Hard-to-heal Wounds: A Holistic Approach - EWMA
POSITIONDOCUMENTHard-to-healwounds: a holisticapproachWound complexity and healingPsychosocial factors and delayed healingEconomic burden of hard-to-heal wounds
MANAGING EDITORSuzie CalneSENIOR EDITORIAL ADVISORSChristine MoffattProfessor and Co-director, Centre for Research and Implementation of Clinical Practice (CRICP),Faculty of Health and Social Sciences, Thames Valley University, London, UKPeter VowdenVisiting Professor of Wound Healing, University of Bradford, and Consultant Vascular Surgeon,Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UKSponsored by an educationalgrant from KCI Europe HoldingBV.The comments and viewsexpressed are those of theauthors only and do notnecessarily reflect those of KCI.“V.A.C. Therapy” referred to inthis document is a KCI product,and all such trademarksdesignated herein are theproperty of KCI Licensing, Inc.EDITORIAL ADVISORSMatthias AugustinHead of Health Economics and Quality of Life Research, Department of Dermatology, UniversityClinics of Hamburg, GermanyAníbal JustinianoGeneral Surgeon and Invited Professor of Nursing, Santa Maria Superior Nursing School, OportoInstitute of Health Sciences, Portuguese Catholic University, Oporto, Portugal; President, APTFeridasChristina LindholmProfessor of Nursing, Department of Health Sciences, Kristianstad University, SwedenDavid MargolisAssociate Professor of Dermatology, Department of Dermatology, University of Pennsylvania,Philadelphia, USAAndrea NelsonReader in Wound Healing, School of Healthcare, University of Leeds, UKPatricia PriceDirector, Wound Healing Research Unit, School of Medicine, Cardiff University, UKMarco RomanelliDirector, Wound Healing Research Unit, University of Pisa, Italy; President, European WoundManagement AssociationJavier Soldevilla ÁgredaProfessor of Geriatric Care, EUE University of La Rioja, Logroño, SpainLuc TéotAssistant Professor of Surgery, Montpellier University Hospital, FranceDESIGNERJane WalkerPRINTED BYViking Print Services, East Sussex, UK MEP LTD 2008All rights reserved. No reproduction,copy or transmission of this publicationmay be made without writtenpermission. No paragraph of thispublication may be reproduced, copiedor transmitted save with writtenpermission or in accordance with theprovisions of the Copyright, Designs &Patents Act 1988 or under the terms ofany license permitting limited copyingissued by the Copyright LicensingAgency, 90 Tottenham Court Road,London W1P 0LP.To reference this document cite thefollowing:European Wound ManagementAssociation (EWMA). PositionDocument: Hard-to-heal wounds: aholistic approach. London: MEP Ltd,2008.FOREIGN EDITION TRANSLATIONSRWS Group, Medical Translation Division, London, UKPRODUCTIONAlison PughDEPUTY EDITORLisa MacGregorEDITORIAL PROJECT MANAGERKathy DayPUBLISHING DIRECTORJane JonesPUBLISHED BY MEDICAL EDUCATION PARTNERSHIPOmnibus House, 39–41 North Road, London N7 9DP, UKTel: 44 (0)20 7715 0390 Email: info@mepltd.co.uk Web: www.mepltd.co.ukEUROPEAN WOUND MANAGEMENT ASSOCIATIONSecretariat: PO Box 864, London SE1 8TT, UKTel: 44 (0)20 7848 3496 Web: www.ewma.org
POSITIONDOCUMENTHard-to-heal wounds: a holisticapproachC Moffatt1, P Vowden2*It is noted that 'hard-to-heal'and 'wound complexity' arebroad terms and are open todifferent interpretations1. Thisdocument explores theseconcepts from a practicalperspective.1. Meame S. Plaies difficiles: dela physiologie à la pratique.Le Quotidien du Médecin16 Novembre 2007; 8258(FMC Spécialistes): 1-23.1. Professor and Co-director,CRICP, Faculty of Health andSocial Sciences, Thames ValleyUniversity, London, UK.2. Visiting Professor of WoundHealing, University of Bradford,and Consultant VascularSurgeon, Bradford TeachingHospitals NHS Foundation Trust,Bradford, UK.Even with increasing knowledge and the development of more sophisticatedinterventions, many clinicians will encounter wounds that are ‘hard-to-heal’ where,despite best efforts, wound healing is prolonged or never achieved. This often causesincreased psychological stress and anxiety for all involved and creates a considerablefinancial burden for already hard-pressed healthcare systems.While some attention has been placed on understanding the biological factorsinfluencing delayed healing, relatively little has been placed on the psychosocial factorsinvolved. This document aims to redress this balance and looks at how all of thesefactors may have an impact on healing and affect a patient’s life.In the first paper, Wound complexity and healing*, Vowden, Apelqvist and Moffattidentify issues that affect wound healing. They bring together the practical aspects ofdealing with wounds and the increasing scientific data that demonstrate why somewounds fail to heal. The authors describe how physical, bacteriological and biochemicalwound- and patient-related factors can be used to give an indication of risk for delayedhealing. The paper sets out a framework showing how the patient, the patient’s wound,the skills and knowledge of the healthcare professional, and resource availability interactto define wound complexity, and how this relates to potential problems with healing.The paper also introduces the importance of psychosocial factors and their impact onhealing. In particular, a short patient commentary gives an insight into the psychosocialimpact of a large non-healing wound and how the introduction of an advanced portabledressing system enabled the patient to return quickly to normal living and employment.This theme continues in the second article Psychosocial factors and delayed healing byMoffatt, Vowden, Price and Vowden, which explores the close interrelationship betweenanxiety and depression, sleep deprivation, socioeconomic status, wounding andnon-healing.Although the main focus of both papers is the patient, it is important to recognisethat non-healing also impacts directly on healthcare professionals who are underincreasing pressure to justify their actions in terms of cost-effectiveness and clinicaloutcomes.The third paper, Economic burden of hard-to-heal wounds by Romanelli, Vuerstaek,Rogers, Armstrong and Apelqvist, examines the potential cost implications of hard-toheal wounds in different countries. The significant economic burden of these complexwounds relates mainly to extended time to healing and to associated complications.Management of wounds should therefore focus on identifying problems early and usingappropriate strategies and interventions to facilitate healing and to avoid complications.This may, however, require the use of apparently more expensive interventions.Clinicians will need to adopt a broad view of total resource use, rather than focusing onacquisition costs alone, in order to present robust economic arguments to fund holders.However, a problem in evaluating the cost of disease states is the wide variation in thecost criteria used by different studies.Although the themes covered in this document are equally relevant to allpractitioners, problems specific to wound complexity and delayed healing will be greatlyinfluenced by individual circumstances such as product availability, the reimbursementsystem and the care setting.The challenge for clinicians is to recognise and take the appropriate measures tosimplify or downgrade the complexity of the wound so that it can heal in the leastinvasive setting, in the shortest time possible and without negatively impacting on thepatient’s quality of life. Early recognition of a wound that is slow to heal is veryimportant and should trigger a reappraisal of the treatment plan. Professionals may needto look for alternative treatment strategies. In some situations, the goal of treatment maychange to effective symptom control, ensuring the patient has the best possible qualityof life despite the presence of a wound.1
POSITIONDOCUMENTWound complexity and healingP Vowden1, J Apelqvist2, C Moffatt3INTRODUCTIONOver the past 20 years there have been major advances in our understanding of thebiology of wound healing. This means that it is now possible to predict the likelysequence of events in the healing trajectory and to forecast the approximate time itwill take for a wound to close completely. However, despite our increasing knowledgeand the development of many interactive wound care products, healthcareprofessionals will encounter wounds where healing is prolonged or never achieved.This paper suggests that the key to appropriate and effective management lies inrecognising the complex combination of factors, both within and outside the wound,that are involved in the process of healing. Management can then focus on initiatingappropriate measures to address any that are causing problems. The challenge is toidentify as early as possible when a wound is slow to heal.PREDICTING HEALINGPROGRESSIONThe importance of regular wound assessment and wound size measurement in identifyingpotentially hard-to-heal wounds has been reviewed by Troxler et al1. Recognising earlywound size reduction by measuring advancement of the wound edge (epithelialadvancement) – the so-called ‘wound edge effect’ – has been shown to be a useful generalmeasure of healing outcome in different wound types. Phillips et al2, looking at percentagereduction in venous ulcer area, found that in approximately 77% of cases, healing outcomescould be predicted based on a wound size reduction of more than 44% at three weeks.Zimny and Pfohl have shown that weekly wound radius reduction could be used to predicthealing in a group of patients with diabetic foot ulceration3. Margolis et al4 have successfullydemonstrated that a simple scoring system for venous leg ulcers, based on ulcer size andduration, can give a good indication of the likely outcome at 24 weeks.Epithelial advancement is, however, only one component of the healing process. Falanga etal5 incorporated measurement of epithelial advancement into a scoring system that correlateswith the healing of venous leg ulcers. This system also examines other characteristicsincluding the extent of periwound dermatitis, the presence of eschar, periwound callus and/orfibrosis, a pink/red wound bed and the amount of exudate and oedema.WOUND COMPLEXITYAND HEALINGPROGRESSIONThe above predictors offer a useful guide and help to alert healthcare professionals tohealing difficulties (ie that the wound is not progressing according to the projected timelines with standard therapy). However, the variability of healing rates among individuals6and the many factors affecting this must also be recognised. Wound complexity will have amajor impact on healing progression and the factors involved can be broadly categorisedinto four key groups: patient-related factors wound-related factors skill and knowledge of the healthcare professional resources and treatment-related factors.1. Visiting Professor of WoundHealing, University of Bradford,and Consultant VascularSurgeon, Bradford TeachingHospitals NHS Foundation Trust,Bradford, UK. 2. AssociateProfessor for Diabetes andEndocrinology, University Hospitalof Malmö, University of Lund,Malmö, Sweden. 3. Professorand Co-director, CRICP, Facultyof Health and Social Sciences,Thames Valley University,London, UK.2Only by appreciating and understanding the interaction of these factors and their impacton healing (Figure 1) can clinicians develop effective and appropriate strategies toimprove patient outcomes. The following sections discuss each of these categories indetail and explore how the factors involved may influence healing progress.KEY POINTS1. Clinicians should be encouraged to recognise, understand and address the factors that contribute towound complexity as these may impact on healing progression.2. It is important to identify as early as possible when a wound is likely to be slow and/or hard to heal3. Interventions should be targeted at reducing all aspects of complexity, including those related to thepatient, the wound, the healthcare professional and available resources.
HARD-TO-HEAL WOUNDS: A HOLISTIC ctorsDuration/senescencePathologySize (area and depth)ComorbidityAllergyWound bed on/infectionPainAnatomical siteConcordanceTreatment are mbursementInterventionalProcess of care Establish goals Address– patient-related factors– wound-related factors Instigate treatment Review progressWound complexity increasesthe likelihood of hard-to-heal statusReview: Diagnosis Circumstances Treatment Progress Care method Options ReferralTreatment progress: failure to progressdespite appropriate 'standard' carePotentially'hard-to-heal' woundTreatment progress: improvingwith appropriate 'standard' careRe-evaluate progress regularlymay become 'hard-to-heal'Unlikely to be a'hard-to-heal' woundFigure 1 Factors thatmay affect complexityand hard-to-heal statusPATIENT-RELATEDFACTORSThe environment in which an individual patient’s wound exists is affected by a number ofphysical (such as underlying pathology, comorbidities, etc), psychological and social factors.Patient-relatedphysical factorsIt has been shown that physical factors, such as diabetes mellitus, obesity, malnutrition,old age (over 60), decreased perfusion, peripheral vascular disease, malignancy, organfailure, sepsis, and even restrictions in mobility, have an impact on healing1. Correcting,where possible, the underlying wound pathology and any comorbidities is, therefore, acentral feature of wound management. If the underlying disease cannot be corrected or isdifficult to manage, wound healing can be delayed.Marston et al7 found that improved glycaemic control positively influences woundoutcome in diabetic foot wounds, particularly when dermal substitutes are used. Similarly,it has long been recognised that restoration of pulsatile blood flow, by either surgery orangioplasty, markedly improves the outcome in ischaemic lower limb ulceration. This is incontrast to the situation in venous ulceration, where early surgical correction of superficialvenous reflux has proved to be no more beneficial than high compression bandaging. Thebenefit of surgery here, as was demonstrated in the ESCHAR study, is in the reduction ofulcer recurrence in both the short- and the long-term8.Diseases and treatments that directly affect the immune system have a major impact onwound healing and often increase the complexity of the wound9,10. The inflammatoryprocess is an integral part of acute wound healing, and derangement of this process isrecognised as one of the primary causes of wound chronicity. Immunodeficiency states,the use of immunosuppressant drugs such as corticosteroids, azathioprine ormethotrexate, or the presence of diseases (such as diabetes mellitus) that are known to affectthe immuno-inflammatory response, all adversely affect healing and increase the risk ofwound sepsis9,10.3
POSITIONDOCUMENTIn addition, other patient-related factors, such as the wound care product usedpreviously or drug sensitivity/allergy, may determine the complexity of the wound and thetreatment outcome by restricting the range of suitable treatments (see Figure 1, page 3).Patient-relatedpsychosocial factorsPsychosocial factors, such as social isolation, gender, economic status11-13 and painexperience, have also been found to influence healing (see Moffatt et al, pages 10–14).Recognition of the impact of these factors is seen as being particularly relevant whendealing with recalcitrant venous ulcers in an elderly population14. It is thereforeimportant that appropriate referral is made (eg to social workers) so that the problemscan be addressed effectively.Stress and depression have been linked to changes in immune function, and maytherefore adversely influence a broad range of physiological processes, including woundhealing. In a human experimental model, it was found that stress and depression had apossible role in the modulation of matrix metalloproteinases (MMPs) and in theexpression of tissue inhibitors of metalloproteinases (TIMPs)15. In a hostile maritalenvironment, pro-inflammatory cytokines were found to be elevated and wound healingwas delayed16.Coping mechanismsPatients with a chronic, non-healing wound will attempt to develop coping strategies17.The nature of their response will be determined by a variety of psychological factors:these include personality type (pessimistic or optimistic, for example), previousexperience and psychological disorders such as depression, phobias and obsessivecompulsive disorder.Patient beliefsSalaman and Harding18 investigated a group of 45 hospital patients with venousulceration, 16 (36%) of whom were considered to be failing to make satisfactoryprogress. Only half of these 16 patients claimed to have received any explanation aboutthe cause of their ulcer and the method of its treatment. Seventy-five per cent of the totalgroup appeared to understand the importance of compression in ulcer healing, but 62%felt that it was not proving effective in healing their ulcer. Seven of the 16 patients withnon-healing wounds (44%) believed their ulcer would heal.Although the study was very small and focused on a mixed group of patients, 36% ofwhom were highly refractory, it raised important issues about the impact on woundhealing of the patients’ beliefs and their confidence in treatment. Further research isneeded to understand patients’ ability to tolerate and adhere to treatment modalitieswhen they do not believe they will help them.ConcordanceDespite some patients feeling that they have no control over their situation, manydo make attempts to ensure that the care they receive meets their own needs (Box 1,page 5). Some patients become experts in their own condition, often using theInternet to access information and frequently developing routines to ensure thattheir treatment plan matches their expectations19. In addition, patients may constantlytake note of how their care is provided. Such patients use a form of coping called‘monitoring’.Another form of coping is called ‘blunting’; this is where patients appearunconcerned about their treatment and may not be greatly interested in their progress20.Although blunting has been shown to be a useful coping strategy in acute situations,for patients with long-term conditions, it may lead to poor adherence to therapy and arefusal to engage in treatment21. Further research is required to confirm the long-termeffects of blunting in patients with chronic wounds.4
HARD-TO-HEAL WOUNDS: A HOLISTIC APPROACHWOUND-RELATED FACTORSIn a study by Margolis et al, specific wound characteristics were shown tocorrelate with healing22. Patients with a large wound area, an ulcer of longduration, a reduced ankle-brachial pressure index or a visual estimate offibrin on more than 50% of the wound surface had delayed venous ulcerwound healing at 24 weeks22. Other wound characteristics such as thecondition of the wound bed and anatomical location may also impact oncomplexity and healing.Wound duration and senescenceWound duration is a recognised indicator for potentially delayed healingin a variety of wound types. This may relate to the development of asenescent cell population (ie a population of cells that is unable toreplicate) in the wound. Henderson has reviewed the potential effect offibroblast senescence on chronic wound healing, looking at theinterrelationship of oxidative stress, pro-inflammatory cytokinegeneration and accelerated telomere degradation23. The author concludesthat although the chronic wound environment promotes senescence, notall cells are uniformly affected23. The ratio of senescent to non-senescentfibroblasts has been linked to healing outcome: an accumulation ofgreater than 15% senescent fibroblasts has been described as a thresholdbeyond which wounds become hard to heal24.Size and de
The third paper, Economic burden of hard-to-heal wounds by Romanelli, Vuerstaek, Rogers, Armstrong and Apelqvist, examines the potential cost implications of hard-to-heal wounds in different countries. The significant economic burden of these complex wounds relates mainly to extended time to healing and to associated complications.
from hard-to-heal wounds. All wounds were located on lower limbs, as per the study’s inclusion criteria. The wounds’ characteristics are listed in Table 3. Overall, 31 wounds were treated with a mean dressing change every 3 days. During the 8-week follow-up, nine
heal wounds, such as venous leg ulcers due to poor circulation, diabetic foot ulcers, and pressure ulcers .1 Hard-to-heal wounds fail to progress through an orderly sequence of repair in a timely fashion .2 Hard-to-heal wounds occur in the general population, but older individuals who are hospitalized or reside in long-term care facilities are .
60%–100% of non-healing wounds. While the role that biofilm play in the chronicity of wounds is still in infancy, it is becoming widely accepted that hard-to-heal wounds contain biofilm — and that somehow their presence delays or prevents healing. Management of biofilm in chronic wounds is rapidly becoming a primary objective of wound care.
wounds inflicted by 1 p HEAL / HARM BASIC POWER COST 15 The Force user bolsters his ally with renewed vigor or saps his foe of vital energy. Heal (Light side Force user only): Spend to heal a number of wound equal to Intellect from an engaged living creature (including user). Harm: Spend to inflict a number of wounds equal
Hard-to-Heal Wounds A wound that has failed to respond to evidence-based standard of care. The concept of wound hygiene is based on the premise that all hard-to-heal wounds contain biofilm. Because of the speed with which wound biofilm forms a wound that exhibits exudate, slough and an increase in
frequent infections and was hard to heal. “They had to clean it out, and they used different products to bring it to a healing stage,” Carol says. “Now they have me on collagen, and that’s helping it heal even better so that’s great. And the staff has been great. They treated me with respect and friendliness, and you couldn’t ask for
Two words, and then a miracle! GOD CAN WORK A MIRACLE THROUGH THE POWER OF YOUR WORDS! OUR WORDS CAN HEAL THE SICK, HEAL A RELATIONSHIP, HEAL SOMEONE’S FAITH, HEAL A ROKEN HEART AND HEAL SHATTERED HOPE! Proverbs 12:18 Reckless words pierce like a sword, but the tongue of the wise brings healing. YOUR
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