Orchestrating Wound Healing: Assessing and Preparing the Wound Bed

Advances in Skin & Wound Care, Sep/Oct 2003 by Hess, Cathy Thomas, Kirsner, Robert S

PURPOSE: To provide an overview of the steps needed to prepare the wound bed for healing.

TARGET AUDIENCE: This continuing-education activity is intended for physicians and nurses with an interest in learning about the process for preparing the wound bed for healing.

LEARNING OBJECTIVES: After reading the article and taking the test, the participant will be able to:

1. Describe the anatomy and physiology of the skin.

2. Describe the wound healing process, the local and systemic factors that may impair healing, and the parameters that assess the wound status.

3. Describe the steps in the process to prepare the wound bed for healing.

The incidence and prevalence of chronic wounds in the United States have risen to epidemic proportions. Consider these statistics:

* Approximately 1% of the general population and 3.5% of people older than age 65 have venous leg ulcers, and the number is rising as the population ages.1 Recurrence of venous ulcers is high, approaching 70%. The estimated per-episode cost of care for venous ulcers can exceed $40,000. If it is estimated that 2.5 million Americans have venous ulcers, the total cost of treatment is believed to be approximately $2.5 to $3.5 billion.1 As many as 2 million workdays per calendar year are lost due to chronic venous ulcers.1

* Approximately 17 million people in the United States have diabetes, with over 1 million new cases diagnosed in 2000.2 In addition, another 16 million have a condition known as prediabetes, an elevated blood glucose level that puts them at risk for type 2 diabetes.3 Of the 17 million people with diabetes, 15% will develop at least 1 foot ulcer.4 Between 56% and 83% of the estimated 125,000 lower extremity amputations performed annually can be directly attributed to diabetes.5 Once a person has an ulceration, he or she is likely to develop others, as the leading risk factor for ulceration is a previous ulceration.

* The number of people in the United States with pressure ulcers is unclear. A monograph on pressure ulcer incidence and prevalence from the National Pressure Ulcer Advisory Panel6 found a wide range of reported rates, often varying by practice site: incidence, 0.4% to 38% in general acute care; 2.2% to 23.9% in long-term care; and 0% to 17% in home health care; prevalence, 10% to 18% in general acute care; 2.3% to 28% in long-term care; and 0% to 29% in home health care. These data should be viewed with caution, however, as variations in staging definitions, data sources used, and methodologies make it difficult to compare studies. The best estimates suggest that 2.5 million pressure ulcers are treated annually among hospitalized patients, with total annual costs of hospital-acquired pressure ulcers estimated at $2.2 to $3.6 billion.7 These figures do not include costs for pressure ulcers that develop in other care settings.

Other types of wounds may add to the total chronic wound population, including wounds related to antiphospholipid syndrome, arterial insufficiency, cryofibrinogenemia, cryoglobulinemia, homocystinemia, infection, pyoderma gangrenosum, and sickle cell disease, as well as factitial ulcers, traumatic wounds, surgical wounds, and vasculitic ulcers.8

The numbers tell only part of the story. Chronic wounds exact an emotional toll from the patient and his or her caregivers as well.

After decades of published clinical practice guidelines, research results, and documented best practices for wound care, one has to ask: Why are there so many chronic, nonhealing wounds?

Over the past several years, researchers have begun to define a multistep process necessary to reverse the chronicity of wounds and move them toward healing. This process-called wound bed preparation-can be thought of as "the global management of the wound to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures."9 Employing the strategies that are the foundation of wound bed preparation can accelerate the healing process and/or maximize the topical management and ancillary services for wound caring.

DEFINING THE CHRONIC WOUND

A chronic wound can be defined as an insult or injury that has failed to proceed through an orderly and timely repair process to produce anatomic and functional integrity, or has proceeded through the repair process without establishing a sustained anatomic and functional result.10 The patient with a chronic wound generally presents with a host of factors that impede the healing process. For example, chronic diseases, such as diabetes, vascular insufficiency, and autoimmune diseases, may inhibit the wound from healing in an organized fashion. Therefore, performing a comprehensive patient assessment is the essential first step toward healing the chronic wound.

PERFORMING A COMPREHENSIVE PATIENT ASSESSMENT

The comprehensive patient assessment begins with a one-on-onc discussion with the patient or caregiver and other professionals who have cared for the patient's wound. Understanding the patient's past and current family, social, and medical history may provide important insight into why the wound is not healing. As a guideline, the clinician would: