New wound order: regular debridement

Debridement is the medical removal of dead, damaged or infected tissue from a wound to improve the healing potential of the remaining healthy tissue, and it is already one element in the standard regimen of treatment for chronic wounds. Although the technique is recognised as highly effective, a new study has looked specifically at the effect of changes in the frequency of debridement, and its results could have far-reaching implications.

The author of the report is Dr D Scott Covington, executive vice-president of medical affairs at Healogics, based in Jacksonville, Florida, US, which operates 560 wound care centres in 47 states and has two centres in the UK. This puts at his disposal a wealth of experience and patient data that led him to observe that chronic wounds usually get trapped in the inflammatory stage of healing, and to investigate the proposition that aggressive debridement transforms chronic wounds to acute wounds, therefore accelerating the healing process.

"We are a wound-healing company, so we drive best practice by using the best clinical evidence," Covington explains. "We treat over 200,000 patients each year and perform more than two million individual wound treatments. As a result, we have a huge patient database that we can use for analysis.

"We look at many different factors such as visit frequency, but the latest report took a retrospective view of debridement. We looked only at moist wound care and the frequency of debridement, excluding all patients who were using other techniques such as hyperbaric oxygen therapy. We included in the study the whole range of wounds that we treat in our centres, and we found that weekly debridement resulted in better outcomes than debridement that took place every two weeks," he adds.

A clear message from the data

The findings of the study, which is the largest of its kind, challenge the conventional wisdom that has informed best practice in wound care.

"Existing best practice is focused on analysis of diabetic foot ulcers using a relatively small patient sample, and there is usually a hodgepodge around what comprises standard practice," says Covington. "Our study is much larger and provides a strong argument that increasing the frequency of debridement speeds up healing and leads to better final outcomes. We cannot say why the frequency of debridement affects healing outcomes; just that it does. This was purely an observational study."

Some of the statistics arising from the study show that doubling the frequency of debridement can half the time required for healing. For instance, the research concluded that diabetic foot ulcers healed in an average of 21 days when they were debrided weekly, but took an average of 76 days to heal when debridement occurred only every two weeks.

Although the study looks at a wide range of wound types, the most common were diabetic foot ulcers, venous leg ulcers and pressure ulcers (see table). In each case, more frequent debridement led to faster and more complete wound healing regardless of wound type,size or duration.

In total, 32 different classifications of wound type were covered in the study. As well as common types such as diabetic foot ulcers, the study also looked at categories such as arterial ulcers, compromised skin grafts/flaps, dehisced surgical wounds, inflammatory ulcers, surgical wounds, trauma and ulcers secondary to infection.

Venous leg ulcers made up the largest component in the study, accounting for 21.6%, with the next largest component being diabetic foot ulcers at 19%, followed by pressure ulcers at 16.2%. The largest wounds covered by the research, however, tended to be skin grafts/flaps, surgical wounds and traumatic wounds, which had median areas of over 2.8cm2. The deepest wounds in the study's data were in the category of surgical and dehisced surgical wounds, with a median depth of 0.5cm. The oldest wounds were once again in the skin grafts/flaps category, with a median of 36 days, and in arterial ulcers, with a median of 30 days.

Over 70% of the wounds includedin the study were reported as fully healed, with the highest rate of healing recorded in the traumatic wounds category at 78.4%. The lowest rate of healing recorded was for pressure ulcers, at 56.6%.

The significant increase in the healing rate of diabetic foot ulcers was not the only example of faster healing times resulting from more frequent debridement. For traumatic wounds, for instance, the median time to heal with debridement sessions occurring no more than one week apart was 14 days. When debridement occurred at intervals between one and two weeks, the median healing time rose to 42 days. If debridement took place less than fortnightly the median healing time rose again, to 49 days.

Other interesting results observed from the data included the slight but significant association of gender with healing time. Males generally took less time to heal. Furthermore, an increase in the frequency of debridement resulted in almost a doubling of the number of venous leg ulcers and diabetic foot ulcers that healed completely, with respective increases of 50% from 28%, and 30% from 13%.

Building a new wound care model

It is clear that there are benefits to more regular debridement of chronic wounds, but, on its own, the data may not be enough to bring patients in for weekly sessions. There are some barriers to increasing the frequency of debridement that must be overcome by conversations between individual patients and their physicians.

"The barriers depend on the nature of the healthcare system in which a patient is receiving treatment," explains Covington. "More frequent debridement would require the patient to come weekly to the doctor's office or wound centre. The procedure also involves some discomfort and, although it is minimal, there is a degree of risk.

"That means that, in some sense, there is a personal cost to the patient for getting more regular treatment, although that is perhaps outweighed by the results, which include shorter healing times. More frequent debridement enables more rapid healing across a wide range of wound types."

If patients were sufficiently incentivised to come in for weekly debridement, this would raise another issue, namely that the physicians performing the treatments would face a substantially higher workload. Capacity could, in some wound care facilities, become stretched.

Combating this problem could be a relatively simple task if, as Covington firmly believes should happen, the ability to treat patients is in the hands of non-physicians. The data from the study already shows that vascular surgeons, in general, debride less often than podiatrists and family physicians. A more integrated approach to wound care, in which non-physicians were able to debride, could ensure that more regular treatments were available to patients across the full spectrum of wound types.

Covington supports the notion that education and training in debridement practices should not be limited to physicians. The efficiency of workflow in wound care centres could increase significantly if general staff members were able to perform the treatment.

"The model for wound care is physician based," notes Covington. "We have 2,700 physicians working in our centres, but we also have a large number of physicians' assistants and nurse practitioners, who are getting more into performing procedures such as debridement. I think it is inevitable and desirable that more non-physicians will be able to do it. For this to happen, they must understand anatomy and the potential complications that could arise from debridement. We need to train them well so that they can take up that responsibility."

Faster healing through regular debridement

As well as the technique of debridement, the training may cover the associated processes to monitor the progress of wounds as they heal. This might include photographing wounds and taking measurements that could be added to electronic medical records. It may also include a system of alerts to ensure that patients whose wounds do not show the required rate of improvement are put forward for other therapies.

As is the case with any good research, Covington's study not only provides useful conclusions but also raises further questions.

"There were some limitations to the study," says Covington. "For instance, there was no control group that was not debrided, so it was not a double-blind study. It would be nice to do a study of that type in the future. We could also look at the impact of elements other than debridement that are part of visits to the wound care centres to see if they also have an effect on healing.

"We might also look in more detail to see if regular debridement had more of an impact on the rate of healing of specific wound types, such as diabetic foot ulcers," he adds.

There is no doubt that this report will change the way in which debridement is perceived within the broader scope of chronic wound care, and that it will prompt further studies to examine other influential aspects of wound care programmes. The importance of patient compliance with any new regimen cannot, however, be overstated.

In some cases, it is hard to get patients to attend debridement sessions at all, and even willing patients may have difficulty attending weekly sessions. With clear data on the advantages of regular debridement, perhaps it will be easier to motivate patients, but the message must be clearly passed on by physicians.