By: Julie Williamson | March 1, 2014
Wound management is one of caregivers' most critical roles, posing a huge challenge. And when wounds become infected, it creates a whole new set of difficulties that can leave residents' health vulnerable and send care teams scrambling for effective solutions.
Pressure ulcers, lesions, cuts, tears or other open injuries to the skin pose a greater infection threat to seniors than other groups. Aside from advanced age, many long-term care residents have comorbidities, such as diabetes, peripheral vascular disease and neuropathy, which can delay healing and increase infection risks.
“When a wound becomes infected, it's critical that it's discovered early — before it has a chance to really take hold,” stresses James Spahn, M.D., FACS, a head and neck surgeon and soft tissue expert who also serves as founder/CEO of EHOB Inc. and co-founder of WoundVision. “Unfortunately, that often does not happen, especially in long-term care where resources are sometimes scarce, education is often lacking and where wound management and infection control experts aren't always available.”
Pressure ulcer statistics alone underscore the need for constant vigilance. Infection is the most common major complication of these wounds, and if left unchecked, can lead to sepsis, osteomyelitis, bacteremia or death. Numerous studies show that wound-related bacteremia can increase the risk of mortality to 55%.
Even though all wounds are colonized with bacteria and its presence doesn't automatically mean a wound is infected, the risks cannot be ignored.
“Once the dermis is breached, it loses the ability to keep in moisture and keep bugs out. Once a wound reaches full thickness, everyone becomes vulnerable to infection,” Spahn says. “It's not just a nursing problem. Everyone must be involved in the process and doing their part to detect infection as early as possible and initiate effective treatment.”
Kicking bad habits
Proper infection detection and treatment can be crippled in the presence of bad practice. Unfortunately, some caregivers aren't even recognizing clinical signs of infection. These may include the presence of increased wound exudate, redness in the wound bed, new onset or increasing pain, non-healing or stalled progress in the wound area, and debris in the wound bed, points out Holly Korzendorfer, PT, Ph.D., CWS, FACCWS, vice president of business and clinical development for DermaRite Industries.
Warmth, erythema or edema are also signs of local infection. Staff also should be looking for signs of systemic infection, such as malaise, fever or chills, nausea and vomiting, or abnormal lab values.
“If three or more of these clinical indicators of infection are present, systemic and local treatment is recommended,” Korzendorfer says.
But not all clinical indicators are a slam dunk. As Spahn explains, fever is not always present and dementia can mask pain and other more overt signs of infection, which makes early detection more difficult.
“If you wait for swelling, pain, diminished function, and pus to surface, it's sometimes too late,” he says.
Diligent, frequent skin and wound assessments are critical for detecting early inflammatory response and for documenting the subtle changes, including mood, appetite, energy levels, and more, that could indicate the start of infection.
“There is a delay between when an infection is starting and when it's truly recognized and treatment begins. It's important to be asking what is different with the wound and the resident,” Spahn says. “This is why it's important to have everyone — from administrative staff all the way to the person who changes bed linens — involved and educated on wound and infection detection and prevention, and all the factors that can increase a person's risks.”
Having skilled wound care experts on hand to guide the process is equally critical, says Laura Dahl Popkes, RN, CWOCN, clinical services manager at McKesson Medical-Surgical. “Wound patients deserve to be evaluated by a medical professional who is competent in wound care.”
In fact, it's a right listed in the Association for the Advancement of Wound Care's Wound Patient's Bill of Rights, she notes.
Drugs, dressings overused
Antibiotics aren't always appropriate, although they remain many facilities' go-to weapon. “Systemic antibiotics should not be considered the first choice for addressing a wound infection, and many times they are not necessary at all,” stresses Margaret Falconio-West, BSN, RN, APN/CNS, CWOCN, DAPWCA, the senior VP of clinical services for Medline Industries. Caregivers must understand that systemic treatments are of little value if the vascular supply to the wound area is inadequate to deliver it, adds Janice M. Smiell, M.D., chief medical officer at Alliqua Inc.
Overtreatment with intravenous and oral medication remains a common problem, according to Vicki Fischenich, RN, MSS, GNP-BC, WCC, of Southwest Regional Wound Care Center in Lubbock, TX. [Editor's note: Fischenich has since become Clinical Specialist for OSNovative Systems.]
The bottom line, Smiell says, is that when a wound change is noted early, intervention as simple as an advanced dressing might be enough to prevent the need for systemic therapies, surgical debridement and, above all, the complication of sepsis from a preventable infection.
Yet overuse of topical antimicrobial dressings continues to be a pitfall in the skilled nursing environment. While empirical treatment with a dressing that isolates microbes from the wound or has a broad-spectrum kill can be instituted at the first (local) sign of potential infection, extended use isn't always prudent.
“Using silver-based products for multiple years to treat chronic wounds is still happening in the field,” Smiell says.
Silver-based dressings can be used up to a week, but the caregiver should see progress, MediPurpose Marketing Manager Valerie C. Johnson advises.
“If the wound becomes stalled, there needs to be a proper assessment, to see if something else needs to happen, perhaps surgical debridement, or evaluating whether there is a secondary infection,” Johnson says.
Poor awareness of the impact of wound biofilm, which cannot be detected by routine swab cultures and doesn't respond to systemic treatment like planktonic bacteria-based infections do, also poses a challenge.
The good news, Korzendorfer says, is improved awareness of the Levine technique for performing swab cultures, better education on the importance of obtaining sensitivities prior to initiating infection treatment, and providing the wound community with more targeted instruction on the treatment suggestions for biofilm have helped kick-start healing of stalled chronic wounds.
Johnson says it's important to remember that “moist wound healing is the standard of care.” Still, that's a step some caregivers miss. Some mistakenly believe that wet-to-dry gauze dressings are designed to heal wounds. In reality, they are made to debride or remove dead tissue, Smiell stresses.
“They do nothing to protect healthy tissue in a wound,” she says, “and they certainly do nothing to prevent bacteria and, eventually, infection from complicating the wound healing process.” A moist wound environment may begin with cleaning and debridement,
There's no one-size-fits-all approach to managing wound infections, but some novel technologies are simplifying the task.
Infrared imaging technologies that measure wound size and thermal intensity, and capture digital and infrared images, are showing promise in early detection of wounds and infection. Combined with a patient history and physical exam, the technology allows trained and qualified clinicians to measure and record wound and body surface data.
“Using thermal imaging, we can detect inflammation before an acute wound infection starts,” says Spahn. The WoundVision Scout received FDA approval in December and is a non-invasive, non-radiating device that combines digital and long-wave infrared imaging technologies. These imaging technologies capture simultaneous digital and infrared images for a congruent anatomical and physiological view of the body.
“The whiter the color on the image, the more heat is present,” he explains, noting that black color is indicative of dead skin. “Anyone who can use a regular camera can use the thermography camera and then use the integrated software to send the images to a trained clinician or physician to determine the results.”
Using secure, cloud-based data capture, sequential image recording allows for image comparisons even by offsite clinicians.
“Seeing changes from today to tomorrow offers a head start on treating infections, before outward symptoms have a chance to surface,” Spahn says.
Mix of old and new
Facilities lacking thermal imaging capabilities can rely on a traditional camera to document the quality of the wound bed and surrounding tissue. Although it can't capture thermal data, photo documentation can help caregivers determine if a wound is improving or worsening, so that appropriate action can be taken, Smiell points out.
When an infection is suspected, long-term care providers can use DNA cultures that quantify bacterial loads and species.
“These are often available as quickly as same-day and are now used for infection identification,” notes Fischenich. So-called “self-adaptive” wound dressings are another notable addition to the wound care market.
“This ‘smart' wound dressing is able to sense the wound bed needs and adjust its function accordingly. For example, it can simultaneously hydrate a dry area, while absorbing drainage from a high-exuding area of the same wound,” she explains.
Another perk? They can turn daily dressing changes into a once-a-week task.
“I've worked with self-adaptive dressings for close to two years now and I would recommend them for any wound, in any stage of healing.”
Negative pressure wound treatments are also showing promise in the fight against infected wounds, as are new debriding techniques, according to Mary Crosby, RN, clinical consultant for Briggs Healthcare.
Adjunctive wound infection treatment modalities, such as low-frequency ultrasound, ultraviolet or electrical stimulation, may also reduce infectious bioburden, Korzendorfer says.
New products are targeting challenging biofilms, as well, including advanced wound care dressings and cleansers with antimicrobial or antiseptic properties, says Dahl Popkes.
As enticing as this ever-growing array of wound care products may be, experts are quick to point out the merits of a less-is-more approach.
“More is not always better when it comes to wound care. There is a product for every phase of healing out there, but often the concept of utilizing multiple products in the right combination and at the appropriate phase of healing can be challenging for even a seasoned wound care provider,” Fischenich acknowledges.
Another word of caution: Caregivers shouldn't swiftly move from one product to the next in a desperate attempt to hasten healing.
The general thought is there should be some indication of healing in two to four weeks, says Falconio-West: “Slow progress is still progress.”