Applied Wound Management as an audit tool to inform practice

Clinical PRACTICE DEVELOPMENT

Applied Wound Management as
an audit tool to inform practice

Wound care practice can be difficult to monitor due to the complex nature of wounds, the patients, the variety
of dressings, and the number of staff involved.Applied Wound Management (AWM) and the three wound
healing continuums provide a simple audit tool to collect data on a daily basis, which can be analysed over time
allowing performance to be monitored and compared with data from other time periods or with other clinical
settings.This paper demonstrates that keeping records of patient numbers, presenting conditions and healing
rates can be invaluable when discussing staff training, staffing levels and the work involved in caseloads.

Pam Cooper, David Gray, Fiona Russell, Sandra Stringfellow, John Timmons,
Melvyn Bertram, Kristine Duguid, Gail Pirie, Evelyn Quinn

KEY WORDS redirected (Clark and Watts, 1991). audit, in itself, is not a solution to
Applied Wound Management Prevalence only gives an indication healthcare quality issues. How the
Audit of the scale of the problem – there information is used to improve care or
Prevalence rates was no information about how the support effective practice is the real
Workload pressure ulcers occurred, or where they value of audit (McIsaac, 2007).With
developed.Thus, this early prevalence the continued emphasis on evidence-
The use of audit in clinical practice data led to the monitoring of pressure based practice (EBP), audit is a vital tool
has become an essential part of ulcer incidence, which provided more to ensure the assimilation of EBP into
the NHS in recent years (Jamvedt data as to the actual numbers of clinical areas (McIsaac, 2007).
al, 2007). Most, if not all clinical settings patients developing pressure ulcers in
will use clinical audits to measure a specific clinical area.This was both A highly successful example of the
performance of certain aspects of impact of audit upon clinical practice has
practice to prove that it meets standards Audits are now accepted been demonstrated through the analysis
set at either local or national level practice as they provide of postoperative wound infection rates.
(McIsaac, 2007), and to ensure that care an essential baseline A number of audits have been published
is clinically and cost-effective. of information from and, indeed, are ongoing, the findings of
which services can be which have lead to a tangible reduction
In wound care, one of the earliest strengthened, resources in the incidence of postoperative wound
clinical audits to be carried out was allocated effectively infection (Taylor et al, 2004; Reilly et al,
the pressure ulcer prevalence audit and improvements in 2001). Central to the success of surgical
(Clark and Watts, 1991). Data from performance (or otherwise) infection audits, was the regular feedback
audits like this helped to highlight areas demonstrated. to the surgeons and staff involved in
where pressure ulcers were particularly the care of the patients, with issues
problematic and, in turn, identify areas more informative about performance such as handwashing, preoperative skin
where clinical resources could be and clinically relevant, as it allowed staff preparation and wound dressings all
to focus on risk assessment and other being reviewed and improved (Reilly et
prevention strategies. al, 2001).

Pam Cooper, David Gray, Fiona Russell and Sandra Audits are now accepted practice An audit carried out on the
Stringfellow are Clinical Nurse Specialists; John Timmons, as they provide an essential baseline population of Hull and East Riding of
Melvyn Bertram, Kristine Duguid, Gail Pirie and Evelyn of information from which services Yorkshire estimated the cost of wound
Quinn are Tissue Viability Nurses, all at the Department of can be strengthened, resources care to be approximately £15–18
Tissue Viability, NHS Grampian, Aberdeen allocated effectively and improvements million per annum (Drew et al, 2007).
in performance (or otherwise) The audit examined the records of
demonstrated. However, performing 1,644 patients with 2,300 wounds.The
majority of the patients were being
treated in the community (74%), 21%
in hospital and 5% in residential or

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Clinical PRACTICE DEVELOPMENT

hospice care (Drew et al, 2007). Of the This practical application to everyday wound are updated according to the
total hospital patient population, more wound care enables practitioners to three continuums and the wounds are
than one in four patients had a wound. approach wound assessment logically measured. All data held is anonymous
This type of audit information provides and systematically by monitoring and and can only be accessed by the nurse
invaluable information for health boards recording wound tissue types, exudate involved in the care of that particular
with respect to planning the effective levels and viscosity, and the presence patient.
allocation of resources. or absence of infection. Each of the
continuums are based on simple The database is able to produce
In addition, there is a growing need measurements which can be carried reports based on the assessment data.
to reduce healthcare-acquired infection out by all members of staff, and are These provide information on the types
rates.These can be addressed by using not designed for use only by specialists. and size of wounds, exudate levels, tissue
audit data such as this to identify areas Increased workloads across the NHS types, healing rates and therapies used to
at high risk of infection, allowing for mean extra efforts need to be made treat the wounds.
effective preventive and intervention to ensure decision-making remains
strategies to be implemented. systematic, clear and coherent.The AWM Data was analysed on all new patients
system aids this type of decision-making, referred to the service from January 2009
Clinical wound audits are also reducing the risk of poor practice and until March 2009.
valuable for demonstrating cost- litigation, through accurate assessment.
effectiveness when implementing Results
changes in therapy. Lambourne et al AWM allows the In a patient group of 199, there were 287
(1996) carried out an audit studying categorisation of most wounds which were reviewed 687 times.
patients with leg ulceration, and found wounds healing by secondary The average number of wounds was
that compression therapy applied in intention and, if applied in a 1.4 per patient and these wounds were
community clinics had economic benefits clinical setting, can facilitate reviewed on average 2.4 times.Wound
and, more importantly, lead to improved clinical audit, producing data types were analysed, with the majority
healing rates. which could define the true being traumatic (39%) or pressure ulcers
extent of wounds healing (35.5%).These two groups accounted for
There is little doubt as to the value by secondary intention in almost 74% of all wound types seen. Table
of auditing practice, with a view to the UK. 1 lists the types of wounds the patients
ensuring that it is both clinically- and presented with.
cost-effective, and resource efficient. Audit
Applied Wound Management
Applied Wound Management (AWM) This paper reports the results of a Wound Healing Continuum data
routine audit carried out over a three- The Wound Healing Continuum is a
AWM allows the categorisation of most month period by staff in the tissue simple method by which wound tissue
wounds healing by secondary intention viability department of Grampian Health types can be recorded as colours (Gray
and, if applied in a clinical setting, can Board, Aberdeen using AWM to collect et al, 2006). Ideally, wounds will pass
facilitate clinical audit, producing data data about their patient group, such as through the continuum moving from
which could define the true extent of the number of patients with wound black to pink.
wounds healing by secondary intention infection and types of dressing used.The
in the UK. tissue viability department covers two Wound tissue types, as defined by
main hospital sites, as well as hospices colour, are outlined in Table 2. Of interest
AWM utilises three different and special cover for care homes when is the high percentage of wounds that
continuums, each relating to a key required.The population of Grampian is had necrotic and/or sloughy tissue
wound parameter: over 500,000, however, this is spread over present (59%; black, black/yellow, yellow,
8 Wound Healing Continuum (WHC): a large geographical area. yellow/red).This shows the severity of the
wounds that are being seen by the tissue
is represented by the tissues in Methods viability department, and also indicates
the wound and is a colour-based During the three-month period AWM that less troublesome and healing wounds
continuum data was collected on all patients’ may not be being referred to the service.
8 Wound Infection Continuum (WIC): wounds at each review. Digital images
is subdivided into named stages were also taken so that details could be From the department’s perspective,
representing varying host responses compared over time.The AWM database there are less referrals for the treatment
to bioburden, each identified by in Aberdeen allows patient data to be of wounds that are progressing towards
clinical clues uploaded into a computer database. healing, such as red granulating and pink
8 Wound Exudate Continuum (WEC): At each patient review, details of the wounds.This could indicate that the
is represented by volume and nursing staff are competent in treating
consistency parameters, and each patients with healing wounds.
can be graded according to a
‘matrix’ continuum.

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Wound Exudate Continuum Tab le 1 Number of wounds Percentage
Wound exudate levels and viscosity 112 39
were recorded according to the Wound Types of wounds 102 35.5
Exudate Continuum. However, viscosity 38 13.2
is not being presented in this paper. Of Type of wound 31 11
interest was the high number of patients Traumatic wounds 2 0.7
with wounds which were assessed as Pressure ulcers 2 0.72
having low exudate levels (60%, n=171), Surgical wounds
indicating that these wounds required Leg ulcers Percentage
dehydration. Overall, there were 74 Burns 9.4
wounds that had either moderate or Diabetic foot ulcers 4
high levels of exudate (Table 3).The 20.5
recording of exudate levels is notoriously Tab le 2 26
difficult and is often viewed as subjective, 29
because there is no clinically accepted Wound tissue types according to the Wound Healing Continuum 4
standard of measurement. Of greater 2
importance is the type of exudate, Colour of wound Number of wounds 5
purulence and odour. Black 27
Black/yellow 12 Percentage
Wound Infection Continuum Yellow 59 14.5
The Wound Infection Continuum Yellow/red 75 60
allows the clinician to analyse the clinical Red 83 14.5
presentation of the wound and by Red/pink 11 11
comparing with the descriptions on the Pink 6
continuum, to assess for the presence or Unknown 14
absence of infection.
Tab le 3 Number of wounds
Wounds can be documented as 42
colonised, critically colonised, locally Volume of wound exudate 171
infected or with spreading infection (Gray 42
et al, 2006). Wounds which are colonised Level of exudate 32
will not exhibit outward signs of clinical No exudate
infection and the bacterial burden will not Low volume
result in clinical signs and symptoms of Medium volume
infection. High volume

The term critical colonisation
describes a state where the wound
bioburden is such that wound healing
is affected (Gray et al, 2006).This stage
is normally witnessed as the slowing or
cessation of wound healing, and may also
be recognised by a change in colour of
the wound bed.

The majority of wounds reviewed
(56%) were assessed as having local
or spreading infection.This, again, is an
indication that the wounds referred to
the tissue viability team required specialist
input.

Most common primary wound treatments 8 Negative pressure wound therapy with wounds which were assessed
The most common primary wound care (NPWT) (3%). as being critically colonised, locally
treatments included: infected or with spreading infection,
8 Antimicrobial agents (48%) A correlation can be seen between and the number of antimicrobials
8 Alginates and hydrofiber the high number of patients presenting being used.

products (13%)

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Tab le 4 cavity is under pressure due to oedema,
there is a risk that the perfusion to the
Wound Infection Continuum data collected intra-abdominal organs can be affected,
which, if left untreated, may lead to
Microbiological state of Number of patients Percentage ischaemia (De Backer, 1999).
the wound
20 15 During the audit period, a total of
Contaminated/no sign 34 patients with an open abdomen
of infection 17 5 were referred to the service.Wound
32 24 measurements were carried out on this
Colonised 40 30 group of patients at their first review
25 26 and the total volume was estimated to
Critically colonised be 6,791cm2.Wounds were measured
from their widest points and volume was
Locally infected estimated on the deepest part of the
wound.While this may not be accurate
Spreading infection with respect to comparisons with other
studies, if the same points are measured
Tab le 5 wound care procedures are carried out. by the same clinician, there is at least
This must be considered when choosing some correlation by which to judge
Average reduction in wound size in patients dressings, as it may directly impact on the improvement or deterioration in the
with open abdominal wounds patient’s quality of life (Young and Roden, wound.
2008).The growth in the use of low
Number of wounds 34 adherent products is therefore welcome There is much controversy about
6791cm2 from both a clinical and quality of life the accurate measurement of wounds,
Total volume of wounds perspective. particularly in relation to deep wounds,
at first review 917cm2 where volume of tissue loss is greater
Open abdominal wounds (Fette, 2006). Studies by Thomas and
Total volume of wounds 1.5cm2–3024cm2 Of particular importance to the tissue Wysocki (1990) on pressure and leg
at final review 200cm2 viability team has been the increase in ulcers demonstrated good correlation
the number of patients presenting with between wound tracing, the Kundin gauge
Range of wound volume 27cm2 post-surgical open abdominal wounds. and computerised photographic analysis.
These wounds can be distressing for It could be argued therefore that more
Average wound volume the patient due to their size and visibility. accurate measurements could have been
at first review Abdominal compartment syndrome is the made using technology, however, as this
pathophysiological consequence of raised was not available, wounds were measured
Average wound volume intra-abdominal pressure, which may at their widest points and depths.
at final review result from a number of clinical conditions,
such as intestinal obstruction, peritonitis The total volume of all wounds
Most common secondary dressings secondary to infection, abdominal trauma reduced from 6,791cm2 to 917cm2 over
Most common secondary wound and intra-abdominal oedema. (De Backer, the audit period of three months, a large
dressings used included: 1999). If abdominal wounds are closed reduction of 86% (Table 5).This may in
8 Foam dressings, 19% by primary suturing when the abdominal part be related to the use of negative
8 Low adherent dressings, 14%
8 Low/non-adherent foams, 10%.

The fact that 24% of patients had Tab le 6
low-adherent products applied to their
wounds indicates that nurses see pain Reduction in wound size for wounds treated with NPWT and those treated with traditional dressings
reduction on dressing removal as an
important feature.Wounds may be Therapy type Volume pre-treatment Volume post-treatment Percentage reduction
painful for a number of reasons, for in volume
example, the actual disease process, such Negative pressure 6417cm2 681.75cm2 84
as in vascular lesions or malignancy, or wound therapy 367cm2 233cm2
they may be painful at specific times, such 36.5
as during dressing changes (Hollinworth, Traditional thera-
2005). Many patients will have a degree of pies
background pain relating to their wound
and this may increase in severity when

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pressure wound therapy (NPWT) 7000
(Table 6). NPWT uses suction through a
wound contact layer to encourage local 6000
tissue perfusion, drainage of exudate and
reduction of local oedema (Molnar, 2004). 5000
The impact on quality of life for patients
when using NPWT on large open wounds 4000
is visible as they are able to mobilise more
easily. Patients may also be discharged 3000
with the NPWT system.The dressings do
not become wet and heavy with exudate, 2000
odour can be reduced and the therapy
may help to reduce embarassment and 1000
discomfort (Jones, 2008).
0 Volume at final review Reduction in volume
One patient had a wound volume Volume at first review
in excess of 3,000cm2. For this size of
wound, combined with the large volume NPWT group
of exudate involved, NPWT was the
treatment of choice. Figure 1. Reduction in volume from first to final review for patients treated with TNP.

400

Table 7 shows the number of patients 350
treated with NPWT, or topical negative 300
pressure (TNP), and those with traditional 250
dressings, while Figures 1 and 2 show the
percentage reduction in wound volume.

These figures demonstrate that 200
NPWT offers greater benefits for
patients with larger wounds and is more 150
clinically/cost-effective.
100
Discussion
50
Overall, the results of the audit reflect the
department’s workload and give a clear 0 Volume at final review Reduction in volume
indication of the patient groups who are Volume at first review
most likely to be reviewed. It should also
be noted that these patients were new Traditional wound dressings
patients who were referred during this
time period, other patients seen before Figure 2. Reduction in volume from first to final review for patients treated with traditional dressings.
this date were not included.
relating to loss of mobility (Close et Tab le 7
The majority of the wounds referred al, 1999). Due to poor health, many of
to the service had necrosis and/or the traumatic wounds in the elderly Number of patients treated with NPWT and
sloughy tissue present, which indicates can become chronic and, in the case of traditional dressings
that these wounds are more likely to pretibial lacerations, there is a risk that leg
require specialist intervention such as ulceration may result if treatment does Dressing used Number of
sharp debridement or other aggressive not include compression and vascular patients
debridement therapy. Of 287 wounds, assessment (Beldon 2008 a, b). Gauze-based TNP
120 had two or more tissue types Silvercel™ (Systagenix) 11
present, which may have implications for The high prevalence of pressure Flamazine® (Smith & Nephew) 11
healing and dressing selection. ulcers in the patient group may also Aquacel® (ConvaTec) 6
relate to the age of the patients and the Iodosorb® (Smith & Nephew) 4
The high prevalence of traumatic inclusion of data from the local acute 2
wounds (39%) may be related to the age medical services for the elderly unit.
of the patients, the time of year — many This shows that a large proportion of
elderly patients are admitted at this time the workload of tissue viability services
of year because of falls and incidents is in the treatment and management of

72 Wounds uk, 2010, Vol 6, No 1

Clinical PRACTICE DEVELOPMENT

Aberdeen Acute Hull Primary Care necrotic tissue.This potentially shows
60% that patients in the acute sector have
wounds which are in a more severe
50% state, i.e. with sloughy tissue present,
and that there may be more wounds
40% which are moving towards healing in the
community.
30%
The majority of patients in Aberdeen
20% and Hull (Barrett, 2008) had wounds
which were low or moderately exuding.
10% This should be reflected in the dressing
changes made during the period of care,
0% Sloughy Granulating Epithelialising Unknown i.e. less frequent dressing changes as
Necrotic wounds are not viewed as highly exuding.

Figure 3. Difference in patient wound tissue types in Hull PCT compared with those in Aberdeen. The wound infection data from
Aberdeen shows a higher degree
pressure ulceration.The data on pressure tissue types in Hull compared with those of wounds which were assessed as
ulcer prevalence can help to identify in the Aberdeen group. infected; 56% local or with spreading
areas which require increased input with infection, compared with just 7% of
respect to clinical education, resources While in essence these groups are wounds in the PCT group. Although the
and pressure-reducing equipment (Clark demographically different, it is helpful assessment criteria are similar, there will
and Watts 1991). to compare the trends for referral. be differences in the observers making
The majority of cases in Aberdeen the assessment, but allowing for this, there
Barrett (2008) used AWM data to have sloughy wounds, while in Hull is still a large variation in the numbers of
examine trends in patients with wounds PCT there were more patients with patients with infected wounds.
in a primary care trust (PCT) in Hull. granulating wounds. Aberdeen also had
Figure 3 shows the differences in wound more patients with wounds containing

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Wounds uk, 2010, Vol 6, No 1 73

CWlionuicnadl cPaRrAeCSTCICIENDCEVELOPMENT

Key points of assessing clinical standards and Close J, Ellis M, Hooper R, Glucksman E,
performance (McIsaac, 2007). In wound Jackson S, Swift C (1999) Prevention of falls
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of health care and provides when treating patients.This can make a controlled trial. Lancet 353(9147): 93–7
valuable information on prescriptive system difficult to employ, as
performance, therapies and every patient and wound is different.The Daniel De Backer (1999) Abdominal
management systems. implementation of wound formularies, compartment syndrome. Crit Care 3(6):
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