I-Flow’s ON-Q SilverDressing delivers extra protection against infection

Surgical-site infections (SSIs) and bloodstream infections (BSIs) represent some of those complications. Infected surgical wounds or catheter sites delay recovery and rehabilitation. When that happens, nobody is happy, not the patient, not the caregivers, not the administrators. Healing that is delayed is healing that carries extra costs. Morbidity and mortality come at a high price in more ways than one.

Caring for wounds has never gotten so much (well-deserved) attention. Trends in wound-care practices and products are driven by a number of matters: the recent changes in Centers for Medicare & Medicaid Services (CMS) reimbursement, mandatory reporting of infections, new technology, an aging population, and cost management, just to name a few.

Terry Bromley, business unit director, negative-pressure wound therapy (NPWT), ConvaTec, Skillman, NJ, explained how some of these issues have influenced trends in caring for postsurgical wounds. "In our experience, postsurgical wound care has been growing in total volume and sophistication as more advanced therapies have been used to treat greater numbers of patients with more complicated issues. Changing demographics and a greater appreciation of the cost-effectiveness of more advanced dressings and therapies are two key factors."

Edward Armstrong, vice president, advanced wound devices, Smith & Nephew, St. Petersburg, FL, named some trends his company has been seeing as they work closely with clinicians "to understand the issues and challenges they face, so that we can deliver products and services that meet their needs." Armstrong noted that, in recent years, "clinicians are focusing on (1) technologies that speed up postsurgical recovery time, so that patients spend less time in the hospital; (2) technologies that reduce the risk of perioperative infection, therefore minimizing complications; and (3) technologies that improve clinical results." He added that these trends "are driven by heightened attention to managing cost. Clinicians, in addition to administrators, are selecting therapies, procedures, and technologies that reduce cost and improve the economics of therapeutic care. We anticipate these trends to be influential well into the foreseeable future."

As with so many aspects of patient care these days, the recent changes in CMS reimbursement practices have focused heightened attention on caring for postsurgical wounds. Brian Dowd, global marketing director, advanced wound care, Covidien, Mansfield, MA, expounded: "Postsurgical wound infections continue to be challenging, so much so that, effective October 1, 2008, CMS made changes in reimbursement for postoperative mediastinitis after coronary artery bypass graft surgery, as well as SSIs following orthopedic procedures and bariatric surgeries."

3M Tegaderm Matrix Dressing with PHIT technology is designed for hard-to-heal wounds

The CMS changes highlight the importance of using best practices and evidence-based decision making. This was emphasized by Jack McMaken, president of AcryMed, Beaverton, OR, a wholly owned subsidiary of I-Flow, Lake Forest, CA: "Certainly one of the trends is to use practices and products that will help reduce the incidence of post-op SSIs. This is helped in part by the recent CMS emphasis on not reimbursing for ‘never events,’ such as some types of hospital-acquired infections."

Private insurers are beginning to adopt the CMS changes in reimbursement for certain hospital-acquired infections, too, noted Nadine Nakazawa, president, Association for Vascular Access, Herriman, UT: "There is a strong trend toward zero tolerance for catheter-related (CR) BSIs. Many experts now feel these dangerous infections can be dramatically reduced with appropriate technologies and protocols. CMS no longer reimburses for CR BSI-related expenses, and private insurers are following in its tracks. A number of states are also requiring mandatory reporting of hospital infection rates."

As a way of managing the impact of CMS changes on the hospital’s finances, healthcare givers are becoming even more conversant on the finer points of advanced wound care. Rachel Savage, senior brand manager, Mölnlycke Health Care, Norcross, GA, connected the dots between advanced wound care and cost management. "Clinicians are acutely aware of the risks of postoperative infections and are becoming more familiar with the dressing options available. The cost of a postoperative infection or complication can be staggering and may include antibiotic treatment, longer or return hospital stays, increased nursing time, and subsequent surgery. This strains our critical healthcare resources and increases stress levels for patients. If any of this can be avoided by use of advanced wound-care dressings postoperatively, we can achieve a more proactive approach to patient care, reduced rates of infection, and decreased healthcare costs."

Molnlycke’s Mepilex Ag is a silver-impregnated, soft silicone foam dressing

Industry continues to respond to the needs of patients and healthcare givers with an ever-expanding portfolio of advanced wound-care products. Armstrong talked to Healthcare Purchasing News about their NPWT product. "Smith & Nephew launched the RENASYS Negative Pressure Wound Therapy systems in the United States earlier this year. The systems are designed to be used with both the foam and gauze wound interfaces. RENASYS allows clinicians to use variable pressure control and enables clinicians to treat surgical, traumatic, or chronic wounds. Smith & Nephew has developed a customer education program for the RENASYS systems. The program includes on-site support and on-call assistance, a 24-hour helpline for technical and clinical questions, and an ongoing education and training program. With our partners, Universal Hospital Services and Apria Healthcare, we have the largest NPWT distribution channel in the United States and can support clinicians and patients with the use of our NPWT systems wherever needed."

ConvaTec also has added a new NPWT system to their product line, noted Bromley: "We are very excited about our newest addition to the ConvaTec portfolio, the Engenex Advanced Negative Pressure Wound Therapy System with Bio-Dome Technology. The components of this system were designed specifically for the application of negative pressure. Our proprietary Bio-Dome EasyRelease dressings are designed to minimize tissue disruption, bleeding, and pain upon dressing removal. The Engenex WoundFlo Therapy Unit provides subatmospheric pressure to the wound and compliant-hours monitoring. This proprietary monitoring system tracks hours of therapy delivered and is linked to our ‘pay for compliance’ system of hourly billing, which may provide a cost-savings compared to daily billing models."

RecoverCare chose Prospera to distribute its NPWT devices. The Prospera PRO-I is an NPWT pump that allows for immediate adaptation and customization of pressure intensity, treatment duration, and treatment intervals. Other features and benefits include near-silent operation, which means the patient may sleep bet-ter; comprehensive alarm systems; multiple canister positions; a lock-out feature; variable-pressure therapy; continuous-pressure therapy; optional battery operation; and keypad operation. It’s lightweight; reduces pain during use and during dressing changes; puts the clinician in control of negative-pressure settings and modalities; and allows the patient or clinician to turn off the pump if there is an alarm that cannot be attended to immediately. The moist antimicrobial dressing protocol means the patient may be disconnected from the pump for up to 48 hours, depending on amount of exudate, without danger of infection. For more information go to http://www.prospera-npwt.com/product_1.htm or http://www.recovercare.com/pdf/NPWT_Introduction.pdf.

ConvaTec’s Engenex advanced negative-pressure wound therapy system

Dowd provided news on Covidien’s latest offering: "Covidien has been selling the Kendall AMD antimicrobial postoperative dressings (Kerlix AMD, Telfa AMD, and Curity AMD) for years with tremendous results. We recently launched Kendall AMD antimicrobial foam dressing, which is used for chronic wounds as well as surgical wounds with significant drainage. Later this summer, we will be introducing the Kendall AMD antimicrobial foam discs, designed to help protect central venous catheters, peripherally inserted central catheters, and pin sites from bacteria." Dowd explained that hospitals using the Kendall AMD antimicrobial dressings as part of an infection control plan have reduced their infection rates with great success. "The reductions range from 24% to 91%. With the average cost of an SSI to the healthcare system estimated to be over $25,000, hospitals’ net savings could exceed $500,000. A recent article1 showed that, with Kendall AMD dressings used as an intervention, overall, hospital infections were reduced by 24% and the instance of methicillin-resistant Staphylococcus aureus (MRSA) infections dropped by 48%. The hospital saved over $400,000."

Mölnlycke Health Care also answers needs voiced by clinicians by offering a wide range of postoperative dressings, according to Savage. "What we hear from clinicians is that they have a number of varying objectives: keep moisture and bacteria out of incision sites, use silver up front to prevent infection, especially from going to the bone; decrease patient pain; and decrease skin stripping—skin breakdown can lead to further infection."

Smith & Nephew RENASYS GO for the mobile patient

Smith & Nephew RENASYS EZ for acute care

"One of our more sophisticated dressings is Mepilex Border with Safetac technology," continued Savage. "The Mepilex Border and Mepilex Border Lite dressings have a moisture- and bacterial-proof backing film. They are easy to apply and painless to remove, which reduces valuable nursing time spent on dressing changes. The longer wear time decreases the overall cost of post-op dressings. Because these products with Safetac technology mold well to body contours, they allow for range of motion key to rehabilitation. Mepilex Ag, an antimicrobial soft silicone foam dressing, has rapid silver release, to inactivate pathogens within 30 minutes, and sustained antimicrobial effect for 7 days. Mepilex Ag may be used on exuding wounds, partial thickness burns, graft and donor sites, or around pin sites for external fixators or devices. Lastly, we offer a range of dressings with polyacrylate adhesive, Mepore and Mepore Pro. Both offer a skin-friendly adhesive and absorptive pad and are cost-efficient options for post-op dressings that may need to be changed frequently."

Use of ionic silver in wound dressings continues to grow. "AcryMed is a leader in silver antimicrobial technologies," said McMaken, noting that they develop "products for chronic wound care and burns, such as SilvaSorb, which combines targeted, ionic-silver antimicrobial protection with advanced fluid management. ON-Q SilverDressing is marketed by I-Flow. These dressings use AcryMed’s proven and proprietary silver technology, which is designed for killing a broad spectrum of microbes, including MRSA; for gentleness to the tissue; and for extended use, up to 7 days if necessary. The dressings protect the wound site by locking out microbes and by killing microbes that may already be in the site and the drainage."

BIOPATCH Protective Disk with CHG (Johnson & Johnson Wound Management, a division of ETHICON, Inc., a Johnson & Johnson Company), releases chlorhexidine gluconate (CHG), a broad-spectrum antimicrobial and antifungal agent, for up to 7 days. A recent study by Bhende and Rothenburger2 compared the antimicrobial properties of BIOPATCH Protective Disk with CHG with four silver dressings, to assess its effectiveness against seven different organisms associated with CR BSIs. BIOPATCH Protective Disk with CHG prevented growth of five of the seven microbes, including MRSA, for the entire 7-day period. It prevented growth of a sixth microbe, Klebsiella pneumoniae, for 6 days and was the only dressing that was microbiocidal against Candida albicans.

BIOPATCH Protective Disk with CHG is placed around the insertion site of central venous and arterial catheters, absorbing blood or exudate and releasing CHG over a 7-day period

Nakazawa, Association for Vascular Access, observed that the CHG-impregnated disk "is part of the standard of care in more than 2,000 hospitals." She explained why: "One simple but highly effective way to help get to zero, as discussed in a study in the Journal of the Association for Vascular Access and other publications, is the CHG-impregnated disk. The CHG disk is clinically proven to reduce CR BSI, local infections, and skin colonization of microorganisms commonly related to CR BSI in patients with central venous catheters, peripherally inserted central catheters, and arterial catheters. It provides ongoing antisepsis, using a proprietary delivery technology, to protect the insertion site and release CHG, a powerful skin antiseptic, over a 7-day period."

"The disk is recommended in the Compendium of Strategies to Prevent Healthcare-Associated Infections in Acute Care Hospitals for use in all institutions with ‘unacceptably high’ rates of central-line-related CR BSI," continued Nakazawa. "Many experts and CMS believe that any rate greater than zero is unacceptably high. The Compendium, which was issued by the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America, is endorsed by the American Hospital Association, the Joint Commission, and the Association for Professionals in Infection Control and Epidemiology, Inc."

Kendall's AMD antimicrobial foam dressing for use with acute and chronic wounds

3M Health Care, St. Paul, MN, recently launched 3M Tegaderm Matrix Dressing with PHI technology, a blend of cations, including potassium, zinc, calcium, and rubidium, found naturally in the body that respond to body temperature and promote a natural moisture balance to help chronic wounds to heal. It does not harm the patient’s skin, affect tissue integrity, or cause maceration. It is indicated for use with chronic, non-infected wounds and has demonstrated favorable results on hard-to-heal wounds.

Case studies of patients with stalled wounds who have used 3M Tegaderm Matrix Dressing with PHI successfully were presented in April at the 22nd Annual Symposium on Advanced Wound Care and Wound Healing Society conference in Dallas, Texas. One case was that of a diabetic patient with a post-amputation wound. More than 2 months post-surgery, the skin graft had only a 50% "take." After 1 month of using the Tegaderm Matrix dressing daily, the patient showed 25% improvement. Four more weeks of treatment resulted in a 90% wound closure. Another case-patient, with bilateral elbow wounds of more than 2 years’ duration, complicated by septic arthritis and osteomyelitis, had been treated on one elbow for 2 months with NPWT but showed little improvement. Treatment was switched to Tegaderm Matrix dressing, and complete wound closure was achieved with this therapy at the end of 3 weeks. Using Tegaderm Matrix dressing represented a cost savings of $12,380 compared to previous treatment modality. For more information go to http://www.3m.com/tegaderm-matrix.

Wound care certainly is not finished. It’s seen tremendous changes in recent years. More advances can be expected. Dowd, Covidien, said that, while much has been done to improve care of wounds, the work is not yet done. "Hospitals are truly working to understand the financial and ethical impacts of SSIs. They are continuously looking for better ways to protect their postsurgical wounds. I believe both hospitals and manufacturers realize that we need to look for additional ways to protect patients and their surgical wounds through the continuum of care."

Prospera PRO-I NPWT pump

Armstrong expects to see experimentation in combinations of therapies. "Smith & Nephew believes that the clinical community has only just begun to understand NPWT and to develop protocols and best practices for using NPWT across a variety of wound types and clinical scenarios. As clinicians continue to learn more about NPWT, there is going to be a tremendous amount of innovation in wound care. Clinicians will try out various approaches with traditional and advanced wound dressings, NPWT, surgical debridement, and other therapeutic techniques in a variety of combinations. With our help, clinicians can tailor the most effective therapy at a lower overall cost to their institution. That’s what true innovation in healthcare should aim to deliver: improved patient outcomes at a lower cost."

More published scientific research on wound care can be expected, too, Savage, Mölnlycke Health Care, told HPN. "We anticipate a continued focus on antimicrobial dressings, silver or otherwise, from the industry in response to customer and patient needs. Options may include dressings designed for specific applications, especially for some of the higher-risk surgeries such as orthopedics and cardiovascular. The data to support advanced wound care use will also increase as more practitioners explore advancements in post-op care and document reductions in post-op infections."

References:

1.Mueller SW, Krebsbach LE. Impact of an antimicrobial-impregnated gauze dressing on surgical site infections including methicillin-resistant Staphylococcus aureus infections." Am J Infect Control 2008;36(9):651-655. Epub 2008 Oct 3.

2. Bhende S, Rothenburger S. In vitro antimicrobial effectiveness of 5 catheter insertion-site dressings. Journal of the Association for Vascular Access 2007;12(4):227-231.