Application of Comfort Therapy under eCASH Concept in Acute and Chronic Wound Treatment

According to the healing process, wounds are divided into acute and chronic, and their prevalence rate is increasing by 9% and 12% per year, respectively, in the UK [1]. Acute wounds are defined as those that develop suddenly and heal quickly, such as surgical incisions, burns, or trauma. If an acute wound covers an excessive injury area, infections and disorders in blood flow and nutrition to the area may lead to a chronic wound [2]. There is no unified definition of chronic wounds, nor is there a time frame for their healing [3]. Almost all chronic wounds start as minor cuts or scrapes and then stop at some stage and linger [3‐5]. The aging population has increased the rate of chronic refractory wounds and the demand for treatment [6]. Pressure ulcers, diabetic feet, and vascular ulcers have become three major diseases in older inpatients [7], and the annual expenditure for them in the USA has risen to approximately $25 billion [8]. With the aging population and the change in the disease spectrum, patient wounds have become a significant social public health problem [9].

Wounds cause pain, and common treatments such as debridement, dressing change, scab cutting, skin grafting, and physical therapy cause additional pain [10]. In addition, pain in wound treatment is closely related to anxiety, which aggravates it [11]. Pain is harmful to the physical, psychological, family, and society of patients with acute and chronic wounds. Improper pain treatment also affects wound healing and disease recovery, so its effective management is essential. However, recent studies have shown that pain management in hospitals is unsatisfactory [12]. Medical staff often neglect to assess the intensity, characteristics, or effects of pain on psychosocial relationships, and music and other adjunctive analgesia have not been routinely used in hospitals [13]. The current people-oriented modern medical model gives more attention to the humanized connotation of wound treatment and puts forward higher requirements for treating wound pain. In traditional analgesia therapy, there are significant individual differences in pain, and it is challenging to measure patients’ demand for drugs. It is easy to cause adverse reactions, and it is difficult to control moderate and severe pain effectively. Therefore, it is necessary to find methods that minimize patient pain, promote comfort, and have few side effects. However, there is a lack of practical research on pain management and nursing wards in mainland China [14] and in the standard management process.

In 2016, Vincent [15], former Chairman of the European Critical Care Medicine Association, proposed the new painless comfort concept of early Comfort using Analgesia, minimal Sedatives, and maximal Humane care (eCASH) to provide a new way to approach wound treatment. On the basis of the idea of eCASH, this study established a painless comfort ward in the burn unit, aiming to determine the best practices for combined intervention in the treatment of pain anxiety in those with acute or chronic wound treatment and to provide a reference for its further optimization and the promotion of ward management.

Wound treatment has become a health concern receiving public attention in recent years. Wounds are caused by trauma, surgery, or acute and chronic diseases and affect millions of people worldwide. They cause physical and mental pain to patients and are heavy burden on the social and medical systems [18]. The systemic effects caused by acute wounds are hard to ignore, as well as is the fact that they can result in systemic inflammatory response syndrome (SIRS) in severe cases [19]. If acute wounds are not treated correctly, they can become prolonged and result in chronic wounds, as seen with diabetic and vascular ulcers of the lower extremities, as well as pressure and scar ulcers. Most patients with chronic wounds are middle aged or elderly, often having underlying diseases such as diabetes, heart disease, vascular disease, or other primary diseases. These individuals have a pain tolerance of wound treatment that is far less than ordinary adults. Since 2017, our department has actively implemented the comfort-therapy modalities associated with the eCASH concept when treating acute and chronic wounds. As part of this focus, we have analyzed the efficacy of comfort therapy using the eCASH concept.

This study showed that patients with acute or chronic wounds all had moderate-to-severe pain with apparent anxiety before treatment, which was also consistent with the research results of Zhou [20] and Yan [21]. Debridement and dressing changes are the main methods for wound treatment. In this process, uncovering the dressing, cleaning the wound, debridement, placing a new dressing, and other operations cause severe pain. This pain may lead to elevated blood pressure, tachycardia, and lack of oxygen due to reduced ventilation. Chronic pain can also affect immune function and wound healing. Studies have shown that pain and anxiety overlap owing to the use of the same neural circuits, and about 45% of patients with chronic pain also have anxiety [22]. Pain has a negative impact on patient physiology, psychology, family, and society and may induce post-traumatic stress disorder (PTSD) in severe cases [23]. The current treatment of pain and anxiety caused by wound treatment is usually ineffective and has side effects. However, this has yielded an opportunity to determine best practices. Here we found that compared with traditional treatment, comfort treatment could significantly relieve pain and anxiety during wound treatment (P < 0.001). The study established a painless comfort unit based on the concept of eCASH. An interdisciplinary team of burn orthopedic surgeons, wound specialist nurses, pain physicians, and rehabilitation therapists was established to manage patient wound problems. By adopting the concept of comfort therapy under eCASH, the team tried to achieve early analgesia to promote comfort, minimize sedation, and maximize humanistic care. The results showed that after 14 days of comfortable treatment, the wound healing rates in both acute and chronic wounds were significantly improved compared with conventional treatment. Therefore, we believe that the comfort therapy under the eCASH concept is an easy and effective program for wound patients. It can reduce pain and anxiety to some extent and indirectly promote the healing of patients’ wounds through more comfortable treatment.

The comfort of patients is closely related to the environment and nursing care [24]. Nurses promote comfort through pain assessment, psychological intervention, comfortable postures, and health guidance. In addition, to optimize the spatial layout of the eCASH unit, we retained the multi-room layout and added an escort lounge area within the unit. The anxiety and depression of patients are improved by promoting communication between medical staff, family members, and patients to meet their emotional and social needs [25]. Studies have shown that adding natural elements to the physical environment can promote comfort and reduce the use of analgesics by “neutralizing” the sense of technology and strangeness in the ward; therefore, we added two windows and several green plants [24, 26]. The eCASH concept emphasizes the optimization of sleep. Therefore, the plan emphasized reducing nursing operations and noise from patients being admitted [24, 27, 28]. Frosted glass was placed between beds to ensure patient privacy and block out noise to promote sleep. Comfortable physical and good social environments can encourage patients to blend into the hospital atmosphere quickly to achieve the best physical and mental state. Finally, ultra-early rehabilitation training is also an essential feature of the eCASH comfort treatment program. Early functional exercise can help to improve limb function reduction caused by an acute or chronic scar contracture, and the risk is smaller than expected [29].

It is worth noting that the intermittent mode is generally believed to have a better effect than the continuous in adverse pressure treatment [30, 31], and has the advantages of fast wound healing, minor dressing changes, less pain for patients, and is a simple operation. However, the study showed that although both methods effectively relieved pain, the degree of pain in IPTEG was significantly higher than CPTEG after 14 days (P < 0.05). This may be owing to the intermittent mode leading to changes in foam dressing relaxation and contraction, as well as the frequent and continuous stimulation of the wound surface increasing the body’s pain threshold. In addition, the intermittent mode was more likely to induce the growth of wound granulation tissue than the continuous mode [32, 33]. Overgrown tissue that grows into foam dressings can also cause pain when changing the dressings. The results showed that compared with the discontinuous mode, the new mode had a better effect on wound healing while alleviating the discomfort of patients. However, the number of patients with chronic wounds in the study was limited, which may affect the final results.

From the micro-perspective, wound repair is a complex and orderly pathophysiological process involving the interaction of various inflammatory cells, repair cells, inflammatory mediators, growth factors, and other components. The inflammatory response first occurs after trauma, and a certain degree of said response is helpful to accelerate wound healing, while an excessive amount is associated with increased mortality. Wound healing is a dynamic interaction process between various cells, growth factors, and extracellular matrix, and the study of the growth factors is of great interest to the field of wound healing [34]. Inflammatory factors induce pain, which in turn stimulates inflammatory response [35]. In this study, the levels of IL-1β, IL-6, TNF-α, VEGF, bFGF, and TGF-β1 in different phases of acute and chronic wounds were determined after comfort treatment. The results showed that the concentrations of inflammatory factors in acute and chronic wound groups were significantly lower than those in the control groups after 14 days of treatment (P < 0.05). This suggests that the comfort therapy under the eCASH concept can effectively reduce wound inflammation and promote the secretion of growth factors in the middle and late periods of wound healing. Notably, after 14 days of treatment, IL-6 levels in IPTEG were significantly lower than those in CPTEG. These results suggest that intermittent negative pressure attraction mode is better than continuous in alleviating wound inflammation, which is consistent with the results of Venturi et al. [31] At the same time, intermittent negative pressure suction mode can form positive pulse regulation of blood flow and form a “shear force” to stimulate the growth of granulation tissue. However, in this study, the effect of intermittent negative pressure mode on growth factors was not significantly different from those in continuous negative pressure mode, which may be related to the small sample size. It is expected that more studies will confirm these results. TNF-α is a marker for the acute stage of the systemic inflammatory response, which induces apoptosis and necrosis, and is involved in many multi-level regulations in tissue damage [36]. However, the microscopic mechanism of inflammatory mediators in wound repair is not clear. Therefore, it remains to be known whether TNF-α inhibitors can be used to intervene in the treatment of chronic wounds.

In summary, comfort therapy based on the eCASH concept has a significant effect on relieving patients’ pain and anxiety and indirectly promoting the healing of patients’ wounds through more comfortable treatment from a clinical perspective. Molecularly, it can effectively reduce the level of wound inflammatory factors and increase the level of growth factors after 14 days of treatment. To further verify the effectiveness of the eCASH concept for different wound types, more studies are needed for acute and chronic wounds on the basis of the existing reports, and more targeted observations should be included.