What's Wrong With Your Wound Clinic?

With an aging patient population in the United States, there’s been a correlating increase in the incidence of chronic ulcerated wounds.¹ Thus, the need for wound care specialists and those trained in taking a directed, aggressive, patient-centered approach is more critical than ever before. In 2009, an estimated $25 billion was spent on wound care in the U.S.¹ However, it’s not known how much variability in wound care practice may have contributed to this cost. As wound care practice continues to become more sophisticated and healthcare becomes more ingrained in a quality-based system, the need for wound care to be more fiscally and clinically productive is also going to intensify. That said, it will be incumbent among those clinicians in the wound care industry to maintain evidence-based practice within their clinics as new science and treatment modalities are introduced. In this article, five major considerations to the clinical approach of wound care will be addressed in an attempt to assist both long-tenured and novice providers in reassessing their practice to ensure their clinics are promoting current standards of care.

WHAT’S BEING DONE INCORRECTLY? 

Besides the more structured wound care education and hands-on training offered to wound care ostomy nurses, few other current wound care providers truly receive formalized training in this emerging field of medicine.² Most patients are not aware that physicians or non-physician practitioners (NPPs) generally have not gone through a true “residency” in wound care. Thus, without a standardized educational curriculum offered to all wound care providers, it’s truly difficult to define true competency in wound care. Should competency be based on experience, healing rates, and/or the number of peer-reviewed cases of wound care patients the clinician has seen? How do providers develop a practice without knowing if what they are doing is right or wrong? Does a wound care educational course that offers a certificate of course completion suffice as appropriate training prior to a clinician being considered a wound care specialist?^2,3 Although the following list of wound care practice considerations is certainly not exhaustive, there are five key issues that should be addressed when the objective in wound care is to heal patients efficiently and aggressively.

1. WOUND CARE, NOT WOUND “STARE”

The accumulation of nonviable tissue on wounds oftentimes leads to slowed or delayed wound healing.² The objective of wound care is to ensure proper debridement is done to accelerate wound healing by allowing the re-growth of healthy, viable tissue.² There are five types of debridement: sharp (outpatient or bedside), surgical (operating room), autolytic, enzymatic, and mechanical, although in an outpatient setting, sharp debridement is generally the most common practice. Sharp debridement includes use of a scalpel, a curette, or scissors to excise nonviable tissue (ie, slough, debris, or callus) alongside viable tissue to stimulate new tissue growth — thus converting a chronic wound state into a more acute wound state. Although it is important to note that sharp debridement in lower extremity wounds should be considered only after proper vascular assessment, current data support that the more frequent the debridement, the better the healing outcome.² Thus, rather than wound “staring,” clinicians should remember that chronic wounds do not behave like acute wounds and may require tissue stimulation to heal. A randomized, controlled, double-blinded trial on diabetic foot ulcers conducted by Steed and colleagues provided the most compelling evidence that frequent, weekly debridement improves healing.⁴ In addition, by tracking the average days to heal for patients’ wounds, providers may prevent falling into the trap of watching and waiting for chronic wounds to begin healing and instead allow them to reconsider a more aggressive approach to wound healing.

2. DRESSING “SANDWICHES” &  “ONE-SIZE-FITS-ALL” APPROACH

With thousands of currently available wound care products, understanding how to choose the correct ones as well as how to use them properly and appropriately are key to successful wound healing. Cost control is also a major factor to consider when selecting the proper dressing. To select the optimal dressing, the initial wound bed assessment should include noting the location of the wound, amount of exudate present, wound depth or tunneling, ability of the patient or caregiver to perform dressing changes, and frequency of dressing changes required.¹ Current wound dressing categories include contact layers, transparent films, foams, hydrocolloids, hydrogels, alginates, collagens, and antimicrobials. With a plethora of choices, providers must therefore take a more algorithmic approach to dressing selection in order to follow a more standardized approach in wound healing. Consider:

A) Is it wet or dry (absorptive dressing versus hydrating gel)?

B) Is it infected or not (antimicrobial component or none required)?

C) Does it require additional debridement (enzymatic, mechanical, or autolytic) between wound care visits?

D) Does the wound bed require further assistance in wound contraction (selection of a collagen-based dressing)?

Based on how the wound is healing with each follow-up visit, clinicians should reassess the wound bed environment in order to choose the most appropriate dressing. Because there are many types of dressings that may combine two different properties (ie, a foam with silver for the infected and moderately draining wound), it’s also important to avoid the trap of creating a “dressing sandwich,” which may lead to increased costs for both the patient and the wound care center (ie, selecting a separate silver dressing with a second absorptive dressing instead of choosing a singular dressing that may address both components). Although clinicians should avoid the “kitchen sink” approach, such as changing the type of dressing on a wound every week, as wounds oftentimes require some time to respond to a given product, there’s also the other extreme of providers who employ the “one-size-fits-all approach” by choosing the same dressing for every patient every week for several months despite lack of significant improvement in wound healing. Depending upon the varying wound types (diabetic, venous, pressure, arterial), wound beds may change with subsequent wound care visits, whether this is due to healing or a plateau in healing, and thus may require different products to facilitate wound progression. In addition, considerations of patient intolerance such as pain or even allergic reaction to certain dressings should be prioritized. Therefore, avoiding the one-dressing-fits-all approach is important to treating patients as individuals and not as groups, of people behaving the exact same way.

3. DIAGNOSING THE WOUND: CHRONICITY Vs. CAUSATION

Diagnosing a wound accurately is important to consider which modalities may be required to achieve more aggressive wound healing. A prime example is the diabetic foot ulcer. Patients who experience neuropathy often come into the wound care center with a chronic, nonhealing wound after having an initial and unknown traumatic injury (ie, stepping on glass or a nail due to lack of feeling). Such a presentation may prompt the provider to consider the most accurate diagnosis: is this a diabetic foot wound or is this a traumatic wound? Considering why the wound will not heal (chronicity) and not the cause of the initiating wounding event (causation) is the key to proper wound care. In this case, patient factors such as underlying diabetes, neuropathy, wound location (ie, plantar foot), and potential infection may prevent the wound from healing, and all such factors must be addressed to heal the wound. Thus, calling this wound a “diabetic wound” instead of a “traumatic wound” is more accurate because the provider must consider all modalities necessary to speed wound healing. In another common scenario, clinicians may often see patients experiencing severe chronic venous insufficiency and varicose veins present with a nonhealing, chronic wound after initial leg trauma. In this case, defining how the wound is behaving (ie, poor healing due to edema and not due to initial trauma) is important because a more accurate diagnosis may lead the clinician to choose better modalities (eg, compression wraps or venous reflux evaluation) rather than treating just the immediate wound bed. Understanding why the wound is behaving chronically rather than treating the wound as a simple event due to the inciting injury may allow providers to choose more accurate and aggressive modalities to treat the underlying problem.

4. ADVANCED THERAPY UTILIZATION: TRACKING HEALING RATES, THINKING AHEAD

After four weeks of slowed or delayed wound healing, advanced therapies should be considered.¹ Advanced therapies may include negative pressure wound therapy, bioengineered skin equivalents, compression, total contact casting, skin grafting, growth factor replacement therapy, and hyperbaric oxygen therapy. Tracking weekly healing rates from the time of initial patient presentation includes looking at weekly wound measurements and ensuring patients do not become outliers (taking longer than the average 12-14 weeks to heal). In addition, taking an accurate history by defining the true duration of the wound allows providers to act on potential advanced therapies more quickly when patients present to the wound care center. Clinicians should consider whether patients have already been seen by other wound care specialists or primary care providers because the time that has already passed may add to the overall wound healing delay. Defining a more accurate wound duration timeline allows the wound care specialist to consider more aggressive and advanced therapies earlier rather than later. Many clinicians fail to track their healing rates or days to heal and, thus, may lose track of how long the patient has been present in their wound care centers.

5. WOUND CARE TRAINING? STANDARDIZING PRACTICE

Finally, in order to standardize wound care practice, it is important to ensure that providers receive proper wound care training prior to being labeled as “wound care specialists.” Patients seeking the aid of a wound care specialist are not only looking for a provider who concentrates primarily on this specialty but one who is also highly skilled in this specified field. A one-week certification course in wound care should hardly suffice as redefining a provider as a wound care specialist. Thus, the burden of training falls upon those in current wound care practice who are tasked with training others considering wound care as a career. Until accredited programs become more prevalent for training medical residents or clinicians to consider wound care, proper wound care training should remain an important requirement for outpatient centers. Examples of such requirements could include a required number of observation hours or peer-reviewed, hands-on cases with patients prior to allowing providers to practice on patients on their own. Rotations for medical residents, nurses in training, and students in allied health should be offered through hospital-based wound care programs that may expose such practitioners to a more standardized wound care training setting. Prevention of poor wound care practice due to lack of knowledge or training should be addressed and therefore promote a more standardized approach to care.

CONCLUSION

The implication of poor wound care may lead to severe outcomes for patients, including hospitalization for severe infection, sepsis, or, in lower-limb wounds, potential amputation. The impact on the patient’s emotional well-being as well as the effect on his or her quality of life are also factors that must be considered as wound care specialists formulate a patient-centered approach in healing patients both physically and psychologically. Managing wounds properly and aggressively with the primary intent of healing patients quickly should remain at the forefront of all providers’ objectives. Thus, the future of wound care as an emerging field of medicine will be highly dependent on a provider’s desire to learn a more standardized approach to wound healing while ensuring that an outcomes-based practice is the focus for optimal patient care. 

Han Pham Hulen specializes in wound care and hyperbaric medicine. Board certified in internal medicine, infectious disease medicine, and undersea and hyperbaric medicine, she is also former co-chair for the Dallas Chapter of the Save A Leg, Save A Life Foundation.

References

1. Oliverio J, Gero E, Whitacre KL, Rankin J. Wound care algorithm: diagnosis and treatment. Adv Skin Wound Care. 2016;29:65–72.

2. Wilcox JR, Carter MJ, Covington S. Frequency of debridements and time to heal: a retrospective cohort study of 312 744 wounds. JAMA Dermatol. 2013; 149(9):1050–8.

3. Darrah J. Measuring the value of a wound care certification in a quality-based healthcare system. TWC. 2016;10(10):27-9. 

4. Steed DL, Donohoe D, Webster MW, Lindsley L. Effect of extensive debridement and treatment on the healing of diabetic foot ulcers. Diabetic ulcer study group.  J Am Coll Surg. 1996;183(1):61-4.