Evidence-Based Wound Care for Advanced Practice Providers

Evidence-Based Wound Care for Advanced Practice Providers

A commonly accepted medical maxim is that it takes approximately 20 years for research to be adopted into clinical practice as a standard of care. In the case of moist wound healing, this process has taken over 60 years, and we continue to educate patient and other clinicians alike on the basic fundamentals of wound care. Dr. Winter first published his study on moist wound healing in Nature back in 1962¹, yet it remains common for patients to present stating another health care provider had recommended they leave their wound open to air for part or all of the day. These providers remain unaware that moist wounds heal faster and with less infection, pain, and scarring than wounds that are left open to air. Thus, the most frequented short educational explanations on wound care include not leaving wounds open to air, decreasing dressing change frequency, and avoidance of gauze dressings.

One of the best ways to understand a concept is to explain it to someone else. Teaching the reasoning behind avoidance of letting wounds dry out or changing dressings every day requires an understanding of the cellular biology and pathophysiology involved in the outcomes they influence. While each basic wound care practice has not only manuscripts, but likely book chapters and meta-analysis on it, the ability to explain these concepts in a concise manner at differing education levels helps make the concepts accessible to patients and clinicians alike.

Explain Wound Care to Your Patients

The simple explanation is that wounds that are covered heal faster with less infection than wounds that are left open to air. White blood cells and healing cells need to be able to swim around in there to find bacteria and to heal. Most patients, and some providers, are happy with that definition.

Wound Care Understanding for Clinicians

Wound healing primarily occurs through granulation tissue formation and epidermal resurfacing: first the wounds fill in, then the edges creep across. Angiogenesis and extracellular matrix creation lead to granulation tissue formation in concert with epithelial cells, including keratinocytes, performing epidermal resurfacing by migrating centripetally until contact inhibition occurs². These processes are facilitated in a moisture balanced wound. Leukocytes such as neutrophils and macrophages also require a moist wound environment to function optimally. When leukocyte migration is impaired bioburden in the wound increases as bacteria and necrotic debris is not cleared through phagocytosis².

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Covering a wound with a protective dressing does more than maintain a moist wound environment. This is why dressings are generally indicated instead of simply using an occlusive ointment. While using ointments and barriers pastes as stand-alone wound treatments may be adequate for partial thickness wounds like Stage 1 & 2 pressure injuries and incontinence associated dermatitis; it is generally avoided due to the added benefits dressings provide. These benefits include minimizing bacterial contamination, maintaining normothermia, and protecting wounds from trauma. Local hypothermia of the wound bed affects the chemical processes involved in healing which includes everything from the chemical reactions of enzymes to the production and use of growth factors; Local cooling at the wound bed also increases the risk for infection due to vasoconstriction and decreased migration and phagocytosis of leuokocytes^3,4. When used over boney prominences dressings can also offload a small amount by dispersing the load throughout the dressing, and in some dressings absorbing shear⁴.

Gauze Dressing 101 for Patients & APPs

While some well-meaning patients and clinicians may feel that a gauze dressing may meet this purpose, gauze dressings are actually generally avoided for a number of reasons. Gauze doesn’t protect the wound from bacterial contamination^3,5. We know that bacteria have been able to penetrate through over 60 layers of gauze⁶! Gauze also can contribute to inflammation in the wound environment by causing a foreign body reaction when fibers are retained as well as its inability to remove inflammatory wound fluids from the wound dressing interface. Newer dressings are able to hold drainage away from the wound bed, trapping bioburden including bacteria, proteases, and inflammatory cytokines away from the wound environment. Because gauze does not hold fluid away from the wound bed and periwound it must be changed at least daily. Frequent dressing changes expose the wound to potential bacterial contamination, contribute to trauma on healing tissues, cause hypothermia at the wound bed, and have negative cost and quality of life associations^2-3,7.

In conclusion, keeping wounds covered expedites wound healing, lowers infection rates, decreases pain, and facilitates better cosmetic outcomes for your patients. 

Meet Our Author: Dr. Laura Swoboda, DNP, APNP, FNP-C, FNP-BC, CWOCN-AP

Dr. Laura Swoboda is a Professor of Translational Science, Nurse Practitioner, and Wound Healing Coordinator at Froedtert & the Medical College of Wisconsin, where she advocates for nurse practitioners and nurse participation in research.  She completed her Doctor of Nursing Practice degree at University of Wisconsin Milwaukee (UWM). Dr. Swoboda is a faculty member of the Clinical & Translational Science Institute of Southeast Wisconsin where she serves as principal investigator for quality improvement, evidence based practice, and research projects including the planning, implementation, management, and dissemination of projects in chronic wound care. She further participates in the research process in serving as a peer reviewer for scientific journals. Dr. Swoboda is on the National Pressure Injury Advisory Panel’s Prophylactic Dressing Standards Initiative Task Force, a member of the editorial board for the Wound Care Learning Network and Wound Management and Prevention, and on the board of directors for the Wound Ostomy and Continence Certification Board as well as the Association for the Advancement of Wound Care.   

Dr. Swoboda is part of the esteemed ThriveAP faculty, if you want the opportunity to learn from her and other experts apply for one our transition to practice programs. 

References:

1. Winter GD. Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig. Nature. 1962;193:293-294. doi:10.1038/193293a0

2. Bryant, R, & Nix, D. Acute & Chronic Wounds: Current management concepts, fourth edition. St Louis, MO: Elsevier. 2012. IBSN: 9780323069434

3. Ovington LG. Hanging wet-to-dry dressings out to dry. Home Healthc Nurse. 2001;19(8):477-484. doi:10.1097/00004045-200108000-00007

4. de Wert LA, Schoonhoven L, Stegen JHCH, et al. Improving the effect of shear on skin viability with wound dressings. J Mech Behav Biomed Mater. 2016;60:505-514. doi:10.1016/j.jmbbm.2016.03.006

5. Cordrey R. Gauze, Impregnated Gauzes, and Contact Layers. Adv Skin Wnd Care. 1:120-125. 

6. Lawrence JC. Dressings and wound infection. Am J Surg. 1994;167(1A):21S-24S. doi:10.1016/0002-9610(94)90006-x

7. Rippon M, Davies P, White R. Taking the trauma out of wound care: the importance of undisturbed healing. J Wound Care. 2012;21(8):359-368. doi:10.12968/jowc.2012.21.8.359