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Debridement as a Component of Wound Bed Preparation-Autolytic, Enzymatic, Mechanical and Sharp Debridement


Pamela Scarborough
Pamela Scarborough, PT, DPT, MS, CDE, CWS
Director of Public Policy and Education American Medical Technologies Irvine, CA
System Requirements Method of Participation Disclosure Information
Lecture Transcription


We're going to start with autolytic enzymatic and biosurgery – the little surgeons. Dot mentioned the DIMES and the TIME acronym, so I’m going to go through these very briefly very quickly. Our goal is a functional wound bed. Not only is it a functional wound bed, it is a sustained functional wound bed. So we start with debridement. That is our D. Infection and inflammatory control – that is our I. M is moisture regulation. You don’t want the wound too wet or too dry and desiccated. Wound edges – Dot has mentioned this several times – you want those edges migrating, and I added one other component: S, for the periwound skin. Officially, the periwound is 4cm from the edge of the wound, but often we see damage even further beyond that, and so we’re going to talk a little bit about that today.



We’re going to start with autolytic debridement, which is the natural degradation using the endogenous enzymes from within the body to, and to achieve this we usually use either moisture donating or moisture absorbing dressings, depending on what we’re trying to do. If you have dry, hard eschar, and debridement is your goal, then cross hatching is going to help to facilitate that process. So when we look at moist wound healing and autolytic debridement, they work synergistically together, to create this autolytic debridement process. So we’re using our moisture retentive or moisture donating dressings that are going to help retain the endogenous enzymes, and this is where the endogenous enzymes are functional. Remember with our older adults, oftentimes the endogenous enzymes are not working the way they need to. So the eschar and slough are going to be liquefied by this process.



Autolytic debridement is appropriate for all wounds with necrotic tissue, and it is beneficial for wounds covered with eschar if you do your cross hatching with your sharp instrument. It’s also known as scoring. There are contraindications to autolytic debridement including gangrenous wounds. We don’t want to open wounds when we have no blood flow, ‘cause all we do is create a bigger hole, and we don’t have blood flow to close the wound, to facilitate the wound healing process. No blood flow, no wound healing. Very, very simple, from that perspective. And you do need to have a vascular consult.



So autolytic debridement is the safest type of debridement. It does not disrupt the healthy tissue. It can be used in conjunction with other types of debridement. It is painless. It is easy to perform. It is caregiver friendly, but it does have some disadvantages. You do have to have a person with a functional immune system for autolytic debridement to be able to work. If it’s going over 30 days as you look and you see 3 to 30 days, if the debridement has not taken place within 30 days, then your patient probably doesn’t have the enzymes to be as functional as they need to be. There is the potential for bacterial growth, ‘cause we are covering the wound over, and we can’t have maceration to the periwound area. And injury to the periwound area – it’s very important that you take care of the periwound area. And this is an important note: please note that autolytic debridement is contraindicated in the presence of an infection, unless – this is the caveat – unless you’re addressing the infection, either systemically or locally.



So when we look at our autolytic debridement decision tree, dressings, drive, dressings, excuse me, drainage, drive, dressing, decisions. Is it minimal, is it moderate, is it copious





drainage? So you’re going to think about that. You're think about which dressing you’re going to pick, you’re going to look at the amount of drainage coming out of that wound. You’re going to look at the periwound condition, ‘cause you want to take care of the periwound area. And think about the frequency of change, because ladies and gentlemen, in general, we’re messing with our wounds too much. There needs to be a very good reason to change that dressing more than once a day – very good reason. I can’t think of too many reasons – not too many, very few – to change a dressing more than once a day. Every time you cool that wound bed down, you take the saline and you clean that wound bed, you chill it down – the cells become chilled and they go “Brrrrr! I’m cold! And I’m not going to move until it warms up around this place!” And it takes hours for it to thermoregulate again and for the wound bed to warm up. So unless you have a really good reason to do VID or three times a day dressing changes, at the most you should be doing once a day. And please use a skin sealant, especially with our older individuals who already have fragile skin. As you look at this photograph you can see the area where the skin sealant has been applied around the periwound area. And when you put the skin sealant on, it is critical that skin sealant is dry before you put the dressing adhesive on the skin. The skin sealant when it’s in place and it’s dry, the dressing adhesive adheres to the sealant and not to this person’s skin, and helps prevent maceration and also stripping when you take the dressing off.



So these are our different types of dressings. We’re going to go fly through these really, really quickly. These are the dressings that contribute to autolytic debridement. Gauze is at the bottom, because that’s where all this dressing mess started – gauze. And then we recognized that gauze wasn’t working very well. But there are some reasons for gauze. You might use it for scrubbing, for, using for wet to dry as a debridement option, which is really the only reason you should be using gauze – unless, unless you’re delivering some type of solution into the wound bed, if you’re using the gauze as a delivery mechanism. Otherwise, it’s simply a wet to dry debridement process. It’s mechanical debridement.



There are several reasons not to use gauze. Now, show me in the audience: who must use gauze? ‘Cause that’s all you have. Anybody in the audience have to use gauze? All right. So we all have some smart dressings. But there are reasons not to use it. They evaporate, the wound bed dries out; there is a higher infection rate with gauze; they have been shown that you have bacteria that get through up to 64 layers of gauze. How many of you are putting on 65 layers? You’re not?! There is, it’s not selective debridement. It doesn’t know viable tissue from nonviable tissue. There is decreased temperature. I told you that the wound needs to warm up. The cells like to move in a nice warm environment. It doesn’t, the wound stays chilled whenever you use gauze. It is labour intensive. We have studies that show that it takes more nursing time to use gauze than to use some of the other products that we have available to us. It’s also can be painful to the patient, it’s more expensive over time, and there is aerosolization of bacteria, which means, when you take that gauze off of this wound, bacteria spray into the air, and stays there for up to 30 minutes. You breathe it, the next nurse, physician, therapist that walks in behind you breathes it, and the patients breathe it. So you’re going to be very, very careful when this happens.



Transparent films – what we call thin films – is one of the dressing categories that we use that works beautifully for autolytic debridement. Now, look at this photograph. On the bottom you’ll see this ooey, gooey stuff. Well, some people think that’s what when they see it? Pus, that’s right. But it’s not. It’s the autolytic debridement process taking place.





That’s good stuff. But sometimes we have to tell the family and even sometimes clinicians that that’s good stuff. And we do need to think about how we’re going to apply the thin film. Cynthia talked about the hydrocolloids that came along as our second smart dressing that we have, that has the hydrophilic colloid particles that are on this polyurethane foam or film. And it forms a gel, and it is a little bit on the stinky side when you take the hydrocolloid off, but it is impermeable to bacteria. So nothing in, nothing out, which is good and can be bad. If you have an anaerobe growing under there, then it is a bad things.



Hydrogels – how many of you are using hydrogels? Show me your hands if you are using hydrogels. Why are you using hydrogels? Why is this important to you? To add moisture to the wound bed. So this is for non to scant draining wounds. It hydrates the wound bed. Sometimes there are things that are added, if you look at this list, you’ll see alginates, sometimes, for viscosity, collagen, hyaluronic acid, for performance, silver, it comes in sheets, it comes in an amorphous form. If you’re going to use a sheet, please, most of them need to be cut to fit inside the wound margin. Anybody ever see a square on the outside of the wound margin when somebody put a hydrogel on and didn’t cut it to fit inside the wound margin? It’s very important that we fit inside the wound margins.



Next category: calcium alginates. Seaweed. It is seaweed. And it comes in ropes or sheets. You can put it in and conform it into many, many different types of wound conformations. It is not suitable for dry wounds however. Hydrofiber, it will absorb up to 30% more than an alginate, and one of the things about alginates, let me go back for just a moment, that’s really wonderful, it’s biocompatible with the body. If you leave a piece of gauze in there you’ve got a problem. You leave some alginate in there, it’s okay. It’s biocompatible with the body. If it comes out dry, you put that alginate in there, it comes out dry, that means that you need to back off to a different type of dressing – the alginate is no longer appropriate.



Foams – wonderful dressings. Wonderful categories. There’s polyurethane open cell configuration, it can be single or multilayer. There’s all types of forms. Sometimes they have, they are adherent where they have the border adhesive around it, and they are indicated from moderate to highly draining wound – moderate to highly draining.



Enzymatic debridement, which is wonderful, for instance if in your older adults, autolytic isn’t working, you might go to enzymatic immediately. This is the use of some topically applied chemical agent to help break down the necrotic tissue, and the only one we have that is FDA approved at this time, is collagenase. So collagenase, as you look at this photograph, collagenase breaks the strands, the necrotic strands. It is specific for necrotic collagen, and it breaks the collagen strands at the bottom of the wound base. So you put your collagenase on about a nickel thickness, as you see in this photograph, and it’ll go down the sides of the wound, down to where the collagen fibers are, the strands are anchoring the necrotic tissue into the wound bed; breaks it, and then that, the necrotic tissue will dissolve and go away. The problem is, some of you are into instant gratification. I am. I’m into instant gratification. And we don’t always see the collagenase is working. It just seem like, oh, it’s sitting there, it’s sitting there, it’s sitting there, and then all of a sudden, you’ll see what it’s done, because it’s been working at the bottom of the wound this whole time. So be patient with collagenase.











It’s derived from the bacteria – they take the bacteria, Clostridium histolyticum, they change the DNA, and then it is identical to your collagenase, the human collagenase. So it’s engineered, bioengineered.



Enzymatic debridement requires that you do it daily. This is one of the reasons to do a daily dressing change. If you have very thick eschar, you might want to do a BID, and you do, again, you want to look at the cross hatching, such as this. This might be a good reason to do BID collagenase, ‘cause there’s a lot of thick eschar there. Application: you put it on about a nickel’s thickness, and you can put it on the dressing, you can put it on directly into the wound bed if you like, and this is just showing a photograph of how well collagenase did in this particular wound.



Biosurgery – the little surgeons. Look at how cute they are! Isn’t that precious? Look at this guy with his little buggy eyes and his little fangy things! I just think they’re so precious. They are wonderful. How many of you are intentionally using, intentional, yes, how many of you are intentionally using the larva to help with – how, how many of you, how many of you have used it unintentionally? Yeah? And when you used it, what did your wound bed look like? It was beautiful, wasn’t it? Yes, they work wonderfully. They also secrete collagenase – that’s one of the, one of the secretions that’s in their secretions. They, the crawling, they think of the crawling and the fact that they use their little fangies to hook on and then pull themselves along, also help to loosen the necrotic tissue. The three reported actions are debridement of the necrotic tissue, disinfection, and they’re not a picky eater. They like bacteria also. So they kill the bacteria actually in their alimentary canal, and also promote wound healing.



They are good for all types of wound. Doesn’t matter what the wound type is. And here they come from California – this is what they look like when they’re delivered to you. And they’re used a lot in Europe. And this is another photograph of using, when you look at the top, top left, and then you look at the bottom right, you can see how well the maggots have done.



All right. So that’s our first one. I’m ready for a second one. Any questions on that? Okay, good.



All right, thank you. So, now we’re going to get into wound bed preparation, debridement as a component of wound bed preparation, Part 2, and we’re going to talk about mechanical and sharp debridement. When we look at mechanical debridement, this is the application of some outside force to dislodge necrotic tissue. So we might use wound scrubbing. How many of you have taken your gauze and kind of scrubbed around in your wound? You know, what’s go, what’s going on in here? Let me scrub around in here and see what’s going on. Almost all of us have used the gauze at some time. If you’re going to use gauze, you can scrub them, the center of the wound, out. Why do I want to go from the center out? Right, I don’t want to bring anything into the wound bed. And be careful with your periwound area, your wound margins, excuse me, your wound margins, when you scrub in to out. Scrub two to three minutes; be careful that you don’t scrub granulation tissue.



Wet to dry dressings is appropriate for debridement. However, look at this photograph. Is wet to dry appropriate for this particular wound? Absolutely not. We are tearing out the granulation tissue. It is non selective. It cannot tell the difference between viable and nonviable tissue. It can be traumatic to the patient and to the wound. It’s painful if the





person is sensate. However, you have a wound completely covered with necrotic tissue. Is it okay for you to do wet to dry? Sure it is. Your job is to call the physician. I have a physician in Dallas. Loves wet to dry. Dr S. I’m going to call him Dr S. So Dr S. loves wet to dry. Good. Many times it’s appropriate. It’s my job to, ‘cause I have to ass it and do them wet to dry, who’s doing the wet to dry? The nurses and the therapists, that’s right.



So I call Dr S., say “Dr S, wet to dry did great.” You know, stroke him, you know, little ego thing going here. “Did great, got a lot of that necrotic tissue out. How about if we change to, ‘cause I think it’s time change – I think I see a tendon, and we’re getting some granulation tissue – so how about if I change to…” and I let Dr S. know what my equipment is, my supplies, my skill set. I don’t get emotional; it’s all objective. Because if I say to Dr S, I’ve said, “I see a tendon, I see some granulation tissue – what do you want me to do?” I just told him that it was working really great. So what’s Dr S. going to do, say? “Keep doing wet to dry.” So I have to let him know, or her know, why I want to change it, and I’ve never had a physician say no when I’ve approached it in this manner.



Stop when you see granulation tissue in the wound bed – you don’t want to damage it - when the patient is experiencing pain and when there’s a potential to damage structures such as tendons.



Hydrotherapy. How many of you have ever done whirlpools? This is where the profession of physical therapy in general started wound care – in the hydro room. The nastiest of the nastiest wounds came down to my hydro room. Now, sometimes the nurses wanted me to bathe their patients, and I did have to draw the line. My hubbard is not your bathtub. But we still remained friends, I have to tell you that. So when we think about whirlpool, it is going away. There are people around the country that have taken whirlpools out of their departments ‘cause they can’t get people to stop referring for it. Okay, we take it out. Can’t refer any more. There are some things that it does. It increases circulation, which could be good, could be bad. However, it can cause skin maceration of course, increases edema, disrupts new cells. I don’t know how many pounds per square inch, PSIs, coming out of that jet. I don’t know how many PSI is coming out of there.



Contraindications: venous insufficiency is now a documented contraindication for whirlpool. So if you’re still giving orders for this, and if you want to put that venous insufficiency leg ulcer in there for a five minutes in tepid water, because it’s truly truly nasty, that’s fine, but it’s just like Cynthia said – all you’re doing is giving it a little bit of a bath without anything going on. You’re just rinsing it off. Doesn’t help very much. Compromised cardiovascular pulmonary function should not be in a whirlpool, especially a full body whirlpool. Renal function, dry gangrene, has no business in a whirlpool. Acute phlebitis, ischemic wounds or neuropathic foot ulcers, patients with impaired cognitive function, or lethargy and unresponsiveness, and it is not effective for adherent necrosis or eschar or fibrinous tissue.



Wound irrigation – how many of our nurses have ever done wound irrigation? Quite a few of you have. Wonderful. It’s been around for a long time and it’s actually from the nursing profession that we learned to do this better. So these are some prefabricated wound irrigation systems, you want to do your wound irrigation and the other things I’m going to show you in just a few minutes – you want to have some pressure. The pressure is important. Anywhere from eight to fifteen pounds per square inch of pressure.











Now pulse lavage with suction is one of those places that changed my career in wound care. Got out of the whirlpool, hydro room, and now I can take the pulse lavage with suction unit to my patient. How many of you are still doing pulse lavage with suction? Anyone? It’s still a very effective modality.



This is a colleague of mine, Dr Harriet Loane, who is the queen of pulse lavage with suction, using it on a pain patient, excuse me, a burn patient. However, with burns, you do have to be careful of pain and you may have to do some type of topical and/or oral analgesic when you do it. Low frequency ultrasound – I’ve used ultrasound my entire career for well over 30 years. High frequency ultrasound is what I would use for strains and sprains. Most of you will know ultrasound related to imaging of some type. Low frequency ultrasound is fairly new, that takes the ultrasound sound wave, slows it down, and we have a whole new area of wound care using this energy. We have non contact low frequency ultrasound which you’re seeing here, where we’re putting out the sound energy through a solution, and are actually changing some things that’s happening in the wound bed. And then there is contact low frequency ultrasound – so there’s non contact and contact low frequency ultrasound, which is appropriate and wonderful for some of the things we want to do in wound care. And we think that the, the theory is that we’re having microcavitations that also destroy the bacteria. We actually blow up the bacteria walls, and so you decrease your bioburden when you use this particular energy.



Now, we do have physicians in the room, and I’m talking to you also, but I want to talk about instrument debridement for non physicians. Sharp debridement, as opposed to surgical debridement – only physicians can do surgical debridement which implies viable and nonviable tissue. Sharp debridement can be done by physicians, podiatrists, which is a physician also, physical therapists, physical therapists’ assistants; in some states, nurses, nurse practitioners, physician assistants, occupational therapists. So I just mentioned surgical versus sharp. Surgical is viable and/or nonviable tissue; sharp is selective and implicit for nonviable tissue only. The advantages of surgical debridement, however, is sometimes you need to get all of that stuff out as fast as possible because you’re afraid your patient is going systemic. Or it already becoming, all right, or it already is a systemic infection. Then get your physician involved. And get that stuff out of there, that dead tissue out, as fast as you can.



Maintenance debridement – you go ongoing sharp debridement, ongoing enzymatic debridement, ongoing autolytic debridement. You keep debriding this wound until you have a sustainable functional wound bed. Very, very important that you keep doing this.



Where do you find your legal standards? State practice act. Ladies and gentlemen, even though you work for the VA, you still have a state practice act, right? You have to get your contact hours, your state practice act is not a suggestion, it is the law. What does your state practice act say about sharp debridement? Are your rules in your state – in my state of Texas, sharp debridement is mentioned in my state practice act as something that I am allowed by law to do. What does your state practice act do, say? What about policies and procedures related to sharp debridement. How many of you have policies and procedures in place for sharp debridement? One person. How many of you are doing sharp debridement? Several of you are. Please, have a policy and procedure in place and then follow it. If you want a policy and procedure, email me and I’ll send you a template that you can use to write up your own.







You look at your national professional standards of practice. You look at your guidelines. The WOCN, the Wound Ostomy Continence Nurses’ Society, has guidelines on sharp debridement. The American Physical Therapy Association has guidelines on sharp debridement. Physicians’ orders – absolutely. Get a physician to order. It is necessary. It’s nice to have a protocol in place also – not necessary, but it’s nice. Each wound site needs to be mentioned. You get a new wound site, you get a new order. It doesn’t cover the one that you were working on. You get a new wound site, get a new order. You might need PRN orders.



This is what the WOCN recommends. Look at this. “Conservative sharp debridement of soft necrotic tissue is what is recommended.” I have a caveat for that, and my recommendation is, for a sample order, selective sharp debridement of necrotic tissue, PRN, as needed, of, and then you mention the location of where you’re going to do that sharp debridement.



Indications, extensive devitalized tissue, advancing cellulitis, presence of a thick eschar, in combination with other methods, but there are contraindications. Remember, no blood flow, no sharp debridement. Gangrene. Stable heel ulcers. In general, people tell you not to remove eschar from a stable, from a heel that is stable. You’re going to have to make a decision. If you decide that you’re going to remove eschar from a heel, you have stable eschar, you’re going to remove it, be sure you document why you’re taking that stable eschar off. And there are reasons to do it, but be sure you say why you’re doing it.



Unidentifiable structures, the key word is a structure. It’s a tendon. I don’t know which tendon it is, but I know it’s tendon. I’d better think about it before I take it out. Terminally ill – there may be times when you want to do sharp debridement, but there are many times when you’re not going to do sharp debridement, because we’re into palliative care or maybe hospice care. Anticoagulation therapy is a relative contraindication. I was in a lawsuit one time where the patient bled out, because the physical therapy team did sharp debridement and they didn’t look at the medication sheet, and the person was on Plavix, Coumadin and Aspirin, and no one, including the physician, look at the INR, and the person was five times anticoagulated on Coumadin alone. And the patient bled out and died, and I had to find two of my colleagues grossly negligent according to the, our state practice act, in the State of Texas, and it broke my heart to do that. But that’s what I had to do. And it was because they didn’t look at the medication sheet before they did sharp debridement.



Blood clotting disorders such as hemophilia – be very, very careful.



How many of you have used disposable sharp debridement tools? Okay. How many of you use reusable sharp debridement tools? Both are wonderful. We’re not doing microvascular surgery here. So disposable instruments work just fine. So, and there are different, you can use different types of scalpels, different types of scissors, curettes, bottom right, look at this photograph and you’ll see the curette. I know several nurses, one of whom is in the room, that loves this particular type of curette, and it’s great for scraping out that fibrin or slough – does it very, very nicely.



You want to get ready to debride – you get all of your supplies in place – make sure you have adequate lighting – that’s very important that you, especially if you are over 40, that you have adequate lighting. My friend Karen Lou Kennedy has one of those headlights that she wears when she’s doing some of her wound care and doing her assessments. Very,





very important. Prepare for bleeding. I am an assertive debrider. I go to that line of demarcation whenever possible between viable and nonviable tissue. And when I get to that line of demarcation, sometimes I get a little bit of bleeding. I’m not going after the viable tissue. That’s outside my practice act. But I’m going to the viable tissue. So, I need to be ready for bleeding.



Plan for the pain. Work with your nursing staff. I cannot pass medications. It’s against the law. So I have to partner very closely with the physicians and the nurses to get my patients medicated.



Reasons to stop debridement. Clinician fatigue or patient fatigue. The patient is bleeding. If you’re bleeding I’m going to question your technique. Pain. You get to viable tissue. Location of a fascial plane. High anxiety of the clinician. How many of you have had a gut feeling in your life? Who’s had a gut feeling in their life? All right. Your gut, that intuition, will never lie to you. This will lie to you, over and over. Your head will lie to you. Your gut will never lie.



Do you get a bad feeling in your gut, and you have sharp instruments in your hands? Put them down, write something in the chart, something that is honest and is appropriate, but stop the debridement process.



Set a time limit and stay within the time limit. Holes? Don’t go there with a sharp instrument. You have to be able to see the tip of your instruments. Very, very important.



Extensive undermining you can’t see? Don’t go there with a sharp instrument. You see gross purulence that you didn’t expect, such as you see in this bottom wound? Stop. Get the patient to the physician. Get the physician involved.



Pressure will stop most bleeding. It’s important to have a method for stopping bleeding pressure. If your patient is on anticoagulants, you’re going to have to hold pressure on longer. So you have to, again, look at the medication sheet.



Elevation – you can do that if you have a lot of bleeding, then you’re maybe going to have to have a suture, and again, I’m going to, I would have to have my physician involved.



Some of the topical agents work very nicely, as you look at this list – thrombin, surgicel, gel foam – there are silver nitrate sticks. You want to make sure your patient has stopped bleeding before you dress the wound and you send them out. Very important, especially in the presence of anticoagulation therapy.



Get the physician back involved if your patient is febrile on a downhill course where there’s been no wound improvement over several sessions. New cellulitis, unexpected gross purulence. You know your anatomy, you know your physiology, you know that you’re getting ready to expose the bone or a tendon. Get the physician back involved, major abscesses, major structures such as vessels, the ephemeral artery, I think I need to get my physician back involved. Very important.



Remember, we want to continue to do debridement. It’s not a onetime event. The aggressiveness of the debridement is going to depend on the load of the tissue. Is it devitalized tissue versus how much healthy tissue? The patient’s tolerance to being still.





You need a patient that will be still while you have a sharp instrument in your hand. You, there can be time constraints for the practitioner. You need to have help available often times. How many of you go in there and debride by yourself? Who debrides by yourself? Oh, so several, oh, you debride by yourselves? All right. Sometimes you need help, especially if you have to help, need help to hold that patient in a position, in the same position for extended period of time, especially in long term care.



Anatomy is going to be the key to comfort for doing sharp debridement. You want to be able to recognize what is normal, avoid trouble, identify what you’re about to remove. Please have a policy and procedure in place. You do need one.



This is a particular patient who was on the operating table for an eight hour period, so she had gross, she ended up with this necrotic wound, three days, three or four days later. Now, they didn’t put the betadine on the wound. They did it around the wound and they did a sharp debridement process. Then they, and they also put the enzyme on. Then they repeated sharp debridement, then they started pulse lavage with suction, and put the enzyme on. Then they did enzymatic debridement, and I happen to know it was collagenase. They continued with collagenase, and for all intents and purposes it’s closed. So this is what happens: you combine your debridement options to get the best outcome of a clean and functional wound bed.



So in summary, debridement is integral to creating a functional wound bed. It transforms this hostile environment of a chronic wound into a more receptive milieu. It is fundamental to facilitate the wound closure and create that functional wound bed. It creates an optimal wound bed for the application of advanced wound products such as skin substitutes or growth factors. It can be accomplished by several different methods, or alone, in combination or alone, and you’re going to choose, the method is going to be dependent on the unique characteristics of your patient and of your wound.



Thank you very much.



[applause]

In this lecture, Dr. Scarborough emphasizes the role of debridement as a component of wound bed preparation in sustaining a functional wound environment. She discusses the different debridement types including: autolytic, enzymatic, biosurgery, mechanical and sharp debridement. Content includes indications/contraindications, safety measures, and products and instruments for performing the different types of debridement. In addition, practice and legal considerations are discussed, particularly for the non-physician. Join Pamela for this information-packed lecture on debridement as a component of wound bed preparation.
Goals and Objectives
After participating in this activity, the viewer should be better able to:
1. Review the rationale behind correct debridement procedures.
2. Propose an acceptable set of practice protocols in relation to debridement
3. List acceptable protocols for safe and effective debridement
4. Identify legal issues in relation to debridement

Estimated time to complete this activity is 32 minutes.
Target Audience
Nurses, Therapist, and other health care professionals who care for patients with wounds, ostomies, and incontinence.
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Debridement as a Component of Wound Bed Preparation-Autolytic, Enzymatic, Mechanical and Sharp Debridement
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Debridement as a Component of Wound Bed Preparation-Autolytic, Enzymatic, Mechanical and Sharp Debridement
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Debridement as a Component of Wound Bed Preparation-Autolytic, Enzymatic, Mechanical and Sharp Debridement
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It is the policy of PRESENT e-Learning Systems and it's accreditors to insure balance, independence, objectivity and scientific rigor in all individually sponsored or jointly sponsored educational programs. All faculty participating in any PRESENT e-Learning Systems programs are expected to disclose to the program audience any real or apparent conflict(s) of interest that may have a direct bearing on the subject matter of the continuing education program. This pertains to relationships with pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the presentation topic. The intent of this policy is not to prevent a speaker with a potential conflict of interest from making a presentation. It is merely intended that any potential conflict should be identified openly so that the listeners may form their own judgments about the presentation with the full disclosure of the facts.
Pamela Scarborough, PT, DPT, MS, CDE, CWS Pamela Scarborough has nothing to disclose
Privacy Policy
Debridement as a Component of Wound Bed Preparation-Autolytic, Enzymatic, Mechanical and Sharp Debridement
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This web site will respect the confidentiality of the information that is transmitted on it in accordance with the provisions of this Agreement. The Web Site uses a random identifier, which is a session number attributed to the Registered User as he enters the site. This session number is expunged of the Web Site system as Registered User leaves. Please be advised that the Registered User's visit to the Web Site leaves a retrievable trace that allows the Web Site to gather raw data on the Registered User. Such technical retrieving system is necessary in order to secure the Web Site system.

This web site uses statistic and measurement systems which compile and process information such as IP numbers and number of visited pages. This information is processed in order to establish members' profiles and trends that may lead to, for example, market studies.

By registering to Web Site services, the Registered User agrees that his/her personal information may be archived in the members database of the Web Site and be used to transmit newsletters published by the Web Site and communications such as press releases or commercial information by the Host.

Information We Collect

In this section of our Privacy Policy, we discuss the different types of information we may collect about you, and the ways in which we collect them.

Information We Collect from Unregistered Visitors

Visitors to each of our Web sites can access the Web site's home page and browse some areas of the site without disclosing any personally identifiable information. We do track information provided to us by your browser, including the Web site you came from (known as the "referring URL"), the type of browser you use, the time and date of access, and other information that does not personally identify you. On most of our Web sites, you must register with us to use the entire site.

Information We Collect When You Register

Customers registering for services on our Web sites are asked to provide us with identifying information, such as name, gender, contact information, and other personal information. On our registration screens, we clearly label which information is required for registration, and which information is optional and may be given at your discretion. You will also be given a choice about whether or not you want to receive newsletters and other information that we distribute from time to time. This PRESENT e-Learning Systems Web site will explain how personally identifiable information will be used and ask for your consent before collecting it.

Other Information

Discussion Boards: When you use a discussion board on one of our Web sites, you may post a message and your user name, which is available for all registered users to see. When you are posting publicly, any user of our Web site can see your message. You should not post any information you want or are required by law to keep private to a discussion board or other public forum on our Web sites.

My CV (Curriculum Vitae): On our web site, we offer an online data based profiling tool in which you supply information that is part of your curriculum vitae or professional resume. This tool stores the information that you provide on our servers. The information is accessible by other members and the public, and is designed to advertise you to the online community and allow other's to find you based on the information that you provide. We will always make it clear to you when information you provide to us through a tool will be saved.

Member Lookup: On our website, other members will be able to look you up and send you messages. If you opt not to be listed (blocked), no other members will be able to look you up.

In addition, we gather information about you that is automatically collected by our Web server, such as your IP address and domain name. We will use this information to personalize its offerings and presentations to you, facilitate your movements throughout our Web sites, provide personalized services, and to communicate with you individually.

Continuing Medical Education

When you register for a Continuing Medical Education ("CME") or a Continuing Education ("CE") activity through our web site, we collect certain personally identifiable information from you such as your name, email address and mailing address. We require that you provide the state in which you are licensed and your license number. In addition to personally identifiable information, we collect aggregated non-personally identifiable information about the activities undertaken by our users. We use the information that we collect through CME/CE activities in several ways:

(i) We are accredited by the Accreditation Council for Continuing Medical Education ("ACCME") to provide continuing medical education for physicians, through a sponsorship agreement with the Mount Sinai School of Medicine. As an ACCME accredited entity, we are required periodically to submit aggregated data about CME participants and the CME activities we certify. We also provide personally identifiable information to other accredited CME/CE providers who certify CME/CE activities posted on our Web sites, as required by the ACCME and other accrediting bodies. These reports may include personally identifiable information about you and credits issued to you, for the purpose of maintaining records that you can request from the accredited provider for up to six (6) years;

(ii) Commercial supporters of CME/CE activities on our Web site will receive only a data about CME/CE activities that are relevant to their interests and/or the courses they support;

(iii) Our Editorial and Customer Support Staff will have internal access to files containing personally identifiable information, including evaluation forms and aggregated CME /CE participant information. These files can be accessed in order to respond to your questions or comments. Our staff may also use personally identifiable information, including registration information and evaluation data, in assessing educational needs and planning marketing activities; and we may use the information we collect as otherwise permitted in this Privacy Policy.

Use of Cookies

Cookies are a technology we use to keep track of users as they move through our Web sites. Your browser allows us to place some information on your computer's hard drive that is associated with the computer you are using. We use cookies to personalize our Web sites and to track your usage across all of our Web sites. Your Web browser can be set to allow you to control whether you will accept cookies, reject cookies, or to notify you each time a cookie is sent to you. If your browser is set to reject cookies, Web sites that are cookie-enabled will not recognize you when you return to the Web site, and some Web site functionality may be lost. The Help section of your browser will tell you how to prevent your browser from accepting cookies.

Although cookies do not normally contain personally identifiable information, if you are a registered user, we may elect to associate your registration information with cookies our Web site places on your computer's hard drive. Associating a cookie with your registration data allows us to offer increased personalization and functionality. For example, you can elect to have our Web sites "remember" your user name and password and bypass the sign-in process on each visit to the site. Without cookies, this functionality would not be possible. Some of our business partners may use cookies on our site (for example, advertisers.) We have told them that we do not want them to use cookie information to track our users' activities once they leave our Web sites. However, because of the way advertisements are served on our Web sites, we do not have total control over how advertisers use cookies on our Web site. If you believe that one of our advertisers is placing an unwanted cookie on your hard drive, please contact privacy officer ( privacy@presentdiabetes.com ) to assist us in resolving the problem.

Uses We Make of Information

In this section of our Privacy Policy, we identify the ways we may use information about you that we have collected.

Aggregate Data

We collect data about visitors to our Web sites for product development and improvement activities. We also use it for market analysis. We may provide information from our Web sites in aggregate form, with identifying information removed, to third parties. For example, we may tell a health care partner what percentage of our registered users are of a particular medical specialty or have certain credentials. Any third party that receives our data must agree not to attempt to re-identify the people it belongs to. For example, we may provide information to a potential advertiser of a product that would appeal to a diabetes patient about what percentage of our users have diabetes. Depending on our agreement with the third parties, we may or may not charge for this information.

Marketing and Advertising

We may target our advertising or marketing depending on information we have about you. For example, a user that is a healthcare professional who treats diabetes may receive advertising for new diabetes therapies (although in neither case will the advertiser have access to any individually identifiable information about you). We may also personalize our Web site based on your interests. For example, you may see different articles in different places on our Web site based on information you have shared with us, or information we have gained by observing your previous behavior, or information we may have gained from your interactions with a third party that shares information with us. We use information for our own internal marketing, research, and related purposes. Third Parties In addition to aggregate information (discussed previously), we may share some kinds of personally identifiable information with third parties as described below.

Other Companies: We have strategic relationships with other companies who offer products and services on our Web sites. When you are interacting with those companies, different rules and privacy policies may apply. We do not control the collection or use of information you provide to these companies, but we do require that those companies clearly state their policies so you can decide whether to give them any information.

Our Employees and Consultants: We contract with other companies and individuals to help us provide services. For example, we may host some of our Web sites on another company's computers, hire technical consultants to maintain our Web-based tools, or work with companies to remove repetitive information from customer lists, analyze data, provide marketing assistance, and provide customer service. In addition, if you are a healthcare professional, we may validate your licensure status and other information against available databases that list licensed health care professionals. In order to perform their jobs, these other companies may have limited access to some of the personal information we maintain about our users. We require all such companies to comply with the terms of our Privacy Policy, to limit their access to any personal information to the minimum necessary to perform their obligations, and not to use the information they may access for purposes other than fulfilling their responsibilities to us. We use our best efforts to limit the use of other companies in areas where personally identifiable information may be involved.

Promotional Offers: Sometimes we send offers to selected groups of customers on behalf of other businesses. When we do this, we do not give that business your name and address. We provide a variety of mechanisms for you to tell us you do not want to receive such promotional offers. For example, we may provide an opt-in box for consumers to receive an email from another business, and we make clear that by opting in you are submitting your data to a third party.

Protection of Information

In this section of our Privacy Policy, we discuss the security measures we take to protect information that we have collected about you.

We have implemented technology and security policies, rules and other measures to protect the personal data that we have under our control from unauthorized access, improper use, alteration, unlawful or accidental destruction, and accidental loss. We also protect your information by requiring that all our employees and others who have access to or are associated with the processing of your data respect your confidentiality. We use security methods to determine the identity of its registered users, so that appropriate rights and restrictions can be enforced for that user. Reliable verification of user identity is called authentication. We use both passwords and usernames, as well as double opt-n verification, to authenticate users. Users are responsible for maintaining their own passwords.

Access to Information and Choices

In this section of our Privacy Policy, we tell you how to obtain and correct information we have about you, and how to choose what types of information you may share with us.

Correction of Information We Have About You

If you believe that registration information collected by our Web site(s) is in error, you may edit your personal profile any time that you like. You can directly edit most of your user profile on the Web site on which you initially registered. Information that you can not edit may only be changed by contacting Web Customer Support (see CONTACTS). Requests for deletion of your record may result in your removal from the registry, but we may keep certain demographic information about you for product improvement purposes. You may contact Web Customer Support and ask for the changes that you would like to make.

Our Employees

Our employees are required to keep customer information private, as a condition of their employment with the company. Only selected, authorized employees are permitted to access personal information. Our employees with access to personally identifiable information are required to attend a confidentiality/privacy training class, and to sign a confidentiality agreement. All employees and contractors must abide by our Privacy Policy, and those who violate that policy are subject to disciplinary action, up to and including termination of their employment and legal action.
Copyright Statement
Debridement as a Component of Wound Bed Preparation-Autolytic, Enzymatic, Mechanical and Sharp Debridement
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This website and its content is copyright of PRESENT eLearning Systems, LLC - © 2007-2012 All rights reserved. Any redistribution or reproduction of part or all of the contents in any form is prohibited other than the following:

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