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Wound care: should healing always be the aim?

Una Adderley
DN RGN BA BSc
Community Tissue Viability Nurse
Scarborough, Whitby and Ryedale PCT

If you ask a nurse to state the aim of wound care the instinctive response will almost certainly be "to achieve healing". Yet for many chronic wounds this may be unachievable or the journey to healing will be long, slow and complex. A chronic wound is likely to require a series of different products in the journey to healing. Evaluating success on such a journey can be challenging particularly if the measures of success lack precision. This article will explore some of the issues and recent innovations around improving the evaluation of the effectiveness of wound care interventions.
Normal wound healing is divided into recognisable phases. Following wounding, the wound becomes inflamed due to vasodilation and a clot is formed. Macrophages and polymorphs arrive to defend against bacteria and to ingest debris. This first "inflammatory and destructive" phase usually lasts between 0-6 days. In the "proliferative" phase, new tissue is constructed as granulation tissue fills the wound bed. Epithelial cells then migrate across the surface of the wound bed until the whole surface is covered. This usually takes between 3-24 days. Finally, the repaired wound bed matures and increases in tensile strength, although it will never regain its original strength. Maturation will continue for anything from 24 days to a year.
Frameworks are a useful form of "aide-mémoire" when evaluating and planning care. It can be helpful to bear in mind the known phases of healing and to use these to assist in planning the different stages of wound care. If a wound is inflamed and sloughy then an aim of care might be to assist the body in removing wound debris while maintaining venostasis. If the wound is clean but with copious exudate, then the aim of care might be to manage that exudate to encourage epithelialisation.
However, many chronic wounds do not follow the stages of wound healing in an orderly fashion. They may never progress beyond the inflammatory state or may bounce between proliferation and inflammation. Even "healed wounds" may fail to complete maturation and return to a proliferative state. How many clinicians have carefully healed a leg ulcer with compression bandaging only to see the wound break down almost immediately if the patient is unable to concord with compression hosiery following epithelialisation?
To complicate matters further, some wounds have very little or no chance of completing healing. Fungating, malignant wounds where active treatment is no longer possible will not epithelialise. Similarly, any wound with an inadequate blood supply, such as an arterial ulcer on the foot, is unlikely to progress to complete healing. Frail patients with a very limited life expectancy may simply not be expected to live long enough to achieve full healing of a large wound. Clearly, "healing" would be an inappropriate aim of care statement for these patients, and aims of care need to be more specific and achievable with an emphasis on the palliation of symptoms.
The wound care symptoms that appear to be most distressing to patients and challenging to clinicians include copious exudate, malodour and pain. Although there is usually agreement between patients and clinicians that these symptoms need to be addressed, it can be very difficult to assess the effectiveness of interventions. Quality research, where it exists, tends to focus on healing as a prime outcome. When research does attempt to measure the management of symptoms as outcomes, the studies are often flawed by using subjective approaches to measurement, such as seeking the opinion of the patient or clinician or based on in-vitro, laboratory-based studies rather than measuring how a wound care product functions on real people.
This gap in knowledge has been recognised, and in 2001 the Wound Research for Appropriate Products (WRAP) Project was funded to examine this issue.(1) WRAP is a collaboration between industry, clinicians and academics to develop and test methods that could be used to identify patients' and clinicians' needs with regard to wound dressings that manage exudate. The collaboration is led by King's College London and incorporates 12 industrial companies, which include the Surgical Dressings Manufacturing Association, the Surgical Materials Testing Laboratory, the Southern Medical Alliance and four clinical centres.
The WRAP project focused on exudate management because this particular symptom had been identified both as a key problem for patients and clinicians managing malignant wounds and as a problem that frequently occurred in other types of wounds. Although many products are manufactured that aim to provide exudate management, clinicians reported that these products were not meeting patients' and clinicians' needs. This was due to a variety of reasons that included issues such as the inappropriate size and shape of products, as well as the inability of semiocclusive dressings to adequately manage exudate so as to avoid leakage or maceration.
The WRAP project identified three principal strands of investigation:

  • To develop a means of measuring the absorbency of dressings within the laboratory setting that is reliable and reproducible so as to enable meaningful comparisons to be made.
  • To develop 3D imaging techniques for studying dressing fixation to inform the design of dressings in terms of improved fit and fixation.
  • To validate a notemaking system that would enable the objective measurement of the effectiveness of the dressing's performance in the clinical setting.

To date, the WRAP project has succeeded in developing a reproducible test rig that has been tested in six laboratories and found to be reliably reproducible and repeatable. It is hoped that this will be used as an agreed industry standard. Successful 3D imaging with regard to discovering more about fix and fixation has proved a more difficult project, but progress is being made.
With regard to the validation of a notetaking system, evaluating wound care objectively is difficult as evaluation usually takes the form of a written description that is inevitably subjective and requires interpretation. The WRAP project selected the TELER(®) (treatment evaluation by Le Roux's method) as the system for study. The TELER system was developed as a method of clinical notetaking for many clinical settings and provides a method for collecting data with regard to measuring change. The WRAP project sought to validate the TELER clinical notetaking system as a method of collecting observational data with regard to how dressings perform in clinical practice.
The TELER system offered a systematic, objective approach to evaluating symptom management, dressing use, dressing performance and patient experiences by measuring the change in the patient's condition against the chosen treatment aim. TELER indicators provide a measuring scale with six reference points, which are coded 0, 1, 2, 3, 4 and 5, with 5 as the usual treatment goal. The codes are written in simple, clear language to enable treatment aims to be jointly decided by the patient and clinician. The WRAP team clinicians developed a number of wound care indicators that were then tested by using the system to record the progress of patients with chronic wounds (See Table 1).

[[NIP26_table1_76]]
 
These indicators were then used to collect data from patients, which was anonymised, collated and then passed to the WRAP team for the calculation of indices of effectiveness and analysis using reasoning systems to develop explanations of dressing performance. The system was validated using a sample of 85 patients from four clinical sites.
At present, the TELER system can only be used by licensed users who have paid for the privilege, which restricts its clinical use. However, the WRAP project's validation of the system has enabled the development of an automated method for analysing the resulting quantitative data. This will have the potential to be used as a clinical record within care delivery, assisting in clinical governance as well as a means of gathering data in research studies.
In the meantime, although most clinicians will not yet have access to a validated notemaking system, the example of TELER is a useful reminder of the need to consider the exact aims of wound care. If the clinician and patient are able to agree treatment aims that are focused, desirable and achievable, then realistic evaluation becomes possible and success is more likely. Failure to heal need not necessarily equate to failed care. Success in palliating distressing symptoms may be more important for both patients and clinicians.

[[NIP26_pp_76]] 

References

  1. Grocott P, Browne N, Cowley S.  WRAP: Defining clinical needs for fluid handling devices. Wounds UK 2005;1(2):11-6.
  2. King's College London. Clinical notemaking. Available from http://www.kcl.ac.uk/wrap/notemaking.html

Resources
WRAP Position Paper
W:www.kcl.ac.uk/wrap