All Roads Lead to Healing - Mastering Wound Bed Preparation

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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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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