International Wound Journal ISSN 1742-4801

REVIEW ARTICLE

Wound management for the 21st century: combining

effectiveness and efficiency
Christina Lindholm1 & Richard Searle2
1 Sophiahemmet University, Stockholm, Sweden
2 Smith & Nephew Medical Ltd, Hull, UK

Key words Lindholm C, Searle R. Wound management for the 21st century: combining effective-
Efficiency; Health economics; Resources; ness and efficiency. Int Wound J 2016; 13 (suppl. S2):5–15
Service improvement; Wound healing
Abstract
Correspondence to
Treatment of wounds of different aetiologies constitutes a major part of the total health
R Searle, PhD care budget. It is estimated that 1⋅5–2 million people in Europe suffer from acute
Health Economics Manager or chronic wounds. These wounds are managed both in hospitals and in community
Smith & Nephew Medical Ltd care. The patients suffering from these wounds report physical, mental and social
Hull, UK consequences of their wounds and the care of them. It is often believed that the use
E-mail: Richard.Searle@Smith-Nephew.com
of wound dressings per se is the major cost driver in wound management, whereas
in fact, nursing time and hospital costs are together responsible for around 80–85%
doi: 10.1111/iwj.12623
of the total cost. Healing time, frequency of dressing change and complications are
three important cost drivers. However, with the use of modern, advanced technology
for more rapid wound healing, all these cost drivers can be substantially reduced. A
basic understanding of the terminology and principles of Health Economics in relation
to wound management might therefore be of interest.

The impact of wounds on the health system – a
growing challenge
Wounds have been called ‘The Silent Epidemic’
Wounds have a variety of causes; some arise from surgical
intervention, some are the result of injury, and others are a
consequence of extrinsic factors, such as pressure or shear,
or underlying conditions such as diabetes or vascular disease.
They are often classified as a result of their underlying cause
into acute wounds, such as surgical wounds and burns, and
chronic wounds, such as leg ulcers, diabetic foot ulcers (DFUs)
and pressure ulcers (1). Whatever the cause, wounds have a
substantial but often unrecognised impact on those who suffer
from them, on their carers and on the health care system. In
fact, the phenomenon of wounds has been called the ‘Silent
Epidemic’ (2).
Living with a wound can have a profound effect on quality
of life (3). The human cost of wounds manifests itself in,
among other things, pain, distress, social isolation, anxiety,
extended hospital stay, chronic morbidity or even mortality.
Many of these issues are preventable (4). Furthermore, because
of underlying factors such as the age of the patient and the
presence of underlying chronic comorbidities, some wounds
do not follow the normal healing process. These ‘hard-to-heal’
wounds [defined as wounds that fail to heal with ‘standard
therapy’ in an orderly and timely manner (5)] cause further
deterioration in quality of life and increase the burden on the
health care system over a prolonged period.
Sometimes, it is thought that the financial cost of wound
management is just the cost of the materials used, such as
dressings, bandages or topical antiseptics. This is not the case;
most of the cost relates to the use of health care professionals’
time and the cost of staying in hospital, as we will see later. The
choice of materials and treatments, however, can have a major
influence on the total cost.
How many people in the population have wounds?
Prevalence surveys in the UK and Denmark indicate that there
are about three to four people with one or more wounds
per 1000 population (6–9).∗ Many of these wounds become
‘chronic’, with studies reporting that around 15% of wounds
remain unresolved 1 year after presentation (7), often resulting
in a prolonged, yet avoidable, burden to patients, their families
and health systems. Based on the above figures, it is estimated
that in a population of 1 million people, approximately 3500
∗ Hospitaland community data from Denmark were combined to give a
prevalence of around three people with a wound per 1000 population

© 2016 Medicalhelplines.com Inc and John Wiley & Sons Ltd 5

Wound management for the 21st century
people will be living with a wound, of which, 525 will have
had their wound for over 1 year.
The majority of chronic wounds are treated in non-acute
health care settings, such as clinics or home health (7–9).
Studies suggest that wound management accounts for over
half of community health nurse resources in European settings
(4,10). However, a substantial number of people with wounds
require hospital treatment at some stage, which can escalate the
costs of care significantly (4,11). Previous studies have sug-
gested that between 27% and 50% of hospital beds are occupied
by patients requiring some form of wound management (4).
Prevalence of wounds
There are estimated to be around 1⋅5–2 million people
living with a chronic wound across Europe (12). In the
USA, chronic wounds affect around 6⋅5 million people at
any one time (13).
Data from Europe suggest that 64% of wounds treated in
home care were chronic in aetiology (7). Of these, 24% are
estimated to have been living with their wound for 6 months
or more, and almost 16% had remained unhealed for a year
or more (9).
Audit data from hospital settings suggest that as many as
50% of in-patients have a wound. A study of 5800 patients
in Western Australian public hospitals found that 49%
had a wound. 31% of patients had acute wounds, 9% had
pressure ulcers and 8% had skin tears. The authors stated
their belief that a quarter of these wounds had the potential
to be prevented (14).
Data from the USA demonstrate a pressure ulcer preva-
lence of 22% in acute critical care settings (13). Audit
data from Europe indicate that 22⋅7% of hospital patients
had signs of pressure damage [Bermark et al. 2004 (15),
reported in Posnett et al. 2009 (4)].
Wounds result in a significant economic cost
to the health care system
Wounds are estimated to account for almost 3% of total health
system costs (2) – approximately £5billion annually according
to data from the UK (16). A recent study in Wales showed that
the cost of managing patients with chronic wounds amounted to
5⋅5% of total health service expenditure (17). Most of this cost
relates to hospital stay and nursing time for treating patients at
home or in clinics, whereas materials such as dressings account
for a small part of the total cost. In the USA, it is reported
that over US$25 billion is spent each year on the treatment of
chronic wounds (13).
At an individual level, the costs of managing wounds are
highly dependent on the wound type, complexity and site of
care. A study from Sweden in 2002 found that the weekly cost
of managing a venous leg ulcer (VLU) was around €103 per
patient, with annual costs estimated to be between €1332–2585
(4). DFUs are estimated to be more costly to treat than VLUs,
with studies indicating a cost per episode of ∼€10 000 (4).
Treatment costs increase rapidly when complications such as
6 © 2016 Medicalhelplines.com Inc and John Wiley & Sons Ltd
C. Lindholm & R. Searle
infections or amputations occur, with a study from the USA
reporting a cost per amputation of $38 077 (13).
The costs of managing surgical wounds are equally difficult
to estimate with any accuracy. The management of an uncom-
plicated surgical incision is relatively inexpensive; however,
when infections occur, these costs can increase significantly. A
study from the USA estimated the costs of treating a surgical
site infection (SSI) to be approximately $20 800 (18).
As well as costs incurred by the health system, there are also
significant indirect costs that fall on individuals and the broader
economy. In the USA, it has been estimated that venous ulcers
cause the loss of 2 million working days per year, costing the US
health care system an estimated $2⋅5–3⋅5 billion annually (13).
The total cost of treating wounds
Wound management has been estimated to account for 3%
of all health care expenditure (2).
The cost of treating pressure ulcers alone in the USA is
estimated to be $11 billion/year (13).
In Europe, the cost o7f managing DFUs is estimated to be
€4–6 billion/year (4).
In the USA, foot ulcers and other complications are
‘responsible for 20% of the nearly 3 million hospitalisa-
tions every year related to diabetes’ (13).
The cost per case is highly dependent on a number of
factors, such as wound type, complications and the site
of care. For example, uncomplicated surgical wounds are
relatively inexpensive to manage, but costs increase sharply
if infection occurs. In Europe, surgical wound infection is
estimated to add, on average, 11 days to in-patient hospital
stay, with an average cost of €5800 per case (19), whilst
data from the USA suggest that the cost of treating a
surgical site infection (SSI) is in excess of $20 000 (18).
A hospital performing 10 000 operations annually can
expect 300–400 infections, resulting in 3300–4000 excess
bed-days, ∼€1⋅74–2⋅32 m in excess costs and 15–20
infection-attributable deaths (20).
The cost of managing wounds is largely hidden,
and the impact is often not recognised
Much of the financial cost of treating wounds is hidden because
many health care professionals across a wide range of profes-
sions and care settings are involved, and so, the total cost is
spread across many different budgets. As a result, their impact
goes largely unrecognised by policy makers, is poorly under-
stood by health care system decision makers and is seldom
reported in the media (2).
Studies have found that between 70–80% of wound patients
are treated in the community, predominantly by community
nurses (9,20). Managing wounds is often the single most impor-
tant use of their time – one study estimated that over 60% of
community nurses’ time was spent on dressing changes (21).
Studies in the UK and Denmark have shown that on average,
dressings are changed around three times per week, resulting in
three home health visits per week (7,9). In a community care
C. Lindholm & R. Searle
setting in Denmark, a survey found that at least half of the
patients surveyed were having their wounds dressed three or
more times per week, with 23% of patients having daily dress-
ing changes (7).
This places a significant, and arguably unsustainable, burden
on over-stretched nurse resources in community and home
health settings. Acute care facilities are constantly looking for
ways of reducing length of stay; expediting discharge means
that community health care providers are having to deal with
greater acuity of patients with more complex needs. In addition
to this, the number of patients requiring wound management is
expected to increase with an ageing population and increased
prevalence of multiple underlying conditions (22).
The impact of these factors on nurses is already starting
to manifest itself. A study from Denmark estimates that the
activity of health professionals has increased by 40% since 2001
(23). Today, 72 nurses are doing what 100 nurses did in 2001,
according to this analysis by the Danish Nurses Organization
(23). In the UK, the number of district nurses decreased by 39%
between 2002 and 2012, partly because of funding constraints
but also as a result of an increase in the number of nurses
leaving practice (24). This is compounded by increasing rates
of retirement and reducing rates of newly qualified nurses (24).
This trend is clearly unsustainable, and as a result, it is vital that
health care providers seek more efficient ways of managing a
resource-intensive casemix with increasingly complex needs,
such as patients with a wound.
Demand for wound management services
Wound management is estimated to account for over 50%
of community nurse time in European studies, with patients
often having three or more home health visits per week
(7,9,10,21).
The demands on nurse time are expected to increase further
because of earlier hospital discharge, ageing populations
and increasing rates of morbidities associated with wounds
(22).
For example, the International Diabetes Foundation esti-
mates that worldwide diabetes prevalence will continue to
increase to 9⋅9% by 2030 (25).
Diabetic patients have up to a 25% lifetime risk of devel-
oping a foot ulcer (26).
The increasing demands on nurse time will become unsus-
tainable if the present trend continues, and health sys-
tems need to identify more efficient ways of managing the
increased workload.
Question: Are there any estimates of how much demand for
wound management services will increase?
Answer: Yes, in some countries. For example, in 2010,
it was estimated that the cost of wound management
© 2016 Medicalhelplines.com Inc and John Wiley & Sons Ltd
Wound management for the 21st century
in municipalities in Denmark was DKK 735 m (18 000
wounds per year requiring over 3 m dressing changes). This
is predicted to rise by up to 30% between 2010 and 2020
(27). In the UK, the cost of providing services for the treat-
ment of wounds could rise by over £200 million annually
from 2014 to 2019. This would include around an addi-
tional 950 nursing staff and an additional 267 500 hospital
bed-days. The total additional cost to the health system
of providing wound management services over this 5-year
period is estimated to be £600 m (22).
How can we reconcile increasing patient
demands with scarce nurse resources?
The answer to this question is improvements in efficiency. Effi-
ciency is an economic term that means increasing the output of a
constant resource – put another way, increasing the productiv-
ity of nurses. Health economists seek to measure efficiency by
contrasting the resources required to deliver health care with the
health benefits that they produce. Health care resources might
include:
• the time used by health care professionals such as nurses,
podiatrists, GPs and surgeons
• dressings and other materials and equipment
• hospital beds
• operating theatre time
• resources used in documentation and administration
Figure 1 indicates how resources are allocated to the man-
agement of wounds (6).
When looking for efficiency improvements, health care
providers will often select the easy targets, such as supplies bud-
gets, which are quantifiable and easily manipulated in the short
term. However, it is important that they focus their attention on
the main cost drivers and also consider the opportunity cost of
resources, which is often less easy to quantify. The opportu-
nity cost of a resource refers to the benefits that are foregone
by allocating a resource to a particular activity. For example, a
nurse making three home visits to a patient with a wound could
have allocated the same time to running a diabetes clinic for 10
patients. In some cases, it is questionable whether resources can
be so easily moved between activities – can the same nurse pro-
viding wound care also provide diabetes management advice?
However, in many cases, the conscious decision to manage a
patient in an inefficient way results in foregone benefits for
other patients.
This is an important consideration for individuals involved
in the management of wounds. The concept of freeing up nurse
resources – for example, through less frequent home visits –
means that the same nurse resource is now available to treat
additional patients. Health care planners and nurses need to
continuously challenge themselves by asking ‘could I be using
my time more efficiently to provide better quality care or treat
more patients?’
7
Wound management for the 21st century
Figure 1 Resources used in treating wounds.
Question: Nurses are already there, and paid for, so why
does it matter how often they visit patients? Saving nurse
time doesn’t save the system any money – surely, it is
better to save money on dressings?
Answer: We need to think about the opportunity cost. What
have we given up in order for the nurse to undertake the
treatment? We have given up the opportunity to treat some-
one else or undertake some other valuable activity. This
time has a monetary cost that we can calculate if we know
the cost per hour of nursing time. Releasing nurse time
is about freeing up time to increase efficiency – the key
to solving the problem of increasing demand for services.
Releasing nurse visits may also reduce the number of dress-
ings required. This has the potential to provide procurement
savings (28).
How can we deliver improved efficiency
in wound management?
The first step in identifying how to improve efficiency is to
consider the inputs and outputs of wound care. Inputs might be
considered to be the nurse time, hospitalisations and dressings
consumed, whilst the outputs are the health benefits to patients.
Figure 2 indicates the main inputs that make up the cost of
treating wounds.
The time it takes to heal a wound
As described earlier, surveys would suggest that in a region
of one million people, there are approximately 3500 people
living with a wound, of which, around 525 people will have
had a wound for 1 year or more. For Europe, with a population
of approximately 500 million people, there would be about
262 000 people with these long-standing wounds. The total cost
of treating these long-standing wounds in Europe runs into
millions of Euros.
The frequency of changing dressings
As we have seen, in wound management, the time spent by
health care professionals is a large part of the total resources
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C. Lindholm & R. Searle
used, especially in community services. Much of this time is
used to change the patient’s wound dressings, which is why the
frequency of dressing change is a very important driver of cost.
Researchers who have audited wound management have
found that, on average, wound dressings are changed about
three times a week. One study of home care in Denmark found
an average of 3⋅53 changes per week, with 23% of wounds
having dressings changed every day (7).
Dressings need to be changed at a frequency that is appro-
priate for the patient and the wound. However, unnecessary
dressing changes can have an impact on both patient well-being
and resources. Higher dressing change frequency can increase
dressing and nursing costs and may lead to an increased risk
of complications because of the increased frequency of wound
exposure (29). It may also mean that the patient has the inconve-
nience of multiple appointments and the physical and emotional
impact of repeated dressing removal and application (29).
The incidence of complications
Wounds do not always follow the expected healing trajectory,
particularly because many patients with wounds have comor-
bidities and underlying long-term conditions. Complications
occur along the way, and these can have a profound effect, not
only for the patient but also for the health system. Complica-
tions are the third of the three drivers of cost we are consider-
ing here.
As an example, let us consider SSIs. SSIs can lead to pro-
longed hospital stay, readmission, additional surgical proce-
dures and use of antibiotics. Several years ago, a study in the
UK estimated that SSIs add, on average, 11 days per episode to
the patient’s stay in hospital (4).
Other wound types can also become infected. It has been
noted that heavy bioburden/infection of chronic wounds is a
major cause of non-healing and a significant contributor to the
increasing cost of health care (30,31). A UK survey across
hospitals and community providers found that 13⋅3% of leg/foot
ulcers and 10⋅4% of pressure ulcers were infected (Figure 3) (9).
Wound infections, whether they are at surgical sites or
in other wound types, can lead to further consequences. A
Swedish study reported that for non-healing chronic wounds,
26⋅6% were receiving systemic antibiotics, and over 60% had
received at least one antibiotic treatment over a 6-month period
(32). Wound infection is commonly associated with heavy exu-
dation of the wound, which has recently been reported to have
an influence on costs for wound management if inappropriate
dressings are selected (33).
In some cases, further complications such as osteomyelitis
may occur, resulting in further resource use. For example, the
additional cost of treating osteomyelitis in Category III and
IV pressure ulcers is substantial (estimated at over £30 000 in
the UK) because the daily cost of treatment is increased and
the time to healing is lengthened (34). This includes costs for
biopsies, MRI, antibiotics, microbiological tests and surgery,
sometimes including major plastic reconstructive surgery.
If any of these three cost drivers can be reduced, with-
out a detrimental impact on patient outcomes, then we can
deliver an improvement in efficiency. Of course, the best result
for health service administrators is the delivery of improved
C. Lindholm & R. Searle
outcomes at lower cost. This is a genuine possibility in wound
management – earlier intervention to mitigate the risk of infec-
tion can result in improved patient outcomes (through the avoid-
ance of complications) and lower treatment costs. There are
fewer and fewer examples of true efficiency gains in health care
that can deliver both better outcomes and lower costs; improv-
ing the efficiency of wound care should be seen as an opportu-
nity rather than a challenge.
So, to reduce the economic cost of wounds, the best place to
start is by looking at the three drivers.
Question: Surely, presenting three factors responsible for
driving cost is an over-simplified picture. Isn’t it a lot more
complicated than this?
Answer: In reality, the picture is of course more complex.
However, by identifying three major drivers of cost, we
are able to think about how we might use these to release
resources and therefore make services more efficient. We
will look at some ways of doing that in the next section.
Putting it in practice – delivering improved efficiency
in wound management for individual patients
As we have seen above, wounds have a substantial impact on
the health system. However, underneath all the statistics and
© 2016 Medicalhelplines.com Inc and John Wiley & Sons Ltd
Wound management for the 21st century
Figure 2 Drivers of cost in wound manage-
ment (9,29).
figures are individual stories of how wounds impact patients,
carers and health care professionals. Here are two examples.
Case study 1: reducing the frequency of nurse visits
for a complex patient
This example was reported as part of an evaluation of com-
munity health care provision for patients with a wound in a
provider in the UK (28). The study results indicate that the
introduction of a novel dressing allowed nurses to reduce the
frequency of their nurse visits by almost two visits per patient
per week and that procurement costs were also reduced through
less frequent dressing changes. The implications of this at a
patient level can be illustrated through a case study of one
patient that had a wet leaking leg that was being re-dressed
twice daily, resulting in 14 nurse visits and dressing changes per
week (28). The cost of these visits and dressing changes was
substantial. After switching to an advanced wound dressing,
the nursing team were able to reduce the frequency of dress-
ing change to four changes per week. The number of dressings
used at each change was also reduced, resulting in fewer dress-
ings per week, reduced cost of dressings per change and per
week and a dramatic reduction in the overall cost of treatment.
In fact, the patient’s weekly wound management treatment costs
were reduced by 81⋅6%, with 5 hours of community nurse time
freed up per week (Table 1).
9
Wound management for the 21st century C. Lindholm & R. Searle

Case study 2: reducing the duration of wound healing

This example was reported in a case series undertaken in
Denmark in 2014 (35). This case series is also referred to in
the final section. A 56-year-old female had a pressure ulcer on
the hip for more than 2 months, covering an area of 48 cm2 .
This ulcer was being dressed daily, and the area was reducing
at approximately 7% per week, on average, with conventional
treatment. The wound-healing trajectory was tracked at each
dressing change using digital planimetry and tracking software.
Using this software, it was estimated that the ulcer would heal
in October using this treatment regime. Single-use negative
pressure therapy (NPWT) was initiated and used for 14 days,
during which time the average area reduction per week was
31% (Figure 4). After discontinuation of the NPWT, the ulcer
continued to heal until fully healing in May, when the weekly
reduction in area was 28%.
This case illustrates the benefits of bringing forward the point
of healing through effective intervention. Using single-use
NPWT, a shorter care package was required, freeing up health
care professionals’ time and enabling them to treat further
patients. In addition to this release of time, fewer nurse con-
tacts per week and shorter visiting times were required. When
interventions such as this are adopted in routine practice, they
have the potential to make a substantial impact on resources.
The next section gives examples of changes that can be made
to do ‘more with less’.

Making the best use of resources – doing more

with less
Figure 3 MRSA at 31 300× magnification. As we have demonstrated above, the gap between available
services and demand for services will continue to widen, and as
a result, it is necessary to find ways of increasing productivity
by making wound management more efficient.
Table 1 Summary of costs for Case study 1 (28) It may be tempting for decision makers in these circum-
stances to look for ways to reduce resources by targeting easily
Wound management
manageable supplies budgets. However, as illustrated above,
cost after introducing
the advanced
this would fail to address the main cost drivers in wound man-
Wound management wound management agement and may even be perverse if it results in the adoption
cost at baseline product of dressings that may increase nurse visit frequency or result in
decrements to health outcomes.
Cost of materials per £29⋅08 £5⋅95
So what can be done to make the most efficient use of
dressing change
the available resources? In other words, how can resources be
Total cost per dressing £65⋅25 £42⋅12
change
RELEASED or freed up so that they can be better used for other,
Total cost per week £913⋅50 £168⋅48 more productive activities? As a way forward, we can take a
look at the three drivers of cost (previous section) and then see
some examples of how these have been used to free up resources
(Figure 5).

Patients that require high levels of resource, as illustrated
in this example, form part of the caseload of most commu-
nity providers, and clinical staff with experience of managing
wounds will recognise cases such as this. Patients receiving
dressing changes daily or more frequently represent a signif-
icant proportion of all wound patients; a Danish community
audit found that 23% of patients fell into this category (7). Later,
we look more closely at frequency of dressing change and the
opportunities that may exist for enhancing efficiency.
Reducing healing time
Case study 1: early intervention to reduce long-duration
wounds
One way to release resources is to concentrate on wounds
that are not currently healing. These static non-healing or
recalcitrant slow-healing wounds can account for a significant
proportion of health system resources (2). By intervening to
‘kick-start’ the healing process, they can be brought back to

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C. Lindholm & R. Searle
PICO start:
37.5 cm2
Figure 4 Reduction in ulcer area after
single-use negative pressure therapy
(PICO† ; † Trademark of Smith & Nephew)
initiation (35).
Figure 5 Some ways of releasing resources.
a healing trajectory, with the potential to release substantial
resources over a long period.
A recent study showed that application of single-use NWPT
was able to accelerate the healing process of slow-healing
chronic wounds (35,36). One case from this study was
described in the previous section. By using healing trajectories
to compare the rates before and after treatment, the study
showed substantial cost saving as a consequence of healing
these wounds earlier (Figure 6). This is an excellent example
in two ways:
• Firstly, it shows how intervention that appears to be of
greater cost in the short term can, in fact, save resources
overall.
• Secondly, it illustrates the value of tracking and monitor-
ing wound progress. This can be performed very simply,
and can provide a wealth of useful data that can be used
to demonstrate resource savings.
Case study 2: report from the Swedish Registry of Ulcer
Treatment (RUT)
A recently published paper described the use of a registry
to shorten ulcer healing time and thereby reduce the use of
resources (37). The use of the registry promoted structured
wound management using a team approach, with documen-
tation of diagnosis and wound progress. This system helped
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Wound management for the 21st century
After 14 days: 4 weeks post-PICO:
20.5 cm2 10.1 cm2
to optimise treatment by following each ulcer patient right
through to the healing endpoint. Data from 1073 patients
with hard-to-heal ulcers, treated between 2009 and 2012, were
reported. Wound types were predominantly leg ulcers but also
included other wound types.
The mean healing time was reduced from 269 days in 2009
to 139 days in 2012, whilst the mean total cost of treatment per
patient decreased from SEK 38 000 in 2009 to SEK 20 500 in
2012. Most of the cost of treatment (approximately 87%) rep-
resented staff costs. This study shows that the use of systematic
treatment strategies to reduce healing times can have a dramatic
impact on the use of resources.
Optimising dressing change frequency
Case study 3: evaluations in the UK
The second driver of cost that was highlighted above was
the frequency with which dressings are changed. The optimal
frequency will depend on a number of factors relating to the:
• wound: infection, exudate level, etc.
• patient and their circumstances: e.g. comorbidities and
underlying conditions
• clinician: e.g. their workload and schedule
• system: e.g. the logistics of when visits can be under-
taken
• products used: e.g. their ability to manage exudate
11
Wound management for the 21st century
Figure 6 Early intervention to reduce long-duration wounds (35).
Innovative practice and well-designed effective products
together play a major role in this (29), and products designed to
help to manage resources as well as to meet the need of patients
are inherently valuable.
For example, three recent evaluations have shown that it is
possible to release resources by changes in practice combined
with the use of appropriate dressings (28,38,39). These studies
described the introduction of a foam dressing into clinical
practice in three community health care providers in the UK.
They reported wound characteristics and details of clinical
practice, such as frequency of dressing change before and
after the implementation of the dressing, and showed a marked
reduction in dressing change frequency (Table 2). From this
information, estimates of the potential to release nurse hours
were made.
One of the evaluations also estimated the cost of dressings
per dressing change and per wound. On average, the number of
dressings per week on each wound was reduced by 79⋅6%, and
the mean cost of dressings per patient per week was reduced by
64⋅0% (28).
It would be interesting to estimate the potential for releas-
ing resources more generally if results such as this were repro-
duced. Such estimates can be made if we use published wound
prevalence figures (see box below).
Potential for resource release through
dressing change practice
As discussed earlier, we assume that there are 3⋅5 people
with a wound per 1000 population (6–9). A survey
12
C. Lindholm & R. Searle
conducted in the UK found that 79% of wounds were
treated in community health care (home health care,
wound clinics, nursing homes, etc.) (6). If we apply these
figures to a population of one million people, this means
that at the time of writing, there are likely to be 2765 people
with a wound being treated in the community.* Jørgensen
et al. (2013) (7) reported that the average frequency of
dressing change in community health care was 3⋅53 times
per week, suggesting that there are approximately 9760
patient contacts for dressing change per week, or around
507 500 per year. If this could be reduced by one visit per
week per patient, this could potentially release 143 800
visits or around 74 300 hours of clinician time per year.†
Even reducing visits for a smaller subset of the patient
population would free up a substantial quantity of time.
For example, reducing frequency by one visit per week
for 30% of patients could release almost 22 300 hours of
nursing time per year. Furthermore, reducing dressing
change frequency in conjunction with a reduction in the
number of dressings used per visit could lead to a reduction
in dressing expenditure. This capacity for reduction in this
expenditure will depend on the pattern of dressing usage
by a care provider, the mix of products that are used and
the frequency with which they are changed. Nevertheless,
even if only one quarter of the potential reduction reported
by Joy et al. (28) were to be realised, this could indicate a
15–20% saving in dressing costs.
* 3⋅5/1000 × 0⋅79 × 1 000 000 = 2765.
†
Assuming 31 minutes per visit (21).
© 2016 Medicalhelplines.com Inc and John Wiley & Sons Ltd
C. Lindholm & R. Searle
Table 2 Optimising dressing change frequency (28,38,39)
Frequency of dressing change (per week)
Evaluation Before introduction
Stephen-Haynes et al. 2013 4⋅52
Simon et al. 2014 2 1⋅35
Joy et al. 2014 3⋅6
Combined* 2⋅80
*Mean weighted by the number of wounds in each evaluation.
Preventing complications such as wound infection
Complications such as infection have the potential to delay
healing, adversely affect the patient’s quality of life and even
increase the risk of mortality as a result of sepsis. For surgi-
cal sites, infection may have a dramatic effect on quality of
life and a substantial impact on resources as there may be a
variety of additional procedures, drugs and materials and staff
time needed to deal with wound complications and their conse-
quences. Leaper et al. (2010) (40) cite several examples:
• peripheral vascular surgery, where catastrophic haemor-
rhage may follow vascular graft infection
• infection of a hip prosthesis, where revision surgery may
be necessary
• infection following hysterectomy or intestinal surgery,
which can result in extensive use of resources and
repeated antibiotic treatment
• infection following cardiac surgery, where sternal dehis-
cence may involve extensive multidisciplinary care
• infection following breast cancer surgery, where an
SSI may extend the waiting time between surgery and
chemotherapy or radiotherapy
At least 5% of patients develop a post-surgical wound infec-
tion, and it has been pointed out that although SSIs have not
generally received a lot of attention, they may be the type of
infection that is the most preventable (41).
Preventing SSIs therefore may have a significant impact on
resource use. An example of this was published in 2014, where
a hospital provider in the UK addressed the problem of SSIs
by making systematic changes to their post-surgical C-section
practice (42). Following the introduction of these measures,
the infection rate dropped from 12% to 6%; in the highest-risk
group, there were no infections or readmissions. The box below
shows some further details.
Case study 4: addressing the problem of SSI (43)
A hospital trust in the UK found that about 12% of
women experienced a surgical site infection following a
caesarean section. Readmission to hospital was a particu-
lar problem, with women with high body mass index (BMI)
(≥35 kg/m2 ) being the most likely to have a readmission.
The provider put together a multidisciplinary team includ-
ing a tissue viability nurse and infection control nurse,
together with the obstetricians and midwives. This team
© 2016 Medicalhelplines.com Inc and John Wiley & Sons Ltd
Wound management for the 21st century
After introduction Difference Number of wounds
2⋅88 1⋅64 28
0⋅65 97
1⋅8 1⋅8 37
1⋅71 1⋅09 162
implemented changes to the wound management products
alongside education for staff and patients. Part of this new
approach was the targeted use of single-use NWPT based
on risk stratification. Obesity is an important risk factor
as it has a strong association with the incidence of SSI.
Therefore, NPWT was used for women with a BMI of 35
and above, whereas a film and pad dressing was used for
women with a BMI less than 35.
The team employed this strategy for a total of 660 women
who had C-sections between February and November
2012. They reported a 50% drop in the incidence of SSIs
across the whole patient group. In the high-risk group, there
were no infections, and the number of readmissions fell
from three per month to zero. It was estimated that the use
of the new protocol would result in a cost saving of £29 449
per year.
This study shows the value of targeting high-risk groups
and demonstrates that using negative pressure on closed
incisions in high-risk patients can potentially reduce wound
complications and readmission rates.
Question: There are several examples of releasing
resources by changing practice. How does an organisation
know which approach to take?
Answer: This will depend on the priorities for the organi-
sation and the opportunities for practice change. It is often
useful to conduct a practice audit to ascertain which are
the best opportunities for change, and several examples
of surveys and audits can be found in published literature
(6–9,43). These can be relatively simple, using a question-
naire format, and are often done over a short, fixed period
of time to give a ‘snapshot’ of wounds and practice. For
example, a community provider might survey each wound
treated over a given week to ascertain characteristics of the
wounds, which products were used, how often dressings
were changed etc. These surveys give a wealth of informa-
tion, which can be used to inform practice change, with a
view to improving efficiency and quality of care.
Is prevention cheaper than cure?
One important way to reduce the cost of wound management in
the future is to make an impact on the number of wounds that
need to be treated. This means that wound prevention has an
important role to play in counteracting the demographic trends
13
Wound management for the 21st century
affecting wound prevalence. For example, below-knee gradu-
ated compression hosiery is recommended to prevent recur-
rence of VLUs in patients with healed ulcers (44), and regular
foot assessments are effective to prevent DFUs alongside other
interventions such as optimising glycaemic control and smok-
ing cessation (45).
Often, when we think of wound prevention, it is the preven-
tion of pressure ulcers in acute care that comes to mind, and
indeed this is probably the most widely studied area and has
received the most attention. Having a pressure ulcer has a pro-
found adverse effect on many aspects of a person’s quality of
life, and although pressure ulcers are not a new phenomenon,
they continue to be a significant health problem as a result of an
ageing population (46). They also represent a significant burden
to health systems, with one report estimating that treatment of
pressure ulceration costs the US $11 billion annually (47).
Recently published international guidelines for the preven-
tion and treatment of pressure ulcers have demonstrated that
there a number of important considerations for prevention to be
effective (48):
• risk assessment
• skin and tissue assessment
• preventive skin care
• the use of emerging therapies such as microclimate con-
trol, prophylactic dressings, fabrics and textiles and elec-
trical muscle stimulation
• good nutrition
• repositioning and early mobilisation
• the appropriate use of support surfaces
Thorough and comprehensive risk assessment is a vital part
of prevention, and several assessment tools have been devel-
oped that, when used in conjunction with clinical judgement
and experience, can help to identify the risk level for individual
patients (49). As there are several potential risk factors for
pressure damage, there are a number of different prevention
approaches that can be used in a prevention protocol. For
a given patient, the mix of these different components will
vary (49).
Suitable support surfaces should be used, and the patient’s
skin should be inspected regularly along with a tailored reposi-
tioning programme (49). Incontinence, skin moisture, nutrition
and hydration must all be managed in collaboration with the
appropriate health care professionals (49). The use of multilayer
foam dressings has also, in recent years, become a valuable
addition to the tools available for pressure ulcer prevention, par-
ticularly for high-risk patients such as those in high-dependency
or intensive care units (49). Such dressings have been shown to
reduce the incidence of PU in these patient groups, and some
hospitals have the use of these dressings as part of their PU
prevention protocol. The choice of dressings is important: they
must have the ability to redistribute pressure, reduce shear and
friction and effectively manage temperature and moisture at the
skin surface. Where surrounding skin is fragile, as is often the
case with patients at risk of PU, dressings with a soft silicone
border may be appropriate (49).
Much has been done to improve and implement pressure
ulcer prevention measures across Europe. Economic incentives
for the reduction of PU incidence and financial penalties for
14
C. Lindholm & R. Searle
increased incidence have been introduced in some countries.
Awareness has increased, and practice has improved, although
there is continued debate about the proportion of pressure ulcers
that are avoidable (50). However, there is more that can be
carried out to adopt strategic approaches to prevention and to
use effective risk-assessment methods (51).
Conclusions
Wounds have a significant impact both on the quality of life of
those who have them and on the world’s health systems. The
number of people with wounds is growing, and this is likely
to continue into the future as a result of demographic trends.
Preventing wounds from occurring has an important role to play
in mitigating the effects of demographic changes that affect
wound prevalence.
We can think systematically about the cost of caring for
people with wounds by considering the resources used. Human
resource is the most valuable asset that the health system has,
and most of the resource used in wound management is as a
result of hospital treatment or nursing visits. Materials such
as dressings account for a relatively small amount of the cost;
however, the choice of materials and dressings used is very
important.
There are three significant drivers of cost: the time it takes
a wound to heal, the frequency of visits by health care profes-
sionals and the incidence of complications.
These three drivers help us to think about how we can make
wound management more efficient by:
• reducing healing time
• optimising dressing change frequency
• preventing complications such as wound infection.
Acknowledgements
With thanks to John Posnett, Paul Trueman, Carina Ekbladh,
Trine Gram and Jane Hampton for valuable contributions to
the content presented here. Christina Lindholm is an indepen-
dent researcher at Sophiahemmet University, Sweden. Richard
Searle is an employee of Smith & Nephew. This work was
funded by Smith & Nephew.
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