At this time, nurses in long term care settings may be even more reliant on managing complex wounds with little or reduced services from NHS trusts as we all try to manage this pandemic.
One of the most common enquiries I get is on how to manage a wound along with explaining the numerous dressings they see. It can be daunting to manage complex wounds and distressing for all involved if the wound fails to heal.
I have therefore put together the below guide on monitoring for signs of wound deterioration and what it means. Don’t forget to ask your local TVN service or CCG if they will share the local dressing formulary with you if they haven’t already and follow your advised policy and producers in managing and prescribing for wounds.
Should wounds be colonised?
It is important to remember that all wounds have transient organisms present these are often usual skin flora. There is no such thing as a sterile wound.
As all wounds are colonised the body will be working hard to naturally clean and heal the injury to the skin.
A wound that is becoming infected means this colonisation is proliferating meaning the wound is becoming ‘critically colonised’ . I always use the analogy in my class of teenagers getting out of hand at a party. What starts with chatting in the living room to blasting the music and breaking into the drinks cabinet. The need to consider sending in a parent (anti-microbial) to restore order.
Early intervention of antimicrobial therapy at this stage may be enough action against microbial proliferation. (Rainey J 2002) ‘Wound Care Handbook for Community Nurses,’
Wound infection continuum:
Wound infection occurs when colonisation is not brought under control and the bio-burden of the wound bed has tipped into critical colonisation and causing distant clinical signs.
A basic and more complex table of the wound infection continuum can be seen below, taken from https://www.wounds-uk.com/journals/issue/557/article-details/evolution-wound-infection-continuum accessed 20th April 2020
These atypical signs are listed below.
Signs and Symptoms of infection:
- Erythema spreading around the wound
- Oedema
- Increased exudate
- Offensive odour
- Pain
- Pyrexia
- Tyachycardia
(Collier, M 2004) Recognition and management of wound infections. accessed on 20th April at : http://www.worldwidewounds.com/2004/january/Collier/Management-of-Wound-infections.html
Other indications of wound infection:
- Delayed Healing
- Discolouration
- Friable granulation tissue which bleeds easily
- Unexpected tenderness
- Pocketing at the base of the wound
- Bridging of soft tissue and epithelium
- Wound breakdown
(Cutting and Harding 1994) ‘Criteria for identifying wound infection’ Journal of Wound Care. accessed on 20th April at: https://www.ncbi.nlm.nih.gov/pubmed/27922298
Should I swab every wound for infection?
When swabbing for clinical infection of the wound the aim should be to identify the organisms resistance and sensitivities to ensure the appropriate antimicrobial/antibiotic therapy is being prescribed.
Therefore if we are being asked to swab a wound it should be for detecting the type of micro-organisms on the wound not to see whether there ARE organisms on the wound.
(Rainey, J 2002) Handbook of wound care for community nurses.
Antimicrobial resistance (AMR)
I’m sure we are all aware or at least have heard of antimicrobial resistance. The overuse of antibiotics, has increased resistances strains microbes.
Antimicrobial resistance (AMR) is accelerated by the misuse and overuse of antibiotics, as well as poor infection prevention and control.
The scale of the problem is daunting, the world health organisation (WHO) states: ‘Antibiotic resistance is one of the biggest threats to global health, food security, and development today effecting all ages’
Available at: https://www.who.int/news-room/fact-sheets/detail/antibiotic-resistance. Accessed 21st April 2020
In terms of managing wounds, avoiding unnecessary prescribing of antimicrobials or antibiotics as well as prevention methods is key.
Increasing awareness of topical antimicrobial primary dressings to reduce aerobic activity and critical colonisation at the wound bed.
The use of topical antimicrobial for an overburden ‘critical colonised’ wound may be a first line defence using antimicrobials such as silver, iodine, honey over the use of antibiotics.
Ousey & Mackintosh (2009) Topical antimicrobial agents for the treatment of chronic wounds available at: https://www.ncbi.nlm.nih.gov/pubmed/19749669. Accessed 21st April 2020.
An example of this could be a ‘red leg’ from appearance an unexperienced nurse may think is cellulitis and refer for antibiotics, whereas in many patients with vascular disease a common complaint is hemosiderin staining caused by poor vascular supply. This may have a similar appearance.
The key to ensure appropriate regime is for inter-professional working. In care homes especially at the moment this may be a challenge. Your community health professionals will be increasingly using online platforms to communicate. MDT meetings can be a great way of debriefing on the patients, signs and symptoms, medical history and allows for an inter-professional assessment. This can be done relatively easily when no-one needs to leave their desk and can be done online.
In the NHS we used the digital platform OmniJoin but ask your local GPs what they are using.
To find out what antimicrobials you can access if no prescriber in-house, refer to your local wound formulary accessible either through your local TVN of CCG.
Ensuring where indicated prescribing of antimicrobials are in a sensible timeline inline with BNF/local guidelines.
As a rule of thumb if no change in wound after 1-2 weeks of topical antimicrobial, stop and review. On chronic wounds consider biofilm and reassess for all intrinsic and extrinsic factors that may be impairing healing.
If GP or prescriber has given Antibiotics be clear on duration of therapy usually 1 –2 weeks for soft tissue, about 6 weeks for bone infection. A really good guide on Px for cellulitis can be found below:
Clinical Resource Efficiency Support Team. 2005. Guidelines on the Management of Cellulitis in adults. Belfast: CREST, available at https://www.rcem.ac.uk/docs/External%20Guidance/10n.%20Guidelines%20on%20the%20management%20of%20cellulitis%20in%20adults%20(CREST,%202005.pdf Accessed on 21st April 2020.
NOTE: Don’t forget your pharmacists, they are such an underused expert resource that have helped me out on more occasions than I can remember! If you’re not sure ask them for their advice.
Lipsky (2016) and Ousey (2020) talk about Antimicrobial Stewardship, the opportunity for a health care professional in each home or unit to become a champion on further understanding AMR . They discuss that applying principles of AMR to the care of patients with wounds should help to reduce the unnecessary use of systemic or topical antibiotic therapy and ensure the safest and most clinically effective therapy for infected wounds
*Lipsky (2016) Antimicrobial stewardship in wound care: a Position Paper from the British Society for Antimicrobial Chemotherapy and European Wound Management Association
They should also involve patients/family in care plan.
Hand-washing and local aseptic technique to prevent infection
Hand hygiene remains the key barrier to cross infection, this has been hopefully engrained in your brain from Nursing school and lingering infection control nurses watching you in practice, as well as those machines they used to use where you pop your hand in and they show you where you have been missing when hand washing! Just in case here’s a little recap below.
Education/ resources/ champion / policy handing over to teams for in-house learning.
One of the best free and short courses for health professionals online is by Professor Karen Ousey who launched a free course on the ‘Future Learn’ platform for heath professionals. See link here.
Finding someone in house that would like to act as an Antimicrobial resistant steward (AMS) can take this course and act as champion and educator within their own teams.
Other good guides with like listed below:
https://ewma.org/what-we-do/ewma-podcasts/
*https://academic.oup.com/jac/article/71/11/3026/2462051
I will continue to support you with these publications throughout the lockdown. My subject matter is chosen from feedback from you so do let me know if there is anything else you would like me to cover. If you haven’t already joined the tissue viability champion network click here.
