Improving outcomes for patients with hard-to-heal wounds following adoption of the Wound Hygiene Protocol: real-world evidence.

OBJECTIVE: To evaluate the impact of a four-step biofilm-based wound care strategy, Wound Hygiene Protocol (WHP: cleanse, debride, refashion, and dress), on hard-to-heal wounds. METHOD: This was a prospective, real-world analysis of hard-to-heal wounds managed with the WHP that incorporated Aquacel Ag+ (Convatec Ltd., UK) dressings. Data were captured electronically between April 2021 and December 2022. The primary endpoint was change in wound volume from baseline to final assessment. RESULTS: A total of 693 wounds in 669 patients (median patient age: 74 years) were included in the analysis with a median treatment time of 31 days. Most health professionals were general nurses (50%) or nurse practitioners (38%). Patient homes (27%) and community clinics (27%) were the most common clinical settings. Venous leg ulcers (26%) and pressure ulcers/injuries (17%) were the most common wound type. Duration was >12 months in 21% of wounds. At baseline, the mean wound volume was 57.8cm3. At the final assessment, mean wound volume was 17.2cm3, corresponding to an 80% reduction from baseline; p<0.001). At baseline, 66% of wounds were static or deteriorating. At final assessment, this had decreased to 5%, and 94% had improved or healed. Exudate levels were moderate or high in 69% of wounds at baseline which decreased to 25% at final assessment (p<0.001). Suspected biofilm and local wound infection decreased from 79% and 43%, respectively, at baseline, to 18% and 3%, respectively, at final assessment (p<0.001 for both). CONCLUSION: The WHP is a new proposed standard of care that successfully treated hard-to-heal wounds by addressing the key local barriers to wound healing.

'Granulitis': defining a common, biofilm-induced, hyperinflammatory wound pathology.

The hard-to-heal (chronic) wound condition, now believed to be inextricably linked to the presence of microbial biofilm, has posed challenges in translating scientific understanding to clinical practice in recent decades. During this time, multiple descriptive terms of the wound pathology have been described, including critical colonisation, biofilm infection and inflammatory stasis. However, the absence of naming this disease state as a specifically identified condition that is tangible to treat has led to some confusion and delay in possible therapeutic approaches. When there is clinical uncertainty of wound status, antibiotics are too often inappropriately administered as a precaution. We therefore propose that introducing the term 'granulitis' (inflamed, unhealthy granulation tissue) could be used to identify the biofilm-induced, persistent inflammatory wound condition. This will help to raise clinician and public awareness of the condition, guide appropriate and prompt local wound hygiene, and encourage allocation of adequate resources to improve wound healing outcomes globally.

Acute and chronic wound infections: microbiological, immunological, clinical and therapeutic distinctions.

Wound infection is a complex pathology that may manifest either as a rapid onset acute condition, or as a prolonged chronic condition. Although systemic antibiotic therapy is often appropriate and necessary for acute wound infections, it is often used inappropriately, excessively and unsuccessfully in chronic wound infections. Overuse of antibiotics in chronic (hard-to-heal) wound management contributes to antibiotic resistance. This literature review confirms that acute and chronic wound infections are significantly differentiated by their cause (microbial phenotype), the subsequent host immune response and by the resulting clinical manifestations. Consequently, recognition of the type of wound infection followed by appropriate and timely therapy is required to improve wound healing outcomes while encouraging more judicious and responsible use of antibiotics.

Wound hygiene survey: awareness, implementation, barriers and outcomes.

OBJECTIVE: In light of the COVID-19 pandemic, which has resulted in changes to caseload management, access to training and education, and other additional pressures, a survey was developed to understand current awareness and implementation of the wound hygiene concept into practice one year on from its dissemination. Barriers to implementation and outcomes were also surveyed. METHOD: The 26-question survey, a mixture of multiple choice and free-text, was developed by the Journal of Wound Care projects team, in consultation with ConvaTec, and distributed globally via email and online; the survey was open for just over 12 weeks. Due to the exploratory nature of the research, non-probability sampling was used. The authors reviewed the outputs of the survey to draw conclusions from the data, with the support of a medical writer. RESULTS: There were 1478 respondents who agreed to the use of their anonymised aggregated data. Nearly 90% were from the US or UK, and the majority worked in wound care specialist roles, equally distributed between community and acute care settings; 66.6% had been in wound care for more than 8 years. The respondents work across the spectrum of wound types. More than half (57.4%) had heard of the concept of wound hygiene, of whom 75.3% have implemented it; 78.7% answered that they 'always' apply wound hygiene and 20.8% 'sometimes' do so. The top three barriers to adoption were confidence (39.0%), the desire for more research (25.7%) and competence (24.8%). Overall, following implementation of wound hygiene, 80.3% reported that their patients' healing rates had improved. CONCLUSION: Respondents strongly agreed that implementing wound hygiene is a successful approach for biofilm management and a critical component for improving wound healing rates in hard-to-heal wounds. However, the barriers to its uptake and implementation demonstrate that comprehensive education and training, institutional support for policy and protocol changes, and more clinical research are needed to support wound hygiene.

Protocolo de tratamiento de heridas con apósito de hidrofibra reforzada, con plata iónica al 1,2%, potenciado con EDTA y cloruro de bencetonio para evitar la recurrencia de biopelícula.

OBJECTIVE: Present a treatment protocol to avoid biofilm reformation in hard-to-heal wounds, using a hydrofiber dressing with 1.2% ionic silver, ethylenediaminetetraacetic acid and benzethonium chloride. METHOD: A retrospective, descriptive and analytic study on the use of a treatment protocol, including three case studies. Patient records for hard-to-heal wounds were analysed according to an algorithm for biofilm detection and best-practice recommendations for wound hygiene. RESULTS: The adopted protocol was based on three pillars: identifying clinical signs suggesting biofilm, performing wound hygiene, and applying an antibiofilm dressing. CONCLUSION: Wound healing rates can improve after protocol implementation. Adequate control of local signs of infection and exudate, as well as visual and indirect signs of biofilm, were achieved. All patients progressed well towards wound-size reduction and closure using the hydrofiber dressing.

OBJETIVO: Presentar un protocolo para evitar la reformación de biopelícula en heridas de difícil cicatrización con apósito de hidrofibra reforzada, con plata iónica al 1,2%, potenciado con ácido etilendiaminotetraacético (EDTA) y cloruro de bencetonio. MÉTODO: Estudio retrospectivo, descriptivo y analítico de aplicación de un protocolo de tratamiento, con tres casos de estudio de pacientes tratados en un centro de referencia internacional. Los registros de pacientes con úlceras complejas se analizaron y evaluaron de acuerdo con la inserción en el algoritmo de identificación clínica de biopelículas, y en base a las recomendaciones prácticas para la higiene de heridas. RESULTADOS: El protocolo adoptado se basó en tres pilares: identificación de signos clínicos de sugerencia para la presencia de biopelícula, prácticas de higiene en las heridas, y aplicación de la cobertura de antibiopelícula. CONCLUSIÓN: La capacidad de cicatrización de heridas con este protocolo puede considerarse alta. Los pacientes obtuvieron un adecuado control de todos los signos locales de infección y de exceso de exudado, y la desaparición de los signos visuales e indirectos de biopelícula. Todos presentaron una adecuada progresión, disminución de la superficie de la herida, y cicatrización tras el uso del apósito.

Protocolo de tratamiento de heridas con apósito de hidrofibra reforzada, con plata iónica al 1,2%, potenciado con EDTA y cloruro de bencetonio para evitar la recurrencia de biopelícula.

OBJECTIVE: Present a treatment protocol to avoid biofilm reformation in hard-to-heal wounds, using a hydrofiber dressing with 1.2% ionic silver, ethylenediaminetetraacetic acid and benzethonium chloride. METHOD: A retrospective, descriptive and analytic study on the use of a treatment protocol, including three case studies. Patient records for hard-to-heal wounds were analysed according to an algorithm for biofilm detection and best-practice recommendations for wound hygiene. RESULTS: The adopted protocol was based on three pillars: identifying clinical signs suggesting biofilm, performing wound hygiene, and applying an antibiofilm dressing. CONCLUSION: Wound healing rates can improve after protocol implementation. Adequate control of local signs of infection and exudate, as well as visual and indirect signs of biofilm, were achieved. All patients progressed well towards wound-size reduction and closure using the hydrofiber dressing.

OBJETIVO: Presentar un protocolo para evitar la reformación de biopelícula en heridas de difícil cicatrización con apósito de hidrofibra reforzada, con plata iónica al 1,2%, potenciado con ácido etilendiaminotetraacético (EDTA) y cloruro de bencetonio. MÉTODO: Estudio retrospectivo, descriptivo y analítico de aplicación de un protocolo de tratamiento, con tres casos de estudio de pacientes tratados en un centro de referencia internacional. Los registros de pacientes con úlceras complejas se analizaron y evaluaron de acuerdo con la inserción en el algoritmo de identificación clínica de biopelículas, y en base a las recomendaciones prácticas para la higiene de heridas. RESULTADOS: El protocolo adoptado se basó en tres pilares: identificación de signos clínicos de sugerencia para la presencia de biopelícula, prácticas de higiene en las heridas, y aplicación de la cobertura de antibiopelícula. CONCLUSIÓN: La capacidad de cicatrización de heridas con este protocolo puede considerarse alta. Los pacientes obtuvieron un adecuado control de todos los signos locales de infección y de exceso de exudado, y la desaparición de los signos visuales e indirectos de biopelícula. Todos presentaron una adecuada progresión, disminución de la superficie de la herida, y cicatrización tras el uso del apósito.

Defying hard-to-heal wounds with an early antibiofilm intervention strategy: 'wound hygiene'.

Biofilm has been implicated as a barrier to wound healing and it is widely accepted that the majority of wounds not following a normal healing trajectory contain biofilm. Therefore, strategies that inform and engage clinicians to reduce biofilm and optimise the wound tissue environment to enable wound progression are of interest to wound care providers. In March 2019, an advisory board was convened where experts considered the barriers and opportunities to drive a broader adoption of a biofilm-based approach to wound care. Poor clarity and articulation of wound terminology were identified as likely barriers to clinical adoption of rigorous and proactive microbial decontamination that is supportive of wound healing advancement. A transition to an intuitive term such as 'wound hygiene' was proposed to communicate a comprehensive wound decontamination plan with an associated message of expected habitual routine. 'Wound hygiene', is a relatable concept that supports meticulous wound practice that addresses barriers to wound healing, such as biofilm, while aligning with antimicrobial stewardship programmes.

Avant-propos.

Hard-to-heal wounds are a problem for both patients and caregivers. The biofi lm is one of the local factors of delayed healing. Wound hygiene carried out in 4 steps (cleansing, debridement, refashion - care of the edges, and dressing) constitutes the basis of proactive and curative anti-biofi lm strategies.