|
INSIDE THE CURRENT ISSUE |
|||||||||||||
|
Infection Connection |
|
||||||||||||
|
Charting a wound care course by Susan Cantrell, ELS H ealing a surgical wound has a lot in common with that expression about it taking a village to raise a child. To be successful, it often takes more than one means of care, and that care must be tailored to the individual’s needs. Sometimes a little—and sometimes a lot—of help is needed, depending on the circumstances. It takes an understanding of the forces at work in the background. It takes attention to detail. And it takes understanding how different aspects of care are interwoven to achieve the goal.Healthcare Purchasing News talked to professionals in the wound-care industry about the complex issue of caring for surgical wounds. We’re also treated to a glimpse of the direction wound care is taking in the future. Controlling the flow Perhaps the foremost point to consider is stopping the flow of blood. If the patient loses too much blood during surgery, no wound-care product is going to help, no matter how good it is.
Uncontrolled bleeding is a potential danger inherent to surgery, and of course some patients are already experiencing profuse bleeding due to trauma upon admission to the hospital. Operating room staff now can take advantage of technology originally designed to control high-pressure arterial bleeding from wounds incurred in the battlefield. HemCon dressings (HemCon Medical Technologies, Inc, Portland, OR) contain chitosan, derived from shrimp shells. Chitosan has a couple of properties that make it a natural for stanching blood flow quickly: it is adherent; it has a negative charge, whereas red blood cells have a positive charge, so chitosan and red blood cells are attracted to each other. These properties work together to form a tight bioadhesive seal against hemorrhaging within minutes. "When HemCon dressings come in contact with blood, they become adherent, sealing the wound, attracting red blood cells, stopping the bleeding independent of the patient’s own ability to clot," explained John Morgan, CEO. "HemCon bandages work even when the patient is on anticoagulant therapy." A major bonus is that HemCon bandages are naturally antibacterial, protecting wounds from exposure to infection. Chitosan disrupts the cell wall of bacteria, causing its contents to spill out. The cell collapses and dies before it can do damage. Another huge advantage of HemCon bandages is that there is no need for debriding the wound after use. Debriding can be painful, and can cause breaches in the skin’s integrity that invite infection. "Chitosan is a naturally occurring material that breaks down to benign substances in the body. With many products, the wound needs to be debrided or cleaned afterward, but that isn’t necessary with use of chitosan," said Morgan. Addressing the concern over the danger of a reaction in a shellfish-allergic patient, Morgan noted, "we’ve shipped over 1 million bandages and have not had even one reportable adverse event. We’ve done testing and found that even those with known shellfish allergies were nonreactive. The protein and iodine in shellfish are what cause an allergic reaction, and most of it has been removed. It’s a very safe product." A number of things are in the pipeline for HemCon explained Morgan. "We’re developing the next phase of our technology, which will be a fully implantable, fully bioabsorbable version of our hemostatic bandage. We expect it to be available next year. Later this year, we’ll be launching a temporary surgical bandage, with the same characteristics, that will be used internally but removed before closing the patient. We also have coming an acute advanced wound bandage that, by means of nanotechnology, can combine a variety of materials into a single device, which can be tailored to address specific requirements of a particular wound. We hope to submit it to the Food and Drug Administration (FDA) at the end of this year. The company also released HemCon bandages for over-the-counter sales, called KytoStat, last month." To see how HemCon dressings work, go to www.hemcon.com/EducationCenterHowHemConDressingsWork.aspx The cover up
Surgical sites are at risk of becoming infected. Covering a surgical incision can pose a barrier to infection and provide an environment that promotes healing. A good bandage or dressing may reduce or eliminate the need for antibiotics. Bandages and dressings that can be left in place for several days save money, by consuming less nursing time and by reducing the number of dressings used; reduce trauma to the wound; and create less discomfort for the patient when removed. "As a response to the very real problem of patient trauma and pain experienced during dressing changes, Mölnlycke developed a soft-silicone technology called Safetac," explained Rachel Savage, brand manager, Mölnlycke Health Care, Norcross, GA. Our dressings that feature Safetac do not adhere to the wound bed, yet adhere gently to the surrounding skin, which minimizes trauma and pain upon removal." Mölnlycke Health Care recently launched two new surgical-wound—care products, Mepilex Border Post-Op and Mepilex Ag. "Mepilex Border Post-Op is a self-adherent, soft-silicone, bordered, foam dressing designed for surgical incisions. It is waterproof and bacteria-proof, and it absorbs moderate to high amounts of exudate. The Safetac layer will not adhere to sutures or incision sites, reduces the risk of maceration, and maintains a moist wound environment conducive to healing," said Savage. For infected wounds or those wounds with a high risk of infection, a dressing impregnated with an antimicrobial agent may be the answer. Savage explained how Mepilex Ag performs: "Mepilex Ag is an antimicrobial, soft-silicone, foam dressing that absorbs exudate and maintains a moist wound environment. Mepilex Ag begins inactivating wound-related pathogens, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus, within 30 minutes of application to the wound, with sustained effect up to 7 days. It is designed for a wide range of exuding wounds, such as leg and foot ulcers, pressure ulcers, and partial-thickness burns. It may be worn for up to 7 days."
Closing a wound after surgery also can contribute to the potential for infection, because bacteria can cling to needles and sutures as they are worked in and out of the skin. 3M has an answer to the problem with its Steri-Strip S Surgical Skin Closure, a non-invasive, adhesive-based device designed to close low-tension surgical incisions or lacerations. Benefits of 3M Steri-Strip S include: Fast application, good cosmetic results, precise wound-edge alignment and approximation, less potential for infection than sutures and staples, and it helps limit tissue trauma and patient discomfort. Skin regeneration Diabetics notoriously have difficulty in healing. If a wound has progressed to the point where there is necrotic tissue in need of surgical debridement, the patient is in jeopardy of experiencing complications such as infection and major tissue loss. A study by Hanft and Surprenant states: "Over 16 million people in the United States suffer from diabetes mellitus. Foot ulcers are among the most serious complications associated with diabetes."1 David Eisenbud, MD, founder of
Advanced
BioHealing, La Jolla, CA, advised: "Every day a diabetic wound is open,
there is the risk of infection, which is the most frequent harbinger of
amputation. Each year, 80,000 diabetics undergo lower extremity amputation;
so, it’s important to achieve wound
Advanced BioHealing’s skin-regeneration product, Dermagraft, is approved by the FDA to claim acceleration of wound healing. It’s one of only a few wound-care products containing living, functioning human cells. The Wound Healing Society recommends "living skin equivalents . . . releasing therapeutic amounts of growth factors, cytokines, and other proteins that stimulate the wound bed" as a treatment that may be of benefit in healing diabetic foot ulcers." 2Eisenbud explained how Dermagraft works: "Human cells are grown on lattice-work comprised of dissolvable sutures. As the mesh dissolves, human cells are left behind. Dermagraft is placed on the wound, where it secretes collagen, matrix proteins, growth factors, and cytokines that grow and divide in the wound to create human dermal tissue. For optimal results, Dermagraft should be applied once per week. The old application is not removed; the new is applied on top of the old." Is it expensive? Well, that depends on how you look at it, said Eisenbud. "Dermagraft costs $1,500 per application, but the cost-effectiveness comes from its ability to prevent wound infections, hospitalizations, and amputations. Compared to the costs and non-economic consequences of losing a leg, a series of weekly Dermagraft treatments is a bargain." Advanced BioHealing continues to employ the science of regenerative medicine to enable improvements and new products. "Among products in our clinical trial pipeline is Celaderm, which a lay person might consider an artificial skin graft, to treat venous leg ulcers," said Eisenbud. "In the near future, we may use techniques of gene modification to enhance the efficacy of our cell-based wound products." Negative pressure, positive results
Another option in wound care is Negative Pressure Wound Therapy (NPWT), an adjunctive wound treatment that involves the application of a controlled level of sub-atmospheric pressure to a wound at 50 mm Hg to 175 mm Hg. The FDA has approved NPWT for the treatment of nonhealing chronic, acute, traumatic, subacute, and dehisced wounds; diabetic ulcers; pressure ulcers; flaps; and grafts. It is especially appropriate for highly contaminated wounds and those with moderate-to-heavy exudates. NPWT promotes wound healing by clearing edema fluid and bacteria; improving moisture balance; increasing blood flow and stimulating cell growth and tissue formation. Two new NPWT options from Smith & Nephew include the EZCARE system and the VISTA portable system. Unlike other NPWT systems, EZCARE and VISTA use gauze instead of foam and are effective at lower pressures, thus reducing costs, improving clinicians’ efficiency and causing less discomfort to patients. Simple – and less frequent dressing changes take less nursing time and are easy to teach and learn. The EZCARE and VISTA systems operate at a pressure of less than 80 mm HG compared to many other NPWT systems that operate at 120 mm HG. This provides gentler and more comfortable treatment for patients and helps reduce their need for pain medication. It can also decrease the risk of periwound tissue damage and other complications. The saline solution Keeping surgical wounds clean is a task that can be made easier and faster with the right product. Health Care Logistics (Circleville, OH) distributes Saljet, sterile saline in a unit dose. Saljet is a product of Winchester Laboratories, LLC, St. Charles, IL. Annett Rose, vice president, sales and marketing, Winchester Laboratories, observed: "Most postoperative wounds require dressing changes and cleansing to aid recovery. The agent of choice by most physicians is sterile saline, sometimes called ‘normal saline’ (0.9% w/v). Saljet is a 30-mL unit-dose container of sterile saline. Twist off the top and squeeze to obtain a directable jet of saline. Saljet is sterile every use; the vial cannot be recapped after use."
"Traditionally, nurses use a large volume container of sterile saline," explained Rose, "pouring some into a sterile basin and using a 30-mL sterile syringe to obtain some pressure for cleaning the wound. The large volume container can be used more than once on the same patient in a 24-hour period, but this does not represent best practice." Rose suggested that the Saljet vial be warmed before using, in a scrubs pocket or in the patient’s hand, so the saline is not cold when coming into contact with the wound. "Cold has been shown to slow down the healing process of wounds." "Unit-dose supplies are the future," averred Rose, "Unit-dose products offer best practice, thereby ensuring that wounds heal quickly and cleanly, enabling patients to return to their normal environment as quickly as possible". Holistic healing Because managing patients involves many aspects of care, Jeff Kao, president for North American acute care, Hill-Rom, Batesville, IN, believes it’s important to "think holistically when caring for patients. The healing process happens in a holistic environment. The intersection of our industry and patient treatment goes beyond a surface or a single device. We’re going through a transformation in the way we think about how care is given. We now think of wound care and surfaces in connection with information technology (IT). Informatics needs to be front and center, so we seamlessly integrate informatics into our bed frames and surfaces and into the IT infrastructure of the environment for better patient care. Hill-Rom led the way in managing patient flow through IT with NaviCare Patient Flow Solutions."
"Hill-Rom is very focused on patient safety, including preventing pressure ulcers and infection," continued Kao. This month marks the introduction of nano Ag+ with Smart Silver Technology, Hill-Rom’s latest technological development in surfaces. "We’re working with nano-technology and ionic silver. We’ve coated the weaving of the mattress ticking with nanoparticles of silver, to eliminate bacteria associated with infections in surgical wounds and pressure ulcers. This manufacturing process allows the silver nanoparticles to last the entire lifecycle of the product. Our goal is to keep the surface as infection-free as possible. As providers of technology, we have a responsibility to the patient, pre- and post-surgery," stated Kao. Hill-Rom’s surfaces are adaptable to the patient’s weight and medical condition, and deliver a microclimate that ensures patient comfort and an environment conducive to wound healing. "The integrated IT platform is the best of industrial technology. Temperature, moisture, material, all these components are integrated to create an adjustable microclimate control to create the best healing environment for the patient," explained Kao. Kao also noted that the patient’s underlying health conditions can present unique challenges to healing. "Patients often have multiple conditions with a variety of complications such as hypertension, obesity, noncompliance, and diabetes. We also see that obese patients are the fastest growing segment. Bariatric patients present a safety issue for staff. Just turning them is a complex problem. Keeping their skin dry can be difficult. Technology and informatics can help caregivers take care of patients in challenging settings." Hill-Rom has been working with the Ascension Health system (St. Louis, MO) to reduce the rate of pressure ulcers at their hospitals. Ascension Health took two major steps to lower their rate: implementing a single, systemwide set of practices and standards, and putting in new bed frames and surfaces that help to reduce the potential for development of pressure ulcers. As a result, Ascension Health notes in its annual report that its average rate of facility-acquired pressure ulcers is now 93% lower than the national rate: 1.29 per 1,000 inpatient days, compared to the national average rate of 18.14 to 21.17 per 1,000 inpatient days. 3Charting the path Exciting things are happening in the wound-care arena. The bank of options is growing. Technological innovation is taking a front seat. The timing for this progress is great, because surgical-wound care and its attendant products may soon be receiving more attention with the coming changes in reimbursement for preventable adverse events. 
References 1. Hanft JR, Surprenant MS. Healing of chronic foot ulcers in diabetic patients treated with a human fibroblast-derived dermis. J Foot Ankle Surg 2002;41:291-299. 2. Steed DL, Attinger C, Colaizzi T, Crossland M, Franz M, Harkless L, et al. Guidelines for the treatment of diabetic ulcers. Wound Rep Reg 2006;14:680-692. 3. Ascension Health. Realizing our vision: 2007 Ascension Health annual report. www.ascensionhealth.org/about/2007_Annual_ Report.pdf.  |
