EVIDENCE-BASED WOUND CARE

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EVIDENCE-BASED WOUND CARE

• Laura Bolton, Ph.D., Adjunct Associate Professor,
  Dept. of Surgery, Bioengineering Section
• University of Medicine Dentistry of New Jersey
• President, BoltonSCI, LLC
• E-mail llbolton_at_gmail.com

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GOALS

• Define evidence-based (EB) wound care
• Describe EB wound care principles and how to
  integrate them into your wound care practice.
• Review results reported using EB protocols of
  wound care

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EVIDENCE-BASED MEDICINE IS

• The conscientious, explicit, and judicious use of
  current best evidence in making decisions about
  the care of individual patients. 1

1Sackett DL et al. Br Med J, 1997 31271-77.
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Sir Isaac Newton1642-1727

• If I have seen further,
• It is by standing upon
• The shoulders of giants.

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YOU CAN CHOOSECARE FOR WOUNDS
DIAGNOSE, CARE FOR WOUND, PATIENT
PROVIDE CARE
MORE CARE...
OR HEAL WOUNDSusing evidence-based practice.
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Scope Of Evidence-Based Wound Care

• WHO can use EB wound care?
• All disciplines MD, RN, ET, APN, PT, DPM ...
• WHERE
• All settings Home, Hospital, Skilled Care...
• All indications Post-op, traumatic, chronic ...
• HOW
• Diagnosis, predicting outcomes and therapy
• WHAT IS USED
• Evidence of both benefits and risks
• To derive patient-centered wound outcomes

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How Does EB Wound Care Differ From Traditional
Wound Practice?1

• Traditional
• Focus on practice
• Parental approach
• Clinician oriented
• Expert opinion-based

• Evidence-Based
• Focus on outcomes
• Informed decision
• Patient oriented
• Science-based

1 Jaeschke R, Guyatt GH, Meade M. Adv Wound Care
1999 11(5)214
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Doctor's Visit Traditional Evidence-Based

• Based on the evidence,
• Therapies A or B may help you achieve your wound
  care goals.
• The risks, benefits and costs of each therapy
  are...
• Which would you be most comfortable using?

• "I think you should take this therapy."
• "Be sure you follow the instructions."

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HALLMARKS OF GOOD EVIDENCE1,2

• Randomized assignment of patients
• Independent blinded comparison of treatment
  effects or comparison to accepted standard
• Efficacy and safety measured and reported
• Valid outcomes measured reliably
• Clinically relevant, patient-centered outcomes
• Representative, similar patient samples
• Adequate timing and scope of follow up
• 1Jaeschke R et al. Adv Wound Care, 1998
  11(5)214-218
• 2 Gray M. et al. JWOCN 2004 31(2)53-61.

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Benefits Of EB Wound Care

• Reliable, safe patient outcomes
• Consistently managed patients
• Reduced recurrence
• Improved professional reputation
• Reduce legal liability
• Economically sound outcomes

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Some EBM Resources http//www.

• Cochrane Initiative
• cochrane.org/
• McMasters
• shef.ac.uk/uni/academic/R-Z/scharr/
  triage/index/EBM.htm
• National Library of Med. (MEDLINE)
• ncbi.nlm.nih.gov/PubMed/
• National Guideline Clearinghouse
• guideline.gov/

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BRIDGING THE GAP BETWEEN EVIDENCE AND
PRACTICEINTEGRATING EVIDENCE-BASED
PRINCIPLES INTO WOUND PRACTICE
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Implementing EB Principles In Wound Care Practice

• G Identify patient-oriented GOAL
• A Evidence-based ACTION PLAN
• P Measure PROGRESS

Hermans MHE, Bolton LL, Establishing a skin
integrity program. Remington Report, 2001 9(6)
Suppl. 16-8
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Patient-oriented Goal Guides the Action Plan

• If the GOAL is...
• Reduce edema
• Reduce pressure
• Protect wound
• Protect skin
• Minimize pain, odor
• Manage excess fluid
• Reduce infection risk
• Heal the wound
• Minimize scar

• ACTION plan requires...
• High multi-layer compression
• Pressure relief surface or shoe
• Off-load insensate extremity
• Moisturizing skin barrier
• Moisture barrier wound dressing
• With optional absorbent primary dressing
• Moisture barrier wound dressing

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Evidence-based (EB) Action To Manage Patient
and Wound

• Diagnose correct tissue damage causes
• Optimize wound bed surrounding skin
• Provide moist healing environment

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Diagnose.
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Diagnose and correct the cause(s) of tissue
damage!
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Chronic wounds require a multidisciplinary team
to diagnose and correct the cause.

• Contributing factors
• Vasculature
• Nutrition
• Endocrinology
• Immune Disorders
• Infection
• Excessive/Prolonged Pressure/Moisture
• Repeated Physical or Chemical Trauma

The wound is attached to A PATIENT. Local care
cant do this alone!
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Example EB Principles to Use on Full- and
Partial-thickness Acute Wounds

• If wound is bleeding achieve hemostasis rapidly1
• Cool burned tissue, but avoid hypothermia2
• Minimize time between trauma and surgery1
• Debride necrotic tissue or debris2,3
• Avoid use of wet-to-dry gauze in debriding3
• Select dressing(s) to meet functional wound
  needs4,5
• Maintain hemostasis or moist environment, absorb
  exudate, debride autolyticallly, isolate/protect
  wound, minimize pain, odor or bioburden
• Evaluate and minimize patient-reported pain2,3

1Spahn DR et al. Critical Care 2007 11(1) 1-22
(EU Guideline) 2www.health.nsw.gov.au/gmct/burninj
ury/docs/guidelines_burn_wound_management.pdf (AU
Guideline, accessed 2 June 2007) 3Nat. Inst. for
Clin. Excellence. Guidance on the use of
debriding agents and specialist wound care
clinics for difficult to heal surgical wounds.
Tech. Appraisal Guid. 24, April 2001. 4Harding K
et al. Diab Metab Res Rev 2000 16(Suppl.
1)S47-S50. 5van Rijswijk L, Beitz J. J. W. O.
C. N. 1998 25(3)116-122.
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EB Practice for Wound DressingsMEDLINE Search
4-Jun-2007 Found (N) Controlled Studies
Supporting Faster Healing and Reduced Pain,
Scarring or Infection Rates using Film or
Hydrocolloid than with Non-Barrier Dressings
(e.g.Gauze)

• Ischemic wounds (1)
• Hypospadias (1)
• Laser resurfacing (2)
• Mohs excisions (1)
• Pressure ulcers (2)
• Skin tears (1)
• Skin graft donor sites (6)
• Surgical incisions (1)
• Vein harvest incision site (1)
• Venous ulcers (2)

• Abrasions (4)
• Amputation sites (1)
• Biopsy sites (6)
• Blisters (1)
• Burns (6)
• Circumcisions (1)
• Epidermolysis bullosa(1)
• Excoriations, trauma (1)
• Flap survival(1)

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Example steps in ImplementingEB Pressure Ulcer
Management1-4

• Correct causes of tissue damage
• prolonged pressure, friction, sheer1-4
• nutritional deficiencies1-4
• Wound bed
• Debride necrotic tissue4
• Treat local or distant infection2
• Protect skin from
• excess moisture or dryness1,3,4
• chemical or physical trauma1,3,4
• Maintain a moist wound environment1-4

Pressure ulcer treatment prevention guidelines
AHRQ,1 WHS2 and WOCN3 4Kerstein et al. Disease
Management Health Outcomes, 2001 9(11)651-663
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EB Venous Ulcer Management1,2,3

• Diagnose and correct the cause
• Rule out arterial cause
• Ankle/brachial index (ABI) gt 0.9
• ABI 0.7-0.9 compress with care
• Sustained, graduated, high, 2- to 4- layer
  elastic compression
• Elevate limb, flex ankle or walk
• Elastic stockings prevent recurrence
• Manage exudate and dermatitis
• Moist wound environment

1McGuckin M, et al. Amer J Surgery 2002
183132-137. 2Bolton et al. Ostomy/Wound Mgmt ,
2006 52(11)32-48 (AAWC Guideline) 3Kerstein MD
et al. Dis. Manage. Health Outcomes,
20019(11),651-63
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Venous ulcers heal as edema declineswith
sustained, graduated, high compression. Duby et
al. Wounds 1993 5(6) 276-279.
Compression?
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EB Action Plan To Manage Arterial or Ischemic
Ulcers

• Diagnose, correct related conditions1,2
• Peri-wound TcPO2 lt 20 mmHg predicts non-healing1
• Vascular specialist locate, correct arterial
  blockage
• Prompt referral if rest pain and/or gangrene2
• Remove necrotic tissue
• limit microorganisms2
• Avoid nicotine1,2

1Hopf H. et al. Wound Rep Regen, 2006 14
693-710. (WHS Guideline) 2Kerstein MD.
Ostomy/Wound Mgmt 1996 42(10A Suppl)19S-35S
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EB Diabetic Foot Ulcer Management1,2,3

• Diagnose and correct the cause
• Control diabetes (HbA1c lt 6.5)
• ABI gt 0.9 rules out arterial insufficiency
• ABI gt 1.3 ? rigid vessel wall use great toe
• No ABI, use TcPO2 gt 40 mmHg
• Check for neuropathy
• Semmes-Weinstein 10 g (5.07) fiber
• Protect skin and off load
• Wound/Skin
• Gel debridement speeds DFU healing4
• No healing progress suspect infection
• Moist wound environment3

1Steed et al. Wound Rep Reg (2006) 14 680692
(WHS Guideline) 2Crawford et al. WOCN Guideline 3
Lower extremity neuropathic disease 3Amer Diab
Assn Consensus Dev. Conf., Diabetes Care 1999
22(8)1354-1360. 42Smith J, Thow J. The Diabetic
Foot 2003 6(1)12-16
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Consistent, Continuous Off-loading
One barefoot walk to the bathroom can undo a
week of healing.
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Evidence For Minimizing Wound Infections

• Passive Mechanisms
• Isolate and protect wound 1,2
• Debride necrosis, foreign matter3
• Active Mechanisms3
• Topical antimicrobial agents
• If signs of infection are present,
• Biopsy or quantitative swab to identify infecting
  organism
• Prescribe correct systemic antibiotic

Infection is 5x more likely in DFU than in
non-diabetic chronic wounds4
1Hutchinson JJ, McGuckin M. Amer J Infec Control
1990 18(4)257-268. 2 Wilson P, et al. The
Pharmaceutical Journal December 17, 1988
787-788. 3 Steed et al. Wound RepRegen, (2006)
14 680692 4 Rubinstein, Am. J. Med. 1983
75(1)161
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Moist Environment to Protect, Isolate Wound
Fewer Infections in Diabetic Neuropathic Ulcers

• BOULTON et al.
• Wound Rep Reg 199977-16
• Retrospective study
• Clinical infections
• diabetic foot ulcers
• Off-load Dressings
• Hydrocolloid (HCD)
• Traditional Gauze

Percent Clinical Infections
Reported
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Moist Environment to Protect, Isolate Wound
Reduces Risk of Infection All Wounds
Percent Clinical Infections

• Hutchinson McGuckin
• Amer J Infect Control, 1990 18257
• Retrospective 30 yr literature review
• Clinical infections
• 1085 gauze (all types)
• 1351 hydrocolloid (HCD)
• 617 foam dressings
• 1021 film dressings

Reported
HCD
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EB Practice Debride Necrotic Tissue1

• Healing efficacy2 only for autolytic gel
  debridement
• Compared to saline gauze on diabetic foot ulcers
• Debriding efficacy
• Autolytic as fast as enzyme on venous3 or
  pressure4 ulcers
• Be aware
• Wounds will appear larger after necrotic tissue
  is removed

• Debridement Types
• Surgical/ Sharp
• Enzymatic
• Autolytic
• Mechanical

1AHCPR Guidelines for Tx, Px of Pressure
Ulcers 2Smith Thow The Diabetic Foot, 2003
6(1)12-16. 3 Romanelli, Wounds,
19979122-126. 4Burgos A et al. Clin Drug
Invest. 19(5)357-365)
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Implementing EB Wound Care Measure Progress
Toward Goal

• Why measure?
• Support care decisions
• Encourage patient
• Early warning of
• infection
• non-healing (4 wk lt20 decrease in wound
  area)
• Benchmark outcomes
• Identify problems

• What to Measure
• Wound dimensions
• Wound bed
• Necrotic tissue
• Granulation
• Epithelization
• Exudate
• Odor
• Pain

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PRESSURE ULCER HEALING(Full-Thickness, Mean
Initial Area 6.3 cm2)





vanRijswijk L. Decutitus, 19936(1)16-21.
? lt0.01
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EB Practice Pressure Ulcer HealingMeta-analysis
N102 N281 N 136
Kerstein MD, et al. Disease Management and Health
Outcomes, 20019(11),651-663
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EB Practice Venous Ulcer HealingMeta-analysis
N223 N530 N130
Kerstein MD, et al. Disease Management and Health
Outcomes, 20019(11),651-663
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Diabetic Neuropathic Foot UlcersPerspective 78
Heal in 10 Weeks With TCC/Hydrocolloid Dressing
Bioengineered Dermis
Bioengineered Skin
Platelet Releasate
RhPDGF BB
Hydrofiber
Gauze
Placebo
Gauze
Gauze
Gauze
(1) AQUACEL Hydrofiber Piagessi A. et al. Diab
Med, 1999S94 20 weeks (2) APLIGRAF
Falanga V. Wounds, 200012(5) 42A. 12 weeks (3)
REGRANEX Smiell J. et al. Wound Rep Regen 1999
7335 20 weeks (4) DERMAGRAFT
Pollack R. Wounds 19979(1)175. 12weeks (5)
PROCUREN Bentkover JD, Champion AH. Wounds,
1993 5(4)207-215 20 weeks
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Implementing Evidence-Based Wound Practice
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How to Implement EB Wound Practice1

• Multidisciplinary wound care team2
• Identify practices and outcomes to improve
• Facility--make a plan based on
• Current and future patients and wounds
• Current and projected costs and revenues
• Forces to use or overcome
• Select best EB protocols for your practice
• Motivate patients, staff and management with
  feedback
• Train all involved on protocol use
• Measure and communicate utilization and outcomes

1 Morrell C. et al. Nurs Stand. 2001 Apr
11-1715(30)68-73. 2 van Rijswijk L. Amer J.
Nursing 2004 104(2)28-30.
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Implementing EB Protocols Venous Ulcer Care If
expected outcomes not achieved, e.g. little
progress in 2-4 weeks, re-evaluate etiology, care
Example EB VU Protocol Patient Wound
Goals Based on evaluation Rule out arterial (ABI) Reduce edema Reduce pain Manage exudate Heal venous ulcer
Action plan Evidence-Based Elastic compression agreeable to patient Absorbent primary dressing, moisture barrier secondary
Progress Measures Patient-reported pain Ankle circumference Length, width, depth Healing time

• Beitz JM, Bates-Jensen B. O/WM, 2001 47(4)33-40

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Implementing Evidence-Based GuidelinesAvoid
Pitfalls

• Credit protocol only if it was clear cause
• Use objective benchmarks
• Listen to what missing data tells you.
• Listen to and use feedback from
• Patients
• Staff
• Management

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Clinical Outcomes Using Evidence-Based Protocols
of Wound Care
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Japan Pressure Ulcer Outcomes Using EB
Protocol Ohura T, Sanada H, Mino Y.Wounds 2004
16(5)157-73
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Mean PSST Scores
31.5
29.8
30
26.9
25
22.5
MCA improved PU outcomes at less than half the
total (labor materials) cost of TC/NA
21.9
20
15
15.8
10
At time of enrollment
At the end of study
MC/A (n29) modern dressings with a standardized
wound management algorithm TC/A (n34)
traditional dressings with a standardized wound
management algorithm TC/NA (n20) traditional
dressings without using a standardized wound
management algorithm
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Validating EB Venous Ulcer Guidelines in US and
UK(McGuckin M. et al. Amer J Surgery 2002
183132-137.)
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Software EB Guidelines in Home Telemedicine
Kobza L, Scheurich A. O/WM . 2000 46(10)48-53
Telemedicine Base Station with validated
Solutions algorithms
Phone/DSL Line Network
Patients Home
Speaker video phone
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More Wounds Healed Faster Using EB Practice in
Home Telemedicine (Kobza L, Scheurich A.
Ostomy/Wound Manag. 2000 46(10)48-53)
10
31
58
36
43
57
34
56
55
83
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Pressure Ulcer Real-World Healing Outcomes Using
Evidence-Based, Validated Algorithms 507
Patients in Home TM, Long Term Care, Acute Care
Clinic1 Using pressure redistribution, less than
5 gauze dressings
Benchmark Best reported RCT results with Rx
PDGF 23 of full-thickness pressure ulcers
healed in 16 weeks2
Depth Thickness Mean heal time
Healed in 12 weeks Partial (N 134)
31 days 61 Full
(N 373) 62 days
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1Bolton L, McNees P, van Rijswijk L et al. JWOCN
2004 31(3)65-71 2Rees R. Wound Rep Reg, 1999,
7141-147.
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Venous Ulcer Real-World Healing Outcomes Using
Evidence-Based, Validated Algorithms 154
Patients in Home TM, Long Term Care, Acute Care
Clinic Using compression and less than 5 gauze
dressings
Depth Thickness Mean SE heal time
Healed in 12 weeks Partial (N 30)
29 7 days 77
Full (N 124) 57 7 days
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Bolton L, McNees P, van Rijswijk L et al. Wound
healing outcomes using standardized care JWOCN
2004 31(3)65-71.
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Implementing an adaptation of EB validated wound
care guideline in Nova Scotia home care reduced
time and costs to healing or discharge to family
care1
(McIsaac C. O/WM 2005 Apr51(4)54-6, 58, 59
passim. )
1Numbers in parentheses are total clients healed
during specified year, not total receiving care.
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Hippocrates 460-400 BCELaw, Book IV

• There are in fact two things, science and
  opinion the former begets
  knowledge, the latter ignorance.