INTRODUCTION

Wounds that heal in a normal, timely sequence follow a predictable trajectory through the 4 phases of healing including hemostasis, inflammation, proliferation, and remodeling.1 The etiology of the wound, comorbid conditions, metabolic aberrations, and wound-related factors such as infection, sustained tissue injury, and system/resource issues may impair normal healing processes, leading to impaired or stalled healing. For example, nonviable (necrotic) tissue not only creates a physical barrier for wound closure, but also provides a medium for bacterial proliferation and excessive inflammation contributing to impaired healing.2

The wound bed preparation (WBP) paradigm describes an organized and systematic approach to guide wound care decisions to optimize clinical outcomes.3 Central to WBP is the need to perform a holistic patient assessment, treat underlying causes, and address patient-centered care concerns prior to decisions regarding local wound treatment using the TIME mnemonic (T-tissue debridement, I-infection/inflammation, M-moisture balance, E-edge effect).2,3

Debridement is defined as active removal of nonviable tissue along with foreign debris, dysfunctional cells, biofilm, and other undesirable materials incompatible with healing.2 Wound debridement enables visualization of the wound bed and edges enabling evaluation of the extent of tissue damage and potential involvement of underlying structures.4,5 Originally defined as surgical removal of dead tissue, or bridle, the term in modern wound care has evolved to encompass various debridement modalities to facilitate the wound healing process.6 However, not all wounds are appropriate for debridement.7-9

Risk is an inherent component of debridement; potential adverse effects include infection, pain, excessive bleeding, damage to underlying structures, loss of normal bodily function, amputation, and prolonged length of stay in an acute, long-term or rehabilitation care setting.7 There is a legal and ethical obligation for healthcare organizations and nurses to safeguard patients and prevent unwarranted harmful events from occurring. Clear language delineating responsibilities, educational preparation, and scopes of practice for nurses to initiate and perform debridement throughout Canada, and across the continuum of healthcare settings, is lacking in national and provincial standards. This gap has created role ambiguity and tension among healthcare providers, managers, patient safety and quality leaders, and the public.

The purpose of this document is to provide Canadian nurses with evidence-informed best practice recommendations (BPRs) for all methods of wound debridement. It is intended these recommendations be integrated into practice to promote patient safety and produce best possible clinical outcomes and health services experience for all Canadians. Although these recommendations may provide a resource for various professions, they are written and intended for use by all nurses (RNs, advanced practice nurses, and registered/licensed practical nurses) in various practice settings throughout Canada. The BPR discusses 6 principal wound debridement methods including autolytic, mechanical, enzymatic, biological, conservative sharp, and surgical debridement. Through a consensus building process, the task force generated 12 BPRs to guide decisions and practice while recognizing the varying levels of risk associated with each debridement method.

These recommendations were commissioned by Nurses Specialized in Wound, Ostomy and Continence Canada (NSWOCC) and developed by a volunteer task force of 21 expert nurses, primarily Nurses Specialized in Wound, Ostomy and Continence (NSWOC); each brought a unique perspective on the topic based on their experiences in different healthcare sectors, practice environments, jurisdictions, and research experiences across Canada (see Table 1). Regular virtual meetings took place between January 2020 and April 2021 to critique and synthesize the best available evidence for the development of recommendations.

TABLE 1. Task Force Members

METHODS

The task force identified relevant topics and translated them into key research questions based on a PICO framework: population (P), targeted interventions (I), comparators (C), and outcomes of interest (O).10 Using the PICO framework, a panelist with expertise in methods of structured literature reviews (K.W.) conducted systematic reviews in collaboration with a medical librarian at Queen's University. The literature was systematically searched to answer the following question: What are the scope of practice, credentials, training, competencies, and regulatory requirements for wound debridement for nurses practicing in Canada?

We searched electronic databases for all relevant evidence, including existing guidelines, systematic reviews, and meta-analyses, as well as primary studies in English and French from 1996 to 2021. Databases searched were: Allied and Complementary Medicine Databases, CINAHL, Cochrane Database of Systematic Reviews, DARE Dissertations International, Effective Practice and Organization of Care, Embase, ISI proceedings: science and technology, Joanna Briggs Institute, MEDLINE, WOCN Society Library, and other websites where guidelines or practice documents may be posted including the National Guideline Clearinghouse, Canadian Medical Association infobase, and the Guideline Advisory Committee. Additional search filters included requirements for nurses to initiate and perform all methods of debridement, including competency, educational, certification, and preceptorship/mentorship requirements; legal considerations per type of debridement; and patient considerations for all methods of debridement. Provincial/territorial scope of practice regulations was investigated by accessing governing documents from each province/territory across Canada. To ensure relevant unpublished materials were reviewed, the task force also identified professional and wound care association websites to look for existing guidelines, guidance documents, consensus statements, and reference lists related to wound debridement.

A scoping review was completed to enable inclusion of the broad range of papers identified by the literature search and to facilitate comparison of information, identify contradictory evidence, and isolate gaps in the literature. The article review was conducted by the task force following the framework proposed by Arksey and O'Malley.11 A data capture matrix based on the Joanna Briggs framework was used to guide mapping, review, and synthesis of the diverse range of existing evidence. Two reviews and data extraction were completed independently for each paper. All task force members participated in this process. The evidence was synthesized and summarized into 12 practice recommendations. Expert opinions from the task force were sought in areas where the body of evidence was deemed insufficient for formulating recommendations.

These statements were reviewed and finalized by the task force using a modified Delphi process to resolve discrepancies and gaps. Each expert task force member voted and indicated their level of agreement on whether proposed recommendations should be included on a 9-point rating scale, where 1 indicated "not important" and 9 indicated "critically important." After each round of voting, results were discussed and recommendations were revised until consensus was achieved. Only statements reaching at least 80% of agreement were included in the draft document. The levels of evidence for each recommendation were then evaluated independently by 2 members of the task force (V.C./N.P.), using the Interpretation of Evidence established by the Registered Nurses' Association of Ontario (RNAO, 2017) (Table 2).12 To ensure face validity and readability of the statements, the task force invited reviewers of various professional backgrounds across all health sectors within Canada to provide anonymous feedback on the recommendations. A total of 38 interprofessional practitioners participated in the peer review process via a web-based survey. The results were discussed among the task force and feedback was incorporated into the document. Overall, 89% of the reviewers felt they would recommend this BPR to colleagues and administrators to provide clear direction on debridement practice for nursing professionals in all care settings. The final recommendations were approved by the NSWOCC board of directors prior to publication in May 2021.

TABLE 2. Interpretation of Evidence: RNAO Levels of Evidencea

SUMMARY OF RECOMMENDATIONS

Recommendation 1: Scope of Practice (Level of Evidence IV-V)

All classes of nurses including RN, RPN/LPN, and NP must work within the controls of federal and provincial/territorial legislation, regulatory bodies, organizational policies, and individual competency. For debridement of wounds, this includes having the knowledge, skills, judgment, and authority to perform all methods of debridement. Nurses are accountable for knowing their national code of ethics and expectations, respective provincial/territorial practice standards and guidelines, their employer's policies, procedures, and operational guidelines, and their competence and limitations for all methods of debridement.

Rationale

There are 4 tiers of control to regulate practice and conduct of an individual nurse in Canada: federal legislation, provincial/territorial legislation, employer/organizational policy, and individual competence. Provincial/territorial nursing regulatory bodies are responsible for defining scope of practice for each category of nurse. The nurse should only perform the type of debridement that is within their scope of practice in a designated role or appropriate setting to align with Canadian legislation, regulations, standards, and organizational policies.

Recommendation 2: Organizational Recommendations (Level of Evidence IV-V)

Employers/organizations should ensure all policies and procedures, or operational resources related to debridement, include, but are not limited to:

a. type/method of debridement each class of nurse is authorized to initiate and/or perform, including the specific level of education, training (including preceptorship), and experience required to perform the method of debridement; and

b. completion of a competency checklist before providing authorization to perform debridement with each new employer and at regular intervals to evaluate the continued competency (validation) of the nurse's knowledge and skills to perform the procedure. This includes the nurse's ability to conduct a comprehensive assessment of the patient and the wound, identify wound type and etiological/causative factors, and collaborate with the interprofessional team to develop, implement, evaluate, and reassess an appropriate plan of care.

Rationale

Policies and procedures are tools designed to facilitate decision-making with the aim to reduce practice variation and promote compliance with regulations and accreditation requirements. With a growing need to build and sustain a culture of safety, establishing a quality and safety framework with formalized accessible policies and procedures identifying necessary competency requirements and operational resources to support the nurse in performing wound debridement is a priority for the employer/organization. Competency broadly describes a combination of knowledge, capacities, skills, attitudes, and decision-making abilities that is expected of a nurse to successfully perform a task for desirable outcomes.13 Several checklists have been compiled detailing key competency indicators, demonstrable skills, and assessment parameters to help nurses make the most appropriate decision and evaluation of their competency each time they are performing debridement.14 This document also provides clear expectations along with objective and measurable performance indicators for nurses competent in debridement. Considering the complexity of wound care, rapidly evolving evidence, and expansive development of new technologies, the nurse should recognize continuing competence as a lifelong learning process to maintain professional nursing practice. Organizations are responsible to maintain quality practice environments that support and foster continuing competence.

Recommendation 3: Prior to Initiation of Debridement (Level of Evidence IV-V)

Prior to initiating any method of debridement, the nurse must:

a. be knowledgeable about the different methods of debridement and the level of skill and training required to perform each type;

b. be aware of their own attitudes, limitations, skills, and competency;

c. recognize and understand the indications, precautions, and contraindications for the various debridement methods;

d. evaluate the patient's health status, solicit patient preferences and wishes, review wound assessment findings and wound healing potential to determine if decisions about debridement can be made independently, or if consultation with the interprofessional team is warranted; and

e. be able to identify, manage, and mitigate potential complications and adverse events, including, but not limited to, bleeding, pain, anxiety, or damage to underlying structures.

Rationale

The task force recognizes all methods of wound debridement can pose risk to the patient. Therefore, it is imperative nurses fully understand potential implications for all methods of debridement including their personal limitations and when to seek help. We recognize that individual nurses, as members of a self-regulating profession, are accountable for their own practice. Inappropriate patient selection or debridement method can result in serious harm. For example, hydrogel dressings or dressings with semi-occlusive backings may seem innocuous; yet, inappropriate introduction of moisture-donating products to a dry gangrenous wound could lead to dire consequences including sepsis and death. Therefore, nurses must critically examine and apply their knowledge, skills, and judgment to deliver safe care and manage untoward outcomes when they arise.

Recommendation 4: Education and Preceptorship (Level of Evidence IIb, IV-V)

Prior to initiation or performing debridement, successful completion of a rigorous curriculum-based wound management program followed by a separate competency-based education program for debridement is highly recommended for all nurses. The debridement education program should include theoretical and clinical preceptorship components. The need for clinical preceptorship may vary based on the method of debridement; however, a clinical preceptorship is recommended as being mandatory prior to independently performing conservative sharp wound debridement (CSWD). All forms of debridement can carry high risk when initiated inappropriately; however, CSWD is considered high risk even when performed by nurses with appropriate knowledge, skills, and judgment.

a. The theoretical component of a debridement education program should enable the learner to understand and describe:

i. the wound healing process;

ii. parameters for WBP including infection;

iii. indications, precautions, contraindications, risks, and benefits for all debridement modalities;

iv. barriers to healing including biopsychosocial factors; and

v. professional scope of practice standards and guidelines for controlled/restricted/reserved acts.

b. The clinical preceptorship component should include self-reflective learning and is recommended once the theoretical portion has been completed prior to independently performing debridement. Regular updates such as skills labs or workshops are recommended throughout the nurse's career.To achieve competency in CSWD specifically, the clinical preceptor for this component of the education program should ensure the nurse is able to:

i. understand when this method of debridement is most appropriate and safe to perform based on the comprehensive patient and wound assessment;

ii. distinguish tissue types and avoid potential injury to underlying anatomical structure such as nerves, muscles, tendons, fascia, bone, and vascular components that may not be visible beneath nonviable tissue; and

iii. manage adverse events such as bleeding, pain, anxiety, or damage to underlying structures.

Rationale

The act of debridement extends beyond a manual skill to remove nonviable tissue. It also involves a purposeful, contextual process of ongoing assessment and evaluation of the patient and their wounds to help make an evidence-informed, patient-centered decision. The need for advanced education and continuing professional development is evident in the literature.15 Self-taught debridement skills do not provide sufficient foundation or training for nurses to independently and safely perform CSWD.15 Learners are encouraged to seek out competency debridement education programs that incorporate a comprehensive approach to wound care, enhance participant activity, use multiple exposures for content, reflect adult learning principles, and offer ample opportunities for learners to practice/demonstrate skills. Upon completion of an education program, learners are expected to demonstrate appropriate knowledge, skills, and judgment of clearly defined competencies or skills relevant to debridement. Equally important are qualified preceptors who play an important role in narrowing the theory-practice gap. Preceptors should understand the scope and limitations for each nurse learner.

Recommendation 5: Patient Assessment (Level of Evidence III-V)

Prior to initiation of any method of debridement, the nurse must conduct a comprehensive patient assessment. Assessment includes, but may not be limited to, a detailed medical and surgical history; psychosocial, environmental, and system considerations; etiological/causative agents; intrinsic and extrinsic patient factors such as current prescription and nonprescription medications; nutritional status; lab values; lifestyle factors; smoking history including vaping and recreational drug use; vascular assessment for wounds on the lower limb including an ankle brachial pressure index (ABPI), and or toe brachial pressure index (if ABPI results are unreliable); level of loss of protective sensation; and other tests that may impact the patient's level of risk and potential for wound healing.

Rationale

Clinical experience clearly demonstrates that wounds are increasingly complex requiring an organized and systematic approach to achieve the best patient outcome. A holistic and systematic assessment is an important first step in guiding nurses to formulate decisions and prioritize care based on their understanding of patient's needs and available resources. Nurses should have extensive knowledge of the differences in various wound types, etiologies, and the myriad of factors affecting wound healing prior to initiating debridement. Nonhealing wounds may be a result of unique host factors such as inadequate vasculature, malnutrition, medications that interfere with the healing process, and immune-compromised or critically ill status with nonmodifiable risk factors.

Recommendation 6: Wound Assessment (Level of Evidence IV-V)

In addition to the comprehensive patient assessment, a comprehensive wound and periwound skin assessment using a validated assessment tool (where available) is recommended to assist the nurse in identifying the wound etiology, stage/categorize/grade the wound, and identify barriers to healing. Use of standardized validated assessment tools will facilitate consistent assessment, documentation and communication between assessors, and enable evaluation of wound outcomes over time. Debridement of any kind is contraindicated for adherent dry eschar on heels, ischemic limbs, toes, and digits. An urgent referral for surgical debridement is recommended for unstable eschar when acute infection or sepsis is suspected and when aligned with goals of care.

Rationale

Wound healing is a dynamic process. Accurate, clear, and complete wound assessment allows the patient's interprofessional team access to information they need to plan care and evaluate interventions; thereby, improving patient outcomes and reducing costs associated with care. We strongly recommend use of a validated wound assessment tool to promote a standardized approach to assessment, provide a uniform method of communication among interprofessional team members, and monitor treatment effectiveness over time.

Recommendation 7: Environmental Assessment (Level of Evidence IV-V)

Assess the patient's environment to ensure the setting is safe to perform the debridement modality. Prior to the initiation of CSWD, resources and personnel must be available during and post the procedure to manage and monitor for potential adverse events such as bleeding, pain, anxiety, damage to underlying structures, or loss of consciousness. The nurse should also:

a. evaluate the patient's environment for cleanliness, adequate lighting, the ability to position the patient to ensure visibility of the wound, patient comfort, and to avoid physical strain for the healthcare professional performing debridement-also ensure adequate uninterrupted time is available to perform the procedure;

b. assess for the type of sterile equipment required such as single-use sterile disposable supplies or reusable equipment with a Health Canada-approved method of sterilization such as autoclave to reprocess the medical equipment;

c. ensure appropriate equipment is available to prevent infection and cross-contamination of the wound, patient, family, and healthcare professional; and

d. ensure the safe disposal of contaminated materials including, but not limited to, biological waste, contaminated dressings, sharps, and larvae.

Rationale

With the increasing number of patients receiving wound care at home, nurses should be cognizant of situations where performing debridement is risky, unavailing, and therefore inadvisable. We acknowledge that a range of hazards such as unsanitary household conditions, lack of potable water, poor lighting, and pet danger are hazards that may render the home environment unsuitable for CSWD. In addition, caution should be taken when performing CSWD in a home or community care setting where patients are not likely to be monitored continuously be professional staff for any untoward events post-debridement.

Recommendation 8: Wound Healing Goals (Level of Evidence IV-V)

Prior to the initiation of any method of debridement, it is essential to establish realistic goals that align with the patient's goals for wound care and the goals for wound healing (healing, nonhealing/maintenance, and nonhealable). Use a patient-/family-centered approach to collaborate with the interprofessional team (including the patient and significant others) to ensure respect for patient concerns, culture, and traditions, and to identify risk factors that may impact healing goals.

Rationale

Development of an optimal care plan must be centered around the patient's values, preferences, and goals for care. Although a wound may have the physiological capacity to heal, patients may not be willing or able to adhere to the recommended interventions, or they may not be able to access necessary resources and expertise for optimal wound healing. Certain debridement options are not feasible, and they may compromise quality of life among people who present with terminal illness, chronic debilitating diseases, advanced disease progression, profound dementia, complex psychosocial issues, diminished self-care abilities, and challenging wound-related symptoms. Individualized wound care plans addressing specific concerns, patient preferences, and choices are most likely to succeed and promote the best outcomes for the patient. The decision to perform debridement should take into account whether complete wound closure is realistic and achievable. Aggressive debridement is not recommended in nonhealable wounds where causative factors that preclude healing cannot be addressed. The most critical of these factors is compromised perfusion as often seen in persons with diabetes mellitus and smokers. Under judicious deliberation, conservative debridement (trimming loose, detached slough, or fibrin to reduce necrotic mass and associated odor without causing excessive bleeding) may be appropriate. The goal of conservative debridement is not to facilitate healing but enhance health-related quality of life and decrease the risk of infection. Where appropriate, the choice of debridement method is dependent on the amount of necrotic tissue, urgency, risk of infection, pain, resources or expertise available, and patient preference.

Recommendation 9: Informed Consent (Level of Evidence V)

Informed consent should include legal and ethical considerations, organizational requirements, and should be obtained for all forms of debridement. While written consent may not be required in all instances, the method used to obtain informed consent and the patient's response must be documented in the patient's record.

Rationale

Informed consent implies explicit explanation of the debridement method and all associated benefits and risks to the patient. Patients have the right to receive detailed information on the type of debridement being performed, what to expect before, during and after the procedure, and any alternative methods of treatment. Ample time should be provided for patients, or substitute decision-makers to process the information and ask questions to make an informed decision. Documentation of the information provided and the patient's or substitute decision-maker's response should always be documented in the patient record.

Recommendation 10: Product Knowledge (Level of Evidence V)

Nurses must be knowledgeable about wound care products and therapies used both above and below the dermis prior to use in practice. This knowledge includes the manufacturer's instructions for use, mechanisms of action, benefits, precautions, contraindications, and approval for product use by Health Canada. Product usage that does not adhere to the approved guidelines for use is considered to be off-label use and is not recommended, as it exposes the patient to unknown risks and the healthcare provider to potential sanction.

Rationale

The Canadian market has an ever-expanding list of wound care products and therapies for use by healthcare professionals. The composition of dressings and certain ingredients within products are designed to perform an action on the wound. It is critical the nurse be aware of the impact the product will have on the wound to ensure its application does not result in a deleterious outcome.

Recommendation 11: Reassessment (Level of Evidence IV-V)

Regular reassessment of the patient and the wound is imperative. Reassess the patient for changes in health status and potential adverse responses to wound interventions such as pain. Reassess the wound for indications of progress or deterioration, and review the treatment objectives to evaluate the effectiveness of the debridement modality, the need to pursue alternate methods of debridement, and to facilitate modifications to the care plan as required.

Rationale

Reassessment is needed on regular and timely basis to ensure correct identification of etiological/causative factors and the effects of management strategies, especially when the patient's condition changes. As wounds progress through the healing process, the nurse may identify a need to alter systemic and local treatment, types of dressing, change frequency, debridement method, or patient education and support. Consistent reassessment by a healthcare professional proficient in wound care is necessary to achieve positive patient outcomes.

Recommendation 12: Cost-effectiveness (Level of Evidence IV-V)

Ensure all associated costs are considered before selecting the method of debridement. This includes costs for the healthcare system, the employer or organization, the nurse, the patient, and family.

Rationale

Provision of wound care is associated with substantial healthcare expenditures due to high prevalence and chronicity of various wound types. The financial burden includes costs incurred by time away from work, job loss, staff time, transportation, dressings, medications, and required supplies and equipment for debridement. While financial restraint is a limiting factor, nurses are in the best position to advocate for cost-effective treatment that may result in more rapid wound healing and reduce the risk of complications.

Gaps and Next Steps

The task force has identified a need to develop a competency framework for wound care and a competency-based debridement education and preceptorship program for nurses to develop and maintain specialized knowledge, skills, and judgment in initiating, directing, and performing debridement.15-18 In addition, A Quick Reference Guide (QRG) summary of the recommendations has been developed to support the implementation of the BPR and to guide nursing roles and responsibilities regarding debridement. National debridement competencies and an advanced debridement course are currently being developed by NSWOCC's Wound, Ostomy and Continence Institute with the launch planned for early January 2022.

SUMMARY

Wound care is a highly specialized area of nursing practice. In particular, debridement is associated with a high level of clinical risk that should not be viewed as a simple task in isolation and performed without in-depth assessment of the patient and their environment. The task force determines only qualified and competent nurses with the knowledge, skills, and judgment be responsible for initiating and performing debridement; self-taught or independent learning and education without proper preceptorship is inadequate for nurses to acquire competency to safely initiate and perform CSWD.15 The principal findings from Debridement: Canadian Best Practice Recommendations for Nurses highlighted the need for consistent and standardized nursing debridement practices to facilitate optimal clinical outcomes and enhance safety for patients and nurses in Canada.1 Nurses and key stakeholders must recognize the urgency to standardize scope of practice requirements and competency for debridement in order to promote patient safety and high-quality wound care services.

We urge all nurses, policy makers, administrators, and practice leaders across the continuum of care throughout Canada to appraise, adopt, and disseminate these recommendations.

ACKNOWLEDGMENT

We would like to thank Lina Martins for her dedication to Canadian publications and her guidance and support with this publication.

REFERENCES