Standardization and Extent of Use of a Hypochlorous Acid–Preserved Wound Cleanser in an Inpatient Acute Care Setting

Wound cleansing via pre-application of a pure hypochlorous acid–preserved wound cleanser (HAPWOC; Vashe, Urgo Medical) has evidence-based clinical benefits.^1-12 The product allows safe and efficient mechanical removal of microbes and wound debris and has wide indications. The author, a certified wound, ostomy, and continence nurse, provides a wound consultation service in a 454-bed Level 1 trauma center in the Midwest. After treating hundreds of patients in the “usual” way (i.e, via HAPWOC/gauze soaks) over the years, the wound cleansing protocol has been widened to more complicated wounds and skin conditions. This standardization in cleansing practice with many types of wounds includes use in conjunction with negative pressure wound therapy (NPWT), both traditional and with instillation. It also includes serious skin damage conditions such as moisture-associated skin damage (MASD) that can progress to severe wounds if not managed promptly.¹³ This article reports the work to measure the extent of standardization and usage with HAPWOC for wounds that are managed with traditional NPWT and for MASD.

MATERIALS AND METHODS

Two types of HAPWOC applications were chosen to understand and describe the extent of standardization during a 2-month period (May/June 2021). First, HAPWOC use was assessed to cleanse wound tissue preparation to initiate NPWT (no instillation), with the cleanser being used for pre-application and NPWT dressing changes. Cleansing was performed with HAPWOC on NPWT patients with 50 to 60 mL of HAPWOC in a 10-mL syringe. Two (2) cases are reported of HAPWOC use with NPWT. Second, HAPWOC was used on MASD patients, using HAPWOC-moistened soft gauze on the affected area, followed by gently wiping away debris. One such case is presented. This article also reports case details for presentation of one representative case in which HAPWOC was used with NPWT instillation.

RESULTS

Use as an adjunct with standard NPWT.  During the study period, 50 patients received HAPWOC care with NPWT, out of the total 146 patients that received HAPWOC. HAPWOC was applied for pre-application and dressing changes. Utilization of the HAPWOC demonstrated safe and effective mechanical removal of visible debris. Microbial removal is implied as the wounds did not generally have infection issues. It is suggested that the combined mechanical effects of the HAPWOC and standard NPWT wounds began the healing process via optimal wound bed preparation, followed by the entry of the wound in a healing trajectory. Wounds remained moist and nonmalodorous when managed in this way. Figure 1 and Figure 2 demonstrate typical results.

Use in MASD. During the study period, 22 of 146 patients treated with HAPWOC had skin damage such as MASD. HAPWOC use allowed the skin to return to healthy and stable status. HAPWOC is best used in difficult areas (eg, within the multiple folds of skin in the creases of the abdomen, pannus, bilateral groin, and bilateral axilla) (Figure 3).

As a general principle, HAPWOC use was always suggested at hospital discharge until resolution.

Case 1. A 64-year-old patient had history significant for acute kidney injury, right upper lobe cavity, failure to thrive, malnutrition, chronic obstructive pulmonary disease with hypoxia, hypertension, and ethanol abuse. The patient had fallen and, upon admission, was diagnosed with well-defined unstageable pressure injuries, incontinence-associated dermatitis, and MASD with malodor and satellite lesions. On day 36, after surgical de-escharification, NPWT with instillation and dwell time (NPWTi-d) was started followed by transition to standard NPWT (Figure 1A), and discharge to a transitional care unit (TCU) on day 38. The TCU continued HAPWOC cleansing between standard NPWT exchanges. The wound care regimen at TCU was as follows: NPWT at 125 mm Hg low continuous therapy and change Monday, Wednesday, and Friday using HAPWOC cleansing. The patient returned to the hospital after 12 days (Figure 1B). Standard NPWT had stopped 3 days earlier.

Case 2. A 40-year-old patient with a history of obstructive sleep apnea, hypertension, gastroesophageal reflux disease, and depression was admitted to the surgical intensive care unit for management of a chronic sacral/coccyx wound. The patient was an inpatient at a behavioral health center and spent more than 8 hours a day in a wheelchair with no offloading cushion. An unstageable pressure injury was present on hospital day 1 (Figure 2A). HAPWOC and the use of a silicone foam dressing were started. On day 3, the patient underwent surgical debridement and started a standard NPWT at 125 mm Hg low continuous regimen with HAPWOC use between standard NPWT exchanges. On day 10 (postoperative day 7), the wound bed was red, moist, showed healthy granulating tissue, and had contracting wound edges (Figure 2B). The patient was discharged on day 15 (postoperative day 12) to a TCU and continued standard NPWT with HAPWOC.

Case 3. A 68-year-old patient with type 2 diabetes, morbid obesity, (5’3”, 359 lb), hypertension, gastroesophageal reflux disease, and hypersensitivity lung disease presented to the emergency department for evaluation of a rash and failure to thrive as well as trauma injuries (multiple spinal fractures) due to a fall. A wound, ostomy, and continence consultation was requested for skin condition in multiple folds, creases of the abdomen, double pannus, and bilateral groin in addition to malodor and chronic MASD with satellite lesions. The wound care regimen was as follows: cleanse the wound with 50 to 60-mL HAPWOC moistened nonsterile gauze, dry, and repeat daily; use silver-based, dry-fit fabric between all creases (Figure 3).

Case 4. A 40-year-old patient with super morbid obesity, hyperlipidemia, and type 2 diabetes was admitted for a painful and copiously exudating sacrum. A sulfamethoxazole-trimethoprim antibiotic regimen was prescribed. Bedside debridement was performed in the emergency department. For inpatient care, NPWT with instillation and dwell time was initiated using reticulated open-cell foam with through hole, instilling 75 mL HAPWOC with 5 minutes dwell time every 3.5 hours, followed by continuous negative pressure. After 6 days, the patient transitioned to standard NPWT until discharged (Figure 4).

DISCUSSION

Such an observational study has limitations (eg, lack of a control group). Standardization and wide use on at least 3 types of wounds, as reported here, was aided by the availability of HAPWOC to the bedside RN from the materials management system. This was a change from CWOCN control and distribution to the bedside. The uses described here are, of course, in addition to the common use of HAPWOC on most wounds in the author’s practice via gauze “soaks” followed by wiping and patting dry prior to common dressing applications.

Serious wounds require pH balance and control of the microbial population to heal. The use of HAPWOC, which is supplied with a pH range of 3.5 to 5.5 (conducive to healing),^14-16 as the key agent to prepare the wound bed prior to the application of NPWT gives a head start to the process of mechanical debris and microbe removal. Evidence^17-20 and the author’s experience suggest that microbial colonization and biofilms are thwarted with HAPWOC use.

Debris removal was visible in the NPWT cases presented (standard NPWT, Figures 1 and 2; instillation, Figure 4). Hospital stays can be short, but a wound bed that is well prepared at the start is much more likely to heal. Therefore, the author uses HAPWOC widely (standardized) and recommends its use after hospital discharge.

MASD can progress to serious wounds if not managed aggressively. It is painful, and cleansing with HAPWOC tends to be painless and effective. MASD can be overlooked, and HAPWOC provides an efficient way to manage it. HAPWOC use is consistent with guidelines^21-25 recommending the use of such products.

Pearls for Practice is made possible through the support of Urgo Medical, Fort Worth, TX (www.urgomedical.com). The opinions and statements of the clinicians providing Pearls for Practice are specific to the respective authors and not necessarily those of Urgo Medical, Wound Management & Prevention, or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process.

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