International Wound Journal ISSN 1742-4801

REVIEW ARTICLE

Wound management for the 21st century: combining

effectiveness and efficiency
Christina Lindholm1 & Richard Searle2
1 Sophiahemmet University, Stockholm, Sweden
2 Smith & Nephew Medical Ltd, Hull, UK

Key words Lindholm C, Searle R. Wound management for the 21st century: combining effective-
Efficiency; Health economics; Resources; ness and efficiency. Int Wound J 2016; 13 (suppl. S2):5–15
Service improvement; Wound healing
Abstract
Correspondence to
Treatment of wounds of different aetiologies constitutes a major part of the total health
R Searle, PhD care budget. It is estimated that 1⋅5–2 million people in Europe suffer from acute
Health Economics Manager or chronic wounds. These wounds are managed both in hospitals and in community
Smith & Nephew Medical Ltd care. The patients suffering from these wounds report physical, mental and social
Hull, UK consequences of their wounds and the care of them. It is often believed that the use
E-mail: Richard.Searle@Smith-Nephew.com
of wound dressings per se is the major cost driver in wound management, whereas
in fact, nursing time and hospital costs are together responsible for around 80–85%
doi: 10.1111/iwj.12623
of the total cost. Healing time, frequency of dressing change and complications are
three important cost drivers. However, with the use of modern, advanced technology
for more rapid wound healing, all these cost drivers can be substantially reduced. A
basic understanding of the terminology and principles of Health Economics in relation
to wound management might therefore be of interest.

The impact of wounds on the health system – a wounds [defined as wounds that fail to heal with ‘standard
growing challenge therapy’ in an orderly and timely manner (5)] cause further
deterioration in quality of life and increase the burden on the
Wounds have been called ‘The Silent Epidemic’ health care system over a prolonged period.
Wounds have a variety of causes; some arise from surgical Sometimes, it is thought that the financial cost of wound
intervention, some are the result of injury, and others are a management is just the cost of the materials used, such as
consequence of extrinsic factors, such as pressure or shear, dressings, bandages or topical antiseptics. This is not the case;
or underlying conditions such as diabetes or vascular disease. most of the cost relates to the use of health care professionals’
time and the cost of staying in hospital, as we will see later. The
They are often classified as a result of their underlying cause
choice of materials and treatments, however, can have a major
into acute wounds, such as surgical wounds and burns, and
influence on the total cost.
chronic wounds, such as leg ulcers, diabetic foot ulcers (DFUs)
and pressure ulcers (1). Whatever the cause, wounds have a
substantial but often unrecognised impact on those who suffer How many people in the population have wounds?
from them, on their carers and on the health care system. In Prevalence surveys in the UK and Denmark indicate that there
fact, the phenomenon of wounds has been called the ‘Silent are about three to four people with one or more wounds
Epidemic’ (2). per 1000 population (6–9).∗ Many of these wounds become
Living with a wound can have a profound effect on quality ‘chronic’, with studies reporting that around 15% of wounds
of life (3). The human cost of wounds manifests itself in, remain unresolved 1 year after presentation (7), often resulting
among other things, pain, distress, social isolation, anxiety, in a prolonged, yet avoidable, burden to patients, their families
extended hospital stay, chronic morbidity or even mortality. and health systems. Based on the above figures, it is estimated
Many of these issues are preventable (4). Furthermore, because that in a population of 1 million people, approximately 3500
of underlying factors such as the age of the patient and the
presence of underlying chronic comorbidities, some wounds ∗ Hospitaland community data from Denmark were combined to give a
do not follow the normal healing process. These ‘hard-to-heal’ prevalence of around three people with a wound per 1000 population

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Wound management for the 21st century C. Lindholm & R. Searle

people will be living with a wound, of which, 525 will have infections or amputations occur, with a study from the USA
had their wound for over 1 year. reporting a cost per amputation of $38 077 (13).
The majority of chronic wounds are treated in non-acute The costs of managing surgical wounds are equally difficult
health care settings, such as clinics or home health (7–9). to estimate with any accuracy. The management of an uncom-
Studies suggest that wound management accounts for over plicated surgical incision is relatively inexpensive; however,
half of community health nurse resources in European settings when infections occur, these costs can increase significantly. A
(4,10). However, a substantial number of people with wounds study from the USA estimated the costs of treating a surgical
require hospital treatment at some stage, which can escalate the site infection (SSI) to be approximately $20 800 (18).
costs of care significantly (4,11). Previous studies have sug- As well as costs incurred by the health system, there are also
gested that between 27% and 50% of hospital beds are occupied significant indirect costs that fall on individuals and the broader
by patients requiring some form of wound management (4). economy. In the USA, it has been estimated that venous ulcers
cause the loss of 2 million working days per year, costing the US
health care system an estimated $2⋅5–3⋅5 billion annually (13).
Prevalence of wounds
There are estimated to be around 1⋅5–2 million people
living with a chronic wound across Europe (12). In the The total cost of treating wounds
USA, chronic wounds affect around 6⋅5 million people at Wound management has been estimated to account for 3%
any one time (13). of all health care expenditure (2).
Data from Europe suggest that 64% of wounds treated in The cost of treating pressure ulcers alone in the USA is
home care were chronic in aetiology (7). Of these, 24% are estimated to be $11 billion/year (13).
estimated to have been living with their wound for 6 months In Europe, the cost o7f managing DFUs is estimated to be
or more, and almost 16% had remained unhealed for a year €4–6 billion/year (4).
or more (9). In the USA, foot ulcers and other complications are
Audit data from hospital settings suggest that as many as ‘responsible for 20% of the nearly 3 million hospitalisa-
50% of in-patients have a wound. A study of 5800 patients tions every year related to diabetes’ (13).
in Western Australian public hospitals found that 49% The cost per case is highly dependent on a number of
had a wound. 31% of patients had acute wounds, 9% had factors, such as wound type, complications and the site
pressure ulcers and 8% had skin tears. The authors stated of care. For example, uncomplicated surgical wounds are
their belief that a quarter of these wounds had the potential relatively inexpensive to manage, but costs increase sharply
to be prevented (14). if infection occurs. In Europe, surgical wound infection is
Data from the USA demonstrate a pressure ulcer preva- estimated to add, on average, 11 days to in-patient hospital
lence of 22% in acute critical care settings (13). Audit stay, with an average cost of €5800 per case (19), whilst
data from Europe indicate that 22⋅7% of hospital patients data from the USA suggest that the cost of treating a
had signs of pressure damage [Bermark et al. 2004 (15), surgical site infection (SSI) is in excess of $20 000 (18).
reported in Posnett et al. 2009 (4)]. A hospital performing 10 000 operations annually can
expect 300–400 infections, resulting in 3300–4000 excess
bed-days, ∼€1⋅74–2⋅32 m in excess costs and 15–20
infection-attributable deaths (20).
Wounds result in a significant economic cost
to the health care system
Wounds are estimated to account for almost 3% of total health
system costs (2) – approximately £5billion annually according The cost of managing wounds is largely hidden,
to data from the UK (16). A recent study in Wales showed that and the impact is often not recognised
the cost of managing patients with chronic wounds amounted to Much of the financial cost of treating wounds is hidden because
5⋅5% of total health service expenditure (17). Most of this cost many health care professionals across a wide range of profes-
relates to hospital stay and nursing time for treating patients at sions and care settings are involved, and so, the total cost is
home or in clinics, whereas materials such as dressings account spread across many different budgets. As a result, their impact
for a small part of the total cost. In the USA, it is reported goes largely unrecognised by policy makers, is poorly under-
that over US$25 billion is spent each year on the treatment of stood by health care system decision makers and is seldom
chronic wounds (13). reported in the media (2).
At an individual level, the costs of managing wounds are Studies have found that between 70–80% of wound patients
highly dependent on the wound type, complexity and site of are treated in the community, predominantly by community
care. A study from Sweden in 2002 found that the weekly cost nurses (9,20). Managing wounds is often the single most impor-
of managing a venous leg ulcer (VLU) was around €103 per tant use of their time – one study estimated that over 60% of
patient, with annual costs estimated to be between €1332–2585 community nurses’ time was spent on dressing changes (21).
(4). DFUs are estimated to be more costly to treat than VLUs, Studies in the UK and Denmark have shown that on average,
with studies indicating a cost per episode of ∼€10 000 (4). dressings are changed around three times per week, resulting in
Treatment costs increase rapidly when complications such as three home health visits per week (7,9). In a community care

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C. Lindholm & R. Searle Wound management for the 21st century

setting in Denmark, a survey found that at least half of the

patients surveyed were having their wounds dressed three or in municipalities in Denmark was DKK 735 m (18 000
more times per week, with 23% of patients having daily dress- wounds per year requiring over 3 m dressing changes). This
ing changes (7). is predicted to rise by up to 30% between 2010 and 2020
This places a significant, and arguably unsustainable, burden (27). In the UK, the cost of providing services for the treat-
on over-stretched nurse resources in community and home ment of wounds could rise by over £200 million annually
health settings. Acute care facilities are constantly looking for from 2014 to 2019. This would include around an addi-
ways of reducing length of stay; expediting discharge means tional 950 nursing staff and an additional 267 500 hospital
that community health care providers are having to deal with bed-days. The total additional cost to the health system
greater acuity of patients with more complex needs. In addition of providing wound management services over this 5-year
to this, the number of patients requiring wound management is period is estimated to be £600 m (22).
expected to increase with an ageing population and increased
prevalence of multiple underlying conditions (22).
The impact of these factors on nurses is already starting
to manifest itself. A study from Denmark estimates that the
activity of health professionals has increased by 40% since 2001 How can we reconcile increasing patient
(23). Today, 72 nurses are doing what 100 nurses did in 2001, demands with scarce nurse resources?
according to this analysis by the Danish Nurses Organization
The answer to this question is improvements in efficiency. Effi-
(23). In the UK, the number of district nurses decreased by 39%
ciency is an economic term that means increasing the output of a
between 2002 and 2012, partly because of funding constraints
constant resource – put another way, increasing the productiv-
but also as a result of an increase in the number of nurses
ity of nurses. Health economists seek to measure efficiency by
leaving practice (24). This is compounded by increasing rates
contrasting the resources required to deliver health care with the
of retirement and reducing rates of newly qualified nurses (24).
health benefits that they produce. Health care resources might
This trend is clearly unsustainable, and as a result, it is vital that
include:
health care providers seek more efficient ways of managing a
resource-intensive casemix with increasingly complex needs, • the time used by health care professionals such as nurses,
such as patients with a wound. podiatrists, GPs and surgeons
• dressings and other materials and equipment
• hospital beds
• operating theatre time
• resources used in documentation and administration
Demand for wound management services
Wound management is estimated to account for over 50% Figure 1 indicates how resources are allocated to the man-
of community nurse time in European studies, with patients agement of wounds (6).
often having three or more home health visits per week When looking for efficiency improvements, health care
(7,9,10,21). providers will often select the easy targets, such as supplies bud-
The demands on nurse time are expected to increase further gets, which are quantifiable and easily manipulated in the short
because of earlier hospital discharge, ageing populations term. However, it is important that they focus their attention on
and increasing rates of morbidities associated with wounds the main cost drivers and also consider the opportunity cost of
(22). resources, which is often less easy to quantify. The opportu-
For example, the International Diabetes Foundation esti- nity cost of a resource refers to the benefits that are foregone
mates that worldwide diabetes prevalence will continue to by allocating a resource to a particular activity. For example, a
increase to 9⋅9% by 2030 (25). nurse making three home visits to a patient with a wound could
Diabetic patients have up to a 25% lifetime risk of devel- have allocated the same time to running a diabetes clinic for 10
oping a foot ulcer (26). patients. In some cases, it is questionable whether resources can
The increasing demands on nurse time will become unsus- be so easily moved between activities – can the same nurse pro-
tainable if the present trend continues, and health sys- viding wound care also provide diabetes management advice?
tems need to identify more efficient ways of managing the However, in many cases, the conscious decision to manage a
increased workload. patient in an inefficient way results in foregone benefits for
other patients.
This is an important consideration for individuals involved
in the management of wounds. The concept of freeing up nurse
resources – for example, through less frequent home visits –
Question: Are there any estimates of how much demand for means that the same nurse resource is now available to treat
wound management services will increase? additional patients. Health care planners and nurses need to
Answer: Yes, in some countries. For example, in 2010, continuously challenge themselves by asking ‘could I be using
it was estimated that the cost of wound management my time more efficiently to provide better quality care or treat
more patients?’

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Wound management for the 21st century C. Lindholm & R. Searle

used, especially in community services. Much of this time is

used to change the patient’s wound dressings, which is why the
frequency of dressing change is a very important driver of cost.
Researchers who have audited wound management have
found that, on average, wound dressings are changed about
three times a week. One study of home care in Denmark found
an average of 3⋅53 changes per week, with 23% of wounds
having dressings changed every day (7).
Dressings need to be changed at a frequency that is appro-
priate for the patient and the wound. However, unnecessary
dressing changes can have an impact on both patient well-being
and resources. Higher dressing change frequency can increase
dressing and nursing costs and may lead to an increased risk
of complications because of the increased frequency of wound
exposure (29). It may also mean that the patient has the inconve-
Figure 1 Resources used in treating wounds. nience of multiple appointments and the physical and emotional
impact of repeated dressing removal and application (29).
Question: Nurses are already there, and paid for, so why
does it matter how often they visit patients? Saving nurse The incidence of complications
time doesn’t save the system any money – surely, it is Wounds do not always follow the expected healing trajectory,
better to save money on dressings? particularly because many patients with wounds have comor-
Answer: We need to think about the opportunity cost. What bidities and underlying long-term conditions. Complications
have we given up in order for the nurse to undertake the occur along the way, and these can have a profound effect, not
treatment? We have given up the opportunity to treat some- only for the patient but also for the health system. Complica-
one else or undertake some other valuable activity. This tions are the third of the three drivers of cost we are consider-
time has a monetary cost that we can calculate if we know ing here.
the cost per hour of nursing time. Releasing nurse time As an example, let us consider SSIs. SSIs can lead to pro-
is about freeing up time to increase efficiency – the key longed hospital stay, readmission, additional surgical proce-
to solving the problem of increasing demand for services. dures and use of antibiotics. Several years ago, a study in the
Releasing nurse visits may also reduce the number of dress- UK estimated that SSIs add, on average, 11 days per episode to
ings required. This has the potential to provide procurement the patient’s stay in hospital (4).
savings (28). Other wound types can also become infected. It has been
noted that heavy bioburden/infection of chronic wounds is a
major cause of non-healing and a significant contributor to the
How can we deliver improved efficiency increasing cost of health care (30,31). A UK survey across
in wound management? hospitals and community providers found that 13⋅3% of leg/foot
The first step in identifying how to improve efficiency is to ulcers and 10⋅4% of pressure ulcers were infected (Figure 3) (9).
consider the inputs and outputs of wound care. Inputs might be Wound infections, whether they are at surgical sites or
considered to be the nurse time, hospitalisations and dressings in other wound types, can lead to further consequences. A
consumed, whilst the outputs are the health benefits to patients. Swedish study reported that for non-healing chronic wounds,
Figure 2 indicates the main inputs that make up the cost of 26⋅6% were receiving systemic antibiotics, and over 60% had
treating wounds. received at least one antibiotic treatment over a 6-month period
(32). Wound infection is commonly associated with heavy exu-
dation of the wound, which has recently been reported to have
The time it takes to heal a wound
an influence on costs for wound management if inappropriate
As described earlier, surveys would suggest that in a region dressings are selected (33).
of one million people, there are approximately 3500 people In some cases, further complications such as osteomyelitis
living with a wound, of which, around 525 people will have may occur, resulting in further resource use. For example, the
had a wound for 1 year or more. For Europe, with a population additional cost of treating osteomyelitis in Category III and
of approximately 500 million people, there would be about IV pressure ulcers is substantial (estimated at over £30 000 in
262 000 people with these long-standing wounds. The total cost the UK) because the daily cost of treatment is increased and
of treating these long-standing wounds in Europe runs into the time to healing is lengthened (34). This includes costs for
millions of Euros. biopsies, MRI, antibiotics, microbiological tests and surgery,
sometimes including major plastic reconstructive surgery.
If any of these three cost drivers can be reduced, with-
The frequency of changing dressings
out a detrimental impact on patient outcomes, then we can
As we have seen, in wound management, the time spent by deliver an improvement in efficiency. Of course, the best result
health care professionals is a large part of the total resources for health service administrators is the delivery of improved

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C. Lindholm & R. Searle Wound management for the 21st century

Figure 2 Drivers of cost in wound manage-

ment (9,29).

outcomes at lower cost. This is a genuine possibility in wound figures are individual stories of how wounds impact patients,
management – earlier intervention to mitigate the risk of infec- carers and health care professionals. Here are two examples.
tion can result in improved patient outcomes (through the avoid-
ance of complications) and lower treatment costs. There are
fewer and fewer examples of true efficiency gains in health care Case study 1: reducing the frequency of nurse visits
that can deliver both better outcomes and lower costs; improv- for a complex patient
ing the efficiency of wound care should be seen as an opportu- This example was reported as part of an evaluation of com-
nity rather than a challenge. munity health care provision for patients with a wound in a
So, to reduce the economic cost of wounds, the best place to provider in the UK (28). The study results indicate that the
start is by looking at the three drivers. introduction of a novel dressing allowed nurses to reduce the
frequency of their nurse visits by almost two visits per patient
Question: Surely, presenting three factors responsible for per week and that procurement costs were also reduced through
driving cost is an over-simplified picture. Isn’t it a lot more less frequent dressing changes. The implications of this at a
complicated than this? patient level can be illustrated through a case study of one
Answer: In reality, the picture is of course more complex. patient that had a wet leaking leg that was being re-dressed
However, by identifying three major drivers of cost, we twice daily, resulting in 14 nurse visits and dressing changes per
are able to think about how we might use these to release week (28). The cost of these visits and dressing changes was
resources and therefore make services more efficient. We substantial. After switching to an advanced wound dressing,
will look at some ways of doing that in the next section. the nursing team were able to reduce the frequency of dress-
ing change to four changes per week. The number of dressings
used at each change was also reduced, resulting in fewer dress-
ings per week, reduced cost of dressings per change and per
Putting it in practice – delivering improved efficiency week and a dramatic reduction in the overall cost of treatment.
in wound management for individual patients
In fact, the patient’s weekly wound management treatment costs
As we have seen above, wounds have a substantial impact on were reduced by 81⋅6%, with 5 hours of community nurse time
the health system. However, underneath all the statistics and freed up per week (Table 1).

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Wound management for the 21st century C. Lindholm & R. Searle

Case study 2: reducing the duration of wound healing

This example was reported in a case series undertaken in
Denmark in 2014 (35). This case series is also referred to in
the final section. A 56-year-old female had a pressure ulcer on
the hip for more than 2 months, covering an area of 48 cm2 .
This ulcer was being dressed daily, and the area was reducing
at approximately 7% per week, on average, with conventional
treatment. The wound-healing trajectory was tracked at each
dressing change using digital planimetry and tracking software.
Using this software, it was estimated that the ulcer would heal
in October using this treatment regime. Single-use negative
pressure therapy (NPWT) was initiated and used for 14 days,
during which time the average area reduction per week was
31% (Figure 4). After discontinuation of the NPWT, the ulcer
continued to heal until fully healing in May, when the weekly
reduction in area was 28%.
This case illustrates the benefits of bringing forward the point
of healing through effective intervention. Using single-use
NPWT, a shorter care package was required, freeing up health
care professionals’ time and enabling them to treat further
patients. In addition to this release of time, fewer nurse con-
tacts per week and shorter visiting times were required. When
interventions such as this are adopted in routine practice, they
have the potential to make a substantial impact on resources.
The next section gives examples of changes that can be made
to do ‘more with less’.

Making the best use of resources – doing more

with less
Figure 3 MRSA at 31 300× magnification. As we have demonstrated above, the gap between available
services and demand for services will continue to widen, and as
a result, it is necessary to find ways of increasing productivity
by making wound management more efficient.
Table 1 Summary of costs for Case study 1 (28) It may be tempting for decision makers in these circum-
stances to look for ways to reduce resources by targeting easily
Wound management
manageable supplies budgets. However, as illustrated above,
cost after introducing
the advanced
this would fail to address the main cost drivers in wound man-
Wound management wound management agement and may even be perverse if it results in the adoption
cost at baseline product of dressings that may increase nurse visit frequency or result in
decrements to health outcomes.
Cost of materials per £29⋅08 £5⋅95
So what can be done to make the most efficient use of
dressing change
the available resources? In other words, how can resources be
Total cost per dressing £65⋅25 £42⋅12
change
RELEASED or freed up so that they can be better used for other,
Total cost per week £913⋅50 £168⋅48 more productive activities? As a way forward, we can take a
look at the three drivers of cost (previous section) and then see
some examples of how these have been used to free up resources
(Figure 5).

Patients that require high levels of resource, as illustrated Reducing healing time
in this example, form part of the caseload of most commu-
nity providers, and clinical staff with experience of managing Case study 1: early intervention to reduce long-duration
wounds will recognise cases such as this. Patients receiving wounds
dressing changes daily or more frequently represent a signif- One way to release resources is to concentrate on wounds
icant proportion of all wound patients; a Danish community that are not currently healing. These static non-healing or
audit found that 23% of patients fell into this category (7). Later, recalcitrant slow-healing wounds can account for a significant
we look more closely at frequency of dressing change and the proportion of health system resources (2). By intervening to
opportunities that may exist for enhancing efficiency. ‘kick-start’ the healing process, they can be brought back to

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C. Lindholm & R. Searle Wound management for the 21st century

PICO start: After 14 days: 4 weeks post-PICO:

37.5 cm2 20.5 cm2 10.1 cm2

Figure 4 Reduction in ulcer area after

single-use negative pressure therapy
(PICO† ; † Trademark of Smith & Nephew)
initiation (35).

Figure 5 Some ways of releasing resources.

a healing trajectory, with the potential to release substantial to optimise treatment by following each ulcer patient right
resources over a long period. through to the healing endpoint. Data from 1073 patients
A recent study showed that application of single-use NWPT with hard-to-heal ulcers, treated between 2009 and 2012, were
was able to accelerate the healing process of slow-healing reported. Wound types were predominantly leg ulcers but also
chronic wounds (35,36). One case from this study was included other wound types.
described in the previous section. By using healing trajectories The mean healing time was reduced from 269 days in 2009
to compare the rates before and after treatment, the study to 139 days in 2012, whilst the mean total cost of treatment per
showed substantial cost saving as a consequence of healing patient decreased from SEK 38 000 in 2009 to SEK 20 500 in
these wounds earlier (Figure 6). This is an excellent example 2012. Most of the cost of treatment (approximately 87%) rep-
in two ways: resented staff costs. This study shows that the use of systematic
treatment strategies to reduce healing times can have a dramatic
• Firstly, it shows how intervention that appears to be of
impact on the use of resources.
greater cost in the short term can, in fact, save resources
overall.
• Secondly, it illustrates the value of tracking and monitor- Optimising dressing change frequency
ing wound progress. This can be performed very simply,
and can provide a wealth of useful data that can be used Case study 3: evaluations in the UK
to demonstrate resource savings. The second driver of cost that was highlighted above was
the frequency with which dressings are changed. The optimal
frequency will depend on a number of factors relating to the:
Case study 2: report from the Swedish Registry of Ulcer
• wound: infection, exudate level, etc.
Treatment (RUT)
• patient and their circumstances: e.g. comorbidities and
A recently published paper described the use of a registry underlying conditions
to shorten ulcer healing time and thereby reduce the use of • clinician: e.g. their workload and schedule
resources (37). The use of the registry promoted structured • system: e.g. the logistics of when visits can be under-
wound management using a team approach, with documen- taken
tation of diagnosis and wound progress. This system helped • products used: e.g. their ability to manage exudate

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Wound management for the 21st century C. Lindholm & R. Searle

Figure 6 Early intervention to reduce long-duration wounds (35).

Innovative practice and well-designed effective products

together play a major role in this (29), and products designed to conducted in the UK found that 79% of wounds were
help to manage resources as well as to meet the need of patients treated in community health care (home health care,
are inherently valuable. wound clinics, nursing homes, etc.) (6). If we apply these
For example, three recent evaluations have shown that it is figures to a population of one million people, this means
possible to release resources by changes in practice combined that at the time of writing, there are likely to be 2765 people
with the use of appropriate dressings (28,38,39). These studies with a wound being treated in the community.* Jørgensen
described the introduction of a foam dressing into clinical et al. (2013) (7) reported that the average frequency of
practice in three community health care providers in the UK. dressing change in community health care was 3⋅53 times
They reported wound characteristics and details of clinical per week, suggesting that there are approximately 9760
practice, such as frequency of dressing change before and patient contacts for dressing change per week, or around
after the implementation of the dressing, and showed a marked 507 500 per year. If this could be reduced by one visit per
reduction in dressing change frequency (Table 2). From this week per patient, this could potentially release 143 800
information, estimates of the potential to release nurse hours visits or around 74 300 hours of clinician time per year.†
were made. Even reducing visits for a smaller subset of the patient
One of the evaluations also estimated the cost of dressings population would free up a substantial quantity of time.
per dressing change and per wound. On average, the number of For example, reducing frequency by one visit per week
dressings per week on each wound was reduced by 79⋅6%, and for 30% of patients could release almost 22 300 hours of
the mean cost of dressings per patient per week was reduced by nursing time per year. Furthermore, reducing dressing
64⋅0% (28). change frequency in conjunction with a reduction in the
It would be interesting to estimate the potential for releas- number of dressings used per visit could lead to a reduction
ing resources more generally if results such as this were repro- in dressing expenditure. This capacity for reduction in this
duced. Such estimates can be made if we use published wound expenditure will depend on the pattern of dressing usage
prevalence figures (see box below). by a care provider, the mix of products that are used and
the frequency with which they are changed. Nevertheless,
even if only one quarter of the potential reduction reported
by Joy et al. (28) were to be realised, this could indicate a
Potential for resource release through 15–20% saving in dressing costs.
dressing change practice
As discussed earlier, we assume that there are 3⋅5 people * 3⋅5/1000 × 0⋅79 × 1 000 000 = 2765.

with a wound per 1000 population (6–9). A survey †

Assuming 31 minutes per visit (21).

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C. Lindholm & R. Searle Wound management for the 21st century

Table 2 Optimising dressing change frequency (28,38,39)

Frequency of dressing change (per week)

Evaluation Before introduction After introduction Difference Number of wounds

Stephen-Haynes et al. 2013 4⋅52 2⋅88 1⋅64 28

Simon et al. 2014 2 1⋅35 0⋅65 97
Joy et al. 2014 3⋅6 1⋅8 1⋅8 37
Combined* 2⋅80 1⋅71 1⋅09 162

*Mean weighted by the number of wounds in each evaluation.

Preventing complications such as wound infection

implemented changes to the wound management products
Complications such as infection have the potential to delay alongside education for staff and patients. Part of this new
healing, adversely affect the patient’s quality of life and even approach was the targeted use of single-use NWPT based
increase the risk of mortality as a result of sepsis. For surgi- on risk stratification. Obesity is an important risk factor
cal sites, infection may have a dramatic effect on quality of as it has a strong association with the incidence of SSI.
life and a substantial impact on resources as there may be a Therefore, NPWT was used for women with a BMI of 35
variety of additional procedures, drugs and materials and staff and above, whereas a film and pad dressing was used for
time needed to deal with wound complications and their conse- women with a BMI less than 35.
quences. Leaper et al. (2010) (40) cite several examples: The team employed this strategy for a total of 660 women
• peripheral vascular surgery, where catastrophic haemor- who had C-sections between February and November
rhage may follow vascular graft infection 2012. They reported a 50% drop in the incidence of SSIs
• infection of a hip prosthesis, where revision surgery may across the whole patient group. In the high-risk group, there
be necessary were no infections, and the number of readmissions fell
• infection following hysterectomy or intestinal surgery, from three per month to zero. It was estimated that the use
which can result in extensive use of resources and of the new protocol would result in a cost saving of £29 449
repeated antibiotic treatment per year.
• infection following cardiac surgery, where sternal dehis- This study shows the value of targeting high-risk groups
cence may involve extensive multidisciplinary care and demonstrates that using negative pressure on closed
• infection following breast cancer surgery, where an incisions in high-risk patients can potentially reduce wound
SSI may extend the waiting time between surgery and complications and readmission rates.
chemotherapy or radiotherapy
At least 5% of patients develop a post-surgical wound infec-
tion, and it has been pointed out that although SSIs have not Question: There are several examples of releasing
generally received a lot of attention, they may be the type of resources by changing practice. How does an organisation
infection that is the most preventable (41). know which approach to take?
Preventing SSIs therefore may have a significant impact on Answer: This will depend on the priorities for the organi-
resource use. An example of this was published in 2014, where sation and the opportunities for practice change. It is often
a hospital provider in the UK addressed the problem of SSIs useful to conduct a practice audit to ascertain which are
by making systematic changes to their post-surgical C-section the best opportunities for change, and several examples
practice (42). Following the introduction of these measures, of surveys and audits can be found in published literature
the infection rate dropped from 12% to 6%; in the highest-risk (6–9,43). These can be relatively simple, using a question-
group, there were no infections or readmissions. The box below naire format, and are often done over a short, fixed period
shows some further details. of time to give a ‘snapshot’ of wounds and practice. For
example, a community provider might survey each wound
treated over a given week to ascertain characteristics of the
Case study 4: addressing the problem of SSI (43) wounds, which products were used, how often dressings
were changed etc. These surveys give a wealth of informa-
tion, which can be used to inform practice change, with a
A hospital trust in the UK found that about 12% of view to improving efficiency and quality of care.
women experienced a surgical site infection following a
caesarean section. Readmission to hospital was a particu-
lar problem, with women with high body mass index (BMI) Is prevention cheaper than cure?
(≥35 kg/m2 ) being the most likely to have a readmission.
The provider put together a multidisciplinary team includ- One important way to reduce the cost of wound management in
ing a tissue viability nurse and infection control nurse, the future is to make an impact on the number of wounds that
together with the obstetricians and midwives. This team need to be treated. This means that wound prevention has an
important role to play in counteracting the demographic trends

© 2016 Medicalhelplines.com Inc and John Wiley & Sons Ltd 13

Wound management for the 21st century C. Lindholm & R. Searle

affecting wound prevalence. For example, below-knee gradu- increased incidence have been introduced in some countries.
ated compression hosiery is recommended to prevent recur- Awareness has increased, and practice has improved, although
rence of VLUs in patients with healed ulcers (44), and regular there is continued debate about the proportion of pressure ulcers
foot assessments are effective to prevent DFUs alongside other that are avoidable (50). However, there is more that can be
interventions such as optimising glycaemic control and smok- carried out to adopt strategic approaches to prevention and to
ing cessation (45). use effective risk-assessment methods (51).
Often, when we think of wound prevention, it is the preven-
tion of pressure ulcers in acute care that comes to mind, and
indeed this is probably the most widely studied area and has Conclusions
received the most attention. Having a pressure ulcer has a pro- Wounds have a significant impact both on the quality of life of
found adverse effect on many aspects of a person’s quality of those who have them and on the world’s health systems. The
life, and although pressure ulcers are not a new phenomenon, number of people with wounds is growing, and this is likely
they continue to be a significant health problem as a result of an to continue into the future as a result of demographic trends.
ageing population (46). They also represent a significant burden Preventing wounds from occurring has an important role to play
to health systems, with one report estimating that treatment of in mitigating the effects of demographic changes that affect
pressure ulceration costs the US $11 billion annually (47). wound prevalence.
Recently published international guidelines for the preven- We can think systematically about the cost of caring for
tion and treatment of pressure ulcers have demonstrated that people with wounds by considering the resources used. Human
there a number of important considerations for prevention to be resource is the most valuable asset that the health system has,
effective (48): and most of the resource used in wound management is as a
• risk assessment result of hospital treatment or nursing visits. Materials such
• skin and tissue assessment as dressings account for a relatively small amount of the cost;
• preventive skin care however, the choice of materials and dressings used is very
• the use of emerging therapies such as microclimate con- important.
trol, prophylactic dressings, fabrics and textiles and elec- There are three significant drivers of cost: the time it takes
trical muscle stimulation a wound to heal, the frequency of visits by health care profes-
• good nutrition sionals and the incidence of complications.
• repositioning and early mobilisation These three drivers help us to think about how we can make
• the appropriate use of support surfaces wound management more efficient by:

Thorough and comprehensive risk assessment is a vital part • reducing healing time
of prevention, and several assessment tools have been devel- • optimising dressing change frequency
oped that, when used in conjunction with clinical judgement • preventing complications such as wound infection.
and experience, can help to identify the risk level for individual
patients (49). As there are several potential risk factors for
Acknowledgements
pressure damage, there are a number of different prevention
approaches that can be used in a prevention protocol. For With thanks to John Posnett, Paul Trueman, Carina Ekbladh,
a given patient, the mix of these different components will Trine Gram and Jane Hampton for valuable contributions to
vary (49). the content presented here. Christina Lindholm is an indepen-
Suitable support surfaces should be used, and the patient’s dent researcher at Sophiahemmet University, Sweden. Richard
skin should be inspected regularly along with a tailored reposi- Searle is an employee of Smith & Nephew. This work was
tioning programme (49). Incontinence, skin moisture, nutrition funded by Smith & Nephew.
and hydration must all be managed in collaboration with the
appropriate health care professionals (49). The use of multilayer
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