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Professional Research Project 1

Running head: PROFESSIONAL RESEARCH PROJECT ON THE USE OF SILVER

The use of silver dressings on slow healing ulcerations

Laura Schmidt

Grand Canyon University

Professional Research Project

NRS-441V

Nicolette Estrada


Abstract

Based on current research, the use of silver alginates has come into the forefront again

for use in slow healing ulcerations. Studies have pointed to the bacterial load of the wound bed

as the main factor for delayed healing. Silver alginates in wound dressings can reduce the

healing time by providing an optimal environment for new tissue to grow. It is shown to be

effective against many bacterial strains such as well as MRSA and VRE. Silver helps to prevent

the bacterium from replicating as it interferes with DNA and RNA preventing the virus from

reproducing allowing for the development of healthy granulation tissue. When the wound bed is

properly protected from further bacterial assault, it will facilitate faster healing times and reduce

the cost of care in nursing time and treatment costs.

Keywords: Silver, slow healing ulcerations, treatment products, assessment, bacterial studies


The use of silver dressings on slow healing ulcerations

Introduction

Many facilities have patients who are under treatment for chronic wound healing. “Leg

ulcers are a problem for both patients and health service resources. Most ulcers are associated

with venous disease, but other causes or contributing factors include arterial disease, immobility,

obesity, trauma and diabetes” (Charles, H., 2010). Patients can also suffer with neuropathies and

autoimmune diseases, which further complicate healing. Many non traumatic lower-limb

amputations and other costly medical treatment for chronic wounds were attributed to the

incidence of diabetic foot ulcers when the ulcers were infected, cellulitis and osteomyelitis could

develop very quickly” (Tong, J., 2009). For this reason, wound infections should be treated early

and aggressively. Patients with chronic wounds have traditionally had a decreased quality of life.

They also have longer hospital stays causing an increased load on the nursing staff, as well as

greater pain and risk for systematic infection. The primary problem for nurses is that many times

the wound does not initially show any clinical signs of contamination.

Another primary concern is the cost of treatment causing an ever increasing burden on

the healthcare system. “Wound infection is one of the most challenging aspects of wound

management today. It is a major contributor to health care costs around the world, and causes

significant distress to patients and caregivers” (Harding, K., & Renyi, R. ,2009). The incidence

of diabetes mellitus is also on the rise. These types of patients typically have a greater incidence

of infection in localized wounds. It is prudent then to find other measures for the prevention of

infection and the reduction of healing time thus improving the patient’s quality of life for the

short and long term.


One intervention being studied in recent years is the use of silver in dressings to facilitate

healing and prevent further infection of the body. “Aside from its antimicrobial effect silver has

been shown to have a pro-healing and anti-inflammatory effect” (Smithdale, 2008). Many of

these wounds are slow healing because of the microbacteriology that are not initially diagnosed,

as these wounds do not show typical signs of infection such as redness or swelling. “The proven

antimicrobial activity of ionic silver includes its broad-spectrum activity against Gram-positive

and Gram-negative microorganisms. It also has antibacterial effects on antibiotic resistant

bacteria, such as methacillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant

enterococci (VRE)” (Barrett, 2009).

“Many practitioners may prefer a few favorite dressings, i.e. dressings that they have

seen work on other patients and feel sufficiently familiar with. The problem with

managing wounds in this manner is that it tends to place greater emphasis on choosing

the dressing, than considering what is happening at the wound bed, and perhaps more

significantly, identifying the underlying etiology” (Smithdale, 2008).

It is further suggested that one of the greatest benefits of newer silver nanocrystalline dressings

is the longer period of time they can be left in situ, reducing the amount of trauma and pain

experienced by the patient” (Elliott, C., 2010). “As well as the economic cost, there is also a

considerable personal cost for the patient– decreased quality of life, reduced self-esteem, loss of

dignity, pain and suffering. Thus it is vital to be able to provide clear and effective strategies for

prevention and management in all areas of patient care” (Riordan & Voegeli, 2009). Finding a

more cost effective strategy for treating infected wounds would also reduce the burden of the

nursing staff.


The decision for a program directed at patients with slow healing ulcerizations should

begin with reviewing chart audits of patients and data collection related to cost and length the

length of treatment. The audit tool for an initial risk assessment; Braden scale has already

developed and being ulitized, however an additional assessment process for patients already with

the ulcers should be initiated as well. New treatment protocols and treatment with silver

products would be the last step for implementing this.

Once the new treatment procedure for silver has been developed and approved for

execution, education of the management team, and the unit managers as well as nursing staff

will take precedence. Continuous summaries of patient wound progress during the initiation

period should be made available to everyone.

Finally, outcome measures will have to be initiated to determine success of the new

treatment. Monitoring and data collection through presentation to the team of all audits should be

completed to determine if compliance was maintained as well as the success of the new

assessment and treatment protocol processes at the end of the six month period. This can be

determined by analyzing length of treatment and ensuing healthcare costs. Monitoring of

patient satisfaction and staff surveys will also be added to the final report.

Implementation

“Pressure ulcers, which are also referred to as decubitus ulcers, pressure sores, and

bedsores, are a significant and costly healthcare problem for patients and providers. They are

defined by the National Pressure Ulcer Advisory Panel as “…localized areas of tissue necrosis

that develop when soft tissue is compressed between a bony prominence and an external surface

for a prolonged period of time” (Fleishman, 2009). The use of medications, treatment supplies

and nursing care for these types of wounds have driven up the cost in healthcare facilities.


Several new studies on the use of silver to manage these slow healing wounds have come into

the forefront again for an alternative to treat non-healing ulcerations. “An increased bacterial

load on the surface of a wound amplifies and/or perpetuates a proinflammatory environment.

Hence, it has been postulated that in order to improve the opportunity for wound healing, it is

necessary to create conditions that are unfavorable to micro-organisms and favorable for the host

repair mechanisms” (Wiegand,C.; Heinze, T.; Hipler, U, 2009).

Change theories in nursing are used in nursing to bring about planned change. Planned

change involves recognizing a problem a creating a plan to address it” (docstoc.com, 2011). In

assisted living facilities many patients have developed slow healing pressure ulcerations.

Standard of care with hydrocolloid and calcium alginate dressings have not proven successful

since microbacteria may be a factor impeding the healing process. It has been suggested by the

wound care nurse that new methods for reducing the bacterial load on the wound bed such as

silver need to be explored. Spradleys Theory of change suggests that a problem has been

identified. Patients are suffering from slow healing ulcerations that have not responded to

traditional therapy. In accordance with the theory, a problem is identified and another alternative

is suggested that might provide a better outcome. In accordance with this theory, the suggestion

is using the alternative and evaluate it for a given period. If the patients do show signs of

improvement over six months, the new protocol would then be implemented to use on all

patients with this type of ulceration across the board as the new best practice for these types of

wounds.

At present, the policy and procedure for treating ulcerative wounds in the facility is as

follows: Initial assessment is done by the assessment nurse at the time of admission. If the

patient has an open area, documentation is completed on the patient chart and the wound team;


comprising of the nurse practitioner, a wound specialist nurse and the unit manager are alerted to

assess the patient for further treatment. After assessment, the patient is treated with calcium

alginate dressing or hydrocolloid dressing based on the appearance of the wound bed. The

wound team then makes weekly rounds on patients. If there is no improvement after one month

of this therapy, the patient is referred to a wound center facility, off campus, for further

treatment options. There is no initial assessment of bacterial load of the wound bed in our

current standard of care. At present, many of our patients with these types of wounds are being

treated at other facilities at great expense to our organization. Due to new standards by

insurance companies not reimbursing for hospital-acquired infections currently underway, as

well as the rising healthcare costs of patient care and nursing time spent on treating these

wounds, it is within our best interests to find other more effective ways of managing wound

infection in our own facility.

The new proposal will be that every patient who has a slow healing ulceration is

immediately cultured for bacterial infection of the wound. Based upon these findings, these

patients will be treated with a specific type of silver impregnated dressing. Those patients will

continue to be assessed weekly by the wound care team for management and assessment tool

will continue to be used to document the changes in wound bed. These patients will also be

given a course of antibiotics if they are positive for gram negative or gram positive rods to

facilitate healing and prevent sepsis from developing during the treatment phase.

The rationale for this proposed solution is based upon the numerous studies conducted on

the use of silver in dressings for locally infected wounds. “Leg ulceration associated with

venous insufficiency affects approximately 1% of the Western population” (Scanlon, E.,

Karlsmark, T., Leaper, D., Carter, K., Poulsen, P., Hart-Hansen, K., & Hahn, T. (2005). Because


of the widespread incidence of venous ulcerations has increased in recent years due in part to the

rise in diabetes mellitus II, new ways of treating this disease must be looked it. “Many non

traumatic lower-limb amputations and other costly medical treatment for chronic wounds were

attributed to the incidence of diabetic foot ulcers. When the ulcers were infected, cellulitis and

osteomyelitis could develop very quickly” (Tong, 2009). Significant time is also spent by the

nursing staff to treat these types of wounds as well as decreased quality of life for the patients.

“It is widely accepted that many ulcers with delayed healing are bacterially challenged, and it

may well be that excess bacteria cause the delay in healing” (Scanlon, E., Karlsmark, T., Leaper,

D., Carter, K., Poulsen, P., Hart-Hansen, K., & Hahn, T. (2005). “The combination of well

balanced antibacterial effect of the new silver dressings with effective exudate management has

proven to be clinically effective in the treatment of long standing venous leg ulcers” (Scanlon,

E., Karlsmark, T., Leaper, D., Carter, K., Poulsen, P., Hart-Hansen, K., & Hahn, T. (2005).

“Silver has proven antimicrobial activity that includes antibiotic-resistant bacteria, such

as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant

enterococci (VRE). Its role as an antimicrobial agent is particularly attractive, as it has a

broad spectrum of antimicrobial activity with minimal toxicity toward mammalian cells

at low concentrations and has a less likely tendency than antibiotics to induce resistance

due to its activity at multiple bacterial target sites” (Scanlon, E., Karlsmark, T., Leaper,

D., Carter, K., Poulsen, P., Hart-Hansen, K., & Hahn, T. (2005).

Numerous studies have indicated that the presence of infection at the site is the primary

cause for non-healing wounds and the use of silver products slows the progress of these types of

infections by preventing the replication of viral cells. “Silver (Ag1) is effective against a broad


range of micro-organisms such as yeast, mold, and bacteria, including MRSA and VRE, when it

is provided at an appropriate concentration”(Wiegand,C.; Heinze, T.; Hipler, U, 2009).

Having identified with the initial wound team members that patients with slow healing

ulcerations are not showing significant signs of improvement, the new proposal for the use of

silver impregnated dressings will be presented in summary form to the administrative team by

the wound nurse. A power point presentation, briefly outlining the use of silver as well as the

progression of ulcers being treated with silver, outline (Appendix A) and handouts (Appendix B)

will be presented to the management team and staff nurses. A brief cost analysis from the

previous year along with the projected outcome for decreasing the duration of the treatment with

the use of silver products will be discussed on initial meeting. Upon garnering support, a new

written protocol (Appendix C) for the use of silver in those patients who have tested positive for

wound infection will be written by the wound team and given to the staff nurses.

Upon initial assessment, the nurse will provide the patient with a questionnaire about the

duration of the ulcer (Appendix D). This will include how long the patient has been seeking

treatment for the wound as well as what types of treatments, including antibiotic therapy, were

used, if any, by the patient. The Braden scale (Appendix E) is used to determine if the patient is

at risk for pressure ulceration, however, this only looks at the risk factors, it does not include

those patients who already have ulcerations, and therefore, the use of an audit tool to define the

initial assessment of the ulceration is crucial. The tool will define the parameters of the wound;

length and width, depth, the wound bed appearance, is there are exudates or eschar present as

well as any localized redness or tenderness to the area. Patients who are already being managed

by the wound team, as well as those patients who are admitted to the facility with a slow healing

ulcerations, will have the wound swabbed for bacterial load. The data will be collected by the


assessment nurse and placed in a file so that this can be assessed by all team members to develop

a plan of care for the individual. Patients who have not responded to hydrocolloids and calcium

alginates will be started on silver treatments. Bacterial load will be evaluated at the beginning

and end of trial period using diagnostic testing as well as monitoring the wound bed for a six-

month period by wound team. A weekly flow sheet will be completed by nursing staff to

document changes in wound bed (Appendix F). Diagnostic testing will also be done once every

four weeks then monthly and meet monthly to discuss findings for efficacy and cost

effectiveness to include the amount of time spent by nursing staff to treat wounds as well as cost

analysis of silver products versus customary standard of care. If the change is valid, the new

standard of care using silver should be implemented.

Evaluation

Since there are a variety of silver dressings on the market today and “these dressings

have varied responses in clinical use due to technological differences in the nature of their silver

content and release and in properties of the dressings themselves” ( Parsons, D.; Bowler, P.;

Myles, V., Jones, S., 2011), the powerpoint presentation will also include several silver

dressings to use in staff meetings as well as with management team to instruct on the different

types of products available on the market. The team will consist of the nurse practitioner who

will work with the wound nurse and unit managers to implement a handout for the staff nurses to

refer to for treatment protocol with silver as well. A short test (Appendix G) will be given to

each participant to see if the information given was adequately understood. Each unit will be

provided with a poster with the names of each of the products and which application they are to

be used in for easy reference. Since medication and treatment administration records (MARS,


TARS) are still used in paper form, a laminated copy of silver products will also be put in the

front of each TAR as well.

A cost analysis will be drawn up by the administrative office to determine the allotted

amounts of monies to be spent for educational materials. All materials will be computerized in a

data collection survey overseen by the wound nurse, who will act as the change agent, to draw

up a statistical study at the end of the project to evaluate the effectiveness of the silver. Copies

will also be kept of the assessment tool to determine the length of time the wound healed to

compare with the previous use of non-silver products and presented to the board members. A

budget analysis will also be made upon completion for the use of the silver products versus the

length of the treatment for each individual to determine overall costs at the end of the six months

and present this to the board as well.

Prior to the initiation of the silver protocol, data collection will be made of the patients

who were being treated with calcium alginate and hydrocolloid products. This data, along with

the presentation of the powerpoint and handouts will be given to the senior nursing staff to

include all unit managers as well as the administrator, medical director, staff nurse practitioner

and the director of nursing. At the end of the six-month time period, this will be used to

determine if the silver treatments actually improved the healing times for the patients. The data

for this project will be collected by the wound nurse and prepared for oral presentation to all

aforementioned groups on a monthly basis to promote discussion and evaluation of current

treatment plans. A general outline of the process and the results of the audits that were collected,

in computerized format, will be made available. Also included will be:


i. A brief survey (Appendix H) will be conducted after seeing the presentation for

the silver protocol of staff nurses to ensure that all staff are comfortable with the

implementation of the silver products and their usage.

Some questions will include

Were the protocols for silver used

Was the patient treated with antibiotics

Did the patient have any untoward symptoms with use of silver products

ii. A brief survey conducted of the patients during and after treatment to assess the

quality of care and patient satisfaction. (Appendix I).

Some questions will include:

The length of the treatment

Quality of treatment

Nursing assessment adequate

Understanding the handouts for treatment with silver.

Since the nursing staff will be the ones providing the treatment, it is imperative to assess

the education given in the initial presentation to evaluate staff perception of the new process. An

evaluation of the staff to determine if they feel comfortable utilizing the new treatments and to

address any areas that warrant further teaching by the wound team on the use of the different

silver products that will be provided in the medication admission record. The patients will also

be interviewed prior to receiving the new protocol as well as some of the literature, such as the

handouts that were presented during the power point presentation to help them understand what

the new treatment will consist of.


Dissemination

This dissemination plan is to be completed within a six-month time frame in order to

allow enough time for all team members to be introduced and provided the needed materials to

start the new protocol with silver. The intended audience for the proposed strategy and process

change will begin with the senior nursing staff to include all unit managers as well as the

administrator, medical director, staff nurse practitioner and the director of nursing. “Key

stakeholders were central to the successful revision of processes and subsequent evaluation of

outcomes” (Fineout-Overholt,E.,Johnston, L. 2007). The goal of the dissemination plan is that

the target audience, as stated above, will have access to review the projects overall outcome

strategy as well as weekly updates and progress reports on patients. The audience will be given a

copy of program protocol outline for treatment, as well as the new documentation flow sheet for

patient evaluation so that they can familiarize themselves with the questionnaire. Presentation of

the proposed change in protocol for the use of silver in slow healing wounds will also include a

short survey to review if the information provided will need to be clarified further. The team

will meet on a weekly basis to evaluate progress of patient wounds as delineated in the

documentation of the patient’s wound flow sheet. They will also be reviewing financial outlays

for treatments and present this to administration. After the evaluation process is completed then

key stakeholders as well as the nursing staff may view all data collected and continue

monitoring and evaluating the success of the process change.

Finally a review and detailed report of the entire project/proposal outcome will be sent to

the Nursing Reference Center at EBSCOhost. The Nursing Reference Center (NRC)” is a

comprehensive reference tool designed to provide relevant clinical resources to nurses and other

health care professionals, directly at the point-of-care” (Nursing Reference Center, 2009). This


will provide an outlet so that the above project/proposal can be viewed by other clinicians who

might have questions about the use of silver dressings.

`Conclusion

The mandate for high quality care will be driven by outcome measures that are

observable, documented and are the result of nursing activities (Frisch, N., & Kelley, J.,2002).

“Nurses now spend 25% to 50% of their time on treating wounds” (Harding, K., Renvi, R.,

2009). “The combination of well balanced antibacterial effect of the new silver dressings with

effective exudate management has proven to be clinically effective in the treatment of long

standing venous leg ulcers” (Scanlon, E., Karlsmark, T., Leaper, D., Carter, K., Poulsen, P.,

Hart-Hansen, K., & Hahn, T. (2005). With this in mind, as the project proposal for the use of

silver is documented and evaluated over the specific time frame and it has been evaluated for its

effectiveness by the team, we can then add our evidence practice to be used by other healthcare

providers to provide quality care for their patients as well. “The purpose of the dressing is not to

heal the wound, but to help provide the optimal conditions for healing to progress more

normally” (Smithdale, R., 2008). Silver has been shown to be an effective treatment in the

healing process.

“The underlying reason to gain and then disseminate new research-based information, is

to assure it is appropriately considered for use in reaching decisions, making changes, or taking

other specific actions designed to improve outcomes” (Rush, 2001). As we reach out for new,

more effective ways in treating our patients and improving their quality of life as well as

considering the rising healthcare costs, we must consider other alternatives that have proven

their efficacy based on numerous studies conducted over the last few decades.


Annotated Bibliography

i. Ballard, K., & McGregor, F. (2002). Product focus. Avance: silver hydropolymer

dressing for critically colonized wounds. British Journal of Nursing (BJN), 11(3), 206.

This case study provides analysis of the use of silver and its antimicrobial

properties and its usage in wound healing.

This provides two case studies along with tables to provide evidence of wound healing

with the use of a specific silver product.

Study supports the proposal that silver does improve healing time and infection control

in bacteriological analysis of both patients.

ii. Brown, A. (2010). Silver dressing use in chronic wounds: let clinical judgment be the

guide. British Journal of Community Nursing, 15S30-7.

This study is being used because it addresses clinical applications on the use of

silver alginates on chronic wound healing as clinical signs of infection are not often

present.

This RCT provides case studies and clinical trials on the use of silver for infection and

wound healing.

It validates the use of silver for improvement in patients quality of life and cost

effectiveness for use

iii. Elliott, C. (2010). The effects of silver dressings on chronic and burns wound healing.

British Journal of Nursing (BJN), 19(15), S32-6.

This paper addresses whether or not the use of silver alginates and silver

sulfadiazine can produce toxicity in patients and well as addressing all the relevant


studies that have been done recently on the antimicrobial properties of silver alginate

dressings as well.

iv. Jorgensen, B., Gottrup, F., Karlsmark, T., Bech-Thomsen, N., & Sibbald, R. (2008).

Combined use of an ibuprofen-releasing foam dressing and silver dressing on infected

leg ulcers. Journal of Wound Care, 17(5), 210-214.

Addresses infection as well as pain control in wounds and how this affects

quality of life for the patient.

The study includes the use of two foam dressings that include ibuprofen and silver to

promote wound healing and pain control and used for both graphs healing times and pain

control.

v. Jude, E., Apelqvist, J., Spraul, M., & Martini, J. (2007). Prospective randomized

controlled study of HYDROFIBER dressing containing ionic silver or calcium alginate

dressings in non-ischaemic diabetic foot ulcers. Diabetic Medicine, 24(3), 280-288.

The study provided information about whether wounds healed faster and had

significant improvement in infection control when utilizing silver dressings.

This RCT compared silver impregnated dressings and calcium alginate dressings

without silver.

Most importantly it does support the proposal in that the silver treated wounds (n-67)

had significantly greater improvement in infection rate and reoccurrence.


vi. Lo, S., Hayter, M., Chang, C., Hu, W., & Lee, L. (2008). A systematic review of silver-

releasing dressings in the management of infected chronic wounds. Journal of Clinical

Nursing, 17(15), 1973-1985.

This study critiqued different research journals on the use of silver products to

find any congruency.

This clinical review is looking at a total of 1957 studies to determine if, in fact, silver

dressings actually are clinically proven to reduce healing time.

Article does support that silver will help improve the patients length of stay and

improving patients quality of life.

vii. Miller, M., Girolami, S., Powers, K., & McDaniel, C. (2006). APWCA case #3: use of

the versatile one negative pressure wound therapy and Silverderm to heal a complex

infected diabetic foot wound. Podiatry Management, 25(5), 147.

The article provides detailed study of the use of silver products with other therapies

and the subsequent reduction of infection and increased wound healing.

It provides statistical information on the regression of wound over a period of time.

Supports the proposal for the use of silver products as an adjunct therapy for infection

control and accelerated wound healing.

viii. Ousey, K., & McIntosh, C. (2009). Topical antimicrobial agents for the treatment of

chronic wounds. British Journal of Community Nursing, 14(9), S6-15.

This article would again be used to show the different antimicrobial agents used

in wound healing such as honey, iodine and silver.

Even though different modalities were looked at, they suggest that silver does improve

patient quality of life, and reduce hospital costs for treatment of slow healing wounds.


ix. Penny, H., Meloy, G., & Penny, M. (2006). APWCA case #2: use of a specialized silver-

containing absorbant dressing in the management of interdigital pressure ulcers. Podiatry

Management, 25(5), 141.

This article was a case study of only one individual who had non-healing ulcers

between the digits.

Even though study is only a few patients using specialized silver treated dressings, it is

relevant to the because it shows significant improvement in pressure ulcers specifically

with the use of silver products.

x. Tong, J. (2009). Case reports on the use of antimicrobial (silver impregnated) soft

silicone foam dressing on infected diabetic foot ulcers. International Wound Journal,

6(4), 275-284.

This study describes diabetic ulcers and how patients quality of life and also the

significance to the cost of treating these slow healing wounds on the healthcare system .

It provides statistical information on the patient load for diabetic wounds as well as case

studies specifically with the use of silver impregnated foam dressings such as Mepilex.

Study does supply significant evidence to support using silver foam dressings with other

modalities such as offloading.


xi. Trial, C., Darbas, H., Lavigne, J., Sotto, A., Simoneau, G., Tillet, Y., & Teot, L. (2010).

Assessment of the antimicrobial effectiveness of a new silver alginate wound dressing: a

RCT [corrected] [published erratum appears in J WOUND CARE 2010 Mar;19(3):109].

Journal of Wound Care, 19(1), 20-26.

Promotes the antimicrobial qualities of silver nitrates and its efficacy and tolerability

in wound care. This study is used to determine if silver makes a difference in the

bacterial level of the wound.

Research uses numerous studies for statistical information and comparison with non-

silver dressings.

xii. Rayman, G., Rayman, A., Baker, N., Jurgeviciene, N., Dargis, V., Sulcaite, R., & ...

Gottrup, F. (2005). Sustained silver-releasing dressing in the treatment of diabetic foot

ulcers. British Journal of Nursing (BJN), 14(2), 109.

The article reports that diabetes is the most prevalent disease now being

discussed by the World Health Organization (WHO). Diabetic ulcerations then are the

biggest concern for healthcare professionals as these are most prone to infection.

It provides statistical data on the use of specific types of silver impregnated dressings as

well as comparative studies.


xiii. Scanlon, E., Karlsmark, T., Leaper, D., Carter, K., Poulsen, P., Hart-Hansen, K., &

Hahn, T. (2005). Cost-effective faster wound healing with a sustained silver-releasing

foam dressing in delayed healing leg ulcers -- a health-economic analysis. International

Wound Journal, 2(2), 150-160.

The article is studying cost effectiveness for four types of silver impregnated

dressings. The article also looked at the length of time for wound healing when using

silver and wounds that would not heal because of bacteriological agents in the wound

bed.

It provides statistical data on the efficacy of the four products and cost comparison as

well as the length of time for complete wound healing to occur.

This does support proposal that the use of silver dressings improved wounds.

xiv. Smithdale, R. (2008). Choosing appropriate dressings for leg ulcers. Practice Nursing,

19(11), 552.

The article describes a comparison study for choosing the best methods for slow

healing and infected ulcers.

Tables were used to compare different types of therapy such as silver, honey and larval

therapy. There was significant improvement in infection control with the use of silver

products.


xv. Wiegand, C., Heinze, T., & Hipler, U. (2009). Comparative in vitro study on

cytotoxicity, antimicrobial activity, and binding capacity for pathophysiological factors

in chronic wounds of alginate and silver-containing alginate. Wound Repair &

Regeneration, 17(4), 511-521.

The nature of the problem presented in this article is the bacteriological

component of wound healings.

Three different types of dressings were used, one without silver (alginate), one containing

ionic silver (alginate1ionic Ag), and with nanocrystalline silver.

This was a great research article as it showed comparison of silver alginate dressings to

non-silver dressing and that micro bacteria were eradicated with silver products .


References

Ballard, K., & McGregor, F. (2002). Product focus. Avance: silver hydropolymer dressing for

critically colonized wounds. British Journal of Nursing (BJN), 11(3), 206. Retrieved

February 12, 2011 from EBSCO.

Brown, A. (2010). Silver dressing use in chronic wounds: let clinical judgment be the guide

. British Journal of Community Nursing, 15S30-7. Retrieved on February 10, 2011 from

EBSCO.

Charles, H. (2010). The influence of social support on leg ulcer healing. British Journal of

Community Nursing, 15S14-21. Retrieved from March 9, 2011 EBSCO.

docstoc. Change theories in nursing. Retrieved February 19, 2011 from

http://www.docstoc.com/docs/24674584/Change-Theories-in-Nursing

eHow.com. How to apply Spradleys theory of change. Retrieved February 19, 2011 from

http://www.ehow.com/how_5940859_apply-spradleys-theory-change-nursing.html

Elliott, C. (2010). The effects of silver dressings on chronic and burns wound healing. British

Journal of Nursing (BJN), 19(15), S32-6. Retrieved February 11, 2011 from EBSCO.

Fineout-Overholt, E., & Johnston, L. (2007). Evaluation: an essential step to the EBP process.

Worldviews on Evidence-Based Nursing, 4(1), 54-59. Retrieved March 3, 2011

from EBSCOhost.

Frisch, N., & Kelley, J. (2002). Nursing diagnosis and nursing theory: exploration of factors

inhibiting and supporting simultaneous use. Nursing Diagnosis, 13(2), 53-61. Retrieved

March 6, 2011 from EBSCOhost.


Harding, K., & Renyi, R. (2009). The International Wound Infection Institute -- a new global

platform for the clinical management of infected wounds. International Wound Journal,

6(3), 175-178. Retrieved from March 9, 2011 from EBSCO.

Jorgensen, B., Gottrup, F., Karlsmark, T., Bech-Thomsen, N., & Sibbald, R. (2008). Combined

use of an ibuprofen-releasing foam dressing and silver dressing on infected leg

ulcers.Journal of Wound Care, 17(5), 210-214. Retrieved February 10, 2011 from

EBSCO.

Jude, E., Apelqvist, J., Spraul, M., & Martini, J. (2007). Prospective randomized controlled study

of HYDROFIBER dressing containing ionic silver or calcium alginate dressings in non-

ischaemic diabetic foot ulcers. Diabetic Medicine, 24(3), 280-288. Retrieved February

11, 2011 from EBSCO

Lo, S., Hayter, M., Chang, C., Hu, W., & Lee, L. (2008). A systematic review of silver-releasing

dressings in the management of infected chronic wounds. Journal of Clinical Nursing,

17(15), 1973-1985. Retrieved February 11, 2011 from EBSCO.

Miller, M., Girolami, S., Powers, K., & McDaniel, C. (2006). APWCA case #3: use of the

versatile one negative pressure wound therapy and Silverderm to heal a complex infected

diabetic foot wound. Podiatry Management, 25(5), 147. Retrieved February 11, 2011

from EBSCO

Nursing Reference Center, http://ebscohost.com/uploads/thisTopic-dbTopic-1045.pdf

Ousey, K., & McIntosh, C. (2009). Topical antimicrobial agents for the treatment of chronic

wounds. British Journal of Community Nursing, 14(9), S6-15. Retrieved

February 11, 2011 from EBSCO


Penny, H., Meloy, G., & Penny, M. (2006). APWCA case #2: use of a specialized silver-

containing absorbant dressing in the management of interdigital pressure ulcers. Podiatry

Management, 25(5), 141. Retrieved February 11, 2011 from EBSCO.

Rayman, G., Rayman, A., Baker, N., Jurgeviciene, N., Dargis, V., Sulcaite, R., & ... Gottrup, F.

(2005). Sustained silver-releasing dressing in the treatment of diabetic foot ulcers. British

Journal of Nursing (BJN), 14(2), 109. Retrieved February 11, 2011 from EBSCO

Research Utilization Support and Help (RUSH) (2001). Developing an effective dissemination

plan. Retrieved March 6, 2011 from

http://www.researchutilization.org/matrix/resources/dedp

Scanlon, E., Karlsmark, T., Leaper, D., Carter, K., Poulsen, P., Hart-Hansen, K., & Hahn, T.

(2005). Cost-effective faster wound healing with a sustained silver-releasing

foam dressing in delayed healing leg ulcers -- a health-economic analysis. International Wound

Journal, 2(2), 150-160. Retrieved February 11, 2011 from EBSCO.

Smithdale, R. (2008). Choosing appropriate dressings for leg ulcers. Practice Nursing, 19(11),

552. Retrieved February 11, 2011 from EBSCO.

Tong, J. (2009). Case reports on the use of antimicrobial (silver impregnated) soft silicone foam

dressing on infected diabetic foot ulcers. International Wound Journal, 6(4), 275-284.

Retrieved February 11, 2011 from EBSCO.

Trial, C., Darbas, H., Lavigne, J., Sotto, A., Simoneau, G., Tillet, Y., & Teot, L. (2010).

Assessment of the antimicrobial effectiveness of a new silver alginate wound dressing: a

RCT [corrected] [published erratum appears in J WOUND CARE 2010 Mar;19(3):109].

Journal of Wound Care, 19(1), 20-26. Retrieved on February 10, 2011 from EBSCO.


Wiegand, C., Heinze, T., & Hipler, U. (2009). Comparative in vitro study on cytotoxicity,

antimicrobial activity, and binding capacity for pathophysiological factors in chronic

wounds of alginate and silver-containing alginate. Wound Repair & Regeneration, 17(4),

511-521. Retrieved February 10, 2011 from EBSCO


Appendix A

Outline for team managers

THE USE OF SILVER PRODUCTS IN WOUND CARE

I. Wound Infection: How does it affect healthcare

A. Wound infection presents the greatest challenge to wound management to date.

i. “Leg ulceration associated with venous insufficiency affects approximately 1% of the Western population” (Scanlon, E., Karlsmark, T., Leaper, D., Carter, K., Poulsen, P., Hart-Hansen, K., & Hahn, T. (2005).

B. It is the major contributor to health care costs.

ii. “Many non traumatic lower-limb amputations and other costly medical treatment for chronic wounds were attributed to the incidence of diabetic foot ulcers. When the ulcers were infected, cellulitis and osteomyelitis could develop very quickly” (Tong, 2009).

C. In the USA, our health care providers will no longer receive reimbursement for hospital acquired infections. (Harding, K., Renvi, R., 2009).

D. This is causing an increased burden on our nursing staff as well as decreasing the quality of life for many patients.

iii. “Nurses now spend 25% to 50% of their time on treating wounds” (Harding, K., Renvi, R., 2009)

II. History of silver

A. Silver’s first recorded use was by the Romans.

B. In the mid-1800s silver had begun in use in wound care.

iv. “Silver is an ancient therapy that was reportedly used by the Romans for purification of water and in the 18th century was used as an antibacterial agent” (Ousey, K., & McIntosh, C.,2009).

C. In the last two decades, we have seen a radical rise in the use of silver for infected wounds.

v. “There are centuries-old records of silver being used in wound treatment, but the past two decades in particular have seen an increasing clinical application of silver-impregnated wound dressings” (Elliott, C., 2010


III. Infection management and use of silver

A. Bacterial balance is important as microorganisms in the wound bed continue to create an inflammatory response, delaying wound healing.

vi. “The combination of well balanced antibacterial effect of the new silver dressings with effective exudate management has proven to be clinically effective in the treatment of long standing venous leg ulcers” (Scanlon, E., Karlsmark, T., Leaper, D., Carter, K., Poulsen, P., Hart-Hansen, K., & Hahn, T. (2005).

B. When silver ions are released into the wound bed, it inhibits the RNA and DNA replication and eventually die off.

vii. “ionic silver released into the wound bed upon contact with wound exudates are toxic to multiple components of bacterial cell metabolism, thereby destroying their life cycle” (Tong, J. ,2009).

C. Bacterial balance is imperative to ensure unhindered wound healing.

viii. Bacterial balance is imperative in the wound environment to ensure unhindered healing. If an increased bacterial burden is present, it needs to be treated, or there is a distinct risk of infection developing (Lo, S., Hayter, M., Chang, C., Hu, W., & Lee, L., 2008).

IV. Antimicrobial properties of silver

A. Silver has demonstrated marked antibacterial activity against all strains of gram positive and gram negative viruses.

B. Silver is also effective against methicillin resistant staphylococcus aureus (MRSA) and VRE.

C. Silver also exhibits strong anti-inflammatory properties.

ix. “Silver has demonstrated marked antibacterial activity against all bacterial strains found in colonized wounds including antibiotic-resistant species such as methicillin- resistant Staphylococcus aureus(MRSA). There is minimal risk of bacterial resistance and it is barely toxic to fibroblasts. It also has strong anti- inflammatory properties” (Trial, C., Darbas, H., Lavigne, J., Sotto, A., Simoneau, G., Tillet, Y., & Teot, L.,2010).


V. There are four main components to optimum wound bed preparation

A. Tissue management.

B. Infection and inflammation control.

C. Moisture balance.

D. Edge of wound care.

x. “The purpose of the dressing is not to heal the wound, but to help provide the optimal conditions for healing to progress more normally” (Smithdale, R., 2008).

Conclusion:

The use of silver has been hotly debated over the last few decades. With the advent of rising healthcare costs and the elimination of insurance reimbursement for hospital acquired infections, we need to find other solutions in wound management.

Using silver can provide the optimum environment for the wound to heal more quickly. It also maintains moisture balance and does not affect surrounding healthy tissue. It also reduces the inflammatory response by prohibiting the proliferation of viruses in the wound bed. While the initial outlay for silver products may be higher than traditional calcium alginates and hydrocolloids, the use of silver alginates will prove to be most cost effective due to the reduction in healing time, nursing time spent on wound care and increase the patients overall quality of life.


Appendix B

Page 1

Samples of Silver Products Actisorb Silver 220 Antimicrobial Dressing

“Silver is used in this product for antimicrobial and bacterial toxin management. The charcoal is used for odor control. The dressing is suitable for use with pressure ulcers, venous stasis ulcers and diabetic ulcers” (Wound Care Shop, 2011). This dressing can be used in conjunction with compression bandaging for those patients who also have edema.

Aquacel Ag

“The ionic silver within the product provides and immediate and sustained antimicrobial activity to kill bacteria. The dry Aquacel fibers “gel” on contact with wound fluids. As the fibers swell they wick away the exudates, including bacteria, away from the wound” (Wound Care Shop, 2011). This is an excellent product to use with wounds that have a lot of drainage.

Contreet Foam 4 x 4 dressing

“This dressing has sustained antibacterial activity combined with effective exudate management and moisture control for optimum wound healing. The top film provides a water resistant, bacteria proof and breathable cover” (Wound Care Shop, 2011). This dressing is suitable for use with wounds that have little depth or tunneling.

Restore non-adhesive foam dressing with silver

“Used for partial and full thickness wounds and those with moderate to large amounts of exudate. It also protects the skin surrounding the wound bed from macerating” (Hollister Wound Care, 2011). These types of dressings are suitable for those patients who might have pressure ulcerations and need extra protection while healing.

Courtesy of:

Wound Care Shop. http://www.woundcareshop.com

Hollister Wound Care. http://www.hollisterwoundcare.com

http://www.hollisterwoundcare.com/

http://www.woundcareshop.com/


Appendix B

Page 2


Appendix C

System Wide Policy and Procedure ManualNursing Department

Chapter Section Subject:Silver Impregnated Dressing Protocol

DateIssued

03/2011

DateRevised

Page

1 of 2

I. PURPOSE The purpose of new policy is to treat the patients with slow healing ulcerations who have a bacterial infection of the wound, and have not responded to traditional therapies, with silver impregnated dressing (attached).

II. POLICY STATEMENT

Our plan address the bacterial load of the wound bed and treat with silver impregnated dressing and antibiotics if deemed necessary by microbacterial swab.

IV. PROCEDURE A. Assessment will be initiated when patients exhibit signs of slow healing ulcerations . Assessments will be made of new patients entering the facility as well as those patients who have not responded to previous treatments.

B. The new silver protocol and any subsequent bacteriological studies will be initiated upon a physician’s order and wound team assessment.

C. All assessments and any interventions with silver dressings and antibiotics (if deemed necessary by microbacteriological study and physican orders (will be completed by a licensed nurse per established protocol.

D. Nursing documentation will be completed on the initial assessment in our facility database as per policy.

System wide Policy and Procedure ManualNursing Department

Chapter

1

Section

1

Subject: Silver

DateIssued6/2009

DateRevised

Page

2 of 2

V. REFERENCES None

VI. ATTACHMENTS Silver impregnated dressing protocolWound Assessment/FlowsheetWeekly flowsheet

Signature: Date:


Title:


APPENDIX D

PATIENT ASSESSMENT

RESIDENTS NAME TPR BP

CODE STATUS BG (IF DIABETIC)

SYMPTOMS OF CONCERN PHYSICAN:CHARACTERISTICS:

QUALITY OF SYMPTOMS (EG. PAIN, REDNESS, SWELLING, WOUND BED APPEARANCE)

COURSE: ARE THE SYMPTOMS RELATED TO WOUND GETTING BETTER OR WORSE

DOES THIS EFFECT ADLS

CHANGE IN:

ABILITY TO MAINTAIN POSTURE

ABILITY TO EAT OR DRINK

MENTAL ALERTNESS ALTERED IN ANY WAYONSET OF SYMPTOMS:

HOW LONG HAS PATIENT HAD WOUND

WAS ONSET OF THE ABOVE SYMPTOMS SUDDEN OR GRADUALLOCATION:

PAIN:

HOW LONG

ANY RELIEVING FACTORS:

HISTORY:

HAS PATIENT BEEN TREATED FOR WOUND BEFORE;MEDICATIONS:


ALLERGIES

ANY RECENT LAB WORK:


Appendix E

BRADEN SCALE FOR PREDICTING PRESSURE ULCER RISK

Sensory PerceptionAbiltity to respondmeaningfully to pressurerelated discomfort

1. Completely Limited:Unresponsive (does not moan, flinch, orgrasp) to painful stimuli, due to diminshed level of consciousness or sedation,ORLimited ability to feel pain over most of bodysurface.

2. Very Limited:Responds only to painful stimuliCannot communicate discomfortExcept by moaning or restlessness,ORHas a sensory impairment, which limitsthe ability to feel pain or discomfortover 1/2 of body.

3. Slightly Limited:Responds to verbal commands but cannot always communicatediscomfort or need to be turned,ORHas some sensory impairment, whichlimits ability to feel pain ordiscomfort in 1 or 2 extremities.

4. No ImpairmentReponds to verbalcommand. Has nosensory deficit whichwould limit ability tofeel or voice pain ordiscomfort

MoistureDegree to which skin isexposed to moisture

1. Constantly Moist:Perspiration, urine, etc keep skin moistalmost constantly. Dampness is detectedevery time patient is moved or turned.

2. Moist:Skin is often but not always moist.Linen must be changed at least once ashift.

3. Occasionally Moist:Skin is occasionally moist, requiringan extra linen change approximatelyonce a day.

4. Rarely Moist:Skin is usually dry;linen requires changingonly at routine intervals.

ActivityDegree of physicalactivity

1. BedfastConfined to bed.

2. Chairfast:Ability to walk severely limited ornonexistent. Cannot bear own weightand/or must be assisted into chair orwheel chair.

3. Walks Occasionally:Walks occasionally during day butfor very short distances, with orwithout assistance. Spends majorityor each shift in bed or chair.

4. Walks Frequently:Walks outside the roomat least twice a day andinside room at leastonce every 2 hoursduring waking hours.

MobilityAbility to change andcontrol body position

1. Completely Immobile:Does not make even slight changes in bodyor extremity position without assistance.

2. Very Limited:Makes occasional slight changes in body or extremity position but unable to make frequent or significant changes independently.

3. Slightly Limited:Makes frequent though slight changesin body or extremity positionindependently.

4. No Limitations:Makes major andfrequent changes in position withoutassistance.

Friction and Shear

1. Problem:Requires moderate to maximum assistance inmoving. Complete lifting without sliding against sheets is impossible. Frequentlyslides down in bed or chair, requiringfrequent repositioning with maximumassistance. Spasticity, contractures, oragitation leads to almost constant friction.

2. Potential Problem:Moves feebly or requires minimumassistance. During a move skinprobably slides to some extent againstsheets, chair, restraints, or other devices. Maintains relatively good position in chair or bed most of the time but occasionally slides down.

3. No Apparent Problem:Moves in bed and in chairindependently and has sufficient muscle strength to lift up completely during move. Maintains goodposition in bed or chair at all times.

TOTAL SCORE(Addressograph)


APPENDIX F

PATIENT ASSESSMENT/FLOW SHEET

RESIDENTS NAME TPR BP

CODE STATUS BG (IF DIABETIC)

SYMPTOMS OF CONCERN PHYSICAN:LOCATION:

PAIN:

HOW LONG:

ANY RELIEVING FACTORS:

WOUND BED MEASUREMENTS:

LENGTH:

WIDTH:

DEPTH :

TUNNELING: SILVER PRODUCT BEING USED: PLEASE CIRCLE ONE

ACTISORB SILVER 220

AQUACEL AG

CONTREET

RESTORE NON-ADHESIVE FOAM DRESSING WITH SILVER:

ANY RECENT LAB WORK:

NURSES INITIALS: TIME: DATE:


Appendix G

Staff survey

Name:

Title:

Date:

Use this space for any additional comments

Please complete the following

evaluation Circle response

Strongly

Disagree

Disagree Agree Strongly

Agree

Disagree Need more

teaching

My ability to assess and address the

residents wounds have improved

Recognizing what products are for what

types of wounds is adequately understood

I understand the different types of silver

products and understand their applications.


Appendix H

Patient number # Length of stay Date

Patient Diagnosis

Physician Name

Yes No N/A1.

2.

3.

4.

5.

6.

7.

8.

9.

Did patient have any side effects from treatment protocol?

Did the patient require hospitalization?

Was bacterial study done?

Was treatment protocol followed?

Did the patient require antibiotics during course of treatment?

Was all documentation completed by the nursing staff?

APPENDIX H

Did patient have any previous treatment for wound?

Was initial assessment tool completed?

What was Braden score?

Criteria

Silver Protocol Data Collection for quality management


Appendix I

Patient survey

Patient Name Satisfied Not satisfied What

improvements

need to be made

Length of

treatment

Quality of

nursing care

Quality of

treatment

Would you

recommend

treatment to

others

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