Chronic wounds: how to kick start healing <Clinical Special>

Transcription

1 Chronic wounds: how to kick start healing <Clinical Special>

2 Agenda Chronic wounds: How to kick start healing Chronic wounds an overview Chronic wound exudate management Increased bioburden, infection and biofilm. Interactive Case studies

3 Chronic wounds Acute wounds heal in a organised process, through the normal stages of wound healing and within the expected time frame for the wound type/patient Chronic wounds do not follow this normal healing process and can become stuck in one of the stages of healing, resulting in a failure to heal or delayed healing

4 Chronic wounds Chronic wounds are increasing in prevalence as the population ages and the number of people living with multiple comorbidities that put them at risk of developing wounds rises 1. As the number of older people increases, the prevalence of chronic wounds will also continue to grow. 2

5 Chronic wounds The current UK population is approximately 65.1 million 3 The NHS has estimated that 4.5% of the adult population has a wound 4 That means more than 2.9 million of wounds

6 Chronic wounds A chronic wound is defined as any wound which has remained unhealed for longer than 6 weeks Adjunctive Therapy Into Practice.html NHS West Midlands, Chronic Wound Toolkit 2010

7 Chronic wounds Drew et al 2007 found 54% of wounds are over 6 weeks old 5 This means more than 1.5 million of those wounds could be chronic Around 460,000 (16%) of those wounds will have been present for one year or longer 5.

8 Health Economic Impact 20 : Estimated health outcomes, resource implications & associated costs attributable to managing wounds in 2012/13 4 : 5 billion spend on managing wounds Two thirds of which ( 3.3 billion) is incurred in the community

9 Chronic wounds Wounds represent a significant cost to patients as well as to the health economy 6. Chronic wounds are often hard to heal, resulting in a cycle of pain, anxiety and reduced quality of life for the patients as well as considerable treatment costs 6.

10 Chronic Wounds Life is dominated by care Impact on daily life Reduced wellbeing Will it ever heal? Pain & discomfort Loss of work Decreased mobility Depression/anxiety My wound smells Is it infected? Exudate levels Dressing changes

11 Chronic wounds: Exudate

12 Defining Exudate A generic term describing the fluid produced by a wound The environment in which healing occurs and in which biochemical activity take place A healing agent in its own right?

13 Function of exudate Prevent wound bed from drying out Aids the migration of tissue repairing cells Provides essential nutrients for cell metabolism Enables the diffusion of immune and growth factors Assists in autolysis When you have the right amount of exudate!

14 Exudate Composition Exudate will change over the natural history of the wound Exudate contains different components at different times. Key differences are observed between the exudate in acute and chronic wounds As healing occurs, the amount of exudate produced usually decreases

15 Content of Exudate Wound characteristics Acute wounds Chronic wounds Wound fluid Low amounts of inflammatory cytokines Low amount MMPs High amount of inflammatory cytokines High amount MMPs Cellular level High cell mitosis Increased level of growth factors Rapid cell response Low cell mitosis Decreased response to growth factors Senescent cells Fletcher J (2002) Exudate theory and the clinical management of exuding wounds Professional Nurse Vol 17 No 8 pp

16 Levels of Exudate during normal wound healing WOUND AREA TIME

17 Levels of Exudate stalled/static/chronic wound WOUND AREA TIME

18 Levels of Exudate stalled/static/chronic wound Indirect Causes WOUND AREA Heart failure Renal failure Lymphoedema Hypoalbuminia Venous hypertension Pyrexia TIME

19 Levels of Exudate stalled/static/chronic wound Direct Causes WOUND AREA Infection Wound temperature Autolysis of necrotic tissue Size and site of wound TIME

20 Exudate in Wound Healing Exudate may influence many aspects of wound healing, the following variables need to be considered: Desiccation Maceration Excoriation Infection Delayed Healing Quality of Life

21 ALLEVYN LIFE dressing in the treatment of category 3 pressure ulceration 7 Debbie Simon, 5 Borough s Partnership NHS Trust

22 Case challenge: Mr. A, a male in his early eighties Category III pressure ulcer. Lives in a residential care home Dementia, incontinence and poor nutritional status. Limited mobility resulting in him spending a considerable amount of time in bed.

23 Key challenges Recent deterioration. Large amount of exudate which was proving difficult to manage effectively Wound bed was almost entirely covered in slough Extremely malodourous Current dressings due to the high levels of wound exudate this required changing at least once per day and on some occasions even more frequently.

24 Wellbeing impacts Mr. A was placed on bed rest due to his wound this resulted in him becoming confused and assuming that because he was in bed it was time to sleep. In consequence he was not eating well and was failing to get adequate nutrition to support the healing of his wound. It was also felt that the level of wound malodour could be suppressing Mr A s appetite and contributing to his reluctance to eat. This failure to eat was further weakening Mr A, reducing any likelihood of the wound progressing to healing. Due to the leakage of wound exudate and malodour, Mr A was unable to join the other residents for meals or any social events.

25 Management objectives Improved nutrition to enhance Mr A s general condition and increase the potential for healing. Reduce the necrotic burden within the wound bed. Select an appropriate dressing regimen. Careful consideration was given to addressing the key issues of: Minimising odour Ability to stay in place Effective management of exudate Post sharp debridement

26 Treatment Sharp debridement to reduce the amount of slough within the wound bed. Barrier film applied to the skin at the wound margins to protect the area from exudate. DURAFIBER ribbon was selected as a primary dressing as an effective means of absorbing and retaining a large proportion of the exudate the wound was producing. ALLEVYN LIFE was selected as a secondary dressing to manage exudate and odour, and maximizing ability to stay in place. Post sharp debridement

27 Week 1 Appearance of the wound had improved considerably Frequency of dressing change had been reduced to once every three days ALLEVYN LIFE dressing was staying securely in place during wear ALLEVYN LIFE and DURAFIBER were effectively managing the exudate. Staff reported a considerable reduction in the level of wound odour with the dressings in situ. The reduction in malodour was such that the staff were now able to take Mr A into the day area for his meals. As a result Mr A was eating more and his nutritional status was improving.

28 Week 3 Wound was continuing to improve Considerably reduction in wound size Wound malodour had been completely resolved Frequency of dressing change had been reduced to twice per week. Mr A was now eating well and his weight was increasing.

29 Outcome ALLEVYN LIFE stayed in place and in conjunction with DURAFIBER effectively managed the level of wound exudate. The anatomical shaping of ALLEVYN LIFE coupled with the extensive dressing border ensured the dressing stayed in place, while the large fluid handling capacity and lockaway core facilitated effective management of fluid and the retention of odour. Staff relied on the ALLEVYN LIFE indicators for change (see picture) to ensure that they changed the dressing only when needed and no more frequently than absolutely necessary.

30 Outcome The ability of the dressing to remain in place and retain exudate had the effect of dramatically reducing the level of malodour associated with the wound. This considerably reduced the impact that the wound was having on Mr A s physical and social wellbeing, allowing him to take meals with fellow residents and participate in social events.

31 Chronic wounds: Infection

32 Development of infection Infection can be defined as the process by which organisms bind to tissue, multiply and then invade tissue and elicit a marked immune response

33 IWII 2016 Stages of Wound Infection Continuum 8,9,10

34 Infection Continuum Contaminated Colonised Local Infection Spreading Infection Systemic Infection

35 Infection Continuum Contaminated Colonised Local Infection Spreading Infection Systemic Infection

36 Infection Continuum Contaminated Colonised Local Infection Spreading Infection Systemic Infection Wound contamination Presence of non proliferating microbes within a wound at a level that does not evoke a host response Unless compromised, the host defences respond swiftly to destroy bacteria

37 Infection Continuum Contaminated Colonised Local Infection Spreading Infection Systemic Infection Colonisation The presence within the wound of microbial organisms that undergo limited proliferation without evoking a host reaction. Microbial growth occurs at a non critical level, and wound healing is not impeded or delayed.

38 Infection Continuum Contaminated Colonised Local Infection Spreading Infection Systemic Infection Local infection Occurs when microbes move deeper into the wound tissue and proliferate invoking a response in the host. Local infection is contained in one location, system or structure. Often present as subtle signs that can be considered covert signs of infection that may develop into the classic, overt signs of infection.

39 Infection Continuum Contaminated Colonised Local Infection Spreading Infection Systemic Infection Spreading infection Invasion of the surrounding tissue by infective organisms that have spread from a wound. Microorganisms spread to a degree that signs and symptoms extend beyond the wound border. Spreading infection may involve deep tissue, muscle, fascia, organs or body cavities.

40 Infection Continuum Contaminated Colonised Local Infection Spreading Infection Systemic Infection Systemic infection Microorganisms spreading throughout the body. Systemic inflammatory response, sepsis and organ dysfunction are signs of systemic infection. The display of covert signs of infection is an early stage of local infection, and does not represent a distinctly different phase in the wound infection continuum.

41 International Wound Infection Institute

42 ACTICOAT Chronic bilateral leg ulcers 11 Anne Pengelly, Deputy Manager RGN, Risby Park Nursing Home. Bury St Edmonds. Suffolk.

43 Background A male resident Mr J has lived in Risby Park since 2004 with a medical history including anaemia, CVA in 2008, urinary incontinence, arthritis and bilateral venous leg ulcers. Mr J suffers from stiff hips and knees due to arthritis which restrict his movement and requires the assistance of one or two carers for all his personal hygiene needs. Mr J is unable to move himself without assistance from staff and has recently become low in mood due to the condition of his legs. Mr J had bilateral leg ulcers for over nine years prior to living at Risby Park and district nurses visited him at home to apply multi layer compression bandaging. After consultation with Mr J s GP it was decided to stop compression bandaging as this would require clinical staff trained to apply compression bandaging coming into Risby Park. The leg ulcerations had previously been colonised with MRSA.

44 Initial Assessment / Key Challenges The bilateral multiple leg ulcerations extended from beneath the knee to the forefoot and presented with friable, beefy red granulation tissue with inflammation to the surrounding skin. The leg ulcerations were very malodorous. All wounds heavily colonised with Pseudomonas aeruginosa. High exudate levels had caused maceration to the surrounding skin which was more severe around the ankles potentially due to the effects of gravity and movement of exudate. Individual wound margins were not identifiable due to the inflammation and maceration. Pain related to the infected leg ulcers.

45 Current treatment Nursing staff had previously used Inadine TM as a primary dressing with cotton retention and wool padding. Mr J had had numerous prescriptions for antibiotics due to the re occurrence of wound infections. The topical treatment of using honey applied with cotton retention and wool padding had also been used on occasions. As a result, both legs became very macerated with increased exudate levels causing a significant increase in discomfort for Mr J. Dressing changes were performed twice daily due to the heavy exudate levels. Due to the development of eczema, VISCOPASTE PB7 paste bandages were also used in an attempt to reduce the irritation and inflammation.

46 Management Objectives Treat wound infection Manage exudate levels Manage odour Manage wound related pain

47 Treatment The author performed a thorough holistic assessment utilising the T.I.M.E* framework for a comprehensive wound bed assessment. The clinical aim was to treat the infection and manage the associated symptoms of pain, exudate levels and malodour. ACTICOAT Flex 3 dressings were selected as a primary dressing on the basis of its three day broad spectrum antimicrobial action, ability to be effective against Pseudomonas aeruginosa and highly conformable nature. The ACTICOAT TWO WEEK CHALLENGE was initiated with dressing changes performed every 3 days. Retention bandages were used as secondary dressings. *Schultz GS, Sibbald RG, Falanga V et al., Wound Rep Reg (2003);11:1 28. Wound Bed Preparation and T.I.M.E. are clinical concepts supported by Smith & Nephew

48 Outcome Week 1 Considerable improvement was noticed within the first week reduced exudate levels were recorded and the bacterial load was reduced. A course of antibiotics completed on day 1 of treatment with ACTICOAT dressings and was not re prescribed. Week 2 A continued reduction in exudate levels was noted and also a reduction in wound related pain. At this stage it was felt that the problematic bacterial burden was reducing but had yet to be entirely resolved, however due to the considerable improvement (Image 2), it was decided to continue with the current treatment plan for a further week and review.

49 Outcome Week 3 The ulcerations to the right leg had nearly healed whilst the ulcerations on the left leg had made considerable improvement with no clinical signs of infection and 100% healthy granulation tissue. The reduction in exudate meant that the condition of the surrounding skin was healthier particularly around the lower limb. ACTICOAT dressings were discontinued as the primary dressing and a non adherent primary dressing was used to maintain optimum wound conditions. Dressing changes were now performed every three days compared to twice daily prior to the use of ACTICOAT.

50 Outcome Impact on patient Mr J s quality of life improved considerably and he was no longer distressed with the pain and malodour from the previously infected leg ulcers. The dressing changes were less frequent and a far less traumatic experience for Mr J. Impact on clinician The nursing staff were delighted that after nine years of suffering with chronic leg ulcers, Mr J experienced a significant improvement which was achieved by changing practice through reassessment and appropriate use of ACTICOAT dressings. The dressing changes were performed less frequently and as a result less dressing usage was observed. Staff were impressed with the ACTICOAT TWO WEEK CHALLENGE as the infection.

51 Chronic wounds: Biofilm

52 Infection Continuum Biofilm Biofilm Contaminated Colonised Local Infection Spreading Infection Systemic Infection

53 IWII Biofilm Consensus_Final web.pdf (Adapted from Stoodley et al, and Clinton and Carter, )

54 Treatment, Optimise host resistance Number of bacteria x virulence Host resistance

55 Treatment optimise wound environment.

56 Infection Continuum Biofilm Contaminated Colonised Local Infection Spreading Infection Systemic Infection Vigilance required Intervention required NO Anti s indicated Topical Anti s Systemic & Topical Anti s

57 Biofilm in chronic wounds 60% chronic wounds have been found to contain a biofilm 1 which are linked to delayed healing Biofilms are difficult to treat as they provide tolerance to antimicrobial treatments and the host immune response Periodic release of motile bacteria from colonies can result in recurrent infections 21. Detection is difficult since classic signs of infection may not be present, but indirect signs and symptoms may include: Antimicrobial therapy failure Delayed wound healing Recurrent infections 21 Chronic, low level inflammation 14

58 Biofilm in chronic wounds IODOFLEX dressing key points Has been show to substantially eradicate mature biofilms under in vitro testing condition 12 Effective against a bread spectrum of pathogens (in vitro) 22 Stimulate granulation 22 Accelerate healing 23

59 IODOFLEX Dressing: Superior activity against mature biofilm ex vivo Most antimicrobials show minimal kill against mature biofilms 28 Substantial kill of mature P. aeruginosa biofilms observed after 24 and 72 hours of continuous exposure to IODOFLEX 28 Ex vivo porcine skin explant biofilm model mature P. aeruginosa biofilm (72 hour)

60 The Two Week Antimicrobial Challenge It has been recommended that antimicrobial dressings should be used for two weeks initially and then the wound, the patient and the management approach should be re evaluated. Best Practice Statement: The use of topical antiseptic/antimicrobial agents in wound management. 2nd edition. Wounds UK, London: After 2 weeks: Have the observed/recorded signs and symptoms of infection removed/reduced? Infected wounds should be inspected and treated as per local clinical protocol. Refer to the product's Instructions for Use for information on indications, contra indications and precautions.

61 Questions

62 When would you class a wound as chronic, stalled or static? 00 1 After 2 weeks of no improvement. 2 After 6 weeks 3 After 4 weeks 4 At initial assessment due to holistic/local factors

63 When would you class a wound as chronic, stalled or static? 1 After 2 weeks of no improvement. 0% 2 After 6 weeks 0% 3 After 4 weeks 0% 4 At initial assessment due to holistic/local factors 0%

64 According to Drew et al5 what % of wounds are over 6 weeks old? % 2 44% 3 54% 4 64%

65 According to Drew et al5 what % of wounds are over 6 weeks old? 1 34% 0% 2 44% 0% 3 54% 0% 4 64% 0%

66 Which of the following influences exudate has on wound healing do you consider to be most detrimental to healing? 00 1 Desiccation 2 Maceration 3 Excoriation 4 Patient Quality of life

67 Which of the following influences exudate has on wound healing do you consider to be most detrimental to healing? 1 Desiccation 0% 2 Maceration 0% 3 Excoriation 0% 4 Patient Quality of life 0%

68 Have you used the ALLEVYN dressings? 00 1 Yes 2 No

69 Have you used the ALLEVYN dressings? 1 Yes 0% 2 No 0%

70 How many dressing sizes are there in the ALLEVYN range (not including antimicrobial Ag)?

71 How many dressing sizes are there in the ALLEVYN range (not including antimicrobial Ag)? % % % %

72 At what stage of the IWII infection continuum are topical antimicrobials indicated? 00 1 Contaminated 2 Local infection 3 Spreading Infection 4 Systemic infection

73 At what stage of the IWII infection continuum are topical antimicrobials indicated? 1 Contaminated 0% 2 Local infection 0% 3 Spreading Infection 0% 4 Systemic infection 0%

74 What percentage of chronic wounds contains biofilms 1,? % 2 70% 3 80% 4 90%

75 What percentage of chronic wounds contains biofilms 1,? 1 60% 0% 2 70% 0% 3 80% 0% 4 90% 0%

76 Have you used the ACTICOAT dressings? 00 1 Yes 2 No

77 Have you used the ACTICOAT dressings? 1 Yes 0% 2 No 0%

78 ACTICOAT Flex 3 and 7 dressings begin to kill bacteria after how many minutes (in vitro)? minutes 2 45 minutes 3 60 minutes minutes

79 ACTICOAT Flex 3 and 7 dressings begin to kill bacteria after how many minutes (in vitro)? minutes 0% 2 45 minutes 0% 3 60 minutes 0% minutes 0%

80 When using antimicrobial dressings it is recommended their effectiveness should be reviewed after how long 30? week 2 2 weeks 3 3 weeks 4 4 weeks

81 When using antimicrobial dressings it is recommended their effectiveness should be reviewed after how long 30? 1 1 week 0% 2 2 weeks 0% 3 3 weeks 0% 4 4 weeks 0%

82 References 1. Gottrup F, Henneberg E, Trangbæk R, Bækmark N, Zøllner K, Sørensen J (2013) Point prevalence of wounds and cost impact in the acute and community settings in Denmark. J Wound Care 22(8): 413 4, 416, Dowsett C, Bielby A, Searle R (2014) Reconciling increasing wound care demands with available resources. J Wound Care 23(11): Office for National Statistics (2016) access on Guest JF, Ayoub N, McIlwraith T, et al. Health economic burden that wounds impose on the National Health Service in the UK. BMJ Open 2015;5: e doi: / bmjopen Drew P et al (2007) The cost of wound care for a local population in England, IWJ 4 (2): Dowsett C, Bielby A, Searle R (2014) Reconciling increasing wound care demands with available resources. J Wound Care 23(11): ALLEVYN LIFE dressing in the treatment of category 3 pressure ulceration Debbie Simon, 5 Borough s Partnership NHS Trust TM Trademark of Smith & Nephew All Trademarks acknowledged April 2016 Smith & Nephew 8. World Union of Wound Healing Societies (WUWHS), Principles of best practice: Wound infection in clinical practice. An international consensus, 2008.MEP Ltd, London. 9. Edwards R and Harding KG, Bacteria and wound healing. Curr Opin Infect Dis 2004; 17(2): Lipsky BA and Hoey C, Topical antimicrobial therapy for treating chronic wounds. Clin Infect Dis 2009; 49(10): ACTICOAT TWO WEEK CHALLENGE with chronic bilateral leg ulcers Author: Nicola Anne Pengelly, Deputy Manager RGN (tissue viability trained) Risby Park Nursing Home, Hall Lane, Risby, Bury St Edmunds, Suffolk IP

83 References 12. Roche ED. Wound Rep Reg. 2012;20: Schierle CF, et al. Wound Repair Regen. 17, (2009). 14. Bjarnsholt T, et al. Wound Rep Reg. 2008;16: Phillips P, et al. Int Wound J. 2013: Wolcott, R. D. et al. J. Wound Care , Stewart PS & Costerton JW Lancet (London, England) 358, Jesaitis AJ, et al J. Immunol. 171, Bjarnsholt, T. et al. Microbiology , , 20. Cochrane, DM, et al J. Med. Microbiol. 27, Costerton JW. Science. 1999;284: Smith & Nephew Data on file Alhede M and Woodmansey, E Poster SAWC, San Antonio. 24. Roche et al. Poster presentation SAWC Atlanta, 25. Smith & Nephew Data on file Oates J Poster SAWC Atlanta. 27. Akiyama H, Dermatol. 2004;31: Phillips P. Int Wound J. 2013: Driffield, K; ACTICOAT Flex 3 has antimicrobial activity in 30minutes, Date on File reference Best Practice Statement: The use of topical antispetic/antimicrobial agents in wound management. 2 nd edition. Wounds UK, London: 2011.

84 Smith & Nephew Croxley Park Building 5, Lakeside Hatters Lane, Watford Hertfordshire WD18 8YE T +44 (0) nephew.com/uk Trademark of Smith & Nephew All Trademarks acknowledged June 2017 Smith & Nephew F +44 (0) Supporting healthcare professionals for over 150 years