Point Prevalence of Chronic Wounds at a Tertiary Hospital in Nigeria

Background. Chronic wounds are a drain on resources both for the patient and health institution. Management of chronic wounds based on evidence-based practice requires baseline data for adequate planning.Objectives. This study was carried out to determine the point prevalence of chronic wounds in a tertiary hospital (University College Hospital, Ibadan, Nigeria) and utilize this information for subsequent wound care planning. Methods. The study was carried out within a 1-month period and included all patients seen in the hospital with chronic wounds. The data obtained was entered into a designed form and was subsequently analyzed. Results. There were 48 patients with 78 wounds representing approximately 11% of patients seen in the Department of Plastic, Reconstructive, and Aesthetic Surgery each month. Their ages ranged from 3 months to 80 years; the median age was 48 years. The male to female ratio was 1.6 to 1. The duration of the wounds ranged from 6 weeks to 780 weeks; the median duration of the wounds was 10 weeks. The area of the wounds ranged from 1 cm² -1,248 cm² (median 24 cm²). The most common chronic wounds were diabetic wounds, followed by pressure ulcers, postinfection ulcers, posttraumatic ulcers, burn wounds, malignant ulcers, and venous ulcers. Conclusion. The point prevalence data serves as a basis for wound care planning. This, in turn, should result in improved wound management grounded in evidence-based practices.

A chronic wound is a wound that has failed to proceed through an orderly and timely process to produce anatomic and functional integrity or a wound that has proceeded through the repair process without establishing a sustained anatomic and functional result.¹ It can also be defined as any wound which has remained unhealed for more than 6 weeks.²

Chronicity of a wound results in a burden on health care facilities and it is not uncommon for it to be financially and emotionally draining for the patient. There is a paucity of information from well-designed prospective studies on chronic wounds to assist in adequate wound care planning in an institution that can allow for appropriate evidence-based practice. The aim of this study was to determine the point prevalence of chronic wounds in a tertiary hospital (University College Hospital, Ibadan, Nigeria) and thus provide data for effective wound care.

The study was carried out in a tertiary hospital in southwest Nigeria. The University College Hospital, Ibadan is an 800-bed hospital with an approximately 80% occupancy rate. It is a referral center for patients with chronic wounds in the subregion. The patients were either reviewed in the surgery outpatient department, the accident and emergency department, or the surgical or medical wards. On average, the plastic surgery outpatient clinic receives 212 patients a month, while the medical and surgical wards admit 268 patients per month. Patients with chronic wounds are usually referred to the plastic surgery department, which has 5 consultants, but there are a complement of other specialists such as vascular surgeons, physiotherapists, dietitians, endocrinologists, and microbiologists who assist with the management of the plastic surgery department.

Patients that were admitted to the University College Hospital, Ibadan or seen in the surgical outpatient clinic with chronic wounds in November 2012 were included in the study. Chronic wounds were defined as wounds that lasted at least 6 weeks. Information was obtained using a form with several sections. The first section had the patient’s demographics, including the sex, age, and hospital number. The second section included the medical and surgical histories such as a history of diabetes or hypertension. The third section was the physical assessment which included the body mass index and nutritional status. This was then followed by a section on wound assessment including the duration of the wound, wound size, and wound bed assessment such as granulation tissue, exudate, and the presence of a wound infection. Lastly, there was a section on wound microbiology results and diagnosis. The nutritional status of the patients was determined by their body mass index and they were classified as obese, well nourished, or undernourished. 

The information obtained was then entered into statistical analysis software (IBM SPSS Statistics for Windows, version 21, IBM, Armonk, NY). Descriptive analysis was subsequently done.

There were 48 patients with 78 wounds reviewed during the 1-month period. This represents approximately 11% of the authors’ potential patients on a monthly basis. Out of these, 56.4% of the wounds were from the surgical ward, 23.1% from the medical ward, 17.9% from the surgery outpatient ward, and 2.6% from the accident and emergency department.

The male to female ratio of the patients was 1.6 to 1. The age ranged from 3 months to 80 years; the median age was 48 years.  There were no significant medical and surgical histories in 38.5% of the patients; 39.7% had diabetes, while 25.7% had hypertension with some patients presenting with both conditions.

In terms of nutrition, 37.2% of the patients were well nourished, 32.1% were undernourished, and 30.8% were obese. Twenty five percent of the male patients were obese, 43.8% were undernourished, and 31.3% were well nourished, while 40% of the female patients were obese, 13.3% undernourished, and 46.7% were well nourished. Also, 42.3% of the patients with diabetic ulcers were obese, 53.8% were well nourished, and 3.8% were undernourished. The duration of the wounds ranged from 6 weeks to 780 weeks; the median duration of the wounds was 10 weeks, and the mean surface area was 86.3 cm² (median 24 cm²). There was statistically significant difference in the distribution of wound types according to location (x² = 109; P = 0.001) (Table 1). 

Fifty-two out of the 78 wounds reviewed were on the lower limbs (legs and feet), constituting about 66.6% of the chronic wounds. Of all wounds in this location, diabetic wounds were the most common (Figure 1 shows the distribution of chronic ulcers on the lower limbs), and tended to be on the dorsum of the foot and toes. Postinfection ulcers (ie, chronic wounds that originated from a soft tissue infection) followed in order of frequency, but they did not present with any pattern of occurrence. Fifty-eight percent of pressure ulcers occurred around the hip-buttock area, the sacrum being the most common location (Figure 2 shows the distribution of pressure ulcers on the body). When pressure ulcers were on the foot, the heel was the most common location. However, when chronic wounds on the foot from all causes were pooled, they were most common on the dorsum of the foot, followed by the medial malleoli, toes, heel, sole, and lateral malleoli in descending order of frequency. 

The pain assessment revealed there was no pain in 11.5% of the patient’s wounds, minor pain in 39.7%, mild pain in 25.6%, moderate pain in 20.5%, and severe pain in 2.6% of the wounds. The most common chronic wounds the authors reviewed were diabetic wounds, and venous ulcers were the least common (Figure 3). 

It is not uncommon also to see chronic wound patients with diseases such as diabetes and obesity, which are recognized as public health issues.³ The authors suggest chronic wounds should also be recognized as a public health issue, especially since in developing countries, poor management of acute wounds often results in chronicity. In the authors’ study, about half of the patients (42%) with diabetes were also obese; the combination of these conditions create poor risk factors for wound healing.⁴ The lack of recognition of chronic wounds as a public health issue may also be related to the lack of data demonstrating the burden of the disease.⁵ This condition is not limited to developing enviroments such as Nigeria; in Canada, little information is available regarding the number of individuals living with chronic wounds, and no national chronic wound prevalence or incidence records exist.⁵ This information is crucial for proper assessment of the related health care costs.^5,6 It is predicted that with the rising number of senior citizens and people with disabilities there will be an explosion of chronic wounds in the near future.⁷ Although in Nigeria only about 4% of the population is above the age of 65 years and the median age is 18 years, there is also a similar prediction of an increase in chronic wounds.⁸ The factors for this prediction include an improvement in standard of living and an increase in the middle class, resulting in better access to care for senior citizens and, therefore, an increase in the aging population. 

The point prevalence in this study is 11% of the potential patients. This is similar to the cumulative wound prevalence in northeast England, which was 12%⁹; however, it is high when compared to a 4.2% prevalence reported in a multicenter, cross-sectional, point prevalence measurement carried out in Dutch nursing homes¹⁰ and the 1.4% prevalence noted in Quebec homecare.¹¹ The Ottawa-Carleton regional leg ulcer project reported the regional prevalence rate per 1,000 population over 25 was 1.8.¹² The high prevalence in this study may be because the study was carried out in a tertiary center where patients with difficult-to-heal wounds are referred for expert care. It is therefore not out of place to have a higher concentration of patients with chronic wounds compared with data that would be obtained in a community-based study.

Wound care in the authors’ study setting is not well organized. Sometimes after initial care in hospitals, patients’ wound management is taken over by inexperienced personnel who apply inappropriate and occasionally toxic agents in an attempt to care for the wounds. In other instances, the patients themselves resort to caring for their own wounds without requisite training. In such a situation where there is inadequate organization of wound management, it is logical to expect many poorly managed acute wounds to become chronic. This is often the case for many posttraumatic and postinfection wounds the authors encounter. These prevalence figures may therefore be a true reflection of the burden of chronic wounds in their clinical care setting. Also, based on the authors’ experience treating patients and with interactions with them, many patients have a phobia of hospital care for various reasons, including a fear of surgery, high cost of care, and receipt of misinformation on proper wound care by various health care providers. As explained earlier, inappropriate management of the acute wounds is one of the leading causes of chronicity of wounds in the authors’ community. As a consequence of this, some patients present with severe complications of wounds (like anemia and sepsis), require resuscitation with fluids, blood, or nutritional aid in the emergency department due to their poor clinical status when they arrive in the hospital.

In this study, the most common type of chronic wounds, in order of prevalence, were diabetic wounds, pressure ulcers, postinfection ulcers, and posttraumatic wounds. The most common cause in a northeast England study was surgical wounds,⁹ while in Ireland, pressure ulcers were most common.¹³ There is an increase in the prevalence of diabetes due to increased urbanization and the change in diet it brings, coupled with the fact that only about a third of Nigerians living with diabetes achieve optimum targets for glycemic control, blood pressure, lipids, and weight, which explains diabetic ulcers as the leading cause of chronic wounds.¹⁴ Postinfection ulcers from necrotizing or nonnecrotizing soft tissue infections are common in Nigeria, and the high incidence of posttraumatic chronic wounds is due to poor management of the initial wounds. In the authors’ clinical experience, wounds sustained from trauma such as traffic accidents are usually not well managed and get secondary infections. The wounds are then dressed, occasionally for years, in the hope that they will heal. These wounds then have complications such as residual ulcers, contractures, and unstable scars and need to be managed by skin grafts or flaps; however, patient factors such as financial constraints, fear of surgery, or a lack of access to appropriate health care then come into play.

In the current study, the most common cause of leg and foot wounds were diabetic ulcers followed by postinfection ulcers, and the low incidence of venous ulcers in this study may not be a true reflection of the disease.

There was statistically significant difference in the distribution of wound types according to location (x² = 109; P = 0.001), which means wound sites have a predilection for particular etiologies such as diabetic wounds on the foot.

This prevalence study may serve as a platform for planning an integrated wound care protocol for the hospital. This plan involves the establishment of an ambulatory wound care clinic, the formation of an interprofessional wound care team, and appropriate, structured wound assessment and treatment. Also, it will stimulate the development of wound care protocols based on best practices.

The management of chronic wounds in the authors’ clinical setting is usually with the use of traditional wound care products such as gauze, honey, and povidone-iodine; there is, however, an influx of advanced wound care products such as hydrogel, hydrocolloids, calcium alginate, and silver dressings such as Acticoat (Smith & Nephew, Andover, MA) in their practice. The advanced wound care products tend to be more expensive than the traditional products, though they can be argued to be more cost effective.¹⁵ The authors’ practice is now to provide the patient with choices of traditional or advanced wound care products so they may decide which products they can afford.

The management protocol for chronic wounds includes the use of topical antimicrobials, antibiotics as indicated, wound debridement, limb elevation, bed rest, analgesics, tetanus prophylaxis, high dose vitamin C, supplementary zinc tablets, and regular wound dressings.

Specific wounds such as pressure ulcers require the strict implementation of pressure ulcer prevention protocols. Some wounds may require coverage with a skin graft or a flap to achieve adequate wound conditioning.

The assessment of wounds helps in developing a language of standardized descriptions for a database of wounds the authors treat in their hospital. It will also allow for evaluation of the progress of wounds over time, comparison of reports on wounds, and interpreting literature about wounds. Although clinical assessments have been documented prior to this, the descriptions are subjective based on each clinician’s observations. It is not uncommon to have instances where documentation shows the wound is improving; however, these observations are only helpful for the clinician who previously assessed the wounds and will not engender proper interrater or interobserver evaluation.

There was a statistically significant difference in the correlation of the wound and the type of wounds, whereby pressure ulcers were most common at the sacrum. This can easily be explained because most of these patients were being treated as inpatients and lying supine on a hospital bed and the hip-buttock region accounts for the majority of pressure ulcers in patients lying decubitus.¹⁶ The lower limbs are a common location for most wounds such as traumatic and diabetic wounds because of neuropathy and angiopathy. The finding that postinfection ulcers appear more often in the lower limbs and the right foot are results that may require a larger and more detailed study to explain. The authors’ study included only 1 venous ulcer, which may be an underrepresentation of these types of chronic ulcers managed in their institution.

Chronic wound care requires an interprofessional approach. Wound assessment and treatment needs to be done based on best evidence practice for most successful outcomes. It is, however, important to take into consideration patient-centered concerns such as financial constraints when deciding the wound care plan and dressings for patients.

From the Department of Plastic, Reconstructive Aesthetic Surgery, University College Hospital, Ibadan, Nigeria

Address correspondence to:
Ayodele O. Iyun, MD
Department of Plastic, Reconstructive and Aesthetic Surgery
University College Hospital
Ibadan, Nigeria
olukayodele@yahoo.com

Disclosure: The authors disclose no financial or other conflicts of interest.