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Use of PICO™ to improve clinical

and economic outcomes in
hard-to-heal wounds
Intro
Wounds impose a substantial economic burden on healthcare systems [1,2] and

–––
have a significant impact on patients’ quality of life. Vital to reducing the costs
associated with wound care is identification and treatment of hard-to-heal wounds.
Failure to recognise when a wound is not progressing to healing increases the
cost of treatment and risk of complications, is more challenging for clinicians and
Authors: significantly impacts patient quality of life. A recent evaluation of the impact of
xxxxx
PICO™ using a defined pathway showed the importance of early intervention in
hard-to-heal wounds and the role of advanced therapies in progressing a wound
towards healing. Implementing the PICO pathway resulted in statistically significant
improvements in the healing trajectory of stalled wounds, both during and after
use. It resulted in a 33.1% (£50,000) cost reduction and released 119 days of nursing
Authors:
Caroline Dowsett, Jane Hampton, time over 26 weeks in the treatment of 52 patients.
Dave Myers & Tim Styche

Acknowledgement
This article was supported by
Smith & Nephew
Caroline Dowsett is Nurse
Consultant, Tissue Viability, East
London Foundation Trust, London, UK
Jane Hampton is Consultant Wound
Nurse, Aarhus Municipality, Denmark
Dave Myers is Director of Market
Access, Smith & Nephew
Tim Styche is Health Economics
Analyst, Smith & Nephew
G
lobally, a significant proportion
of healthcare budget is spent on
treatment of wounds. For example,
the cost of wound care and comorbidities
in the UK in 2012/13 was estimated at
between £4.5bn and £5.1bn[1]. Healing time,
frequency of dressing change and incidence of
complications are the three main cost drivers[3]
that impact the overall health economy.
Some £3.2bn is spent on treating hard-to-heal
wounds, which account for 39% of the total
number of wounds[1,2].
Wound management is a predominantly
nurse-led activity[1,2], with the majority of care
delivered in the community. Some 80% of
hard-to-heal wounds are treated in the
community[4]; consequently, it is the community
that bears most (66%) of the costs of treating
these wounds[2].
Early discharge targets are putting greater
pressure on community care, moving treatment
and other associated costs from one setting
to another. It can often result in increased re-
admissions which, in turn, push up total system
costs and can result in poor patient outcomes
and experience.
This is a dilemma faced by many health
systems in Europe; even in countries where
an acute trust would cover the cost of care for
a recently discharged patient, the reality of
increased cost across the system remains.
Impact on patients
Hard-to-heal wounds represent a complex
clinical problem that can take weeks or months
to resolve, and are costly for both the patient
and the health economy[5].
This cycle is often exacerbated by delays in
assessment, failure to treat underlying cause or
seek timely advice. Balancing costs and effective
care requires good communication between
all stakeholders, and implementing available
technologies that are easy to use, promote faster
healing, improve patient satisfaction and free up
clinical time.
The negative impact on patient quality of life
and wellbeing of chronic wounds is comparable
to that of other major chronic diseases. It is
important that a comprehensive, chronic disease
management approach is adopted in order to
deliver patient-centred, multidisciplinary care
aimed at achieving positive outcomes in both
clinical and quality-of-life terms[6].
Hard-to-heal wounds
Breaking the cycle of hard-to-heal wounds has
never been more important. To do so requires
clinicians to take a proactive approach to
recognising those wounds that are not healing
at 4 weeks despite best practice interventions.
Inappropriate or delayed treatment has a
detrimental effect on the healing trajectory, as
well as impacting patient quality of life[7].

52 Wounds International 2017 | Vol 8 Issue 2 | ©Wounds International 2017 | www.woundsinternational.com

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In a wound survey of 4,772 patients, 37.4% of
Box 1. Definition of a hard-to-heal wounds were found to be either static (28.2%)
wound (Vowden). or deteriorating (9.2%)[8]. The cost both clinically
and economically of inaction in treating these
■■ A hard-to-heal wound has wounds is significantly higher than the cost
been defined as one that fails of intervention. However, awareness that wound
to heal with standard therapy management extends beyond dressing choice
in an orderly and timely
remains poor[7].
manner[21]. This definition
applies equally to both acute Appropriate care including thorough,
and chronic wounds and is documented patient and wound assessment,
independent of the wound diagnosis of underlying disease and
type and aetiology[22] comorbidities, and effective wound bed
■■ Common, interchangeable preparation are vital in tackling the burden of
terms for hard-to-heal wounds hard-to-heal wounds. So too are appropriate
include stalled, static chronic, choice of dressing and early intervention.
non-healing and challenging.
If after the first 4 weeks of standard care
and having addressed the underlying cause
a wound is not healing, the patient should
be reassessed. As part of the re-assessment,
alternative treatment regimens, including
Box 2. Hard-to-heal wounds advanced therapies, should be considered and
explained. implemented in line with local protocols and
treatment pathways.
■■ Hard-to-heal wounds tend to
stall in the inflammation stage The role of advanced therapies
of healing. Despite different Advanced therapies, such as negative pressure
aetiologies at molecular wound therapy (NPWT) have been traditionally
level, stalled wounds share
viewed as expensive treatment options as the
some common features
including, excessive levels of unit cost only is taken into consideration and
pro-inflammatory cytokines, not the long-term effectiveness of treatment.
proteases, reactive oxygen However, evidence suggests that used
species (ROS) and senescent appropriately and integrated into existing care
cells, as well as persistent pathways, which are known to improve care
infection[23]. and patient outcomes, these technologies
improve healing rates, reduce clinical time,
prevent admission/re-admission and improve
the patient experience[9]. Use of such technology
can reduce the cost drivers of healing time,
dressing change frequency and complications[3].
Newer devices, such as PICO™, make NPWT
more accessible in the community. The device is
small, discrete, disposable and easy to use[10,11,12].
They also reduce exudate levels and wound
volume, while increasing granulation tissue
Figure 1. Modes of action of NPWT. formation and blood perfusion [Figure 1].
■ Exudate levels[24]
■ Tissue oedema[25,26]
■ Wound volume[27]
Increase
Decrease
■ Wound bed stimulation[10,11,28]
■ Wound edge contraction[27]
■ Granulation tissue formation[29,30,31,32]
■ Blood perfusion[27]
Wounds International 2017 | Vol 8 Issue 2 | ©Wounds International 2017 | www.woundsinternational.com 53
NPWT has been shown to improve patient
and wound outcomes, and reduce the cost of
care by:
■■ Promoting healing[13,14]
■■ Reducing the number of dressing changes[15]
■■ Releasing resources[14,15]
■■ Helping to improve patient outcomes and
wellbeing[10,16,17,18].
A study of NPWT in Denmark[19] revealed that
using PICO in patients with a hard-to-heal
wound:
■■ Reduced wound size faster:
pre-NPWT = 3.5%; under NPWT = 21% and
post-NPWT (4 weeks) = 72%
■■ Improved healing: 3 wounds healed on
average 13 weeks earlier than estimated
■■ Reduced treatment costs: 3x less per week
following NPWT
■■ Reduced overall treatment costs because of
shortened treatment time[20].
Implementing the hard-to-heal
wounds pathway
To date, there has been no clear evidence to
support when to introduce advanced therapies
and for how long they should be used. The aim
of this evaluation was to develop a pathway
that supports decision-making when using
PICO, as well as to improve healing outcomes.
The PICO pathway [Figure 2] was developed to
support clinical decision making when using
it in the management of hard-to-heal wounds
across 10 sites. The sample of 52 wounds
evaluated varied in aetiology [Figure 3] and
duration [Figure 4], and was representative of a
typical community caseload.
The pathway is designed to encourage
clinicians to think about taking a different
approach to hard-to-heal wounds; to
encourage them to focus on progressing a
stalled wound to healing as opposed to simply
managing wounds of longer duration. Crucially,
the pathway pinpoints at what stage clinicians
need to make a decision about whether or not
to continue therapy, and the importance of
early intervention.
The aim of the pathway is to ensure
appropriate use of advanced therapies, such
as PICO, on the right patient at the right time
for the right duration to optimise outcomes
for the patient, as well as to ensure efficient
use of resources for healthcare providers. The
pathway facilitates clinical decision-making and
encourages regular patient review with a focus
on outcome improvements.
Before implementing the PICO pathway on a
 Products & technology

Figure 2. PICO pathway[38,39,40,41,42,43]

* Wounds with overt signs of clinical infection
(e.g. increased pain, levels of exudate, cellulitis etc.)
should be excluded from the evaluation. Colonised/
critically colonised wounds are not excluded from
the evaluation. Site standard protocol should be
implemented to address bacterial burden.
Entry criteria
- Wound >6 weeks in duration — wound has reduced in area by <10% per week over previous 4 weeks
- Wound has not received NPWT within the last 6 weeks
- Wound is not clinically infected*
- If VLU, ABPI confirmed as >0.8 and <1.3
- None of the PICO contraindications for negative pressure apply

Week 0 — Apply PICO Weekly Wound Assessment:

** Wounds that have healed by <10% but have shown - Use simple length and width measures for area
significant improvement in granulation tissue quality/ and % healing calculation (using supplied grid)
quantity may be considered for further PICO treatment Week 1 — Wound assessment and apply PICO - Change in exudate levels
based on clinician judgement. - Change in granulation tissue %
- Change in pain levels
Week 2, 3, 4 decision point (discontinue PICO if any of the PICO
contraindications are present)

Wound reduced in area by <5% at week 2 (compared to Wound reduced in area between 10%–40%.
week 0 area), <7.5% at week 3 or <10% at week 4 with Wound reduced in area by >40%. Use clinical and economic judgement to
no significant improvement in granulation tissue quality/ Good responder. Stop PICO determine whether PICO treatment should be
quantity**; static (0%) or increased in size (deteriorated). (but can re-instate if wound healing rate stalls continued on a week-by-week basis.
Non-responder. Stop PICO — at clinicians judgement). Implement standard therapy (AWC) when PICO
Wound requires further investigation or onward referral Implement standard therapy (AWC) not in use
to a specialist service

Week 4–12 — Continue weekly wound assessment

Week 12 — Final assessment & discontinuation from evaluation

systematically on all of the critical elements of

Figure 3. Wound types a non-healing wound to identify the cause, and
12 12
12 implement a care programme that progresses
10
10 the wound to healing[35].
8 Wound bed preparation is essential to ensure
6
advanced therapies have the best chance of a
5 5
successful outcome for the patients. Infection
4 3
2 2 should be resolved before using advanced
2 1 therapies to provide maximum opportunity
0
Dehisced VLU Pressure Other Traumatic Mixed DFU Not Arterial for effective, efficient use of resources.
surgical ulcer wound aetiology specificed leg ulcer
wound
PICO is compatible with ACTICOAT TM Flex
Wound type nanocrystalline silver dressings[36,37].
The pathway can be used on wounds of more
than 6 weeks duration that have reduced by
<10% per week in the preceding 4 weeks, and
Figure 4. Wound duration
have not been treated with NPWT within the
last 6 weeks [Figure 2]. The wound must be free
20 17 from infection and if it is a VLU, the ABPI must be
15
confirmed as >0.8 and <1.3.
The ‘decision point’ for whether or not to
10 continue PICO can occur at weeks 2, 3, 4 is
7 7
pivotal. If the wound is not responding (e.g. has
4 4
5 3 3 reduced by <5% at wk2; <7.5% at wk3 and <10%
1
at wk4), PICO should be discontinued and the
0 Less
than 3
3–6
months
6–9
months
9–12
months
1–2 years 2–3 years 3–4 years Over 4
years
patient referred to a specialist clinic.
months If the wound has reduced in area by >40%
Duration
and is a ‘good responder’ PICO should also be
Mean duration: 56.8 weeks (1.1 years); median duration 23 weeks (0.4 years)
stopped (clinicians are advised to use their
judgement in reintroducing the therapy if the
hard-to-heal wound a full holistic re-assessment wound stalls again).
of the patient and wound, and diagnosis of However, for wounds that have reduced in
the underlying disease and comorbidities area by 10%–40%, clinicians are encouraged
should be carried out and documented. Using to use both clinical and economic judgement
a structured approach to patient and wound to determine if PICO should be continued on
assessment, such as TIME[33] or the Triangle of a week-by-week basis up to 12 weeks for the
Wound Assessment[34] enables clinicians to focus pathway [Figure 2].

54 Wounds International 2017 | Vol 8 Issue 2 | ©Wounds International 2017 | www.woundsinternational.com

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Table 1. Healing rates by wound duration. Table 2. Pathway healing costs at 26 weeks versus predicted
standard care.
Duration Wounds Healed Healing Proportion
trajectory healed/healing Predicted Calculated Calculated
standard costs with costs, including
Less than 3 months 17 8 8 94.1% care 14 healed additional
3–6 months 7 2 3 71.4% wounds 18 wounds
projected to heal
6–12 months 7 1 2 42.9%
Healed 4 14 32
Over 1 year 15 2 3 33.3% wounds
Unspecified 6 1 2 50.0% Nursing cost £120,708.32 £60,602.11 £49,215.42
Total 52 14 18 Dressing cost £30,518.48 £40,533.13 £39,069.58
Total cost £151,226.80 £101,135.24 £88,285.22
Table 3. Nursing hours saved. Percentage N/A 33.1% 41.6%
saving on
Predicted standard Pathway hours Pathway hours used with predicted
care hours used used with 14 additional 18 wounds standard care
healed wounds projected to heal
Nursing 1801.6 904.68 730.6
hours

Healing outcomes wounds reducing on average 9.6% more each

PICO significantly improved the healing week versus the pre-PICO rate (p=0.001).
trajectory of hard-to-heal wounds in the sample. After 12 weeks, 14 of the 52 wounds had
The data show it also significantly improved healed versus 4 predicted to heal if the wounds
the healing trajectory post-application when had remained on standard treatment. The
compared to the baseline trajectory of the same healing rates documented in the pathway
population [Figure 5]. represent a significant improvement on targets
Where the wound was not documented as for hard-to-heal wounds in England where the
healed by week 12, the predictive outcomes aim is to treat and heal complex wounds, e.g. leg
model used assumes that it would continue to ulcers within 18 weeks (AQP guidance requires
use resources to week 26. 70% within 24 weeks)[44].
During the PICO phase (weeks 1 and 2 in Significantly, at the end of the 12 weeks, a
which PICO was advised using the pathway), the further 18 wounds were also observed to be on a
weekly average data showed that the wound healing trajectory. In total, 61% of wounds healed
area reduced by 13.4% more than the pre-PICO or were progressing to healing at 26 weeks.
rate (p=0.006). In the 12 weeks post-baseline,
data was also statistically significant with Impact of early intervention
Data showed that while PICO significantly
improves the healing trajectory of longer-
duration (1+ years) hard-to-heal wounds, early
20 intervention (within the parameters of use
Baseline wound PICO Phase decrease
-11.7% detailed in Figure 2) significantly improves the
0
Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week Week
-4 -3 -2 -1 0 1 2 3 4 5 6 7 8 9 10 11 12
time to healing of wounds of duration under 6
-20 months [Table 1]. Improved healing and healing
trajectories were shown across all wound types
-40
in 12 weeks.
-60
Quality improvement data
-80
Cost comparisons
-100
Baseline PICO Phase Post Baseline
Data show that implementing the PICO pathway
resulted in total cost savings of 33.1% versus
predicted standard care. Nursing costs fell 49.7%
in the pathway versus predicted standard care
[Table 2]. This equates to the release of 897 hours
Figure 5. Weekly area reduction rate (%). of nursing time versus predicted standard care.

Wounds International 2017 | Vol 8 Issue 2 | ©Wounds International 2017 | www.woundsinternational.com 55

 Products & technology
Box 3. Cost and nursing time
evaluation method.
Using the data created for the
healing comparison, costings
were created as follows:
Baseline (standard care)
■■ Clinicians documented the
week 0 care plan, including
dressings used and dressing
change frequency
- The cost of dressings was
calculated using the UK drug
tariff (June 2016)
- Cost of care was calculated at
£34.62/dressing[45]
- Estimated dressing change
time was 31 minutes[46]
■■ PICO was costed at £135.19
(average price using the UK
Drug Tariff, June 2016)
■■ It was assumed that once a
wound was healed, no further
nursing time or dressing
resource was required.
Where the wound was not
documented as healed by week
12, the predictive outcomes
model used assumes that it would
continue to use resources to
week 26
Box 4: PICO pathway audit sites.
Sites involved in the audit
included
3 UK
■■ Caroline Dowsett, East London
Foundation Trust
■■ Nina Laut, North East London
NHS Foundation Trust
■■ Sue Murphy, Bristol
Community Health CIC
2 Denmark
■■ Jane Hampton, Aarhus
Municipality
2 Sweden
■■ Malin Wilson, Helsingborg
Hospital
■■ Nina Åkesson, Lyckeby Wound
Healing Centre
3 Canada
■■ Caroline Claveau, Rosemont
Hospital, Montreal
■■ Debi Abner, McGill Hospital,
Montreal
■■ Anabelle Entredicho,
Mississauga Halton CCAC
56 Wounds International 2017 | Vol 8 Issue 2 | ©Wounds International 2017 | www.woundsinternational.com
Wound progression 6.9% 17.2%
Device functionality
8.0% 46.3%
Patient experience 6.8% 51.1%
Clinician feedback 19.3%
0% 20%
Very poor
Figure 6. Clinician feedback.
Dressing costs recorded an increase of 32.8%
for the pathway versus predicted standard care,
as PICO has a higher unit cost versus traditional
dressings, particularly in weeks 1–4 [Table 2].
However, the overall combined treatment costs
(including predicted costs for slower or non-
healing wounds) reduced significantly because
wounds in the PICO pathway healed earlier. If
the economic model were continued over 52
weeks, using the PICO pathway would result in
an 11.2% reduction in dressing costs.
The 14 healed wounds released 897 nursing
hours [Table 3], which is the equivalent of 120
nursing days, and represented a saving of
£50,000 over 26 weeks. When considering the
additional 18 wounds projected to heal, this
increased to 1,071 hours or 143 days, and a
£63,000 saving.
By freeing up nursing time the pathway
enables nurses to dedicate more time to holistic
assessment, reducing the likelihood of hard-
to-heal wounds occurring and potentially
preventing hospital admission/re-admission as
the result of a wound. It also enables nurses to
spend more time with current patients, improving
levels of involvement and engagement, and to
potentially treat new patients.
Improving patient outcomes
The pathway gives a clinical option for some
patients with hard-to-heal wounds to become
wound free. Data predict that at 26 weeks 61%
(32 of 52) of wounds would have healed.
For patients with a healed wound or one that
is progressing to healing, the improvement in
physical, mental, emotional and psychosocial
46.6% 25.9%
44.6%
40.9%
39.8% 40.9%
40% 60% 80% 100%
Poor Fair Good Excellent
wellbeing may be significant. It enables them
to resume normal daily activities, including
work and social engagements that they may
have withdrawn from due to discomfort, poor
mobility or embarrassment.
Improving quality-of-life outcomes may offer
financial benefit too, not just for the individual
and his/her family, but also to the community
and the wider economy.
Feedback from patients treated as part of
the pathway was positive, according to the
treating clinicians.
Clinician feedback
The clinicians who took part in the evaluation
were asked about their experience of using PICO
[Figure 6]. When asked about wound progression,
72.5% said it was ‘good’ or ‘excellent’– using the
pathway, two-thirds of the sample of hard-to-heal
wounds responded positively to treatment. When
asked about the device functionality, 90.9% said
it was ‘good’ or ‘excellent’; 92% of clinicians rated
patient experience as ‘good’ or ‘excellent’; and
80.7% rated their experience of using PICO as
‘good’ or ‘excellent’.
Conclusion
The evaluation shows that using the PICO
pathway supports clinical decision-making
when using PICO, improving patient outcomes,
lowering the cost of treatment and reducing
the cost burden on the health economy of
treating hard-to-heal wounds. WINT
 Key points: Case study 1: A 55-year-old gentleman with a venous leg ulcer.

■■ Implementing the PICO Case study 1: A 55-year-old gentleman with a venous leg ulcer
pathway resulted in
Mr AB is a 55-year-old gentleman with a recurrent history of venous leg ulceration and deep
statistically significant
improvements in the vein thrombosis, who is overweight and suffering from osteoarthritis.
healing trajectory of stalled He has a non-healing venous leg ulcer of 24 months duration despite recommended best
wounds, both during use and practice with compression therapy. On assessment his ulcer is 3.1cm2. He was started on
afterwards NPWT using PICO.
■■ Of the 52 wounds, 14 were At week 1 the ulcer had reduced in size to 1.5cm2 showing a 50% reduction in would size.
observed as healed at 12 The patient had a reduction in pain and found the device enabled him to participate in his
weeks of data collection usual daily activities.
■■ Using PICO resulted in a 33.1% PICO was discontinued at week 3 and he was fully healed at 12 weeks. Compression hosiery
(£50,000) cost reduction and
was applied to prevent recurrence of his leg ulcer.
released 119 days of nursing
time over 26 weeks
■■ Of the 38 wounds not Week 1 Week 2 Week 12
documented as healing at 12
weeks, 18 were on a healing
trajectory that, if continued,
would heal within 26 weeks of
the pathway starting
■■ Using PICO would result in an
annualised 11.2% reduction in First application PICO in situ
dressing costs
■■ Healing or healing trajectories
were seen across all
documented wound types
■■ Feedback from clinicians was
overwhelmingly positive

Case study 2: A 77-year-old female with a dehisced surgical wound.

Ms CD is a 77-year-old female with a dehisced surgical wound in the groin, which resulted
after an abscess was drained 8 weeks previously. The patient also has arthritis, cardiovascular
disease and reduced mobility, and is taking prednisolone. The wound is increasing in size
and has excessive exudate. A course of antibiotics had a minimal effect. Ms CD was being
treated at home by community nurses using an antimicrobial primary dressing and foam
secondary dressing, which were changed daily. At week 0 PICO was started with ACTICOAT
Flex on the wound bed; the wound had an area of 8.6cm2.
At week 3 (after 21 days with PICO) the wound measured 4.8 cm2 (55% reduction on week 0)
At week 7 the wound measured 3.6 cm2 (weekly reduction of 27%)
At week 12 the wound measured 0.8 cm2 (weekly reduction of 13%)
Complete healing was delayed due to hypergranulation. The wound healed in week 16.

Week 0 Week 3 Week 7

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Reference: Hampton - Providing cost-effective treatment of hard-to-heal wounds in the community through use of NPWT.2015
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