Wound Bed Preparation – Challenges and the Role of Documentation

Normal wound healing involves the wound going through a timely reparative process and restoring its anatomic and functional integrity. If disruption occurs in these phases, wound stalls in the inflammatory phase and this may result in delayed healing.

Wound bed preparation allows wound care physicians to focus their attention systematically on a non-healing wound, determine the cause of the problem and implement a care program to make the wound stable with healthy granulation tissue and a well vascularized wound bed. However, there are several challenges involved in this process and accurate, comprehensive wound documentation using reliable wound EMR is crucial to overcome them.

Choosing Appropriate Debridement

Wound care physicians rely on debridement for wound bed preparation, which aims at removing any foreign body and necrotic tissue. Removal of necrotic tissues is very important for visualization and assessment of wound bed since those tissues mask the signs of local infection. There are several methods of debridement such as:

  • Surgical debridement – Though this is the fastest means of debridement, sharp surgical debridement may inadvertently remove healthy tissue as well as necrotic tissue. It is also non-selective most of the time. Ultrasound debridement can be an alternative to this.
  • Mechanical debridement – This conventional method involving manual removal of dressing may not be that much effective with dry dressing as you may remove adherent fibrous tissue. This method can be non-selective, often causes pain and bleeding and may inadvertently remove any healing epithelium.
  • Enzymatic debridement – This method utilizing chemical enzymes is often employed for non-surgical patients having highly necrotic wounds. There would be minimal to no damage to healthy tissues, if applied properly.
  • Autolytic debridement – This uses the body’s own enzymes and moisture to rehydrate and is very selective for necrotic tissues. You can augment it with occlusive or semi-occlusive dressings.

Consider the overall condition of the patients and goal for care while choosing the method of debridement.

Achieving Moisture Balance

Achieving moisture balance is a crucial aspect of wound bed preparation. In order to achieve that, it is required to create a warm, moist bed and avoid excessive periwound moisture that results in surrounding skin maceration. Lack of moisture balance in under-hydrated wounds causes an inhibition of cellular activity and form eschar. If the moisture balance turns toward an overhydrated wound, it causes maceration of tissue edges that weakens the defensive barrier against microbial invasion.

Addressing Wound Bioburden

For wound bed preparation, it is important to consider the nature and extent of the bacterial bioburden and make sure that it will not interfere with wound healing. Bioburden can be described as the number of contaminating microbes which compete with normal cells for the available oxygen and nutrients. Bioburden assessment can be done on the basis of host resistance, wound characteristics and wound culturing.

Identifying the Impact of NPWT

Negative pressure wound therapy or NPWT is considered to be an effective adjunct for wound bed preparation and can be a foundation in wound management. NPWT is applicable to either acutely infected or colonized wound and this removes excessive fluids to promote a healthy granular bed. We can say NPWT stimulates chronic wound to support a foundation for healing and identifying its impact is essential for wound bed preparation.

Criticality of Proper Documentation via Wound EMR

To overcome these challenges, wound care specialists must understand that wound bed preparation is a continuous process and it requires better understanding of the patient, the underlying cause of the wound and the wound environment. Appropriate knowledge regarding wound bed preparation is inevitable for effective and timely wound healing. In most of the cases, there would be a complex mix of local and host factors that prevent the wound from healing. These factors need to be assessed and treated, which would be the foundation for proper wound bed preparation. A complete and detailed documentation of patient assessment can reveal the underlying aetiology of the wound and other factors (for example, pain and poor nutrition) that impede healing and thereby helps specialists to employ an efficient care program. Specific details of wound history and physical examination report such as the type of wound, its history, patient-centered plan of care and targeted patient-specific goals can help specialists in preparing the wound bed more effectively.

Documenting details of wound assessment alone is not enough, but the details should be communicated to other wound care professionals when referrals are made. This helps the inter-professional team agree upon an individualized care plan for healable and non-healable wounds and modify the plan according to a new holistic inter-professional assessment. With wound EMR having wound-specific templates, it is easy for wound care professionals to enter and access the specific wound details without searching through many templates as in general EMR. Wound EMR supported with a separate interface for physician and nurse can further enhance the communication. Outcome reporting facilities can help you quickly generate customized reports as well.