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A Focus on the Triangle of Wound Assessment — Addressing the Gap Challenge and Identifying Suspected Biofilm in Clinical Practice

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A Focus on the Triangle of Wound Assessment — Addressing the Gap Challenge and Identifying Suspected Biofilm in Clinical Practice Clinical practice A focus on the Triangle of Wound Assessment — addressing the gap challenge and identifying suspected biofilm in clinical practice Authors: Wound assessment should be comprehensive, systematic and evidence- Caroline Dowsett, Terry Swanson and Tonny Karlsmark based (World Union of Wound Healing Societies [WUWHS], 2016a). The Triangle of Wound Assessment offers clinicians a framework to assess the patient and their wound, taking into consideration the wound bed, wound edge and periwound skin (Dowsett et al, 2015). The framework can be adapted to incorporate new developments and new challenges in wound care such as the ‘gap challenge’ and biofilm prevention and management. Using the framework can assist in determining the status of the wound bed and support clinical decision making to prevent problems associated with exudate pooling at the wound bed and the potential for biofilm formation. he Triangle of Wound Assessment This article will discuss how the Triangle of was established in 2014 and provides Wound Assessment identifies infection and T a systematic approach to wound biofilm, tackles the gap challenge, and how assessment and in setting management goals, this framework can be developed for new to guide optimal treatment choice (Dowsett et challenges in wound care. al, 2015), ensuring that the periwound skin is incorporated into the assessment. Periwound The importance of holistic assessment skin can be a significant problem in patients Wounds are a significant source of cost to with chronic wounds, with between 60–70% patients, as well as to the health economy. of wounds found to be surrounded by either Chronic wounds are often hard to heal problematic or unhealthy periwound skin resulting in a cycle of pain, anxiety and (Cartier et al, 2014). It is, therefore, fundamental reduced quality of life for the individual for these chronic wounds, and all other types of patient. Delayed wound healing and wound wounds to be assessed in three key areas: the complications add considerably to the cost of wound bed, the wound edge and the periwound care and are associated with longer and more skin, which are incorporated by the Triangle of intensive treatment, extended hospital stays Wound Assessment (Dowsett et al, 2015). or readmission, and specialist intervention More recently, the framework highlights (Dowsett, 2015). the significance of the gap challenge and the Evidence suggests that many patients potential for biofilm formation when exudate with wounds lack an accurate diagnosis and pools at the wound bed (Dowsett et al, 2018). are often managed with an inappropriate The wound gap refers to the gap that can present treatment plan (Guest et al, 2017). Accurate between the wound bed and the dressing. and timely wound assessment should be Caroline Dowsett is Clinical Nurse An appropriate wound dressing should make integral to managing a patient with a wound. Specialist Tissue Viability, East intimate contact with the wound bed, while Wound assessment needs to be comprehensive, London NHS Foundation Trust, absorbing and retaining levels of wound exudate systematic and evidence-based, providing London & Independent Nurse (Snyder, 2005; Cutting et al, 2009). It can be a baseline information against which clinicians Consultant in Wound Care, London Terry Swanson is Nurse Practitioner clinical challenge to manage and close the gap, can establish the current status of the Wound Management, South West which occurs when a dressing fails to conform to wound, set realistic treatment goals and Healthcare, Australia the wound bed. Additionally, managing wound monitor progress over time using appropriate Tonny Karlsmark is Clinical bioburden can be challenging and biofilm based interventions. Poor assessment can lead to Associate Professor, Department wound care needs to be considered in non- inappropriate treatment choices, contributing of Dermatology, Copenhagen University Hospital, Bispebjerg healing chronic wounds that are not responding to poor outcomes for patients and additional Hospital, Copenhagen to standard best practice. resource costs. RAT A LEB IN EBR TIN E G EL G C C 34 Wounds International 2019 | Vol 10 Issue 3 | ©Wounds International 2019 | www.woundsinternational.com 10. YEARS 10 YEARS We asked healthcare ...none professionals around the However, in a recent met all of the world about their priorities study of 14 wound criteria for assessment tools ... ? for wound care optimal wound assessment4 We found that most people Respondents said that The Triangle of Wound Assessment is a treating wounds are not protecting the periwound specialists in a hospital1 skin is very important1 holistic framework that allows practitioners üto assess and manage all areas of the Figure 1. The Triangle of Wound wound, including the periwound skin. Assessment. Wound bed assessment ■ Tissue type ■ Exudate ■ Infection It is a simple and systematic Approximately Wound bed Up to approach that guides the Health 79% Care Professional from complete of wounds are 70% of WOUND being treated in wounds are wound assessment to setting 2 management goals and selecting Wound edge Periwound skin the community surrounded by Periwound skin assessment 3 relevant treatmentWound options.edge assessment unhealthy skin ■ Maceration ■ Maceration ■ Excoriation ■ Dehydration ■ Dry skin ■ Undermining 2 ■ Hyperkeratosis3 ■ Thickened/rolled edges ■ Callus ■ Eczema CPWSC_TOWA_Brochure_210x210_2018.indd 2-3 10/01/2018 15.14 The role of structured assessment tools that can be incorporated into any patient record Wound assessment and management frameworks system (Dowsett et al, 2015; WUWHS, 2016a). offer clinicians an opportunity to improve wound The concept was developed from a global assessment, patient outcomes and reduce the anthropological study conducted in 2013–2014 burden of chronic wounds. Assessment should with the aim of gaining a better understanding aim to establish the correct diagnosis to ensure of the impact of a wound on the patient. A key treatment of the underlying cause of the wound, finding from the study showed that clinicians as well as assessing size and depth of the wound and patients separated the wound into three and managing the wound. Wound assessment distinct, yet interconnected areas. should record the wound type, location, size, The Triangle of Wound Assessment focuses wound bed condition, wound edge and the on the wound bed, wound edge and periwound condition of the periwound area, and this should skin, each with significant importance in wound be ongoing as part of re-assessment. There are healing [Figure 1]. The wound bed is where many benefits to improving wound assessment clinicians seek to assess tissue type, manage of chronic wounds and best practice in holistic exudate, prevent infection, reduce inflammation, wound assessment has the potential to: remove devitalised tissue and promote ■ Improve healing rates granulation tissue formation. At the wound edge, ■ Reduce the physical, emotional and the aim is to reduce the barriers to healing by socioeconomic impact of wounds on patients debriding thickened and rolled wound edges, ■ Benefit practitioners and the health economy identifying areas of undermining and improving by reducing the overall burden of wounds, exudate management. For the periwound skin potentially decreasing workload and the costs the aim is to protect the skin surrounding the associated with wound care wound from maceration, excoriation, dry skin, ■ Raise practitioner and patient morale by hyperkeratosis, callus and eczema. improving patient outcomes (Wounds UK, 2018). Developing the Triangle of Wound Assessment for new challenges The Triangle of Wound Assessment New developments in wound care highlight the The Triangle of Wound Assessment is a well- importance of preventing exudate pooling and established and easy to use framework for reducing the dead space or ‘gap’ between the intuitive wound assessment that combines wound bed and the dressing, to avoid wound evaluation of the periwound skin within the complications, such as maceration and biofilm wound bed preparation paradigm, while formation and infection. Highly exuding wounds acknowledging the importance of treating the and wounds with undermining and a steep angle patient as well as the wound. It was developed between the wound edge and wound bed are at to facilitate accurate and timely wound a higher risk of dead space. The Triangle of Wound assessment in a simple and easy-to-use format, Assessment can be used to (Dowsett et al, 2018): RAT A LEB IN EBR TIN E G EL G C C Wounds International 2019 | Vol 10 Issue 3 | ©Wounds International 2019 | www.woundsinternational.com 35 10. YEARS 10 YEARS Clinical practice ■ Identify and assess the gap, and evaluate the infection. Wound exudate contains an excess impact of the interventions number of enzymes and other substances that ■ Measure wound depth as part of wound can inhibit the healing, as well as proteins that assessment promote the growth of bacteria. Thus, pools ■ Identify irregular wound bed topographies of exudate promote bacterial growth, leading and cavities to increased risk of infection and subsequent ■ Identify areas of undermining. development of biofilm. An optimal wound The Triangle can also be adapted to dressing should conform to the wound bed to incorporate new developments and new manage the gap and reduce exudate pooling, challenges in wound care, such as the creating a less favourable environment for gap challenge and biofilm prevention biofilm to form. and management. Managing
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