Spotlight: managing chronic wounds, diabetic foot ulcers and pressure ulcers

Introduction

A chronic wound, also known as a hard-to-heal wound, is one that shows no signs of healing within a period of three months. They can last for several years and some remain unhealed for decades. They rarely occur in healthy individuals and most frequently occur in the elderly population as a comorbidity of other health conditions.^[1]

Chronic wounds can be classified based on their aetiology, examples of chronic wounds include diabetic foot ulcers (DFUs) and pressure ulcers (PUs).^[2] These wounds all share common characteristics, including prolonged inflammation, bacterial burden and the inability of the epidermal and dermal cells to respond to stimuli to repair. ^[3] There are approximately 2.2 million people with a chronic wound in the UK.^[4]

Chronic wounds are associated with high costs for the NHS, with DFUs and PUs costing £1 billion and £531 million, respectively.^{[5] [6] [7]} UK population trends indicate that there is a growing ageing population with associated comorbidities such as cardiovascular disease, which will in turn increase the prevalence of chronic wounds such as DFUs and PUs and the subsequent financial burdens.¹

What are the major chronic wound care challenges in the UK?

One of the many challenges that nurses face when providing wound care is that some healthcare providers have not agreed upon definitive treatment pathways for chronic wounds such as DFUs and PUs, which means that these wounds may be ineffectively managed.^[8]

It is important to note that while chronic wounds may have similar treatment pathways there may be differences in how treatment is administered.^[9] For example in the case of DFUs, they should be managed by a multidisciplinary team (MDT), which includes podiatry, diabetology, vascular surgery, radiology, diabetes specialist nursing and wound care.^[10] If such clear guidelines are not in place wound healing may be delayed and in the worst cases complications may occur which can result in amputations.⁶

Another challenge is that wound care uses up a significant amount of healthcare resources, in particular nurses’ time, which presents a challenge as there is currently a shortage of 40,000 nurses in the UK, even before Covid-19 pressures on the NHS.^{4 [11]} It is therefore important that healthcare practitioners are aware of and adhere to best practice to effectively manage chronic wounds to avoid high levels of inappropriate use of healthcare resources to cut costs, improve nurse availability and to ultimately ensure positive patient outcomes.^{4 6}

How can primary care practitioners recognise chronic wounds and when should they refer to secondary care?

In order for primary healthcare practitioners to determine when to refer patients to secondary care, it is important for them to have a clear understanding of DFUs and PUs and their causes as there are differences in their treatment pathways.⁶ A PU is defined as a localised injury to skin and/or underlying tissue usually over a bony prominence as a result of pressure or pressure in combination with shear.^[12] A DFU, on the other hand, is defined as a full thickness wound below the ankle of a person with diabetes.⁹

DFUs occur primarily due to neuropathy and peripheral arterial disease usually in combination with some trauma, whether multiple minor trauma caused by, for example, a shoe rubbing, or a sudden instant trauma caused by, for example, standing on a foreign body or stubbing a toe.^[13]  DFUs are usually as a result of mobility and PUs occur due to immobility and can be seen in patients that have been bedbound.⁶

There are tests that can be carried out by nurses, to confirm the presence of a DFU. These tests are based on the aetiology of DFUs, these tests include touch toe test, monofilament test, pulse palpation and Doppler ultrasounds.^{6 [14] [15] [16] [17]} If tests indicate loss of sensation or absent blood flow, this could indicate that the wound is a DFU and the patient should be referred to an MDT, ideally within 24 hours.^{6 [18]} Pressure ulcers are usually managed by the primary healthcare team.^[19]

What are the risks for a patient with a chronic wound?

If all therapeutic interventions have been unsuccessful an amputation may be necessary resulting in disability. 85% of ulcers precede all amputations and the five-year mortality rate following an amputation is between 40 and 70%.¹ Chronic wounds not only cause severe pain for patients, they also cause significant emotional distress. Some of the reasons for this is reduced mobility, fear of pain, odour of wounds and exudate leakage from dressings.^{1 [20] [21]}

How is Covid-19 affecting patient care?

Fortunately, MDTs, diabetes foot care teams and wound care have been prioritised by the NHS during the COVID-19 pandemic. However, many nursing and podiatry teams who provide prevention and ongoing management of lower limb wounds have been redeployed into other areas during the crisis. There is also an increase in the number of virtual consultations and an increase in the use of telemedicine which has started to revolutionise care provision but only after the crisis has ended will we be able to evaluate the outcomes of these new ways of delivering care.

What is also of concern is patients who are reluctant to attend hospitals and clinic appointments for fear of catching Covid-19 and as such potential limb and life-threatening complications such as critical limb ischemia and severe infection can occur. Many routine foot protection appointments for high risk patients have been cancelled, so preventative care is reduced which potentially will lead to further problems in the future.

What are the standard treatment methods for a patient with a chronic wound?

The standard treatment plan for DFUs and PUs are similar according to NICE NG19 and NICE CG179 guidelines which includes:

• Offloading/pressure redistribution
• Identifying and managing the underlying cause
• Wound dressings to manage wound exudate
• Debridement^{10 [22]}

How does topical oxygen therapy work and when is it recommended?

Oxygen is needed for wound healing. It is important for cell metabolism and pathways that promote wound healing such as angiogenesis and revascularisation, cell metabolism and energy production, synthesis of connective tissue and infection resistance.¹³ As DFUs and PUs are often hypoxic, it might be necessary to provide oxygen directly to the wound site to increase oxygen concentration to promote healing.⁶

One treatment Granulox is an oxygenating haemoglobin spray for the treatment of chronic wounds. When Granulox is sprayed on a wound, highly purified haemoglobin is released. This binds with oxygen from the environment and diffuses through the wound exudate, and the haemoglobin supplies the base of the wound topically with oxygen. The oxygen supply to the base of the wound supports wound healing and patient outcomes.

A reduction in wound area of 40% within four weeks of treatment is an indicator of healing and effectiveness of treatment.^[23] If after four weeks there has been no improvements to the patient’s wound, their treatment plan would need to be reviewed and may require referral and adjunctive therapies such as Granulox incorporated in their treatment plan to enhance wound healing.^{6 19}

Key messages

• Chronic wounds affect 2.2 million people in the UK
• There are different types of chronic wounds, of which include Diabetic foot ulcers (DFUs) and pressure ulcers (PUs)
• Chronic wounds have a significant financial, emotional and physical impact
• Chronic wounds can result in amputations if treatment has been unsuccessful and if inappropriate treatment pathways have been administered or if a multidisciplinary team approach is absent
• If healthcare providers commit to set guidelines for the management of DFUs and refer patients for adjunctive therapies when standard of care alone is ineffective, patient outcomes can improve and alleviate the financial burden for the UK healthcare system

References

[1] Järbrink K, Ni G, Sönnergren H et al (2017) The humanistic and economic burden of chronic wounds: a protocol for a systematic review. Systematic Reviews 15, 1-7. DOI 10.1186/s13643-016-0400-8

[2] Werdin F, Tenenhaus M, Rennekampff HO (2008) chronic wound care. The Lancet. 1860-1862

[3] H.Trostrup, T.Bjarnsholt, K Kirketerp-Moller et al  (2013) What is the new understanding of Non Healing Wounds Epidemiology, Pathophysiology and Therapies. Ulcers 1-8

[4] Guest JF, Ayoub N, McIlwraith T et al (2015). Health economic burden that wounds impose on the National Health Service in the UK. British Medical Journal. 5, 1-7.http://dx.doi.org/10.1136/bmjopen-2015-009283

[5] Guest JF, Fuller GW, Vowden P et al (2018) Cohort study evaluating pressure ulcer management in clinical practice in the UK following initial presentation in the community: costs and outcomes. British Medical Journal. 8, 1-12. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6067374/pdf/bmjopen-2018-021769.pdf

[6] Ousey K, Chadwick P, JawieÅ„ A et al (2018) Identifying and treating foot ulcers in patients with diabetes: saving feet, legs and lives. Journal of Wound Care. 27:5, 5-42.  https://www.magonlinelibrary.com/doi/pdf/10.12968/jowc.2018.27.Sup5.S1

[7] Jeffcoate WJ, Vileikyte L, Boyko EJ et al (2018) Current Challenges and Opportunities in the Prevention and Management of Diabetic Foot Ulcers. American Association for Diabetes Care. 41:4, 645-652. https://doi.org/10.2337/dc17-1836

[8] Best Practice Statement: Optimising wound care. Wounds UK, Aberdeen, 2008

[9] Vowden P, Vowden K (2016) The economic impact of hard-to heal wounds: promoting practice change to address passivity in wound management. Wounds International. 7:2,10-15

[10] National Institute for Healthcare Excellence (2015) Diabetic foot problems: prevention and management. 5-33. https://www.nice.org.uk/guidance/ng19

[11] Royal College Of Nursing (2019) Patient safety in danger unless nurse numbers increase, RCN warns

[12]  European Pressure Ulcer Advisory Panel, National Pressure Injury Advisory Panel and Pan Pacific Pressure Injury Alliance. Prevention and Treatment of Pressure Ulcers/Injuries: Guidelines. Emily Haesler (Ed.). EPUAP/NPIAP/PPPIA:

2019.

[13] Expert Panel Report (2019) The role of topical oxygen therapy in the management of diabetic foot ulcers. The Diabetic Foot Journal, 1-10

[14] Rayman G, Vas PR, Baker N (2011) The Ipswich Touch Test: a simple and novel method to identify in patients with diabetes at risk of foot ulceration. Diabetes care. 34:7, 1517-1518. https://doi.org/10.2337/dc11-0156

[15] Boulton JM A, Armstrong DG, Albert SF (2008) Comprehensive Foot Examination and Risk Assessment. Diabetes Care. 31:8, 1679-1685. https://doi.org/10.2337/dc08-9021

[16] Lewis JE, Owens DR (2010) The Pulse Volume Recorder as a Measure of Peripheral Vascular Status in People with Diabetes Mellitus. Diabetes Technology and Therapeutics. 12:1, 75-80. https://doi.org/10.1089/dia.2009.0061

[17] National Institute for Health Excellence (2012) Peripheral arterial disease: diagnosis and management. 2-22 https://www.nice.org.uk/guidance/cg147/resources/peripheral-arterial-disease-diagnosis-and-management-pdf-35109575873989

[18] National Institute for Healthcare Excellence (2015) Diabetic foot problems: prevention and management. 5-33. https://www.nice.org.uk/guidance/ng19

[19] Pagnamenta F (2014) The role of the tissue viability nurse. Wounds UK. 9:2, 65-66. https://www.wounds-uk.com/resources/details/the-role-of-the-tissue-viability-nurse

[20] Davies P, Stephenson J, Manners C (2019) Understanding undisturbed wound healing in clinical practice €” a global survey of healthcare professionals. Wounds UK. 15:4, 56-64

[21] Moffatt CJ, Franks PJ and Holinworth H (2002) Pain at wound dressing changes. European Wound Management Association. 1-16.https://ewma.org/fileadmin/user_upload/EWMA.org/Position_documents_2002-2008/position_doc2002_ENGLISH.pdf

[22] National Institute for Healthcare Excellence (2014) Pressure ulcers: prevention and management. 6-28. https://www.nice.org.uk/guidance/cg179

[23] Leanne Atkin, Bućko Z, Conde E et al (2019) Implementing TIMERS: the race against hard-to-heal wounds. Journal of Wound Care. 28

[24] Elg F (2019) Cost-effectiveness of adjunct haemoglobin spray in the treatment of hard-to-heal wounds in a UK NHS primary care setting. Journal of Wound Care.  28:12, 1-5 https://doi.org/10.12968/jowc.2019.28.12.844

[25] Wounds UK (2015) Granulox: Topical Haemoglobin.1-6