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Introduction

Acute wounds such as surgical wounds, burns, traumatic wounds and skin tears constitute the wound types most frequently encountered by health professionals^1,2. Prevalence surveys have reported the majority of wounds in hospital and outpatient community settings were acute/surgical wounds (76% and 35% in each setting respectively)¹, and 56% of wounds cared for in an Australian community nursing service were acute wounds or skin tears². Their management consumes significant healthcare resources, estimated as 1.6–2.4% of total health service costs¹, with a reported cost of A$390,641 to treat a sample of 1053 acute wounds in a recent Australian study³. An acute wound can be defined as “a recent wound, of any aetiology” that is expected to progress “through the normal sequential to achieve healing”^4(p.2). Definitions of acute wound types are provided in Box 1^5-10. However, despite their frequency of occurrence, inconsistency in management is frequently reported^11,12.

 

Box 1. Definitions of acute wound types

 

The implementation of research evidence into clinical practice has been shown to deliver safe, cost-effective wound care and improved patient outcomes^13,14. Considering the high burden of acute wounds on individuals and healthcare systems outlined above, it is essential to review available research findings to provide the means to optimise care delivery and facilitate more efficient and cost-effective ultilisation of healthcare resources. The Australian Health Research Alliance Wound Care Initiative aimed to address wound care challenges, lower the health burden of wound care in Australia, and develop a national and integrated approach to wound management and research that can be readily embedded in the Australian health system. One activity under this initiative was to review research findings on wounds (acute, chronic and fundamental science of wound healing) to guide the future direction of Australian wound research through the identification of research gaps and priorities.

This scoping review aimed to identify research on the assessment, management and prevention of acute wounds, from 1) primary research studies conducted in Australia, and 2) worldwide synthesised evidence available within systematic reviews (SRs), evidence-based guidelines (EBGs), evidence summaries and consensus documents to provide a global context. The research questions guiding the review were:

• What are the characteristics of Australian research on the assessment, management and prevention of acute wounds?
• What research evidence is available in the global context in synthesised research documents and guidelines on the assessment, management and prevention of acute wounds?
• What are the research gaps specific to the assessment, management and prevention of acute wounds in Australia?

Methods

This scoping review is reported in accordance with the guidance provided by the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist¹⁵ and the Joanna Briggs Institute (JBI) scoping review methodology¹⁶. The review protocol was prospectively registered in the Open Science Framework (https://osf.io/bzs38) and published in Sandy-Hodgetts et al¹⁷.

Eligibility criteria

Inclusion criteria:

• Original qualitative or quantitative studies on the assessment, management or prevention of acute wounds conducted in Australia.
• Published in English.
• Worldwide EBGs, evidence summaries, consensus documents and SRs on the assessment, management or prevention of acute wounds.
• Human studies with adults aged from 18 years and older. Note that epidemiological studies were identified which provided data from both adults and younger age groups. These were included, as the data provided on adult wound prevalence was valuable.
• Any setting (e.g., community, general practice, outpatient department, residential aged care facilities, hospitals).
• Published between 1 January 2010 to 30 April 2022.

Exclusion criteria:

• Case series, case study or studies, editorials, general literature reviews.
• Conference abstracts, and conference proceedings.

Information sources

Sources were MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, Joanna Briggs Institute, Cochrane Library, American Psychological Association PsycInfo, Australian and New Zealand Clinical Trials Registry, International Standard Randomised Controlled Trials Registry and ClinicalTrials.gov. Websites and publications of professional associations for wound management included Wounds Australia, Wounds UK, Wounds International, Wounds Canada, European Wound Management Association, International Wound Infection Institute, International Surgical Wound Complications Advisory Panel, National Institute for Health and Care Excellence, World Health Organization, Wound Healing Society, World Union of Wound Healing Societies and New Zealand Wound Care Society.

Search strategy

Databases and sites were searched for published literature fitting the inclusion criteria between 1 January 2010 to 30 April 2022. Key search terms were wound, incision, laceration, site, skin tear, surgical, postoperative, operative, trauma and burns. Limiters included only studies conducted with human participants, research articles, and studies published in English language. An example full search strategy is shown in Table 1.

 

Table 1. Search strategy example for Australian original research studies

 

Selection of documents

Results from searches were imported into EndNote X9. After excluding duplicates, two levels of screening were used to identify articles to be included: (i) title and abstract screening and (ii) full text screening. At each level, search results were reviewed by two independent researchers, and any disagreements reviewed by a third reviewer.

Data extraction

A data extraction tool was developed by one of the researchers and pilot tested and reviewed by two other researchers. Data were independently extracted by one researcher and cross checked against original articles by a second researcher to ensure the accuracy of extracted information. Data extracted included (i) study characteristics, (ii) research design or document type, (iii) type of acute wounds, (iv) study population, (v) focus topic and (vi) main outcomes.

Synthesis of results

Results were grouped and reported according to the type of acute wound the study or document focused on, i.e., surgical, burns, traumatic wounds, skin tears or samples with mixed types of acute wounds. Results were then organised under sections on the assessment, management or prevention of each type of wound. A narrative synthesis is reported in each section on the amount and types of studies and documents, primary focus topics, and an overview of results from the Australian studies.

Results

Following the searches, 10,543 potential articles were found. Of these, 2106 were duplicates, and 7286 articles did not fit the inclusion and exclusion criteria, including 251 articles which focused on non-wound related primary outcomes of surgical techniques. These articles are available in Supplementary file A. Of the 1151 remaining included articles, there were 318 Australian studies (294 quantitative studies and 24 qualitative studies), and 833 international studies (680 SRs, 28 EBGs, 79 evidence summaries and 46 consensus documents). Figure 1 displays the flow diagram of document inclusion. Australian documents on assessment (38%) included 120 quantitative studies and one qualitative study, documents on management (60%) included 179 quantitative studies and 11 qualitative studies, while documents on prevention (2%) included seven quantitative studies. Specific study designs of the included articles are displayed in Table 2. Due to the large number of SRs, references for the SRs are available in Supplementary file B.

 

Figure 1. Full search strategy

 

Table 2. Study designs of included articles (n=1151)

 

The largest number of documents were on surgical wounds (n=727, 63%), followed by burns (n=288, 25%), samples of mixed acute wound types (n=62, 5%), traumatic wounds (n=42, 4%), and skin tears (n=32, 3%). Of the Australian original research studies, 46% (n=148) were on burns, 44% (n=139) on surgical wounds, 6% (n=18) on skin tears, 3% (n=9) on traumatic wounds, and 1% (n=4) on mixed acute wound types. The most frequent research design of Australian studies was observational cohort studies (48%). Australian studies concentrated on wound management (60%), with only 38% on assessment, and 2% on the prevention of wounds.

The majority of Australian studies were conducted in hospital settings (78%), 7% were in follow-up care settings (outpatients, rehabilitation), 3% in community care, 3% in residential aged care, 3% in specialist surgery clinics, 2% in emergency care (ambulance, ED), 2% in combined settings, and 2% in general practice. Most study samples consisted of adults with wounds or adults with the possibility of developing a wound (81%), 6% were epidemiological population samples, 5% were samples of health professionals, and 4% were samples of ‘older adults’, defined as either 50 years and over, 60 years and over, 65 years and over or 70 years and over. Two studies were conducted with samples of both patients and health professionals, and one study with young adults aged 15–29 years.

The most frequent topics of investigation of Australian studies for each wound type are displayed in Table 3. An overview of the findings is reported below by wound type and area of investigation (assessment, management and/or prevention).

 

Table 3. Topics of investigation in Australian studies by wound type (n=318)

 

Surgical wounds

The largest number of documents (n=727) focused on surgical wounds, including 139 Australian studies. Study designs and topics are shown in Tables 2 & 3.

Assessment

A total of 97 documents focused on assessment of surgical wounds – 35 Australian studies, three EBGs, one evidence summary and 58 SRs.

Australian studies

Most studies on surgical wound complications focused on surgical site infections (SSI). Reported SSI incidence rates varied across type of surgery and setting, from 0.5–18.9%^18–27. Two large studies found SSI rates decreased over time, i.e., SSI surveillance network data on cardiovascular, digestive, gynaecological-obstetrical, neurosurgical and orthopaedic surgery found decreased SSI rates over a median of 9 years of data²⁸, while a Victorian surveillance program found decreased SSI rates from 2002–2013 from data on cardiac, Caesarean section, hip and knee prosthesis, colorectal, other abdominal, hysterectomy and vascular surgeries²⁹. SSI rates varied according to procedure, with highest rates reported for colorectal survey²⁸ and orthopaedic surgery²⁹. In contrast, a study of pelvic exenteration found increasing SSI rates from 1994–2006 data, to 2014–2017 data³⁰. One study of hip replacement found an 8.8% incidence of wound complications in general³¹.

Results on risk factors for surgical wound complications are shown in Table 4. Looking at assessment tools or methods, one small 2012 study found superficial sternal wound swabs and blood cultures were useful in early diagnosis of deep sternal wound infection³², while a study of fluorescence imaging found it improved sensitivity of bacterial detection³³.

 

Table 4. Risk factors for surgical wound complications identified in Australian studies

 

Worldwide reviews (SRs, EBGs, evidence summaries, consensus documents)

Three EBGs covered assessment of surgical wounds^5,34,35 in addition to one evidence summary on assessing SSIs³⁶. The SRs focused on incidence of SSIs; risk factors or assessment tools for complications; and defining SSI.

Management

Surgical wound management was investigated in 104 Australian studies, in addition to 683 SRs, 15 evidence summaries, 15 EBGs and 16 consensus documents. Designs and topics of studies are shown in Tables 2 & 3.

Australian studies

Primary findings from intervention studies to prevent wound complications are listed in Table 5. Findings on interventions to promote healing included that: there were positive outcomes from a house advancement flap for pilonidal sinus³⁷ and V-Y advancement flaps for pretibial skin defects³⁸; there was no improvement in healing from warming or oxygenation³⁹; negative pressure wound therapy (NPWT) reduced the need for flap closure⁴⁰; there were no differences in healing between polyurethane vs calcium alginate dressings⁴¹, or biosynthetic vs hydrocolloid dressings⁴²; pilonidal abscess incisions took longer to heal after a midline vs lateral incision⁴³; and there were increased complications from a 2cm excision margin compared to a 1cm margin for melanoma⁴⁴. One study on pain management found intermittent wound infusion regimes were associated with greater reduction in pain scores⁴⁵.

 

Table 5. Australian research findings on interventions to prevent surgical wound complications

 

On evidence-based practice (EBP), a qualitative study found barriers to EBG implementation were knowledge and skills deficits, access to protocols, suboptimal documentation and timing of education; while facilitators were active information seeking and patient participation⁴⁶. Other results included that: there were significant gaps between EBGs and actual practices^47–51; evaluation of implementation strategies improved EBP^52,53; there were improvements adhering to antibiotic prophylaxis guidelines⁵⁴; content and accuracy of documented wound assessment was variable⁵⁵; and barriers in evidence-based wound management included traditional pretexts, economic factors, clinical knowledge and expertise and patient factors. Drivers were product choice, infection surveillance, interdisciplinary collaboration and regulatory mechanisms⁵⁶.

On costs, studies found that: surgical wound complications were associated with significant costs^57–61; NPWT for high-risk Caesarean section wounds was cost-effective⁶²; antibiotic prophylaxis and antibiotic impregnated cement in hip arthroplasty reduced costs⁶³; and reduced smoking rates before surgery would provide substantial economic benefits⁶⁴. Studies on health service aspects reported that: wound care practice varied across clinical sites⁶⁵; a checklist improved documented wound management⁶⁶; wound care documentation did not meet Australian standards⁶⁷; and a qualitative study reported difficulties with postoperative advice when managing after Caesarean section⁶⁸. Eight trial protocols were registered without reported results, on dressings, NPWT, smartphone technology, skin preparation, surgical humidification, wound closure methods, care pathways, and topical medications^69–76.

Worldwide reviews

A total of 15 EBGs covered the management of surgical wounds, 13 on SSIs^5,35,77–87, and three including other surgical complications and/or strategies^34,78,88. There were 15 evidence summaries covering: NPWT⁸⁹; post-sternotomy mediastinitis⁹⁰; skin preparation^91,92; topical antibiotics⁹³; perioperative strategies to prevent SSI⁹⁴; delayed primary skin closure⁹⁵; SSIs caused by methicillin-resistant Staphylococcus aureus (MRSA)⁹⁶; skin graft and donor sites⁹⁷; and the OT environment^98–103. Consensus documents focused on: wound care and dressings¹⁰⁴; SSI prevention^105–111; skin graft donor sites¹¹²; wound dehiscence¹¹³; antibiotics after abscess excision¹¹⁴; NWPT^115,116; wound infection¹¹⁷; and preventing wound complications^10,118.

The SR topics included: skin preparation; glycaemic control; prophylactic antimicrobials; surgical hand antisepsis; temperature-related interventions; surgical techniques; wound closing techniques; exudate management; NPWT; debridement; infection management; dressings; platelet treatments; laser therapy; postoperative showering; care bundles; pain management; OT environment factors; nutrition; scar management; costs; and combined management protocols or pathways. Further details on the SRs are available in Supplementary File B.

Burns

Burn wound care is complex as demonstrated by the number and diversity of documents (288), with 148 Australian research studies, 88 SRs, nine EBGs, 39 evidence summaries, and four consensus documents. The study designs and topics are shown in Tables 2 & 3.

Assessment

A third (33%) of the documents looked at assessment – 72 Australian studies, four evidence summaries, four EBGs and 15 SRs.

Australian studies

The focus and main outcomes of Australian studies on epidemiology and risk factors for poor burn outcomes are presented in Tables 6 & 7. Outcomes on burn and peri-wound assessment included that: bioimpedance spectroscopy was useful to assess oedema^119,120 and progress in healing¹²¹; water displacement volumetry was reliable to assess postburn volume changes¹²²; total body surface area (TBSA) was more accurately assessed using an online ‘Burnschart’ compared to conventional systems¹²³; and there were significant inaccuracies in burn size estimation¹²⁴. Two studies evaluated burn injury severity scores^125,126, and one the Burn Specific Health Scale-B to assess recovery¹²⁷.

 

Table 6. Australian research on epidemiological aspects of burns

 

Table 7. Australian research on risk factors associated with poor outcomes from burns

 

Studies on psychosocial factors reported that: half of patients with burns had psychiatric, behavioural and/or drug use disorders¹²⁸; persons with intentional burns had poorer outcomes¹²⁹; psychosocial factors were associated with length of stay (Increased LOS)¹³⁰; qualitative studies explored experiences of trauma, psychosocial adjustment and impact of burns on behavioural change re social activities^131–137; patient concerns¹³⁸ and depression impacted post-traumatic growth^139,140; Type-D personality was associated with higher psychopathology¹⁴¹; hospitalised adults with burns spent two-thirds of time alone¹⁴²; and attachment style was related to psychosocial recovery¹⁴³.

On symptom research, predictors of fatigue were: being female; having a higher TBSA; and living in non-metropolitan areas¹⁴⁴. Studies on pain found that: severity at 3 months predicted satisfaction with pain management¹⁴⁵; the use of validated pain assessment tools enhanced assessment¹⁴⁶; and pain assessment varied considerably¹⁴⁷. A significant relationship was found between mental health and itch¹⁴⁸, and that younger age was a predictor of itch¹⁴⁹. A number of tools were validated, including: a dysphagia risk model¹⁵⁰; Lower Limb Functional Index¹⁵¹; nomogram to predict quality of life (QoL)¹⁵²; Brief Fatigue Inventory¹⁵³; and Canadian Occupational Performance Measure¹⁵⁴. On dysphagia, one study found no association between burn location and risk of dysphagia¹⁵⁵, while another found burn area, head and neck burns, inhalation injury and ventilation were risk factors for dysphagia¹⁵⁶.

Eight studies focused on assessment of complications, including the modified Vancouver Scar Scale^157,158, Brisbane Burn Scar Impact Profile¹⁵⁹, and photographic scar evaluation¹⁶⁰. A positive troponin test was associated with cardiac complications¹⁶¹, while burn area, ICU admission and prolonged ventilation were associated with acute coagulopathy¹⁶² and increased risk of VTE¹⁶³. Inhalational burns were a risk factor for infection¹⁶⁴.

Worldwide reviews

Four EBGs, three evidence summaries, and 15 SRs covered assessment. The EBGs focused on acute pain¹⁶⁵ or general burn assessment^7,166,167. The evidence summaries focused on: clinical assessment¹⁶⁸; TBSA assessment¹⁶⁹; body image assessment¹⁷⁰; and laser doppler imaging¹⁷¹. The SRs covered: burn microbiology; biomarkers; wound infection; measurement of burn depth or healing potential; infrared thermography; machine learning for burn assessment; and impact of burn injuries on body image or psychological outcomes.

Management

The management of burns was addressed in 192 documents – 75 Australian research studies, nine EBGs, 73 SRs, 35 evidence summaries and four consensus papers.

Australian studies

Study designs and topics are found in Tables 2 & 3, and findings on management intervention studies in Table 8.

 

Table 8. Australian studies on management of burns

Worldwide reviews

EBGs covered: burn management^{7,166,172–176}; non-silicone or silicone gels¹⁷⁷; management of noncomplex burns¹⁶⁷; allied health and psychosocial management¹⁷²; burn care under austere conditions¹⁷⁸; and pain management¹⁶⁵. Evidence summaries were on: first aid^179–181; non-pharmacological interventions for pain and anxiety^182–184; pruritus¹⁸⁵; recombinant human growth hormone¹⁸⁶; growth factors¹⁸⁷; topical treatments or dressings^188–194; burn surgery and grafting^195–199; axillary burns²⁰⁰; silver-based antiseptics²⁰¹; hydrotherapy²⁰²; blister management²⁰³; TNP²⁰⁴; health services^205,206; shock wave therapy²⁰⁷; nutrition^208,209; models of care²¹⁰; liquefied petroleum gas burns²¹¹; and cement burns²¹². Consensus documents covered: pre-hospital management of burns²¹³; first aid clinical guidelines²¹⁴; burns care in mass casualty incidents²¹⁵; and enzymatic debridement²¹⁶. The SRs covered first aid; symptom management; infection; advanced biological treatments; debridement; dressings and topical treatments; adherence to treatment; nutrition and skin grafts.

Prevention

One Australian study addressed the prevention of burns, a controlled, comparative study which evaluated a targeted burn prevention message on safety knowledge and behaviour in an at-risk adult population²¹⁷. One EBG provided recommendations in the prevention of burn injuries⁷.

Mixed acute wounds

A total of 62 documents addressed mixed types of acute wounds, including four Australian studies. Study designs and topics are shown in Tables 2 & 3.

Assessment

One Australian study found chemotherapy was significantly associated with longer healing time²¹⁸. In addition, the Wounds Australia Standards provide recommendations for wound assessment, prevention and management²¹⁹.

Management

A total of 59 documents addressed management – two Australian research studies, two EBGs, 19 evidence summaries, 17 consensus documents and 19 SRs.

Australian studies

A report from a mixed methods study found positive evaluations of a decision tree for products and wound management²²⁰, while a survey of nurses found around half were unaware of national wound management standards, and only 35% reported good knowledge of wound products¹².

Worldwide reviews

Guidelines included a 2011 EBG on NPWT²²¹ and national standards for wound management²¹⁹. Evidence summaries covered: debridement^222,223; pain management^224–226; topical treatments or dressings^227–237; and techniques to identify infection²³⁸. Consensus documents focused on: NPWT^239,240; debridement²⁴¹; exudate management^242,243; wound infection^244,245; aseptic technique²⁴⁶; dressings and topical treatments^247–253; advanced cell, physical and IT based therapies²⁵⁴; scar management²⁵⁵; and team management²⁵⁶. The SRs focused on: wound bed management; debridement; NPWT; wound infection; dressings/topical treatments; nutrition; and adjunct interventions.

Prevention

Three documents addressed prevention of acute wounds – the Australian Standards for Wound Management²¹⁹, a pre/post study of a model to promote evidence-based wound prevention²⁵⁷, and a SR on aloe vera for wound prevention²⁵⁸.

Traumatic wounds

There was a total of 42 documents on acute traumatic wounds – nine Australian studies, 28 SRs, one consensus document, three evidence summaries and one EBG. Study designs and topics are shown in Tables 2 & 3.

Assessment

Three documents addressed assessment – two Australian research studies and one SR.

Australian studies

There were two large Australian retrospective cohort studies on risk factors for obstetric perineal or anal sphincter traumatic injury. One study found ethnicity, shoulder dystocia and assisted delivery were risk factors for severe perineal tears²⁵⁹, while the other found gestational diabetes and a macrosomic baby combined with assisted delivery were risk factors for severe perineal tears or anal sphincter injuries²⁶⁰.

Worldwide reviews

One SR was found on risk factors for severe obstetric perineal trauma²⁶¹.

Management

A total of 33 documents addressed management – six Australian research studies, one EBG, one consensus document, two evidence summaries and 23 SRs.

Australian studies

Two retrospective studies of lower limb traumatic wounds found improved outcomes from free-flap reconstruction within 3 days of injury and immediately following fracture fixation²⁶² and significantly decreased deep infection rate in patients receiving NPWT compared to conventional dressings²⁶³. Another retrospective study found stable patients with single abdominal stab wounds could be safely managed with close observation without surgery²⁶⁴. A descriptive study of laceration repair outcomes reported good patient satisfaction with management; however, less with follow-up advice²⁶⁵. Studies on obstetric perineal trauma reported inconsistent health services and lack of standardised care²⁶⁶, and a trial of straight vs curved episiotomy scissors found no differences in outcomes²⁶⁷.

Worldwide reviews

One 2011 EBG focused on NPWT for traumatic wounds and reconstructive surgery²⁶⁸. Evidence summaries were found on the management of traumatic wounds in community settings²⁶⁹, and the impact of shaving on perineal wound infection²⁷⁰. A consensus document covered the risk, management and prevention of wound complications from birth injuries²⁷¹. The SRs focused on the management of obstetric perineal trauma; preventing infection; NPWT; hyperbaric oxygen therapy (HBOT); lower extremity traumatic wounds; gunshot wounds; dog bite wounds; antiseptic solutions; haemostatic dressings; and flaps for revascularisation and soft-tissue coverage.

Prevention

Six documents addressed prevention – one Australian research study, one evidence summary and four SRs. A randomised controlled trial (RCT) found no effect from the use of a birth trainer to prevent pelvic floor trauma²⁷². An evidence summary focused on preventing medical adhesive injury²⁷³. The SRs covered techniques to reduce perineal trauma.

Skin tears

A total of 32 documents were identified on skin tears – 18 Australian research studies, three SRs, one EBG, two evidence summaries and eight consensus documents. Study designs and topics are shown in Tables 2 & 3.

Assessment

A total of 16 documents addressed assessment – 11 Australian studies, one evidence summary, one SR and three consensus documents.

Australian studies

Two studies on skin tear prevalence reported: prevalence of 8.9% (5.5% hospital-acquired) in a hospital setting over 10 years, decreasing over time²⁷⁴; and 58–66% over 6 months in a retrospective study in aged care factilities²⁷⁵. On classification of skin tears, a multinational Delphi study (including Australia) of the validity and reliability of the International Skin Tear Advisory Panel classification system found moderate to high agreement, and added a definition of ‘skin flap’ to the system²⁷⁶.

Risk or prognostic factors for skin tears were identified in six studies: malnutrition²⁷⁷; use of heel protectors or anti-embolic stockings²⁷⁵; ecchymosis^278,279; skin purpura^278–280; haematoma²⁷⁸; history of previous skin tears^278,280; oedema²⁷⁸; inability to reposition independently²⁷⁸; older age²⁷⁹; lower Braden score²⁷⁹; higher risk of falling²⁷⁹; osteoporosis²⁷⁹; use of corticosteroid inhaler²⁷⁹; history of falls in the previous 3 months^280,281; elastosis^280,281; and male gender^280,281.

Four validity or reliability studies tested assessment tools or risk models for skin tears. A study in an aged care setting of non-invasive instruments for assessment of trans-epidermal water loss, hydration, skin thickness, elasticity, surface sebum and pH found mostly good intra-rater reliability and reproducibility with ultrasound measurements²⁸². A prospective validation of a skin tear risk assessment tool in hospital patients found the tool did not perform well in predicting skin tears within 10 days²⁸³. However, a risk model for skin tears developed with aged care residents resulted in an area under the receiver operating characteristic curve of 0.854, sensitivity 81.7%, and specificity 81.4%²⁸⁰. Another study undertook a comparative analysis of predictive risk models for skin tears, finding predictive abilities ranged from AUC (Area Under the Curve) 0.67–0.85²⁸⁴.

Worldwide reviews

One SR found age-related skin changes, dehydration, malnutrition, sensory changes, mobility impairment, immunosuppressive medication, anticoagulants and mechanical factors were risk factors for occurrence of skin tears²⁸⁵. An evidence summary was identified on skin tear assessment in community settings²⁸⁶. Three consensus documents^10–289 covered risk factors and assessment of skin tears.

Management

Ten documents addressed management – three Australian studies, one evidence summary, five consensus documents, and one EBG.

Australian studies

A protocol evaluation on emergency management of skin tears found a significant improvement in healing time²⁹⁰. Two pre-post studies aimed to increase implementation of EBGs – one in an acute aged and rehabilitation setting found increased compliance to guidelines and decreased prevalence of skin tears²⁹¹. The second in a community setting found increased uptake of best practice in most items evaluated²⁹².

Worldwide reviews

One EBG covered management of skin tears²⁹³ and an evidence summary covered management in community settings²⁹⁴. Consensus documents were found on: skin tear management^10,287; management in aged skin²⁸⁸; lower limb skin tears²⁹⁴; and dressings²⁹⁵.

Prevention

A total of 14 documents covered prevention – six Australian papers, one SR, one EBG, and six consensus documents.

Australian studies

Four studies investigated the effectiveness of skin moisturising on prevention of skin tears. A cluster RCT of twice-daily moisturising vs usual care in aged care facilities found the intervention reduced the incidence of skin tears by almost 50%²⁹⁶, while a case control study of a similar intervention in an acute care setting found decreased incidence of skin tears, however, no statistically significant differences²⁹⁷. In contrast, a case-historical control study of twice daily moisturiser application in adults ≥65 years in an acute setting found a significant decrease in incidence of skin tears (p=0.006)²⁹⁸. Evaluation of a national program to increase use of emollient moisturiser to prevent skin tears in DVA (Department of Veterans Affairs) patients found increased dispensing of emollients; however, skin tear outcomes were not reported²⁹⁹. As noted above in the management section, two pre-post studies focused on implementation of EBGs; with regards to prevention, one in the acute aged and rehabilitation setting found decreased point prevalence of skin tears²⁹⁰, while the second in a community setting found increased uptake of best practice; however, it did not report incidence of skin tears²⁹¹.

Worldwide reviews

A SR concluded there was inadequate evidence for recommendations on hygiene and emollients in preventing skin tears³⁰⁰. One EBG covered prevention of skin tears²⁹². Six consensus documents were identified on maintaining skin integrity and prevention of skin tears^{10,288,301–303}.

Discussion

This scoping review identified a consistent amount of Australian original research studies generated on acute wound care over the time of the review – with around 20 to 30 studies published each year between 2010–2022. The majority of Australian studies (90%) were focused on either burns or surgical wounds, with minimal studies on skin tears (6%) and traumatic wounds (3%). As surgery accounts for 25% of all hospital admissions³⁰⁴ and burn care also requires significant health system resources, there is a substantial impost on health service funds³⁰⁵, thus opportunities to reduce the impact are understandably the focus for research. This includes but is not limited to continuing education to remain abreast of the latest advances in the field and appropriate policy changes to reflect updates in EBP. Interestingly, this review revealed a paucity of research on skin tears, which is at odds with the reported prevalence of these wounds (e.g., 8.9% in an acute hospital population²⁷⁴, 19% in aged care settings²⁵⁷, 15–17% of wounds in community nursing setting²) and the subsequent demands on healthcare resources.

Results also demonstrate a gap in studies providing high level evidence, with small numbers of experimental or controlled study designs. Without evidence from these study types, there are limited opportunities to obtain robust findings from SRs, which themselves support development of clinical practice guidelines and policies. It is notable that an extremely large number of SRs were identified on surgical wounds in this review (n=541), in comparison to burns (n=88), traumatic wounds (n=28), acute wounds in general (n=20) and skin tears (n=3).

Most of the Australian studies were focused on wound assessment or management (97%), with only 2% on prevention^{217,257,272,290,296,297,298,299}, despite the obvious potential benefits for the population and healthcare settings and resources through preventing avoidable wound types (e.g. burns, skin tears). A gap was noted in studies conducted in primary care settings, with 78% of studies conducted in hospital settings although a large proportion of care for wounds such as burns, surgical wounds, lacerations and skin tears is provided in primary health settings, including general practice, residential aged care and home/community nursing care³. The costs of wound care in these Australian primary healthcare settings is considerable^2,3,61, thus an increased priority on research in primary healthcare settings is warranted to address the issue.

The identified gaps in this review, i.e., lack of research on skin tears and traumatic wounds, studies with strong research designs, studies on prevention and in studies in primary healthcare settings, provide important directions for future research. Similar gaps in studies on prevention and studies with strong research designs were found in a review on chronic wound research³⁰⁹. It is recommended to increase the focus of Australian wound research on prevention and prioritise resources for well designed research, particularly in community and primary healthcare settings. Outcomes from this future research are needed to form the essential building blocks for development of best practice guidelines, healthcare policy and optimal clinical practice to improve outcomes in all settings.

Limitations

This scoping review was broad within its scope, resulting in a large number of documents. As such, there are limitations to be considered such as the diversity of study designs, wound types and topics of research, populations and settings. Due to the broad nature of this scoping review, a quality evaluation was not undertaken. Our search strategies, despite testing and refining, may have not identified all eligible documents on this review topic.

Conclusions

Australian research on acute wounds has remained constant over the last decade, focused primarily on burns and surgical wounds, with relatively little research on skin tears or traumatic wounds. Results indicate additional gaps in research on wound prevention and in community and primary healthcare settings, despite the high prevalence of differing acute wound types cared for in these settings.

Conflict of interest

The authors declare no conflicts of interest.

Ethics statement

An ethics statement is not applicable.

Funding

This project was supported by funding from the Australian government under the Medical Research Future Fund. The funder had no role in the design, conduct or publication of the review.

Author contribution

All authors contributed to study design, UTB, KS-H and KF contributed to document identification and review, and KF and UTB to data analysis and synthesis. KF and UTB were responsible for manuscript preparation and all authors for feedback on the manuscript. All authors read and approved the final manuscript.

Author(s)

Kathleen Finlayson¹, Ut T Bui*¹, Fiona Wood², Fiona Coyer³, Kylie Sandy-Hodgetts^4,5
¹School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, QLD, Australia
²Burns Service Western Australia, Burn Injury Research Unit, University of Western Australia, Perth, WA, Australia
³School of Nursing, Midwifery and Social Work, The University of Queensland, Brisbane, QLD, Australia
⁴Centre for Molecular Medicine & Innovative Therapeutics, Health Futures Institute, Skin Integrity Research Group, Murdoch University, WA
⁵School of Biomedical Sciences, University of Western Australia, Perth, WA, Australia

*Corresponding author email thiut.bui@qut.edu.au

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188. Moola S. Evidence summary. Biosynthetic skin substitutes: burns/wounds care. JBI EBP Database 2021;JBI-ES-3332-1.
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191. Dorri M. Evidence summary. Burns and donor sites: film dressings. JBI EBP Database 2021.
192. Munn Z, Magtoto LS. Evidence summary. Hydrocolloids: burn wounds and donor sites. JBI EBP Database 2020;JBI-ES-3773-1.
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195. Rathnayake T, Mathew S. Evidence summary. Use of Tumescent technique in burn surgery. JBI EBP Database 2021;JBI-ES-3257-1.
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199. Munn Z. Evidence summary. Hand burns: surgery. JBI EBP Database 2021;JBI-ES-1898-1.
200. Munn Z, Minooee S. Evidence summary. Axilla burns: post-surgical care. JBI EBP Database 2021;JBI-ES-388-1.
201. Moola S, Fong E. Evidence summary. Burns: silver-based antiseptics. JBI EBP Database 2020;JBI-ES-2090-1.
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204. Carstens J, Minooee S. Evidence summary. Burns: topical negative pressure. JBI EBP Database 2021.
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