Transcript Wound Bed Preparation - Kindred Hospital San Antonio

Wound Care:
Where do we go from here?
Jesse M. Cantu, RN, BSN, CWS,
FACCWS
April 20, 2012
San Antonio, TX
Disease Management
(Wound Care Management)
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Evidence Based
Best Practices
Standards of Care
Positive Outcomes
Cost Containment
Evolution of Dressings
Summary
Wounds
• Types
– Acute
– Chronic
• Closure
• Phases of Wound Healing
Wounds
• Acute wound
– Planned / unplanned event
– Healing proceeds in an orderly and
timely fashion
– Examples:
• Surgical
• Abrasion / laceration
Acute Wound
• Surgical incision
Wounds
• Chronic wound
– Exists two weeks or longer
– Does not proceed through normal
healing process
– Examples:
• Pressure ulcers
• Diabetic / neuropathic ulcers
Chronic Wound
• Pressure ulcer
Chronic Wound
• Venous ulcer
Chronic Wound
• Post-operative dehisced wound
Wound Closure
• Primary intention
• Delayed primary
• Secondary intention
What do you do if the burden is too big?
Evidence Based / Best Practice
• Randomized control trials
• Protocols (NPUAP, WOCN, Canadian
guidelines, AHCPR)
• Moist Wound Healing (George Winters)
• Wound Bed Preparation (Vincent Falanga)
The Building Blocks of the
Foundation for Wound Care
Debride
Moisture
Off-Load
Topicals
SUCCESSFUL WOUND CARE
BIOLOGIC
DRESSINGS
NEGATIVE
PRESSURE
THERAPY
HYPERBARICS
GROWTH
FACTORS
Debride
Moisture
SILVER
DRESSINGS
BIOENGINEERED
TISSUES
Off-Load
Topicals
Best Practices
• Evidence Based
• Wound Bed Preparation
Wound Bed Preparation
What Does It Mean?
Originally
Fibrotic Tissue
• Debridement
Hyperkeratotic Rim
Wound Bed Preparation
What Does It Mean?
Today
“…a very comprehensive approach aimed
at reducing edema and exudate, eliminating or
reducing the bacterial burden and, importantly,
correcting the abnormalities … contributing to
impaired healing.”
Vincent Falanga , MD
Professor, Boston University School of Medicine
Other Voices….
“Think of it as removing various ‘burdens’ from the
wound and the patient.”
• Exudate
• Bacteria
• Necrotic/cellular debris
Elizabeth A. Ayello, PhD, RN & Janet Cuddigan, PhD RN
Standards of Care
• NPUAP
• WOCN
• AHCPR
• Canadian Guidelines
Positive Outcomes
• Wound Assessment at each dressing
change
Cost Containment
• Wet to Dry Dressings (Gauze and Saline)
– Frequent dressing changes
• Moist Wound Healing (George Winters
1961)
• Active Wound Healing (NPWT,
Hyperbarics)
Evolution of Dressings
• Debridement
• Maintain a moist wound environment
• Reduce bacteria load
• Prolong dressing interval changes
• Stem cell technology
Summary
• Wound management not wound care
– Need to jump start nonhealing or slow
wounds
• Adequate assessment, debridement, and
wound irrigation based on Best Practices,
Evidence based, Standards of Care,
Positive Outcomes, and Cost containment
• Case studies
Wound Care as Wound
Management
• Properly treated wounds create the ideal
win-win situation by decreasing
hospitalizations, promoting wound healing
in the home, improving quality of life, and
improving patients’ sense of independence
and well being.
Other Voices….
Wound Bed Preparation is
“the management of a
wound in order to
accelerate
endogenous healing or to
facilitate the
effectiveness of other
therapeutic measures.”
Schultz G, Sibbald G, Falanga V, et
al:Wound bed preparation: A
systematic approach to wound
management.Wound Rep Regen 2003
What’s Needed to Heal a Diabetic
Neuropathic Ulceration?
Control of Diabetes and General Health
Adequate Diet
Blood Supply
Absence of Infection
Regular Debridement
Offloading of Pressure
Moist Healing Environment
Common Methods to
“Off-Load” the Foot
Total Contact Casts
Custom Splints
Therapeutic Shoes
Removable Cast
Walkers
So what is this going to cost me?
A lot less than traditional care…
“Incidence, Outcomes, and Cost of
Foot Ulcers in Patients with
Diabetes”
• What is the cost of a
new foot ulcer, not
previously treated?
–$27,987 over a
two year period!
Ramsey, Reiber, et al. Diabetes Care, Mar 1999 – Univ of Washington
1. Benefits of a Closed
Environment
• Moisture Balance
• Reduction of
Nosocomial Infections
• Prevents patient
interaction with the
wound
2. Promotes Perfusion
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Replacement of fibrinous tissue with
granulation tissue
• Filling deficits in wounds
• Wound constriction
Promotes granulation tissue formation
Dompmartin A, et al J Wound Care 2004 June
4. Benefits of Maintaining a Moist
Wound Bed
Why do we keep a wound moist?
Promotes rapid migration of epidermal
cells across the wound bed
Promotes perfusion
Why do we keep a wound moist?
Promotes rapid migration of epidermal cells across the
wound bed
Promotes perfusion
Barrier against environmental
contamination
Benefits of Using Negative
Pressure Therapy as an Adjunct
70 patients with chronic,
non-healing wounds
treated with VAC
following skin grafts
100 % of the grafts
healed in an average
of 48 days
Carson SN, Overall K, Lee-Jahshan S, Travis E.
Ostomy Wound Manage. 2004 March
Escalating Bacterial Loads
of nonreplicating microorganisms
in the wound
• Colonization – Presence of
nonreplicating microorganisms
adhering to the wound, NOT
causing injury to the host
• Critically Colonized –
Bacteria cause a delay in wound
healing
• Infection Local to
Systemic – Presence of
replicating microorganisms in
wound and presence of injury to
the host
10
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0 0 0 0 0 0 0 0 0 0 0
• Contamination – Presence
B
A
C
T
E
R
I
A
L
L
O
A
D
Ayello and Cuddigan, 2003
Wound Bed Preparation:
Combining Topicals with NPWT
Control of:
• Contamination,
colonization and critical
colonization to optimize
the wound bed
• Odor
Case Studies
The Challenge of a Large Deficit
Wound and Poor Vascularity
Ready for grafting