Original Title: Guides et normes: Soins de plaies - évaluation, prise en charge et usage optimal des traitements

Authors' objectives: A wound occurs as a result of injury, trauma, or in the presence of an underlying cause that cannot be prevented or controlled - e.g., diabetes, atherosclerotic vascular disease, bed rest. In order to restore the structure and functions of the skin, the healing process is initiated in the wound in four successive phases. If this process stagnates in the inflammatory phase due to elements intrinsic to the individual or to the wound, the wound may become complex and chronic, especially if the care provided is not optimal. Given the multiple issues involved in wound management, combined with the variety of treatments, dressings, devices, and tools developed by various organizations and available to health care professionals, the INESSS was asked to develop recommendations and clinical tools according to its usual methodological process, in order to: • Support various health care professionals who provide outreach or second-line care and services in the assessment and optimal management of chronic and acute wounds based on the type of tissue in the wound; • Encourage nurse clinicians in their scope of practice in wound care activity, in which they are fully autonomous; and • Promote the full implementation of nurses' prescriptive authority in this area.

Authors' results and conclusions: RESULTS: (#1 ASSESSMENT OF THE PERSON): A holistic assessment of the individual with a wound includes a health assessment, the location of the wound and events surrounding its onset, the presence of pain, and the identification of physical and psychosocial factors that may compromise wound healing. This assessment is essential to identify quickly urgent clinical situations associated with the risk of bacteremia and amputation. It also helps to clarify the etiology and determine the therapeutic care goals based on the wound's healing potential. The following aspects are part of the assessment. (#2 ASSESSMENT OF THE WOUND): The intrinsic wound characteristics and the surrounding skin partially define the type of debridement, whether antiseptic or antimicrobial agents should be applied, and the type of dressing to be used. It may be necessary to clean the wound before its assessment in order to grasp the specifics of the wound. Appearance, dimensions, type of tissue in the wound bed, amount and type of exudate, odor, and the presence of infection, foreign bodies, bleeding, or hematoma are some examples to document during the assessment. At this stage, the wound may show atypical characteristics. If the situation is beyond the professional's expertise, it is his or her responsibility to call in an experienced colleague or refer the person to a specialist or specialized team. These clinical benchmarks also help to assess the evolution of the wound during follow-up. Numerous tools are mentioned in the literature and exist in certain health care institutions, which can serve as references. (#3 LABORATORY AND PARACLINICAL TESTING): The cause or reason for delayed wound healing can sometimes be revealed through biomedical and paraclinical testing. Laboratory tests are particularly useful in confirming the presence of atherosclerotic vascular disease and assessing its severity when palpable pulses or ankle-brachial systolic pressure index are abnormal or ambiguous during clinical evaluation. In contrast, the use of laboratory tests to identify local infection is less relevant, as clinical signs are usually sufficient, except in the case of neuropathy. Neuropathy is identified by paraclinical examination. Malnutrition, on the other hand, is primarily determined by questionnaires from which laboratory testings are used to complement the assessment of the person’s overall health. (#4 TREATMENT PLAN): The preferred wound treatment includes interventions in the wound bed to control moisture and microbial load, taking into consideration the vascular supply. This is complemented by the control of risk and causative factors if present, optimization of nutrition and hydration, and pain management, all of which help to control the wound healing process. Timely actions can prevent complications, enhance one's quality of life and use resources efficiently. Contrary to old beliefs that it is best to dry the wound, moist wound healing is desirable in a wound with adequate tissue blood flow. If tissue vascular supply is inadequate, moist wound healing is generally to be avoided.(#5 CHALLENGES AND SOLUTIONS RAISED BY THE WORK): In addition to identifying all of the clinical aspects and recommendations from the systematic review of practice guidelines to support practice improvement and harmonization, the following challenges and solutions were identified from the consultations: • Competencies - For professionals with less exposure to wounds, competencies to perform certain wound-related activities are a challenge. Inappropriate interventions, as well as inaction on a deteriorating wound, can be detrimental and lead to complications such as hospitalization or amputation. Thus, up-to-date training is one of the cornerstones of optimal care delivery. In order to maintain or acquire expertise, basic training, as well as peer practice and continuing education, are keys to face this challenge. • Collaboration and inter-professional work - Wound care is an activity shared by several health care professionals - e.g., nursing assistant, nurse prescriber, stomatologist, nurse practitioner specialist, physician, physiotherapist, dietitian/nutritionist, occupational therapist. The range of interventions varies according to the parameters set by the area of practice of each of the professions involved. By focusing on professional autonomy, inter-professional collaboration and interdisciplinary delivery, the impact on intervention time, costs, and recovery time can only be beneficial to all parties involved. • Standardization in wound assessment and follow-up - There are several essential items to document during wound assessment for ongoing care and follow-up. Some hospitals have a data collection form specific to their setting. In order to harmonize practices across Quebec, whether in an institutional or ambulatory setting, and to facilitate follow-up throughout the care continuum, the possibility of having a standardized form was identified by stakeholders consulted as an important requirement. CONCLUSION: A wound optimally treated has the best chance of evolving favorably, limiting the number of clinical follow-up visits required and reducing the adverse impact on the affected individual's functioning and quality of life. Conversely, non-optimal or detrimental management has a significant impact on the quality of life of the individual and their loved ones, which can lead to amputation or death. The increasing complexity of a wound has a significant impact on the use of resources, including the repeated use of clinicians and multiple visits to specialized complex wound clinics, hospitals or emergency rooms, and the use of several possibly inappropriate dressings for months or even years, with a costly end result. Without substituting for clinical judgment, the tools developed in this research should support practice by increasing the comfort of less experienced clinicians in treating wounds. Thus, safe, quality care adapted to the clinical situation encountered, as well as a reduction in the number of low-value interventions, are emphasized in the tools. The purpose of this work is also to promote care continuity by supporting interprofessional collaboration and interdisciplinary care delivery. Enhancing and harmonizing practice, however, will depend on: • implementation of clinical tools associated with this report; • adherence to these changes and adoption of the recommendations by the health care professionals targeted; • promotion of the tools by nursing managers within the network, the autonomy of nurses in carrying out wound care activities according to their scope of practice in this field, and the full deployment of nurses' authorization to prescribe in this area; • establishment of winning conditions for inter-professional work in various care settings; • and anticipated improvements in access, and reimbursement of dressings - improvements that will require an assessment review, and reimbursement processes, and an expansion of the categories of dressings covered, including innovative solutions in this area. UPDATE: The relevance of updating the recommendations will be assessed in four years from the date of publication according to the advancement of scientific data and the evolution of clinical practices, significant changes in the criteria for reimbursement of dressings under the public drug plan, and according to the needs of the Institute or the health and social services network regarding future research in wound management.

Authors' recommendations: At the end of the work and following an iterative process with Advisory Committee members, in which scientific data, information, and recommendations from the literature consulted, contextual factors and the perspective of the various stakeholders consulted were triangulated, a series of recommendations were formulated. These recommendations, which are at the core of the report, are also summarized in a clinical toolkit derived from the work and intended primarily for clinicians with less expertise in wound care. The wound care clinical tools are: • Decision Support Tool: Assessing the wound and determining its healing potential; • Decision Support Tool: Optimal treatment plan based on etiology, vascular supply, infection risk, tissue type and amount of wound exudate; • Quick reference guide: Dressing specifics; • A series of management support tools based on wound etiology - e.g., burn, skin tear, surgical wound, etc.

Authors' methods: A systematic search of the scientific literature was conducted, in collaboration with a scientific information specialist (librarian), in the MEDLINE, Embase, EBM Reviews and CINAHL databases. A manual search of the grey literature associated with the subject theme was also carried out by consulting, among others, the websites of scientific societies specialized in the field. Document selection, extraction and methodological quality assessment were performed independently by two scientific professionals. The references of the selected publications were also consulted to identify other relevant literature, including systematic reviews that support the recommendations published in the clinical practice guidelines. For the narrative review on the differential characteristics of wound dressings, documents were first selected from the systematic search described above. An additional search was then conducted using PubMed, Google search engine, and Google Scholar by a single scientific professional. For information on products and dressings available in Canada, as well as indications for payment in Quebec, Health Canada's Medical Supplies and Equipment Guide and Benefit List and the Régie de l'assurance maladie du Québec's drug lists were also consulted. The analysis and synthesis of the information collected was carried out by one professional and validated by a second. To fully understand the framework and scope of practice of the various health professionals who share dedicated wound care activities, the websites of professional orders were consulted. To gather the perspective of stakeholders, an advisory committee made up of clinicians with various specialties and expertise, as well as a follow-up committee made up of representatives from various professional orders, medical federations and Quebec associations were created. Finally, the overall quality of the data, its acceptability and applicability were assessed, first with representatives of the follow-up committee, and then with external readers who were specialists in the field of interest as well as future users who had not participated in the research.

Project Status: Completed

URL for project: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/soins-de-plaies-evaluation-prise-en-charge-et-usage-optimal-des-traitements.html

Year Published: 2023

URL for published report: https://www.inesss.qc.ca/publications/repertoire-des-publications/publication/soins-de-plaies-evaluation-prise-en-charge-et-usage-optimal-des-traitements.html

English language abstract: An English language summary is available

Publication Type: Full HTA

Country: Canada

Province: Quebec

Organisation Name: Institut national d'excellence en sante et en services sociaux

Contact Address: L'Institut national d'excellence en sante et en services sociaux (INESSS) , 2021, avenue Union, bureau 10.083, Montreal, Quebec, Canada, H3A 2S9;Tel: 1+514-873-2563, Fax: 1+514-873-1369

Contact Name: demande@inesss.qc.ca

Contact Email: demande@inesss.qc.ca

Copyright: Gouvernement du Québec