December 2016

Wound bed preparation: A novel approach using

Leanne Atkin, Karen Ousey Leanne Atkin, Lecturer Practitoner/Vascular Nurse Specialist, Institute of Skin Integrity and Prevention, School of Human and Health Sciences, University of Huddersfield, Queensgate, Yorkshire Karen Ousey, Professor and Director, Institute of Skin Integrity and Infection Prevention, School of Human and Health Science [email protected]

Accepted for publication: November 2016

In association with

This article is pre-printed from the British Journal of Community Nursing, Vol 21, No 12, Community Wound Care December 2016 © 2016 MA Healthcare Ltd Accepted for publication: November 2016 [email protected] Human andHealthScience Skin Integrity andInfection Prevention, Schoolof Karen Ousey, Professor andDirector, Institute of Queensgate, Yorkshire Health Sciences, University ofHuddersfield, Infection Prevention, SchoolofHumanand Nurse Specialist, Institute ofSkinIntegrity and Leanne Atkin, Lecturer Practitoner/Vascular Ousey Karen Atkin, Leanne becoming more frequent (Sibbald etal, 2013). Additionally, as thepopulationgrows bothacuteandchronic wounds are more than6weeks isconsidered tobechronic innature, and as chronic (Sibbald etal, 2013) suggestany wound present for promote healing (Snyder etal, 2016). cause ofthewound andtheoptimisationof thewound bedto it ensures patientfocusedoutcomesandtreatments, relating tothe preparation isaholisticapproach towound diagnosisandtreatment, remains asrelevant today aswhenitwas introduced. first Wound bed 2008). The concept ofwound bedpreparation isnotnew, but C ■ Abstract velessitamdebis faccuptiis ercia HydroTherapy quatesequi blaccum voloribustis eaA novel approach using CWC Title volorem Ita faciWound omnieni ut bed preparation: tissue through autolytic debridementand this dressing enablesremoval ofdevitalised of HydroTherapy involves HydroClean plus™, an optimalhealingenvironment. The first step treatment calledHydroTherapy aimsto provide the wound from healing.Auniquewound including sloughandeschar, that canprevent debridement to remove devitalised tissue, stalled wounds progress through healingis important step inassisting thesechronic or encountered by community nursingstaff. An Wounds that fail to healquicklyare often This article ispre-printed from theBritishJournal ofCommunity Nursing, Vol 21,No 12,Community Wound Care December 2016 wound bedpreparation There whenawound isdebatesurrounding becomesclassed Clinical focus Clinical Clinical focus Clinical resources andare disabling forpatients, (Posnett andFranks, continue toplacesignificant burden onhealthcare systems’ ommunity oftenencounterchronic nurses wounds, which ■ devitalised tissue ■ debridement ■ ■ may inconsistency(Milne, beleathery 2015). other handhastheappearanceof blackish dry, thicktissue which asmoist,appears loose, yellow deadtissue. stringy Eschar, onthe tissue thatmay bepresent inchronic wounds. –slough The former (Snyder etal, 2016). Bothsloughandescharare typesofdevitalised (Nunan etal, 2014)thatinterferes withanddelays wound healing In many chronic wounds there isabuild-up ofdevitalised tissue Devitalised tissue Union of Wound HealingSocieties(WUWHS, 2008). the developmentand support ofmanagementplans(World wound ordelay wound healing, assess thestatusofwound any co-morbidities/complicationsthatmay tothe contribute assessment should: thecauseofwound, determine Identify bed (Atkin, 2014). To ensure effective patienttreatment the whole patientanddoesnotsimplyconcentrateonthewound knowledge hastheappropriate nurse andskillstoassessesthe weeks (Margolisetal, 2004, Sibbaldetal, 2013). is projected of12 thatthewound willclosewithinaperiod wound area afteronly4weeks, surface ifthisisachieved it estimates thatthere shouldbea30%reductiontrajectory of not follow ofwound theexpectedtrajectory healing. Normal wounds canbeclassedasrecalcitrant (non-healing)ifthey do debridement. plus™ whichdemonstrates effective wound slow healingwounds treated withHydroClean fashion. This paperpresents 3case studies of re-epithelialisation to occur inanunrestricted hydrated wound environment that enables dressing, HydroTac™, provides anongoing preparation hasbeenachieved asecond tissue oreschar. Once effective wound bed the dressing furtherremoves any necrotic cleansing provided by solutionfrom Ringer’s absorption ofwound fluid.Irrigation and ■ ■ Mimic orhideinfection, tothewound, attract bacteria Prevent ordelay awound’s healingprocess (Weir, normal 2007) Dead tissue, inawound can: sloughanddebris When healinghasstalleditisvitalthatthecommunity ■ de-sloughing ■ hydration

© 2016 MA Healthcare Ltd wound asshown inTable 1 (Dowsett, 2008). Moisture imbalance; advancement oftheepithelialEdge wound bedpreparation; control ofInfectionandInflammation; 1 This guidanceincludesthe TIME managementprocess (seeTable guidelines developed toaidthecliniciandothis(Pilcher, 2016). steps tohealingwounds andisthebasisofanumber ofspecific techniqueisimperative tissue usingadebridement inthe first wound tobeprepared forhealing. Therefore, removal ofdevitalised is thatany oralldevitalised tissuemust beremoved allowing the this, abasictenantonthetreatment ofchronic (oracute)wounds infection thatcanbelifethreatening (Leaperetal, 2015). Inlight of 2015). Ultimatelythismay deeptissue leadtoamore serious consequence results inwound infection(Percival andSuleman, biofilms,which microorganisms canattachandform a whichas ■ ■ “HydroTherapy” of two Hydro- thatconsists primarily highlightsauniquewoundThis article treatment regimen HydroTherapy whyunderstand andhow thisneeds tobedone. thedifferent methodsofdevitalised tissue critique removal, but to results. toreview Itisnotwithinthescopeofthisarticle and may alsobeusedtoachievemethods ofdebridement better co-morbidity, andthepatient’s generalcondition. Combined bed, sizeand depthofthewound, underlyingdisease, possible depends onthetype, amountofdevitalised tissueinthewound (Doerler etal, 2012). However, technique choiceofdebridement (hydro-, water-jet) toultrasound-assistedwound treatment from methods ranging pulsedlavage debridement debridement allowed andotherhealthcare nurses professionals accesstonewer techniques (MatSaadetal, 2013). Advances intechnology have chemical, (larvae) debridement enzymaticandbiological can remove devitalised tissueincludingmechanical, autolytic, There are several “standard” methodsby whichtheclinician Wound debridement This article ispre-printed from theBritishJournal ofCommunity Nursing, Vol 21,No 12,Community Wound Care December 2016 ), whichistheacronym given to Tissue managementinvolving ■ ■ E M I T Table 1.TIMEManagementframework supported by HWRDs Devitalised tissueisknown toprovide anenvironment in Increase odourandexudate(Vowden and Vowden, 2011) pressure ulcerdamage(Weir, 2007) the wound, problematic whichisparticularly whenstaging Prevent from practitioners assessingtheextentandsizeof ofinfection(O’Brien,increasing therisk 2002) Clinical focus Clinical failing to migrate across thegranulation tissue? edges ofthewound underminedandistheepidermis Edge ofwound non-advancing orundermined-Are the exudate oristhewound too dry? Moisture imbalance –Doesthewound have excess of bacterial contamination, infection orinflammation? Infection orInflammation –Doesthe wound have signs viable tendon orbone? non-viable tissue suchasnecrotic tissue, slough,non- Tissue non-viable ordeficient–Doesthe wound contain wound healing. HydroTac™ provides acontinuum ofhydration that aids wound exudate. HydroClean plus™aidsinabsorptionandmanagementof a nidusfor infection. HydroClean plus™–removes devitalised tissue that provides wound bedpreparation. HydroClean plus™–removes devitalised tissue enables the wound bedhadbeensuccessfully prepared forhealing. The (Figure 3). HydroClean plus™was stoppedatthispointbecause wound andtheskinflaphadfullyadhered was fullydebrided the skinflap to adhere (Figure2).was starting At 13days, the commenced thewound was moist, itsdepthwas reducing and adhered. Sixdays afterHydroClean plus™treatment was wound edgesthatwere retracting andtheskinflaphadnot depth withincreasing sloughandnecrotic edges, ithaddry improvement (Figure1). The wound was staticextendingin to hispresentation attheclinic, but hadshown noobvious two weeks debridement had undergonesurgical previously A 58-year-old malewithadiabeticfootulcer. The 1 study Case fashion. an unrestricted wound environment thatenables re-epithelialisation tooccurin wound dressing HydroTac™ provides anongoinghydrated necrotic tissueoreschar. SubsequentuseofthesecondHRWD from thedressing HydroClean removes plus™) thatfurther any andcleansingmechanism(withRinger’sirrigation solution in thefluidthatmay delay healing. Thisis combined withan fluid, whichaidsinthe removal components ofany deleterious ofwoundproviding andabsorption autolyticdebridement woundsupports bedpreparation. This isachieved by both enables removal ofdevitalised tissue, whichsubsequently Responsive Wound Dressings (HRWDs), ofwhich thefirst HydroClean plus Figure 3.Following 13days oftreatment with HydroClean plus Figure 2.Following 6days oftreatment with surgical debridement Figure 1.Diabeticfoot ulceration 2weeks post

© 2016 MA Healthcare Ltd © 2016 MA Healthcare Ltd HydroClean plus Figure 7. Following 8 days oftreatment with surgical debridement Figure 6.Diabeticfoot ulceration 2weeks post HydroClean plus Figure 5.Following 7days oftreatment with surgical debridement Figure 4.Arterial ulceration 4weeks post of thewound, there were no signsofinfection, thewound with increasing amountsofsloughy tissuevisible atthebase Two weeks following thewound tostall, surgery started ( suffered from aneuropathy supply. but hadanintactarterial foot infectionthatrequired incisionanddrainage. The patient A 65-year-old gentlemanwhosuffered from anacutediabetic 3 study Case with healthy visible granulation (Figure5). andthewoundevidence bedwas ofdebridement shallower growth. granulation to facilitate After only1week there was andoptimisationofthewoundto allow bed rapiddebridement supply remained adequate. HydroClean plus™was commenced tissue (Figure4). The patientwas reassessed andhisarterial tostall,started andthere was evidence ofincreasing sloughy Initially thewound progressed well but around week 4ithad revascularisation andamputationofthe4th5thtoes. disease whodeveloped ofhistoesandunderwent The secondcasewas arterial a72-year-old manwithperipheral 2 study Case some hyper-hydration but was notmacerated. thewound,skin surrounding skin, theperi-wound showed This article ispre-printed from theBritishJournal ofCommunity Nursing, Vol 21,No 12,Community Wound Care December 2016 Figure 6) healing. and effectively, aidinginthepreparation ofthe wound bedfor HydroClean plus™isable toremove devitalised tissuequickly care process. The casestudiespresented here suggestthat assist inreducing timetohealingandsimplifythewound using awound dressing will thatallows speedydebridement of different effective options debridement available however the wound itforhealing. bedthuspreparing There are avariety where devitalised tissueispresent effective cleans debridement management involving wound bedpreparation, that ensuring (Dowsett, 2008). stepinthisprocessThe vitalfirst istissue epithelial (edge)advancement aspresented in–Table 1 inflammation andinfectioncontrol, moisture balance, and “TIME” framework whichencompassestissuemanagement, wounds shouldincludewound ofthe bedpreparation interms fortreatment ofchronicSuccessful managementstrategies Discussion wound was completelysloughfree allowing skingrafting. growth.granulation Hydroclean plus™was continued untilthe todebride,had started andthere was evidence ofnew healthy progression intheconditionofwound, thesloughy tissue at thispoint, afteronly8days (Figure7)there was significant of wound edgemigration. HydroClean plus™was started andassuchtherebed appeared was slightlydry noevidence sometimes result inhyper-hydration of theskinsurrounding The casespresented demonstrated thatHydroTherapy may Hyper-hydration tissue. ofgranulation quick formation cleansing actionoccurs. Together, theseeffectsstimulate the softened by the material ofnecrosis andfibrinous absorption istaken upintothebodyofdressing.bacteria) Further time, wound and exudate(containingproteinaceous material coatings.softening ofnecrotic tissueandfibrin Atthesame from thesuperabsorbentpolyacrylate core beadsleadstothe tissueformation.granulation The release ofRinger’s solution cleansing, andabsorbinginorder tostimulate debriding within the TIME framework isdemonstratedinTable 1. treatment chronic ofvarious wounds inthiscasestudyseries 2013). The effectiveness ofusingHydroTherapy asabasisfor epithelium from wound edgesenables healing(MatSaadetal, ofthe formigration of thephysical andbiochemicalbarriers healing environment healingwillbeenabled. Finally, removal of thisframework andthrough achieving amoistwound biofilms),bacterial which relates toInfectionandinflammation involve balance(includingreduction of restoration ofbacterial HydroTherapy aimstoassistlaterstepsintheprocess that (Pilcher, methodsofdebridement tissue usingvarious 2016). tissue managementanessentialelementistoremove devitalised As previously discussed, whenusingthe TIME framework for frameworkTIME wound healing The modeofactionHydroClean plus™involves Clinical focus Clinical will resolve withinafew minutes leaving nodamagetothe dressing. The most significantdifference isthat hyper hydration cases created by theRinger’s solutioncontainedwithinthe hyper-hydration results from themoistenvironment, inthese (Graysuch aswound and exudateorurine Weir, 2007)whereas Maceration results from tothe skin liquidsthatare damaging are similarthey are notthesame(Ripponetal, 2016). although thepresentation ofhyper-hydration andmaceration (Davies,integrity 2013). However, tonotethat itisimportant thatexcessexudateontheskincanjeopardiseunderstood its Initially thiswas someuneasebecauseitiscommonly HydroClean plus™, whichaidsinwound bedpreparation. resulting fromconsequence oftheautolyticdebridement using the wound, ascanbeclearlyseenincase3(Figure8). This isa This article ispre-printed from theBritishJournal ofCommunity Nursing, Vol 21,No 12,Community Wound Care December 2016 Maceration Hyper-hydration Hydration ■ ■ ■ ■ ■ ■ ■ healing – taken from Ousey et al, 2016 Ousey –taken et from al, healing Table wound of moist Benefits 3. Table 2.Definitionsandimpactofhydration, hyper-hydration andmaceration ■ ■ ■ ■ ■ ■ ■ et al,1991) Nemeth Leaper etal,2012; Coutts et al.,2008;Feldman, 1991; 2004; Reduces painperception (Wiechula, 2003; Metzger, Hutchinson andLawrence, 1991;Lawrence, 1994) Lower wound infection rates (Kannon andGarret, 1995; et al,2006;Vogt etal,1995) al, 1992; Attinger al, 2000;Hacklet2014; Powers etal,2013; Chenet Retention of growth factors at wound site (Svensjö et et al,2013) Tandara etal,2007; Hoeksema O’Shaughnessy etal,2009;Mustoe andGurjala,2011; Reduces scarring (Atiyeh etal,2003, 2004; Ayello, 2004;Katz etal,1991) et al,2010; Fieldand Kerstein, 1994;Dowsett and et al,1992; Leung Dyson etal.,1992; Mosti, 2013; Korting etal,2010; Chen cell proliferation, ECMsynthesis (Svensjö etal,2000; Promote dermal/wound bedhealingresponses, e.g., et al,1989; Wigger-Alberti etal,2009) 1991; Madden 2001; Ågren etal.,2001; Varghese etal,1986;Rubio, Promote epithelialisation rate (Winter, 1962;Eaglstein, Beam etal,2008) Faster wound healing(Winter, 1962;Dyson etal,1988; Clinical focus Clinical Definition act intissue degradation further of chemicalelements(specific enzymes–MMPs) that presence prolonged exposure to moisture –exacerbated by the The softening andbreaking down ofskinresulting from on cellular/tissue structures andorprocesses amount ofliquidto bodilytissues, resulting inaneffect The process ofproviding more thananadequate to bodilytissues The process ofproviding anadequate amountofliquid al, 2016). the contentoffluidthatismajorimportance” (Ousey et “excessive fluidisnotpersethecauseofskindamage but itis This doesnothappenifskinismaceratedby wound fluidthus when theHydroClean plus™dressing was nolongerused. solution thatcausedthehydrated environment, forexample stateifleftwithouttheRinger’s to amorereturned normal tissue,of whiteandwrinkled thiswas transientandtheskin hyper-hydration was apparent, by supported thepresentation skin. More thedifferences detailsurrounding isinTable 2. Atiyeh BS, DhamR, CostagliolaM, Al-Amm CA, L(2004)Moistexposed Belhaouari Atiyeh BS, El-MusaKA, function DhamR(2003)Scarqualityand physiologic barrier MS,Agren Karlsmark T, HansenJB, Rygaard J(2001)Occlusionversus airexposure Declaration ofinterest: None stalled wounds should considerhydrotherapy fortreatment ofchronic or straightforward we suggestnurses methodofdebridement and aidingprogression ofhealinginchronic wounds. As a was successfulineffectively removing devitalised tissue The initialprocess ofHRWD involving HydroClean plus™ Conclusion advantages ofmoistwound healing(Junker etal, 2013). bathed inahyper-hydrated environment may benefitfrom the et al, 2002; Vogt etal, 1995), andrathersuggestthatawound tissue damage(Breuing etal, 1992; Svensjö etal, 2000; Vranckx indicated thatawound thatisoverly hydrated may notresult in effective inaidingthehealingprocess. A number ofstudieshave of wound tissuehydration (hyper-hydration) have proved tobe of hydration inwound healing. high levels More importantly decades (Benbow, 2008). Table highlightssomeofthebenefits 3 hydration ofwounds hasbeenshown formany tobeimportant but alsoforhealing.only inthecontextofdebridement Infact, Additionally, results demonstratethebenefitsof hydration not Hydration assists wound healing therapy: aneffective and valid alternative toocclusive dressings for postlaser Surg29(1):Dermatol 14–20 restoration wounds. aftermoistandmoist-exposeddressings ofpartial-thickness on full-thicknessbiopsywounds. Care10(8): JWound 301–4 These casestudiessuggest(Figures3, 5and8)thatwhere Damage potential High to extremely high Low to moderate Low Healing potential None Very high High CWC

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