The Available Technology Dressing (ATD) technique for wound management

The Available Technology Dressing (ATD) technique for wound management

Authors: Linda Benskin [1] [2] and Richard Benskin [1]

1. Benskin Research Group, Austin, TX, USA.
2. Ferris Mfg. Corp., Fort Worth, TX USA.

Abstract

Wounds present a particular challenge in remote areas of the tropics, where infection rates are high and healthcare professionals and basic wound care supplies are both scarce. The need for an effective, safe, sustainable, evidence-based, wound-dressing solution for this setting led the authors to develop and clinically evaluate the Available Technology Dressing technique.

Introduction

The number of lives seriously impacted by wounds worldwide is underestimated.1,2 In rural tropical settings, many people with wounds care for themselves or seek care from a family member or friend initially.1 Some seek care from a village health worker or traditional health practitioner.1 Wound care outcomes are often poor and costs are surprisingly high.1 Acute wounds often become disabling chronic wounds due to poor management.3 Almost 25 years ago, while working over a 5-year period in a small rural clinic in northern Ghana, the magnitude of this problem became painfully evident.4 This awareness motivated us to develop the Available Technology Dressing (ATD) technique.5

Limitations of available dressings

Working at the clinic provided us with the opportunity to systematically trial a wide variety of donated advanced wound dressings.4 Unfortunately almost all of them performed very poorly in the harsh environment of the tropics.4,5 Mixed bacterial and fungal infections developed overnight under foams, hydrocolloids and hydrogels.4,5 Many of the dressings either cracked in the dry season or melted in the hot or rainy seasons. The only type that performed well was polymeric membrane dressings (PMDs), which consistently balanced moisture, kept wounds clean, decreased pain and promoted brisk wound healing despite extremes of temperature and humidity.4,5 However, importing PMDs is not a sustainable solution for patients and caregivers, particularly in villages.1,5

A review of the literature found that commonly recommended natural wound management approaches often have serious drawbacks.3 Papaya, the natural source of papain, is widely available in much of the tropics.3,5 The flesh, directly applied to a wound, will act as a debriding agent. However, papain concentrations vary and after papaya debrides necrotic tissue it must be removed promptly to avoid destroying healthy tissue.3 In a village outpatient setting, it can be difficult to monitor patients carefully enough to avoid disaster5 (Fig. 1). Similarly, while medical maggots may only eat necrotic tissue, the wild maggots found in villages will invade healthy tissue and can be painful.1,5 Unlike honey produced in temperate climates, honey produced in the tropics is often so watery that it ferments; such honey does not have strong antimicrobial properties.3,5,6 Honey in commercial dressings drips out in warm climates.5 Banana leaf dressings help keep wounds moist, but they carry such a high bioburden that autoclaving is required, which is not an option in remote settings.7

Existing practices

Following the principle that one should always assess before diagnosing or prescribing, we conducted a usual wound practice study with village health workers, traditional health practitioners and villagers performing self-care in villages throughout Ghana, Cambodia and Zambia.1,5,8 In order to obtain reliable results, we used the unique story completion survey method.1,5,8 The principal investigator related the beginning of the story of a patient coming to receive care while showing the participant their wound photo. Then, the participant related how they would complete the story – how they would manage that wound – without any prompting. This process was repeated for a total of seven wound types per participant. The study found that, just as in wealthy countries, non-experts often try to dry wounds, which delays healing and increases infection rates.1 In contrast, village health workers and traditional health practitioners who are recognized for their expertise in wound care agreed with expert wound healthcare professionals worldwide that the goal is to keep wounds appropriately moist.1 These expert village lay healthcare providers expressed frustration because their crushed leaves and poultices could not keep wounds ideally moist, which led to disappointing results.1

Developing the ATD technique

Knowledge of the basic science of wound care guided the development of the proposed ATD technique.1,9 We sought an approach that:

• keeps wounds clean and appropriately moist;
• uses only materials from the natural environment or local village market;
• is acceptable to patients and caregivers;
• can be taught to lay health providers, patients and families.

We discovered that plastic food wrap has been used effectively for wounds in Japan, but patients found the wrapping technique used there intolerable in a hot tropical environment.3,5 In India, plastic surgical drapes were effective primary dressings for burns because they do not stick to the wound bed.9 Food wrap and surgical drapes are not available in most village markets,5 but thin, strong, clear, food-grade plastic bags, which are also semipermeable membranes, are widely available across Africa, South America and Southeast Asia.5,9 Because they are routinely used to carry water, rice, soup and other prepared foods, these clear bags are not affected by bag bans.9 Given the great success of thin plastic improvised dressings in Japan and India, and the reliable availability of food-grade plastic bags in tropical village markets, we developed a dressing technique to meet the above goals using these bags as the wound contact layer.5,9

Assessment of the ATD technique in a tropical setting

Methods: After refining the ATD technique through informal case studies, a 12-week, staggered start and stop, outcomes-blinded, randomized controlled trial was conducted at the University Hospital of West Indies in Mona, Jamaica in patients with chronic sickle cell leg ulcers (which are often regarded as the most challenging of all wound types).5,9 The ATD technique consists of: (1) thoroughly irrigating the wound with a strong squeeze on a homemade device filled with homemade saline (a ~500 mL soda bottle with a hole in the cap from a hot bicycle spoke or similar sized wire); (2) drying the skin next to the wound, then protecting it with a thick layer of a non-toxic moisture barrier (e.g. zinc oxide paste or shea butter); (3) gently conforming a cut-to-fit piece of food-grade clear plastic bag (a clean semipermeable membrane) to the wound bed and to the moisture barrier (cut slits – not holes – in the plastic to allow excess fluid from autolytic debridement to escape); (4) placing fluffed clean absorbent material over the slits to absorb the excess fluid; (5) holding all of this in place (and, when tolerated, applying compression) with a snug wrap.5 Daily, remove the ATD, irrigate the wounds thoroughly, dry the periwound and apply more moisture barrier, plastic with slits, absorbent and wrap. Exact dressing components can vary based upon availability5 (Fig. 2).

Results: Forty patients completed the study (WTM n=16; ADT n=13; PMD n=11).5 The ATD technique, which is more available than WTM gauze dressings, was also far safer (zero complications vs. 4/16 (25%) mild pseudomonas infections), and more effective (12/13 (92%) of participants experienced a net wound closure, compared with 8/16 (50%) in the WTM gauze group and the group percentage mean change in wound area at 12 weeks was 27% smaller vs. only 7% smaller in the WTM gauze group).5 Weekly ATD total supply costs were USD $3.23 vs. USD $6.35 with WTM gauze.5 In addition, the ATDs reduced dressing change pain and overall pain better than WTM gauze.5,9 As expected, the gold-standard advanced wound dressings, PMDs, provided superior outcomes in every aspect tested except cost (median cost for PMDs was USD $28.87 per week).5,9 Within the PMD group, 2/11 (18%) of the sickle cell leg ulcers closed completely.9 However, PMDs and other advanced dressings are simply not available in rural areas of developing countries.5

Although the ATD technique proved suitable for teaching self-care to patients, the specifics are critical to success. Our experience revealed that patients often did not intuitively understand the purpose of each step of the dressing process, and so they tended to make mistakes.5 Teaching the reasons for each step, with appropriate analogies when possible, and coaching during return demonstration of the technique quickly enabled patients to learn how to complete their dressing changes correctly.5

Conclusion

This small study revealed that the ATD technique was safer, more effective, associated with less pain and cheaper than WTM gauze dressings. Patients were able to change the dressings themselves, especially when taught the basic reasons for each step involved. In settings where gold-standard PMDs are too expensive or unavailable, it is beneficial to teach patients and lay healthcare providers the ATD technique.

References

1. Benskin L. Discovering the current wound management practices of rural Africans: a pilot study Dissertation, University of Texas Medical Branch, 2013. Available at: https://utmb-ir.tdl.org/handle/2152.3/538 (last accessed 15 September 2024).
2. Ryan TJ. One of the greatest of health needs without effective advocacy and shamefully neglected! Br J Dermatol 2008; 158:205–7.
3. Benskin LLL. A review of the literature informing affordable, available wound management choices for rural areas of tropical developing countries. Ostomy Wound Manage 2013; 59:20–41.
4. Benskin LL. Polymeric membrane dressings for topical wound management of patients with infected wounds in a challenging environment: a protocol with 3 case examples. Ostomy Wound Manage 2016; 62:42–50.
5. Benskin L, Benskin R. The development of the available technology dressing, an evidence-based, sustainable solution for wound management in low-resource settings. Wounds  2024; 36:137–47.
6. Sommeijer MJ, Beetsma J, Boot W-J, Robberts E-J, Vries R de. Perspectives for Honey Production in the Tropics. Proceedings of the Symposium organised by the Netherlands Expertise Centre for Tropical Apicultural Resources (NECTAR) held in Utrecht, 18 December 1995. The Hague: NECTAR, 1997.
7. Guenova E, Hoetzenecker W, Kisuze G et al. Banana leaves as an alternative wound dressing. Dermatol Surg 2013; 39:290–7.
8. Benskin LLL. A unique “story completion” research method for obtaining accurate survey data. Poster #32 presented at the 29th Annual Nursing & Midwifery Research Conference and 30th Mary J. Seivwright Day, Kingston, Jamaica, 30 May 2019.
9. Benskin L. A Test of the safety, effectiveness, and acceptability of an improvised dressing for sickle cell leg ulcers in a tropical climate. NCT04479618. Available at: https://clinicaltrials.gov/ct2/show/NCT04479618 (last accessed 15 September 2024).