Press Release

NICE 2001/014 Issued: 27 April 2001

NICE has today issued its guidance to the NHS in England and Wales on the use of debriding agents and specialist wound care clinics for difficult to heal surgical wounds. In summary the guidance states:

To date there is no Randomised Control Trial (RCT) evidence to support any particular method of debridement but less robust studies suggest modern dressings may reduce pain and be more acceptable to patients.

The Institute therefore recommends that the choice of debriding agent for difficult to heal surgical wounds should be based on impact on comfort, odour control and other aspects relevant to patient acceptability, type and location of wound, and total costs.

In addition there should be enhanced education of health care workers, patients and carers, and sharing of clinical expertise in the provision of specialist wound care services.

Prof Peter Littlejohns, Clinical Director of NICE said, "Removing debris from the wound is a recognised part of the management of surgical wounds that are proving difficult to heal. Today's guidance makes it clear to the NHS and patients that the method used should consider not only the cost but also the impact for patients. In addition it summarises the current evidence in this area and makes suggestions for future research"

Ends

Notes for Editors

Background

1. Most wounds created by surgery heal without delay, either by primary closure, or planned healing by 'secondary intention'. Difficult to heal wounds are those that fail to heal in the normal way.

2. Delays to healing can be affected by malnutrition, malignant disease, diabetes mellitus and other chronic medical conditions. Local factors that delay healing include infection (which may persist due to necrotic or foreign material within the wound), and poor blood supply.

3. Over six million operations were undertaken in the NHS in England and Wales in 1998/9. There are no reliable figures for the number of surgical wounds that become difficult to heal. One estimate based on data from the surgical department of a small district general hospital, suggests there may be 21,000 difficult to heal surgical wounds per annum in England and Wales.

4. The management of patients with surgical wounds is shared between hospitals and the community, with an increasing trend to management in the community. High levels of knowledge and skill, together with access to advice from a range of clinical disciplines, should be available in both settings, and should be cascaded through the service.

5. Good wound care requires generalist care for the majority of wounds with expert services for the most intractable cases. An effective network of care requires improved education for all the clinicians who may be involved, together with rapid access to expert support when required. This may require specialist nurses as well as a range of other disciplines including, dieticians, plastic and vascular surgeons and dermatologists. Patients and their carers should be given the opportunity to be actively involved.

NICE guidance

6. The full guidance states:

a. There is no RCT evidence to support any particular method of debridement for difficult to heal surgical wounds, but less robust studies suggest modern dressings (products thought to promote autolytic wound debridement, including hydrocolloids, hydrogels, polysaccharide beads/paste, foam dressings, and alginate dressings as well as bio-surgical techniques (sterile maggots) may reduce pain and be more acceptable to patients.

b. In the absence of sufficient evidence for or against any particular method of debridement, or for one type of modern dressing over another, the choice of debriding agent for difficult to heal surgical wounds should be based on impact on comfort, odour control and other aspects relevant to patient acceptability; type and location of wound; and total costs. Costs of wound care are very sensitive to the frequency with which dressings are changed; this applies particularly to home wound care requiring a visit by a nurse.

c. Although there is no direct evidence to support the provision of specialist wound care services for managing difficult to heal surgical wounds, a structured approach to care (including pre-operative assessments to identify individuals with potential wound healing problems) is required in order to improve overall management of surgical wounds. To support this, enhanced education of health care workers, patients and carers, and sharing of clinical expertise will be required.

The technology

7. Debridement is the removal of devitalised or infected tissue, fibrin, or foreign material from a wound ("debris"). The body can remove these by natural processes, but large quantities of debris can delay healing and provide an environment for infection.

8. The frequency of dressing changes and patient acceptability are important factors in the choice of dressing for a particular wound. For example, some wounds may be appropriately treated by gauze dressings kept moist and changed daily or more frequently, while others may be more appropriately treated using a modern dressing changed less frequently.

Further research

9. Suggestions for further research are listed in section 6 of the guidance.

Costs to the NHS

10. The actual costs associated with treating difficult to heal surgical wounds have not been measured. The net cost of selected dressings dispensed in the community some of which are used for debridement, was £37 million in 1998, but the majority of this expenditure is likely to have been on chronic wounds such as leg ulcers and pressure sores.

11. Health care costs related to wound care include not only the unit costs of the products used, but particularly the frequency of dressing changes needed, the period of treatment and the associated nursing time. By far the largest component of these costs is nursing time.

12. The number of patients affected by difficult to heal surgical wounds is not known, and clinical practice in the NHS varies widely. It is therefore difficult to estimate the current or likely cost and service impact on the NHS, of changes in the use of debriding agents or specialist wound care services for managing difficult to heal surgical wounds.

General Information

13 Copies of the full guidance and supporting documentation will be available on the NICE web site (www.nice.org.uk) from 12pm (lunchtime) on Friday 27th April 2001.

14. Health professionals are expected to take the Institute's guidance fully into account when exercising their clinical judgement for individual patients. This guidance does not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.

15. The National Institute for Clinical Excellence (NICE) is a part of the NHS. Part of its work is technology appraisals. The Institute produces guidance for both the NHS and patients on medicines, medical equipment and clinical procedures based on evidence of clinical and cost effectiveness. Each appraisal takes an average 12 months to complete and involves the manufacturers of the technology, groups that represent patients/carers and healthcare professionals.

16. NICE promotes clinical and cost effectiveness through its technology appraisals, clinical guidelines and audit tools. NICE supports the work of those who make the complex treatment decisions - doctors, nurses, and other health professionals. The needs of the patient are central to NICE's work, and the Institute has forged strong links with patient groups and representatives.

17. NICE appraises new and existing health technologies, as selected by the Department of Health and the National Assembly for Wales and advises the NHS on how these technologies can best be used. It is also responsible for the production of national clinical guidelines, promoting best practice throughout the NHS. To support and assess the implementation of such guidelines, NICE will produce audit tools for use in the clinical setting.