Wound care artistry
The infection initially was found in the foot wound of a 69-year-old diabetic resident
From wound care dressings utilizing collagen and glycerin to fish-skin tissue regeneration technologies, new materials are being introduced and piloted all the time to aid healing in the growing field of wound care.
Complex and chronic wounds such as pressure, venous, arterial and diabetic foot ulcers continue to challenge the long-term care industry. They are hard to heal and can be a significant drain on resources and nursing time.
Additionally, the rising prevalence of lifestyle-related diseases such as diabetes and obesity that result in chronic wounds nearly guarantees that the need for innovative products and strategies for wound care will only continue.
Advanced wound care products including alginates, hydrogels, hydrocolloids and collagen increasingly are emerging as the standard therapy for treating such slow healing wounds. Effectiveness in preventing accumulation of excess exudate must be balanced with maintaining the right level of moisture.
In some ways, though, negotiating the myriad wound care options has become as much of an art as a science these days. New discoveries, including skin substitutes and biological growth factors, continue to advance the field. At the same time, third-party, large-scale research comparing the effectiveness of various products — particularly among long-term care residents — lags behind, says Judy Bolhuis, BS, LNHA, vice president of post-acute care at Ferris Manufacturing Corp.
Therefore, it's typically incumbent on clinicians to customize their wound care plan based on an individual resident's needs.
Nursing homes also are constrained by cost, notes Diane Krasner, Ph.D., RN, FAAN, a wound and skin care consultant and part-time nursing instructor in York, PA, and editor of Chronic Wound Care: The Essentials (2014).
“The bottom line right now is that the technologies and products that are the least labor intensive and the least expensive and the most user-friendly are the ones that are going to have the most impact in this environment,” Krasner says. “So while there are wonderful products that may be developed, usage often falls back to the old standbys because they're inexpensive.”
Given the high incidence of wounds in the healthcare setting, and their associated risks, it's understandable why researchers continue to devote time and effort to studying new technologies in wound management and prevention. Roughly 6.5 million people are affected by chronic wounds, and an estimated $25 billion is spent annually in the United States on treating them.
Some of the most innovative wound care advancements have been in the area of cellular- and tissue-based product development, and biologic and biosynthetic dressings, says Bolhuis. She notes that skin substitute products present a novel approach to wound care. Collagen dressings, for example, are naturally derived, stimulate new tissue growth, and encourage the deposition and organization of newly formed collagen fibers and granulation tissue in the wound bed. Many also contain an antimicrobial agent such as silver — a way to control pathogens within the wound, Krasner notes.
New evidence also is emerging with regard to the development of a tissue-engineered human skin substitute. According to a study published in October in Advances in Skin and Wound Care, Canadian researchers successfully healed venous ulcers with human skin grown in vitro. The study was conducted with five patients who had been unresponsive to conventional wound care treatments such as compression bandages.
And in November, an Iceland-based healthcare startup, Kerecis, received U.S. Food and Drug Administration clearance for its fish-skin treatment. It takes cod skin and removes all the cells and antigens. Fish skin is largely made from the same material as human skin, with the addition of Omega3 polyunsaturated fatty acids — which have long been known to reduce inflammation. When the product is inserted into or onto damaged human tissue, protease activity is curbed, the fish skin is vascularized and populated by the patient's own cells, and it is ultimately converted into living tissue, the company notes.
Time for trials
Much tissue-based engineering has been studied only with small patient samples, but Bolhuis notes, “some of this research is so ready to be trialed in a larger market like long-term care.”
Experts also have seen increasing interest in placenta-based tissue, or amniotic membrane allografts. These often contain many of the growth factors found in the cell-based products, but they can be used right off the shelf, notes Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA, senior vice president of clinical services for Medline Industries.
“With many of the cell- and tissue-based products, there's time and effort taken into preparation, and they usually require special handling and storage conditions,” Falconio-West says. “Wound care and long-term care facilities are busier than ever, so room temperature storage, multi-year shelf life and no prep work required are huge advantages with some of these new placenta-based grafts.”
“Self-adaptive” or “smart” wound dressings are another innovation. Healing needs shift dramatically and sometimes unpredictably from wound onset to later stages, says Vicki Fischenich, RN, MSS, GNP-BC, WCC, a clinical specialist for OSNovative Systems. Self-adaptive dressings sense moisture levels and automatically create optimal healing conditions, hydrating dry areas and absorbing excess moisture. They only need to be changed about once a week.
“The less you pull off the dressing, the less you alter that ideal wound bed temperature, which leads to better outcomes,” Fischenich says.
Another trend has been the demand for preventive care, says Paula Erwin-Toth, MSN, RN, CWOCN, CNS, FAAN, a clinical consultant for MediPurpose. She notes that some studies support the use of foam-based dressings in the sacral region as part of a prevention protocol. Other research has focused on broad-spectrum silver and other antimicrobial dressings, including Manuka honey, to treat biofilms and prevent local wound bed infections, though results have been mixed.
“The science and practice of wound prevention and treatment is continually evolving,” Erwin-Toth says.
Keeping it simple
More than any product trends in wound care, however, the biggest shift Falconio-West says she's seen recently is a return to basics.
“Practices like hand hygiene, which is well documented as a first line of defense for infection prevention, are not as good as they should be, so refocusing on simple tasks like that are emerging,” she says. “Understanding the basic principles of wound healing will also take the clinician down an appropriate path to choosing the correct type of dressings.”
Joe Flaherty, M.D., professor of geriatric medicine at Saint Louis University, agrees, noting that while dressings are important, healing can happen only when the underlying wound cause is corrected. What really matters is whether nurses and staff follow the basic principles of wound care — pressure relief and keeping the wound clean and moist.
“After reviewing the data, we really haven't found much difference in various products,” Flaherty says. “That doesn't mean people should be afraid to try a new product, but you don't want to let the new product supersede the basic principles, because that's what really heals wounds — it just takes some time.”