a dressing history

A dressing historyDouglas Queen, Heather Orsted, Hiromi Sanada, Geoff Sussman

ABSTRACTOver the past 30 years as caregivers, clinicians have been exposed to a plethora of new advanced wound dressings.The moist wound care revolution began in the 1970s with the introduction of film and hydrocolloid dressings, andtoday these are the traditional types of dressings of the advanced dressing categories. Wound-healing science hasprogressed significantly over the same period, as a result of intense clinical and scientific research around theseproduct introductions. Today, the clinician understands moist wound healing, occlusion, cost effectiveness, woundbed preparation and MMP activity to name but a few of the many concepts in wound care that have flourished as aresult of technology and product advancement. This review article presents a condensed history of dressingdevelopment over the past 30 years. However, in addition, such advancement is discussed in respect to itsadoption in different parts of the world. The largest single markets of the world are generally the United States ofAmerica and Europe; as such, the development of both practice and technology generally begins there. Much hasbeen written about these markets in previous review articles. For the purposes of this review, the development ofwound care and the maturing of practice is discussed in respect to Canada, Japan and Australia representingsmaller geographical areas where the development has been more recent but nonetheless significant.

Key words: Dressing . Wound . Occlusive . Modern . Review . Australia . Japan . Canada

INTRODUCTIONMany articles have been written concerningthe development of both product (14) andtechnology over the past three decades (625),often updates from the last. As such, thesereviews have presented a regional perspectiveof the development of modern wound careduring this period.

The development of the modern woundcare concept and adoption of advanced pro-ducts, however, are not universal (i.e. global)even today. Different markets develop at dif-ferent times. Change of practice takes timeand also differs by geographical region andculture.

Certain areas lead the way (e.g. the UnitedStates of America and United Kingdom), oftenas a result of market size and the globality ofthe English language. Other geographical areasfollow, each learning from the other, which

in turn results in a more rapid and focuseddevelopment of practice and product.

Today, wound care is a global arena, withmost geographical areas having some ele-ments of technology and product, in additionto standards of practice, albeit at differentstages of the evolutionary wound care path.

A DRESSING HISTORYThe management of wounds began in Egyp-tian times (26) with grease-soaked gauzebandages with little thought to wound man-agement. Over the centuries, such care hasbecome a little more sophisticated, but itsprimary goal that of healing remains thesame. Traditional dressings such as gauzeare non occlusive and dry out. Once thishappens, they adhere to the wound bed.Even if they do not dry out, capillary loops(i.e. granulation tissue) can grow into thedressing structure (27), thereby resulting indressing adherence. Such adherence leads towound trauma, often noted with bleedingduring dressing removal, and this can causepain to the patient.

During the 1980s, wound care took a newdirection with the widespread introduction ofmoist wound healing (28). In the next twodecades, much has been proven around thebenefits of moist healing.

Key Points

. many reviews previously written but are normally region specific orinfluenced

. this review provides a differentperspective

. the 1980s saw the proliferationof modern wound care products

Authors: D Queen, BSc PhD, MBA, Medicalhelplines.com Inc.,35 Rosedale Road, Unit 4, Toronto, ON, Canada M4W 2P5;H Orsted, RN, ET, 9003-33 Ave NW, Calgary, AB, Canada;H Sanada, RN, PhD, Professor of Nursing, School of HealthSciences, Kanazawa University, 5-11-80 Kodatsumo,Kanazawa, Japan; G Sussman, BSc, Department of PharmacyPractice, Monash University, 381 Royal Parade, Parkville,AustraliaAddress for correspondence: D Queen, CEO andPresident, Medicalhelplines.com Inc., 35 Rosedale Road, Unit 4,Toronto, ON, Canada M4W 2P5E-mail: [email protected]

Blackwell Publishing Ltd and Medicalhelplines.com Inc. 2004 . International Wound Journal . Vol 1 No 1 59

REVIEW&

Wound dressings have been designed tofunction in a specific manner. Often, theirinteraction with adjunct/complementarydevices may also have been designed for orat least clinically evaluated. The choice ofproduct for optimal wound management isnot straightforward. This choice should notbe for a single wound factor or indeed onespecific function. The wound, the patientand their multiple needs should also beconsidered (29).

Optimal wound care wisdom understandsand promotes the need for a moist interactivedressing in chronic wounds with the ability toheal (30). Unfortunately, practice does notnecessarily follow and a large number of inap-propriate dressings are still used today. Anytreatment choice should be cognisant of otherpatient-centred factors involved in the qualityof their life in addition to healing.

Moist interactive wound care has beenaround for the last three decades. Therefore,the concept of moist wound healing is notnew. Indeed, it is some 40 years since Winter(31) first published his findings regardingkeeping a wound moist. But, even today,there is low use of this moist wound conceptin regular wound care practice, albeit at agrowing trend. Documentation of moistwound-healing practices varies, depending onlocation and care setting, but it is generallyaccepted that less than 50% of chronicwounds receive modern moist wound dress-ings even when they are appropriate (32).

The main justifications are budget con-straints (cost and unavailability) and lack ofknowledge, particularly in routine health careproviders, the result being that a large numberof inappropriate dressings are applied topatients on a routine basis. These are mainlygauze-based dressings, which do little forhealing.

The basis for Winters findings was fasterhealing, where a plastic cover created a moistenvironment. Others (33) went on to study thisphenomenon in humans and demonstrated notonly faster healing but better tissue quality [lessscarring (34)] and reduced pain (35).

Dressing manufacturers have been cognisantof these findings for some time, and as a result,an evolutionary development process, throughinnovation, has provided the comprehensiverange of moist interactive dressings availabletoday.

The moist interactive dressings of todaywork on the same principle. By creating amoist environment, not only do they aid heal-ing, they also soothe nerve endings, minimisingor eliminating wound pain, allowing healing toprogress more naturally.

During the evolutionary development ofthese products, manufacturers have becomeaware of product shortcomings and havedesigned better product variants. The modernwound care revolution truly began in the late1980s and early 1990s, with an explosion ofproducts and significant scientific/clinicalresearch around the area of moist healing. Itis now routinely accepted among key opinionleaders that moist wound healing has beenshown to be superior with respect to woundmanagement, when compared with dry dres-sings (3541). This is not solely based on heal-ing but a number of patient- and wound-related factors as presented in the woundbed preparation paradigm (42).

The wound bed preparation paradigm dis-cussed by Sibbald et al. (42) involves treating thecause, local wound care and patient-centredconcerns (Figure 1). Treating the cause revolvesaround the correct diagnosis of the woundaetiology. Patient-centred concerns must focuson what the patient sees as the primary reasonsfor receiving treatment for their wound. Localwound care needs to revolve around thethree pillars of local wound care practice:debridement, bacterial balance/prolongedinflammation and moisture balance.

The three key considerations of local woundcare, as outlined in Figure 1, are debridement,bacterial balance/prolonged inflammationand moist interactive healing.

Wound debridement can be achievedthrough different means, namely surgical, auto-lytic, enzymatic and mechanical (43). A numberof factors come into play when choosing anappropriate debridement method (43). Careshould be taken regarding the chosen method,as each can have a negative or positive impacton wound pain. More aggressive debridementregimes (e.g. surgical and mechanical) are initi-ally detrimental to healing and more likely to bepainful for the patient.

Wound infection (both in the superficial andin deep compartments) and prolonged inflam-mation can delay healing and may presentwith similar features clinically. Maintenanceof wound bed bacterial balance can be of

Key Points

. choice of product should bebased on the wound, the patientand their multiple needs

. moist interactive wound care hasbeen around for three decades

. around 50% of all wounds do notreceive appropriate care

. wound bed preparation paradigmpresents a more encompassing con-cept vs simple moist wound healing

. debridement can be achieved bya variety of means

A dressing history

Blackwell Publishing Ltd and Medicalhelplines.com Inc. 2004 . International Wound Journal . Vol 1 No 160

significant benefit in wound management,with increased local bacterial burden leadingto the release of pro-inflammatory mediatorsand modulators of inflammation that result inlocal pain (44) and delayed healing.

THE HEALING REVOLUTIONThe initial moist interactive dressings were poly-urethane films that were designed around Win-ters initial findings. They simply adhered to thesurrounding skin and maintained moisturewithin the wound environment. These dressingsprovided some pain relief by preventing dehy-dration of the wound surface and bathing theexposed nerve endings in physiological woundsecretions. The aggressive adhesive, however,sometimes caused trauma upon removal (45),although recently developed removal tech-niques help to minimise this issue (46). Strongadhesive bonds in these dressings are likely tocause skin tears on removal, unless the adhesivebond is weakened by stretching the dressinglaterally and parallel to the wound surfacebefore trying to remove the dressing by gentlylifting at a 90 angle above the wound surface.Despite the precautions with removal, their nonabsorbency continues to be a problem. Whenfluid accumulates below the surface or leakage

channels break the seal to the external environ-ment, bacterial proliferation is facilitated.

Following the limitations of the film dres-sings, a number of more absorbent moistwound care categories were developed and aplethora of products followed:

. hydrocolloids (4752) were shown to pro-duce a moist environment by gelling withwound fluid over the wound bed andbelow the semi-occlusive film covering;

. foams (5361) provided an easy-to-remove non adhesive contact surface(some newer products contain adhesivesurfaces);

. alginates (62,63) transform from a fibre toa gel with wound fluid contact and there-fore provide a non stick wound contactsurface and a moist wound environment;

. hydrogels (6473) provided high watercontent in a gel lattice that rendered themnon adherent and soothing and providedthe wound with the necessary moisture.

All of these new products were designedwith moist wound healing in mind, seekingthe Holy Grail of healing. Some productswere designed to provide security with regard

Key Points

. initial wound care productsbased on Winters findings

. dressings with aggressive adhe-sive can be problematic

. limitations of earlier dressingslead to the development ofsuperior offerings

. continued development in tech-nology can lead to furtheradvancement in wound care

Patient withchronic wound

Treat cause Local woundfactors

Patient-centeredconcerns

Superficial infection/inflammationDebridement

Moist interactivehealing

Venous

Arterial

Diabetic

Surgical Pressure

Palliative

Quality of life Adherence, coherence

Degree of painSurgical ++Autolytic +Enzymes +Mechanical ++

High absorbencyFoams

Calcium alginatesHydrocolloidsHydrogelsFilms Low absorbency

Bacterial burdenContaminationColonization

Bacterial burdenInfection

InflammationCellsMediatorsInhibitors

Softsi licones

Figure 1. The chronic wound paradigm [adapted from Sibbald et al. (42)].

Key Points

A dressing history


to adhesion, while maintaining a moist envir-onment. Other products provide moisture bal-ance by absorbing exudate. Finally, foroptimal pain control, products needed tohave a non stick, soothing nature (e.g. hydro-gels). Continued and more widespread use ofthese products has provided insight into theiradvantages as well as their limitations.

Film and hydrocolloid dressings, with theiraggressive adhesives, can result in skin strip-ping of the wound margins, if they are inap-propriately removed (74,75). Foams can stickto the wound bed if wound exudation is lowor has decreased during use (76).

Some products rely heavily on secondarycoverings for retention (e.g. hydrogels), butproduct combinations can sometimes bedetrimental to wound healing. For example,an absorptive secondary covering mayremove the hydrogel moisture in the second-ary layer and dehydrate the wound bed. Onthe other hand, if an adhesive film is usedover an amorphous hydrogel, the excessmoisture delivered to the wound margins cancause maceration and wound deterioration.

Alginates suffer from a combination of thelimitations experience by both foam andhydrogel dressings (77). Alginates absorbwound fluid onto their fibres, and if theybecome supersaturated in their gel transfor-mation, they may cause maceration of thesurrounding skin or strikethrough of excessexudate, through any secondary dressing. Ifa wound is too dry to transform an alginatefibre into a hydrogel-like material, then thewound surface remains dry and the undis-solved fibres do not provide moist interactivehealing.

These findings led manufacturers todevelop second- and third-generation pro-ducts of existing devices (e.g. better hydrocol-loids or foams) (78,79). Several variants ofmodern dressing classes appeared withwound contact surfaces to reduce adhesion(80). Absorptive fibres (e.g. hydrofibres)(8186) and next-generation hydrocolloiddressings were developed to minimise adhe-sion to the wound, increase the absorptionand permit painless removal of the dressings(87,88).

These dressings were followed by the devel-opment of specialised wound contact materialsthat were purposely developed for pain man-agement through easy non traumatic removal.

Materials were specifically redesigned to havecoatings that did not dry out and thereforeremained non adherent. The most popularcoating is silicone.

Silicones are not new to wound care;indeed, they have been around in the burnsarea for some 30 years (89,90). The majority oftheir use has been as non adherent silicone gelsheets for the treatment of burns (91) and inthe resolution of hypertrophic scars (92). Sili-cones provide painless removal (93). Thesematerials have now progressed beyond sim-ple gels and coatings, recently being redeve-loped as soft silicone dressing technology.

Soft silicone dressings rely on a hydropho-bic soft silicone layer that prevents the dres-sing from adhering to the wound surface.They do so by maintaining contact withoutcausing friction and shear, thereby reducingthe tear force on removal.

The soft silicones are among the first pro-ducts to be specifically designed for atrau-matic removal from the wound andsurrounding skin, with a focus on pain man-agement (94). A variety of product variantsexist, providing a versatile technology for anumber of clinical situations (95).

A BIOLOGICAL APPROACHMore sophisticated biological approacheshave been around for the over the 30 yearsin which the development of advancedwound care has taken place. Such anapproach began in the burns area with theuse of artificial skin substitutes (96), althoughthese have become significantly moreadvanced (97100) with the recent approvalsof Dermagraft (101), Apligraf (102) and simi-lar modalities.

Biologically active dressings, based on col-lagen (103,104), chitosan (105), hyaluronic acid(106,107), peptides (108) and growth factors(109,110), have been developed and evaluated,but most still require pivotal data to substan-tiate widespread use in beyond-difficult-to-heal wounds. This generally relates to their sig-nificant unit cost and the unavailability ofgood cost-effective data.

Recently, clinicians have seen the reintro-duction of maggots into medical practice.This is a novel biological approach to wounddebridement and cleansing (111). A number ofcommercial organisations now make theseavailable in a number of countries.

Key Points

. often product limitations areovercome using combinations ofproducts

. use of combinations makes it dif-ficult to assign healing perfor-mance to any single product

. second and third generationproducts evolve with time

. the ultimate dressing may be skinitself and as a result many biolo-gical approaches to healing havebeen tried

. various biological materials (e.g.collagen) and cell derived materials(e.g. fibroblasts) have been evalu-ated

A dressing history


Recent developments around the antimicro-bial dressings category (112,113) and regener-ated cellulose-collagen dressings (114) havegiven significant focus on the area of metallo-proteases and other pro-inflammatory media-tors (cytokines/chemokines) in woundhealing. Current research into the function ofthese products is greatly adding to the know-ledge in this area.

ALTERNATIVE APPROACHESSome non dressing approaches to woundhealing exist. These generally centre on nega-tive pressure therapy (115,116), hyperbaricoxygen (117), topical oxygen delivery (118)and warm-up therapies (119). Otherapproaches including transcutaneous electri-cal nerve stimulation, ultrasound and variousskin grafting techniques (e.g. pinch grafts)have also been tried.

Some attempts have been made using sys-temic drugs to treat recalcitrant wounds (120)but with little success.

THE FUTUREAs knowledge in this area progresses, moresophisticated dressings can and will be devel-oped. However, there is still much to bediscovered regarding the healing processitself.

Although new theories and concepts [e.g.wound bed preparation (121)] bring focus tothis area of care, significant advances are stillrequired, particularly in the area of wounddiagnosis, to allow effective dressings andtherapies to be more accurately targeted.

SUMMARYWound therapies have evolved significantlyover the past three decades, providing moreeffective and easily used dressings. Technol-ogy and product proliferation, however, var-ies by geography, usually as a function ofeconomics and health care policy.

From the banana-leaf (122,123) and potato-peel (124) approaches of the Third world tothe sophisticated hyaluronates (125) andgrowth factors (126) of the developed world,much has advanced.

Significant opportunity still exists, however.Newer and better technologies can and will bedeveloped. Diagnostic tools and products willbecome available.

Even today, however, much choice exists,and the choice of a particular product remainsa guessing game (127,128).

With the advent of care plans and theincrease in clinical knowledge that thesenewer technologies and products bring to thewound care arena, as caregivers, we are betterarmed than ever before.

A well thought out local wound careregime, with the appropriate dressing or ther-apy choice (Table 1) that is patient, wound anddisease specific, the healing outcome shouldbe a vast improvement to that seen clinicallythree decades ago.

The remainder of this review focuses on thedevelopment of both dressings and practicefrom three geographical areas around the globe.

THE DEVELOPMENT OFDRESSING USAGE: AN AUSTRALIANPERSPECTIVEThe use of wound dressings and wound pro-ducts has been gradual in Australia, with arapid increase over the past decade. To fullyunderstand the issues involved, it is import-ant to clarify the health systems in this coun-try as it compares with Europe, USA and Asia.

The health system in AustraliaAustralia has a universal health system partlyfunded by a contribution by each taxpayerdeducted from his/her weekly salary. Thissystem provides payment of doctors fees,pathology tests, radiology and other specialistservices based on a schedule of fees. Patientsare treated by their local general practitioneror by referral to a specialist. If there is a needfor medication, this is prescribed by the doctorand dispensed by a pharmacist. The cost ofmedication is also reimbursed by the govern-ment, with the patient making a copayment ofa few dollars if on a pension, or a maximum of$23 until a total of approximately $700 isspent; thereafter, the medication is at the con-cession rate. The list of drugs available isdetermined by the government on advicefrom an advisory committee. In general,wound dressings or wounds products suchas bandages are not included on the scheduleof products made available. The exceptionsare some stomal products and a range ofwound dressings, bandages and miscel-laneous products available to veterans and

Key Points

. recent developments have lookedat the area of inflammatory med-iation

. other non dressing approacheshave also been attempted (e.g.hyperbaric oxygen)

. more sophisticated dressings willbe developed in the future

. technology and product prolifera-tion, however, varies by geogra-phy, usually as a function ofeconomics and health care policy

. Australia has seen a rapid increasein the use of modern wound careproducts in the last ten years

. wound dressings are not reim-bursed in Australia and, as such,their full cost is borne by the user

A dressing history


Key Points

. many classes of dressings exist,each exhibiting different func-tions and behaviours

. choice should be based on func-tionality but must also addresspatient-centred concerns

. examples of each class are pro-vided but are by no means allencompassing

Tab

le1

Cla

sses

ofdr

essi

ngs

[ada

pted

from

Redd

yetal.

(29)

]

Moi

stur

eba

lanc

e(1

30)

Cla

ss/c

ateg

ory

(129

)D

onat

es/a

bsor

bsFl

uid

(131

)

Prev

ents

mac

erat

ion

(132

)D

ebrid

emen

t(a

utol

ytic

)(1

33)

Bact

eria

lba

lanc

e(1

34)

Oth

erpa

tient

-cen

tred

conc

erns

addr

esse

dEx

ampl

es

Wou

ndco

ntac

t

laye

rs(1

35)

Non

eN

oN

oN

one

Non

eJe

lone

t,N

AD

ress

ing,

Ada

ptic

,U

rgot

ul

Film

s(1

36)

Non

e

ambi

ent

moi

stur

ele

vels

only

No

Min

or

due

tooc

clus

ion

Min

or

due

toba

rrie

r

func

tion

(137

)

Non

eM

efilm

,O

psite

,Te

gade

rm

Hyd

roge

ls(1

38)

Abi

lity

todo

nate

;so

me

have

min

or

abili

tyto

abso

rb

No

Hig

hN

one

spec

ifica

lly,

but

they

do

not

supp

ort

bact

eria

l

grow

th.

They

may

beus

edas

vehi

cle

for

antib

iotic

s

Gen

eral

lyco

mfo

rtin

g

and

soot

hing

durin

gus

e

Nor

mlg

el,

Hyp

erge

l,

Duo

derm

gel,

Inta

Site

gel,

Tega

gel,

Cle

arsi

te

Soft

silic

ones

(139

)A

bsor

benc

yva

ries

from

min

imal

tohi

gh,

depe

ndin

gon

form

at

Yes

Min

or

due

tooc

clus

ion

Non

e,ex

cept

whe

noc

clud

edA

trau

mat

icre

mov

al(1

40)

Mep

itel,

Mep

ilex,

Mep

ilex

Bord

er,

Mep

ilex

Tran

sfer

Hyd

roco

lloid

s(1

41)

Mod

erat

eab

sorp

tion

No

Hig

hM

inor

du

eto

acid

icpH

and

barr

ier

func

tion

(142

)

Vira

lba

rrie

rD

uode

rm,

Tega

sorb

,

Com

feel

Alg

inat

esan

d

hydr

ofib

res

(143

)

Mod

erat

e-to

-hig

hab

sorp

tion

Yes

Mod

erat

eN

one,

exce

ptw

hen

occl

uded

Gen

eral

lyea

sily

rem

oved

Mel

giso

rb,

Kalto

stat

,

Tega

gen,

Alg

isite

M,

Sorb

san,

Aqu

acel

Foam

san

d

hydr

oact

ives

(144

)

Mod

erat

e-to

-hig

hab

sorp

tion

Yes

Min

or

due

tooc

clus

ion

Non

e,ex

cept

thro

ugh

occl

usio

n(1

37)

Cus

hion

ing

ofth

ew

ound

site

Lyof

oam

,A

llevy

n,

Tega

foam

,Ti

elle

,Bi

atai

n,

Cut

inov

aH

ydro

Ant

imic

robi

als

(145

)M

inim

al-t

o-m

oder

ate

abso

rptio

nYe

sD

epen

dson

form

ulat

ion

Hig

hN

ewfo

rmul

atio

nsm

ore

effe

ctiv

eA

ctic

oat,

lodo

sorb

,

Aqu

acel

Ag,

Act

isor

b

Col

lage

ns(1

46)

Mod

erat

eab

sorp

tion

Yes

Mod

erat

eN

one,

exce

ptw

hen

occl

uded

Prov

ides

need

edw

ound

fact

orPr

omog

ran

Hya

luro

nate

s(1

47)

Mod

erat

eab

sorp

tion

Yes

Mod

erat

eN

one,

exce

ptw

hen

occl

uded

Prov

ides

need

edw

ound

fact

orH

yalo

fill

Skin

repl

acem

ents

(148

)N

one

Non

eN

one

Non

ePr

ovid

esa

moi

sten

viro

nmen

t

but

mai

nly

prov

ides

need

edce

lls

Biob

rane

,D

erm

agra

ft,

Tran

cyte

,In

tegr

al,

Apl

igra

f,O

rcel

,O

ASI

S

Gro

wth

fact

ors

(149

)N

one

Non

eN

one

Non

ePr

ovid

esne

eded

wou

ndfa

ctor

Regr

anex

Adj

unct

s(1

50)

No

Yes

Non

eN

one

Use

ful

for

wou

nds

stag

nant

with

dres

sing

s

VA

C,

War

m-u

p

A dressing history


their dependents. The schedule of these pro-ducts is also determined by the governmenton advice of a reference committee. Theveteran and their dependents are the onlygroup who are able to obtain wound productssubsidised by the government; all otherpatients regardless of their financial statusmust purchase their products themselves.

This, however, does create a problem for theongoing use by, in particular, the lower-income groups such as pensioners who maynot be in a position to afford the cost ofwound dressings and products needed fortheir treatment. In general, local general prac-titioners will provide products for dressingwounds when the patient visits their clinic,and while treated in hospital, all productsare provided.

Australia has a dual hospital system withpublic hospitals funded by the various Stategovernments from grants by the federal gov-ernment and private hospitals operated by var-ious organisations and paid for by the patient orby a health insurance company if the patienthas private health cover. Some private hospitalsmay insist on the patient paying extra to coverthe costs of specialised dressings.

Product distribution in AustraliaThe distribution method for wound productshas a strong impact on their use in Australia.Products are, in most cases, distributeddirectly to hospitals by the manufacturer oragent and via wholesalers to medical practicesand pharmacies. Nursing home and specialaccommodation facilities obtain their suppliesfrom a community pharmacy. The publicusually obtain their dressings from one ofover 5000 community pharmacies or a limitednumber of companies who supply treatmentaids directly to the public. Apart from vet-erans and their dependents, all other patientspay for their supplies directly with no reim-bursement, refund or tariff system in operation.This impacts on the ability of lower-incomegroups such as pensioners to continue to usemodern wound products.

The other factor that influences availabilityis pack size. In some cases, manufacturersprovide products in pack sizes from 50 to100, suitable for hospitals or medical practicesbut excessive for the individual patients. Itwill be important for greater penetration tooccur for pack sizes to be consumer sensitive.

Wound management organisations inAustraliaIn March 1993, in Perth, Western Australia, dur-ing the Inaugural Australian Conference onWound Care, Turning Wound Care Upside Down,a steering committee was convened to overseethe formation of the Australian Wound Manage-ment Association (AWMA). The association wasformally recognised a year later in Melbourne atthe Australian International Wound Manage-ment Conference, in March 1994.

The AWMA is a multidisciplinary, non profitassociation consisting of people who are com-mitted to developing and improving woundmanagement for all individuals through educa-tion, research, communication and networks.

The association acts as a parent body to theautonomous state wound management asso-ciations in New South Wales, Queensland,South Australia, Tasmania, Victoria, Austra-lian Capital Territory and Western Australia.There are approximately 2000 members fromthe disciplines of nursing, medicine, phar-macy, podiatry, industry and the sciences.The New Zealand Wound Care Society isan affiliate of AWMA. Membership of theassociation is either through membership ofstate associations or directly through AWMA.Corporate membership is also welcomed.

Every second year, the association holds anational wound care conference with valuableassistance from the host state wound careassociation. On the alternate year, each stateassociation holds a wound care conference.

Primary Intention The Australian Journal ofWound Management is produced and publishedby the Association four times a year. TheAWMA has forged strong links with otherinternational wound healing societies. TheAssociation hosted the First World WoundHealing Meeting in Melbourne in September2000. At this meeting, the International Unionof Wound Healing Societies was formed.

Guidelines and standards for woundmanagement in AustraliaThe association aims to improve the communitysunderstanding of wounds and wound manage-ment practices, and the association formed aPressure Ulcer Interest Subcommittee in 1996.This committee has developed guidelines for theprediction and prevention of pressure ulcers.

The topics included in the clinical practiceguidelines are:

Key Points

. Australia has a dual hospitalsystem, private and public

. distribution methods within Aus-tralia impact use

. pack size also influences avail-ability with the large hospitalpacks being inappropriate forthe community

. the Australian wound care con-ference circuit began some 11years ago

. The Australian Wound Manage-ment Association has some 2000members

. the inaugural World WoundCongress held in Australia in2000

A dressing history


. staging of pressure ulcers

. risk factors:

intensity and duration of pressure tissue tolerance for pressure extrinsic factors intrinsic factors

. risk assessment tools

. skin care:

skin assessment skin hygiene skin moisture maintenance maintenance of a suitable skin tem-

perature influence of nutrition on the skin

. mechanical loading and support surfaces:

positioning and repositioning eliminating shear and friction reducing heel pressure activity and mobilisation support surfaces basic hospital mattresses foam pressure-reducing devices sheepskins, fibre-filled overlays and

gel pads static air mattresses and overlays alternating pressure devices low-air-loss devices high-air-loss or air-fluidised beds turning beds evaluating support surfaces selecting a support surface

. documentation

. summary of pressure ulcer preventativestrategies.

The clinical practice guidelines are availablein three forms: the full text, an abridged ver-sion and a pocket guide. They have beenwidely distributed around the country, andthe full text version is available on theAWMA website (http://www.awma.com.au).

In 2002, the association also published stan-dards for wound management.

The standards cover a broad range of practices:

Collaborative practice and interdisciplinarycareThe optimal healing of the individual with awound or potential wound is promoted by acollaborative and interdisciplinary approach towound management.

Professional practiceThe safety and wound healing potential of theindividual is ensured by clinical practice inwound management that respects and complieswith legislation, codes of practice, clinical prac-tice guidelines and organisational policies.

Clinical decision-making in woundmanagementThe optimal healing of the individual with awound is facilitated by an ongoing process ofclinical decision-making in order to determinethe risk of wounding, wound aetiology andwound healing responses.

Best practice in wound healingWound management is practised according tothe best available evidence for optimisinghealing in acute or chronic wounds.

DocumentationDocumentation in the individuals record or man-agement plan must facilitate communication andcontinuity of care between interdisciplinary teammembers and fulfil legal requirements.

EducationEducation of individuals and their carersshould facilitate better health care seekingbehaviours. The clinician maximises opportun-ities for advancing self-knowledge and skills inwound management.

ResearchWound healing is a dynamic process, and theclinician must anticipate that wound manage-ment practice will change as new scientificevidence becomes available.

EducationOne of the most important and significantinfluences of practice has been the level ofeducation of health professionals in Australia.Wound management is part of the undergrad-uate training, to some extent, in medicine,pharmacy, nursing, podiatry and veterinaryscience. Over the past 1015 years, a numberof training courses, mostly short courses, havebecome available. The interest is growing inseminars, tutorials, training days and confer-ences with many opportunities for health pro-fessionals to participate.

Postgraduate training and courses are avail-able in particular for nurses with Masters of

Key Points

. national guideline developmentbegan in 1996 with the formationof a pressure ulcer interest group

. in 2002 the AWMA publishedstandards for wound management

. the standards covered interdis-ciplinary approach, education,documentation and more

. education was recognised as aspecific influencer of practice bythe development and launch ofpostgraduate training courses

. a Masters of Clinical Nursingspecialising in wound manage-ment exists today

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Clinical Nursing specialising in wound man-agement from University of Central Queens-land. Monash University in Melbourne has arange of postgraduate courses including gradu-ate certificate, graduate diploma and masters, alldelivered by distance education.

OverviewModern wound management practice has beenwell accepted in Australia and, compared withmany other countries, is well developed. Thereare a number of multidisciplinary woundclinics in Australia and research centres under-taking basic and clinical research.

A wide range of dressings are available inAustralia. There is still wide use of the simpleinert non stick dressings and modern gauzebased dressings.

Moist wound products available for useinclude:

. film dressings

. hydrocolloid dressings

. hydroactive dressings

. alginate dressings

. foam dressings

. hydrogel dressings.

In addition, a number of miscellaneous pro-ducts are available, for example:

. cadexomer iodine dressings

. various silver dressings

. hypertonic saline dressings

. silicone dressings

. topical zinc

. charcoal odour absorbing dressings.

The use of bandages and compressionstockings is also well established, includingthe use of multilayer systems.

In general, wound management practice ismoving forward steadily and will increase aspractitioners gain more experience with modernproducts. There is still, however, considerableroom for improvement, and this will be achievedby education, good communication betweenhealth professionals and governmental supportof modern wound management practice.

WOUND DRESSINGS: ACANADIAN APPROACH

The Canadian health care systemCanada is a large, unique and diverse country,of 316 million people, divided among 13 pro-

vinces and territories. Each province or territoryhas its own size (from 29 000 in Nunavut to 12million in Ontario) and personality based oneconomics, cultural blend, resources, etc. (151).

Canada is known for its socialised medicine,which had its origins under the Canadian con-stitution, where the federal government wasrequired to fund health care, and the provinceswere delegated jurisdiction in the delivery ofhealth care (152). However, many do not realisehow much Canada has changed in its approachto health care over the last decade. The currentnational health system (Health Canada) beganin the late 1950s, with a system of publiclyfunded hospital insurance, and completed inthe late 1960s and early 1970s when compre-hensive health insurance was put into place.The federal government finances about 40%of the costs, provided the provinces set up asystem satisfying federal norms. The CanadianHealth and Social Transfer Fund (post-second-ary education, social welfare programmes andhealth) gives the provinces a lump sum, and theprovinces can allocate the money according tothe provinces needs (153,154). All provincialsystems are, thus, very similar, but to furtheridentify the regional needs within each pro-vince or territory, multiple health regions havebeen created within the province or territorythat are guided by their own board to deliverhealth care in the most effective way based ontheir regional needs. In recent years, the healthcare in Canada has been changing with theCanadian government delisting previouslycovered services and rationing of care. Woundcare is an example for that change, withsome provinces paying for the cost ofwound care services and dressings, whilesome do not.

Canadian wound care practiceCanada has had a national wound care orga-nisation since 1995 the Canadian Associationof Wound Care (CAWC). The CAWC is dedi-cated to the advancement of wound care inCanada by coordinating a collaborative, inter-disciplinary effort among individuals andorganisations involved with wound caring.The associations efforts are focused on fivekey areas: public policy, clinical practice, edu-cation, research and connecting with the inter-national wound care community. The CAWCworks to significantly improve patient care,

Key Points

. modern wound management iswell accepted and developed inAustralia

. a wide range of dressings areavailable in Australia

. there is still considerable roomfor improvement

. Canada has a socialised medicinesystem

. Canadian health care system ischanging, however, with somemedical products being delistede.g. wound care products

. Canada has had a nationalwound care organisation since1995 the CAWC

A dressing history


clinical outcomes and the professional satis-faction of wound care clinicians (155).

In 2000/2001, the CAWC published fourpivotal articles to guide and support best prac-tice in Canada. These articles, recently translatedinto French, are available in full text version onthe CAWC website (http://www.cawc.net).This resource and their accompanying quickreference guides assist the health care profes-sional in addressing patient-specific concernsthat support wound healing. The CAWC hasalso introduced a new publication Wound CareCanada that is dual language (FrenchEnglish)and is also fully downloadable online.

Clinical enablersPreparing the wound bed has been recentlyreviewed (44), which led to a modification inthe wound-healing paradigm including theepidermal edge effect to demonstrate healing ofthe wound (156). This paradigm supports theclinician, in not only best practice for woundmanagement from a holistic perspective but sup-ports dressing selection based on the guiding-practice principles of wound management:wound aetiology, patient-centred concerns andlocal wound care requirements (debridementrequirements, infection control and moisturebalance).

The CAWC has developed a longitudinalapproach to wound care education withbasic knowledge, skill and attitude develop-ment programme in a three-part seminar ser-ies. This programme is offered yearly atvarious sites across Canada to all health careprofessionals in both English and French.

Canada is also fortunate to have a univer-sity-based wound care programme, theInternational Interdisciplinary Wound CareCourse (IIWCC), offered by University ofToronto that supports wound care knowledgedevelopment (157,158).

By seeding not only our country withwound care leaders, but others, we supportbedside clinicians in making best practicerecommendations for wound management.

Bedside practiceA brief questionnaire was sent out to woundcare experts (nurses) across Canada (BritishColumbia to Newfoundland) in an effort tounderstand regional differences in wounddressing practice.

1 Does your health region pay for woundcare dressings in acute care, in commu-nity care and in long-term care?

2 Who decides which dressing to use?

Acute careIt was clear by the responses that all hospitals

covered the cost of dressings while thepatients were in the hospital, and some hada form of high-cost dressing control or reviewin place for some products (i.e. VAC orbiologicals).

Home careCaring for wounds in patients who had beendischarged home for community-based carewas a bit different but still rang with similar-ities. Some regions had all dressings paid forregardless of where the care occurred, but themost common response was, as always inwound care, it depends! Many provinceshave a government programme that assistswith the coverage of dressings for chronicwounds. Some provinces have a cost-of-livingbenchmark that assists low-economic patientswith the cost of dressings.

Care centresBecause care centres (nursing homes andlong-term care facilities) are often privatelyowned, there was less consistency. Some pro-vided dressings to their residents but mostseemed to look at insurance plans andfamilies to cover costs. Some regions haveprogrammes to support treatment that hasbeen initiated by a wound specialist.

Who selects the dressing?The nurse (wound care nurse or enterostomaltherapist) was the most often mentioned clin-ician that selected the dressing; however, forsurgical wounds, the surgeon was frequentlymentioned. Many mentioned skilled teamsthat supported best practice through theirskilled interventions. Care centres often reliedon doctors and registered nurses for guidance.One factor that was important with dressingselection was agency inventories and productcontracts; the ordering clinician needs to beaware of what is available.

Just as there is no such thing as one dres-sing for all wounds, there is no such thing asone way to obtain and prescribe a dressingfor a wound. Canada is a large and diverse

Key Points

. CAWC responsible for guidelineand standards development

. CAWC publishes material in bothEnglish and French

. CAWC heavily involved in educa-tion

. Canada has a formal educationqualification provided by theUniversity of Toronto the Inter-national Interdisciplinary WoundCare Course (IIWCC)

. in Canada dressing selection wasmainly undertaken by nurses

. in Canada selection is influencedby facility inventory and contracts

A dressing history


country with a variety of regionally specificneeds, and each region addresses its wound-related concerns according to its abilities.

Summary of the Canadian approachIt is good to remember that dressing is only onepart of a complex treatment plan required to heala wound. However, that one aspect of our woundcare practice remains complicated with the ever-increasing variety of wound care products. Howdo clinicians choose the correct dressing? This isthe question many health care professionals wantthe answer to. Most dressings fall into a categorythat describes its benefits, indications and contra-indications, and it is up to the wound clinicians tonot only select the best product for our patient butto teach other clinicians the cost-effective use ofwound care dressings (159).

Education needs to revolve not only aroundthe wound-healing paradigm, removing thecause and patient centred concerns, but alsoaround regional wound care practices andresources in order to give clinicians a frame-work for best practice in wound care.

THE DEVELOPMENT OF DRESSINGUSAGE AND WOUND CAREGUIDELINES IN JAPAN

Introduction of modern dressingsPrior to the introduction of a moist-environ-ment-type dressing in 1987 by ConvaTec(a Bristol-Myers Squibb Company), basicwound care involved the use of an antisepticcleanser where the professionals main objec-tives were to prevent infection and keep thewound dry to promote epithelialisation. Thus,the introduction of a hydrocolloid moderndressing (Duoactive or DuoDERM Varishe-sive, Granuflex) that provided a moist envir-onment for wound healing sent reverberationsthroughout the medical community in Japan.

Impressed by the initial results, the enter-ostomal therapist (ET) nurses revolutionisedthe use of a moist or modern dressing inJapan. This spurred on competition by othercompanies to introduce new types of moderndressings to Japan to meet the growing demand.

Polyurethane film dressings first receivedapproval as an official medical supply foruse in Japan in 1992. Subsequently, severaldressing types followed, starting with alginatedressings in 1993, hydrogel dressings in 1995,polyurethane foam dressings in 1996, sulfa-

diazine silver-lined dressings in 1997 andhydrofibre and hydropolymer dressings in2000. At present, there are seven types ofmodern dressings currently used in Japan.

Modern dressings marketUniquely characteristic to the Japanese marketis that 44% of most of the chronic woundpatients are still treated with gauze dressings,compared with only 16% who are treated withmodern dressings.

The modern dressings market has beenincreasing yearly from $242 million in 1994to $418 million in 2003 (exchange rate basedon 1 US dollar = 110 yen). Some 7080% ofmodern dressings are used for pressure ulcertreatment, with less than 10% being used fordiabetic foot and venous ulcer patients. Thisratio is the same as the chronic wound demo-graphics in Japan.

Hereafter, all data will accordingly focus onpressure ulcers as the predominant group.

Actual conditions of modern dressingusage for pressure ulcers

Pressure ulcer care penalty systemThe population of Japans ageing society hasreached an unprecedented number, and accord-ing to estimates, one-quarter of the populationwill be 65 years of age, or older, by 2015. Alongwith an ageing society, the ratio of bedfastpatients is also rapidly increasing to the pointwhere in 2000, 130% of this demographicgroup were bedfast. The occurrence of pressureulcers in a hospital setting is 49%, and 14% in ahome setting has been reported. The fact that70% are reported to be stage III or IV [NationalPressure Ulcer Advisory Panel (NPUAP)classification] has led to a steady increase inpressure ulcer and medical treatment costs.

The concern over pressure ulcers has reacheda level where the Ministry of Health, Labour andWelfare has introduced a penalty that is leviedon hospitals that fail to comply with the recentlyimplemented legislation that requires all hospi-tals to meet the following criteria based on riskassessment, wound assessment and treatment:

. to establish a team of pressure ulcer spe-cialists to prevent and treat pressure ulcers;

. to establish a risk and wound assessmentand management protocol for pressureulcers;

Key Points

. dressing revolution in Japan ledby ConvaTec with the launch oftheir hydrocolloid dressing in1987

. at present there are seven typesof modern dressings currentlyused in Japan

. 44% of chronic wound sufferersare still treated with gauze dres-sings

. some 7080% of modern dres-sings used for pressure ulcers

. an ageing population and increas-ing number of pressure ulcers hasled to a steady increase in medicalcosts

. Ministry of Health, Labour &Welfare has levied a penalty onhospitals that fail to establishappropriate treatment and preven-tion programs

A dressing history


. to provide adequate support surfaces forpressure ulcer patients.

This legislation came into effect as of 1 October2002, where hospitals that do not meet the abovecriteria, five points [55 cents (exchange ratebased on 1 US dollar = 110 yen)] per patientwill be excluded from the basic admittanceinsurance coverage that the hospital can claim.For example, this will amount to approximately$165 000 (exchange rate based on 1 USdollar = 110 yen) per year of lost revenue for an800-bed hospital.

Modern dressings and the insurancesystemAs of 1 April 2001, the cost of modern dressings,covered by the insurance system, which couldbe invoiced for reimbursement, was standard-ised nationwide. This reimbursement feedepends upon the amount of dressing used forthe category of Dressing for Skin Breakdowndeclared by the companies selling the dressings.

The type of dressing that the insurance sys-tem covers is determined by the depth of thepressure ulcer. The period in which the insur-ance covers the dressings is also an additionalproblem. At present, it is limited to only 3weeks, after which the users must cover thefull cost themselves.

Current use of modern dressingsIn 1999, Ohura et al. (160) conducted a nationalsurvey to determine the extent of use of moderndressings in Japan. According to their findings,159 of the 205 (78%) facilities that participatedin the study used modern dressings.

Of all the modern dressings used, hydrocol-loid dressings were the most widely used (all159 facilities). Second were the polyurethanefilm dressings, used in 134 facilities, followedby alginate dressings that were used in 80facilities, with hydrogel dressings being usedin 24 facilities and polyurethane foam dres-sings in 19 facilities. From these results, itwas found that hydrocolloid dressings,which were the first modern dressing to beintroduced in Japan, were used by all thefacilities surveyed (160).

Modern dressing and the nationalguidelineIn 1998, the Ministry of Health and Welfarecreated a pressure ulcer prevention and treat-

ment guideline (161). This guideline wasdeveloped by a panel of expert opinionsbased on their experience and not scientific-based evidence. In this guideline, the properselection and use of dressings are classified bythe colour of the wound.

Developed by Fukui (162) in 1993, this coloursystem separately categorises shallow and deeppressure ulcers and classifies the healing pro-cess into four phases. The colour of a woundfrom an acute condition progressively changesfrom black-to-yellow to red-to-white phase.

According to the guideline, modern dres-sings are recommended for shallow pressureulcers and deep pressure ulcers in the red-to-white phase. However, at present, there are nodetailed selection standard criteria.

Modern dressings and prescriptionauthorityIn Japan, dressings are handled as prescrip-tion materials and can only be prescribed byphysicians. In 1998, a survey conducted byOhura et al. (163) revealed that pressure ulcertreatment is handled 40% by nurses, 40% byphysicians and nurses and 7% by physiciansonly, and the remainder by others.

The actual state of the situation is thatalthough the nurses do not have the authorityto write prescriptions, they select most of thedressings to be used for the patients and thephysicians only write the prescription.

Future outlookAlthough the history of modern dressings inJapan is a mere 20 years old, 79% of the facil-ities began using them within the first 10 yearsafter their introduction, and its demand stillremains high.

However, concerning pressure ulcer, thesedressings that have been introduced face thefollowing problems:

. Insurance plan only covers it for 3 weeks.Thus, stage III or IV pressure ulcers can-not receive full coverage, as they nor-mally take 6 months to 1 year to heal.

. Nurses only select dressings and do nothave the authority to issue prescriptions.This authority still remains the physi-cians sole responsibility.

. In Japan, owing to strict standards imple-mented by the government, at present,there are no modern dressings that are

Key Points

. products are reimbursed

. type of dressing covered by reim-bursement is determined by thedepth of the pressure ulcer

. usage is limited to three weeksat present. After this time thepatient must cover the full costsof their dressings

. nearly 80% of Japanese facilitiesuse modern wound care products

. guidelines for treatment and pre-vention of pressure ulcers put inplace in 1998

. guideline based on colour ofwound

. in Japan wound dressingshandled as prescription materials

. Japan has progressed rapidlyregarding modern dressings butsignificant development opportu-nities remain

A dressing history


effective for treating infected wounds. Asa result, traditional topical ointmentsmust be used in combination withgauze during the entire healing period.

. We do not have adequate guidelines forpressure ulcer dressing usage. The pre-sent guideline is a based upon a panel ofexpert opinions and does not necessarilyuse the best scientific-based evidence.

Recent studies and approaches have beendeveloped to rectify this situation. In order topromote the proper use of modern dressing,Sanada et al. (164) performed a cost-effective-ness analysis between traditional topical oint-ments with gauze and modern dressing.

The results provide evidence that for stageII and stage III pressure ulcers, there was asignificant reduction in the overall cost oftreatment using modern dressings.

Based on this evidence, the Japanese Societyof Pressure Ulcers, realising the need to easethe modern dressing restrictions, submitted apetition to the Ministry of Health, Labour andWelfare.

The society also increased the courses toeducate nurses to become wound care specia-lists and is currently revising the nationalguideline using scientific-based evidence.

CONCLUSIONWound care dressings and practice are slowlybut surely becoming a global practice. Tech-nologies and practice do change but changetakes time! This review has provided insightinto the development of three different geo-graphical areas, with three different healthcare systems, but the ultimate outcomeremains the same, that is the proliferation ofmoist wound healing and best practice.

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Key Points

. Japanese Society of PressureUlcers petitioned the Japanesegovernment regarding easingmodern dressings restrictions

. Society has also developed anumber of education courses

. moist wound healing is slowlybut surely becoming a globalpractice

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a dressing history

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