CLINICAL PRACTICE Special Considerations in Bed Preparation 20 11: An Update

Part one of this article was published in the Spring 2012 issue of Wound Care Canada . Part two is published here.

R. Gary Sibbald BSc Local Wound Care There are several new electronic technologies avail - MD MEd FRCPC(Med, Derm) MACP FAAD 5. Assess and monitor the wound history and physical able for , but they may be costly MAPWCA, Professor, examination for clinicians and healthcare systems. Novel camera Public Health Sciences Documentation of a detailed patient and wound systems accurately calculate the length, width, depth and Medicine; Director, International assessment is a legal requirement from both an and surface of exposed wound areas. Limitations Interprofessional Wound organizational and professional standards perspective. include undermined areas or sinuses that are not Care Course and Masters of Science in Community Specific details about the wound history and physical measureable using this technology, requiring supple - Health; Dalla Lana appearance will facilitate communication within the mentation by visual clinical inspection and probing. School of Public Health, University of Toronto, patient’s circle of care. This includes the type of wound Wound assessment devices differ markedly from Toronto, Ontario, Canada and its history, the patient-centred plan of care and computer-based documentation systems that capture 57 Laurie Goodman BA targeted patient-specific goals. The details of the multiple data points and assessments about wound RN MHScN, Director, wound assessment should be communicated to parameters inputted by skilled clinicians. and Mississauga Halton Wound Care Initiative, other professionals when referrals are made. Whether Toronto Regional a wound is healable, nonhealable or maintenance, an 6. Gently cleanse with low-toxicity solu - Wound Clinics, Toronto, individualized care plan is made to identify specific tions: , and acetic acid (0.5–1.0%). Do Ontario, Canada interventions and outcomes that the patient and not irrigate wounds where you cannot see where Kevin Y. Woo PhD RN interprofessional team agree upon and modify based the solution is going or cannot retrieve (or aspirate) FAPWCA, Assistant Professor, Faculty of on a new holistic interprofessional assessment. the irrigating solution Health Sciences, School Using a framework allows consistent documentation The standard of care for wound cleansing is to use of Nursing, Queen’s University, Kingston; of a wound. When a framework is used to assess a solutions that are gentle and the least cytotoxic to the Wound Care Consultant, wound over time, clinicians can identify if a wound wound: saline, water and acetic acid (0.5–1.0%). West Park Health Centre, Toronto, Ontario, Canada is improving, stalled or deteriorating. One example of Research has shown that certain solutions can be such a framework is the mnemonic MEASURE 58 – the cytotoxic to healing cells, such as fibroblasts, in vitro. 59 Diane L. Krasner PhD RN CWCN CWS MAPW - wound location plus MEASURE is described: In an analysis of Cochrane Reviews prior to 2008, CA FAAN, Clinical Nurse • Measure size – the longest length and the widest the authors concluded: “There is not strong evidence Specialist/Wound, width at right angles. that cleansing wounds per se increases healing or Ostomy, Continence Nurse, Rest Haven–York; • amount (none, scant, moderate, heavy) reduces .” The Cochrane Collaboration Wound and Skin Care and characteristics (serous, sanguineous, pustular or updated evidence reviews on wound cleansing Consultant, York, Pennsylvania, USA combinations). for PUs in 2011 and concluded there is “no good • Appearance (base: necrotic [black], fibrin [firm yellow], evidence to support use of any particular wound Hiske Smart MA RN 60 PG Dip (UK) IIWCC slough [soft yellow] or granulation tissue [pink and cleansing solution or technique for PUs.” A specific (Canada), Clinical Nurse healthy vs. red and friable = easy bleeding, unhealthy]). type of solution for wound cleansing in adults was Specialist and IIWCC Course Coordinator – • Suffering (pain). the subject of an additional evidence review in 2010. South Africa, Division • Undermining (measure in centimetres and use The authors concluded that there was no evidence of Community Health, Department of hands of clock to document: 12 o’clock, 6 o’clock and to indicate that using tap water to cleanse an acute Interdisciplinary Health so on). wound increases infection rates. In addition, there Sciences, Stellenbosch University, Stellenbosch, • Re-evaluate. was no strong evidence demonstrating that cleansing South Africa • Edge (hyperkeratotic, macerated, normal). of wounds at all decreases healing infection or

Wound Care Canada / Volume 10, Number 3 Soins des plaies Canada / Volume 10, numéro 3 25 Gulnaz Tariq RN promotes healing. 61 Expert opinion recommends that Alternatively, autolytic debridement is most accepted to BSN PG Dip (Pak), caution should be considered in the use of tap water work by keeping a moist wound environment to enhance Wound Care Specialist, Sheikh Khalifa for immunocompromised individuals, especially the the activities of phagocytic cells and endogenous Medical City; IIWCC use of nonpotable water, which may be a problem in enzymes on nonviable tissues. Mechanical debridement Course Coordinator – Abu Dhabi, Abu Dhabi, developing countries. with saline wet-to-dry contributes to local trauma United Arab Emirates Avoiding cytotoxic solutions, such as Dakin’s and povi - and pain. In the US, the Centers for Medicare and done-iodine, to cleanse healable wounds or using them Medicaid Services, in its Tag F314 guidance, cautions that Elizabeth A. Ayello PhD RN ACNS-BC for only limited periods is reasonably prudent practice. there should be limited use of wet-to-dry dressings. CWON MAPWCA FAAN, However, there is a place for these agents in the Emerging technology using ultrasonic devices has also Faculty, Excelsior College School of Nursing, management of maintenance or nonhealable wounds been demonstrated to aid with - Albany; President, to potentially control bioburden and odour. In these out the incumbent painful and traumatic scraping and Ayello, Harris and Associates, Inc., cases, the reduction in bioburden and moisture reduc - cutting associated with sharp and mechanical debride - Copake, New York, USA tion outweighs the small potential for tissue toxicity. ment. When using enzymatic debridement, clinicians Wound irrigation has also been the subject of should ensure that the cleansing solutions and type of Robert E. Burrell PhD MSc, Professor and controversy and disagreement between health profes - dressing used to cover the wound do not interfere with Chair, Department of sionals. In general, the authors recommend that or cancel out the action of the enzyme. Biomedical Engineering, Faculties of Engineering clinicians should not irrigate wounds where they In summary, the different methods of debridement and Medicine and cannot see where the solution is being instilled into have distinct features in terms of pain potential, cost, Dentistry; Professor and Canada Research the dead space at the base of the wound, or if they healthcare professional time and skill level required, Chair, Nanostructured cannot retrieve the irrigating solution. More research resources used and wound characteristics. Select Biomaterials Chemical on wound cleansing is needed. the appropriate method of wound debridement and Materials Engineering, Faculty of considering the patient, the wound characteristics, Engineering, University 7. Debride: healable wounds – sharp or conservative and the skill and knowledge of the clinician, along of Alberta, Edmonton, Alberta, Canada surgical, autolytic, mechanical, enzymatic, biological with the available resources. (medical maggots); nonhealable and maintenance David H. Keast, MD MSc BSc(Hon) – conservative surgical or other methods of 8. Assess and treat the wound for superficial critical DipEd CCFP FCFP, removal of nonviable slough colonization/deep infection/abnormal persistent Centre Director, Aging, The wound bed is optimally prepared by aggressive (mnemonic NERDS), deep infection Rehabilitation and Geriatric Care Research and regular debridement of any firm eschar or soft (mnemonic STONEES) or persistent inflammation: Centre, Lawson Health slough if the wound is healable. A firm eschar serves any 3 NERDS – treat topically: Nonhealing, h Research Institute, London, Ontario, Canada as a pro-inflammatory stimulus inhibiting healing, Exudate, Red friable tissue, Debris, Smell; any 3 whereas the slough acts as a culture media for STONEES – treat systemically: h Size, h Temperature, Dieter Mayer MD bacterial proliferation and should be removed. 62 Os, New breakdown, Exudate, Erythema/ FEBVS FAPWCA, Head h h of Wound Care, Senior Debridement may also promote healing by removing edema (cellulitis), Smell; persistent inflammation Vascular Consultant, senescent cells that are deficient in cellular activities (non-infectious): topical and/or systemic anti- Clinic for Cardiovascular 63 Surgery, University and that contain the bacterial colonies. inflammatories. Hospital of Zurich, Sharp debridement is the most expeditious method Chronic wounds containing bacteria and/or the Zurich, Switzerland but may not always be feasible because of pain, presence of bacteria obtained from a surface swab Linda Norton BScOT bleeding potential, cost, professional/system regulations do not define or portend infection. In fact, the mean OT Reg(ONT) MScCH, and lack of clinician expertise. Cardinal et al number of bacterial species per chronic ulcer has National Educator, 65 Shoppers Home conducted a retrospective review of 366 persons with been found to range from 1.6 to 4.4. Critical to wound Health Care; Director, VLUs and 310 persons with DFUs over 12 weeks, observ - healing, however, is achieving an appropriate bacterial Interprofessional Team, 64 Canadian Association ing wound surface area changes and closure rates. balance and understanding the differences between of Wound Care Institute, Interestingly, VLUs had a significantly higher median contamination, colonization and frank bacterial damage Toronto, Ontario, Canada wound surface area reduction with surgical debridement with surface critical colonization or surrounding/deep Richard “Sal” Salcido (when clinically indicated due to the presence of debris) infection. The risk of infection is determined by the MD, William Erdman vs. no surgical debridement (34%, p<0.019). Centres number and nature of invading bacteria as well as host Professor, Department of Rehabilitation Medicine; with more frequent debridement were associated wit h resistance, as outlined in the following equation: Senior Fellow, Institute higher rates of wound closure ( p<0.007 VLUs, p<0.015 on Aging; Associate, Infection = number of organisms x organism virulence Institute of Medicine and DFUs). The debridement frequency did not statistically Bioengineering, University correlate to higher rates of wound closure. There was Host resistance of Pennsylvania Health some minor evidence of a positive benefit of serial Host resistance is the most important factor in infec - System, Philadelphia, Pennsylvania, USA debridement in DFUs (odds ratio 2.35; p<0.069). tion, and refers to the host’s ability to resist bacterial

26 Wound Care Canada / Volume 10, Number 3 Soins des plaies Canada / Volume 10, numéro 3 invasion and prevent bacterial damage through the wound is in bacterial balance, antibacterial the immune response. 66 In addition, an adequate dressings are not needed for the re-epithelialization blood supply is needed for the wound to heal, as a stage of , unless they also provide decreased or inadequate blood supply favours anti-inflammatory activity. 70,71 They are also not effica - bacterial proliferation and damage that may prevent or cious in the treatment of deep and surrounding delay healing. Infection is more prevalent in certain tissue infection that requires the use of systemic disease conditions. For example, individuals with agents. Studies that do not select the proper subpop - have at least a 10-fold greater risk of being ulation (e.g. healable critically colonized wounds hospitalized for soft tissue and bone of the without deep infection) or measure complete wound foot than individuals without diabetes. 67 Local factors healing have failed to demonstrate any benefit from inhibiting healing may include a large wound size, the these dressings. 72 presence of foreign bodies (e.g. prosthetic joints, a The use of antimicrobial dressings should be thread or remnants of gauze or a retained suture) and reviewed at frequent and regular intervals every 1–2 an untreated deeper infection, such as osteomyelitis. 68 weeks and discontinued if critical colonization has External contamination of the wound bed by microor - been corrected or if they do not demonstrate a ganisms can occur from the ambient environment, beneficial effect after 2–4 weeks. There is currently a dressings and the patient’s secretions and hands, great tendency to overuse antimicrobial dressings, along with the hands of healthcare providers (alcohol creating a cost-inefficient use of these useful devices. hand rinses are more effective in reducing hand The conflicting evidence and misuse of these dress - bacteria than washing with soap and water). ings have led some European healthcare systems to By using this superficial and deep-surrounding completely delist silver products. tissue separation, the clinician can identify wounds with increased bacterial burden that may respond to Silver dressings topical antimicrobials and deep infection that usually The effectiveness of silver-releasing dressings in requires the use of systemic antimicrobial agents. the management of nonhealing (stalled) chronic The mnemonics NERDS and STONEES represent wounds has been reviewed in a meta-analysis. 73 the initials of the signs to categorize the 2 levels of In comparison to alternative antimicrobials, silver bacterial damage or infection (see Enabler on page 22, dressings significantly: Spring 2012). This concept was introduced in 2007 • improved the wound-healing rate (95% confidence and validated in 2009. 66,69 Three or more of these signs interval [CI] 0.16–0.39, p<0.001); should be sought for the diagnosis in each level. If • reduced odour (95% CI 0.24–0.52, p<0.001) and increased exudate and odour are present, additional pain-related symptoms (95% CI 0.18–0.47, signs are needed to determine if the damage is super - p<0.001); ficial, deep or both. • decreased wound exudate (95% CI 0.17–0.44, There are now at least 5 classes of antimicrobial p<0.001); and dressings and some miscellaneous products for use • had a prolonged dressing wear time (95% CI in chronic wounds with critical colonization, as defined 0.19–0.48, p<0.028). by any 3 of the NERDS criteria: Silver’s broad spectrum of antimicrobial activity • Silver dressings combined with alginates, foams, can be used in critically colonized chronic wounds Hydrofibers and hydrogels. that have the ability to heal. Silver must be ionized • Honey dressings in a calcium alginate wafer and to exert an antimicrobial effect. Ionized silver requires hydrogel. an aqueous or water environment and should not • Iodine in a cadexomer carbohydrate or polyethyl - be used in a maintenance or nonhealable wound ene glycol slow-release formulation. where the desired outcome is the combination of • PHMB (polyhexamethylene biguanidine) derivative moisture reduction and bacterial reduction. Silver of chlorhexidine in a foam or gauze packing. should not be in close proximity to any oil-based • Miscellaneous antimicrobial dressings, often with a products (e.g. petrolatum, zinc oxide) where the paucity of clinical studies to support their use. oil molecules may interfere with the ionization of The treatment of critical colonization often takes the silver. Products that produce a continuous supply 2–4 weeks in a healable wound where the cause of ionized silver are likely to be more efficacious, has been corrected and patient-centred concerns and higher levels of silver release are often necessary have been addressed. There is some, but limited, to treat micro-organisms such as Pseudomonas in evidence to show the benefit of these dressings. 70 If a complete environment, such as a wound.

Wound Care Canada / Volume 10, Number 3 Soins des plaies Canada / Volume 10, numéro 3 27 Pseudomonas requires a higher silver level than because these results often do not correlate with most other bacterial organisms. Silver resistance is clinical activity. Although studies may demonstrate uncommon because there are at least 3 antimicrobial statistical significance, clinical significance is the mechanisms with silver targeting and combining with parameter of interest; moreover, the strength of membranes, cytoplasmic organelles and DNA. evidence for the majority of these in vitro studies is The amount of silver released from these dressings low. When evaluating topical antimicrobial agents for is a fraction of that released from silver sulfadiazine wound treatment, appropriate tests must be used. For cream formulations. silver levels even from instance, the in vitro evaluation of an antimicrobial high-release silver dressings are in the 1–5 ␮m range. agent such as silver can be performed with a multi - Modern silver dressings seldom exceed the normal tude of tests, but of these, only the logarithmic reduc - range unless large surface areas are treated over a tion or decimal reduction time test conducted in serum prolonged time or the patient has a large skin surface has been shown to predict clinical outcomes. 77,78 In vivo area to total weight ratio. Silver dressings can cause antimicrobial assays, such as the Walker Mason modi - temporary periwound staining but do not leave fied model (rodent) or the Wright model (porcine), permanent silver deposits in the dermis (argyria or can also be used with success to determine antimicro - blue discoloration of the skin). The silver in the bial efficacy. 79 Similarly, the efficacy of topical agents dressing should be combined with the appropriate on wound healing can be evaluated in vitro (cellular moisture balance format matched to the wound to culture or tissue explant models) or in vivo (rodent or control exudate and prevent maceration, but facilitate porcine wound-healing models). However, the only the delivery of ionized silver to the wound surface. model that predicts a clinical outcome is the porcine model of wound healing. 80 Honey, iodine and PHMB A recent Cochrane Review explored and The Cochrane Collaboration conducted a systematic antiseptic use for persons with VLUs. The authors con - review of the honey literature and concluded that cluded that there is no evidence for the routine use of honey, as a topical treatment for superficial and systemic 75 when treating the cause of VLUs. partial-thickness burns, may improve healing times compared with some conventional dressings. Jull et al 9. Select a dressing to match the appropriate wound conducted a multicentre randomized controlled trial and individual person characteristics: on VLUs with compression comparing honey to usual • Healable wounds: autolytic debridement: alginates, care. 74 There were 187 patients in the honey group hydrogels, hydrocolloids, acrylics and 181 patients in the usual-care group, with no • Critical colonization: silver, iodides, PHMB, honey difference between the 2 groups for total wound heal - • Persistent inflammation: anti-inflammatory dressings ing at 12 weeks. • Moisture balance: foams, Hydrofibers, alginates, In clinical practice, honey dressings may be hydrocolloids, films, acrylics useful for thick eschar, which often continuously • Nonhealable, maintenance wounds: chlorhexidine, reforms when treated with other dressings. Some povidone-iodine of this action may be due to the antibacterial and Whenever patients and healthcare professionals hyperosmolar characteristics of the honey. Scoring develop a treatment plan for patients with wounds, the wound with a blade to help break down the dressing selection is an important primary focus. eschar may facilitate the process. Ten trials have Once the healable, nonhealable or maintenance been conducted with cadexomer iodine and status of a wound is determined, appropriate holistic some are old, with venous ulcers treated topically interprofessional interventions that address cofactors without compression. In a randomized controlled can be optimized. The dressing selection should be the trial study comparing cadexomer iodine with standard last part of the process because if the healability is not care with both groups receiving compression, the accurately assessed or other cofactors are unmanaged, daily or weekly healing rates favoured cadexomer the wound will not heal. Dressing choice needs to iodine. 75 In a pilot study of PHMB foam compared consider unit costs and clinical effectiveness. Kerstein with foam alone, the PHMB dressing resulted in et al explored cost-effectiveness for venous ulcers and decreased pain and no change in wound size. 76 PUs, and concluded that the purchase price of the dressing should not be the only indicator. 81 Normal saline Evaluating Evidence of Antimicrobials in Vitro gauze dressings (least expensive for product) were and Animal Models: The Literature found to be the most expensive when nursing time and Beware of in vitro testing of antimicrobial dressings patient feedback were taken into account (Table 6).

28 Wound Care Canada / Volume 10, Number 3 Soins des plaies Canada / Volume 10, numéro 3 TABLE 6 Modern classes of dressings Class Description Tissue Infection Moisture Indications/contraindications debridement balance 1. • Semipermeable +––• Moisture vapour transmission rate varies from Films/membranes adhesive sheet; film to film impermeable to water • Should not be used on draining or infected wounds * molecules and bacteria • Create an occlusive barrier against infection 2. • Sheets of low adherence –––• Allow drainage to seep through pores Nonadherent to tissue to secondary dressings • Nonmedicated tulles • Facilitate application of topical medications 3. • Polymers with high water content ++ –/+ ++ • Should not be used on draining wounds Hydrogels • Available in gels, solid • Solid sheets should not be used on sheets or impregnated gauze infected wounds 4. • May contain gelatine, sodium +++ –/+ ++ • Use with care on fragile skin Hydrocolloids carboxymethylcellulose, • Should stay in place for several days polysaccharides and/or pectin; • Should not be used on heavily draining sheet dressings are occlusive or infected wounds* with a polyurethane film • Create an occlusive barrier to protect the outer layer wound from outside contamination • Odour may accompany dressing change and should not be confused with infection 5. • Clear acrylic pad enclosed +++ –/+ ++ • Use on low- to moderately draining wounds where Acrylics between 2 layers of transparent the dressing may stay in place for an extended time adhesive film • May observe wound without changing 6. • Sheets or fibrous ropes of ++ + +++ • Should not be used on dry wounds Calcium alginates calcium sodium alginate • Low tensile strength – avoid packing into (seaweed derivative); narrow, deep sinuses have hemostatic capabilities • Bioreabsorbable 7. • Multilayered, combination +–+++ • Use on wounds where dressings may stay in place Composite dressings to increase for several days* absorbency and autolysis 8. • Nonadhesive or adhesive ––+++ • Use on moderately to heavily draining wounds Foams polyurethane foam; may have • Occlusive foams should not be used on occlusive backing; sheets or cavity heavily draining or infected wounds* packing; some have fluid lock 9. • Contains odour-absorbing ––+• Some charcoal products are inactivated by moisture Charcoal charcoal within product • Ensure dressing edges are sealed 10. • Sheet, ribbon or gel ++++ • Gauze ribbon should not be used on dry wounds Hypertonic impregnated with • May be painful on sensitive tissue sodium concentrate • Gel may be used on dry wounds 11. • Sheet or packing strip of sodium +–+++ • Best for moderate amount of Hydrophilic fibres carboxymethylcellulose; converts • Should not be used on dry wounds to a solid gel when activated by • Low tensile strength – avoid packing into moisture (fluid lock) the narrow, deep sinus 12. • Silver, iodides, PHMB, honey + +++ + • Broad spectrum against bacteria Antimicrobials aniline dyes with vehicle for • Should not to be used on patients with delivery: sheets, gels, alginates, known hypersensitivities to any foams or paste product component 13. • Negative-pressure wound –++++ • This negative pressure-distributing dressing Other devices therapy applies localized actively removes fluid from wound and negative pressure to the surface promotes wound edge approximation and margins of wound • Advanced skill required for patient selection 14. Biologics • Living human fibroblasts provided –––• Should not be used on wounds with infection, in sheets at ambient or frozen sinus tracts or excessive exudate or with patients temperature; extracellular matrix known to have hypersensitivity to any of the • Collagen-containing preparations; product components hyaluronic acid, platelet-derived • Cultural issues related to source growth factor • Advanced skill required for patient selection

Adapted from the CAWC. * Use with caution if critical colonization is suspected. –, no activity. +, minimal activity. ++, moderate activity. +++, strong activity.

Wound Care Canada / Volume 10, Number 3 Soins des plaies Canada / Volume 10, numéro 3 29 Persistent Inflammation can be combined antimicrobials, depending on the Chronic wounds may stall in the inflammatory stage. presence of the mnemonic NERDS (superficial anti - These wounds demonstrate markedly increased bacterial dressing criteria) or STONEES (systemic activity of inflammatory cells and associated mediators antibiotic criteria) and where the presence of such as matrix metalloproteinases (MMPs) and elas - increased inflammation can also be treated topically tase. 82 Wound healing is stalled because degradation or systemically. of the extracellular matrix and growth factors occurs Appropriate moisture is required to facilitate the more rapidly than their synthesis, hindering the wound action of growth factors, cytokines and migration of from progressing toward the proliferative phase and cells including fibroblasts and keratinocytes. Moisture ultimately re-epithelialization. Harding et al reported balance is a delicate process. Excessive moisture can that the longer a wound remains in the inflammatory potentially damage the surrounding skin of a wound, phase, the more cellular defects are detected with leading to maceration and potential breakdown. 84 potentially delayed healing. 83 Recently, there has Conversely, inadequate moisture in the wound envi - been a renewal of interest in wound diagnostic testing ronment can impede cellular activities and promote that will result in tests for increased MMPs at the eschar formation, resulting in poor wound healing. bedside. There are wound dressings with oxidized A moisture-balanced wound environment is main - reduced collagen and cellulose that can trap MMPs, tained primarily by modern dressings with occlusive, and these dressings can be combined with antimicro - semi-occlusive, absorptive, hydrating and hemostatic bials such as silver. In the Sibbald cube (see Enabler characteristics, depending on the drainage and other on page 22, Spring 2012), these specialized dressings wound bed properties.

10. Evaluate expected rate of wound healing:

TABLE 7 healable wounds should be 30% smaller by week Summary of advanced therapy options 4 to heal by week 12. Wounds not healing at the expected rate should be reclassified or reassessed, Substantiated Indication RCT or meta- Results advanced analysis and the plan of care revised therapies available? It is noted that a 20–40% reduction in 2 and 4 weeks 11,85 OASIS VLU Yes 87 Complete healing is likely to be a reliable predictor of healing. Sheehan et al noted that a 50% reduction at week 4 DNFU Yes 88 Complete healing was a good predictor for persons with DFUs. 86 One equal to PDGF measure of healing is the clinical observation of the 89,90 Growth factors DNFU Yes Complete healing edge of the wound. If the wound edge is not migrating (PDGF) after appropriate wound bed preparation (debride - 91–93 Apligraf DNFU Yes Complete healing ment, bacterial balance, moisture balance) and healing (epidermal cells, VLU Yes 94 Complete healing is stalled, then advanced therapies should be consid - dermal fibroblasts, ered. The first step prior to initiating the edge-effect bovine collagen) therapies is a reassessment of the patient to rule out Dermagraft DNFU Yes 95–97 Complete healing other causes and cofactors. Clinicians need to remem - (fibroblasts) ber that wound healing is not always the primary Hyperbaric DNFU Yes 98 Prevents amputation outcome. Consider other wound-related outcomes, oxygen therapy such as reduced pain, reduced bacterial load, reduced dressing changes or an improved quality of life. Electrical stimulation PU Yes 99 Complete healing Therapeutic VLU Yes 100 Faster healing 11. Use active wound therapies (e.g. skin grafts, ultrasound biological agents, adjunctive therapies) when other 101 DNFU Yes Complete healing factors have been corrected and healing still does Negative-pressure Postsurgical Yes 102 Complete healing not progress (stalled wound) wound therapy wounds A nonhealing wound may have a cliff-like edge Promogran VLU Yes 103,104 Decrease wound size between the upper epithelium and the lower granula - tion in comparison to a healing wound with tapered © 2006 Woo and Sibbald edges like the shore of a sandy beach. Several DNFU = diabetic neurotrophic foot ulcer; PDGF = platelet-derived growth factor; PU = ; RCT = randomized controlled trial edge-effect therapies support the addition of missing components: growth factors, fibroblasts, or epithelial

30 Wound Care Canada / Volume 10, Number 3 Soins des plaies Canada / Volume 10, numéro 3 cells or matrix components. If all the factors are only 2 disciplines working collaboratively with the corrected in a healable wound, active adjunctive patient and/or family may be successful. therapies may be considered (Table 7). 87-104 Clinicians must distinguish between interdisciplinary networks with 2 members of the same profession Provide Organization Support (such as 2 nurses or assistants vs. a nurse practitioner, 12. For improved outcomes, education and who may have a similar role to a physician on an inter - evidence-informed practice must be tied to inter - professional team), compared with the physician and professional teams and improved cost-effective nurse of an interprofessional team. For patient care outcomes with the cooperation of care, the physician and nurse are best supplemented healthcare systems with a member of the allied healthcare team (e.g. When a patient has a wound, it is important that the occupational therapist, physical therapist, foot care healthcare team provides education to the patient specialist, dietitian, social worker). and his/her circle of care and involves everyone in the Many patients with chronic stalled wounds are treatment plan. Healthcare professionals may assume complex older adults who live with multiple comor - that patients know more about their wounds than bidities, and who require lengthy assessment and their current understanding. One study surveyed coordination of the treatment interventions. This persons with DFUs and their self-foot-care behaviours. necessitates the healthcare system policy maker to Healthcare providers conducted a detailed foot assess - support interprofessional clinician teams to provide ment and provided education on each visit. The results the best possible evidence-informed practice. indicated that the knowledge base is often less than expected by the healthcare professional and that this Conclusion leads to treatment gaps. 105 The behaviour of healthcare The concept of wound bed preparation includes the providers changed during the course of the study, treatment of the whole patient (treat the cause and resulting in an increased chance that the patient’s patient-centred concerns) (Table 8). The approach to socks were removed, leading to a thorough examina - the local wound bed has 4 components, starting with tion and patient education.

Importance of Holistic Interprofessional TABLE 8 Coordinated and Collaborative Care Summary Accurate wound diagnosis and the development of Wound bed 2011 Recommendations successful treatments plans can be a challenging Treat the cause • Determine blood supply to heal undertaking, given the complexity of chronic wounds. • Identify/treat the cause (if possible) A holistic interprofessional approach to care requires to determine healability that each member of the team has unique profes - • Review cofactors/comorbidities to create an siona l knowledge that contributes to the individualized individualized plan of care plan of care. In the management of patients with Patient-centred • Assess, support and provide education for DFUs, utilizing a team approach and primary healing concerns individualized concerns (e.g. pain, activities of daily outcomes can be associated with relatively low living, psychological well-being, smoking, access costs related to a visit to an interprofessional team, to care) antibiotics and plantar pressure downloading in the community setting. 106 When healing occurs following Local wound care • Cleanse, assess characteristics and monitor an amputation, multiple hospital admissions and an (DIM+ E) local wounds extended length of hospital stay are tabulated, with a • Debride healable wounds (conservative for significantly higher cost of healing. Implemented nonhealable or maintenance wounds) treatment plans that do not yield wound-healing • Treat critical colonization, infection and rates at the expected trajectory require a timely referral persistent inflammation to an interprofessional team that can re-evaluate • Achieve moisture balance the diagnosis and causative factors. Redefining the • Consider advanced therapies for healable but treatment goals with input from the patient, family and stalled chronic wounds healthcare provider is essential. Given geographical Systems • Link improved cost-effective patient outcomes to and system differences, the ideal full complement education, evidence-informed practice, interprofes - of an interprofessional expert team may not always sional teams and healthcare system support be accessible. Therefore, it is important to realize that

Wound Care Canada / Volume 10, Number 3 Soins des plaies Canada / Volume 10, numéro 3 31 60. Moore ZE, Cowman S. Wound cleansing for pressure ulcers. Cochrane Database Syst Rev . 2005;(4):CD004983. Practice Pearls 61. Fernandez R, Griffiths R. Water for wound cleansing. Cochrane • Clinicians should classify wounds as healable, nonhealable or mainte - Database Syst Rev . 2008;(1):CD003861. 62. National Collaborating Centre for Women’s and Children’s Health. nance. Treatment plans differ depending on healability. Surgical Site Infection: Prevention and Treatment of Surgical Site • Distinguish a superficial increased bacterial burden that can be treated Infection . London: NICE; 2008. (NICE guideline CG74). Available at: www.nice.org.uk/nicemedia/live/11743/42378/42378.pdf. topically versus from surrounding tissue infection requiring systemic Accessed July 11, 2011. therapy (mnemonics NERDS and STONEES). 63. Hurlow J, Bowler PG. Clinical experience with wound and management: a case series. Ostomy Wound Manage . 2009; • A new topical diagnostic will help distinguish wounds stuck in the 55:38-49. inflammatory stage. 64. Cardinal M, Eisenbud DE, Armstrong DG, et al. Serial surgical debridement: a retrospective study on clinical outcomes in chronic • Wound bed preparation emphasizes treating the whole patient and not lower extremity wounds. Wound Repair Regen . 2009;17:306-311. just the hole in the patient (treat the cause). 65. Landis S, Ryan S, Wo K, Sibbald RG. Infections in chronic wounds. In: Krasner DL, Rodeheaver GT, Sibbald RG (eds). Chronic Wound • Patient-centred concerns include the accurate documentation and Care: A Clinical Source Handbook for Healthcare Professionals , treatment of pain. 4th ed. Malvern, PA:HMP Communications; 2007, 299-221. 66. Sibbald RG, Woo K, Ayello EA. Increased bacterial burden and • Optimal local wound care for a healable wound includes debridement, infection: the story of the NERDS and STONES. Adv Skin Wound Care . 2006;19:447-461. infection/inflammation and moisture balance before the edge effect 67. Lavery LA, Armstrong DG, Wunderlich RP, et al. Risk factors for and use of advanced therapies. foot infections in individuals with diabetes. Diabetes Care . 2006; 29:1288-1293. • If a wound is not 30% smaller by week 4, it is unlikely to heal by week 68. Gardner SE, Frantz RA, Doebbeling BN. The validity of the clinical 12. Reassess and consider interprofessional team involvement if “stalled.” signs and symptoms used to identify localized chronic wound infection. Wound Repair Regen . 2001;9:178-186. 69. Woo K, Sibbald RG. A cross-sectional validation study of using NERDS and STONEES to assess bacterial burden. Ostomy Wound the mnemonic DIM (Debridement, Infection/pro - Manage . 2009;55:40-48. 70. Demling RH, DeSanti L. The rate of re-epithelialization across longed inflammation control and Moisture balance) meshed skin grafts is increased with exposure to silver. Burns . before the mnemonic DIME, which includes advanced 2002;28:264-266. Edge-effect therapies for wounds with the ability to 71. Nadworney PL, Wang JF, Tredget EE, Burrell RE. Anti-inflamma - to ry activity of nanocrystalline silver in a porcine contact dermatitis heal. In addition, this article has introduced the model. Nanomed Nanotechnol Biol Med . 2008;4:241-251. concept of healable, nonhealable and maintenance 72. Vermeulen H, van Hattem JM, Storm-Versloot MN, et al. Topical wounds, along with the integration of clinical criteria silver for treating infected wounds. Cochrane Database Syst Rev . 2007;(1):CD005486. for superficial critical colonization (mnemonic NERDS) 73. Lo SF, Chang CJ, Hu WY, et al. The effectiveness of silver-releas - and topical antimicrobial dressings versus deep and ing dressings in the management of non-healing chronic wounds: surrounding tissue infections (mnemonic STONEES) a meta-analysis. J Clin Nurs . 2009;18:716-728. 74. Jull A, Walker N, Rogers A, et al. Randomized clinical trial of requiring systemic agents. Bacterial damage needs honey-impregnated dressings for venous leg ulcers. Br J Surg . to be distinguished from persistent inflammation 2008;95:175-182. with soon-to-be-available bedside MMP testing. The 75. O’Meara S, Al-Kurdi D, Ologun Y, et al. Antibiotics and antisep - tics for venous leg ulcers. Cochrane Database Syst Rev . 2010; ultimate treatment process should include the leader - (1):CD003557. ship of an interprofessional wound management 76. Sibbald RG, Coutts P, Woo K. Reduction of bacterial burden and team, and patient participation is paramount for pain in chronic wounds using a new polyhexamethylene biguanide antimicrobial foam dressing – clinical trial results. the best achievable outcome. After reading this article, Adv Skin Wound Care . 2011;24:79-84. clinicians will be able to distinguish between healable, 77. Spacciapoli P, Buxton D, Rothstein D, et al. Antimicrobial activity nonhealable and maintenance wounds and design of silver nitrate against periodontal . J Periodontal Res . 2001;36:108-113. appropriate management plans. 78. Nadworny PL, Burrell RE. A review of assessment techniques for silver technology in wound care. Part 1: in vitro methods for References assessing antimicrobial activity. J Wound Technol . 2008;2:6-13. 79. Burrell RE, Heggers JP, Davis GJ, et al. Efficacy of silver-coated 57. Wild T, Rahbarnia A, Kellner M, et al. Basics of nutrition and wound dressings as bacterial barriers in a rodent burn sepsis model. healing. Nutrition . 2010;26:862-866. Wounds . 1999;11:64-71. 58. Keast DH, Bowering CK, Evans AW, et al. MEASURE: a proposed 80. Nadworny PL, Burrell RE. A review of assessment techniques assessment framework for developing best practice recommen - for silver technology in wound care. Part II: tissue culture and dations for wound assessment. Wound Repair Regen . in vivo methods for determining antimicrobial and anti-inflam - 2004;12:S1-17. ma tory activity. J Wound Technol . 2008;2:14-22. 59. Rodeheaver GT, Ratliff CR. Wound cleansing, wound irrigation, 81. Kerstein MD, Gemmen E, van Rijswijk L, et al. Cost and cost- wound disinfection. In: Krasner DL, Rodeheaver GT, Sibbald RG effectiveness of venous and pressure ulcer protocols of care. (eds). Chronic Wound Care: A Clinical Source Book for Dis Manage Health Outcomes . 2001;651-663. Healthcare Professionals , 4th ed. Malvern, PA: HMP 82. Trengove NJ, Stacey MC, MacAuley S, et al. Analysis of the acute Communications; 2007:331-342. and chronic wound environments: the role of proteases and their

32 Wound Care Canada / Volume 10, Number 3 Soins des plaies Canada / Volume 10, numéro 3 inhibitors. Wound Repair Regen . 1999;7:422-452. 95. Newton DJ, Khan F, Belch JJ, et al. Blood flow changes in diabetic 83. Harding KG, Moore K, Phillips TJ. Wound chronicity and fibroblast foot ulcers treated with dermal replacement therapy. J Foot Ankle senescence – implications for treatment. Int Wound J . 2005; Surg . 2002;41:233-237. 2:364-368. 96. Hanft JR, Surperant MS. Healing of chronic foot ulcers in diabetic 84. Basketter D, Gilpin G, Kuhn M, et al. Patch tests versus use patients treated with a human fibroblast-derived dermis. J Foot tests in skin irritation risk assessment. Contact Dermatitis . 1998; Ankle Surg . 2002;41:291-299. 39:252-256. 97. Marston WA, Hanft J, Norwood P, et al. The efficacy and safety of 85. Falanga V. Wound healing and its impairment in the diabetic foot. Dermagraft in improving the healing of chronic diabetic foot Lancet . 2005;366:1736-1743. ulcers: results of a prospective randomised trial. Diabetes Care . 86. Sheehan P, Jones P, Caselli A, et al. Percent change in wound area 2003;26:1701-1705. of diabetic foot ulcers over a 4-week period is a robust predictor 98. Roeckl-Wiedmann I, Bennett M, Kranke P. Systematic review of complete healing in a 12-week prospective trial. Diabetes of hyperbaric oxygen in the management of chronic wounds. Care . 2003;26:1879-1882. Br J Surg . 2005;92:24-32. 87. Niezgoda JA, Van Gils CC, Frykberg RG, et al. Randomized clinical 99. Akai M, Kawashima N, Kimura T, et al. Electrical stimulation as an trial comparing OASIS Wound Matrix to Regranex Gel for diabetic adjunct to spinal fusion: a meta-analysis of controlled clinical ulcers. Adv Skin Wound Care . 2005;18:258-266. trials. Bioelectromagnetics . 2002;23:496-504. 88. Arévalo JM, Lorente JA. Skin coverage with Biobrane biomaterial 100. Flemming K, Cullum N. Therapeutic ultrasound for venous leg for the treatment of patients with toxic epidermal necrolysis. ulcers. Cochrane Database Syst Rev . 2000;(4):CD00180. J Burn Care Rehabil. 1999;20:406-410. 101. Baba-Akbari SA, Flemming K, Cullum NA, et al. Therapeutic ultra - 89. Smiell JM, Wieman TJ, Steed DL, et al. Efficacy and safety of sound for pressure ulcers. Cochrane Database Syst Rev . 2006; becaplermin (recombinant human platelet-derived growth factor- (3):CD001275. BB) in patients with nonhealing, lower extremity diabetic ulcers: a combined analysis of four randomized studies. Wound Repair 102. Armstrong DG, Lavery LA, Diabetic Foot Study Consortium. Regen . 1999;7:335-346. Negative pressure wound therapy after partial diabetic foot amputation: a multicentre, randomized controlled trial. Lancet . 90. Steed DL. Clinical evaluation of recombinant human platelet- 2005;366:1704-1710. derived growth factor for the treatment of lower extremity ulcers. Plast Reconstr Surg . 2006;117:143S-151S. 103. Vin F, Teot L, Meaume S. The healing properties of Promogran in 91. Dinh TL, Veves A. The efficacy of Apligraf in the treatment of venous leg ulcers. J Wound Care . 2002;11:335-341. diabetic foot ulcers. Plast Reconstr Surg . 2006;117:152S-159S. 104. Wollina U, Schmidt WD, Kronert C, et al. Some effects of a 92. Veves A, Falanga V, Armstrong DG, et al. Graftskin, a human skin topical collagen-based matrix on the microcirculation and wound equivalent, is effective in the management of non-infected healing in patients with chronic venous leg ulcers: preliminary neuropathic diabetic foot ulcers: a prospective randomized multi - observations. Int J Low Extrem Wounds . 2005;4:214-224. center clinical trial. Diabetes Care . 2001;24:290-295. 105. Litzelman DK, Slemenda CW, Langefeld CD, et al. Reduction 93. Redekop WK, Stolk EA, Kok E, et al. Diabetic foot ulcers and of lower extremity clinical abnormalities in patients with non- amputations: estimates of health utility for use in cost-effectiveness insulin-dependent diabetes mellitus. A randomized, controlled analyses of new treatments. Diabetes Metab . 2004;30:549-556. trial. Ann Intern Med . 1993;119:36-41. 94. Falanga V, Margolis D, Alvarez O, et al. Rapid healing of venous 106. Apelqvist J, Ragnarson-Tennvall G, Larsson J, Persson U. Diabetic ulcers and lack of clinical rejection with an allogeneic cultured foot ulcers in a multidisciplinary setting. An economic analysis human skin equivalent. Human Skin Equivalent Investigators of primary healing and healing with amputation. J Intern Med . Group. Arch Dermatol . 1998;134:293-300. 1994;235:463-471.

Wound CARE Instrument Available Now!

The Canadian Association of Wound Care and the Canadian Association for Enterostomal Therapy collaborated to produce the Wound CARE (Collaborative Appraisal and Recommendations for Education) Instrument. The Wound CARE Instrument provides a set of standards that support healthcare providers, organizations and health authorities to undertake a comprehensive and collaborative evidence-informed appraisal process before launching a wound management educational event or program. The Wound CARE Instrument can be used to evaluate existing wound care programs, as well as to develop new programs. Visit http://cawc.net/index.php/resources/wound-care-instrument/ to download a copy.

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