In my recent WoundSource webinar, I discussed the topic of chronic wound etiology and management. The webinar is still available for viewing on WoundSource.com. Chronic wounds are vexing and frustrating to manage; they can be expensive and are a huge source of morbidity and mortality. Infection prevention is a key part of chronic wound management, with recognition of the role that biofilms play. In the webinar, I addressed:

• How to differentiate between acute wounds and chronic wounds
• The risk factors for chronic wound development
• How to identify the four most common types of wounds: pressure injuries, venous ulcers, arterial ulcers, and diabetic ulcers
• The development of biofilm and the role it plays
• How best to conquer biofilm and prevent wound infection
• How to apply the concepts of antimicrobial and moisture retentive dressings and treatments to chronic wound healing

I was able to answer a few questions after the presentation, but there were so many more! Here are the answers to some of these questions.

Frequently Asked Questions

Question: How does one treat a heel eschar on a chronically non-compliant patient with diabetes?

Answer: There isn't much you can do or healing to expect when you run into such non-adherence to wound healing suggestions. Patients have the right to refuse treatment, but like I have said in the past, they also have the right to sue you for bad outcomes. This is where good documentation is key! Documentation should always include your education of the patient about the possible outcomes (loss of limb and maybe even life), your patient's reactions to that education, the reasons for non-adherence, and what other possible alternative treatments may have been offered. I am sure you have checked out the patient's HbA1c to try to correct any chronic hyperglycemia, as well as circulation for any possible interventions to correct ischemic issues. Barring all that, it may be time to take a more palliative approach to this wound, explain it to your patient, and maintain the eschar with Betadine to keep it dry and stable.

Question: Do you agree it is pertinent to remind nurses that conservative sharp wound debridement is a nursing competency that requires further training and education?

Answer: I think I understand the root of your question, and that is, if we are focusing so much on the importance of debridement as a very first important step in chronic wound management, how can we expect nurses, if unable to debride, to take the helm? In the USA, regulations for sharp debridement vary from state to state, and each state's Nurse Practice Act or Board of Nursing dictates specific regulations for this procedure. In my travels around the country, when querying various nurses about the regulations in their state, the answer seems to be the same as in mine. Generally, wound-certified nurses are able to debride, but be sure to check with your individual state's licensing body. The Wound, Ostomy, and Continence Nurses Society™, in their best practice document titled "Methods of Wound Debridement,"¹ state that the skill level required of someone to debride is a "Licensed healthcare provider who has been specifically educated, trained, and demonstrated competency in sharp debridement in accordance with licensure and facility policies and procedures." So, to protect your license and make sure your skills and knowledge are up to snuff, it is best to develop a competency-based document and then be evaluated and signed off by your medical director or other licensed professional qualified to do so.

Question: Is "unavoidable" an applicable designation for a pressure ulcer in acute care?

Answer: The quick answer is, to date, NO. In acute care, the pressure ulcer must be documented on admit for it to get a "POA code" (Present on admit); otherwise, it is considered a hospital-acquired condition (HAC), and the costs for it are not reimbursed. There are some exempt hospitals to this, which include the Veterans Affairs hospitals, critical access hospitals, and others. Of course, this poses a real dilemma for hospitals, which are taking care of the sickest patients at risk of unavoidable ulcers despite best care, especially when experiencing skin failure at end of life. Also, a deep tissue injury may not be apparent for a good 48-72 hours, so the skin may appear intact on initial presentation, but then over the next few days devolve to a deep tissue injury-type ulcer. Here is where a really good history will come in handy; for instance, has the patient been down on the ground for days or had other exposure to increased pressures?

Question: If the bone is exposed, should I keep it moist?

Answer: Bone should be kept moist if possible, to prevent it from desiccating. It is possible to granulate over bone.

Question: Does negative pressure wound therapy affect biofilm?

Answer: Negative pressure wound therapy with instillation has proven itself to be a marvelous agent in reducing bioburden in a wound. With its programmed instill – hold – vacuum times it "washes" bacteria and biofilm out of the wound, yet continues to provide negative pressure to aid in granulation. I am told that, initially, an antimicrobial solution works most efficiently in really contaminated wounds, and then you can step down to a normal saline solution.

Question: Isn't crushing Flagyl tablets onto a wound inappropriate? All the pharmacists I have talked with about this recommend the Flagyl gel. PO meds in wound beds are off-use, right? But if you do use it, what dosage and how often?

Answer: For me, crushing the Flagyl tablets (either 250 or 500mg) and sprinkling onto foul wounds, particularly fungating tumors, has been a marvelous agent! It decreases the odor and the drainage even after just a couple of applications, and patients and their families have been so grateful for that. After sprinkling the Flagyl, I generally cover the wound with a single layer of Vaseline gauze, which is non-adherent and easy to remove, covered with dry gauze. Secure it with some type of mesh netting so you don't have to use tape. Of course, you would have to use a cover dressing that is more absorbent if it is a highly exudating wound. Usually once or twice a day is a good frequency, depending on the exudate, which often subsides with Flagyl use. But you are right that using a PO med is going off label, and so Metrogel (which contains metronidazole) has been suggested. Maybe it has worked for some, but I find that the crushed tablets are more effective. Metrogel also contributes moisture to the wound and so is not appropriate for a wound with a lot of drainage. How to get around that dilemma? If your facility has strict protocols that expressly prohibit this off-label use, you are kind of stuck. But I know that hospice nurses in the home prefer the crushed tablets as well and are usually able to get them for their patients.

Question: I have been hearing about and seeing studies mention that Silvadene is not really effective anymore for wound healing. Your thoughts on this?

Answer: Silvadene (silver sulfadiazine) was invented in the 1960s for burn care, and as far as I know, could be said to be the first commercial silver product on the market. Like other silvers, it is a broad-spectrum antimicrobial with no known resistance and is still used for wound care to this day. The problem with Silvadene is that it contains a large amount of silver that is rapidly"dumped" into the wound with each application. This silver is quickly depleted, and then there is no more coverage of silver as an antimicrobial in the wound bed until the next application. This is unlike more modern silver dressings that provide continuous silver coverage and antimicrobial effect.

The high amount of silver dumped into the wound may be cytotoxic and could actually delay wound healing. Also, Silvadene creates what some have called a "pseudo-eschar"that comes about with continued application despite wound cleansing. This means the Silvadene is going on top of the previous layer of Silvadene and so on and so forth and not getting to the wound bed. It is contraindicated in pregnancy and in neonates, with concern for systemic absorption. With large wounds, it can even cause hematologic effects such as agranulocytosis and aplastic anemia and also sensitivities. Not even to mention the soupy mess it can make! Having said that, I do still use it occasionally in my practice. When do I use it? Usually when other options are really limited and for whatever reasons we are unable to get other dressings for patients. It has occasionally worked well in palliative wounds where healing maybe is no longer the goal. It is easy to get, relatively cheap, easy to teach patients to apply, and is usually covered by insurances.

Question: Could you again review the strength of Dakin's Solution?

Answer: As you know, Dakin's (bleach or sodium hypochlorite) fell out of favor for a while with concerns for cytotoxicity, but today is the comeback kid for use in foul wounds with high bioburden. It was developed during World War I and saved a lot of legs and maybe even lives! At least twice-daily dressing changes are usually needed, or Dakin's can be used as a wound cleanser. Generally, I use no stronger than ¼ strength Dakin's, which is 0.125%. So often I have seen ¼ strength mistaken for 0.25%, which is actually ½ strength Dakin's, so be sure to check your patients' bottles. Full strength is a 50% hypochlorite dilution (0.5%). In one study, a 0.025% Dakin's Solution was found to be 100% bactericidal for Staphylococcus aureus and non-cytotoxic for fibroblasts.²

Higher concentrations of Dakin's solution were bactericidal as well, but they were also cytotoxic. So it is not a bad idea to limit its use to those really foul wounds covered with devitalized tissue and discontinue use when the wound is cleaner. It is a marvelous mechanical debriding agent as well! Who is going to worry about its effect on fibroblasts if we don't yet have any granulation tissue possible in the wound? More modern chlorine-based agents are on the market such as hypochlorous acid, with all the benefits of sodium hypochlorite but none of the cytotoxicity; however, available at a different price-point. Check out the article by Cornwell et al.³ for more information about Dakin's and some case studies.

Conclusion

Thanks for the great questions! I find myself learning a lot in the process, trying to make sure my information is up to date and follows all the tenets of best practice. Also, be sure to check out my blogs on WoundSource, "Legal Perils and Pitfalls of Wound Care."

References

1. Wound, Ostomy and Continence Nurses SocietyTM. Methods of Wound Debridement: Best Practice for Clinicians. Mt. Laurel, NJ: Wound, Ostomy and Continence Nurses SocietyTM; 2015.

2. Lineweaver WC, Howard R, Soucy D, et al. Topical antimicrobial toxicity. Arch Surg. 1985;120:267–270.

3. Cornwell P, Arnold-Long M, Barss SB, Varnado MF. The use of Dakin’s solution in chronic wounds: a clinical perspective case series. J Wound Ostomy Continence Nurs. 2010;37(1):94–104.

About the Author

Heidi H. Cross, MSN, RN, FNP-BC, CWON, is a certified Wound and Ostomy Nurse in Syracuse, NY. She has extensive experience caring for wound and ostomy patients in acute care as well as in long term care facilities. Currently, she is employed by CNY Surgical Physicians consulting for nursing homes in the Syracuse area, and has served as an expert witness for plaintiff and defense attorneys.