Selecting the appropriate dressing for stalled wounds based on mode of action
Author: Keith Cutting, Clinical Research Consultant, Hertfordshire, UK.
Wound dressing selection is an imprecise procedure that can have considerable implications for patient wellbeing and wound progress. When considering the role that dressings have to play in creating an environment that is conducive to the promotion of healing it is unfortunate that not every clinician takes into account the need for precision in the dressing selection process.
Todays challenges: Putting knowledge into practice
At a wound care conference held in the UK in 2016 two clinicians, one nurse and one podiatrist, consecutively proclaimed that dressing choice should be governed by unit cost and that when considering therapeutic interventions wound dressings came way down the list of options. These presenters showed a total disregard for the considerable progress that has been made over the last 30-50 years in terms of research and wound dressing technology and of the integral role that dressings have to play in wound treatment. It is as if Winter’s work [1] among others contributed nothing at all to wound science and failed to initiate a progressive line of scientific inquiry. Apart from the scientific perspective of promotion of healing careful dressing selection has an important role to play in improving patients’ quality of life [2, 3] and this fact should receive the recognition it deserves. Could it be that a fundamental misunderstanding in terms of material performance underpins this apparent disregard how a dressing can profoundly influence clinical outcomes?
Can categorising dressings based on mode of action rather than material composition aid clinicians in the delivery of high quality wound treatment?
Dressings are usually categorised from the perspective of their principle ingredient e.g. alginates, foams, hydrocolloid etc. On the one hand, this method of categorisation is convenient and uncomplicated but on the other, does nothing to support meaningful selection of dressings. Mode of action, function and potential clinical outcomes are far more important in terms of dressing selection when compared to dressing ingredient composition. It has been pointed out that not only is the current method of classification out of date but more important potentially counter-productive when taking into account advanced dressing technology [4]. The ingredient approach to classification seems to be peculiar to wound care as in other areas of healthcare we find classification along the lines of pharmaceutical function e.g. diuretic, anti-inflammatory and antibiotic.
A way forward in improving dressing selection so that the chosen dressing objectively suits the needs of the wound is to identify the desired discrete clinical outcomes. These outcomes should align with the performance capability of the dressing material. This approach is congruent with the principle of initial identification of patient/wound needs and competent wound bed preparation.
It has been proposed that clinicians who are involved in wound care should ask two questions before embarking on dressing selection and application:
1 – do I possess up to date knowledge in respect of material performance?
2 – do I have the practical skills and knowledge in relation to optimal dressing application and dressing change interval [5]?
If you are not in possession of these attributes then professional responsibility indicates that referral should be made to the person who can apply the obligatory precision – ostensibly, this would be the tissue viability specialist.
References
- Winter, G.D., Formation of the scab and rate of epithelialisation in the skin of the young domestic pig. Nature, 1962. 193: p. 293-295.
- Queen, D. and K. Harding, The evolution of wound care. International Wound Journal, 2016. 13(3): p. 302-302.
- Cutting, K., Wound dressings: 21st century performance requirements. Journal of Wound Care, 2010. 19(5 (Supplement)): p. 4-9.
- van Rijswijk, L., Ingredient-based wound dressing classification: a paradigm that is passé and in need of replacement. Journal of Wound Care, 2006. 15(1): p. 11-14.
- Cutting KF. The imprecision surrounding wound dressing selection and application. Br J Nurs 2016, Jun 23;25(12):S4.