NEW TOOL FOR WOUND ASSESSMENT – IMPACT ON THE

CHOICE OF TREATMENT STRATEGIESMARCUS GÜRGEN

SENIOR CONSULTANT SURGEONOUTPATIENT WOUND CLINIC/DEPT. OF

SURGERY

SØRLANDET HOSPITAL FLEKKEFJORD / NORWAY

NORDIC SCIENTIFIC SYMPOSIUM 07.10.2005

GRACE

IS THERE IMPROVEMENT?

WOUND ASSESSMENT

LENGTH , WIDTH, DEPTH,AREA;

OTHER PARAMETERS (EG pH)

WOUND DIAGNOSIS

APPEARANCE OF WOUND BED, WOUND

EDGES AND SURROUNDING

SKIN

FACTORS IMPAIRING

WOUND HEALING

PROGNOSIS

DOCUMENTATIONWOUND ASSESSMENTWOUND ASSESSMENT

ADAPTED FROM FLANAGAN 2003, KRASNER AND RIJSWIJK 1994

THE ROLE OF WOUND ASSESSMENT

• Reaching diagnosis• Providing baseline data to which

future data can be measured• Monitoring the effect of treatment• Predict the outcome • Important to have a standardized

assessment tool• ”You can’t manage what you don’t

measure”

WOUND HEALING

I= WOUND AREAII= CONTRACTIONIII= EPITHELIALIZATION

ADAPTED FROM NOCKEMANN PF: DIE CHIRURGISCHE NAHT. THIEME, STUTTGART 1980

Mechanisms providingcontraction:•Fibrine drying (day 3-5)•MyofibroblastsFactors impairing contraction:•Ischemia•Hypoproteinaemia•Old age•Infection•Necrosis•Foreign bodies•Localisation of the wound•Radiation / cytostatic or immunocomprimising medication

THE ROLE OF WOUND ASSESSMENT IN WBP

TISSUEMANAGEMENT

INFECTIONCONTROL

MOISTUREBALANCE

EPIDERMALADVANCEMENT

T I M E

WOUND ASSESSMENTIDENTIFY BARRIERS TO HEALING

TREATMENT DECISION

HEALINGASSESSMENT

ADAPTED FROM MOORE 2005

PROGNOSTIC INDICATORS

• The rate of healing in the early stages can provide information on the likelihood of total healing

• Sheehan et al. 2003: diabetic ulcers (12 w)• Kantor and Margolis 2000: venous ulcers (24

w)• Kantor and Margolis 2000: Percent reduction

of area from week 0 to week 4 is a significant prognostic factor

• Gelfand et al. 2002: 68% of all wounds which showed 28,8% area reduction in the first 4 weeks of treatment healed within 24 weeks

MEASUREMENT OF WOUND AREA

• One observable outcome of underlying cellular events in wound healing is contraction and migration of the epidermis over healthy granulation tissue = wound margins reaching the centre of a wound

METHODS

• Length x width (linear measurement)• Tracing and counting squares (area)• Digital planimetry (area)• Tracing using grids, scanner and

equivalent software (area)• 3-D-analysis using laser• Volume measurement (molding material,

Kundin device)• Stereophotogrammetry• Ultrasoundscanning

METHODS

Schultz G, Mozingo D, Romanelli M, Claxton K. Wound healing and TIME; new concepts and scientific applications. Wound Rep Regen 2005;13(4):S1-11

KEEP IT SIMPLE…

… AND PRECISE!

DIGITAL PLANIMETRY

• VISITRAK™• Tracing grid is placed over

the wound• Wound margins are traced

on the upper layer of the grid• Grid is placed on the battery

operated digital unit and transferred to the unit by retracing the perimeter with a stylus so the underlying sensor records wound perimeter

ADVANTAGES

• Area, length and width are measured

• Calculation of percent area change possible

• Necrotic areas can be measured

• Area calculations with 94 – 98 % accuracy

• Includes software for storage of data and wound healing curves

• Safe to use • Easy to use• High intrarater

reliability• Non-invasive• Portable• Permanent copy for

patient journal• Helps to get the

patient informed• Fair price

DISADVANTAGES

• Sometimes difficult to determine wound edges

• Vapor on the backside of the tracing sheets

EXAMPLE

28,6 % area reduction after 17 days

MEASUREMENTS OF 92 WOUNDS

VISITRAK™ VS. COUNTING SQUARES

n=92 Same area measured with counting squares and Visitrak™: 13

Counting squares

0,5 cm² - 149 cm² 7,5 cm²

Visitrak™ 0,3 cm² - 130,8 cm²

7,2 cm²

%-difference

0 - 60

Mean difference = 0,78 cm²

INITIAL ASSESSMENT WOUND AREA A๐

NEW ASSESSMENT WOUND AREA Aı

% REDUCTION A๐/Aı

CHOICE OF TREATMENT

20-40 % <20 % NO CHANGE/INCREASE

CONTINUE SAME TREATMENT, WOUNDLIKELY TO HEAL WITHIN 24 WEEKS

CONTINUE SAMETREATMENT,RE-ASSESSMENT WITHIN 4 WEEKS

RE-ASSESSMENT

ADVANCED TREATMENTOPTIONS

WOUND BED PREPARATION

4WEEKS

ENDPOINT: WOUND CLOSURE

HEALING NOT HEALING

47,2

27,1 25,421,4

0

10

20

30

40

50

0 5 10 15 20 25 30

WEEKS

CM

2

47,2 cm²27,1 cm²Δ 43,6%

25,4 cm²Δ 6,3%

21,4 cm²Δ 15,8%

WOUND HEALING CURVES

• Wound healing is not a linear process

• Different types of wounds heal at different rates

• Data on wound healing can be obtained by regularly measuring wounds with a standardized method

• Would allow better prediction of healing

0

10

20

30

40

50

60

70

80

4 8 12 16 20 24

WEEKS

%

VENOUS ULCERS DIABETIC ULCERS

PERCENTAGE OF ULCERS HEALED AFTER 4 TO 24WEEKS OF GOOD WOUND CARE

ADAPTED FROM KANTOR J, MARGOLIS DJ. EXPECTED HEALING RATESFOR CHRONIC WOUNDS. WOUNDS 2000; 12(8):155-158

BETTER CLINICAL PRACTICEFLANAGAN 2004

IMPROVED WOUND MEASUREMENT

PREDICTION OF HEALING RATES

IMPROVED DOCUMENTATION

IMPROVED DECISION-MAKING

IMPROVED PATIENT OUTCOMES

CONCLUSIONS

• Epidermal advancement is a parameter which is easy to measure

• There is evidence that %-change of area can be used as a prognostic indicator

• Wound measurement should be simple and reliable

• Results of wound measurement help us to make decisions in wound treatment

THANK YOU!

ØVERLI

NIFS-SEMINAR 2006

• TOPIC: ”If wounds are not healing”• WHERE: SAS Radisson Hotel, Tromsø / Norway• WHEN: February 2nd and 3rd, 2006• INFORMATION: Guro Vaagbø, Seksjon for hyperbar

medisin, Haukeland Universitetssykehus, N-5021 Bergen; http://www.nifs-saar.no