How to guidesMeeting CQUIN targets: effective dressing selection

Meeting CQUIN targets: effective dressing selection

Complex wounds, Exudate Management, How to guides, Pressure Ulcers, Skin integrity | Gill Wick

What is exudate?
Wound exudate is produced as a natural part of the wound healing process and all wounds produce exudate in varying amounts, colour and viscosity. It keeps the wound bed moist and supplies it with proteins, growth factors, white blood cells, tissue repairing cells and other essential nutrients (WUWHS, 2007).  

Exudate levels will guide us to the dressing product we choose and the frequency with which we change these dressings. This in turn has an impact on the numbers of nursing hours utilised in wound care and therefore has a direct correlation to the cost of a nursing service.

Each dressing will come with the manufacturers instructions as to when it needs changing. However, saturated dressings enable bacteria to invade the wound and put the patient at risk of developing maceration or excoriation.

Effects of maceration
Maceration means that the wound edges have become overhydrated due to wound exudate not being managed effectively and the wound edges not being protected. This may be due a change in the state of the wound; for example, the wound may have become infected resulting in an increase in the exudate levels and the chosen dressing may no longer be absorbent enough, or the dressing may be too small for the wound, or just not absorbent enough.  

The overhydration of the periwound skin will appear white and be friable, potentially leading to the wound becoming larger or deeper, which may progress the category of the pressure ulcer and affect the CQUIN targets.
Effects of excoriation
Excoriation is when the epidermis is stripped or eroded by enzymes in the exudate called proteases. One group of proteases is called matrix metalloproteinases (MMPs) and they have a vital role to play in debriding and cleaning devitalised tissue in a wound (Moore, 2003; Wicks, 2008). However, in some chronic wounds, these proteases become more prolific and can cause significant damage to the wound bed and periwound skin (Trudgian, 2005). Therefore effective management of exudate is essential by:

  • protecting the periwound skin with barrier products
  • using effective absorbent wound dressings
  • changing the dressings frequently enough to prevent deterioration of the wound and surrounding skin.  

Appropriate dressing selection for optimal outcomes
Most traditional foam dressings are made of a polyurethane foam. The actions of foam dressings vary in the speed in which they absorb exudate and their ability to absorb and retain exudate. Some foam dressings wick laterally and the exudate spreads across the foam. Others wick vertically and are aided by a good moisture vapour transmission rate (eg evaporation), allowing for more effective fluid handling. Consideration should also be given to how well the foam retains fluid under pressure or compression. All of these factors should be taken into account when choosing a dressing, as a foam that does not handle fluid well will put the patient's wound at risk of maceration.    

Hydrofiber® dressings and alginates
These primary dressings have varying absorption capacities depending on the product. They provide a moist wound healing environment and are generally easy to remove. They can used underneath foams or other absorbent pads to increase the levels of absorbency in a highly exuding wound. 

Superabsorbent dressings
If the wound requires frequent dressing changes to manage the exudate, the level of absorbency could be stepped up to a superabsorbent dressing. These dressings also vary in their ability to absorb and retain fluid and how they function under pressure or compression. Some superabsorbent dressings are also able to lock in bacteria and proteases, which may be harmful to a wound. A superabsorbent dressing may allow for a longer time period between dressing changes, reducing nursing time and making them a cost-effective dressing choice.

Negative pressure wound therapy
If the level of exudate is still too high for either a foam or a
superabsorbent dressing to be effective, negative pressure wound therapy could be considered for exudate management. Other more pertinent reasons are its ability to promote healing and reduce healing times (Romanelli et al, 2010), also potentially helping healthcare providers meet CQUIN targets.   

The accurate assessment and diagnosis of wounds will have a direct financial impact on healthcare providers.  More specifically, the correct diagnosis of pressure ulcers could ensure that CQUIN targets are met and the quality of care provided to patients can be proven by the reduction in the numbers of pressure ulcers. Furthermore, each organisation has to strive to have zero avoidable pressure ulcers to meet the recommendations by the NHS Institute of Innovation and Improvement (2009).  

The correct choice of dressings will also have an effect, not only on patient outcomes, but on healing rates, nursing time and dressing budgets. Choice therefore has further financial implications for any healthcare provider when wound care is connected to targets. 

It is clear that the government is concentrating on the quality agenda for the NHS and it is the responsibility of nurses at all levels to ensure that the targets and innovations are met. If they are not met, the financial implications will affect us all. Understanding the bigger picture and the consequences of our actions can help us achieve better outcomes for our patients and for all NHS providers of care. 


  • Department of Health (2010)  Using the Commissioning for Quality and Innovation (CQUIN) payment framework - a summary guide.  DH, London
  • Guy H (2012) The difference between pressure ulcers and moisture lesions. Wounds Essentials 1: 36-44. Available from:
  • National Nurse Sensitive Outcome Indicators for the NHS and commissioned care (2010)
  • NHS Institution for Innovation and Improvement (2009) High impact actions for Nursing and Midwifery. NHS Institution for Innovation and Improvement, Coventry.  Available on line at:
  • Romanelli M, Vowden K, Weir D (2010) Exudate management made easy. Wounds International 1(2). Available from:
  • Shorney R, Ousey K (2011) Tissue viability: the QIPP challenge. Clin Services J  6-9
  • Trudgian J (2005) Exudate management and wound bed preparation: taking the MOIST approach. Wounds UK supplement 1(2) 10-15
  • Wicks G, Stephen-Haynes J (2008) Wet wounds: practical steps to improving active fluid management Br J Community Nurs 13 (6) (Suppl)
  • WUWHS (2007) Wound exudate and the role of dressings. A consensus document. London: MEP Ltd. Available from:

Author: Gill Wicks, Consultant Nurse, Tissue Viability, Great Western Hospitals NHS Foundation Trust, Trowbridge, Wilts


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