The Johnson brothers in the U.S., Smith and his nephew in Britain formed companies in the late 1800’s to commercialize the then revolutionary concept of sterile surgical bandages. The corporate progeny of these four entrepreneurs are the only two companies with more than 100 years experience in wound care. In the late 1800s neither the Johnsons nor Smith nor his nephew could have imagined where wound care would wind up 130 years later. Wound care in 2010 is as much about negative pressure wound dressings, nanocrystalline silver dressings, and 1, 000 PSI water jets as it is about infection control.
Wound care; it doesn’t do your surgery—it just makes your surgery better.
Shifting Practice of Surgery
When SNN’s PR folks called to ask if we’d interview the head of wound care we jumped at it. The practice of orthopedic surgery is shifting, we think, to more risk management and strategies for creating better outcomes using such low-cost, low-risk innovations as wound care.
Tomorrow’s orthopedic surgeon is going to have to get BOTH the surgical carpentry right and master the perhaps arcane aspects of wound care. Surgeons who do both well will invariably post-up superior outcome statistics. Time may heal all wounds, but in today’s hospital, time is big money so attending to wound care is no trivial matter. For every day a wound goes unhealed, reciprocal costs involving care delivery, medications, and other risk factors (such as infection) increase. Lastly, products and methods used to treat wounds have evolved significantly in recent years, and product price is not an accurate performance gauge.
A recent study “Cost and Cost Effectiveness of Venous and Pressure Ulcer Protocols of Care, ” makes this point well. Three wound care protocols were tested on about 5, 300 patients with chronic ulcers (among the hardest to heal wounds). The “tried-and-true” protocol was saline gauze (1, 785 patients). The other two protocols were Comfeel and DuoDerm. The “old standard, ” lower-priced saline gauze approach was actually a higher cost approach (estimated to be $3.9 million on a 100, 000 patient population) than the other, more expensive protocols (Comfeel and DuoDerm) when hospital stay, home healthcare, or long-term care costs were considered. The saline gauze protocol was penny wise/pound foolish.
Smith & Nephew’s wound care division is the market leader in Europe and the second largest supplier in the United States. Tom Dugan is SNN’s new President, North American business. He’s excited about wound care. Especially the tough cases—like chronic wounds. In Tom’s bag are a group of technologies that, no kidding, are interesting and exciting. We’ll highlight just three.
Nanocrystaline Silver Dressings
Acticoat Absorbent with
SILCRYST/Smith & NephewSilver’s anti-microbial properties have been known for more than a century. Smith & Nephew created Acticoat which delivers to the wound site an Ag+ form of silver, which can be release in a sustained, predictable way. Silver, which can be deactivated by choride or organic matter, must be released in a controlled manner.
SNN uses a nanocrystalline version of silver. Nanocrystalline refers to a production method called physical vapor deposition. This method creates a very porous material—essential to wound healing. Because it is porous, it allows water to permeate the silver more completely. In simple terms, the silver reaches dissolution in water at between 70 and 100 parts per million—reliably, consistently, every time.
What does this mean for the surgeon?
- A silver anti-microbial barrier that is in direct contact with the wound bed
- An ability to kill micro-organisms in as little as two hours
- Broad spectrum activity against over 150 pathogens
- Sustained activity throughout the wear time of the dressing (up to seven days in vitro).
Wound Care at 1, 000 Miles per Hour
I saw this once. Tough-guy motorcycle accident victim is sitting on the gurney waiting for the ER nurse to clean up his skin abrasions. She walks in with a scrub brush. He almost passes out.
A key part of wound care is debridement which is the removal of damaged, infected or dead tissues in order to create a healthy bed of tissues for eventual wound healing. But scrub brushes and scalpels are, to put it mildly, crude tools.
Enter Versajet. Versajet uses 1, 000 miles per hour water in a safe, hand-held system to debride damaged or dead tissue with very high precision. With Versajet, case managers find that they can reduce the number of debridements, reduce healing time (compared to scalpel or scrub brushes), consume less operating room time, and, of course, lower costs.
Source: Smith & NephewBetter debridement means better outcomes. What kinds of outcomes? Better graft and synthetic dressing results (Cubison CS et al., “Dermal preservation using the VERSAJET Hydrosurgery System for debridement of pediatric burns”, Burns, 2006, 32, 714-720 and McCardle JE, “VERSAJET hydroscalpel: treatment of diabetic foot ulceration”, British Journal of Nursing, 2006, 15, Tissue Viability Supplement).
Negative Pressure
Negative Pressure Wound Therapy (NPWT) seals the wound and prevents premature “bursting” open of a wound along the suture line (called dehiscence). This is a surgical complication that results from poor wound healing. NPWT reduces dehiscence with a gauze or foam filler dressing, a drape and a suction or vacuum source that applies negative pressure to the wound bed with a tube threaded through the dressing. The vacuum can continuous intermittent—depending on the type of wound and the physician’s clinical objectives.
Negative Pressure Wound Therapy/Smith & NephewThe vacuum pulls and drains excess serous fluids from the wound. In 1995 the Food and Drug Administration approved the first negative pressure system. It was originally marketed as a vacuum assistant closure (VAC) device by its manufacturer, Kinetic Concepts. In medical trials, the VAC device was shown to be as safe as, and more effective than, moist treatment for diabetic ulcers
Most experts agree (see Willy C, editor. The theory and practice of vacuum therapy. Scientific basis, indications for use, case reports, practical advice. Ulm, Germany: Lindqvist book publishing; 2006. 405 p) that there are five ways that aids the healing process:
- Wound retraction
- Stimulation of granulation tissue formation
- Continuous wound cleansing after adequate primary surgical debridement
- Continuous removal of exudate, and
- Reduced interstitial edema
Willy, in his book, states that wound retraction under negative pressure brings the edges of the wound closer together and thereby puts mechanical stress on the tissue. That stress helps to create micro deformations in individual cells. When they are so “deformed” they then stimulate production of cellular messengers which trigger more matrix synthesis and cell proliferation within the wound.
Several studies have noted that NWPT increases the rate of granulation tissue formation. Continuously pulling excess exudate reduces the bacterial burden present in a wound. Interstitial fluid (exudate) that accumulates in a wound may mechanically compress local capillaries and restrict blood flow into the wound. Removal of exudate from a wound may reduce tissue edema and promote blood flow back into the wound area.
In 2007, Smith & Nephew acquired Blue Sky Medical, which had developed its own NPWT system. Roughly a year ago, SNN announced and brought to market the RENASYS EZ and RENASYS GO NPWT systems. RENASYS works with both foam and gauze wound dressings.
Tom Dugan Gauging the Wind
Tom Dugan came to Smith & Nephew after 27 years in health care. Most recently he was SVP of Global Marketing and U.S. Sales at Sonosite. He was President of InverVascular (subsidiary of Datascope Corporation) before that. He also served as Vice President of Marketing for US Surgical Corporation, a division of Tyco Healthcare from 1999 to 2001, with responsibility for their Auto Suture and USS/D&G Suture businesses. From 1996 to 1999, he headed Business Development for US Surgical during a period of substantial corporate activity. Tom started his career at Johnson & Johnson’s Critikon division and then continued his career in sales, marketing and international with C.R. Bard and Puritan-Bennett.
Dugan knows he has the chops and the technologies to make every surgery better, every surgeon stronger, every patient a faster healer. As Bob Dylan wrote a long, long time ago, you don’t have to be a weatherman to tell which way the wind is blowing. Dugan can feel the winds of health care blowing and they would appear to be blowing in the direction of improved wound care.
