Wound care: Key Slides notes

Slide 1
These key slides review the management of chronic wounds in two parts: 1 - background, the types of wounds, factors affecting wound healing, how to assess a wound and some of the management issues around cleansing wounds. 2 - brief review of the many different dressings available.

Slide 2
The management of chronic wounds is a very high cost area for the patients affected and not just in terms of money, as quality of life can be severely affected through reduced mobility, constant pain and in some cases long term absence from work. Wound care is also a high cost area for the NHS in time and costs of staff, and in the costs of hospital admissions, treatment and prevention strategies. As covered in other wound materials, there is little good quality evidence available in terms of RCTs to guide therapeutics to help us know if one treatment is better than another in terms of time to wound healing or closure. Even with the recent price reductions of many dressings, most prescribers will find that the volume and cost of dressings is one of the top ten growth areas in prescribing. It currently accounts for about 2% of the national primary care prescribing budget, but added to this will be the non-prescribing costs which can only be estimated. Its also worth noting that most wound care products do not have to be prescribed on FP10. Many PCTs have moved to an alternative non-prescription supply system.

Slide 3
The assessment of chronic wounds requires holistic approach looking at factors other than the wound itself. This may include social as well as health care. Assessment must include a full medical history, nutritional and vascular status to determine factors which may delay healing. A systematic approach to the assessment of wounds is needed as each patient is different and will therefore have differing needs. Good documentation is essential for continuity of care as well as being useful should the notes be required for legal purposes.

This resource has been produced with the support of a number of NHS individuals and organisations. It is intended as a template from which you can produce local versions adapted to your own local needs.

Slide 4
Wound assessments should be systematic in approach, starting with a baseline from which treatment effects can be measured at future re-assessments. National guidelines such as Clinical Knowledge Summaries (CKS - formerly known as PRODIGY), the Northern Ireland Wound Management Handbook and also the Scottish guidelines, SIGN, list the areas to be monitored at baseline and at future assessments. This includes wound size, wound bed classification, infection, exudates, periwound surface and pain. Overall, the aim of the assessment is to ensure that a clean, moist wound healing environment is created.

Slide 5
Guidance issued by the Health Protection Agency in 2007 advises that clean technique is needed when treating most chronic wounds. A clean technique is one that aims to prevent the spread of pathogens in wounds healing by secondary intention such as those wounds already colonised by bacteria. An aseptic technique aims to reduce the risk of introduction of pathogens into a wound. All local Trusts should have produced guidelines on each technique and detailed operational procedures, so any healthcare practitioner involved in wound management needs to be familiar with the local requirements.

Slide 6
Part of the infection control guidance suggests that we use gloves and aprons when treating wounds. This brings us on to the use of dressing packs in primary care. The NHS currently spends about 2.4 million on dressing packs issued on prescription. How useful are the most commonly prescribed sterile dressing packs in wound care management today?

Slide 7
The contents of the most popular dressing packs prescribed in NHS primary care have barely changed over the years. The contents are listed here and contain items such as cotton wool balls that now have no place in modern wound treatment.

Slide 8
It might be worth having a debate locally about the appropriate use of sterile dressing packs. Should their use be reserved for aseptic procedures? Should you be investing in SDPs with more appropriate contents? Does your PCT have an alternative method of supply of more appropriate packs? Many PCTs have developed innovative ways of alternative supplies, such as a non-prescription supply direct from a central store, or through an order from mechanism through community pharmacies.

This resource has been produced with the support of a number of NHS individuals and organisations. It is intended as a template from which you can produce local versions adapted to your own local needs.

Slide 9
Wounds should be cleaned only if debris or foreign material is present, not as a ritual at each dressing change if it is not necessary. There is a lot of debate in the literature about whether to use saline of water when cleaning wounds and well look at this in a moment. For venous ulcers, national guidance from Clinical Knowledge Summaries (CKS) advises that tap water or saline at body temperature should be used to cleanse the wound and also recommends gentle irrigation rather than swabbing with cotton wool or swabs. Antiseptics arent recommended as they can inhibit the wound healing process, perhaps by disrupting the fibroblasts that are trying to knit together new tissue. These solutions may also be painful for the patient.

Slide 10
In January 2008, a Cochrane systematic review looked at the evidence for saline vs. tap water in the management of acute and chronic wounds, mostly in a hospital setting, as there were few studies giving information in community settings. It found that there was no evidence that using tap water to cleanse acute wounds in adults increased infection, and some evidence that tap water in these wounds reduced infection. It found that there was no evidence that cleansing wounds per se increased healing or reduced infection. It recommended that in the absence of potable tap water, boiled, cooled and distilled water could be used as a wound-cleansing agent. Another Cochrane review of cleansing of pressure ulcers concluded the evidence available from studies was poor, and that there was no good evidence to support the use of any particular wound cleaning solution.

Slide 11
This slide of the national prescribing data for saline solutions for England and Wales shows the amounts spent over the past year. Items and costs of saline solutions are increasing. It is evident that where saline is prescribed, some of the most expensive forms of saline are being prescribed when cheaper alternatives are available. The use of saline sprays accounts for half of all scripts. This is an area for reflection. When used for chronic wounds, is the pressure spray delivering gentle irrigation at body temperature?

This resource has been produced with the support of a number of NHS individuals and organisations. It is intended as a template from which you can produce local versions adapted to your own local needs.

Slide 12
This slide gives a comparison of costs of the different saline solutions available on prescription by volume. It is a crude comparison but given so that we can demonstrate the differences in cost of the different solutions. As we can see, aerosols tend to be more expensive, and the variability in costs of the pod solutions may merit further investigation locally.

Slide 13
All chronic wounds will be colonised with bacteria. Clinical signs of infection become apparent when the number of bacteria present outweighs the bodys own immune response and this will mean that wound healing is slowed down. Guidance from NICE, SIGN and the HPA, based on a review of the evidence, advises that systemic antibiotics, not topical antimicrobials, should be used first line where clinical signs of infection become apparent. Swabs need only be taken where there is clinical sign of infection and the wound will need daily or alternate day assessments. Debridement will remove non viable tissue and give the wound a chance to improve its healing rate and this along with basic infection control measures, should help towards managing the infection.

Slide 14
National guidance advises the use of systemic antibiotics where there is clinical sign of infection, but where a topical antimicrobial is considered necessary, use should be short term. Topical antimicrobials are contained in several types of dressings silver impregnated and iodine dressings are the two most common, but there is increasing use of honey dressings in primary care. Topical creams and gels used are silver sulphadiazine cream and metronidazole gel.

Slide 15
Iodine dressings if used should be applied directly to the wound surface and covered with a secondary dressing. Iodine has contraindications for use in pregnant or breastfeeding patients, in very young children and those with impaired renal function. The dressing should be changed daily or on alternate days and use should be reviewed after 7 days.

This resource has been produced with the support of a number of NHS individuals and organisations. It is intended as a template from which you can produce local versions adapted to your own local needs.

Slide 16
Silver-containing dressings are dressings as described above, such as foam or hydrocolloid, but with silver added into the dressing matrix. For some time silver has been thought to have antimicrobial properties, and the theory behind these dressings is that when applied directly to a wound the silver ions will act as a bactericidal and will reduce the bacterial population. The dressing is applied direct to the wound surface and reviewed at least every 3 days.

Slide 17
The costs of silver dressings in the NHS primary care prescribing is currently 24million per year and rising The current volume of silver containing dressings prescribed suggests that this is an area we can examine to ensure we are following best practice for our patients, as we have already seen from systematic reviews of the evidence that the effectiveness of silver dressings over other, dressings has not been proven. Where topical antimicrobials are recommended by specialists, their use should be short term only and subject to regular review and re-assessment.

Slide 18
To summarise this brief session on wound care, its important to note that a moist wound bed is needed for all stages of wound healing, but also that wound healing is about more than just the wound itself. There are other extrinsic and intrinsic factors involved which need to be considered when managing wounds to promote good healing. Wounds also need to be assessed at baseline and regularly thereafter to evaluate healing and treatments. Above all, infection control guidance should be followed to minimise bacterial contamination. Within this, the use of sterile dressing packs can be evaluated locally, as well as the use of saline solutions, especially those which are not used at body temperature.

Slide 19
Because of methodological problems in studies of dressings in chronic wound care, we have insufficient evidence to determine if one type of dressing is superior to another. Infected wounds should be treated where there are clinical signs of infection, such as pyrexia. National guidance tells us that the first line treatment for most infected wounds is systemic antibiotic therapy. Topical antimicrobials, if used, should be used in the short term only, and any dressings applied need to be re-applied every one or two days to allow frequent re-assessment of the infected wound.

This resource has been produced with the support of a number of NHS individuals and organisations. It is intended as a template from which you can produce local versions adapted to your own local needs.