.³ Over a period of eight months, LFUD was performed on 17 patients, with a minimum follow-up of three months. None of the patients required antibiotic treatment after beginning LFUD. The authors concluded that this early experience with LFUD was favorable, and recommended further randomized clinical studies to explore this modality in more detail.

Novel debriding and moist wound therapy systems will prevail, Fleck states. She also mentions polyacrylate debriding systems, which are designed to provide simple and pain-free debridement in a user-friendly dressing that provides 24-hour simultaneous rinsing and debriding. Fleck notes that this dressing is only changed once per day, which could make it ideal for sending patients home or to long-term care facilities with the dressing. Another advantage is that this system is the only dressing that does not require wound cleansing, Fleck continues. It provides constant cleansing of the wound bed, removing devitalized material and biofilm. Biofilm is being connected to many incalcitrant wounds, so dressings such as polyacrylates (for example, TenderWet, from Medline Industries) can help eradicate this troublesome slime. Look for more of these types of uncomplicated and easy-to-use advanced products that prepare the wound bed and jumpstart healing without a lot of training or expertise.

Comstock notes that one of the strategies her organization is using to promote effective wound care is the idea of simplicity. 3M Skin Health is trying to take the complexity out of choosing the best wound-care products for a given situation, she says. In this increasingly complex environment, healthcare workers need simple, intuitive products that are easy to apply and use time after time, in addition to being clinically effective. We are focused on bringing simplicity to aspects like product packaging making sure instructions are intuitive and easy to follow, and making sure it is easy to distinguish products from one another.

Comstock references the new 3M Tegaderm Ag Mesh Dressing with Silver and the 3M Coban 2 Layer Compression System as effective wound-care products. Antimicrobial dressings can be particularly effective on complex wounds, and can help to accelerate the wound healing process, she says. The 3M Coban 2 Layer Compression System uses new materials to address age-old challenges. The more complex technology incorporated into this system allows for effective compression while still maintaining a thin profile, so patients can more easily go about their daily life.

Evaluating Products

In terms of deciding which products will be right for a given facility, Fleck suggests that HCWs look at the entire wound- and skin-care lines that companies offer. Breadth of product availability from one vendor usually saves costs and streamlines facility protocols and adherence, she says. Education, support, and training also must accompany state-of-the-art products. Clinicians need to be educated on the importance of the products and how they are to be used. The companies that facilities partner with should make it easy.

Sometimes I consult with facilities that have several products of the same kind and they are not getting used appropriately. Clinicians are overwhelmed; they dont have time and need quick answers. Broad-spectrum antimicrobials such as ionic silver should be chosen on not only their ability as a biocide, but also their versatility. You dont need 12 different silver products; perhaps three or four carefully chosen dressings that can fulfill several needs are all that is necessary.

Comstock advises HCWs to keep the following points in mind when evaluating and purchasing wound care products:

• Ensure that the products are clinically effective and cost effective from a health economics point-of-view. It is important to consider product effectiveness, wear time, application time and other factors when evaluating the total cost of a wound-care product

• Ensure that the patient experience is going to be a positive one. Patients are more involved in their wound care than ever before. They are being discharged faster and are often required to do their own wound care from home. Because of this, dressings need to be comfortable, effective, and easy to use

• Ensure that the wound-care product provider chosen is truly a solutions partner. Choosing a provider is about more than just the products they offer; its also about training, education, and clinical expertise. This is especially important in the infection control world, where meeting regulatory requirements is critical. Partnering with a wound-care solutions provider that offers products as well as training and expertise is important

Future Trends

Look forward to seeing more bioengineered smart dressings (such as bioengineered cellulose) that provide more than one function, offering care for a variety of wound needs while additionally addressing issues such as pain management, Fleck comments. I also predict a surge in collagen dressings, cost-effective dermal replacements, MMP (matrix metalloproteinase) modulators, and other biologics that tackle various issues in the wound bed and surrounding tissue and skin.

Fleck also sees a surge in advanced skincare products. Just as we need good nutrition to survive, our skin can now be nourished from the outside in. The cosmeceutical industry has known this for years, yet wound and skin care providers are only beginning to utilize these products to address at-risk skin, not just help cure wrinkles. Skin-care products containing specific, specially treated amino acids, antioxidants, MSM (methylsulfonylmethane), and vitamin co-factors can nourish and strengthen the skin, providing an insurance policy against skin breakdown and wounds. These products can not only improve the skins appearance and texture, but help build collagen and develop the skins resistance to damage. To prevent a break in the skin is to prevent potential infection. Look for the trend to continue with nutritional skin care products becoming the norm.

References:

1. Samson D, et al.. Wound-healing technologies: low-level laser and vacuum-assisted closure. Evid Rep Technol Assess (Summ). 2004 Dec;(111):1-6. Review.

2. Stillman RM. Wound care. http://www.emedicine.com/med/topic2754.htm

3. Breuing KH, et al. Early experience using low-frequency ultrasound in chronic wounds. Ann Plast Surg. 2005 Aug;55(2):183-7.