The triangular treatment21 January 2020
Globally, the demand for healthcare resources continues to grow as the demographics of the population change, long-term conditions become more prevalent, patient expectations rise and medical technology advances. Associated with this is a projected rise in the number of people with chronic wounds. The impact of a wound on the patient is significant, with patients reporting pain, a reduced quality of life and social isolation. The World Union of Wound Healing Societies outlines how the triangle of wound assessment can help ensure comprehensive and evidence-based wound management.
The majority of patients (79%) in Europe with chronic wounds are managed in the community, and it is normal for their first assessment to be undertaken by a generalist practitioner, such as a community nurse. This assessment needs to be reliable and accurate to ensure the correct treatment pathway and early referral to a specialist service where appropriate. Assessing a patient with a wound requires a range of clinical skills and knowledge to ensure an accurate diagnosis and an appropriate plan of care. The process should include a holistic patient assessment, as well as an assessment of the wound, to determine the underlying cause, identify underlying conditions that may delay healing, and determine appropriate topical therapy based on the status of the wound bed, wound edge and periwound skin.
In order to promote optimal wound healing and reduce the impact of chronic wounds on the health economy, clinicians need tools and education that facilitate accurate and comprehensive wound assessment and evidence-based wound management.
There are many wound-assessment tools currently available; however, evidence suggests that many patients are still not receiving comprehensive and knowledgeable wound assessment, which can result in delayed or inappropriate treatment and can prolong the negative impact of the wound on the individual. Inappropriate or inaccurate assessment can lead to delayed wound healing, pain, increased risk of infection, inappropriate use of wound dressings and a reduction in quality of life for patients.
A recent study of 14 wound-assessment tools found that while each provided a framework to record certain parameters of wound status, none met all of the criteria for optimal wound assessment, and many did not guide practice in terms of setting goals for healing, planning care and determining critical interventions. For example, in one study, 30% of the wounds had no diagnosis – the aetiological factors had not been determined.
Furthermore, there is currently no easy-to-use validated assessment tool that fully integrates the assessment of the periwound skin together with that of the wound bed and wound edge. Assessment of the periwound skin as part of a full wound assessment is seen as integral by healthcare professionals and patients.
Assessment of wound status
The triangle of wound assessment is a new, intuitive framework that integrates evaluation of periwound skin within the wound assessment. It has been developed to facilitate an accurate and timely evaluation in a simple and easy-to-use format that can be incorporated into any patient record system. It uses simple descriptors and images to aid the decision-making process and facilitate continuity of care. The concept was developed from a global anthropological study conducted in 2013–14 with the aim of gaining a better understanding of the impact of a wound on the patient.
In total, 200 wound care patients and healthcare professionals from the UK, Germany, Brazil and China were included in the study. The study sought to observe the physical, social and cultural behaviours of patients with a wound and how it affected their daily life. It also explored everyday wound management practice. The results and conclusions from the study offer a new perspective on wound healing and were validated by a quantitative survey of 412 healthcare professionals and 104 patients. A key finding from the study showed that professionals separated wounds into three distinct, yet interconnected zones: wound bed, wound edge and periwound skin. The wound bed, wound edge and periwound skin can be seen as three zones of a triangle, each with significant importance in wound healing.
The wound bed is where practitioners seek to remove devitalised tissue, manage exudate, prevent infection, reduce inflammation and promote granulation tissue formation. At the edge of the wound, the aim is to reduce the barriers to healing by eliminating dead space, debriding thickened wound edges and improving exudate management. For the periwound skin, the aim is to protect the skin surrounding the wound from maceration, excoriation, dry skin, hyperkeratosis, callus and eczema. From this study, the concept of the triangle of wound assessment was developed and has been incorporated into an assessment tool for use in practice.
This new approach extends the understanding of wound assessment ‘beyond the wound edge’ and expands on the current model of wound bed preparation, which focuses primarily on tissue type, infection/inflammation, moisture balance and the wound edge. The model recognises that periwound skin problems are common and may influence wound healing considerably. Correct assessment and early diagnosis of problems at the wound bed, wound edge, and the periwound skin are likely to lead to interventions that improve patient outcomes and reduce healing times. They are also likely to improve levels of engagement in patients who, despite having serious underlying conditions, are often primarily concerned with their wound because of the impact it has on daily life. Patients are regularly frustrated by a lack of progress in wound healing and often look for ways to act on their condition. In some cases this involves inappropriate use of ointments on the periwound skin, which they deem less risky than the wound bed.
While the triangle of wound assessment is focused primarily on assessment of the wound bed, wound edge and periwound skin, its use is predicated on the assumption that the clinician has first determined and addressed aetiologic and systemic factors affecting wound repair. The triangle of wound assessment should be used within the context of a holistic patient assessment, recognising the significant and individual impact that a wound has on the patient. This approach takes the clinician from the assessment process through to determining a suitable management plan focusing on the wound bed, the wound edge and the periwound skin, with the aim of facilitating healing or relieving symptoms associated with the wound. Assessment should include wound location, duration, underlying cause and wound measurements of length, width, and depth at baseline and subsequent visits.
Making connections to change lives
The 6th WUWHS Congress: Global Healing, Changing Lives, ‘Honouring the past, treasuring the present and shaping the future of Wound Care’, March, 2020 – held at the award-winning venue Abu Dhabi National Exhibition Centre – gives access to global researchers in a single platform and makes every connection matter, offering an extensive scientific programme including multiple symposia, training sessions, workshops and focus sessions. The leading-edge programme agenda features pioneering themes, with renowned international experts in the field of wound management from across the globe, making it a remarkable journey of knowledge.
Leading scientists and clinicians from all over the world present their lectures on the hot topics in wound healing. Interactive sessions inspired by the ‘learning by doing’ method allow attendees to experience a practical approach to disorders, therapies and techniques in order to transform their knowledge into actions with the aid of case studies. Short and intensive morning sessions, held by a single speaker, aim to give participants an in-depth knowledge on a specific issue. Half-day didactic sessions are dedicated to participants who wish to increase their basic knowledge about a specific topic or get closer to a new field. Also, immersion on the regional approach, vision about the healing world and short oral presentations, chosen by the review committee from all the submitted abstracts, will feature at the event. Some of the courses are organised at two levels of difficulty (basic or advanced) in order to offer a full educational programme.