Recherche de publication

Introduction

Non-healing, complex or stalled wounds fail to heal in the expected time required for tissue repair, in spite of their optimal wound management.1,2 Wound management requires addressing the etiologic causes and underlying disorders such as venous hypertension.2 A multidisciplinary approach to wound management including the whole chain of care is recommended. A project was developed in the Azienda USL, south east Toscana, Italy, a region of about 300 x 150 km, to improve quality of care for patients with wounds. The region has 8 hospitals and 13 nursing homes for a population of 850.000. Daily, on average 1200 community patients receive wound management. The project aimed to improve knowlegde and skills when delivering wound treatment in the community. The current study compared clinical efficacy and cost of autolitic, enzymatic and mechanical debridement using a monofillament pad and a pad with a hanle.

Method

Currently in the community enzymatic and autolytic debridement is used for patients with wounds that contain sloughy tissue. To address the need for mechanical debridement a monofilament debrider was proposed for its added value in terms of efficacy, safety, tolerability, results and ease of use.3-6 Eighty community patients with complex wounds of various etiologies containing sloughy tissue were included in the study and followed up for 15 days. Patients gave informed consent. Patients were allocated to the different treatment groups at random. At baseline patient's medical history, wound characteristics and privious treatment was recorded. During follow up visits a questionnaire was completed scoring wound condition, patient reported comfort/pain during debridement, time required for the procedure and product handling, using a 5-point Likert scale. Costs were calculated taking into account clinical efficacy, time to debridement, number of home visits, nursing costs, costs per product used.

Results

Debridement was effective and comfortable using all evaluated methods (on a 5-point Likert scale, the 2 types of monofilament products scored a mean of 4,9 and 4,8, enzymatic debridement sored a mean of 4,6 and autolytic debridement a mean of 3,6). The total costs for debridement using the monofilament pad and product with handle was Euro 58,67 and Euro 72,47 respectively. For enzymatic debridement the total costs were Euro 213,35 and for autolytic debridement total costs were Euro 98,67. Cost was significantly lower in the monofilament group due to a reduction in debridement time, number of visits and nursing time. Based on these results the monofilament product is proposed to be added to the list of products available for wound debridement in the community.

Discussion

Mechanical debridement is historically associated with the use of wet-to-dry gauze, which non-discriminatorily removes devitalized tissue, resulting in significant pain and damage to healthy tissue.1,2 Enzymatic and autolytic debridement may be slow and not suitable for wounds such as diabetic foot ulcers. In clinical studies mechanical wound cleansing and debridement using a monofilament polyester fiber product was effective, pain and trauma free.3-6 Our study showed the monofilament products to deliver better and faster debridement and a good patient tolerance. Both the number of visits and nursing time was reduced leading to a significant reduction in total cost of debridement.

Conclusion

The addition of the monofilament products to our debridement portfolio use for wound management in the community represents an essential added value in the range of dressings available for patients with complex wounds with appropriate use of tight resources.

INTRUDUCTION

Biofilm, one of the main issues that prevent a chronic wound from healing, is a combination of bacterial and fungal cells, embedded in an extracellular matrix composed of hydrated polymers and debris [1]. Antibiotics are of limited use in biofilm-infected wounds, because biofilm can be polymicrobial [2] and the cells are many times more resistant to it [3]. Therefore the biofilm has to be physically disrupted and removed by debridement. This survey was designed to investigate on a 2 week wound management pathway, including the use of a monofilament fiber debridement pad (Debrisoft® - Lohmann & Rauscher) in combination with an antimicrobial dressing.

MATERIALS AND METHODS

The survey includes data of 706 professional users located in the UK. The users were asked to treat chronic non-healing wounds by following a 2-weeks wound management pathway including mechanical debridement and an antimicrobial treatment. Clinicians reported on the outcomes and the potential impact on the healing of chronic wounds. Even if the clinicians were asked to follow the wound management pathway, 21% of them were only using the debridement pad without the antimicrobial treatment. This analysis compares these two groups, showing the impact of mechanical debridement in combination with antimicrobial treatment compared to mechanical debridement alone.

RESULTS

454 (64%) of the users followed the 2-weeks wound management pathway (Group A). 147 (21%) used Debrisoft alone (Group B). 105 (15%) did not give that information. 76% of the treated wounds were static/non-healing and 9% were healing. 15% of the users did not give that information. 94% of all wounds in Group A showed a visible change after 2 weeks, but only 79% in Group B (p<0.0001). For static wounds only 94% of patients in Group A and 85% in Group B (p<0.001) showed improvement and for non-static wounds 97% and 52% respectively (p<0,0001). On a scale of 1 (completely satisfied) to 5 (dissatisfied) the overall clinical outcome was rated 1.543 in Group A and 1.617 in Group B. The healing progression and skin improvement was rated 1,657 in Group A and 1,807 in Group B. The patient satisfaction was rated 1.593 in Group A and 1.778 in Group B.

CONCLUSION

In conclusion the debridement with Debrisoft® shows its capability to put a biofilm-infected non-healing wound into the position to heal. By using mechanical debridement in combination with antimicrobial treatment by following the 2-weeks wound management pathway the positive effect is even more prominent.