Edition: March 2002 - Vol 10 Number 03
Author: Cathy Thomas Hess
Effective skin and wound care is both an art and a science. Art refers to the skilled, clinical expertise that is involved in caring for patients with potential/alteration in skin integrity. Science is the clinical blueprint that is created to guide the management of patients with wounds. Because wounds vary from patient to patient, it is prudent to have a comprehensive system built upon both art and science.
Advanced skin and wound caring takes time, patience and understanding. Time affords the practitioner the opportunity to evaluate and reevaluate the effectiveness of the plan of care. Patience is a trait that demonstrates the willingness or ability to sustain involvement throughout the healing process. Understanding, perhaps the most comprehensive and learned trait, blends the delicate balance between art and science in the management of effective skin and wound care delivery. Understanding captures many other factors as well, including etiology of the wound, local and systemic factors contributing to the healing process, and the adjunctive therapies and products used to assist in healing. These principles and learned skills not only include assessment, but also planning, implementation, evaluation, and ongoing reassessments.
Establishing a Wound Management System
To achieve positive outcomes and control costs, one must define the steps necessary to build a wound management program through a seamless system:
1. Define the Tools and Build the Team. The essential tools needed to build a system include patient and practitioner education, information systems, utilization review, and outcomes management tracking systems that assess the program's effectiveness. The outcomes measured include clinical, functional, and financial. Developing a multidisciplinary team of skin and wound care practitioners (dedicated to continuous quality improvement practices for the patient), maximizes efficiencies of the skin and wound healing process.
2. Define Clinical Practice Guidelines. Protocols should be developed and employed in a systematic skin and wound care system to ensure consistent care and achieve the best possible outcome. The Clinical Practice Guidelines for prevention and treatment of pressure ulcers have been published by the Agency for Health Care Policy and Research (now known as AHRQ), and may be used as the benchmark for protocol development.
3. Select Skin and Wound Care Products. The arsenal of products includes topical skin and wound care products, tissue load management products, nutritional interventions, and adjunctive therapies and products. When choosing products and developing the plan of care for the patient, the practitioner should consider skin and wound-related factors, patient-related factors, and product-related factors.
4. Define an Educational Pathway. Standardizing documentation is essential for quality care, outcomes research and payment. Clinicians must define common terminology used to document skin and wound care. Classification or etiology of the wound provides an essential baseline for assessment and intervention. Measurements and descriptions of the wound include length, width, depth, tunneling, odor, drainage, and other pertinent characteristics. Color of the wound bed is an important tool for skin and wound assessment and intervention.
5. Develop a Skin and Wound Management Information System. As health care payers and providers strive to develop clinically effective and cost-efficient pathways to successful outcomes, information systems need to be implemented to assess a patient's skin, wound, and overall medical condition. Outcomes should be assessed by the system through utilization review to ensure that existing ulcers heal, reduce the incidence of new or recurrent ulcers and prevent the deterioration of existing ulcers. Electronic data capture systems are one type of documentation tool to assist the provider in coordinating wound and skin documentation.
Selecting the right product and therapy is essential to successful wound care management. Here are some of the types of products available. (For more information, visit www.woundcarestrategies.com.)
Absorptive Dressings: Specialty
These dressings are comprised of two or more layers manufactured as a single dressing, and are generally non-adherent. The layers are made up of fibers such as cellulose, cotton or rayon, which absorb fluids. Specialty absorptive dressings can be used as a primary dressing (the first dressing to cover the wound's surface) or secondary dressing (a dressing to cover the primary dressing). They are easy to apply and remove, and may have an adhesive border, making additional tape unnecessary.
These dressings are soft fibers made from brown seaweed. They can hold up to 20 times their weight, and fill in open spaces. They are available in rope, ribbon, and pad form. Ropes are usually used to pack a hollow area, or a hole. Ribbons are used to pack smaller or narrower areas than that of a rope. And pads may be used to pack a deeper area. When an alginate is packed into a wound, it usually works with the natural fluids within the wound and forms a gel. This gel maintains a moist wound-healing environment within the wound. Alginates are easily applied and can be easily removed. These dressings often require an additional, or secondary dressing.
These products are used to protect (''barrier'') our skin from moisture. For example, they act as a barrier to perspiration, urine, stool, etc., protecting our skin from becoming irritated. They are available in various forms, such as bottles, jars, and tubes, or as spray pumps, foam applicators, wipes or swabs. They are also available in powder form to absorb moisture, and they may deodorize the wound or skin.
These dressings were originally developed as a means of temporarily covering burns. Today they are still used as a substitute for skin to temporarily cover such areas as burns, but also skin tears, or areas otherwise missing skin. This dressing is available in a sheet form or a gel, and comes packaged as a sterile or non-sterile product. A biosythetic dressing promotes the growth and development of skin during the healing process.
Wound cleansers are manufactured with various ingredients. For example, ingredients may act as a preservative or as an anti-microbial. They will generally create a moist wound-healing environment. Wound cleansers can be used on infected or non-infected wounds.
These dressings are made up of two or more physically distinct products that are combined into a single dressing. They have at least four characteristics:
They form a barrier to bacteria.
They have a coating (other than an alginate, foam, hydrocolloid, or hydrogel) that absorbs fluids (drainage from the wound, called exudate).
They may not adhere to the wound.
They have a border surrounding the wound that allows the dressing to adhere to healthy skin surrounding the wound.
These dressings assist in removing the undesirable tissues to allow the wound to heal. They also allow for moisture from the wound to be evaporated through the dressing. They can be shaped as necessary to conform to the wound. And they are easy to apply and remove.
These products and devices are used to manage edema and promote the return of venous blood flow to the heart. This is achieved with the use of compression bandage systems, stockings, elastic wraps and pumps. Conventional management with a zinc-oxide-impregnated bandaging system provides inelastic compression. This modality is unable to conform to the leg's reduced circumference as edema decreases, making these products less effective over time. Multilayered, sustained, graduated high compression bandages decrease edema throughout the day regardless of the lower extremity volume. Different levels of compression are available, depending on the product or device. Certain types of garments are also available to provide compression. These garments are available in both single- and multiple-layers, with or without zippers, or self-adhesive to keep the garments closed.
These dressings, generally placed on an open wound, are made with a single layer of woven material (netting), and do not adhere (stick) to the bed of the wound. They protect the tissue in the wound from direct contact with foreign matter, such as dust, dirt, etc. They prevent trauma to the wound (especially during subsequent dressing changes). Contact layers protect the wound from other dressings and allow topical products to pass through to the wound bed. These dressings allow fluid (drainage, called exudate) to pass through and be absorbed by the secondary dressing used in the healing process.
The removal of dead tissue is critical in the wound healing process. Hardened, black tissue (called eschar) or moist, yellow stringy dead tissue (called slough) needs to be removed to facilitate healing. This is accomplished in a number of ways. A sharp instrument, such as a scalpel, scissors, or laser, can be used to remove this tissue. Scrubbing (a ''wet-to-dry'' technique), known as mechanical debridement, may be preferred. Using dressings that retain moisture is another alternative (called, autolytic debridement). The health care provider may prefer the use of chemicals (called, chemical debridement, as debriding agents ). Select debriding agents are by prescription only.
Even though the caregiver may do everything possible to keep a wound clean and to assist in the healing process (such as changing dressings on time and prescribed medicine), the wound may have an odor. A variety of sprays, air fresheners, and odor eliminators are available. Also available are synthetic dressings that include a layer of charcoal to help decrease the odor emitting from the wound. These particular dressings come in the form of wafers, which absorb fluids, or pads without the absorbing characteristic.
These devices are used for blood flow and pressures measurements. One device, known as a Laser Doppler, does not penetrate the skin when taking measurements and pressures. Some examples are Laser Doppler Flowmetry (LDF), and Laser Doppler Imaging (LDI). LDF uses a probe that is placed on a particular area of the skin to measure the blood flow to a particular area of the body. LDI uses mirrors to guide a laser beam over a selected site on the skin's surface. After proper imaging and calculations, the information can then be entered into a computer, using statistical software, to analyze the situation. Another non-invasive diagnostic tool is the Doppler ultrasound. A handheld probe is applied to a particular area of skin. The normal movement of skin cells in our blood vessels will change and the ultrasound will detect this movement (called the Doppler effect).
These dressings can absorb light or heavy amounts of fluid (drainage, called exudate). They may also resist dust, dirt and other contaminants. They have a non-sticking surface that allows for ease of removal with less shock or trauma to the affected area. Some of these dressings have an adhesive border, and may have a film coating to act as an additional barrier to bacteria. Foams create a moist healing environment for the affected area. They also act as insulation. Some have a charcoal filter integrated into the dressing to reduce odor. Foam dressings are available in the form of sheets of variable thickness, with or without adhesive coatings, and with or without film coatings on one side. They are easy to apply (and remove, as stated above), and may be used under compression (see the section: Compression Therapy Products and Devices). These dressings may require a secondary dressing, tape, or securing device to keep them in place.
Gauze: All Purpose (Woven and Non-woven)
These dressings may be made from a fiber (100% cotton) and woven into a fabric-like material. They are also made in a non-woven nature, from various materials with the fibers arranged to present a woven-like appearance. Either type may be ''impregnated'' with additional substances (e.g., water or normal saline), or without additional substances (called ''non-impregnated gauze''). These dressings, both in woven and non-woven form, are available in many sizes and forms, such as pads, strips, ropes, sponges, tubes, and ribbons. Generally these dressings can absorb moderate amounts of drainage (exudate). They are cost-effective and easily obtained. They can be combined with other topical products, or other types of dressings, and can be loosely packed into open wounds.
Hyberbaric oxygen therapy
Several studies report the benefits of hyperbaric oxygen therapy in the management of problematic ischemic wounds. This therapy uses a special chamber to deliver 100% oxygen under increased atmospheric pressure, significantly increasing tissue oxygenation. The greatest benefit is seen in tissues with compromised blood flow.
These dressings are occlusive (do not allow air to escape through the dressing) or semi-occlusive (allows some air to escape through the dressing). They vary in their ability to absorb, and may or may not leave a residue in the wound. These dressings generally provide for a moist healing environment and allow for clean wounds to progress with their natural healing process. These dressings are available in various sizes, shapes, adhesive ability, and come in the form of a wafer, paste, and powder. Generally these dressings are resistant to bacteria and other contaminants. They are porous to moisture, but not water. They assist the healing process, are self-adhesive, easy to shape, and absorb fairly well for light to moderate drainage. These dressings can be left on the skin for three to five days. Changing them less frequently reduces the stress and shock, or trauma, to the affected area. These dressings may also be used under compression.
These dressings are adaptable to the affected area and absorb drainage. The hydrofiber interacts with the wound's drainage (exudate) to form a gel. This maintains a moist wound-healing environment assisting in the wound's natural healing process. There must be enough exudate in the wound so that the hydrofiber can be transformed into a gel. These dressings are available in both sheet and rope form. They require a secondary dressing.
These dressings are water- or glycerin-based gels, impregnated gauzes (see ''Gauze'' above), or sheet dressings. Because of their high water content, they do not absorb large amounts of drainage (exudate). They may help maintain a moist wound-healing environment promote the natural wound-healing process. These dressings generally reduce pain, or otherwise produce a soothing effect. They provide minimal to moderate amounts of absorption, and are easy to apply and remove.
Irrigation and Drainage Systems
Irrigation is the means of directing a cleansing solution to an affected area. Select products allow for high-pressure debridement (removal of dead or unhealthy tissue) and low-pressure cleansing. There are a number of ways to do this. For example, a syringe, needle or catheter may be used. Or, a plastic bottle with a screw cap, that when squeezed, delivers the cleanser (normal saline) to the affected area. Another irrigation alternative is a pulsating purifying device that uses various attachments to cleanse wound sites. Drainage systems are used to collect urine for patients who have indwelling catheters and can be used as bedside drainage systems or leg collection systems.
New skin growth, or the regeneration of skin cells, is a normal occurrence to wound healing. Trauma to the wound, or other conditions, can cause an overgrowth of skin tissue and form scars. Compression, or the application of select dressings (gel sheets) treated with silicone or glycerin may be used to treat these conditions. These products can be used on both old and new scars.
The products create a protective coating on the skin, acting as a barrier between healthy skin and the topical management product. They are available as ointments, gels, wipes and sprays.
Topical Wound Management Products: Powered
This method of therapy is designed to assist the healing process in conjunction with traditional dressings. These products require power to be generated from an electrical source in order to function. One type of therapy is electrical stimulation (sometimes referred to as ''e-stim''). Electrical energy, in the form of an electrical current, is delivered into the wound's tissue to assist in debriding (removing dead or unhealthy tissue) the wound, or to assist in the wound healing process when the wound is free of dead or necrotic tissue. Two electrodes are placed in direct contact with the skin surrounding the wound area or through a moist dressing on the wound. The electrical current can be positive or negative, depending on the desired outcome.
Pulsed electromagnetic field energy (PEMF) is transmitted without the use of electrodes in direct contact with the skin. A coil placed close to the skin delivers a high frequency (a high rate of vibration) magnetic field. This process is delivered into the tissue, creating a weak electric current. There is no difference in the electrical current (polarity), but the high frequency, electrical and magnetic procedure may cause the tissue temperature to increase slightly.
Another form of electrical therapy is that of temperature and normothermic therapy. This therapy warms the wound and surrounding area, which increases the size of the blood vessels, increasing the blood supply and oxygen to the affected area. With normothermic therapy, there is no contact with the wound. It attaches to the skin surrounding the affected area and delivers heat to the wound. An absorbing dressing is placed into the wound to collect the drainage (exudate).
These dressings are used to fill a wound or dead space. They generally allow for a moist healing environment, but absorb fluids and help keep the affected area clean by softening dead tissue. Wound fillers are available in various forms such as powders, beads, gels, pads, pastes and granules. They are easy to apply and remove, and may be used in combination with other dressings or products.
About the author: Cathy Thomas Hessis, president of Wound Care Strategies, Harrisburg, PA, an independent clinical and payment strategy and sales/staff training company that services manufacturers and providers in:
Researching payer policies regarding products, procedures, and services.
Training management team how products, procedures, and services are paid in various sites of service.
Facilitating management team development/implementation of a reimbursement/ payment strategy for existing products, new products, future products, and acquisitions.
Conducting periodic reimbursement roundtable discussions regarding coverage, coding, and payment policies of payers.
Participating in planning of clinical trials in order to acquire economic and clinical outcome data and to develop a publication strategy.
Educating management team regarding time lines required to acquire coverage, coding, and payment decisions.
Serving as manufacturer's representative to national wound care coalitions.
Assisting in content development for reimbursement / payment marketing materials.
Preparing applications for HCPCS codes, when products qualify.
Wound Care Strategies markets the TriAssess® electronic data capture system, designed primarily for purposes of patient tracking, risk assessment (prevention), documentation and utilization review (intervention), and treatment and outcomes assessments (validation). TriAssess® assists the practitioner in reducing fragmentation of services and costs while enhancing skin and wound care results by tracking outcomes for patients, products, care delivery systems, patient satisfaction, as well as providing for cost analysis.
For more information, visit the company's website at www.woundcarestrategies.com or call (717) 541-1165.
This article was adapted from the Wound Care Strategies website (www.woundcarestrategies.com) and used with permission.