Defining Advanced Wound Care in 2016: A Panel Discussion

“Providing wound care in 2016 means we need to practice smarter, not harder. It means that when we have the chance and opportunity to make a difference in our patients’ lives and quality of life, we do what is medically and/or surgically necessary to accomplish that goal in healing their wounds. With the beginning of merit-based and pay-for-performance care, it is almost imperative that we as wound care professionals need to heal the wound as quickly as possible with the least amount of cost. This, however, does not mean that we stop at conservative care. If the wound requires advanced therapies, use them. If the wound needs autograft or allograft, utilize them. If the patients need negative pressure wound therapy or hyperbaric oxygen, use them. This also means that we have to do a better job of screening patients for etiology of the wound sooner rather than later. Order arterial and venous studies. Order labs and microbiology studies. Order advanced imaging. Do what it takes earlier in the cycle of treating the wound and the patient in order to get the best outcomes. In essence, be the most proactive advocate for your patient. Explain each step of the way. Explain why debridement is needed. Explain why we use certain dressings. Explain it all. The best way to practice advanced wound care in 2016 is to practice as if it’s going to be here in 2018 and beyond.” 

— Eric J. Lullove, DPM, CWS, FACCWS, staff physician, West Boca Center for Wound Healing, Boca Raton, FL; healthcare policy committee, Association for the Advancement of Wound Care (AAWC); AAWC liaison, Alliance for Wound Care Stakeholders; consultant, Hollister Wound Care (Libertyville, IL), Medline Industries Inc. (Mundelein, IL), and ABL Medical, American Fork, UT).

“As a nurse, advanced wound care has always meant making a difference in the lives of my patients by healing their wounds as quickly as possible in a financially responsible way. Recently, I experienced chronic wound care as a patient. As a busy mother of two with a nonhealing surgical wound, I was frustrated with the frequent follow-up visits and ongoing wound care. The impact on daily life was a burden. I learned through my experience just how important it is to have and maintain open dialogue with your patients. Don’t make treatment decisions without consulting the patient. Advanced wound care is more than getting a wound healed; it’s healing the person as a whole. Evolving treatment plans to expedite healing in a financially responsible manner is important, but including the patient in the treatment plan is equally as important.” 

— Trisha Markowitz, MSN, MBA-HCM, RN, CWCN, DAPWCA

“Advanced wound care today means integrating established concepts with dynamic changes in technology and resources, and overlooking frustrations inherent in the healthcare system while attempting to provide the highest level of care as providers and patient advocates. Despite the hurdles and difficulties, we must realize that we are privileged to serve and utilize our skills in our specialty as a gift and reason to always remain positive in our outlook.” 

— Desmond Bell, DPM, CWS, First Coast Cardiovascular Institute P.A., Jacksonville, FL.

“Since I began practicing as a dedicated wound care specialist 15 years ago, advances in wound care have occurred at a staggering pace. Of course, most clinicians might conclude that I am referring to clinical advances (which most certainly have occurred with the development of new diagnostic and biologic treatment options that are in our hands today with more on the horizon). However, I also believe it is the advancement of physician education, awareness, and engagement into the specialty of wound care that has led to improved clinical and cost-effective outcomes for our difficult patients. Therefore, I would define advanced wound care in 2016 as the physician-led integrated wound care community model. As wound care specialists, it is time for us to lead the charge of building the team and developing the strategy to share our expertise with all wounded patients everywhere we can and for every patient who would benefit. With the concept of population health, this starts with the notion of never discharging patients, but rather helping them through the care continuum to get to the most appropriate clinical care setting, providing the most appropriate and cost-effective treatment, and doing the right thing for the right patient at the right time. Physician leadership is paramount to align the strategies of all interested parties, including administrative and clinical support mechanisms in both the acute and the post-acute facilities and services. As always, the backbone of our success will be reliable data in order to measure success, move the needle, and implement an advanced standard of practice through evidence-based care.” 

— Chris Morrison, MD, executive medical director, Healogics Specialty Physicians, Jacksonville, FL; medical director, Wound Systems, Atlanta, GA.

“When I began working as a dietitian 48 years ago, we were just beginning to understand the importance of nutrition for managing acute and chronic wounds. My fellow wound care nurses were just starting to learn about the importance of moist wound healing, compression for venous stasis ulcers, and offloading of diabetic foot ulcers. All of those treatments (plus infection control, edema control, debridement, blood glucose control, and elimination of tobacco use) are standards of care in 2016. If this standard treatment fails to show evidence of healing, wound care professionals should turn to 2016 advanced technologies as soon as possible:

• advanced diagnostics;
• electrical stimulation/electromagnetic therapy;
• negative pressure wound therapy (both traditional durable medical equipment and disposable, nondurable medical equipment);
• advanced methods of debridement (such as hydrodebridement, enzymatic debridement, etc.);
• noncontact, low-frequency ultrasound;
• fluorescence angiography;
• hyperbaric oxygen therapy; and
• cellular and/or tissue-based products for wounds (outdated term ‘skin substitutes’).

Wound care professionals should select the appropriate wound management system based on: 1) published clinical evidence and registry information, 2) contribution to providing the best outcomes at the total lowest cost of care, and 3) patient satisfaction. Wound care professionals must learn to implement standard wound care, followed by advanced wound care. All of their work should be documented and evaluated for quality outcomes, total cost of care, and patient satisfaction. In other words, advanced wound care is the care that meets the Institute for Healthcare Improvement’s Triple Aim Initiative across the continuum of care.” 

— Kathleen D. Schaum, MS, president and founder, Kathleen D. Schaum & Assoc. Inc., Lake Worth, FL; director, medical products, reimbursement, biotherapeutics, Smith & Nephew, St. Petersburg, FL.

“To me, advanced wound care means thinking outside the box when necessary and knowing when staying ‘in the box’ is fine for a particular patient. For example, if a patient’s wound fails to respond to good wound care (treating underlying pathophysiology, addressing infection, correcting systemic conditions, debriding necrotic tissue, etc.) within 3-4 weeks, bringing in adjunctive modalities (outside the box) is frequently needed — use of growth factor therapy, cell- or tissue-based therapy, hyperbarics, systemic medications, arterial pumps, physical therapy modalities, and/or surgical intervention such as skin grafting. On the other hand, if a patient’s wound responds well to basic good care (the box) and is steadily progressing towards healing, there is rarely a need to bring in more expensive products. Using our armamentarium appropriately, and in a timely manner, is the hallmark of a clinician practicing advanced wound care.” 

— Susie Seaman, NP, MSN, CWOCN, Sharp Rees-Stealy Medical Group, San Diego; founder, Sharp Grossmont Hospital Wound Healing Center, La Mesa, CA.

“As scientifically trained clinicians, our bias is to expect the best practices in wound care to be a bell-shaped curve with 3%-5% holding on to the ‘old ways,’ 90% learning and applying evidence-based medicine, and 3%-5% creating the new evidence to lead the way. Traditionally, we would consider the 90% as standard of care and the new evidence being generated as ‘advanced.’ But not so much in the practice of wound care as a part of medicine across the world today. The current practice of wound care is better characterized as an amoeba with a very long pseudopod (or two), and the harder the pseudopod tries to pull the amoeba forward the tighter it holds on to its ‘place.’ For example, wet-to-dry dressings are still the dominant choice of dressing across the world. Mainly, providers with no wound care training are the reason and most are not that interested to be trained in something as ‘simple’ as wound care. Administrators push the cheapest treatments, and payers will only pay for the cheapest treatment to control cost. So wound care is stuck in the old ways … in its place. Viewed from this perspective, just assessing and addressing each patient for wound healing barriers such as pressure, repetitive trauma, poor perfusion, infection, and systemic disease is ‘advanced’ therapy. Products (topicals, dressings, cells, cytokines, substrates, etc.) and procedures (debridement, revascularization, surgery) would then have to be considered ‘next-generation’ wound care. Which means, in this paradigm, emerging diagnostics (molecular methods [DNA] for microbial identification; enzyme-linked immunosorbent assay; and proteomics for biomarkers, imaging technologies, etc.) and therapeutics (synergistically combine treatments, energy-transfer methods, stem and genetically modified cells, antibiofilm products and methods) would have to be ‘next generation.’ The problem for wound care today is not that the science has not moved forward, but for various reasons these scientific advances (advanced therapies with valid evidence of efficacy) have not translated into the mainstream of wound care. Through new scientific discoveries and developments the pseudopod of wound care has reached out very far, yet may need some help to get the main body to follow along.” 

— Randall Wolcott, MD, CWS, founder, Southwest Regional Wound Care Center, Lubbock, TX.