Practice Accelerator

Prevention and management of biofilm and infection in wounds can be supported by using antimicrobial and antibiofilm dressings. Internationally, there has been a rising prevalence of antibiotic-resistant organisms; this has resulted in increased incorporation of antimicrobial dressings in wound management. These dressings offer many advantages because they are easy to use, are readily available, have a decreased risk of resistance, and deliver sustained release of antimicrobial agents to the wound bed. This mode of action allows for a lower concentration of the agent and thereby lowers the possibility of toxicity to host cells.

Bioburden: Bioburden is the number of microorganisms in a wound, and a high bioburden can cause delayed wound healing.

Biofilm: Biofilms are usually composed of mixed strains of bacteria, fungi, yeasts, algae, microbes, and other cellular debris that adhere to the wound surface.

Epibole: Epibole refers to rolled or curled-under closed wound edges. These rolled edges are thickened epidermis that may be callused, dry, scaly, and/or hyperkeratotic. When epibole is present in a wound, it signals to the body that the wound has healed, even though the wound remains open. Epibole must be resolved to allow the wound to close.

Delayed wound healing occurs in various wound types and in patients with significant comorbidities. Hard-to-heal wounds have proven to be a challenging and worldwide crisis resulting in high financial burdens.

Biofilms are found in the majority of chronic wounds and pose a critical health threat, causing nearly 80% of refractory nosocomial infections. They also have a damaging virulence mechanism, which induces resistance to antimicrobials and evasion from the host’s immune system. Over 90% of chronic wounds contain bacteria and fungi living within a biofilm construct. Biofilms have been reported as major contributing factors to a multitude of chronic inflammatory diseases. Given the resistance of the bacteria, biofilms increase the risk of infection and cost the health care system millions of dollars annually. Clinicians should have practical knowledge of the role and impact that biofilms play in impeding chronic wounds, thus leading to risks of complications such as infection.

Wound debridement is a critical strategy in treating hard-to-heal wounds. It is a process that expedites healing by removing necrotic tissue, non-viable tissue, and foreign material. It can also be used to manage biofilm to prevent infection. Debriding a wound exposes the healthy underlying tissue to promote healing. There are several methods of debridement. Determining the best option will depend on the health care setting as well as the characteristics of the wound being treated.

Patients who develop stage 3 and 4 pressure injuries with prolonged wound chronicity and complexity may require surgical intervention. One surgical method used to encourage healing in pressure injuries is flap surgery, which involves taking a section of skin with an intact blood supply and placing it over the injured area. Flaps play a major role in the healing of wounds with exposed structure. Flap surgery can help prevent hospitalization and decrease morbidity. Flap surgery is used to prevent and resolve complications, including surgical site infections and other infections, dehiscence, recurrence, flap necrosis, nutrient deficiencies, and prevention of future malignancy (Marjolin ulcer) and seroma or hematoma.

When pressure injury prevention fails as a result of non-adherence, various comorbidities, or gaps in care, it makes a major impact on the nation’s economy and has estimated costs of more than $100 billion in the United States.

Pressure injuries are among the most significant health and patient safety issues that health care facilities face daily. Aside from the strong impact on patients’ quality of life, they also have high costs of treatment, not just to the patient, but also to the health care industry. The Agency for Healthcare Research and Quality reported $20,900 to $151,700 per individual patient and pressure injury in health care costs. The prevalence of present-on-admission (POA) pressure injuries is 26.2% among those admitted to the hospital from a nursing home and 4.8% among those admitted from another living setting. Hospital-acquired pressure injuries (HAPIs) cost the US health care system $9.1 to $11.6 billion a year.

The coronavirus disease 2019 (COVID-19) pandemic has forced health care professionals to take a closer look at the most effective and appropriate measures for pressure injury prevention. In 17% of all COVID-19 cases pneumonia secondary to acute respiratory distress syndrome is the most common complication; therefore, prone positioning is used as an adjuvant therapy. The prone position allows for dorsal lung region recruitment, end-expiratory lung volume increase, and alveolar shunt decrease. To be most effective, this position should be maintained for 10 to 12 hours, thereby increasing prolonged pressure on certain areas of the body. However, prone positioning should be supervised and monitored regularly by nursing staff experienced with this positioning technique.

Adherence: Adherence is a term used to replace "compliance" in reference to a patient following clinician orders for wound care. Compliance implies that the patient should passively comply with the health care provider’s instructions, whereas adherence allows for patients to have the freedom to follow the provider’s recommendation without blame being focused on them if they do not or are not able to follow these recommendations.

Medical device–related pressure injury (MDRPI): MDPRIs are localized injuries to the skin or underlying tissue resulting from sustained pressure caused by a medical device, such as a brace, splint, cast, respiratory mask or tubing, or feeding tube.

Offloading: Offloading refers to minimizing or removing weight placed on the foot to help prevent and heal ulcers, particularly those caused by poor circulation to the feet due to diabetes.