Wound care products: a guide to choice.

Does your nursing staff "slap on" a wound dressing without appropriate assessment or cost considerations?

Perhaps the single most important factor in the successful treatment of chronic wounds is taking the time to assess the wound appropriately before proceeding with treatment. Unfortunately, because of the discomfort these wounds can cause residents and the stigma attached to facilities in which such wounds occur, nursing home staff often want to get busy immediately and "stick something on" to fix it. This ends up doing a disservice to both resident and facility - clinicians who rush to treatment without taking the time for proper assessment end up making wound care much more complex and expensive than it needs to be.

A global approach - assessing not just one but all the characteristics of a wound - is essential to directing therapy, not only initially, but throughout the course of treatment. For example, the first time you see a wound, you might select a dressing based on the amount or type of necrotic tissue present. The next time it might be the amount or appearance of exudate or the status of surrounding tissue that dictates which therapy would be most suitable.(*) Wound characteristics guide therapy.

It is also important to determine the wound's etiology. If treatment does not address the underlying cause(s) of a wound, it really doesn't matter what topical treatment you use - the wound won't heal properly. It is important to attempt to reduce causative factors by:

* enhancing the host adaptation mechanism;

* reviewing the resident's nutritional parameters; and

* educating caregivers and family members in avoiding further trauma to the site.

Besides directing treatment, the initial evaluation also will provide a benchmark for comparison, helping to show the effectiveness of a given therapy over time.

So Many Dressings, So Little Time

With more than 2,400 wound care products available and new ones cropping up almost daily, it is impossible for anyone to keep up with them all. For those who deal with chronic wounds in the long-term care setting, it is important to be knowledgeable of the various categories of products (see Table 1) and where within treatment each category fits, based on the products' predominant characteristics (see Table 2). Armed with that basic knowledge, practitioners can figure out when and how to use what.

The choice is ever-widening. One newer category of woundcare products to reach the market is collagen-based dressings. Some new hydrocolloid / alginate combinations are available, as well, and more and more dressings (especially hydrocolloids) now come in special shapes - for example, Hydrocol (Dow Hickam Pharmaceuticals), designed for use in the coccyx area.

Another innovation is the addition of zinc to wound dressings. The premise is that since zinc is a cofactor in cellular proliferation, including it in dressings should be beneficial. Derma Sciences has several zinc-containing dressings on the market, one example being their Dermagran Hydrogel.

In addition to these newer agents, enzyme debriding agents, because of their unique actions, are briefly reviewed here, with some guidelines for their appropriate use.

As a guide to selecting and timing the use of some of the newer dressings and of enzyme debriding agents, here is a bit more detail:

Collagens. One advantage of collagens is that they can be used on either uninfected or infected/contaminated wounds. Some of these products can be left on the wound for as long as 7 days, which drastically reduces nursing time compared with products that must be applied daily or several times daily. Collagens are slightly to moderately absorbent and can be used with other topicals. Some are supplied as pure collagens and others, such as Fibracol (Johnson & Johnson Medical), come in a 90% collagen/10% alginate form.

One potential drawback with collagens is that they are bovine-derived, and some patients are hypersensitive to bovine products. Other possible disadvantages are that these products require a secondary dressing to hold them in place and that dry wounds need to be hydrated with saline before collagens are applied.

Enzyme debriding agents. These agents are available only by prescription. They are useful for wounds that have necrotic tissue present, and some offer the advantage of once-daily application (e.g., Santyl, Panafil). They should be used until the wound bed is predominantly free of necrotic debris and should always be used cautiously in patients with coagulation disorders.

Substances that inhibit enzyme activity - such as soap, detergents, other acidic solutions and metallic ion solutions (e.g., Phisohex, Burrow's solution, betadine) - should not be used concurrently with enzyme debriding agents. Before these products are applied, any hard eschar present must be scored. These products, too, require a secondary dressing.

Hydrocolloid/alginate dressings. These products allow you to use a hydrocolloid in a wound that is highly exudative. They're usually supplied in a form similar to that of a standard hydrocolloid: They look like a sheet or wafer. These hydrocolloid/alginate dressings are used in the same manner that you would use a hydrocolloid, but because of their increased absorbency, can stay in place longer (3x/weekly application) than standard hydrocolloids.

New and Unique Devices

In addition to the new dressings, two novel devices are now available for the care of wounds. One is the Wound V.A.C.[TM], manufactured by Kinetic Concepts, Inc. (V.A.C. stands for "vacuum-assisted closure"). The V.A.C. equipment consists of a battery-operated pump unit with a canister for collecting exudate from the wound. Flexible tubing connects a special foam dressing - used to pack the wound - to the unit via the collection canister. A semipermeable membrane placed over the dressing and wound area creates an airtight seal, so that that the device can apply negative pressure to the wound area and draw the edges of the wound to the center.

Besides removing wound fluid, the application of negative pressure is believed to accelerate healing by increasing vascularization, decreasing bacterial colonization and stimulating the growth of healthy granulation tissue. It should be noted that, before the device is used, all necrotic tissue should first be debrided.

The other new device is the Warm-Up Active Wound Therapy[TM] system by Augustine Medical, Inc., which uses infrared heat to promote levels of temperature and humidity in the wound environment that are ideal for healing. This device consists of a raised, disposable "bandage" (called a "wound cover") into which a disposable warming card is placed. The warming card is attached to a temperature control unit, which is plugged into an AC adapter. The wound cover does not touch the wound but surrounds and protects it, acting as a "miniature greenhouse."

Both these products are quite exciting and definitely unique compared with anything we've seen in some time. Their effectiveness is supported by case studies and some data from clinical trials. Further study might be required to establish their value, but these devices could prove to be useful options in wound care.

Cost Considerations

With the wide variety of products available, consideration should be given to their comparative costs - and that means weighing more factors than a product's price. For example, calcium alginates are fairly expensive, but if used on a wound that is draining significantly they can in fact represent a considerable savings, simply because they can remain in place longer than other dressings. Not only does this save nursing time, but the less a wound is disturbed, the less likely complications will develop, such as additional tissue trauma. Using something that is less expensive but delays or interferes with healing is, of course, no bargain.

Cost calculations must take ancillary costs into account. For example, if one is using gauze dressings with normal saline on a clean wound that is proliferating, one has to assume one of two situations: (a) the dressing is being applied inappropriately, usually less frequently than recommended (unfortunately, an almost universally routine practice), or (b) excessive nursing time is involved in changing the dressing as frequently as recommended - a sort of no-win situation.

One has to view this in an overall context: You can certainly use gauze, for instance, on many types of wounds and produce healing - but you have to ask two questions: "Are these wounds healing as fast as they would if something else were used?" and "Can I afford the nursing time involved in the use of these products?"

Etiology of a wound is important not only in assessment, but in financial "outcomes." If, for example, one assumes that an ulcer on a lower extremity is venous in origin and applies topical treatment accordingly, one might find at the one-week evaluation that the wound is larger, more clinically significant and looks worse. Why? Because the lesion really was arterial in origin. Conversely, if a wound is not identified as venous, one might apply any topical treatment available and it won't heal until the venous congestion is addressed. In either scenario, if the wound had been assessed properly, the main underlying cause probably would have been correctly identified and the most effective treatment could have been applied in a timely manner - as always, the most cost-effective approach.

Summary

First and foremost, proper initial assessment of chronic wounds - including identification of the underlying cause or causes - is the first step to successful treatment. Gaining a working knowledge of which wound dressings are best for which types of wounds, rather than trying to become familiar with every new product that comes out, will enable pracitioners to choose appropriate therapy. This approach will not only enable patients' wounds to heal more quickly, but it will reduce treatment costs and save nursing staff a great deal of time and frustration.

Barbara Bates-Jensen, MN, RN, CETN, is Assistant Professor of Clinical Nursing and Director of the Enterostomal Therapy Nursing Education Program, University of Southern California, Los Angeles.

* Editorial note: A future issue of Nursing Homes Magazine will include an article by Barbara Bates-Jensen on her research-based instrument for evaluating pressure sores, the Pressure Sore Status Tool.

[TABULAR DATA FOR TABLE 1 OMITTED]

[TABULAR DATA FOR TABLE 2 OMITTED]