Infected chronic wounds represent one of the biggest challenges to healthcare systems because they are difficult to heal and consequently expensive to treat (CROWD, 2014). Guidelines for the management of infected wounds are available from national and international scientific organisations. Transposing these guidelines into effective and easy to implement clinical protocols might be challenging. In the community, healthcare professionals do not consistently have guidance on how best to treat patients with infected wounds and on what outcomes mean quality care.
To address these issues, Kent Community Health NHS Trust has been working with Academia and Industry in a project to develop a clear strategy for the management of infected wounds.
A trust wide audit of 1500 patients with wounds led to the development of the Wound Infection Risk Evaluation Tool (WIRE). It is based on the clinical presentation of the patient and their wound; covering predisposing factors, put under thirteen subgroups that would increase the level of infection risk in a patient. This tool supplements clinical judgement by allowing the clinician to identify patients with localised infection before systemic infection develops.
A local audit of 50 patients was carried out following the development of the form to consolidate the visual score compared with actual growth. For this audit, five sites were identified: four community nursing teams and a wound medicine centre, each tasked with using the tool on at least 10 patients on their caseload with wounds.
The tool was completed at initial assessment and at weeks 2, 4, 8 and 12. If the tool and/or clinical judgement indicated localised or systemic infection, a wound swab was taken and sent off for culture test to ascertain the causative bacteria; and treatment commenced accordingly. Swabs ranged from 1-5 per patient over the period of audit. The existent management plans remained the same during the audit unless clinically indicated as per clinical judgement, or swab results.
The results of the swabs were then analysed and compared with the scores from the WIRE predictive tool completed at the same time as when the swab was taken. This comparison was to establish the correlation between the analogue scale, and laboratory results to establish the effectiveness of the tool and its accuracy in predicting level of wound colonisation or infection; so that effective management strategies could be placed in place for correct product usage.
Results based on 150 wound swab results and WIRE scores from 48 wounds . At the beginning of the local validation 55 patients were recruited, however data from 7 were inaccessible or not included due to being lost, patient death, inaccurate documentation or long hospital stay.
The results indicate a 78% correlation between the WIRE tool and laboratory results. In the remaining 22% where there was high bacterial growth even though the WIRE score was low, it is suspected to be as a result of the presence of biofilm at the wound bed. According to Cowan (2011), it appears biofilms adopt a parasitic relationship at the wound bed and therefore do not always cause a host reaction resulting in the lack of visible signs; also the presence of bacteria at a wound bed does not necessarily mean the wound is infected and therefore would not show any signs of infection.
This validation has resulted in the revision of the WIRE predictive tool to include other factors originally not considered. With the inclusion of these factors, it is expected that the new form will be more accurate in predicting not only local infection but also systemic infection. Following the audit, an infection management strategy and a patient management pathway have also been developed to serve as a guidance for staff. These are yet to be finally stratified with the involvement of external experts.
The delivery of quality care must be at the heart of all services provided by the NHS to improve patient’s quality of life (Department of Health [DH], 2008). Identification and appropriate management of infection must therefore be incorporated in the practice of all healthcare professionals who manage patients with wounds.
The results from the audit have proven a high correlation between the WIRE tool and high bacterial presence. Although this does not necessarily mean the wound is infected, but identifying the clinical signs early and putting the patient on a correct management pathway will reduce harm and improve quality outcomes.