Due to the increased costs associated with wound care, such as additional hospital/clinic visits, dressing changes, nursing care, and hospital stays, chronic or difficult-to-heal skin wounds – such as diabetic leg ulcers, burns, or pressure ulcers – impose an economic burden on the affected patient and healthcare system. Unfortunately, the number of patients with chronic wounds is expected to continue to grow due to the world’s aging population and the high incidence of chronic illnesses among the elderly. Antibiotic resistance is on the rise, as are comorbidities including diabetes, obesity, venous hypertension, and peripheral vascular disease, all of which drive up wound care expenses.

Dressings that require fewer changes — or more significantly, actually aid in the healing of wounds — may not only save money but also benefit patients by decreasing trauma surrounding the wound and imposing less restrictions on daily life [Image: Shutterstock].

Furthermore, proper wound care frequently necessitates modifications in practice, including the use of sophisticated technology. Effective therapy is characterised by rapid healing and with the use of newer, more cost-effective wound dressing technologies, several studies have demonstrated quicker wound healing periods and reduced wound diameters. It is critical to use dressings that decrease the need for cleaning, debridement, or ulcer evaluation while being clinically effective.

Wounds have a substantial influence on a patient’s health, quality of life, and family life. Patients believe pain to be the most prevalent and troubling symptom, resulting in decreased mobility, sleep disturbances, and work issues. Pruritus, discharge, and malodor are some of the other unpleasant symptoms.

HIGH COST OF WOUND CARE

The length of therapy is frequently connected to the cost of treatment, since the shorter the treatment, the lower the total cost of treatment. Apart from speeding up wound healing, a therapy may also be cost-effective since it minimizes the number of wound dressing changes necessary or the time it takes to apply the dressing.

Nurses’ time spent caring for wounds is a significant expenditure, according to studies conducted in various countries. For dressing changes alone, 57 full-time nurses were required in a Swedish community with a median wound incidence of 2.4 wounds per 1000 people. Wound treatment is known to consume up to 66 percent of community nursing time in Ireland.

The regularity with which dressing changes are required is a major resource problem, thus dressing selection is critical. Dressings that require fewer changes — or more significantly, aid in the healing of wounds — may not only save money but also benefit patients by decreasing trauma surrounding the wound and imposing less restrictions on daily life. Furthermore, the time saved by nurses responding to wounds may be spent on other critical care duties.

Infection, complications, and delayed healing can all result from using the improper dressing or wound-healing agent for the patient and wound, all of which drive up wound care expenses. Non-healing wounds are common, and they drive up wound care expenses dramatically. Many of these cost factors may be avoided. The basis for preventing increasing expenses by ensuring the wound management plan is full and suitable is a thorough, holistic evaluation with a strategy for regular reassessment. Both techniques for treating the underlying aetiology of the wound and the choice of dressing or wound-healing product should be included in the care strategy.

CHRONIC WOUNDS

Chronic wounds are those that have not gone through the usual healing process and have been open for longer than a month. Chronic wounds have a variety of causes, all of which place a strain on the health-care system. The process of cutaneous wound healing is extremely complicated, requiring a complex interplay between a variety of highly controlled variables to return damaged skin to a restored barrier function. In most superficial wounds, this sequence of events occurs normally; nevertheless, it can go wrong at any point, especially if there is an underlying illness such as diabetes.

The great majority of patients who have a long-term open wound also have additional serious health problems. Comorbidity refers to the existence of multiple chronic illnesses at the same time. Comorbidities complicate chronic wounds, making it difficult to track chronic wounds as a disease in and of itself. Chronic wounds, which are mostly a disease of the elderly, are growing more common, more difficult to cure, and relate to high treatment costs.

Chronic wound care has evolved into its own speciality, with sophisticated treatments such as growth factors, extracellular matrices (ECMs), synthetic skin, and negative pressure wound therapy being used. Vascular ulcers (e.g., venous and arterial ulcers), diabetic ulcers, and pressure ulcers are the three types of chronic wounds. Prolonged or excessive inflammation, chronic infections, the creation of drug-resistant microbial biofilms, and the inability of dermal and/or epidermal cells to respond to reparative stimuli are all frequent characteristics of these wounds.

The inability of these wounds to heal is the result of a combination of pathophysiologic events. The underlying diseases, on the other hand, differ amongst different forms of chronic wounds. Hemostasis, inflammation, proliferation, and remodeling are the four temporary and geographically overlapping stages that make up the physiological process of wound healing. Hemostasis occurs shortly after injury and is characterized by vasoconstriction and blood clotting, which stops blood loss and provides a temporary matrix for cell migration.

To start the healing process, platelets release growth factors and cytokines, which attract fibroblasts, endothelial cells, and immune cells. The inflammatory phase that follows might continue up to 7 days. In this phase, phagocytic cells such as neutrophils and macrophages are the most active. Neutrophils produce reactive oxygen species (ROS) and proteases, which help to clean the wound and prevent bacterial infection. At the wound site, blood monocytes develop into tissue macrophages. These not only eliminate germs and nonviable tissue, but they also produce growth factors and cytokines, which stimulate fibroblasts, endothelial cells, and keratinocytes to heal blood vessels.

The proliferation phase begins when the inflammatory phase fades away, accompanied by apoptosis. Tissue granulation, the development of new blood vessels (angiogenesis), and epithelialization are the main features of this phase. The last phase begins after the wound has healed and might continue anywhere from 1 to 2 years. The provisional matrix is transformed into collagen bundles at this phase.

Chronic wounds frequently stall during the inflammatory phase of healing. Despite variations in molecular aetiology, chronic wounds have a number of characteristics, including high levels of proinflammatory cytokines, proteases, reactive oxygen species (ROS), and senescent cells, as well as persistent infection and a lack of stem cells that are frequently often dysfunctional.

CHRONIC WOUND DRESSINGS

With the growth of chronic wounds and the morbidity that comes with them, wound care has become increasingly essential. Debridement, or the removal of non-viable tissue material, is an essential topic in wound care. This can be accomplished through surgical or autolytic/enzymatic mechanisms; in either case, the goal is to expose healthy, well-perfused tissue that can proliferate and populate the wound bed via epithelial cell migration, rather than necrotic debris that serves as fuel for infection and obstructs wound healing.

The quantity and complexity of wound dressings accessible to healthcare professionals is increasing, with each one having a unique set of characteristics. Multiple dressings are frequently used in combination. Because of the diversity of available products, clinicians and patients must exercise caution when choosing a dressing based on its intended use and performance qualities. Many wound dressings have been created to shield the healing wound from infection while also assisting in the wound healing process.

A moist occlusive dressing supports the inflammatory phase by generating a low oxygen environment (activating factors like hypoxia-inducible factor-1) and also speeds up the re-epithelialization process. Additionally, retaining a little amount of exudate on the wound allows for autolytic debridement, which helps to promote wound healing. Traditional dry gauze wound coverings, on the other hand, may impair this process while also causing further harm when removed.

Low adherent and semi-permeable film dressings

The most popular forms of wound dressings are low adherent dressings and semipermeable films, which are designed to prevent liquid and microbiological penetration while allowing air and water vapor to pass through. Hydrocolloids and hydrogels employ a hydrophilic substance that absorbs a little amount of exudate while maintaining a moist environment; hydrocolloids are also impervious to air and stay longer but should not be used on exudative wounds due to their impermeable nature. Because of its impenetrable nature, it may heal wounds.

Hydrogels can also be utilized to assist a wound that is ordinarily dry retain moisture. Alginate dressings, which are made from seaweed and are used to treat extremely exudative wounds due to their capacity to absorb significant volumes of fluid, are another alternative. As a result, unfavorable consequences might be evident in alginate-dressed dry wounds. Foams, on the other hand, have some absorptive ability and may be used on mildly exudative wounds, which is particularly useful since it reduces stress during dressing changes.

Collagen dressings

Collagen products have been utilized to treat persistent ulcers and resistant wounds. While this collagen is not intended to be a direct replacement for new collagen production in wounded tissue (since it can be derived from a variety of sources, including bovine and porcine collagen), it is thought to aid in the creation of an environment that attracts wound-healing cell types while depleting negative effectors like free radicals and proteases.

Multilayered hydrocellular polyurethane foam

Some dressings, such as multilayered hydrocellular polyurethane foam dressings, aid wound healing by minimizing leakage through a highly absorbent core that permits exudate to be retained. These dressings have a change indicator to guide dressing change frequency, as well as exudate masking to improve patient adherence to treatment and reduce wound social effect. They may also help to prevent infection by acting as a barrier to liquids and germs.

In 2 recent clinical trials of patients admitted to intensive care units, the use of multi-layer foam dressings was an effective way of preventing pressure ulcers. A recent randomised trial showed that using multi-layer polyurethane foam dressings in the sacrum region significantly helps to prevent the onset of pressure ulcers at the sacrum (8 vs 28; P = .001) when combined with standard preventive care by reducing the rate of pressure ulcers by 10.9%, possibly due to a redistribution of the mechanical forces of the foam.

In patients with heel pressure ulcers, application of a multi-layer polyurethane foam dressing with

a silicone border to volunteers with healthy skin decreased the interface pressure between the heel and a standard viscoelastic hospital mattress. A multi-layer foam hydrocellular prophylactic dressing also showed good effect in a long-term care setting when compared to simple protective bandaging.

A recent study examined the impact of a newly introduced multi-layer polyurethane foam dressing on efficiency and quality of care in routine clinical practice in a Spanish community setting. Between November 2017 and March 2019, the study was carried out in 24 primary care centers and 6 nursing homes throughout four Spanish regions.

The study found that the mean number of dressing changes was significantly reduced with the study dressing from 3.14 ± 1.77 changes per week to 1.66 ± 0.87 (P < .001), a 47.1% reduction in frequency. Wound area significantly reduced from 9.90 ± 19.62 cm2 to 7.10 ± 24.33 cm2. In addition, a 58.7% reduction in weekly costs was achieved with the intervention. Patients and providers agreed that their satisfaction with wound care improved.

CONCLUSION

Chronic wounds have a tremendous impact on the evolving science of wound care, proving especially troublesome for elderly patients with underlying conditions such as diabetes. An over-reliance on standard of care is not helpful, given the availability of chronic wound dressing solutions such as negative pressure wound therapy and multi-layer polyurethane foam dressings, the utility of which has been proven by numerous studies.

 

REFERENCES
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