An Evidence-Based, Sustainable Solution for Wound Management in Low-Resource Settings: Part 2

The Available Technology Dressing (ATD) Randomized Controlled Trial 

Linda Benskin, PhD, RN, SRN (Ghana), CWCN, CWS, DAPWCA, WOCNF and Richard Benskin

Editor’s Note: This series originally appeared on Today’s Wound Clinic and is adapted with permission. The peer-reviewed article from which this commentary originated is published with Wounds. 

Part 1 in the series can be found here.

Knowledge of the basic science of wound healing guided the development of an improvised wound dressing for resource-limited settings in the tropics. The FW dressings used in Japan were modified significantly to accommodate the special needs of patients in a much warmer environment with fewer resources.^19,20,41 A Wound Healing Foundation grant helped fund a three-armed,12-week, evaluator-blinded, non-inferiority RCT.⁴² The study, conducted at the University Hospital of the West Indies in 2021, was registered on ClinicalTrials.gov prior to the first patient visit.⁴¹ Sickle cell leg ulcers (SCLUs) became the focus due to their relative homogeneity, relative abundance in Jamaica, and the critical need for a more effective wound dressing solution for these patients.^43–46 The added challenge of ischemia helps explain why SCLUs heal 3 to 16 times more slowly than VLUs.^45,47,48 SCLUs tend to be recurrent, and are often so painful that opioids are insufficient.^45–48 

Technology is the application of scientific knowledge for practical purposes.^49,50 The improvised dressing was named the Available Technology Dressing (ATD) technique because the study participants demonstrated that accurate implementation is not intuitive to untrained wound patients, and it is critical to its success; careful teaching and demonstration/return demonstration is required.^41,51 

The ATD technique consists of: (1) thorough wound irrigation with strong squeeze on a homemade device (a ~500ml soda bottle with a hole from a hot bicycle spoke in the cap) filled with homemade saline; (2) drying the periwound, then protecting it with a non-toxic moisture barrier (eg, zinc oxide paste); (3) a cut-to-fit piece of food-grade clear plastic bag (a clean semipermeable membrane), with slits to allow excess fluid to escape, gently conformed to the wound bed and the moisture barrier; (4) fluffed clean absorbent material placed over the slits to absorb the excess fluid; (5) all of this held in place (and, when tolerated, compression applied) with a snug wrap.^9,41 Daily, the ATD was removed, the wounds were irrigated thoroughly, the periwound was dried, and a new ATD was applied.^41,51–53 Exact dressing components can vary based upon availability. 

Comparator dressings: Because other wound management methods have not led to superior outcomes, standard of care for SCLUs world-wide is wet-to-dry gauze or dry gauze over an ointment.^47,54 However, these dry and adhere to the wound bed, which is not congruent with the goals of lay health practitioners in village settings or modern wound theory.^4,55 Therefore, the researchers chose saline-soaked (wet-to-moist) gauze, or WTM, for the usual practice (negative control) arm of the study, fluffing the gauze to help keep it moist.⁴ The wound was irrigated well, at daily dressing changes. 

The Sickle Cell Unit in Mona, Jamaica had trialed many advanced dressings, including honey, Unna boots, FW (used circumferentially, as in Japan), and hydrocolloid dressings, which all failed to produce superior results and/or were not accepted by patients, in part due to the warm climate.⁴¹ However, comparing the ATD only to WTM dressings would assure the impending obsolescence of the study results, because saline-soaked gauze is widely regarded as inferior to advanced dressings.^56–59 

The only advanced wound dressing type with a strong record of success in the tropics is polymeric membrane dressings, or PMDs (PolyMem^®, Ferris Mfg. Corp., Ft Worth, TX, USA).^14,60 PMDs do not melt, break apart, or adhere to wound-beds in a warm environment, and they are well tolerated in the tropical heat.^14,61,62 The continuous cleansing system that is an integral function of PMDs mitigates the problem of increased wound infections in the tropics.^14,61 PMDs also control inflammation and decrease pain, two key influencers of healing important for SCLUs.^14,60,63 When used on VLUs, even without compression, PMD use led to increased wound closure rates and decreased pain.^62,63 PMDs are among the very few advanced wound dressings mentioned favorably in the sickle cell scientific literature.^47,64 This made PMDs the logical choice for a positive control.^{14,61,65–69}

Study results: Due to the pandemic, the 40 study participants tended to be older, with large, long-standing SCLUs - all predictors of ulcers increasing, rather than decreasing, in size.^41,48 Statistical results were obtained and evaluated by three statisticians to ensure accuracy of interpretation of this small, heterogeneous data set. Participants in all three groups saw improvement in both ulcer closure and quality of life compared with their previous practice. Overall, the ATDs (13 participants) were clinically superior to WTMs (16 participants), and only modestly clinically inferior to PMDs (11 participants) with respect to decreased wound size and pain. ATDs proved to be safe: the only study complications were in the WTM group, with four (25%) patients developing Pseudomonas infections. These resolved quickly when irrigated with 0.5% vinegar, per the study protocol.⁴¹ 

Although Wound Quality of Life and ASCQ-Me Pain scores improved most with PMDs, ASCQ-Me Pain scores improved more in participants using the ATDs than WTMs.  Wounds decreased in size much more often with ATDs than with WTMs as well (92% vs 50%). PMDs were by far the least time consuming to use, but ATDs were far less expensive (daily ATD materials costs were half that of WTM costs). Participants in all three groups gave ATDs high marks for acceptability. WTMs, which are commonly used worldwide, were not superior to ATDs by any metric. 

Concluding Thoughts

Rigorous surveys confirmed that moist wound management is preferred, even in a tropical environment. However, until now, cost and availability has made it difficult for lay health care providers to provide a moist wound environment. The ATD technique proved safe, effective, affordable, and acceptable on sickle cell leg ulcers in Jamaica, and their use dramatically improved pain scores when compared with WTMs. Although PMDs outperformed ATDs for both pain relief and healing, ATDs were not dramatically inferior, they are far less expensive, and they are far more available. Study participants were able to master the dressing technique quickly, and preferred the ATD technique over other choices. WTMs were inferior to ATDs in every respect. The ATD technique finally provides a sustainable evidence-based solution for wound management in remote and conflict areas of tropical developing countries, and it shows promise for use in other resource-limited environments as well. 

This study demonstrated that the proposed ATD concept is sound. All materials (the irrigation device, periwound protectant, primary dressing, absorbent, and wrap) should be chosen for their functional properties and be readily available (which implies affordability) in the setting of the learners. Because the technique must be rigorously followed for the dressing to provide optimal benefits while minimizing risk of complications, the reason for each aspect of the dressing technique must be taught. This will empower the learners with the basic scientific knowledge to know which aspects of each material and which aspects of each step in the technique are critical. 

The below figure(s) are used with permission from Linda and Richard Benskin:

Linda Benskin gained extensive wound management experience providing primary care for five years in a remote conflict-prone area of West Africa. She wrote a comprehensive handbook for the self-supporting village health worker training program she developed. The lack of sustainable wound management solutions in this challenging environment drove her to a deeper understanding of the basic principles and physiology underlying wound healing. 

Dr. Benskin emphasizes working with the body to promote healing, often with information-dense heavily-referenced articles and presentations. Topics include basic wound healing principles, managing wound infection, pain and inflammation, and the role of vitamin D. She presents at conferences, in classrooms and hospitals, via webinars and podcasts, in church foyers, and under mango trees. Her eager audiences have ranged from experienced surgeons to barely-literate villagers across six continents. 

Dr. Benskin works for Ferris Mfg. Corp. and independently with her husband, Richard. The Benskin Research Group developed the Available Technology Dressing technique for resource-limited settings, conducting a grant-supported RCT demonstrating its safety and effectiveness. Linda Benskin was inducted into the inaugural class of WOCN Fellows in 2023. 

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