Management of Nonhealable and Maintenance Wounds: A Systematic Integrative Review and Referral Pathway

The Use of Active Coagulation Whole Blood-An Innovative Treatment Strategy for Hard-To-Heal Wounds

BACKGROUND

Deep and tunneling wounds are a challenge to apply and maintain most advanced wound dressings to promote effective healing. An autologous whole blood clot is a topical treatment and has been found to be safe and effective in healing cutaneous wounds. The active coagulation whole blood (ACWB) clot treatment, using the patient's own blood, is used to treat deep and tunneling wounds, by mixing the blood with coagulation components and applying it into the wound cavity allowing the clot to re-form inside the wound. We aimed to explore ACWB treatment in hard-to-heal wounds.

METHODS

5 patients with multiple comorbidities, exhibiting surgical abdominal wound, chronic pilonidal sinus, stage 4 sacral pressure ulcer with exposed bone, post-amputation surgical site wound, and non-healing wound dehiscence at the site of a prior hip replacement, were all treated with the ACWB clot treatment.

RESULTS

Complete wound healing was observed in 4/5 cases. In the fifth case, there was a 70% reduction in the depth and surface area of the abdominal surgical wound.

DISCUSSION

The ACWB treatment was found to be effective in deep wounds with cavities and exposed structures. ACWB, in its flowable form, can effectively provide coverage of the deepest interstices of the wound's cavities by virtue of its liquid properties, forming a fibrin matrix, mimicking the role of the extracellular matrix. The flowable formulation of ACWB treatment safely and efficiently provides coverage of the entirety of the wound surface to improve the time and process of complex wound surface healing.

The role community-based healthcare providers play in managing hard-to-heal wounds

It is common for community-based healthcare providers (CHPs)-many of whom have not received specialised training in wound care-to deliver initial and ongoing management for various wound types and diverse populations. Wounds in any setting can rapidly transition to a stalled, hard-to-heal wound (HTHW) that is not following a normal healing trajectory. Failure to recognise or address issues that cause delayed healing can lead to increased costs, healthcare utilisation and suffering. To encourage early intervention by CHPs, a panel of wound care experts developed actionable evidence-based recommendations for CHPs delineating characteristics and appropriate care in identifying and treating HTHWs. A HTHW is a wound that fails to progress towards healing with standard therapy in an orderly and timely manner and should be referred to a qualified wound care provider (QWCP) for advanced assessment and diagnosis if not healed or reduced in size by 40%-50% within 4 weeks. HTHWs occur in patients with multiple comorbidities, and display increases in exudate, infection, devitalised tissue, maceration or pain, or no change in wound size. CHPs can play an important initial role by seeing the individual's HTHW risk, addressing local infection and providing an optimal wound environment. An easy-to-follow one-page table was developed for the CHP to systematically identify, evaluate and treat HTHWs, incorporating a basic toolkit with items easily obtainable in common office/clinic practice settings. A flow chart using visual HTHW clinical cues is also presented to address CHPs with different learning styles. These tools encourage delivery of appropriate early interventions that can improve overall healthcare efficiency and cost.

Healing Time of Skin Ulcers in Homecare Residents in the Province of Reggio Emilia, Northern Italy

The growing phenomenon of skin ulcers represents an important health problem; therefore, we conducted a pilot study to evaluate the ulcer healing time among adult subjects followed by the Home Nursing Service of the AUSL-IRCCS of Reggio Emilia, Northern Italy, and diagnosed with at least one skin ulcer during the period of January-August 2020. We recruited 138 subjects (45.5% men) with a mean age of 86.1 years. The subjects presented with 232 ulcers, of which 76.7% were pressure ulcers (60.1% were stage II), 18.1% were vascular ulcers, and 4.7% were diabetic foot ulcers. Ulcer management required only one weekly access for the majority of subjects, with a recovery frequency of 53.6% at the end of the observation period. The median ulcer healing time was 3.6 months and was shorter in women (2.6 months) than men (5.1 months), with an increasing trend according to the number of ulcers and the severity of pressure ulcers for vascular and diabetic foot ulcers. In conclusion, this is the first study carried out in an Italian population describing the distribution and characteristics of homecare residents with skin ulcers and highlighting the factors influencing the healing time and as consequence the duration of nursing care.

Autologous whole blood clot and negative-pressure wound therapy in South Africa: A comparison of the cost and social considerations

BACKGROUND

Advanced wound treatment modalities enhance healing of hard-to-heal wounds, decrease the risk of amputations, and improve the quality of life of patients. Modalities have different rates of efficacy and incur different social and financial costs to the individual and the healthcare system. Two such modalities, the autologous whole blood clot (WBC) and negative-pressure wound therapy (NPWT), were compared in the South African (SA) context. The comparison was conducted on hard-to-heal wounds, with a specific focus on diabetic foot ulcers (DFUs).

OBJECTIVES

To compare the social considerations and financial costs of using autologous WBC v. NPWT in the treatment of DFUs in SA.

METHODS

Data were obtained based on current supply costs from SA suppliers for the two modalities, the standard of care for both modalities, the number of applications required for each, and social considerations provided by SA wound management clinicians. Wound healing rates were obtained from the published literature. This information was used to calculate costs of two scenarios (scenario 1: low exudate v. scenario 2: high exudate), which were compared over two treatment durations (4 and 12 weeks) for each treatment modality. Calculations included weekly cost of supplies, total cost saved by a patient with a DFU managed with either of the wound therapies, and the difference in total cost saved between the two modalities. Key social considerations were assessed qualitatively from discussions with SA clinicians experienced in both autologous WBC and NPWT, and from published research.

RESULTS

The cost of supplies per week was ZAR3 250 for autologous WBC and ZAR4 804 for NPWT in scenario 1, and ZAR3 332 and ZAR6 612 in scenario 2. With healing rates over 4 weeks' treatment duration of 19% for autologous WBC and 10% for NPWT, autologous WBC saved ZAR17 719.93, or 9% more than using NPWT, in scenario 1 and ZAR18 381.47, or 10% more, in scenario 2. At 12 weeks' treatment duration, healing rates for autologous WBC and NPWT were 75% and 43%, respectively. In scenario 1, results indicated a 43% cost difference between the two modalities. Autologous WBC had a total cost saving of ZAR61 874.40 compared with NPWT over a period of 12 weeks. In scenario 2, results indicated a 46% cost difference between the two modalities. Autologous WBC had a total cost saving of ZAR70 454.68 compared with NPWT over a period of 12 weeks. One of the identified social considerations is that NPWT needs a reliable supply of electricity to recharge the pump, while autologous WBC does not.

CONCLUSION

Both modalities are safe and effective in treating hard-to-heal wounds of the lower extremities. Autologous WBC consistently demonstrated better outcomes than NPWT in terms of both healing rate and cost-effectiveness, as well as having some advantages in terms of social considerations in SA.

Concurrent optical and magnetic stimulation therapy in patients with lower extremity hard-to-heal wounds

OBJECTIVE

The treatment of patients with hard-to-heal wounds represents a major multidisciplinary challenge. Therefore, the development and clinical validation of new technologies remains extremely important. The novel application of concurrent optical and magnetic stimulation (COMS) offers a promising noninvasive approach to support physiological wound healing processes, especially in hard-to-heal wounds.

METHOD

In a multicentre, prospective, comparative, clinical trial, patients with hard-to-heal wounds on lower extremities of different aetiologies were treated with COMS as an adjunct to standard of care (SOC). The primary endpoint was safety; secondary endpoints were wound healing, pain and wound-specific quality of life (Wound-QoL).

RESULTS

A total of 40 patients were enrolled in this study (intention to treat population (ITTP), n=40). Of these patients, 37 were included in the analysis of the primary endpoint (primary endpoint population, (PEP), n=37). A further subgroup of 30 patients was included in the analysis of the secondary endpoint (secondary endpoint population (SEP), n=30). Finally, the SEP was stratified regarding patients' responsiveness to SOC in an SOC non-responder subgroup (NRSG), n=21, and in an SOC responder subgroup (RSG), n=9. A total of 102 adverse events (AEs) were recorded, of which 96% were 'mild' or 'moderate', and 91% were either a singular or transient event. Only 11 AEs were serious and associated with inpatient treatments unrelated to the studied intervention. In the NRSG, reductions in wound size were found to be statistically significant within the different study periods. Additionally, an acceleration of the healing rate was detected between the baseline and the first four weeks of COMS treatment (p=0.041). The rate of near-complete and complete wound closure in the SEP after 12 weeks were 60% and 43%, respectively. Pain reduction across the treatment group was statistically significant (p≤0.002 for both the SEP and NRSG). The Wound-QoL score improved by 24% during the study (p=0.001).

CONCLUSION

In this study, COMS treatment for patients with hard-to-heal wounds on lower extremities was a safe and effective novel treatment option, especially for patients who did not respond to SOC.

[Wound treatment without curative intention: position paper of the Initiative Chronische Wunden (ICW) e. V.]

Today, patients with chronic wounds are treated in many different fields of medicine. Despite this great interdisciplinary and interprofessional importance, there is still a lack of uniformly accepted definitions and classifications. Therefore, a group of experts from the professional society Initiative Chronische Wunden (ICW) e. V. translated and adapted the classification of chronic wounds into healable, maintenance and nonhealable wounds on the basis of the internationally published literature into German. This classification results in the aim of curative, limited respectively non-curative or palliative wound care, which are very important for everyday clinical practice. It thus becomes clear that complete wound closure is not always the central intention of wound treatment. For many patients with chronic wounds, other aspects such as the best possible quality of life and the promotion of health-related self-management as well as the avoidance of complications are important for treatment concepts. These therapy intentions should be differentiated and individually discussed with patients in order to facilitate shared decision making.

A ‘game of dressings’: Strategies for wound management in primary health care

Wound care management and the dressing of wounds represent some of the most basic services offered in primary health care facilities across Southern Africa. Clinicians should have a basic understanding of the processes of wound healing and wound bed preparation to match the ideal cost-effective dressing to the particular type of wound to be managed. In the ‘kingdom of wounds’, the authors use a popular analogy and propose the best five strategies for the clinician in choosing the right management option in the ‘game of dressings’.

A regenerative approach to the pharmacological management of hard-to-heal wounds

A wound is considered hard-to-heal when, despite the appropriate clinical analysis and intervention, the wound area reduces by less than a third at four weeks and complete healing fails to occur within 12 weeks. The most prevalent hard-to-heal wounds are associated with underlying metabolic diseases or vascular insufficiency and include arterial, venous, pressure and diabetic foot ulcers. Their common features include an abnormal immune response and extended inflammatory phase, a subdued proliferation phase due to cellular insufficiencies and finally an almost non-existent remodeling phase. Advances in wound care technology, tested in both pre-clinical models and clinical trials, have paved the way for improved treatment options, focused on regeneration. These interventions have been shown to limit the extent of ongoing inflammatory damage, decrease bacterial load, promote angiogenesis and deposition of granulation tissue, and stimulate keratinocyte migration thereby promoting re-epithelialization in these wounds. The current review discusses these hard-to-heal wounds in the context of their underlying pathology and potential of advanced treatment options, which if applied promptly as a standard of care, could reduce morbidity, promote quality of life, and alleviate the burden on a strained health system.

Clinical approach to chronic wound management in older adults

Older adults are at high risk of developing chronic wounds due to numerous changes that occur with aging. It is reasonable to consider chronic wounds as a geriatric syndrome-highly prevalent, multifactorial, and associated with substantial morbidity and mortality. Due to the morbidity and cost associated with chronic wounds, prevention, early diagnosis, and treatment are important. The most common chronic wounds presenting in older adults are pressure and vascular wounds, including those associated with diabetes. Atypical wounds are also common and should raise the suspicion for skin malignancy. Diagnosis is primarily clinical and assessment should include documentation of wound characteristics, such as location, size and depth, presence of slough, drainage, odor, and infection. The mainstay of treatment is based on the TIME principle: Tissue debridement, Infection control, Moisture balance, and optimal wound Edges. The use of protein supplements has been shown to improve wound healing in subsets of older adults. In addition to wound care and optimizing nutrition, disease-specific wound therapy forms an integral part of wound management. Pressure reduction for pressure injury, compression therapy for venous wounds, evaluation of arterial circulation with ABI or arterial Doppler and iCC for diabetic ulcers form the mainstays of therapy. Atypical wounds may present as chronic ulcers and should be biopsied. The goals of treatment should be realistic and for some older adults, palliative wound management may be more appropriate.

Wound Bed Preparation 2021

GENERAL PURPOSE

To present the 2021 update of the Wound Bed Preparation paradigm.

TARGET AUDIENCE

This continuing education activity is intended for physicians, physician assistants, nurse practitioners, and nurses with an interest in skin and wound care.

LEARNING OBJECTIVES/OUTCOMES

After participating in this educational activity, the participant will: 1. Apply wound assessment strategies. 2. Identify patient concerns about wound care. 3. Select management options for healable, nonhealable, and maintenance wounds.