Q & A with Cynthia A. Fleck

ICT: Whats the latest and greatest in wound care?

A: Wound bed preparation, including debridement and bioburden control, are mainstays for effective wound healing. Silver dressings continue to be the No. 1 advanced wound care product choice available. These innovative dressings persist in gaining widespread usage, not just for the worst wounds and sites but for safe, broad spectrum prophylaxis of infection and increased healing outcomes across the spectrum of wound care. Perhaps one of the safest and easiest ways for clinicians to combat bioburden (the total population of bacteria, fungus and viruses) within a wound is to utilize ionic silver. Ionic silver can often provide the kick start that a stalled, chronic ulcer needs to begin healing again.

Matrix metalloproteases (MMPs) are structurally related protein-degrading enzymes (proteases) that alter the extra cellular matrix (ECM) during the wound healing process. MMPs control platelet aggregation, macrophage and neutrophil function, cell migration and proliferation, neoangiogenesis, and collagen secretion and deposition. They turn on or turn off matrix proteins, cytokines, growth factors and adhesion molecules. Crucial for the inflammatory phase of wound healing are the same molecules that, when produced in surplus, hinder healing in chronic wounds. Chronic wounds generally have high protease levels (MMPs) and low protease inhibitor levels (TIMPs) compared with acute wounds.¹ Collagen dressings with advanced native collagen and intact triple-helix structures (which gives it the potential to biochemically alter the wound environment); including MMPs and elastase (another detrimental enzyme that can negatively affect a healing wound) provide an answer for difficult- to-heal, chronic wounds. The significance of MMPs and elastase on wounds is that they tend to put a road block on healing by disrupting the extra cellular matrix. They consume the components of healing and if we can keep them busy munching away at advanced collagen dressings, soaking up the MMP, and shutting down elastase by binding and trapping it like a magnet, and providing a jungle gym for fibroblasts to grow and proliferate via their microscaffolding, we can heal these problematic wounds.

Well also see more cost-effective dermal replacements, MMP modulators, as well as other biologics that tackle various issues in the wound bed and surrounding tissue and skin.

A novel, virtually pain-free way to prepare the wound bed is ultrasonic debridement. It allows the clinician to control the amplitude (and thus the level of pain experienced by the patient), therefore increasing the level of precision while having an antimicrobial effect subdermally. It will change the way bedside debridement is performed. These newly available devices offer rapid results, safely and effectively, while providing exceptional granulation with minimal or no bleeding. This technology is being used within inpatient and outpatient clinics throughout the country. This relatively gentle wound bed preparation tool offers hope to patients whose wounds have stalled. This new equipment introduces new options for the necrotic wound.

New innovations in wound odor control using cyclodextrin technology are taking the dressing market by storm. Most odors are lipophilic (oil loving). New dressings that utilize cyclodextrins (same technology as in Proctor and Gambles Febreze®) use a bucket-shaped conformation of the hydrated cyclodextrin molecule to irreversibly capture lipophilic odor molecules, which then neutralizes the odor.² Cyclodextrins occur naturally and are proven safe to use in modern wound care. Newly-available hydrocolloids incorporate the cyclodextrin technology to dramatically reduce the odor, making dressing changes more comfortable for the patient and caregiver.

Pain-reducing dressings that combine silicones for gentle no-stick, pain-free dressing changes, as well as super-absorbent foam materials for greater fluid handling, will continue to expand since quality of life is integral to wound care practice. And, dont overlook other pain-free products like alcohol- free, non-stinging prep wipes to protect the fragile periwound skin from maceration and adhesive stripping. These easy-to-apply copolymers provide protection for the vulnerable epidermis, without the pain and stinging sensation that alcohol- based ones historically created.

Polyacrylate moist wound healing and debriding systems provide quick, simple, safe and pain-free debridment in a trouble-free, user friendly dressing that provides 24-hour simultaneous rinsing and debriding. The dressing is activated by Ringers solution, the most perfect physiologic fluid, and is only changed once per day making it an ideal choice in acute care and can be taught to the family for home care at discharge. Another plus is that this system is the only dressing that does not require wound cleansing, further reducing costs of saline or wound cleansers. In addition, polyacrylate moist wound therapy debrides just as well as collagenase. ³ It provides constant cleansing of the wound bed, removing devitalized material and biofilm, debriding wounds at a mean rate of 38.11 percent per week.^{4, 5}

Just as we require good nutrition to survive, our skin can now be nourished from the outsidein⁶ with advanced nutritional goods. Skin care products containing specific, specially-treated amino acids, antioxidants, MSM (methylsulfonylmethane), a naturally occurring anti-inflammatory agent, and vitamin cofactors can nourish and strengthen the skin providing an insurance policy against skin breakdown and trauma such as skin tears and wounds. These products can not only improve the skins appearance and texture but help build collagen and develop the skins resistance to damage. Advanced skin care products additionally provide high-tech protection due to their ingredients such as quality silicones, like dimethicone, zinc oxide, calamine, and surfactant-free phospholipids cleansers that clean with derivatives of vegetable oil instead of harmful, drying detergents or soaps.

ICT: Are there any new hot topics concerning wound care?

A: Definitely! Palliative issues are gaining recognition with pain management being a top concern. Thank goodness since many barbaric practices were being performed with little or no pain medication or attention to the patients perspective. Patient centered concerns are finally garnering interest with protocols that address these important issues.

Two other big issues relating to wound care include pay for performance (P4P) and the Institute for Healthcare Improvements (IHI) Protecting 5 Million Lives From Harm campaign in hospitals.

ICT: What has been your experience with wound care? Do you have any successful case studies or any unusual stories you can share?

A: There are literally hundreds of success stories or what I like to call, wound care makeovers that would challenge even the best reality TV. One in particular involved a 42-year-old African-American man who had a terrible genetic skin disease called x-linked ichthyosis (fish scale disease). He was diagnosed when he was only 10 months old and suffered the devastating affects (pain, itching, odor, thick, calcified and unsightly skin resembling the bark of a tree) despite seeing dermatologists and other skin care specialists for years. He had become a recluse, working the night shift to avoid contact with the others. He wore long pants and long-sleeved shirts, even in the heat and humidity of Midwest summers. He had become quite depressed as well. A very sad case.

He saw me as a last-ditch effort. I applied a simple skin care regimen that included soap and surfactant-free cleansers that also offered endermic nutrition (externally applied nutritional cleanser); a skin-strengthening cream that had advanced ingredients such as amino acids and a free-radical scavenger called hydroytyrosol; and a moisturizer that contained seven sophisticated silicones that resisted wash-off.

He began using the system religiously and lo-and-behold, he began to have relief! The skin cells slowly sloughed off, he no longer itched or had pain, the odor was gone and he could wear short sleeved shirts. As time went on and I continued to follow up with this gentleman, he made a miraculous recovery and was no longer depressed. He looked like a new man! His condition was not cured, but it was treated and under control.

ICT: What measures have proven most beneficial in minimizing complications during wound care?

A: Getting a certified individual an expert in wound healing involved in the case as early as possible. This is of utmost importance for the best outcomes. These clinicians may be certified by the WOCN (Wound, Ostomy and Continence Nurses Society; CWOCN) or by the American Academy of Wound Care (AAWM) as a certified wound specialist (CWS).

Applying the team approach is the next measure to minimize complications and problems in wound management. Assembling the right group of clinical folks to dictate and manage care is important since wounds are caused by many things and are often best treated by experts in their particular field.

Qualitative and quantitative research demonstrating positive outcomes and the value of comprehensive, multidisciplinary wound care abounds. For instance, in a three-year acute care hospital project, the multidisciplinary wound care teams interventions successfully decreased the admission rate of patients with pressure, venous, arterial, and diabetic foot ulcers from 95 percent to less than 5 percent while improving healing outcomes, quality of life, mobility, and reducing pain.7

In long-term care, a decentralized, multidisciplinary approach to wound care has been effective in reducing the incidence and prevalence of pressure ulcers in geriatric patients.8, 9 In the clinic, a multidisciplinary wound care team eliminated duplication of services, enhanced patient compliance, and increased patient satisfaction and success.10

Due to the complexity of most chronic wounds, it is imperative that a comprehensive, multidisciplinary approach to care be taken in order to adequately address each contributing factor, to optimize care, and to improve outcomes. Synergy develops from cross disciplinary care resulting in improved outcomes, according to the AAWCs Statement on Comprehensive Multidisciplinary Wound Care.11

ICT: What is the single most overlooked aspect concerning wound care?

A: I believe its not treating the host first or expecting a wound to heal thats connected to a sick individual. Underlying diseases such as diabetes mellitus, lower extremity arterial disease (LEAD), venous hypertension and insufficiency, malnutrition, and poor mobility, can cause chronic wounds to stall. Oftentimes taking a holistic view of the patient and giving their body a tune-up can assist the bodys natural healing ability. For example, the wound cannot heal if it doesnt have the oxygen and nutrient delivery system (arterial blood flow). This is one of the first things I inquire about when I consult on a case.

Another concern is chronic wounds with sub-clinical infection. Not all wounds that are critically colonized have the clinical signs and symptoms of classic infection and we can miss this and not treat it. I use a lot of ionic silver in my practice. Ionic silver gels and calcium alginate/CMC combinations are two of my favorites. They are safe, have no known resistance in nature, and assist in wound bed preparation by bringing the bio-burden into check while providing an optimally moist wound healing environment.

ICT: Do you have any pointers/best practices for infection control teams on how to implement a solid course of action/ improved standard of care concerning wound care in their facility?

A: I find that keeping it simple helps clinicians understand the importance of infection control issues. Since we cant see microbes, they are sometimes forgotten. Asking ourselves, Whats in it for them? In other words, how does infection control affect clinicians and their world? For example, they wouldnt want to take a case of MRSA home to their children or become infected themselves.

Hands continue to be the biggest culprit for spreading the transmission of MRSA. When I lecture or educate clinicians, I use the analogy that their hands are probably dirtier than their toilet seats. That usually gets some gasps! We have to make sure that we are offering the right products along with the right programs (education campaigns, etc.). If your facility is using harsh soaps that strip the epidermis of its protective mechanism, a vicious cycle begins with the hands drying, becoming uncomfortable, cracking and causing the user to avoid the cause, washing their hands. I recommend good quality hand creams available right next to the wash basin in every room. Having staffs involvement in choosing these products is paramount since it is a very personal situation.

There are also some incredible gloves available too. One in particular offers a spa treatment of aloe vera extract that is released by the warmth of the hand each and every time gloves are donned.

The skin is moisturized and hydrated, keeping it soft and healthy. Healthcare professionals are quite familiar with the frustrations of dry and irritated skin that results from frequent glove use and hand washing. These new gloves offer a soothing solution to the age old issue that healthcare workers face on a daily basis.

Staff compliance sky rockets when skin is cared for and they feel protected. Institutional programs and staff participation is imperative to make all this information stick. In the wound care arena, a key factor that is often neglected is if supplies made contact with the client or an infected surface, they must be cleaned and disinfected before use on the next patient. Supplies should be kept to a minimum. In my practice, I recommend that each patient have their own supplies in his/her room. This way, were not cross-contaminating with hidden vectors like community bandage scissors for instance.

Cynthia A. Fleck, MBA, BSN, RN, ET/WOCN, CWS, DNC, DAPWCA, FCCWS is a certified wound specialist and dermatology advanced practice nurse. Her expertise has thrust her into becoming a writer and speaker on the topic of wound care. Fleck is president-elect of the American Academy of Wound Management (AAWM), member of the board of directors of the Association for the Advancement of Wound Care (AAWC), and diplomat of the American Professional Wound Care Association. She is vice president of clinical marketing for Medline Industries, Inc., Advanced Skin and Wound Care, based in Mundelein, Ill.

References

1. Fleck CA. Differentiating MMPs, Biofilm, Endotoxins, Exotoxins, and Cytokines. Advances in Skin and Wound Care 2006;19(2):77-81.

2. Fleck CA. Beyond Band-Aids, Advance for Providers of Post-Acute Care, March/April 2006.

3. Konig, et al. Enzymatic versus autolytic debridement of chronic leg ulcers; a prospective randomized trial. Journal of Wound Care; 14(7), July 2005.

4. Paustian C. Debridement rates with activated polyacrylate dressings. Ostomy Wound Management 2003; 49(Suppl 1):2.

5. Bruggisser R. Bacterial and fungal absorption properties of a hydrogel dressing with a super absorbent polymenr core. J Wound Care; 14(9), October 2005.

6. Fleck CA and McCord D. The Dawn of Advanced Skin Care. Extended Care Product News 95(5): 32, 34-39, September 2004.

7. Jaramillo O, et. al. Practical guidelines for developing a hospital-based wound and ostomy clinic. Ostomy Wound Manage. 1997;43(4):28 39.

8. Granick MS, Ladin DA. The multidisciplinary in-hospital wound care team: two models. Adv Wound Care. 1998;11(2):8083.

9. Long CD, Granick MS. A multidisciplinary approach to wound care in the hospitalized patient. Clin Plast Surg. 1998;25(3):425431.

10. Ratliff C, Rodeheaver G. The chronic wound care clinic: one-stop shopping. J Wound Ostomy Continence Nurs. 1995;22(2):7780.

11. Association for the Advancement of Wound Care (AAWC). Statement on Comprehensive Multidisciplinary Wound Care, 2005. Available at: www.aawcone.org/start1.htm. Accessed 2-20-07.