Volume 29 Number 1

Hard-to-heal wounds are a significant burden across the globe regarding financial cost, human resources, negative impact on persons with a wound, and loss of limb or life due to complications^1–4. Significant efforts to determine the causes and best interventions for wound chronicity have been made by clinicians, scientists and wound societies^5–7. Since 2008 it has been suggested that biofilm in wounds may be one of the causative reasons for delayed healing^8,9.

Wound bed preparation is a concept that was adopted over 20 years ago as good practice for optimal wound care^10,11. In 2010 Randy Wolcott coined the term and practice of “biofilm based wound care”¹² and emphasised the need and importance of debridement. An expert biofilm panel in 2017 published on identification and strategies for wounds suspected of biofilm and encouraged clinicians to invest in proactive wound care early and not wait for further complications⁶. These publications and growing concerns about the impact of delayed healing led to ConvaTec hosting an advisory board meeting in March 2019 in London and creating a publication that posed the question – is the current standard of care adequate¹. With growing concerns about antibiotic resistance, the impact of delayed healing on quality of living and financial resources, ConvaTec hosted another expert panel in August 2019 which resulted in a consensus document that was published in March 2020¹³.

This 26-page document provides the reader with four easy steps regarding wound hygiene, the rationale for and definition of wound hygiene, and how to implement it into your everyday practice. The term hygiene was chosen as it is a fundamental and accepted practice that has improved practice and prevented illness, with examples such as oral hygiene, hand hygiene, personal hygiene and limb hygiene. Within the document you will find key terms, myth busters, clinical examples, step by step components of wound hygiene, a summary of solutions for cleansing, practical clinical tips, and a summary of topical antimicrobial and antibiofilm agents commonly used in wound dressings, and it concludes with how to implement all of this into your practice.

The international consensus document Defying hard-to-heal wounds with an early antibiofilm intervention strategy: wound hygiene is free to download from https://www.woundhygiene.com and has further information and resources on this dedicated website. The four easy steps in wound hygiene are designed to clean and decontaminate a wound so that the barriers caused by the presence of biofilm can be overcome.

Step 1: cleanse

Wound hygiene should be performed at every dressing change. Use of an antiseptic wash or surfactant is recommended for the wound and the periwound. When cleansing the periwound skin, the area should include anywhere there was a dressing and bandage, with at least a 10–20cm margin away from the wound edges.

Step 2: debride

Options for types of debridement are provided in this document so that any clinician can conduct some level of debridement. The long-standing caveat still stands that healability needs to be determined before commencing with moist wound healing or debridement if there is stable eschar.

Step 3: refashion the wound edge

The edge of wound provides indicators of healing such as attached edges and migration of epithelium; however, it requires that the wound edges be clean and free of debris. The agitation that is recommended will stimulate the expression of growth factors to kick-start the healing. Refashioning the wound edge builds on the previous steps to improve the wound environment.

Step 4: dress the wound

Antimicrobial dressings alone are not sufficient to disrupt and remove biofilm but is appropriate as an adjunctive method to manage residual biofilm and prevent/delay re-formation. To improve efficacy, all the steps must be completed to reduce the risk of infection.

It has been almost a year since the document was launched in February 2020 and it has been widely promoted through webinars, international satellite symposiums and podcasts. This practical and accessible practice is literally for everyone and has been translated into seven major languages. The goal is to improve practice and outcomes through the four easy steps of wound hygiene.

Author(s)

Terry Swanson
Nurse Practitioner Wound Management
Wound Education Research Consultancy (W.E.R.C.)
Email  Swansonterry7@gmail.com.au

References

1. Murphy C, Atkin L, Dissemond J, et al. Defying hard-to-heal wounds with an early antibiofilm intervention strategy: “wound hygiene.” J Wound Care 2019;28:818–22. doi:10.12968/jowc.2019.28.12.818
2. Campbell D. Chronic wounds: the hidden health crisis hitting 2m Britons. The Guardian. 2019 Jul 29 [cited 2020 Feb 14]. Available from: https://tinyurl.com/yy2xtjfn.
3. Guest JF, Ayoub N, McIlwraith T, et al. Health economic burden that wounds impose on the National Health Service in the UK. BMJ Open 2015;5.
4. Olsson M, Järbrink K, Divakar U, et al. The humanistic and economic burden of chronic wounds: a systematic review. Wound Repair Regen 2019;27:114–25.
5. Bjarnsholt T, Eberlein T, Malone M, et al. Management of biofilm. Wounds Int 2017;8(2).
6. Schultz G, Bjarnsholt T, James GA, et al. Consensus guidelines for the identification and treatment of biofilms in chronic nonhealing wounds. Wound Repair Regen 2017;25:744–57. doi:10.1111/wrr.12590
7. International Wound Infection Institute (IWII). Wound infection in clinical practice: international consensus update 2016. Wounds Int 2016.
8. James GA, et al. Biofilms in chronic wounds. Wound Repair Regen 2008;16(1):37–44.
9. Bjarnsholt T, Kirketerp‐Møller K, Jensen PØ, et al. Why chronic wounds will not heal: a novel hypothesis. Wound Repair Regen 2008;16(1):2–10.
10. Sibbald RG, Williamson D, Orsted HL, et al. Preparing the wound bed – debridement, bacterial balance, and moisture balance. Ostomy/Wound Manage 2000 Nov 1;46(11):14–22.
11. Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen 2003 Mar;11:S1–28.
12. Wolcott RD, Rhoads DD. A study of biofilm-based wound management in subjects with critical limb ischaemia. J Wound Care 2008 Apr;17(4):145–55.
13. Murphy C, Atkin L, Swanson T, et al. International consensus document. Defying hard-to-heal wounds with an early antibiofilm intervention strategy: wound hygiene. J Wound Care 2020;29(Suppl 3b):S1–28.