Jesse M. Cantu, RN, BSN, CWS,
FACCWS
April 20, 2012
San Antonio, TX

• Evidence Based
• Best Practices
• Standards of Care
• Positive Outcomes
• Cost Containment
• Evolution of Dressings
• Summary

• Types
– Acute
– Chronic
• Closure
• Phases of Wound Healing

• Acute wound
– Planned / unplanned event
– Healing proceeds in an orderly and timely fashion
– Examples:
• Surgical
• Abrasion / laceration

• Surgical incision

• Chronic wound
– Exists two weeks or longer
– Does not proceed through normal healing process
– Examples:
• Pressure ulcers
• Diabetic / neuropathic ulcers

• Pressure ulcer

• Venous ulcer

• Post-operative dehisced wound

• Primary intention
• Delayed primary
• Secondary intention

What do you do if the burden is too big?

• 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
HYPERBARICS
Debride Moisture
NEGATIVE
PRESSURE
THERAPY
GROWTH
FACTORS
SILVER
DRESSINGS
BIOENGINEERED
TISSUES
Off-Load Topicals

• Evidence Based
• Wound Bed Preparation

Wound Bed Preparation
What Does It Mean?
Originally
• Debridement
Fibrotic Tissue
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

“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

• NPUAP
• WOCN
• AHCPR
• Canadian Guidelines

• Wound Assessment at each dressing change

• Wet to Dry Dressings (Gauze and Saline)
– Frequent dressing changes
• Moist Wound Healing (George Winters
1961)
• Active Wound Healing (NPWT,
Hyperbarics)

• Debridement
• Maintain a moist wound environment
• Reduce bacteria load
• Prolong dressing interval changes
• Stem cell technology

• 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

• 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.

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
• 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

• Contamination
– Presence 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
A
90
0
20
A
10
0
I
70
R
60
50
L
40
Ayello and Cuddigan, 2003

Wound Bed Preparation:
Combining Topicals with NPWT
Control of:
• Contamination, colonization and critical colonization to optimize the wound bed
• Odor

Ready for grafting