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20 Patient Evaluation: exudate management evaluating the clinical and cost efficacy of a CMC dressing in a variety of clinical community settings within the UK

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Professor and Consultant Nurse in Tissue Viability, Worcestershire Health & Care NHS Trust and Birmingham City University


[email protected]






Tissue Viability Nurse, Worcestershire Health & Care NHS Trust [email protected], CLAIRE STEPHENS

Independent Consultant Nurse. Complex Wound Manager, WC4Heroes.





In 2014, the annual cost of wound care was approximately £2,165

million and this figure has been predicted to rise by £212 million

to £2,377 million by 2019 (DowseW et al. 2014). In community

seYngs, nurses commonly treat wounds including pressure ulcers

which vary in exudate volume and this can be an expensive

process (Morgan, 2015). There are many challenges that

community nurses face when managing the levels of exudate

such as selecZng the right dressings to control this level whilst

ensuring the paZents are comfortable with this selecZon

(Morgan, 2014). Unit cost, dressing, dressing efficacy, wear Zme,

ease of use, ease of training are all significant factors influencing

any change in pracZce. One dressing range widely used as a

contact dressing for its efficacy in exudate management and nont

r a umaZc int e r a c Z o n w i t h t h e wound be d i s

Carboxymethycellulose (CMC). Considering unit price alone this is

a more costly dressing choice deeming clinical outcome and

extension of dressing life a more favorable cost consideraZon

measure. A new CMC potenZally offering significant unit cost

savings has been evaluated to assess its clinical efficacy and





Clinical Governance approval to undertake this 20 paZent

evaluaZon of a CMC dressing over a 4-week period was granted.

Consent to partake in the evaluaZon and use photography for

publicaZon was obtained. Eligible for inclusion and parZcipaZon

in this evaluaZon are paZents: Over the age of 18 years, Capacity

to understand the nature of the evaluaZon and provide consent,

Deemed as suitable for inclusion under evaluators clinical

judgment, Has received previous CMC dressing treatment or be

deemed suitable to receive CMC dressing treatment. Not eligible

for parZcipaZon or to be excluded from this evaluaZon are

paZents: Below the age of 18 years, Without capacity to

understand the nature of the evaluaZon or provide consent,

Deemed as unsuitable for inclusion for any other reason under

evaluators clinical judgment, Wound type unsuitable for CMC

dressing treatment.




20 paZents were recruited male (n8) and female n(12) of ages

ranging from 34-97 years (n8) had received other hydrofibre or

gelling fibre dressings for >2weeks prior to the evaluaZon.

Wound types

(Fig 1)

include pressure ulcers (n9), leg ulcers (n4),

diabeZc foot ulcer (n1), fungaZng (n2), burn (n1), bursa (n1) and


traumaZc, post-surgical and lymphaZc compromised wounds (n2).


Wound age varied dramaZcally from 2 weeks to being present for


several years and (n2) wounds were recorded to be recurrent


episodes. Wounds were located in a variety of anatomical areas




(Fig 2)



. Tissue types recorded as healthy granulaZon (n5),

unhealthy granulaZon (n6), sloughy (n6), fungaZng (n2) and (n1)


documented as full limb maceraZon.


Exudate levels



(Fig 3)

were reported to be: Copious (n3), Heavy

(n5) and Moderate (n12). Exudate type reported to vary from thin


watery serous to thick fibrous in viscosity. (n5) subjects were


reported to have thick fibrous exudate throughout the 4 week


duraZon of the evaluaZon.


Dressing wear Zme compared to previous dressing: same number


of days (n14), Increased number of wear days (n5) and decreased


number of wear days (n1). Dressing wear Zme was reported to be


62% three day wear



(Fig 4)

. A total number of 80 dressing changes

were recorded during this evaluaZon. Dressing leakage was


documented in 2 cases; wear was 3 days and exudate levels heavy.


Wear Zme was reduced to more appropriate frequency of 2 days


in one case and daily in another resulZng in no further leakage.


InteresZngly zero leakage was seen in the subjects with copious


levels of exudate at 3 days wear. Overall dressing wear Zme


increased n(6), remained the same n(13) and reduced n(1).


No adherence to the wound bed or painful removal was reported


in the data of n (18) subjects. Peri-wound skin reported: same as


or improved in all subjects with no deterioraZon reported and


barrier film use recorded in only (n6) subjects. Pain scores: (n12)


remained unchanged, (n4) reducZon in pain, (n2) Chronic Regional


Pain Syndrome (CRPS) and unable to scale and (n2) increased pain


which correlates with infecZon, bleeding within the data set.






DowseW, C., Bielby, A. and Searle, R. (2014) Reconciling increasing wound care demands with available resources.


Journal of Wound Care



, 23(11), pp. 552 – 62.

Morgan, T. (2014) Wound care in the community: infecZon, exudate and conformability.



Journal of Community





, 28(5), pp. 43 – 48.

Morgan, T. (2015) Are your wound management choices cosZng you money?



Journal of Community Nursing

, 29(4),

pp. 17 – 20. Available at:






[Accessed 06

August 2016].




End of evaluaCon raCng


Ease of applicaZon rated mostly 10 (excellent) (n14) rated 10, (n1)

rated 9, (n4) rated 8 and (n1) rated 6.

Ease of removal rated mostly 10 (excellent) (n11) rated 10, (n1)

rated 9, (n6) rated 8, (n1) rated 7 and (n1) rated 6.

Exudate management and overall outcome (n12) rated 8-10

(superior/excellent) (n7) rated 5-7 (good) and (n1) rated at 3.

100% stated they would like to conZnue use of the new CMC (n1)

did not complete the field in the data.




KerraCel™ dressings effecZvely managed varied exudate volumes

and viscosiZes in a wide range of wound aeZologies. The secondary

dressing choice for each evaluaZon subject remained unchanged

and wear Zme was equal to if not beWer than. In 2 cases where

dressing leakage was seen it is highly probable that this would have

occurred with the usual CMC and possibly a result of dressing

failure involving primary and secondary dressings. It is also

important to note that n(12) of the 20 paZents were not receiving

treatment with CMC prior to inclusion into this evaluaZon therefore

the improvements noted are due to the introducZon of CMC rather

than a change in type of CMC dressing used. PosiZve wound

outcomes have been drawn from this data and the end of

evaluaZon feedback demonstrates acceptance from both paZents

and clinicians.




Managing wounds remains a clinical challenge and managing

exudate is a key challenge. This 20 paZent single centre clinical

evaluaZon demonstrates clinical efficacy in exudate with

consideraZon to volume and viscosity. PosiZve paZent outcomes in

relaZon to applicaZon, removal, and wear Zme have been

demonstrated. The evaluaZon has demonstrated the ease of

implementaZon into pracZce when using a less expensive CMC

dressing material. KerraCel™ dressings were changed less

frequently, which has significant implicaZons for both paZent

convenience and cost of care. A conclusion is made that KerraCel™

is a promising new dressing that could offer significant advantages

to improve the clinical and financial outcomes and warrants a larger

scale study.


Figure 1







– Wound Type



Figure 2







- LocaCon



Figure 4







– Dressing Wear Days



Figure 3







– Exudate Level



Case One


76 year-old lady presented with an un-gradable

pressure ulcer to the sacrum. The wound is

sloughy with moderate levels of thin fibrous exudate

and peri-wound maceraZon is present on recruitment

to this evaluaZon.

Dressing changes were undertaken at 3 day intervals

and at dressing change 4 (12 days) wound bed is

dramaZcally improved with 90% healthy granulaZon

Zssue and a small amount ofslough remaining. Periwound

maceraZon has

reversed (note no barrier film products were used).

The evaluaZon dressing did not leak during higher

exudaZng period and did not adhere to the wound

despite exudate levels dropping to low levels at the

end of evaluaZon.


Case Two


97 year-old lady presented with a grade 3 pressure ulcer

to thigh. Moderate levels of watery serous exudate with

both peri-wound maceraZon and peri-wound

excoriaZon to the wound edge and wound margins.

Barrier film

skin protecZon has been used prior to

commencing evaluaZon dressing.

The wound bed on recruitment comprised of 70%

granulaZon Zssue with a 30% island of fibrous slough.

Dressing changes were performed at 3 day intervals and

at day 12 the wound showed significant improvement

with no signs of peri-wound maceraZon. The evaluaZon

dressing did not leak during higher exudaZng period and

did not adhere to the wound despite exudate levels

dropping to lower levels towards the end of the

evaluaZon period

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