Wound care
As such, when choosing the most appropriate dressing for a wound, focusing on purchase price is short-sighted and can potentially end up costing more. For example, a cheaper dressing might be less effective, delay healing and need to be changed more frequently. In acute settings, this could mean patients spend longer in hospital, making their care more expensive and potentially riskier than it would be otherwise.
Biologic wound dressings in particular are designed to help restore patients’ interrupted wound repair mechanisms. They comprise active biological agents with antimicrobial (including honey, silver and iodine), antioxidant (like N-acetylcysteine, curcurmin or hyaluronan) or anti-inflammatory attributes (such as hydrocolloid, hydrogel or foam dressings). These attributes help prevent the loss of heat, protein, electrolytes and water from the wound, as well as lowering the risk of contamination. They also promote wound debridement through autolysis – the breakdown of cells or tissues by their own enzymes – and create a granular wound bed, the presence of which indicates the wound is progressing from the inflammatory to the proliferative healing phase.
The right choice
While some dressings release the biological agent into the wound – like those containing silver and honey – others work by absorbing bacteria from it first. However, for these high-tech dressings to make a difference, clinicians need to understand when and where to use them. Alison Schofield, tissue viability team lead and clinical nurse specialist at North Lincolnshire and Goole NHS Foundation Trust, explains that the first thing to consider when choosing a dressing is wound assessment. “As specialists in wound care, we have the knowledge and expertise to be able to apply the best practice guidance, and to educate general clinical staff on what to look for,” she says. According to the 2016 National Institute of Health and Care Excellence (NICE) ‘Chronic wounds: advanced wound dressings and antimicrobial dressings’ evidence summary, the factors that should be considered when selecting a dressing include the stage of wound healing, the amount of exudate, the presence of an infection and the wound odour.
But wound care is about more than the wound itself. It’s also important to consider a dressing’s adhesiveness and ease of removal, as well as the potential for the adhesive to cause irritation. Absorption, ease of use, protection of the surrounding skin, and the frequency and discomfort of dressing changes are also important factors, as, of course, is patient preference. Schofield explains that the TIMES principle is typically used
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The TIMES principle
T – Tissue The overall appearance of the wound bed is key in determining how healthy the tissue is and whether debridement is required. Devitalised tissue encourages microbial growth and should be removed. I – Infection/inflammation Bacteria can multiply and cause infection, slowing healing and increasing pain and exudate. In the absence of clear infection, biofilm can also delay healing. M – Moisture If excessive or, conversely, deficient moisture levels are evident, moisture balance may be needed to protect the skin surrounding the wound and optimise healing. E – Edge of wound Rolled edges around a wound, or lack of new, healthy tissue at the wound edge suggests impaired healing. S – Surrounding skin Examination of the skin surrounding the wound is important in the management strategy; addressing its condition can minimise the potential for infection and inflammation.
to help decide whether a biologic dressing is appropriate for a particular patient –and wound. The acronym was coined to summarise clinical considerations in effective wound bed preparation and stands for tissue, infection/inflammation, moisture, edge of wound and surrounding skin. Useful as it may be, the TIMES protocol is not an exact science, so it relies heavily on the clinician’s expertise. The British National Formulary (BNF) gives further guidance on how to match infection characteristics to specific biological wound care products. As such, it advises that a topical antimicrobial dressing can be used to reduce bacteria levels at the wound surface but that won’t stop an infection that’s spreading. It also notes that medical-grade honey can be used if antimicrobial and anti-inflammatory properties are indicated, while iodine dressings can be used to treat clinically infected wounds. Dressings containing silver should only be used when clinical signs or symptoms of infection are present. Dressings containing other antimicrobials, like polihexanide or bacteria-binding dialkylcarbamoyl chloride, can be used on wounds in a similar way.
The specific wound dressing depends on the stage of healing.
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