White Paper – Wound balance: Achieving wound healing with confidence 

Alison Garten, Christine Blome, Florian Dumas, Hans Smola, Harikrishna KR Nair, John Schäfer, Lesa G. Williams, Magali Veiga Marques, Michele Carr, Sharon Trouth, Zena Moore
25 April 2023

The concept of ‘wound balance’ is multifactorial, encompassing interconnecting issues related to the wound healing process and clinical practice. The wound balance concept aims to integrate various critical parameters which offer continuity, individualised care and support clinical decision-making, to place the patient at the centre of all care [Figure 1, see page 4].

Fundamentally, aiming for ‘wound balance’ constitutes a shift in focus, from managing wounds to leveraging the clinical intention of healing wounds whenever possible and as early as possible. The patient and clinician are on this journey together, with the patient’s quality of life needs and preferences, as well as expected clinical outcomes, at the centre of the decision-making process. Patient engagement is crucial, both to achieve agreed outcomes and to improve patient experience.

Quality of life is a key component that is often misunderstood, as it can be a challenge to measure or quantify, and it is often harder to apply this to evidence-based practice. Living with a wound is often different to living with other chronic conditions, and care needs to be individualised accordingly, with patient communication and listening at the core of all interactions.

While healthcare systems and settings vary, this change in focus is needed to facilitate a transformation in clinical practice. Ritualistic practice needs to be eliminated through an understanding of the science of wound healing, and an application of this to the individual patient and their unique needs. Clinicians’ lack of specialised knowledge or confidence in wound care can lead to suboptimal practice, such as failing to address the underlying contributing factors or not selecting the optimal dressing for the individual patient’s needs. Considering whether a specific treatment approach is in the best interests of a particular patient is essential, and clinicians should always ask themselves whether the most familiar product to them is the most appropriate for the patient.

The wound balance approach aims to provide clinicians with the information to understand the science of wound healing, in addition to the skills in how to communicate this effectively with patients to help them to get the best out of their treatments and, ultimately, achieve good clinical outcomes. 

A change in the way we think about and discuss wounds is needed, focusing on healing, where appropriate – as opposed to managing wounds. Ultimately, this can reduce the cumulative burden of wounds, easing the pressure and psychological stress on both patients and clinicians.

This document provides guidance in achieving ‘wound balance’, and specifically how this can be applied to practice to improve outcomes. The goals are to help clinicians in:

Understanding the science of wound healing 

Identifying what may be preventing a wound from progressing, including external factors and healing wound barriers

Recognising wounds likely to become non-healing or chronic early on, rather than waiting for up to 12 weeks, which is sometimes deemed the timeframe for a wound to be considered chronic; however, this is a range and different countries have varying timeframes

Understanding the importance of adopting a patient-centred approach, thereby identifying the patient’s individual needs and ensuring that the patient is at the centre of all decision-making processes – a process that starts at the beginning and continues at every stage of the patient journey

Using positive language to optimise wound healing rather than just managing wounds

Considering and measuring patient quality of life, social determinants of health, and the impact of living with a wound, to improve outcomes and build evidence

Applying the knowledge gained to achieve outcomes in an appropriate and timely manner.

This document is the outcome of a meeting of international wound care experts held in Frankfurt, Germany, in November 2022. This represents the first step in the ‘wound balance’ education journey. Further work is planned to expand upon the concept and provide clinicians with an enhanced understanding of best practice to help optimise outcomes for patients by achieving wound balance.

References

Atkin L (2014) Understanding methods of wound debridement. Br J Nurs 23: S10-2, 14-5

Augustin M, Radtke MA, Zschocke I et al (2009) The patient benefit index: a novel approach in patient-defined outcomes measurement for skin diseases. Arch Dermatol Res 301: 561-571

Augustin M, Conde Montero E, Zander N et al (2017) Validity and feasibility of the wound-QoL questionnaire on health-related quality of life in chronic wounds. Wound Repair Regen 25(5): 852-7

Beidler SK, Douillet CD, Berndt DF et al (2008) Multiplexed analysis of matrix metalloproteinases in leg ulcer tissue of patients with chronic venous insufficiency before and after compression therapy. Wound Repair Regen 16(5): 642-8

Blome C, Baade K, Debus ES et al (2014) The ‘Wound-QoL’: a short questionnaire measuring quality of life in patients with chronic wounds based on three established disease-specific instruments. Wound Repair Regen 22(4): 504-14

Buchstein N, Hoffmann D, Smola H et al (2009) Alternative proteolytic processing of hepatocyte growth factor during wound repair. Am J Pathol 174: 2116-28

Cho SK, Mattke S, Gordon H et al (2020) Development of a model to predict healing of chronic wounds within 12 weeks. Adv Wound Care 9(9): 516-24

Corbett LQ, Ennis WJ (2014) What do patients want? Patient preference in wound care. Adv Wound Care 3(8): 537-43

Dhoonmoon L, Fletcher J, Atkin L (2021) Addressing skin tone bias in wound care: Assessing signs and symptoms in people with dark skin tones. Wounds UK

Eming S, Smola H, Hartmann B et al (2008) The inhibition of matrix metalloproteinase activity in chronic wounds by a polyacrylate superabsorber. Biomaterials 29: 2932-40

Finlayson KJ, Parker CN, Miller C et al (2018) Predicting the likelihood of venous leg ulcer recurrence: The diagnostic accuracy of a newly developed risk assessment tool. Int Wound J 15(5): 686-94

Frykberg RG, Banks J (2015) Challenges in the treatment of chronic wounds. Adv Wound Care 4(9): 560-82

General Medical Council (2016) Mental capacity tool

Grinnell F, Ho C-H, Wysocki A (1992) Degradation of fibronectin and vitronectin in chronic wound fluid: Analysis by cell blotting, immunoblotting, and cell adhesion assays. J Invest Dermatol 98: 410-6

Guest JF, Fuller GW, Vowden P (2020) Cohort study evaluating the burden of wounds to the UK’s National Health Service in 2017/2018: update from 2012/2013. BMJ Open 10(12): e045253

Guo S, LaPietro LA (2010) Factors affecting wound healing. J Dent Res 89(3): 219-29

Humbert P, Faivre B, Veran Y et al (2014) Protease-modulating polyacrylate-based hydrogel stimulates wound bed preparation in venous leg ulcers – a randomized controlled trial. J Eur Acad Dermatol Venereol 28: 1742-50

Kapp S, Santamaria N (2017) The financial and quality-of-life cost to patients living with a chronic wound in the community. Int Wound J 14(6):1108-19

Klein TM, Andrees V, Kristen N et al (2021) Social participation of people with chronic wounds: A systematic review. Int Wound J 18(3): 287-311

Liu Y, Min D, Bolton T et al (2009) Increased matrix metalloproteinase-9 predicts poor wound healing in diabetic foot ulcers. Diabetes Care 32(1): 117-9

Mikosinski J, Kalogeropoulos K, Bundgaard L et al (2022) Longitudinal evaluation of biomarkers in wound fluids from venous leg ulcers and split-thickness skin graft donor site wounds treated with a protease-modulating wound dressing. Acta Derm Venereol 102

Moore Z, Strapp H (2015) Managing the problem of excess exudate. Br J Nurs 24(15): S12–7

Moore Z (2016) Patient empowerment in wound management. Wound Essentials 11(1): 32-5

Muller M, Trocme C, Lardy B et al (2008) Matrix metalloproteinases and diabetic foot ulcers: the ratio of MMP-1 to TIMP-1 is a predictor of wound healing. Diabet Med 25(4): 419-26

Page-McCaw A, Ewald AJ, Werb Z (2007) Matrix metalloproteinases and the regulation of tissue remodelling. Nat Rev Mol Cell Biol 8(3): 221-33

Rayment EA, Upton Z, Shooter GK (2008) Increased matrix metalloproteinase-9 (MMP-9) activity observed in chronic wound fluid is related to the clinical severity of the ulcer. Br J Dermatol 158(5): 951-61

Roth C, Wensing M, Breckner A et al (2022) Keeping nurses in nursing: a qualitative study of German nurses’ perceptions of push and pull factors to leave or stay in the profession. BMC Nursing 21: 48

Schultz GS, Sibbald GR, Falanga V et al (2003) Wound bed preparation: a systematic approach to wound management. Wound Repair Regen 11: S1-28

Sommer R, Augustin M, Hampel-Kalthoff, Blome C (2017) The Wound-QoL questionnaire on quality of life in chronic wounds is highly reliable. Wound Repair Regen 25(4): 730-2

Theocharidis G, Thomas BE, Darkar D et al (2022) Single cell transcriptomic landscape of diabetic foot ulcers. Nat Commun 13: 181

Thomas DC, Tsu CL, Nain RA et al (2021) The role of debridement in wound bed preparation in chronic wound: A narrative review. Annals of Medicine and Surgery 71: 102876

Trengove NJ, Stacey MC, Macauley S et al (1999) Analysis of the acute and chronic wound environments: the role of proteases and their inhibitors. Wound Repair Regen 7: 442-52

Trengove NJ, Bielefeldt-Ohmann H, Stacey MC (2000) Mitogenic activity and cytokine levels in non-healing and healing chronic leg ulcers. Wound Repair Regen 8: 13-25

Ulrich D, Lichtenegger F, Unglaub F et al (2005) Effect of chronic wound exudates and MMP-2/9 inhibitor on angiogenesis in vitro. Reconstr Surg 116: 539-45

Vogt TN, Koller FJ, Dias Santos PN et al (2020) Quality of life assessment in chronic wound patients using the Wound QoL and FLQA-Wk instruments. Invest Educ Enferm 38(3): e11

von Stülpnagel CC, da Silva N, Augustin M et al (2021) Assessing the quality of life of people with chronic wounds by using the cross-culturally valid and revised Wound-QoL questionnaire. Wound Repair Regen 29(3): 452-9

Wiegand C, Abel M, Muldoon J et al (2013) SAP-containing dressings exhibit sustained antimicrobial effects over 7 days in vitro. J Wound Care 22(3): 120–7

Wiegand C, Hipler UC (2013) A superabsorbent polymer-containing wound dressing efficiently sequesters MMPs and inhibits collagenase activity in vitro. J Mater Sci Mater Med 24(10):2473-8

World Union of Wound Healing Societies (2019) Consensus Document: Wound exudate: effective assessment and management. Wounds International

World Union of Wound Healing Societies (2020a) The role of non-medicated dressings for the management of wound infection. Wounds International

World Union of Wound Healing Societies (2020b) Optimising wound care through patient engagement. Wounds International

Wounds International (2009) MMPs Made Easy. Wounds International

Wounds International (2017) Proteases Made Easy. Wounds International

Wounds UK (2018) Improving holistic assessment of chronic wounds. Wounds UK

Wysocki AB, Staiano-Coico L, Grinnell F (1993) Wound fluid from chronic leg ulcers contains elevated levels of metalloproteinases MMP-2 and MMP-9. J Invest Dermatol 101: 64-8

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