Healing innovation

22 November 2023

Chronic wounds are a major challenge worldwide. This from an economic standpoint – as managing them expends time and resources – and from a patient outcome perspective, as wounds that aren’t managed effectively can lead to significant morbidity and mortality. Professor Joachim Dissemond, MD, Department of Dermatology, Venerology and Allergology, University of Essen, Germany, is one of several academics who believe bringing more standardisation to the care of chronic wounds will improve their management, and outcomes. He tells Practical Patient Care about the M.O.I.S.T. concept developed by him and his colleagues and how it improves upon the current framework for treating wounds.

What makes chronic wounds a challenge for healthcare professionals to manage?

Prof. Joachim Dissemond: One major problem is the heterogeneous approach to patients with chronic wounds. Each patient with wounds must be considered individually because there are many individual cofactors and comorbidities that must be considered. This is true both for the diagnosis and therapy applied. Age is a common consideration, but there are also medical issues such as obesity and mobility restrictions, as well as the individual and combined impact of medications. All of these things can be compounding factors in impaired wound healing.

What are the most common reasons behind impaired wound healing?

Worldwide, chronic wounds are most frequently caused by damage to the venous and/or arterial vascular system, either in the context of diabetes mellitus or by pressure damage.

In addition to these common causes there are numerous less-common factors that can contribute to impaired healing in chronic wounds – especially when they’re considered together as part of a holistic picture of patient health. Infectious diseases or autoimmune conditions are two relevant examples; in both cases, a difficult-to-control inflammation can be triggered that makes it harder for wounds to transition from the inflammatory to the proliferative phase. Inflammation is the immune system’s response to harmful stimuli, such as pathogens, damaged cells, toxic compounds, or irradiation. An inflammatory response is aimed at removing injurious stimuli and initiating the healing process. But if a wound doesn’t complete the transition from inflammation to proliferation, prolonged inflammation can occur and may result in deregulated differentiation and activation of skin cells. This impedes the normal stages of wound healing and ultimately results in a wound that doesn’t heal, otherwise known as a chronic wound.

How do healthcare professionals currently decide on the appropriate treatment for wounds?

The most important component of therapy is always treating the cause behind a wound that isn’t healing. The basic principle of conservative treatment revolves around modern moist wound care, oriented toward the different phases of treatment. Individual products are typically selected based on the experience of healthcare professionals, the availability of products, costs and patient preferences. There is a wide range of wound dressings produced by the respective manufacturers for specific phases of wound care. Despite this, there are only a few high-quality clinical studies that validate the implementation of an evidence-based wound treatment concept.

How does the M.O.I.S.T. framework improve on the current standard of care?

The M.O.I.S.T. concept was developed to give healthcare professionals a structured approach to follow for patients with chronic wounds. Here, the M (moisture balance) means that attention must be paid to good exudate management. The O (oxygen balance) aspect refers to the often-disturbed balance of oxygen supply.

Hypoxia is present in most chronic wounds, and in recent years, more and more therapies have been developed that actively bring oxygen into wounds from the outside, for example via haemoglobin transport. The letter I (infection control) describes all measures that treat infections in wounds. It is therefore primarily concerned with combating bacteria. The letter S (supporting strategies) describes a very heterogeneous group of wound products that are intended to actively influence and improve the wound healing process. The modulation of matrix metalloproteinases is an example here. Finally, there is T (tissue management), which encompasses basic wound conditioning with a focus on cleansing and debridement, but also the promotion of granulation, for example with NPWT. If healthcare professionals were to follow the M.O.I.S.T. concept, the standard of care would improve considerably.

How did the concepts behind the framework develop into what’s being proposed today?

The M.O.I.S.T. concept is essentially based on the widely used TIME concept, which was developed back in 2002. However, since some of the modern aspects of wound care aren’t represented by TIME, the M.O.I.S.T. concept was developed by a group of experts as an update. The new areas are represented by the letters O for oxygen and S for supportive strategies, and they take into account innovations and successful therapies that should be included in the complex process of wound treatment if necessary.

For oxygen this includes treatments like haemoglobin spray, higher cyclical pressure oxygen and low constant pressure oxygen in a contained chamber. Supportive strategies is the umbrella term for any products applied with an aim to rebalance the wound environment to push it towards a healing trajectory, such as advanced bandages.

Right now, a lot of wound care is nurse-led. Does M.O.I.S.T. encourage the involvement of physicians in the management of wounds?

The treatment of patients with chronic wounds should always be conducted by a multidisciplinary team where possible. But depending on the country, the treatment of patients can be regulated very differently to accommodate for the resources available.

With the M.O.I.S.T. concept, it plays a subordinate role in which occupational group carries out the wound treatment. It is more important to consider all relevant aspects in the framework and, if necessary, to integrate them into a treatment concept using the resources available.

Is there a lack of standardisation in wound care, and does M.O.I.S.T. seek to bring more of it to the field?

Yes, exactly! A key point of the M.O.I.S.T. concept is to bring structure to the complex treatment strategies used for patients with chronic wounds. We are currently in the process of rolling out the M.O.I.S.T. concept, which was originally developed in German-speaking countries, worldwide. To do this, it must be adapted to the specific conditions in each country. After that, we are confident that we can show how each respective situation has improved.

How do the HEIDI (History, Examination, Investigation, Diagnosis and Implementation) and M.O.I.S.T. concepts work together to provide better patient care?

HEIDI is a very good concept for describing the entire patient treatment process. The M.O.I.S.T. concept focuses exclusively on localised wound treatment. Patients with chronic wounds must be seen and treated in a larger overall context. Thus, the M.O.I.S.T. concept is only one important building block in complex holistic wound treatment.

Have the concepts gained any traction among healthcare professionals or associations?

The M.O.I.S.T. concept was developed by experts from the umbrella association of German-speaking wound healing societies WundDACH. It has been the recommendation of the professional societies in Germany (ICW e.V. for example), for more than five years. In recent years, the concept has also been presented internationally to stimulate more and more interest worldwide.

How do you and the other proponents of M.O.I.S.T. plan to take it from an academic concept to the standard of care in hospitals?

First, the concept had not only to be translated from German language, but also adapted to international standards. We have started doing this very successfully in the last two years and presented our progress at numerous conferences. Now, further publications will follow that will focus more on the respective national conditions. In the end, the M.O.I.S.T. concept should not be an academic concept but a tool for everyday clinical practice that can be used anywhere in the world.

Do you see the growing interest in technologies that assist with the diagnosis and treatment of wounds as an important part of increasing the benefits M.O.I.S.T. could have in the clinic?

Innovations for wound care are regularly introduced to the market, and they have the potential to further improve wound treatment. Since it doesn’t include recommendations for any specific products but instead focuses on points of action for treating wounds, the M.O.I.S.T. concept can accommodate new technologies in its treatment pathways. I see a lot of potential for the broader application of M.O.I.S.T. in the clinical field in the near future. ­

From T.I.M.E. to M.O.I.S.T. (Dissemond et al, 2017).

T: Tissue
I: Infection and inflammation
M: Moisture balance
E: Edge of the wound

M: Moisture balance
O: Oxygen balance
I: Infection control
S: Supporting strategies
T: Tissue management

The factors of the T.I.M.E. concept designated by ‘T’, ‘I’, and ‘M’ were deemed to be still highly applicable and important. They were, therefore, included, albeit slightly modified, in the M.O.I.S.T. concept.

The letter ‘E’ of the T.I.M.E. concept originally stood for epidermis and subsequently for edge (wound margins) (Schultz et al, 2003; 2004), and comprised very different concepts aimed at wound-bed preparation and promotion of re-epithelialisation, such as debridement, skin grafts, and biological wound therapies. In the M.O.I.S.T. concept, ‘E’ has now been replaced by the letters ‘O’ for oxygen balance and ‘S’ for supporting strategies, thus allowing for the inclusion of new treatment options for targeted therapy in a much more differentiated fashion.

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