Resources: Chronic Wound Care

Recent Publications Related to Chronic Wounds

Katherine Jones

• Jones KR. (2009). Why Do Chronic Venous Leg Ulcers Fail to Heal? Journal of Nursing Care Quality. 24(2):116-124. Selected for continuing education feature.

• Jones KR. (2009). Identifying Best Practices for Pressure Ulcer Management. Journal of Clinical Outcomes Management. 16(8):375-381.

• Jones KR. (2009). Wound Management in Older Adults. Age/Aging (In press).

• Jones K, Fennie K, Lenihan A. (2007). Chronic Wounds: Factors Influencing Healing Within 3 Months and Non-healing After 5-6 Months of Care. Wounds, 19(3):51-63.

• Jones K, Fennie K. (2007). Factors Influencing Pressure Ulcer Healing in Adults Over 50: An Exploratory Study. Journal of the American Medical Directors Association, 8:378-387. (Plus Accompanying Editorial)

• Jones K, Fennie K. Lenihan A. (2007). Evidence-based Chronic Wound Care: How Well Are We Doing? Advances in Skin & Wound Care, 20(11):591-600. 
  

• Jones, KR, Makuch, G, Fennie, K, & Lenihan, A. (October 2005). Wound Care Practices and Outcomes: A Multisite Study. The Gerontologist, Volume 45, Special Issue II, Program Abstracts, p. 247.

• Jones, KR, Fennie, K, Lenihan, A. (September 2006). Identifying Factors Influencing Pressure Ulcer Healing in Older Adults. Proceedings, Clinical Symposium for Advances in Skin & Wound Care.

• Jones, KR. Fennie, K. (October 2007). Venous Ulcer Management and Healing in Older Adults. The Gerontologist, Volume 47, Special Issue 1, Program Abstracts, p. 472.

• Jones, KR. Wound Care Practices and Outcomes. Presented at the 16th International Nursing Research Congress: Renewing Nursing Through Scholarship, Sigma Theta Tau International Honor Society of Nursing, Hawaii (July 2007).

Clinical Practice Guidelines

Venous leg and diabetic foot ulcers:

• Guideline for the management of wounds in patients with lower-extremity venous disease. Wound, Ostomy Continence Nurses Society (WOCN), 2005.

• Assessment and management of venous leg ulcers. Registered Nurses Association of Ontario (RNAO), 2004 (Updated 2007).

• Chronic wounds of the lower extremity. American Society of Plastic Surgeons, 2007.

• Diabetic foot disorders: a clinical practice guideline. American College of Foot and Ankle Surgeons, 2000 (Updated 2006).

• Assessment and management of foot ulcers for people with diabetes. Registered Nurses Association of Ontario (RNAO), 2005.

• Guideline for management of wounds in patients with lower-extremity neuropathic disease. Wound, Ostomy, Continence Nurses Society (WOCN), 2004.

• Clinical guidelines for type 2 diabetes. Prevention and management of foot problems. National Collaborating Centre for Primary Care, 2004 (Update pending).

• Diagnosis and treatment of diabetic foot infections. Infectious Disease Society of America, 2004.

• Venous leg ulcers. Dutch College of General Practitioners, 2002.

• Best practice statement: compression hosiery. National Library of Guidelines, 2002.

Pressure ulcers:

• Pressure ulcer prevention and treatment following spinal cord injury. Consortium for Spinal Cord Medicine (PVA), 2000 (Reviewed 2005).

• Risk assessment and prevention of pressure ulcers. RNAO, 2002 (Revised 2005).

• Assessment and management of Stage I to IV pressure ulcers. RNAO, 2002 (Revised 2007).

• Pressure ulcers in the long-term care setting. American Medical Directors Association (AMDA), 1996 (Revised 2008).

• Preventing pressure ulcers and skin tears. In: Evidence-based Geriatric Nursing Protocols for Best Practices. Hartford Institute for Geriatric Nursing, 2003 (Revised 2008).

• Pressure ulcer treatment. Health care protocol. Institute for Clinical Systems Improvement (ICSI), 2008.

• Skin safety protocol: risk assessment and prevention of pressure ulcers. Health care protocol. ICSI, 2007.

• Pressure relieving devices: the use of pressure relieving devices for the prevention of pressure ulcers in primary and secondary care. National Institute for Health and Clinical Excellence (NICE), 2003. 

Systematic Reviews

General:

• Hyperbaric oxygen therapy for chronic wounds. P Kranke, MH Bennett, SE Debus, I Roeckl-Wiedmann, A Schnabel. Cochrane Database of Systematic Reviews, 3:75320-03166, 2009.

  In people with chronic foot ulcers, HBOT significantly reduced risk of major amputation and may improve chance of healing at one year. Economic evaluations are needed, as well as larger trials. No evidence to support its use with other types of wounds.

• Negative pressure wound therapy: a vacuum of evidence? S Gregor, M Maegele, S Sauerland, JF Krahn, F Peinemann, S Lange. Archives of Surgery, 143(2):189-196, 2008.

  This meta-analysis concluded that, although there is some indication that NPWT may improve wound healing, the body of evidence available is insufficient to clearly prove an additional clinical benefit of NPWT. The large number of prematurely terminated and unpublished trials were cited as a concern.

• Topical negative pressure for treating chronic wounds. DT Ubbibk, SJ Westerbos, D Evans, L land, H Vermeulen. Cochrane Database of Systematic Reviews,3:75320-01309, 2009.

  Trials comparing TNP with alternative treatment for chronic wounds have methodological flaws. Data do demonstrate a beneficial effect of TNP on wound healing, but more, better quality research is needed.

• Topical silver for treating infected wounds. H Vermeulen, JM van Hatten, MN Storm-Versloot, DT Ubbink. Cochrane Database of Systematic Reviews, 3:75320-04476, 2009.

  Insufficient evidence exists to recommend use of silver-containing dressings or topical agents for treatment of infected or contaminated wounds.

Pressure Ulcer Prevention and Management:

• Electromagnetic therapy for treating pressure ulcers. A Olyaee-Manesh, K Fleming, NA Cullum, H Ravaghi. Cochrane Database of Systematic Reviews, 3:75320-01954, 2009.

  No evidence of benefit – further research needed.

• Nutritional interventions for preventing and treating pressure ulcers. G Langer, A Knerr, O Kuss, J Behrens, GJ Schlomer. Cochrane Database of Systematic Reviews, 3:75320-02165, 2009.

  Not possible to draw any firm conclusions on the effect of enteral and parenteral nutrition on the prevention and treatment of pressure ulcers. Further trials are needed.

• Repositioning for treating pressure ulcers. ZEH Moore, S Cowman. Cochrane Database of Systematic Reviews, 3:75320-05645, 2009.

  Despite widespread use of repositioning as a component of management plan, no randomized trials exist that assess the effects of repositioning on healing rates of pressure ulcers. Effectiveness of repositioning on pressure ulcer healing needs to be evaluated.

• Risk assessment tools for prevention of pressure ulcers. ZEH Moore, S Cowman. Cochrane Database of Systematic Reviews, 3:75320-05237, 2009.

  Despite widespread use of risk assessment tool for assessment of individual’s risk of developing pressure ulcers, no randomized trials exist that compare them with unaided clinical judgment, or no risk assessment in terms of rates of pressure ulceration. The effect of structured risk assessment tools on pressure ulcer incidence needs to be evaluated. 

• Support surfaces for pressure ulcer prevention. E McInnes, NA Cullum, SE Bell-Syer, JC Dumville. Cochrane Database of Systematic Reviews, 3:75320-01074, 2009.

  This systematic review concluded that, in people at high risk of pressure ulcer development, higher specification foam mattresses rather than standard hospital foam mattresses should be used. Relative merits of higher-tech constant low pressure and alternating pressure for prevention are unclear, but alternating pressure mattresses may be more cost-effective than alternating pressure overlays. Organizations should consider use of some forms of pressure relief for high risk patients in the operating room. Seat cushions and overlays designed for use in ERs have not been adequately evaluated.

• Therapeutic ultrasound for pressure ulcers. AB sari, K Flemming, NA Cullum, U Wollina. Cochrane Database of Systematic Reviews, 3:75320-00098, 2009.

  No evidence of benefit of ultrasound therapy in the treatment of pressure ulcers. Further research is needed.

• Wound cleansing for pressure ulcers. ZEH Moore, S Cowman. Cochrane Database of Systematic Reviews, 3:75320-04045, 2009.

  No good trial evidence exists to support use of any particular wound cleansing solution or technique for pressure ulcers. One study showed a significant improvement in pressure ulcer healing with saline spray containing Aloe Vera, silver chloride, and decyl glucoside over isoltonic saline solution.

Venous Leg Ulcers:

• Antibiotics and antiseptics for venous leg ulcers. S O’Meara, D Al-Kurdi, LG Ovington. Cochrane Database of Systematic Reviews, 3:CD0007532, 2009.

  This systematic review concluded that no evidence supports the routine use of systemic antibiotics to promote healing in VLUs. There is some evidence to support use of cadexomer iodine. Current prescribing guidelines – use antibiotics only in cases of defined infection.

• Compression for preventing recurrence of venous ulcers. EA Nelson, SEM Bell-Syer, NA Cullum. Cochrane Database of Systematic Reviews, 3:75320-01713, 2009.

  No trials compared use of compression with use of no compression for venous ulcer recurrence. Not wearing compression bandages/stockings was associated with recurrence. Recurrence rates may be lower in high compression hosiery compared with medium compression, so patients should use the strongest level with which they will comply.

• Compression for venous leg ulcers. S O’Meara, NA Cullum, EA Nelson. Cochrane Database of Systematic Reviews, 3:75320-00970, 2009.

  Compression increases ulcer healing rates compared with no compression, Multi-component systems more effective than single component. Multi-component systems with elastic bandages appear more effective than systems consisting mainly of inelastic components.

• Dressings for healing venous leg ulcers. SJ Palfreyman, EA Nelson, R Lochiel, JA Michaels. Cochrane Database of Systematic Reviews, 3:75320-00875, 2009.

  Type of dressing applied beneath compression has not been shown to affect ulcer healing. Meta-analysis did not show significant difference in healing rates between hydrocolloid dressings and simple, low-adherent dressings when used beneath compression.

• Electromagnetic therapy for treating venous leg ulcers. H Ravaghi, K Flemming, NA Cullum, A Olyaee-Manesh. Cochrane Database of Systematic Reviews, 3:75320-01953, 2009.

  No reliable evidence of benefit of electromagnetic therapy – further research is needed.

• Intermittent pneumatic compression for treating venous leg ulcers. EA Nelson, R Mani, K Vowden. Cochrane Database of Systematic Reviews, 3:75320-01366, 2009.

  Intermittent pneumatic compression may increase healing compared to no compression, but not clear if it increases healing when added to treatment with bandages, or if it can be used instead of compression bandages. Rapid IPC was better than slow IPC in one trial.

• Laser therapy for venous leg ulcers. K Flemming, NA Cullum. Cochrane Database of Systematic Reviews, 3:75320-00548, 2009.

  No evidence of any benefit associated with low laser treatment on venous leg ulcer healing.

•  Oral zinc for arterial and venous leg ulcers. EAJ Wilkinson, CC Hawke. Cochrane Database of Systematic Reviews, 3:75320-00387, 2009.

  Oral zinc sulphate does not appear to aid healing of arterial and venous leg ulcers.

•  Pentoxifylline for treating venous leg ulcers. AB Jull, B Arnold, V Parag, J Waters. Cochrane Database of Systematic Reviews, 3:75320-00392, 2009.

  Pentoxifylline is an effective adjunct to compression bandaging for treating venous ulcers and may be effective in absence of compression. Majority of adverse effects are gastro-intestinal in nature.

• Skin grafting for venous leg ulcers. JE Jones, EA Nelson. Cochrane Database of Systematic Reviews, 3:75320-00187, 2009.

  Bilayered artificial skin used in conjunction with compression bandaging increases chance of healing a venous leg ulcer compared with compression and a simple dressing.

• Therapeutic ultrasound for venous leg ulcers. D Al-Kurdi, SEM Bell-Syer, K Flemming. Cochrane Database of Systematic Reviews, 3:75320-00097, 2009.

  Available evidence suggests that ultrasound therapy may increase healing in venous leg ulcers.

• Topical agents or dressings for pain in venous leg ulcers. M Briggs, EA Nelson. Cochrane Database of Systematic Reviews, 3:75320-00533, 2009.

  EMLA provides effective pain relief for venous leg ulcer debridement, but its effect on ulcer healing is unknown.

Diabetic Foot Ulcers:

• Debridement of diabetic foot ulcers. J Edwards. Cochrane Database of Systematic Reviews, 3:75320-02647, 2009

  There is evidence to suggest that hydrogel increases the healing rate of diabetic foot ulcers compared with gauze dressings or standard care. More research is needed to evaluate the effects of the range of widely used debridement methods and of debridement per se.

• Patient education for preventing diabetic foot ulceration. GD Valk, DMW Kriegsman, WJJ Assendelft. Cochrane Database of Systematic Reviews, 3:75320-00837, 2009.

  RCTs mostly of poor quality. Weak evidence suggests that patient education may reduce foot ulceration and amputation in high risk patients. Foot care knowledge and behavior of patients seem positively influenced by patient education in the short-term.

• Pressure relieving interventions for preventing and treating diabetic foot ulcers. SA Spencer. Cochrane Database of Systematic Reviews, 3:75320-01633, 2009.

  Very limited evidence of effectiveness of total contact casts in treatment of diabetic foot ulcers. There is an overall need to measure effectiveness of range of pressure relieving interventions for prevention and treatment of diabetic foot ulcers.

• Silver-based wound dressings and topical agents for treating diabetic foot ulcers. S Bergin, P Wraight. Cochrane Database of Systematic Reviews, 3:75320-04152, 2009.

  Despite widespread use of silver containing dressings and topical agents for treatment of diabetic foot ulcers, no randomized trials exist that evaluate their clinical effectiveness. Trials are needed to determine their clinical and cost-effectiveness, and long-term outcomes.

Database of Abstracts of Reviews of Effects (DARE)

1. Reviewed SR: A systematic review of silver-releasing dressings in the management of infected chronic wounds. Lo, Hayter, Chang, Hu, Lee: Journal of Clinical Nursing, 2008.

Authors’ conclusions: Silver-released dressings had an overall positive effect on management of chronic infected wounds; quality of evidence was limited, more research is needed.

CRD 2009 review conclusion: In view of methodological problems and poor reporting, as well as questionable quality and heterogeneity of primary studies, authors’ conclusions may not be reliable.

2. Reviewed SR: A systematic review of topical negative pressure therapy for acute and chronic wounds. Ubbink, Westerbos, nelson, Vermeulen: British Journal of Surgery, 2008.

Authors’ conclusions: There is little evidence to support use of topical negative pressure in the treatment of wounds.

CRD 2009 review conclusion: This is a generally well conducted review; the authors’ conclusions are likely to be reliable.

In Preparation: Look for the following systematic reviews to be published in the Cochrane Library in the near future.

• Pressure relieving devices for preventing heel pressure ulcers

• Pressure relieving devices for treating heel pressure ulcers

• Educational interventions for healthcare professionals to prevent pressure ulcers

• Re-positioning for pressure ulcer prevention

• Autologous platelet rich-plasma for treating chronic wounds

• Chinese herbal medicine for treating diabetic foot ulcers

• Community clinics versus home management for leg ulcer treatment

• Complex interventions for preventing diabetic foot ulceration

• Dressings and topical agents containing hyaluronic acid in would healing

• Dressings and topical agents for preventing pressure sores

• Dressings for pressure sores

• Dressings for the treatment of diabetic foot ulceration

• Educational interventions for health care professionals to prevent pressure ulcers

• Electrical stimulation for chronic wounds

• Flavonoids for treating venous leg ulcers

• Protease modulating dressings for treating diabetic foot ulcers

• Topical silver for preventing infected wounds

• Topical warming for treating chronic wounds

• Wound care teams for preventing and treating pressure ulcers