A feeling for healing

There is no one-size-fits-all wound dressing. Today’s advanced technology allows for dressings and systems tailored for certain situations, such as trauma wounds, burns, diabetic ulcers, surgical-site incisions, chronic wounds, infected wounds, pressure injuries (PIs), and more. Wounds also have different needs at different stages of healing.

Some of the ways dressings help wounds to heal are by keeping them moist but not wet, not sticking to the wound and adding further trauma to the affected skin, providing a barrier to bacteria, keeping the wound close to normal body temperature, aiding debridement if there is necrotic tissue, conforming to body parts and not interfering with body function, and allowing frequent inspection.

There are so many wound-care options available that it can be confusing. It is impossible to include all products available here, but the following is a compilation of different types of wound-healing aids available and what sets these products apart from each other. As always, ask for the evidence of efficacy, preferably from independently conducted and published scientific studies.

Dressing options

Cooper noted, “Although significant progress has been made to prevent pressure ulcers/injuries, the Agency for Healthcare Research and Quality recently reported the incidence increased by 10 percent between 2014 and 2016.³ To break this cycle, facilities must adopt a skin-first approach, one that takes a holistic view and focuses on people, practice, and products that impact cost, quality, and outcomes.”

Each year, the 3M Award for Excellence in Skin Safety, funded by a grant from 3M to the Wound, Ostomy, Continence Nurses Society (WOCN), recognizes facilities that have demonstrated positive clinical outcomes achieved through best-in-class prevention protocols, teamwork, interdisciplinary participation, senior leadership engagement, and effective staff and patient education. The 2018 honoree is Connecticut Children’s Hospital. Amy Korber, MSN, RN-BC, Manager, Learning & Performance, said, “We’re proud to have received this year’s 3M Award for Excellence in Skin Safety for the depth and breadth of our skin-integrity program services and for sustaining high-quality patient outcomes for more than six years.”

Korber said their skin-care program began in 2012, to help minimize prevalence of PIs. “At that time, we did not have a dermatology department, so the program began organically when a group of nurses at the hospital began to explore ways to improve skin integrity across the hospital. The foundation of our skin-care program was built around, and adheres to, the 5 Solutions for Patient Safety PI–prevention standard bundle elements: assessment, device rotation, patient positioning, appropriate bed surface, and moisture management. Other components include resources to educate and support patient-care team members on the importance of both skin risk assessment and PI prevention, and dedicated ‘Healthy Skin Champions’ who are devoted to skin care as a top priority in each inpatient unit. We also conduct quarterly PI prevalence audits and regularly track the hospital’s performance against children’s hospitals nationwide.”

The 3M grant also provides financial support for an individual or a maximum of four members of a skin-care team to attend the annual WOCN conference.

Vitamins and minerals

Ionic silver has inherent antimicrobial properties, making it useful for wound healing. Raul Brizuela, President and CEO, Argentum Medical, explained what sets their product apart. “Silverlon uses a unique silver-plated nylon substrate, providing up to 100 times more silver than impregnated dressings, and is activated by moistening before application to generate antimicrobial silver ions. Silverlon eradicates methicillin-resistant Staphylococcus aureus in four hours and remains active for up to seven days.” He added that it is inexpensive and easy to use.

Brizuela pointed out the efficacy of Silverlon is supported by multiple peer-reviewed published studies conducted in different disciplines, including orthopedics, colorectal surgery, open heart surgery, scoliosis, and laminectomies. “An independent study from Harvard showed a 54 percent reduction of prosthetic joint infections (total hip and knee surgeries), both superficial and deep infections.⁴ A study from the University of South Florida showed a 46 percent reduction in central-line infections, compared to the standard chlorhexidine sponge dressing. The rate was sustained for six years.⁵

“One of the greatest problems in hospitals today is the burden of postoperative wound infection,” stated Brizuela. “A surgical-site infection costs a minimum of $23,000 and can easily exceed $100,000. For central lines in the University of South Florida study, the authors estimated that use of Silverlon saved their facility over $1,000,000 per year.”⁵

Kerecis offers Omega3 Wound , an unusual but effective wound-care product. Gunnar Johannsson, MD, Director of Medical Affairs, described it as “intact fish skin that, when grafted onto damaged human tissue, recruits the body’s own cells and ultimately is converted into living tissue. Larger, thicker sheets last longer in the wound and are ideal to cover exposed bones and tendons,” said Johannsson.

“The product helps wounds heal because of the structure of the fish skin and the presence of Omega3 polyunsaturated fatty acids,” explained Johannsson. “Because there is no risk of disease transmission, the fish skin is only minimally processed. The result is that the fish skin is much more similar in structure to human skin than other skin substitutes. Also, fish skin is rich in Omega3, which possesses multiple health benefits, including anti-inflammatory and pain-relief properties.” Johannsson said fish skin is easy to use, has a three-year shelf life at room temperature, and requires no complicated preparation or thawing procedure.

Johannsson cited a double-blinded, randomized, controlled clinical study that found wounds treated with Kerecis Omega3 Wound healed significantly faster than wounds treated with leading mammalian-based products. “In the study, which compared the fish skin to pig tissue, up to twice as many wounds closed at the study time points.⁶

Negative-pressure wound therapy

Negative-pressure wound therapy (NPWT) is the application of sub-atmospheric pressure to a wound to remove exudate and debris. It is delivered through an integrated system of a suction pump, separate exudates collection chamber, and dressing sets.

Brenda Hart, MSN, FNP-C, ARNP, CWON, Senior Clinical Consultant, NPWT and Wound Care, Cardinal Health, explained that NPWT is commonly used for chronic or difficult-to-heal wounds. “Studies show up to four times increased likelihood of healing as compared to standard wound care,”⁷ said Hart.

“The Cardinal Health NPWT device is intuitive, easy to use and troubleshoot,” continued Hart. “The NPWT devices have a unique feature called Simultaneous Irrigation. This therapy can be added to Cardinal Health NPWT at onset of therapy or at any time after NPWT has been initiated. Like intermittent irrigation, the irrigant flows throughout the wound bed; however, unlike intermittent therapy, it provides continuous flow of irrigant, thereby eliminating time gaps in treatment. Studies show reduction in bacterial contamination and wound infection rates when NPWT is combined with simultaneous normal saline irrigation.⁷ A comparison study using normal saline versus Prontosan wound irrigation solution (B Braun) showed no significant difference in infection, and, similarly, there has been no difference with flow rate of 15 cc to 30 cc per hour.

“With the escalating cost of healthcare and increased pressure to decrease length of stay, prevent infection, and provide evidence-based practice, use of Cardinal Health Simultaneous Irrigation boasts an average 30 percent to 50 percent (data on file) cost savings over use of instillation therapy, while providing a state of the art, evidence-based therapy that is effective and easy to use,” stated Hart.

Vicki Strugala, PhD, Smith & Nephew, Professional Education, Advanced Wound Management, Europe, described PICO NPWT as having a proprietary AIRLOCK Technology that delivers NPWT across a surgical incision and the surrounding zone of injury. This feature helps to reduce risk of wound complications by reducing postoperative fluid, swelling, and associated tension around a closed surgical incision.

Strugala cited a recent meta-analysis that found “using PICO with AIRLOCK Technology reduced the rate of surgical-site complications by 58 percent and the rate of dehiscence by 26 percent. PICO-treated patients spent a half-day less in hospital on average.”⁸ Risal Djohan, MD, Department of Plastic Surgery, Cleveland Clinic, a PICO user, observed, “This meta-analysis confirms the benefits and significant role of the PICO system. The current published data underline the importance of adapting the use of this advanced and novel innovation in helping to treat our patients with confidence to lower the potential incidence for surgical complications.”

Strugala cited evidence showing use of PICO resulted in fewer complications and reduced length of stay, on average by more than 8 days, in closed laparotomy wounds after abdominal surgery.⁹ “In patients undergoing primary hip and knee arthroplasties, it was estimated that care with PICO enabled cost savings of more than £7,000 (equivalent of $9,220) per high-risk patient, compared with care with standard dressings.”¹⁰

Patient compliance

Ron Silverman, MD, Chief Medical Officer, KCI, said, “Patient adherence to treatment is an ever-present concern for wound-care clinicians, but new technology has helped alleviate that concern for more effective home care. KCI’s iOn PROGRESS Remote Therapy Monitoring (RTM) works with ACTIV.A.C. Therapy, an NPWT system that uses a vacuum to enhance wound healing. It is the first system to deliver continuous at-home monitoring for NPWT patients and leverages digital connectivity to monitor adherence and securely transmit data to the KCI iOn PROGRESS Care Network, a group of highly-trained individuals who interact with patients to support compliance.”

Silverman cited results from a study by Kinetic Concepts, Inc., presented at the 2018 Symposium of Advanced Wound Care Spring Conference and published in Wounds¹¹ that demonstrated iOn PROGRESS RTM led to 73.5 percent of patients increasing use and adherence to NPWT. Patients’ rate of daily change in wound-volume reduction also increased for patients going from less than 60 percent therapy use to 90 to 100 percent therapy use.

Silverman noted that iOn PROGRESS RTM with ACTIV.A.C. Therapy positively affects healthcare systems’ finances. “In the U.S., 6.5 million patients are affected by chronic wounds, costing approximately $50 billion annually. It’s estimated that treating chronic wounds in the U.S. costs more than 10 times the cost of single-year readmissions. Further, 24 percent of all Medicare readmissions are wound-related. The iOn PROGRESS System can positively impact patient adherence and reduce wound volume, reducing the cost burden on the healthcare system.”

Rapid diagnostic tool

Culturing a wound steals time at what may be a critical point in the patient’s health. While awaiting culture results, doctors sometimes make an educated guess as to which antibiotic should be used. If they are proved wrong, valuable time has been wasted and the door to antimicrobial resistance may have been opened unnecessarily. An alternative to wound culture is DxWound, from CogenDx, a DNA-based tool for rapid and comprehensive assessment of the microbial environment of a wound.

Angela G. Huskey, PharmD, CPE, Senior Vice President and Chief Clinical Officer, Millennium Health, LLC, stated, “Skin and soft-tissue infections (SSTIs) are common, consequential, and costly inpatient admissions. Surgical-site infections (SSIs) are the number one reason for unplanned readmission following surgery.¹² The cost of care has been reported as 1.43 times greater for patients with an SSI than for patients without an SSI^.13 Antimicrobial therapy that is not targeted to the causative pathogen within 48 hours of presentation is an independent risk factor for treatment failure for those with SSTIs.¹⁴

“Using microbial DNA, DxWound provides accurate, sensitive detection of an array of microbes, including aerobic and anaerobic bacteria and fungi, plus antibiotic-resistance genes, all delivered in a single actionable report, generally within one business day, which is faster than final results can typically be delivered via culture and sensitivity testing,” said Huskey. “DxWound saves time and effort because no bacteria-growth step is required. The swab sample is collected in an inactivating solution that kills the microorganisms at the same time as protecting the microbial DNA, thus preserving the wound microbiome in time at the point of specimen collection.”

Huskey briefly outlined points that benefit the patient but also benefit the hospital’s bottom line. “DxWound may lessen hospital length of stay for SSTI patients, providing clinicians with fast turnaround time of comprehensive information about the wound microbiome, to help them effectively and rapidly navigate important treatment decisions for their patients. DxWound also offers versatile test ordering and report delivery, through both paper and online-based options, with readily available electronic medical record integration and minimal training, with no equipment purchase or labor costs typically associated with diagnostic devices.”

Skin care

The skin is the body’s first line of defense against injury and pathogens. Keeping patient skin clean and moisturized helps to maintain skin integrity and to prevent infection.

Thomas Vigso, Vice President, Head of US Wound & Skin Care, Coloplast Corporation, talked about how their product contributes to skin health. “Coloplast’s EasiCleanse is a no-rinse, self-sudsing, disposable washcloth for patient bathing in healthcare facilities. EasiCleanse uses include head-to-toe bathing, shampooing, perineal cleansing, incontinence cleansing, catheter care, and neonatal to geriatric bathing. EasiCleanse can do all of this with a single product, whereas other companies may require a multitude of different products. Managing cost and protocol compliance are central in the minds of customers. Versatile products can address these issues by helping standardize and streamline processes. The more versatile the product, the fewer products materials managers must purchase and store, and the simpler it is for nursing staff to manage.”

Vigso added that EasiCleanse is chlorhexidine gluconate (CHG)-compatible with Coloplast’s Micro-Guard four percent CHG solution, and it does not support the growth of any microorganisms during the product’s shelf life.

“A satisfactory patient experience is a growing focus for many facilities,” noted Vigso. “EasiCleanse delivers on this front with an ultra-soft and sudsy cloth designed to mimic a real sudsy bath. In a study of 36 patients and 25 caregivers that compared EasiCleanse with basin bathing, it was shown that 95 percent of the participants completely agreed or agreed that they preferred EasiCleanse over the alternative.”¹⁵

Lisa Levison, Founder and CEO, Innovative Bioscience Solutions, explained how her skincare line works. “dermaglove products were developed to strengthen the skin’s vitality by reducing the risk of compromising exposures through a proprietary technology known as invis-0-bond (I0B). I0B provides a healthy environment for the body to produce its own oils and lipids, called the acid mantel. A healthy acid mantel is a natural preventative measure, naturally designed to avoid infection and cross-contamination exposures.”

invis-0-bond works by forming a flexible barrier on the skin’s surface, allowing the body to enhance its own acid mantel. Levison related that AMA Laboratories “conducted a moisturization study, demonstrating dermaglove’s ability to improve skin moisture by 74.9 percent within 15 minutes of application, versus a leading sanitizing brand that only improved skin moisture by 17.0 percent. Noticeable moisturization was sustained for 24 hours following the initial application.”

Levison said, “The Georgia State Medical Association, Inc., endorsed dermaglove in 2010 as a superior solution to traditional hand sanitizers and hygiene products, due to the I0B technology, which is designed to strengthen the skin’s ability to protect itself naturally by infusing moisturizers, nutrients, oils, and minerals onto the skin. Patients and healthcare workers will respond better to protocols if the treatment is seen as both beneficial and effective.

“Healthy skin equals skin protection,” said Levison, “which leads to less infection, resulting in reduced health-care costs.”

Follow the evidence

A five-point checklist for evaluating pressure ulcer prevention dressings

by Sue Creehan, MSN, RN, CWOCN, VCU Health System

Five-layer foam dressings are now an essential element of global standards for pressure ulcer prevention in the U.S. and elsewhere. However, choosing the best one can be challenging. The following checklist outlines significant information to consider.

1. Follow the clinical evidence. It is important for hospital purchasing managers to sort out solid science from marketing hype. Ask the supplier to provide you with peer-reviewed, published studies that demonstrate the clinical efficacy of their pressure ulcer prevention dressings. And be sure the evidence provided supports the dressing being sold, not just the use of a “five-layer foam” dressing.
2. The true causes of pressure ulcers. Based on recent research, the most serious pressure ulcers do not begin at skin level. Rather, they are caused by deformations deep in the tissue caused by four extrinsic factors — shear, pressure, friction and microclimate. These types of ulcers are especially difficult to detect, challenging and expensive to treat, and dangerous for the patient. Dressings should protect against all four extrinsic factors. Look for supporting evidence of the dressing’s protection of deep tissues.
3. Look beyond skin pressure. Skin pressure alone is an insufficient measurement when evaluating dressings. Don’t be misled into believing pressure distribution alone will protect your patients. We have seen some dressings promoted as “effective” by showing how well they distribute pressure using a steel ball on a hard surface. However, that fails to consider other factors such as friction and shear. A dressing should be tested for its ability to protect soft tissues beneath the skin. This can be done using Finite Element Modeling, a 3-D computer modeling methodology, and validated with clinical evidence.
4. Ensure dressings are engineered based on
   scientific data. To address all the factors that cause pressure ulcers, dressings must incorporate advanced features that offer the right combination of strength and flexibility. Recent studies show the best protection against pressure ulcers comes through “anisotropic design,” which means they have strength in the patient sliding/shearing direction along with flexibility in the horizontal direction. Durability is also key from both effectiveness and cost standpoints. If a dressing’s structural integrity becomes compromised once subjected to in-use conditions, it cannot retain its protective properties. Be sure the dressing’s design is based on the latest scientific findings, and retains its protective properties in clinical conditions.
5. Focus on ROI. In evaluating dressing purchasing options, it is natural to make comparisons based on initial cost. However, given the high cost of treating pressure ulcers, it is important to consider that an incremental savings on upfront price can be wiped out quickly if the prevention dressing is not efficacious and an expensive pressure ulcer occurs. Reading broad peer-reviewed and published studies can help you sort through marketing hype.

References

1. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. Emily Haesler (Ed.). Cambridge Media: Osborne Park, Western Australia; 2014.
2. 3M. State of skin: elevating the science of skin management. https://engage.3m.com/State_of_Skin. Last accessed July 2, 2018.
3. Agency for Healthcare Research and Quality. AHRQ National Scorecard on Hospital-Acquired Conditions Updated Baseline Rates and Preliminary Results 2014–2016. June 2018. https://www.ahrq.gov/sites/default/files/wysiwyg/professionals/quality-patient-safety/pfp/natlhacratereport-rebaselining2014-2016_0.pdf. Last accessed June 29, 2018.
4. Tisosky AJ, Iyoha-Bello O, Demosthenes N, et al. Use of a silver nylon dressing following total hip and knee arthroplasty decreases the postoperative infection rate. JAAOS Glob Res Rev. 2017;1:e034. https://www.scribd.com/document/367554277/Use-of-a-Silver-Nylon-Dressing-Following-Total-Hip-3-1. Last accessed June 30, 2018.
5. Karlnoski R, Abboud EC, Thompson P, et al. Reduction in central line–associated bloodstream infections correlated with the introduction of a novel silver-plated dressing for central venous catheters and maintained for 6 years. J Intensive Care Med. 2017 Jan 1:885066617745034. http://journals.sagepub.com/doi/10.1177/0885066617745034
6. Baldursson BT, Kjartansson H, Konradsdottir F, et al. Healing rate and autoimmune safety of full-thickness wounds treated with fish skin acellular dermal matrix versus porcine small-intestine submucosa: a noninferiority study. Int J Low Extrem Wounds. 2015 Mar;14(1):37-43.
7. Davis KE, Moquin KJ, Lavery LA. The fluid dynamics of simultaneous irrigation with negative pressure wound therapy. Int Wound J 2016 Aug;13(4):469-474.
8. Strugala V, Martin R. Meta-analysis of comparative trials evaluating a prophylactic single-use negative pressure wound therapy system for the prevention of surgical site complications. Surg Infect. 2017 Oct;18(7):810-819.
9. O’Leary DP, Peirce C, Anglim B, et al. Prophylactic negative pressure dressing use in closed laparotomy wounds following abdominal operations. Ann Surg. 2017 Jun;265(6):1082-1086.
10. Nherera LM, Trueman P, Karlakki SL. Cost-effectiveness analysis of single-use negative pressure wound therapy dressings (sNPWT) to reduce surgical site complications (SSC) in routine primary hip and knee replacements. Wound Repair Regen. 2017 May;25(3):474-482.
11. Griffin L, Casillas LL. Evaluating the impact of a patient-centered remote monitoring program on adherence to negative pressure wound therapy. Wounds. 2018 Mar;30(3):E29-E31.
12. Schweizer ML, Cullen JJ, Perencevich EN, et al. Costs associated with surgical site infections in Veterans Affairs hospitals. JAMA Surg. 2014;149 Jun(6):575-581.
13. Hatoum HT, Akhras KS, Lin SJ. The attributable clinical and economic burden of skin and skin structure infections in hospitalized patients: a matched cohort study. Diagn Microbiol Infect Dis. 2009 Jul;64(3):305-310.
14. Amin AN, Cerceo EA, Deitelzweig SB, et al. Hospitalist perspective on the treatment of skin and soft tissue infections. Mayo Clin Proc. 2014 Oct;89(10):1436-1451.
15. Raizman R, Studeny K, Storey L, et al. Bath in the bag: perspective of patients and caregivers versus financial implications. Wound Care Conference of the Canadian Association of Wound Care; Oct/Nov 2015; Toronto, Canada. Abstract.