Expediting Acute Wound Healing by Integrating Multiple Therapeutic Strategies: A Case Series

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Acute wounds due to traumatic or surgical disruptions in skin integrity are frequently treated by cleansing and applying a topical antibiotic with a bandage, which may result in the expected healing pattern.¹ However, wound etiology, severity of injury, comorbidities including tobacco use and malnutrition, and certain medications can increase the susceptibility to infection, development of wound chronicity, limb loss, and even mortality.^2,3 These negative outcomes are costly and debilitating, leading to a substantial burden on the patient and the health care system; therefore, it is imperative to prevent deterioration of acute wounds from their onset.^4,5 Non-healing wounds affect over 8 million people, profoundly impacting their quality of life and socioeconomic status while requiring them to rely on continued medical resources.^5,6 Health care teams with members who are certified in wound management have the knowledge and experience to treat wounds more effectively from their onset. Successful wound care can be attributed to a multidisciplinary team approach, evidence-based guidelines, advanced wound care products, debridement, patient engagement, patient/caregiver education, and close follow-up.⁷ Reduction of bioburden and creation of an adequate wound bed are the hallmarks of complex wound healing. However, the individualized therapies described in this report reflect on the artistry involved in advanced wound care that cannot always be achieved by a rigid protocolized approach.

The Acute Surgical Wound Service (ASWS) at the authors’ institution integrates multiple therapeutic modalities in novel ways to prevent complications while facilitating wound healing. This multimodal approach is an alternative to a simpler antibiotic ointment/gauze plan that a clinician without wound-specific training may prescribe. The expertise of an ASWS team and the coordination of patient-specific advanced wound care products may be essential to the success observed at the authors’ institution in accelerating healing of complex traumatic and surgical wounds.^6,8 The objective of this case series was to assess if healing rates were correlated with the utilization of unique combination therapies by experienced ASWS providers.

This report describes patients treated at a large level 1 trauma center with complex acute surgical or traumatic wounds. These patients were routinely managed by the ASWS team throughout their continuum of care, beginning with hospital admissions, through surgery, and concluding during their outpatient course once wounds were deemed healed. An ongoing observational prospective analysis was performed, reviewing wound care provisions and outcomes for these patients after approval was granted from the center’s Institutional Review Board. To be included, patients had to have acute wounds and be managed by ASWS until wound closure. Systematic assessments were standardized, employing a variation of T.I.M.E. (tissue, infection /inflammation, moisture balance, edge/periwound) with an “S” for wound size at every patient encounter.^9,10 The “S” also accounted for social considerations, as some patients were unable to obtain recommended wound supplies or home health care. This was attributed to a lack of insurance, language barriers among the local Spanish-speaking and mushroom-farming communities, and poor adherence among the homeless and intravenous drug-addicted populations. Home health care was also a limited resource due to personnel shortages. Consequently, the aforementioned patients appeared to have delayed wound healing. Whenever possible, readily available dressing samples were substituted and in-office visits were added; however, complete information on some patients was not obtainable.

 The T.I.M.E. framework was developed in 2002 by international wound care specialists and is still recognized as a tool to systematically guide wound management. It is intended to be utilized in coordination with a comprehensive patient evaluation.¹⁰ The assessments included in the T.I.M.E. framework were part of the center’s usual documentation found in each patient’s electronic health record. Treatments were documented and reevaluated at every patient encounter, with adjustments based on healing, treatment options/availability, and updated individualized needs. Key outcome measures included wound progression determinations, wound dimensions, specific treatment regimens, time to healing, and health care utilization metrics. These components provided a framework to determine if wounds were improving appropriately or deteriorating and if the treatment regimen should be modified.

Since project inception, 124 patients have met the inclusion criteria, remained within the service, were stable for wound healing, and survived until wounds were healed (Tables 1-4). Among these patients, single or multiple complex acute wounds of various etiologies with dimensions up to 1120 cm³ were healed. The median time to ASWS consultation was 2 days from injury. It was determined that all patients had been treated with hypochlorous acid-preserved wound cleanser with saturated gauze soaks or via negative pressure instillation therapy as part of a combination therapy approach with collagen, silver, manuka honey, and foam dressings.

Healing was observed in 366 wounds with a median healing time of 19 days. Some wounds healed in as few as 6 days. Wound healing delays were associated with tobacco use, immunocompromise, and inability to obtain recommended wound care supplies. No adverse events were noted with any of the therapies utilized. Several notable cases among the included patients are described below.

Case 1: traumatic left lower quadrant and groin wound
A 66-year-old male with a history significant for morbid obesity, atrial fibrillation requiring antiplatelet therapy, and tobacco use presented with a complex left lower quadrant/left groin full thickness wound sustained from a lawn tractor rollover accident. His original wound was 17 cm × 6 cm × 8 cm (816 cm³) with tunneling to 5 cm at 9 o’clock and to 3 cm at 3 o’clock, with undermining of 1-2 cm around the entire wound. After emergent intraoperative stabilization with irrigation and debridement, ASWS was consulted and implemented the following advanced therapy regimen: 1) Postoperatively, gauze packing saturated with pHA (Vashe^®; Urgo Medical North America) was secured with abdominal pads with daily dressing changes (Figure 1A). 2) Once the treating clinician was confident there was no exposed vasculature, bleeding, necrosis, or other wound concerns, the dressing was revised to negative pressure wound therapy (NPWT) with instillation of pHA and dwell time (NPWTi-d).^11-13 The investigators’ basic NPWTi-d protocol during the inpatient stay was 10 minutes of instillation every 4 hours. Dual tubing pads, one for fluid/exudate removal and one for instilling the pHA, were utilized to reduce potential blockages. Additionally, twice-weekly NPWTi-d dressing changes, usually on Monday/Thursday or Tuesday/Friday, were utilized to allow time for healing while reducing complex care during weekends. This was adhered to during the inpatient stay. 3) The healthy tissue formation allowed partial delayed primary closure with staples. When medically stable, the patient was discharged with traditional NPWT. His wound etiology and anatomical location had a high propensity for infection; therefore, the pHA was continued as a 5-minute saturated gauze soak with his twice-weekly NWPTi-d dressing changes. 4) The wound demonstrated rapid progression to decreased depth, allowing discontinuation of NPWTi-d. While the pHA soaks and twice-weekly dressings continued, collagen/oxidized regenerated cellulose with silver (Promogran™; 3M) was utilized for residual undermining/tunneling, with a thicker hydrofiber impregnated with silver used to cover the remaining wound. An absorbent non-adherent foam was used as the secondary dressing to secure and protect the wound. Close follow-up was arranged in the ASWS office, where sharp debridement and occasional silver nitrate were used to maintain a clean wound bed (Figure 1B). The patient continued to use tobacco during treatment despite recommendations to abstain. Time to complete wound healing was 78 days.

Case 2: gunshot wound to abdomen 
A 33-year-old male with no comorbidities sustained a gunshot wound to his abdomen. He required emergent surgery and was treated with intravenous antibiotics post-operatively. He subsequently developed an abscess of the abdominal incision. His midline wound was significant at 20 cm × 6 cm × 3.5 cm, while his right lower quadrant (RLQ) wound measured 1 cm × 3.5 cm. × 1.5 cm with tunneling of 2 cm at 3 o’clock and frank purulence. On evaluation by the ASWS team, RLQ purulence was evacuated and a small amount of necrotic tissue was debrided (Figure 2A). The following regimen was implemented: 1) NPWTi-d with pHA was initiated for both wounds. The standard protocol was followed; however, due to proclivity for infection, the initial dressing was changed one day sooner. Figure 2B demonstrates the dramatic transformation of the RLQ wound, with beefy red granulation and no purulence. Closure was not performed at that time as a precautionary measure, extending wound therapy. 2) Five days later, continued rapid healing allowed delayed partial primary closure with staples at the bedside (Figure 2C). Due to minor concerns for infection, pHA-saturated gauze soaks were applied for 5 minutes, coordinated with twice-weekly dressing changes, to the remainder of the superficial open wound. Collagen/oxidized regenerated cellulose with silver was applied to minimal undermining/tunneling and hydrofiber impregnated with silver was applied to the remainder of the wound bed, which was covered with a non-adherent foam dressing. Significant progression is depicted in Figure 2D. Time to healing was 22 days for the RLQ wound and 76 days for the midline wound.

Case 3: large hematoma of the right lower extremity 

A 93-year-old female with multiple comorbidities on antiplatelet therapy tripped and fell at home, sustaining a large hematoma to her right lower extremity. Due to transportation issues, there was a delay in her seeking initial evaluation with ASWS, placing her leg at substantial risk. The wound size initially measured at 9.2 cm × 5.6 cm × 0.3cm and was covered with a large amount of nonviable tissue (Figure 3A). During her office visit, her family was contacted to discuss the importance of immediately establishing home health care and the necessity of regular evaluations by ASWS to save her leg; thereafter, her family accompanied her for all scheduled appointments. Combination of therapies used included: 1) pHA-saturated gauze soaks, sharp debridement of nonviable tissue, collagen/oxidized regenerated cellulose with silver, and hydrocolloid to attempt preservation of salvageable tissue. Both the silver and pHA offered antimicrobial benefits. 2) After all nonviable tissue was removed, porcine urinary bladder matrix was applied to facilitate readiness for skin graft. 3) Split-thickness skin graft was applied in the operating room, covered with non-adherent cellulose acetate petroleum and NPWT (Figure 3B). A similar combination approach also pertained to the donor site dressing. After hemostasis was achieved, collagen/oxidized regenerated cellulose was applied and completely covered by an absorbent non-adherent foam and secured with rolled gauze wrap. This allowed donor site and primary wound dressings to be removed at the same time on post-operative day 5.¹⁴ Time to healing was 57 days (Figure 3C).

Case 4: extensive abrasions to right hand and buttock

A 66-year-old male was struck by an automobile while bicycling and suffered extensive partial- and full-thickness abrasions to the right hand and buttock. The latter wounds approached his perineum, increasing their complexity. Of note, due to hand involvement and the desire to achieve maximum return of hand functionality, care was closely coordinated with a plastic surgeon who specialized in hand surgery.

On ASWS evaluation, wound measurements were as follows: right buttock/posterior upper thigh, 25 cm × 21 cm × 0.1 cm (Figure 4); right palm (Figure 5), proximal, 4.5 cm × 4.5 cm × 0.1 cm, distal, 1.2 cm × 1.2 cm × 0.1 cm, thenar, 3 cm × 3 cm × 0.1 cm; right second finger, 2 cm × 1.5 cm × 0.1 cm; right third finger, 2 cm × 1 cm × 0.1 cm; right fourth finger, 2.5 cm × 1.0 cm × 0.1cm; and right fifth finger, 1 cm × 0.7 cm × 0.1 cm. The authors applied the center’s road rash protocol, which is also a combination therapy approach: 1) soak/cleanse with pHA-saturated gauze, apply hydrofiber impregnated with silver, and cover completely with transparent film to create a moist wound environment. This was all secured with rolled gauze. Dressing changes were performed twice a week. 2) One week later, per the plastic surgeon’s recommendations, bacitracin ointment and non-adherent cellulose acetate petrolatum was applied to the hand wounds. Medical-grade honey was added to areas of the right buttock to promote autolytic debridement. These regimens were continued as healing progressed without complication (Figures 4 and 5). Time to heal was 30 days for the hand and 51 days for posterior thigh/buttock.

Integrating multimodal wound management strategies—including pHA in coordination with other advanced therapeutic dressings—has shown reduced healthcare utilization, in part by shortening time to healing. In this case series, wound healing at a median time of 19 days was observed among the 124 patients who met the inclusion criteria. These results compared favorably to the 35 days described in the literature.² By shortening the healing time of complex wounds the financial burden to the patient and the health care system is reduced.^4,5

Acute wounds, particularly those of traumatic etiology, have a propensity for infection. Control of the bioburden adds an additional level of complexity to the management of these wounds. Conventional wound dressings act as a shield from infection without addressing the bioburden. With the tools in the ASWS armamentarium, particularly pHA solution and silver-impregnated dressings, the investigators showed successful healing of even the dirtiest of wounds in the most challenging of locations. Earlier consultation of wound specialists can enable optimization of the treatment plan. Although beyond the scope of this paper, the authors acknowledge the importance of physical therapy, occupational therapy, nutritional support, and case management in assisting these patients throughout their healing continuum.¹⁵ The resulting decrease in dressing change frequency, follow-up outpatient appointments, and home care could lead to increases in patient satisfaction in addition to optimal wound healing outcomes.

This report has several limitations. First, it represents the experiences, practices, and products available at only one level 1 trauma center. Evaluation across multiple facilities would provide a better understanding of potential benefits of this practice model. Second, there was no comparator as all patients treated by ASWS underwent individualized treatment plans directed at healing their unique injuries. Similarly, as this report was observational in nature, there was no randomization of patients to allow for direct comparison of case-matched patients utilizing traditional care versus those receiving wound specialist services. Another limitation was that this study site has a high incidence of patients with post-traumatic stress disorder and substance abuse, which contributes to loss to follow up (Table 3). A further 5 patients were excluded as their overall health condition was so unstable that their wound healing could not be adequately assessed. Finally, the small sample size may not be adequately representative of complex wound patients nationwide.

In conclusion, the patients represented in this case study were complicated and deserved the expertise of wound-care trained professionals to coordinate novel and individualized treatment plans to effectively accelerate their healing potential and avoid unnecessary complications. The ASWS relied on a few core therapies, which were combined to take advantage of their beneficial properties in synergistic ways. The pHA use was a consistent feature in all study patients, starting from wound bed preparation at initial consult and continuing through ongoing dressing changes with and without NPWT use, and NPWTi-d was often used. Further evaluation of wound specialist-driven programs will allow for better understanding of the benefits that integrating multiple therapeutic strategies individualized to patients’ dynamic scenarios can provide. This practice model will continue to evolve as other treatment options become available.

Authors: Kathy E. Gallagher, DNP, APRN-FNP, CWS, WCC^1,2; Emily C. Alberto, MD²; John Getchell, RN,BSN²; Jessie Powell, MSN, FNP-C, AGACNP-BC, CEN^1,2; and Luis Cardenas, DO, PhD^1,2

Affiliations: ¹Acute Surgical Wound Service, Department of Surgery, Christiana Care, Newark, DE; ²Department of Surgery, Christiana Care, Newark, DE

Correspondence: Kathy E. Gallagher, DNP, APRN-FNP, CWS, WCC, 2471 Everetts Corner Rd, Hartly, DE 19953; kathy.e.gallagher@gmail.com

Disclosure: Kathy Gallagher is a clinical advisor to Urgo Medical, North America. The other authors have no conflicts of interest to disclose.

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