There is greater pressure on community health programmes (resources and budget) than ever before. A significant challenge that besets the nurse working in the community setting is related to wound care. Over one year, managing wounds in the community requires around 18.6 million practice nurse visits, 10.9 million community nurse visits, 7.7 million GP visits and 3.4 million hospital outpatient visits (Guest et al, 2017a). Community nurses visit 1.45 million people with wounds each year and 39% of those wounds will not have healed after 12 months (Guest et al, 2017a). This incurs significant cost on the health service, and impacts negatively on patient quality of life.

In both acute and chronic wounds, the presence of devitalised tissue (slough and/or eschar) can prevent or delay the healing process (Swanson et al, 2015; Ousey et al, 2016). Removal of this devitalised tissue by debridement is a prerequisite for enabling wound healing progression (Robson et al, 2001; Falanga et al, 2006; Barrett, 2017). Debridement is supported by a raft of clinical evidence (Wilcox et al, 2013; Nazarko, 2015) and is an integral component of clinical guidelines and a basic tenet of wound bed preparation (Sibbald et al, 2000; Schultz et al, 2003; Strohal et al, 2013).
 
A number of different debridement methods – surgical/sharp, autolytic, enzymatic, biological, and mechanical – are available (Schultz et al, 2003; Gray et al, 2011; Vowden and Vowden, 2011). The method chosen is based upon a number of criteria including the patient’s general condition, wound status, skills of the clinician and the availability of resources (Schultz et al, 2003; Gray et al, 2011; Vowden and Vowden, 2011). In a community setting, autolytic debridement using moisture-donating dressings is frequently used owing to its simplicity and ease of use —it doesn’t need specialist training or competency and dressings are readily available — but it can be perceived as being a slow process. In addition, the prolonged presence of devitalised tissue within the wound can increase the risk of infection, if autolytic debridement is lengthy. A quick and easy to use debridement method that can speed up removal of devitalised tissue and promote healing would therefore be a useful tool for nurses delivering wound care in the community setting
 

HYDRO-RESPONSIVE WOUND DRESSING (HRWD)

HydroClean® plus is a Hydro-Responsive Wound Dressing (HRWD) that is indicated for the removal of devitalised tissue (e.g. slough and eschar) in acute and chronic wounds, such as pressure ulcers, diabetic foot ulcers, and venous leg ulcers. The HRWD cleanses, debrides, desloughs and absorbs. It comprises a soft and comfortable pad, which contains a Hydro-Responsive matrix at its core. Superabsorbent polyacrylate (SAP) particles containing Ringer’s solution — an isotonic salt solution that has been reported to have clinical benefits (Colegrave et al, 2016) — form part of the matrix and provide a continuous rinsing and absorbing effect to support effective wound bed preparation. Pre-activation of the SAP with Ringer’s solution allows for rapid and sustained cleansing of the wound bed (König et al, 2005; Humbert et al, 2014; Spruce et al, 2016). 
 

STUDY AIM

The aim of this study was to assess the ability of HRWD to cleanse, debride, deslough and absorb wound exudate in a variety of sloughy/necrotic wounds in a community setting

 

METHOD


Study population
This study was a sub-population analysis in which 10 patients treated in the community were drawn randomly from a larger study: an open, non-comparative, multi-centre investigation case study series of 100 patients (as reported in Hodgson et al, 2017).

The inclusion/exclusion criteria are presented in Table 1.

The patients were drawn from across the Greater Glasgow and Clyde region and the patients had a variety of different wound types (Table 2).



Table 1 Patient population
Table 1. Patient population
 
 
Ethics approval
Patient participation was voluntary. Study participants were provided with patient information and were asked to sign an informed consent form before inclusion.

The study protocol, patient information and consent form were approved by an Independent Ethics Committee before patient enrolment (Approval reference Number AT0202). The investigation was performed in accordance with the Declaration of Helsinki and applicable regulatory requirements.
Table 2 Summary Data collected for community groups
Table 2. Summary data collected for community analysis
Patient assessment­­­
Each patient selected at random (n=10) had a retrospective interrogation of their case notes to identify wound and other parameters, including the treatments used in the two-week period immediately before treatment with HRWD, then to record information over a two-week treatment period or for a minimum of four dressing changes with HRWD. Wounds were treated according to local clinical practice and evaluated during a treatment period of two weeks or for a minimum of four dressing changes with HydroClean® plus. All dressings were applied according to the manufacturer’s instructions. Patients were assessed at baseline and again at subsequent dressing changes, which were made at a frequency dictated by individual clinical need. Parameters collected for analysis to determine clinical efficacy were:
  • Percentage of devitalised tissue present
  • Wound bed preparation (e.g. development of granulation/epithelial tissue)
  • Pain
  • Wound size
  • Peri-wound skin condition.
Data relating to the cost of treatment in two-week periods, before and during the use of HRWD was also collected retrospectively and compared.
 
Treatment cost analysis
Costs were assigned to each treatment using:
  • Wound-care products: Wound Care handbook 2017–2018. www.woundcarehandbook.com
  • Nurse time:  via Royal College of nursing NHS Payscales 2017–18 valid from 1st April
  • Pharmaceuticals: Dermatology Handbook 2017–18. Published in association with Journal of Community Nursing, British Journal of Nursing, Aesthetic Nursing, Nursing and Residential Care, Practice Nursing and Independent.


RESULTS

Wound type, duration and size
The data collected for the 10 patients showed that they had a wide variety of both acute (e.g. skin fold lesions, leg trauma, amputation) and chronic (e.g., pressure ulcers) wounds of varying sizes (range =1.1 cm2 to 182 cm².  The wounds had been present for a wide duration of time (range =14 days to 4 years; mean duration = 310 days; SD = 475 days). During or at completion of treatment with HRWD, a decrease in wound size and correlating increase in the percentage of granulation tissue demonstrated wound bed preparation and progress of healing, respectively. Nine out of 10 patients continued to show wound progression after the HRWD treatment.
 
Previous treatment
A wide variety of different dressing regimens had been used to treat the wounds (foam, hydrogel, negative pressure wound therapy (NPWT), etc) with foam dressings pre-dominating.  

Tissue types present
The data (Figure 1) showed a high volume of slough and necrosis in the patients at baseline before treatment. However, after two weeks of treatment with HRWD, the majority of the wounds had effectively been debrided such that 5, 1, 3 and 1 patients showing a corresponding increase to 100, 95, 80 and 60 % granulation tissue, respectively after the treatment period.  Three wounds also showed re-epithelialisation. In conjunction with, and as a consequence of, the wound bed improvement seen in these patients, a reduction in wound area and progression to healing was seen in 9 of 10 subjects (Figure 2). This was particularly remarkable as some of the patients had suffered chronic wounds for months and years. In particular, one patient with a heel ulcer of more than four years’ duration saw a wound area reduction of 59% after treatment with HRWD, and a 95% granulating wound bed.
 
Pain
In this study, 8 out of 10 patients suffered a degree of pain in the period before treatment with HRWD. All 8 of the patients suffering pain before treatment with HydroClean® plus demonstrated a reduction in pain during treatment (Table 3; Figure 3).
Figure 1. Wound Bed Changes Before and After Treatment with Hydroclean plus

Figure 2. Percentage Reduction in Wound Area

Figure 3. Changes in Pain Scores and Peri-wound Skin Conditions after Treatment with HRWD
Peri-wound skin
Table 3 shows that 8 out of 10 patients had damaged peri-wound skin in the 2 weeks before treatment with HRWD, with issues including eczema, excoriation and maceration present. However, after treatment with HRWD, 7 out of 8 patients with damaged skin showed significant improvements (Figure 3).
 
Cost analysis
An audit was undertaken to identify and collate the costs of the treatment regimens for the ten patients in two week periods before and during the use of HRWD. The results are presented in Table 4. This analysis shows that the costs were £1405.60 compared with £1058.56, before and during use of the HRWD, respectively, and equates to a saving of £347.04 (25%).
 

Discussion
According to the most recent perspectives on causes and treatment of wound chronicity (Parnham and Bousfield, 2018), the ability to remove devitalised tissue will facilitate healing. This has been demonstrated in the clinical outcomes seen in this study. Furthermore, it has been estimated that 60% of all chronic non-healing wounds have a biofilm component (Moore, 2017). In order to address the clinical challenges of biofilms in chronic wounds, Hydroclean plus has been developed as a dressing with a multi-modal (but non-medicated) antimicrobial action. These mechanisms include 1) breaking up and dispersal of biofilms such that the resultant planktonic bacteria are absorbed by the dressing and then 2) sequestered and retained (trapped) within its matrix. Additionally when PHMB (polyhexamethylene biguanide) is bound within the dressing core, but is not released into the wound environment there is the added anti-microbial effect resulting from 3) physical contact with this antiseptic component. Reducing the pathogenicity of the bacteria still further is the ability of this dressing to 4) absorb and sequester the damaging proteases released by pathogenic bacteria (Rippon et al, 2018).

Marked improvement in peri-wound skin condition was seen in 7 out of those 8 patients who had damaged skin in the two weeks before the evaluation (Figure 3). This is particularly important because the skin surrounding either an acute or chronic wound is generally subject to varying degrees of traumatic insult, either from application/removal of wound dressings/tapes or application of cleansing regimens. This makes care of peri-wound skin challenging.

This is particularly so in patients with, for example, venous leg ulcers, because changes in the local circulation in conjunction with venous hypertension can lead to micro-oedema which can then cause conditions including lipodermatosclerosis, atrophie blanche, hyperpigmentation, dry, scaling and atrophic skin and venous stasis eczema. These conditions are often associated with vulnerable peri-wound skin that is thin and easily damaged by chemicals (e.g., wound dressing adhesives) (Lawton and Langøen, 2009). 

These skin conditions can be further complicated by dermatitis (defined as an inflammation of the skin) caused by infection, allergy (allergic contact dermatitis), and irritating substances (irritant contact dermatitis). It is likely that the mechanisms by which HydroClean® plus aids in peri-wound damage limitation includes the absorbent and retention capabilities of HydroClean® plus removing the wound exudate (containing damaging biological components such as proteinases and MMPs) and the provision of dressing’s Ringer’s solution providing a dilution effect of damaging components. Both of these mechanisms will help to alleviate the peri-wound damage and support improvement of the surrounding cutaneous tissue.  
 
 
Pain
Pain is a significant problem in patients with chronic wounds and a challenge that frequently has to be addressed by the community nurse (Vandenkerkhof et al, 2013). In this study, 8 out of 10 patients suffered a degree of pain in the period before treatment with HRWD. All 8 of the patients suffering pain before treatment with HydroClean® plus demonstrated a reduction in pain during treatment (Table 3; Figure 3). This data is comparable to that of previous studies that have shown that the use of HRWD has resulted in pain reduction (Hodgson et al, 2017). This is in part thought to be as a consequence of the Ringer’s solution that is released into the wound environment from the dressing (Colgrave et al, 2016) and the moist wound healing environment established when using modern wound dressings. High wound bioburden is associated with pain (Bjarnsholt et al, 2008) and the decrease in perceived pain reported here may also relate to a reduction in wound bioburden and reduced inflammation. Additionally, comments from both the nurses and patients involved in this study were very positive and re-inforced the results presented in Table 3.
 

Cost analysis
An audit was undertaken to identify and collate the costs of the treatment regimens for the ten patients in two week periods before and during the use of HRWD. The results are presented in Table 4. This analysis shows that the costs were £1405.60 compared with £1058.56, before and during use of the HRWD, respectively, and equates to a saving of £347.04 (25%).

These costs compare favourably with other studies that have looked at cost savings elicited using HRWD. Table 5 presents the ‘real life’ cost of using various debridement methods (Hodgson et al, 2017) and compares them with overall and mean costs of debridement calculated from data obtained from the sub-population analysis of those patients treated in the community setting. The results show that there were cost savings when using HRWD for debridement versus other methods.

Such cost savings have also been seen in a comparison of the full set of 100 patients that were matched with data obtained from the THIN (The Health Improvement Network) database, a database of over 10 million medical records (including almost 4 million active patients) (http://www.ucl.ac.uk/pcph/research-groups-themes/thin-pub/). In this analysis, the results showed that costs for chronic wound debridement were, for THIN versus Glasgow study, £750 vs £255, respectively and that HRWD was the dominant treatment (Guest, 2017b). In the main, these costs savings have been related to the time nurses have spent in treating/debriding the wounds rather than the cost of the dressing per se which is actually a very small part of the overall cost.
 
Case Study examples:
The Case study presented in Figures 4 and 5 relate to patients 8 and 9, respectively and illustrate the effective debridement and healing capabilities of HRWD.
Figure 4. Patient 8 Before and After treatment with HydroClean® plus
A 72-year-old male with previous blackout problems and haematuria.
 
Wound history: patient burnt himself with hot water and porridge
Wound size and duration: wound size 26cm x 7cm of 7 weeks’ duration
Wound history: very slow autolytic debridement over the previous 7 weeks with conventional dressings which included Actiform cool with 365 films to cover and Aquacel and UrgoClean to top of the forearm area. Wound had a slight odour.
 
 
Wound-dressings-case-study1.1
12/04/17

12/04/17
 
 
Wound-dressings-case-study1.1
12/05/17

12/05/17
 
 
Outcomes
Patient comments – comfortable dressing reduced pain at wound site Clinician comments – clinical objectives met. Area desloughed within 14 days. Slough had been present for 6 weeks but other products not removing devitalised tissue. Good conformability and acceptability. The condition of surrounding skin was good. Dressing hydrated area well and enabled some sharp debridement to show clean wound bed. Slight hyper-granulation but this quickly resolved
Figure 5. Patient 9 Before and After treatment with HydroClean® plus
A 56-year-old female presented with a history of previous lower limb and foot water blisters leading to ulceration. The patient had Vitamin B12 and D deficiency, Discoid eczema and mild neuropathy.
 
Wound history: the patient had various wounds that had been present for two months.
On presentation (03-Feb-2017), blistered area 45 mm x 25 mm with a sheen lying over the wound. A very thick fibrous slough with almost 100% coverage of the wound was evident.
Previous Treatment history: Inadine, Mepilex, Softban and Kling. Flaminal was also tried. 
 
 
Wound-dressings-case-study
3/02/17

10/02/17
 
 
Outcomes
Clinician comments: clinical objectives met. Good conformability, easy to apply and remove. Good for patients with thick fibrinous slough which cannot be removed by sharp debridement or for patients where sharp debridement is too painful. Thick fibrinous slough became much softer and easier to debride with continued use of HydroClean® plus [AQ; pic 10/2 as above?] and by 24-Mar-2017 there was 100% epithelialisation, i.e. the wound went on to heal completely using HydroClean® plus
 
 
 
Conclusion
This study has shown that in terms of debridement HRWD has an advantage over other debridement methods in terms of cost. However, more importantly, the simplicity of its application – especially in a community setting – means that the most valuable resource of ‘time’ is saved. It is also significant that even in this small population of patients, wounds that had been present and indeed static for many months/years showed transformations from non-healing to healing. This not only impacts significantly in terms of patient health benefits (including psychological and social), but also the longitudinal costs of treating long term chronic wounds may be drastically reduced.

This is of significance to the nurse who has a limited allotment of time for the patient at each visit and this then allows for more to be done within that time period, or for more patients to be visited on a daily basis.

Community nurses are working increasingly in isolation and without the supporting infrastructure of a hospital or a surgery, and with the added pressures of more patients, less time and less resource allocations. From this perspective, even more reliant on the use of evidence-based practice to guide them. From their perspective the overall results from this study highlight the benefits of using HRWD as a rapid and effective debridement tool that provides benefits for both the nurse and the patient.
 

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