Wound Care Technologies: Emerging Evidence for Appropriate Use in Long-Term Care

Wed, 12/10/08 - 12:01pm
0 Comments
4088 reads

Author(s):

Paul Takahashi, MD, Anu Chandra, MD, Les Kiemele, PA, and Paul Targonski, MD, PhD

Author Affiliations: Drs. Takahashi, Chandra, and Targonski are at the Department of Internal Medicine, Division of Primary Care Medicine, Mayo Clinic; Drs. Takahashi and Targonski are also at the Mayo Clinic Robert and Arlene Kogod Program on Aging; and Mr. Kiemele is at the Department of Internal Medicine, Division of Vascular Medicine, Mayo Clinic, Rochester, MN.

Introduction

Wound management in long-term care (LTC) can present many challenges to the ultimate goal of complete wound healing. Healthcare providers frequently encounter and manage pressure ulcers, ischemic ulcers, venous ulcers, and diabetic foot (neuropathic) ulcers. All residents should be assessed for their risk of developing an ulcer. If a resident is at high risk, staff should implement aggressive maneuvers like nutritional support or pressure reduction to prevent an ulcer from occurring. If an ulcer develops, the primary goal is to completely heal the ulcer as quickly as possible and at a reasonable cost. Providers should identify ulcer type as a pressure, ischemic, venous, or neuropathic ulcer, while understanding that it can be mixed and have two or more components.1 To achieve this goal, providers should ensure good fundamental care (Table I),2 adequate nutrition, good blood supply, edema control, and excellent topical wound care. Good topical wound care enhances wound healing with a hydrating environment while minimizing necrotic tissue.3 To further achieve these goals and objectives, providers and LTC facilities often use a multidisciplinary approach. This multidisciplinary approach includes help from nursing, physical therapy, dietary, pharmacy, occupational therapy, among many others who provide wound care support. Wound care technology can be utilized in addition to standard wound care to achieve these goals by all providers.

Wound care technology continues to expand with the development of devices and dressings to assist with wound healing. Often, this technology is used to obtain healing in a nonhealing ulcer, to hasten healing of an acute or chronic ulcer, or to reduce the cost of caring for the ulcer by reducing nursing burden. The provider should possess a reasonable expectation of what each technology provides and how it will help with resident care. Many of the proposed technologies for wound care fail to evaluate all of the major healing outcomes and are very rarely studied in LTC residents. This review will evaluate the available evidence for commonly used technologies of negative pressure wound therapy (NPWT; eg, vacuum-assisted closure [VAC]), hyperbaric oxygen therapy (HBOT), pressure reduction mattresses, silver-based dressings, and ultrasonic mist. Other technologies such as growth factors,4 topical electrical stimulation,5 and maggot therapy,6 among others, are available but will not be addressed by this review.

Methods

This review used different search methods to arrive at the evidence for each individual technology. Searches were made with the broad terms of wound care and the individual therapies of interest in this review (negative pressure therapy, HBOT, silver-based therapy, and pressure mattresses), acknowledging that previous systematic reviews have been published that address, in part, these topics.7-10 Randomized controlled trials (RCTs) or meta-analyses of RCTs for each therapy published in the time period from 1960 to June 2007 included in MEDLINE or PubMed were eligible for this review. The primary measures of interest were complete wound healing, the time to wound healing, and cost-effectiveness.

Negative Pressure Wound Therapy (Vacuum Devices)

Negative pressure wound therapy is a common technology that is available in the nursing home. VAC therapy is a closed system that utilizes negative pressure to drain wound fluid away from and nutrients into a wound.

References:

1. Takahashi PY. Chronic ischemic, venous, and neuropathic ulcers in long-term care. Annals of Long Term Care: Clinical Care and Aging 2006;14(7):26-31.
2. Takahashi PY, Kiemele LJ, Jones JP Jr. Wound care for elderly patients: Advances and clinical applications for practicing physicians. Mayo Clin Proc 2004;79(2):260-267.
3. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005;293(2):217-228.
4. Wieman TJ, Smiell JM, Su Y. Efficacy and safety of a topical gel formulation of recombinant human platelet-derived growth factor-BB (becaplermin) in patients with chronic neuropathic diabetic ulcers. A phase III randomized placebo-controlled double-blind study. Diabetes Care 1998;21(5):822-827.
5. Edsberg LE, Brogan MS, Jaynes CD, Fries K. Topical hyperbaric oxygen and electrical stimulation: Exploring potential synergy. Ostomy Wound Manage 2002;48(11):42-50.
6. Sherman RA. Maggot therapy for treating diabetic foot ulcers unresponsive to conventional therapy. Diabetes Care 2003;26(2):446-451.
7. Evans D, Land L. Topical negative pressure for treating chronic wounds. Cochrane Database Syst Rev 2001;(1):CD001898.
8. Kranke P, Bennett M, Roeckl-Wiedmann I, Debus S. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev 2004;(2):CD004123.
9. Vermeulen H, van Hattem JM, Storm-Versloot MN, Ubbink DT. Topical silver for treating infected wounds. Cochrane Database Syst Rev 2007;(1):CD005486.
10. Cullum N, McInnes E, Bell-Syer SE, Legood R. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev 2004;(3):CD001735.
11. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: A new method for wound control and treatment: Animal studies and basic foundation. Ann Plast Surg 1997;38(6):553-562.
12. Samson DJ, Lefevre F, Aronson N. Wound-healing technologies: Low level laser and vacuum-assisted closure. Agency for Healthcare Research and Quality Website. www.ahrq.gov/clinic/epcsums/woundsum.htm. Accessed October 31, 2008.
13. Mouës CM, Vos MC, van den Bemd GJ, et al. Bacterial load in relation to vacuum-assisted closure wound therapy: A prospective randomized trial. Wound Repair Regen 2004;12(1):11-17.
14. Wanner MB, Schwarzl F, Strub B, et al. Vacuum-assisted wound closure for cheaper and more comfortable healing of pressure sores: A prospective study. Scand J Plast Reconstr Surg Hand Surg 2003;37(1):28-33.
15. Ford CN, Reinhard ER, Yeh D, et al. Interim analysis of a prospective, randomized trial of vacuum-assisted closure versus the healthpoint system in the management of pressure ulcers. Ann Plast Surg 2002;49(1):55-61.
16. Eginton MT, Brown KR, Seabrook GR, et al. A prospective randomized evaluation of negative-pressure wound dressings for diabetic foot wounds. Ann Vasc Surg 2003;17(6):645-649. Published Online: October 13, 2003.
17. McCallon SK, Knight CA, Valiulus JP, et al. Vacuum-assisted closure versus saline-moistened gauze in the healing of postoperative diabetic foot wounds. Ostomy Wound Manage 2000;46(8):28-32, 34.
18. Joseph E, Hamori C, Bergman S, et al. A prospective randomized trial of vacuum-assisted closure versus standard therapy of chronic nonhealing wounds. Wounds 2002;12:60-67.
19. Armstrong DG, Lavery LA; Diabetic Foot Study Consortium. Negative pressure wound therapy after partial diabetic foot amputation: A multicentre, randomised controlled trial. Lancet 2005;366(9498):1704-1710.
20. Blume PA, Walters J, Payne W, et al. Comparison of negative pressure wound therapy using vacuum-assisted closure with advanced moist wound therapy in the treatment of diabetic foot ulcers: A multicenter randomized controlled trial. Diabetes Care 2008;31(4):631-636. Published Online: December 12, 2007.
21. Knighton DR, Hunt TK, Scheuenstuhl H, et al. Oxygen tension regulates the expression of angiogenesis factor by macrophages. Science 1983;221(4617):1283-1285.
22. Lin TF, Chen SB, Niu KC. The vascular effects of hyperbaric oxygen therapy in treatment of early diabetic foot ulcers. Undersea Hyper Med 2001;28(Suppl):67.
23. Hammarlund C, Sundberg T. Hyperbaric oxygen reduced size of chronic leg ulcers: A randomized double-blind study. Plast Reconstr Surg 1994;93(4):829-834.
24. Faglia E, Favales F, Aldeghi A, et al. Adjunctive systemic hyperbaric oxygen therapy in treatment of severe prevalently ischemic diabetic foot ulcer. A randomized study. Diabetes Care 1996;19(12):1338-1343.
25. Doctor N, Pandya S, Supe A. Hyperbaric oxygen therapy in diabetic foot. J Postgrad Med 1992;38(3):112-114.
26. Abidia A, Laden G, Kuhan G, et al. The role of hyperbaric oxygen therapy in ischaemic diabetic lower extremity ulcers: A double-blind randomised-controlled trial. Eur J Vasc Endovasc Surg 2003;25(6):513-518.
27. Brandeis GH, Berlowitz DR, Hossain M, Morris JN. Pressure ulcers: The Minimum Data Set and the Resident Assessment Protocol [published correction appears in Adv Wound Care 1996;9(6):8]. Adv Wound Care 1995;8(6):18-25.
28. Lansdown AB. Silver in health care: Antimicrobial effects and safety in use. Curr Probl Dermatol 2006;33:17-34.
29. Jorgensen B, Price P, Andersen KE, et al. The silver-releasing foam dressing, Contreet Foam, promotes faster healing of critically colonised venous leg ulcers: A randomised, controlled trial. Int Wound J 2005;2(1):64-73.
30. Meaume S, Vallet D, Morere MN, Téot L. Evaluation of a silver-releasing hydroalginate dressing in chronic wounds with signs of local infection [published correction appears in J Wound Care 2005;14(10):479]. J Wound Care 2005;14(9):411-419.
31. Munter KC, Beele H, Russell L, et al. Effect of a sustained silver-releasing dressing on ulcers with delayed healing: The CONTOP study. J Wound Care 2006;15(5):199-206.
32. Gehling ML, Samies JH. The effect of noncontact, low-intensity, low-frequency therapeutic ultrasound on lower-extremity chronic wound pain: A retrospective chart review. Ostomy Wound Manage 2007;53(3):44-50.
33. Kavros SJ, Miller JL, Hanna SW. Treatment of ischemic wounds with noncontact, low-frequency ultrasound: The Mayo Clinic experience, 2004-2006. Adv Skin Wound Care 2007;20(4):221-226.
34. Ennis WJ, Foremann P, Mozen N, et al. Ultrasound therapy for recalcitrant diabetic foot ulcers: Results of a randomized, double-blind, controlled, multicenter study [published correction appears in Ostomy Wound Manage 2005;51(9):14]. Ostomy Wound Manage 2005;51(8):24-39.
35. Kavros SJ, Liedl DA, Boon AJ, et al. Expedited wound healing with noncontact, low-frequency ultrasound therapy in chronic wounds: a retrospective analysis. Adv Skin Wound Care 2008;21(9):416-423.
36. Andersen KE, Jensen O, Kvorning SA, Bach E. Decubitus prophylaxis: A prospective trial on the efficiency of alternating pressure air mattresses and water mattresses. Acta Derm Venereol 1983;63:227-230.
37. Collier ME. Pressure-reducing mattresses. J Wound Care 1996;5(5):207-211.
38. Goldstone LA, Norris M, O'Reilly M, White J. A clinical trial of a bead bed system for the prevention of pressure sores in elderly orthopaedic patients. J Adv Nurs 1982;7(6):545-548.
39. Gray DG, Campbell MA. A randomized clinicial trial of two types of foam mattresses. J Tissue Viability 1994;4:128-132.
40. Hofman A, Geelkerken RH, Wille J, et al. Pressure sores and pressure-decreasing mattresses: Controlled clinical trial. Lancet 1994;343(8897):568-571.
41. Fleurence RL. Cost-effectiveness of pressure-relieving devices for the prevention and treatment of pressure ulcers. Int J Technol Assess Health Care 2005;21(3):334-341.