Wound care
The five-stage infection continuum Stage 1: Contamination
All wounds have micro-organisms, which will not grow and proliferate in an non- conducive environment.
Stage 2: Colonisation
Micro-organisms successfully grow and divide but they don’t cause wound infection or any harm.
During the first and second stages, no antimicrobials are required but vigilance is recommended.
Stage 3: Local infection Covert and overt signs and symptoms occur in and around the wound. Early intervention is crucial and topical antimicrobials are indicated.
Stage 4: Spreading infection Worsening local symptoms and more general signs of wider infection develop.
Stage 5: Systemic infection
The original infection spreads through the whole body, and can lead to sepsis, organ damage and death.
During the fourth and fifth stages, systemic and topical antimicrobials are needed. Weighing up
As the BNF guidance suggests, though evidence of local wound infection can help guide clinicians in their choice of treatment, it is far from a simple measure. Infections progress along a scale from mild to severe, with clinical signs and symptoms changing accordingly.
Antimicrobial dressings can be used as a preventative measure.
This progression is represented by a five-stage ‘infection continuum’ that runs from contamination and colonisation through to local infection, where topical antimicrobials become necessary, all the way to spreading and systemic infections, when systemic antimicrobials are also needed.
That’s not all. Clinicians must consider a range of other factors in deciding treatment pathways and appropriate dressings. “We look at the patient’s history and use a holistic approach because it’s important to consider risk factors,” Schofield says. “For example, a diabetic patient with a foot wound might also have neuropathy and have no feeling in their feet. So, they will likely not display signs of infection in the same way as other patients. As a clinician, I would weigh up whether it’s better to use antimicrobial dressings as a preventative measure, or to wait until there are overt signs of infection.” Antimicrobial stewardship is a growing priority in healthcare settings, so the expertise of clinical specialists like tissue viability nurses (TVNs) increasingly comes into play when biologic dressings are an option. Work on understanding antimicrobial resistance and stewardship in the context of wound management is ongoing. That work is made more difficult because dressings are typically classified as medical devices, so there is often a lower evidence-quality threshold for their approval than for medicines. As a result, randomised controlled trials (RCTs) of these products tend to be of poorer quality, and it is argued that NHS procurement fails to give adequate weight to other types of evidence, including that gathered during product assessment, as well as evidence and recommendations from expert groups.
Local and national variations in procurement practices, formularies and treatment frameworks contribute to wide disparities in services and care. With so many knowledge gaps, the expertise of TVNs is particularly important in assisting with dressing selection. The National Wound Care Strategy Programme (NWCSP) is working towards developing a national strategy for wound care across England to address disparities and support clinicians, focusing on limb ulcers and wounds.
It has produced recommendations for healthcare professionals drawing on evidence from recognised, widely used sources like NICE, Public Health England and the WHO. Interestingly, according to the NWCSP, there is no definitive evidence favouring a particular type of dressing type over another for lower limb wounds, or to manage surgical wounds and prevent infection at the wound site. If anything, that makes the expertise of individual TVNs and doctors even more important. “Tissue viability nurse specialists have the knowledge and access to all the best-practice statements, consensus documents and published guidance,” Schofield concludes. “The ultimate decision is the clinician’s, whose individual preference will be based on their own experience and patient feedback.”
42 Practical Patient Care /
www.practical-patient-care.com
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