Practice Setting and Infection Control
Debridement options may be limited in the home environment due to safety concerns such as cleanliness, lighting, availability of additional personnel and the risk of contamination due to pets. To optimize safety home care patients can attend a home care wound clinic for the more invasive types of debridement.
Environment and infection control are two very important considerations when determining the type of debridement, particularly CSWD. All organizations involved in the delivery of wound care in any health care sector including acute care, long term care, primary care, and home and community care should have debridement resources and policies available based on current evidence. The decision to debride should be made only after a thorough assessment of the patient, wound, and environment to ensure the setting is appropriate with infection control measures in place. Safety, infection control, and cleanliness of the surrounding environment should factor into the decision when assessing patients in their home or in the community. Specifically, CSWD poses the greatest risk of harm to patients: it is therefore important the environment is conducive to performing the debridement safely both for the patient and the regulated health care professional. The home environment lacks resources and may be unpredictable; therefore, CSWD is strongly encouraged to be performed in a community or outpatient clinic setting. If this alternative cannot be accessed, CSWD should only be performed in the home by highly skilled and experienced health care professionals.
Consider the following during the assessment to determine if the setting is safe to perform the debridement modality.
- Prior to the initiation of CSWD, determine what resources and personnel are available during and post procedure to manage and monitor for potential adverse events such as bleeding, pain, anxiety, damage to underlying structures, or loss of consciousness. Rural areas tend to pose the greatest risk in managing adverse effects to debridement due to the remote locations.
- Is the patient’s environment safe to perform the procedure? Look for cleanliness, adequate lighting, and ability for the patient to be positioned in such a way as to ensure visibility of the wound, patient comfort, and proper body mechanics for the health care professional performing debridement.
- Ensure you have adequate uninterrupted time available to conduct the required assessments and perform the procedure.
- Ability to maintain a clean or aseptic environment is crucial to maintain infection control practices and avoid cross-contamination of the wound. Availability of potable water, unpredictable pets, pet hair, bed bugs, cockroaches and personal hygiene of the patient can impact contamination of the wound.
- Assess for the type of sterile equipment required such as single-use, disposable supplies when debriding in the patient’s home.
- Ensure appropriate supplies and equipment are available to prevent infection and cross-contamination of the wound, patient, significant other, and health care professional.
- Ensure there are available methods for the safe disposal of contaminated materials including, but not limited to, biological waste, contaminated dressings, sharps, and larvae.
What type of assessments need to be conducted to assess the cause of pain? What would you be concerned about with this information?
Reassessment of Debridement
It is the responsibility of the regulated health care practitioner to ensure a follow-up assessment is scheduled to reassess debridement outcomes, patient response and to perform additional serial debridement, if required. While this chapter focuses on debridement specifically, assessment parameters identified here should only come after a comprehensive holistic patient and wound assessment has been conducted to determine continued treatment appropriateness. Using a validated wound assessment tool can aid the practitioner in determining wound progression, or lack thereof, and frequency for serial debridement. As tissue changes throughout the debridement process, reassessing for the most appropriate method of debridement should be done at each visit. Considerations when choosing a method of debridement may include, but are certainly not limited to, speed, selectivity, pain, exudate, infection, and cost (see Table 1). Therefore, it is imperative these factors are assessed at each visit pre- and post- debridement and at regular intervals by the authorizer. Since debridement poses a risk to the patient, especially when on the lower limbs, it is essential for documentation to be prescriptive and clear to avoid any errors that could potentially be devastating.
When assessing nonviable tissue, one must consider the type, colour, amount, and adherence to determine whether the method of debridement is impacting the wound positively and meeting the goals of care instituted by the interprofessional team and the patient (HSE, 2018; Young, 2011). The type of nonviable tissue will change in a specific order with effective mechanical, autolytic, and enzymatic methods of debridement. Progression of properly debriding tissue advances from hard black eschar to a very loosely adherent white/yellow slough (Figures 9, 10, 11, and 12). Likewise, adherence of tissue should become weaker as tissue progresses through the natural debridement process.
Reassessment should consider the time required between visits to ensure the method of debridement has sufficient time to demonstrate effect. If no change is evident, revision to the plan of care is required. For wounds deemed nonhealing, where surgical interventions or modifiable barriers are addressed, it is appropriate to discuss, with the interprofessional team, whether debridement would now be indicated.
Canadian Debridement Best Practice Recommendations
The development of best practice recommendations guides consistent and standardized wound debridement practices for health care professionals. They have the potential to positively influence patient safety related to all methods of debridement across the continuum of care and to be circulated and implemented widely at all professional levels. Health care administrators in a variety of health care settings should consider using these types of documents to further define debridement and support safe and effective high-quality patient care.
The 12 best practice recommendations for nurses in Canada are adapted below in Table 3 (NSWOCC, 2021, Appendix 2). Refer to the original document for the levels of evidence and applicable individual references. There are 12 recommendations and accompanying rationales developed by a national task force of expert Canadian nurses. Regulated health care professionals other than nurses may derive some useful information from the discussion about the different debridement modalities and considerations for the decision-making process. [Add links to BPG, QRG]
Three recommendations are health system-related, four are nursing-related, and five are patient-centred. The scope of practice, organizational recommendation and environmental assessment concern the health care organizational policy and procedures as foundational prerequisites for health care professionals to have the mandate to debride patients. Nine of the recommendations are directly related to assessment parameters prior to initiating or performing any method of debridement and one recommendation about reassessment post debridement.
Table 3 Adapted best practice recommendations
|1. Scope of Practice||Nursing||As a prerequisite, all classes of nurses must work within the controls of federal and provincial/territorial legislation, regulatory bodies, organizational policies, and individual competency. Nurses are accountable for knowing their national code of ethics and expectations, respective provincial/territorial practice standards and guidelines, their employer’s policies, procedures, and operational guidelines, and their competence and limitations for all methods of debridement.|
|2. Organizational recommendations||Health system||As a prerequisite, employers/organizations should ensure all policies and procedures, or operational resources related to debridement, including the type/method of debridement each class of nurse is authorized to initiate or perform. This includes the specific level of education, training (including mentorship), and experience required to perform the method of debridement.|
|3. Prior to initiation of debridement||Nursing||Before initiating
any method of debridement, the nurse must:
– be knowledgeable about the different types of debridement and the level of skill and training required to perform each method;- be aware of their own attitudes, limitations, skills, and competency;- recognize the indications, precautions, and contraindications for the various debridement methods;- evaluate the patient’s health status and wound goals, wound assessment findings and wound healing potential to determine if a consultation with the interprofessional team would be beneficial to confirm decisions regarding debridement;
– and be able to identify, manage and mitigate potential complications and adverse events, including anxiety, pain and bleeding.
|4. Education & preceptorship||Nursing||Before initiation or performing debridement, successful completion of a recognized wound management program and an additional competency-based debridement module is highly recommended. In addition, mandatory clinical preceptorship is strongly advised prior to independently performing CSWD. Other forms of debridement equally require education and preceptorship, however, the need for a preceptor would depend on the level of risk associated with the method.|
|5. Patient assessment||Patient||Before initiation of debridement the nurse must conduct a comprehensive patient assessment.|
|6. Wound assessment||Patient||Before initiation, a comprehensive wound and periwound skin assessment, using a validated assessment tool is recommended to assist the nurse to identify the wound etiology, and identify barriers to healing. Debridement of any kind is contraindicated for stable dry eschar on heels, ischemic limbs, toes, and digits. An urgent referral for acute surgical debridement is recommended when acute infection or sepsis is suspected and when aligned with goals of care.|
|7. Environmental assessment||Health system||Assess the patient’s environment to ensure the setting is safe to perform the debridement modality. Before initiation of CSWD resources and personnel must be available to manage potential adverse events.|
|8. Wound healing goals||Patient||Before initiation of any method of debridement it is essential to establish realistic goals that align with the patient’s goals, including concerns and cultural traditions and the goals for wound healing (healing, nonhealing, nonhealable).|
|9. Informed consent||Patient||Before initiation, informed consent should include legal and ethical considerations, organizational requirements, and should be obtained for all forms of debridement. The method used to obtain informed consent and the patient’s response must be documented in the patient’s record.|
|10. Product knowledge||Nursing||Before initiation, nurses must be knowledgeable about wound care products and therapies used both above and below the dermis before using them in practice. Off-label use of products is not permitted.|
|11. Reassessment||Patient||Thereafter, regular reassessment of the patient and wound is imperative.|
|12. Cost-effectiveness||Health system||Before initiation, consider all associated costs before selecting the method of debridement, including costs to the health care system, the employer or organization, the nurse, the patient/ significant other.|
Certain types of debridement such as autolytic and mechanical have been part of wound care practice for many decades and, although they are frequently initiated under the direction of a wound care specialist or physician, they can be routinely performed by a variety of regulated health care professionals including nurses, physiotherapists, others and in some instances the patient or caregiver (McNichol et al., 2021). Although all forms of debridement pose potential risks to the patient, some have a greater risk of patient harm such as CSWD and therefore should only be performed by a wound care specialist with advanced wound care training, additional debridement education with mentorship, and demonstrated competency in the skill.
- An advanced curriculum based wound care course is highly recommended for regulated health care professionals who practice wound care regularly in their practice. Because CSWD has a high level of risk of patient harm, the completion of an additional debridement educational program and clinical preceptorship to gain competency in debridement skills is strongly recommended.
- Assess your facility/employer/governing body policies, procedures, and directives for debridement, especially CSWD. Know and outline your scope of practice, as some more aggressive forms of debridement may be restricted in some jurisdictions for certain health care professionals.
- Knowledge of wound healing processes; comprehensive patient assessment parameters; mechanism of action for each method of debridement and associated indications, contraindications, and precautions; wound care dressings; and when to refer are crucial when managing a patient with a wound.
- Be aware of your own attitudes, limitations, skills, and competency is essential to providing safe and effective wound care and any form of debridement.
- Debridement of any kind should NOT be performed without a firm diagnosis or until the cause of the wound is determined. If you do not know the etiology, STOP and consult the interprofessional team.
- When in doubt about whether to initiate a form of debridement, DON’T.
- DO collaborate with the interprofessional team who specialize in wound management and debridement.
- Where able, all wounds should be assessed at every dressing change and at minimum weekly to evaluate the impact of the chosen debridement method and overall patient response.
- All forms of debridement can carry high risk when initiated inappropriately; however, CSWD is considered highest risk and can significantly harm the patient, even when performed by health care professionals with appropriate knowledge, skills, and judgment.
- If you are unable to accurately identify the tissue types in the wound or if tissue protrudes from the wound, immediately refer to the interprofessional wound care team.
- Caution should be considered with signs and symptoms of infection of the wound as debridement of any type may be contraindicated until the wound is assessed and debridement is deemed appropriate by the interprofessional wound care team.
- Special care and consideration are required for patients with multiple comorbidities as there is increased risk of impaired healing ability and harm with debridement. This population of patients should be referred to an interprofessional wound care team.
- Debridement of any kind is contraindicated for adherent dry eschar on heels, ischemic limbs, toes, and digits.