Project design
One avenue explored in adult patients with chronic wounds was asking how the implementation of a WAR score for all patients admitted with chronic wounds affects the use of systemic antibiotics compared with adult patients with chronic wounds receiving usual care in patients not at increased risk for infection. By implementing a WAR score for all patients admitted with chronic wounds over a 6-week period, this evidence-based practice project aimed to: (1) identify chronic wounds at risk for infection; (2) identify the risk factors associated with chronic wound infection; (3) evaluate the use of systemic antibiotics in patients with chronic wounds; and (4) reduce the use of systemic antibiotics in chronic wounds that are not infected or at risk for infection.
Data from a control group of all patients also admitted with chronic wounds during the 6-week period before project implementation were collected for the WAR score and other data comparison with the implementation group. Data were collected from a convenience sample of all adult patients over the age of 18 years admitted with a chronic wound(s) present on hospital admission in a 325-bed acute care hospital in Texas. Chronic wounds were defined as wounds present for at least 3 weeks and included DFUs, VLUs, arterial ulcers, nonhealing surgical wounds, and PU/Is. A total of 57 patients made up the pre-intervention/control group, and 78 patients were included in the intervention group (N = 135).
The WAR score
In 2010, an international group of wound experts created the WAR score to better assess the risk of infection in chronic wounds by evaluating both the actual wound and host factors that can contribute to an increased risk of infection.12,15,16 The risk factors in the WAR score incorporate the patient’s immune status, including acquired immunosuppressive diseases (eg, diabetes, HIV), immunosuppressive therapies (eg, glucocorticoids, other chemotherapies), systemic hematological diseases that can affect the inflammatory response, occupational and social conditions, wound location and likelihood of contamination, the patient’s age, and the type and chronicity of the wound, among other factors.12,15,16
The tool uses a simple screening scale (Table) to score the risk of infection in wounds by scoring each risk factor. The listed risk factors for infection are represented by 1, 2, or 3 points; a score over 3 justifies the use of systemic antibiotics, as it indicates an increased risk for infection. Patients with a score at or below 3 are not at an overall increased risk for infection; therefore, the use of antibiotics is not clearly indicated. Though not used as an absolute indicator, the tool can guide decision-making for both novice and expert wound care clinicians.15
In their official guidelines for the management of chronic wounds, the Polish Wound Management Association recommends the WAR assessment tool when evaluating a patient with a chronic wound.15 In 2018, the International Society of Antimicrobial Chemotherapy (formerly known as the International Society of Chemotherapy for Infection and Cancer), the Chronic Wound Initiative, Austrian Society for Infection Control, Organization of all German-speaking Societies and Groups in Wound Management, and the German Society for Hospital Hygiene published a consensus report for antiseptic and antimicrobial recommendations in wound care using the WAR score as the primary assessment tool to help clinicians in deciding the appropriateness and indications for topical antiseptic wound therapy or systemic antibiotics.16
Other risk factors for infection in chronic wounds
Risk factors for infection in chronic wounds also were measured before and after project implementation. The risk factors noted in the WAR score were used to collect retrospective data on the risk factors of those patients found to have high WAR scores (≥4), compared with other demographic and clinical information. Examples include the prevalence of diabetes, microbiological burden and pathogen, and wound measurements, if obtained.
The measured bacterial burden and potential pathogen(s) of chronic wounds play a significant role in determining bacterial colonization versus bacterial infection in wounds.13,17 Pseudomonas and methicillin-resistant Staphylococcus aureus (MRSA) are common pathogens found in chronic wounds, but do not necessarily cause true infection.12 Jockenhöfer et al12 noted that most of the patients with chronic wounds had the presence of both Pseudomonas and MRSA, and especially in those patients with a WAR score of less than 3.
Procedure
Internal review board approval was obtained from the University of Texas at Arlington and from the project site hospital through the Medical Research and Medical Executive Committees. In addition, informational in-services were provided to nursing staff in the wound care department and medical-surgical floors.
All patients with wounds present for at least 3 weeks who were admitted to the hospital between November 5, 2018, and December 13, 2018, were given a WAR score based on data obtained from the electronic medical records (EMRs). A copy of the patient’s specific WAR scoring tool was placed in the patient’s physical chart, and a note was written in the patient’s EMR as a progress note. Based on the patient’s WAR score, the EMR note read:
• “WAR scale score ≤ 3: patient not at increased risk for infection; systemic antibiotics may not be indicated”; or
• “WAR scale score ≥ 4: patient at increased risk for infection; systemic antibiotics may be indicated.”
Simultaneously, data were collected on the use and indication of systemic antibiotics and other clinical data, including wound measurements, type of wound, microbiological burden and pathogen (if culture was obtained), and demographic data. A retrospective chart review was completed of patients admitted with chronic wounds during the 6 weeks prior to project implementation. These patients were given a WAR score based on the information from the EMR, and the same clinical and demographic data also were collected. No patient identifying information was collected or stored. Patients in the intervention group were identified by the date of recruitment and the patient number. Patients in the control group were identified by the date of admission and the subsequent patient number.