Debridement Another Tool for Your Box! Foot Health Day 2 Kettering Wednesday 11 th June 2014 Sue Simm Regional Woundcare Specialist Activa Healthcare
Best practice
Debridement Debridement is a natural occurrence If the process is accelerated there is the potential to speed up healing better classification of wound bed.
Why is debridement important? Non-viable tissue and debris - physical barrier to healing Prevents access for topical preparations eg antimicrobials Masks /mimics signs of infection (Obrien 2002) Provides a breeding ground and nutrients for bacteria Prevents accurate wound assessment- particularly in Pressure ulcers DFU May induce chronic inflammation Lead to overproduction of exudate & odour (Vowden and Vowden 2011) Contribute to overproduction of inflammatory cytokines promote a septic response over production of MMPS (Eir et al 2007)
What would you choose?? Sharp Debridement?Larval Therapy? Hydrogels? Combination of Treatments
Debridement Methods Autolytic Hydrosurgery Laval Therapy Enzymes Gauze Debrisoft Ultrasound Sharp Surgical Identified a need for an Updated overview and clarification of the role of debridement. Esp. PU DFU
Mechanical Debridement Chapter The use of : Dry Gauze (wet dry) impregnated Paraffin tulle Debrisoft to remove non-viable tissue from the wound bed. www.ewma.org
EWMA Debridement Process Cycle
Old hierarchy of debridement Surgical debridement Sharp debridement Autolytic debridement
Choice of tecniques:benifits and disadvantages related to various techniques
Why debridement is important Ritualistic behaviour Document contents Table of methods colour coded, green for generalist Checklist for debridement decisions NHS priorities Debridement service www.wounds-uk.com
Debrisoft Variety of wound types : venous leg ulcers, DFU (neuropathic and neuro-ischaemic), arterial ulcers, mixed etiology ulcers, pressure ulcers and traumatic wounds Effective on a range of tissue types including the removal of hyperkeratosis In the case of thick tenacious slough and hard necrosis it is recommended that the tissue is softened prior to using Debrisoft Can be used in all care settings hospital and community
Debrisoft - mode of action Absorbing and safe binding of the loosened debris in the fibre composite ( filter- or cobweb-effect ) (electron microscope): Debrisoft fibre composite before treatment (electron microscope): Debrisoft fibre composite after treatment (electron microscope): Debrisoft fibres holding debris Folie 13
Some clinical examples and Best Practice- to help you!
Debrisoft is intended for use without analgesia, and the process takes, on average, 2-4 minutes Debrisoft possibly would produce less discomfort for patients than other methods
Jackie Stephen Haynes Roise Callaghan EPUAP Cardiff (Sept 2012) 12 patents Enabled more accurate categorisation of pressure ulcers in 100% Clearer wound management objectives Reduction in visits 11/12 pts
Andrew High Risk Specialist Podiatrist Liverpool Michael Senior Lecturer on Podiatry University of Huddersfield
Case Study Mrs V 81-year-old female type 2 diabetes. House bound poor mobility,nephropathy, neuropathy and irondeficiency anaemia. Presented with a right lateral midfoot ulceration which started in November 2010. The suspected cause was pressure while Mrs V was in bed.
Treatment plan Clean the wound bed promote healing. Sharp debridement not an option -tendon exposure. Debrisoft chosen to remove non-adherent/light slough and clean the wound. After use Edge wound clearly defined,more granulation tissue evident. Although some slough remained more prominent and could be treated clinically with forceps and a scalpel. The tendon remained intact There was a marked improvement of the lateral foot ulcer evidenced by increased vascularity
Conclusion Advanced podiatrists with proficient levels of wound care, see many challenging ulcers Debrisoft facilitates wound cleansing without compromising key features that would be a concern with sharp debridement, Eg damage underlying structures, pain and ischaemia. Also offers an advantage in time and application (compared to autolysis or larval therapy). Patient has some hyper-sensitivity but with Debrisoft Mrs V did not demonstrate any discomfort. Pleasantly surprised How quickly these ulcers have healed. In the ability to clean the wound bed and optimise normal healing process, we believe Debrisoft may have played a key role.
5 Minutes with Andrew & Michael Why did you decide to start using Debrisoft? Activa visit -reading the literature Offer a viable alternative patients not able to receive sharp debridement Autolytic debridement was taking too long or not working appropriately Referral for surgical debridement was not indicated. Q. How does Debrisoft compare to other debridement techniques you have used? Does Debrisoft work? Debrisoft compares well Choice of wound. ie: Dry necrotic or heavily sloughy Lightly sloughy wounds /foreign matter Used successfully for wound bed preparation prior to further debridement. Not to say replaces all other debridement techniques, but it complements those currently used, especially debridement itself.
Q. How easy is it to use Debrisoft? Easy to use - saline gauze aseptic techniques.. Q. Did your patients comment on the product? Apprehensive patients /painful ischaemic foot ulcers or amputation sites were the most surprised at how relatively painless the treatment was. Others found it pain free Q. Would you recommend it to other practitioners? Yes, we already have done! Eg : ischaemic and neuropathic ulcers and we ve been pleased with its use. We are always happy to share good practice, especially if it benefits the patients.
Mike Diabetes Specialist Podiatrist Birmingham Community
Mrs K 92-year-old West Indian lady Nursing home. Type 2 diabetic 27yrs, Knee pain Registered blind Referred to podiatry -pressure ulcer on the posterior aspect of her left heel.
Treatment Plan Referral (June 2011)macerated edges base 80% thick yellow slough. 4 months duration Dressed every 2 days honey /foam /tubifast Offloaded Sharp debridement and dressing changes - slight decrease in slough and size of the wound. Third visit -Debrisoft would be useful as the wound was static. After Debrisoft wound base much improved 10% slough and a granulating base visible.mrs K reported no pain following Debrisoft 4 minutes. no pain (had felt some discomfort with sharp debridement ) Bled slightly -soon stopped digital pressure. Due to so little slough felt that Debrisoft was not needed and As the wound base was very vascular decided that Debrisoft would not be continued
Mikes Conclusion Debrisoft made a significant improvement in the wound base of the ulcer and will ultimately increase the speed with which the ulcer heals. Provided a fast and easy-to use debridement of the wound on an hard to reach area especially in a home visit environment where it is much harder to elevate the limb
Five minutes with Mike Q. Why did you decide to start using Debrisoft? Slough thick and glue-like. Wound location of the Prior to using Debrisoft lying on the floor to look up to debride the area. Despite two episodes of sharp debridement, slow progress. Could Debrisoft could kick-start the healing process? Q.How does Debrisoft compare to other debridement techniques you have used? Does Debrisoft work? 17 years experience four other techniques of debridement: Varidase : this was a poor technique any improvement often very slow Larval therapy: very effective; needs coordination /explanation to the patient re yuk factor Dressings: various to hydrate slough /speed autolysis. Do work but slow /sometimes over-hydrate a wound
Sharp debridement: fast, effective my preferred method. Technique improves the more you do it. I use this technique every day. Debrisoft :offers fast, easy-to-use technique no specialist training required, useful in home visit situation. In my experience Debrisoft worked.
Q. How easy is it to use Debrisoft? Could not be easier; The debrided fluid/skin is then locked up in the pad Q. Did your patients comment on the product? My patient said they didn t feel anything when using Debrisoft even though had experienced some discomfort with sharp debridement
Q. Would you recommend it to other practitioners? No hesitation to recommend, very useful addition. Still needs to be used in collaboration ie: Dressings Suitable footwear Offloading of pressure Nutrition. Debrisoft offers a fast, easy-to-use technique with no specialist training required
Repeated Diabetic foot abscesses 59 old male Type 2 Diabetic Previous Surgical Debridement of foot abscess Debrisoft used for 3 mins -1 pad Small circular movements
Diabetic Heel Ulcer Johnson 2011 68yr old male Type 2 Diabetic Long history of neuro-ischaemic foot ulcers Previous left BKA Heel pressure damage
Digital amputation site 60yr old male Rare connective tissue disease Previous digital amputations Post operative tidying up 2 applications 3 mins Small circular strokes. No pain
(World Wide Wounds- Wound Bed Preparation) Where you would NOT debride... Not all wounds will benefit from debridement and in some cases an undisturbed dry eschar (as seen in this mummified toe ) is a better option for the patient. In this case, any attempt at debridement, unless combined with treatment of the underlying condition by limb revascularisation, may simply convert inert dry gangrene to potentially limb or life threatening moist gangrene. Goals of treatment must therefore be based on a realistic assessment on the 'healability' of the wound
Evidence submitted, 15 multiple-patient case studies (5 peer-reviewed papers and 10 posters) Expert opinion No Reported adverse events
NICE Nice update Accepted and supported expert advice hydrogel and maggots most appropriate community comparators- Honey There was evidence of efficacy for the use of the Debrisoft pad on sloughy wounds with exudate and hyperkeratotic skin Debrisoft was convenient and easy to use, and well tolerated by patients
Nice update The case for adopting Debrisoft as part of the management of acute or chronic wounds in the community is supported by the evidence Debrisoft is indicated for adults and children with acute or chronic wounds Debrisoft is particularly effective for chronic sloughy wounds with exudate and hyperkeratotic skin
Using Debrisoft instead hydrogels or maggots may reduce the number, length and frequency of nurse visits Debrisoft can be easily included as an option for debridement in wound management in the community nursing homes Debrisoft is portable and readily available No special arrangements are needed for disposal of used Debrisoft
The NICE guidance supports the case that Debrisoft provides both patient benefits and cost savings to the NHS. Is more effective at debridement than the current practice. Gives quicker debridement, allowing earlier visibility of the wound bed and therefore better management of the wound May reduce pain associated with debridement Results in less frequent and fewer overall care visits Reduces risk of trauma to healthy tissue and reduces bleeding Reduces overall number of wound dressings used The NICE guidance cost calculator estimates that using Debrisoft has the potential to save the NHS over 15m /yr
AMBITION I want to put the patients needs first I want to provide the best care I can for patients I want to remove the slough and odour as quickly as possible I want the wound to start healing as quickly as possible I want to empower patients and give them choice I want a debridement service REALITY NICE RECOMMENDATIONS Efficacy Simplicity Acute and chronic wounds Sloughy wounds with exudate Hyperkeratotic skin COST
Conclusion Prof Keith Harding Head of Dept of Surgery Director of Wound Healing Research Unit Cardiff WWN Feb 2011 Do the simple things first and the simple things well Remove dead cells and reset the healing response
Over time dressings evolve and improve on existing technology. It s not often that something comes along which revolutionizes practice like Debrisoft. Debrisoft gives the practitioner the opportunity to provide optimum care by improving how we treat the wound bed and care for skin. Simon Barrett, Tissue Viability Specialist NICE guidelines March 25 th 2014
courtesy of Barbara Pritchard 4 minutes with Debrisoft
suesimm@activahealthcare.co.uk 07891 683441
References Consensus guidance for the use of debridement techniques Grey et al wounds uk 2011 The wound debrider a new monofilament fibre technology G Haemmerle et al BJN 2011 Clinical efficacy of a new monofilament fibre containing wound debridement product Bahr et al Journal of woundcare may 2011 Debridement made easy wounds uk nov 20115. Assessing the clinical performance of a new selective mechanical wound debridement product D Gey et al Wounds uk 2011 7. Debrisoft revolutionising debridement preparation is everything BJN /BJCN educational supplement Autumn 2011 Nice 2014 Guidelines supporting the use of Debrisoft
A winning combination