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Section Editor's Message
Improving Wound and Lymphedema Treatment Outcomes in Limited-Resource Environments: An Integrated Approach
March 2010
Medical professionals are increasingly compelled to do more with less and wound care is no exception. This special focus issue of WOUNDS will share the experiences of a dedicated global multidisciplinary team of wound and lymphedema clinicians, academic institutions, public health experts, industry partners, and non-governmental development organizations (NGDOs) participating in the World Alliance for Wound and Lymphedema Care (WAWLC). Their mission is to develop an integrated approach to improve wound and lymphedema patient outcomes in low-resource environments.
The WAWLC builds on strategies initiated by the Association for the Advancement of Wound Care (AAWC) Global Alliance, Handicap International, and other NGDOs in cooperation with the WHO Global Programme to Eliminate Lymphatic Filariasis (GPELF). GPELF developed and implemented an effective, low-resource set of evidence-based, home-care activities including hygiene, wound care, exercise, and raising the affected limb. During the first 19 months of testing this protocol in pilot projects and operational studies, the project’s primary measure, incidence of acute lymphedema attacks, declined from more than 12% to 5%.1
The WHO disseminated technical and training tools to make the GPELF sustainable. There are discussions about how to adapt these tools for other disabling chronic diseases including Buruli ulcer, diabetes, and leprosy. The International Consensus Conference on Disability Prevention Related to Leprosy held in Cebu, Philippines in September 2006, officially recognized benefits of integrating a unified approach to leprosy and lymphatic filariasis by adopting the same protocol of community home-based care, so that the NGDOs became partners in improving outcomes for these diseases. In 2007, representatives of the AAWC, Handicap International, Health Volunteers Overseas, and WHO held a meeting in Geneva, Switzerland to develop a system of relevant clinical and public health activities to manage all chronic wounds and lymphedema in an integrated manner in limited-resource settings. During this meeting, Dr. John Macdonald and Dr. Mary Jo Geyer were commissioned to edit a white paper2 that would collate the basic principles of both wound and lymphedema care. This document is intended to serve as the foundation for developing integrated training and educational materials adapted for different levels of the healthcare system within limited-resource settings worldwide. 
A second meeting that was held March 5–7, 2008 in Geneva, Switzerland, was convened to further define the white paper and to establish the “Global Initiative for Wound and Lymphedema Care” (GIWLC). As a result of this meeting, pilot site evaluations were conducted in Cameroon, Ghana, Sierra Leone, and Uganda. A June 2008 Footwear Workshop in Mali supported by several NGDOs and led by Dr. Geyer added the potential for off-loading the insensate foot to this uniquely integrated agenda. In March 2009, the first GIWLC teaching seminars were conducted in Ghana in the cities of Accra and Kumasi.
In October 2009, representatives from multiple international associations, NGDOs, and industry met in Geneva, Switzerland. The official name of the organization was changed from the Global Initiative for Wound and Lymphedema Care to the World Alliance for Wound and Lymphedema Care (WAWLC). The WAWLC is truly the first global organization devoted to advocating and coordinating the work of different associations involved in wound and lymphedema activities.
As you read the WAWLC story by Dr. Macdonald, WAWLC Secretariat, consider the insight, courage, and integrity of these pioneers who were all willing to collaborate and listen to one another to find effective evidence-based ways of improving the lives of people with chronic wounds and lymphedema. Imagine the work involved in summarizing the enormous burden of wound and lymphedema care and working with public health authorities to lift that burden.
Drs. Erik Post and Mary Jo Geyer describe how the WAWLC is developing integrated teaching materials to support health workers in implementing wound and lymphedema care across diseases. These materials reflect the content of the white paper2 providing the plan for pilot projects to improve wound and lymphedema outcomes. The process continues with the time-tested paradigm of the WHO, beginning with standardized, valid, reliable baseline indicators related to wound and lymphedema outcomes, such as amputation rates, in each WAWLC training site. At specified intervals after pilot implementation, the same indicators will be used to measure progress toward the goal of improving wound and lymphedema outcomes in each site to document WAWLC intervention efficacy and set the stage for protocol improvement.
Attaining goals does not stop with measuring progress. Communicating that progress and improving the processes that achieved it are vital for program success. Providing caregiver feedback regarding measured outcomes reportedly helps improve venous and diabetic foot ulcer healing,3,4 further enhancing patient outcomes and program results. Post and Geyer describe how the WHO Innovative Care for Chronic Conditions4 framework involves healthcare professionals, the patient, and the community in a comprehensive expanding spiral of interaction, communication, and wound and lymphedema outcomes improvement.
Consider wound and lymphedema challenges in your own setting. What aspects of your practice are under-resourced? Some professionals practicing in certain regions of the United States may not be reimbursed for adequate multilayer graduated sustained compression required to heal venous ulcers and manage chronic venous insufficiency.4 Resulting limitations on access to quality wound and lymphedema care in these regions amounts to placing patients and the professionals who serve them in a dangerously under-resourced environment. Perhaps the proven WHO Innovative Care for Chronic Conditions framework and methods5 for making a difference in under-resourced environments may serve as a template for improving patient outcomes in environments faced with such constraints on access to quality resources.
Nancy Kelly describes roles and responsibilities of Health Volunteers Oversees (HVO), the organization that assesses potential sites, advises, and prepares volunteers for their adventure in teaching and learning. HVO partners with many organizations including the AAWC Global Alliance for Wound Care,6 which serves sites in Cambodia, India, Peru, and St. Lucia. Ms. Kelly describes the effort behind assuring that wound care volunteers are safe, secure, and prepared to help train or work with local caregivers on improving patient outcomes. You’ll appreciate all that goes into smoothly expediting volunteers’ journeys and providing them with the tools to optimize the success and enjoyment of their experiences.
Drs. Treadwell and Keast complete the description of the WAWLC initiative to improve wound and lymphedema patient outcomes by describing volunteer experiences while conducting initial site assessment processes in Ghana and Uganda. Their experiences offer an example of the extraordinary reports you will find on the WAWLC website (www.WAWLC.org). How would you cleanse a wound without water? What would you use to debride a wound? How would you manage a patient’s wound when there is a limited supply of dressings? The volunteer medical professionals who performed these baseline assessments were faced with many similar questions that forced them to think “outside the box.” The creativity and versatility of local professionals in meeting patient needs with enthusiasm and consideration despite lack of resources inspired awe and humility. WAWLC learning is a two-way experience.
This review of patient outcomes initiatives associated with the WAWLC provides a fascinating overview of how the program began, gained momentum and credibility, and with the support of the WHO, is now in the process of developing a standardized program to improve wound and lymphedema outcomes in settings with limited resources. Read on and visit www.WAWLC.org or www.HVO.org to learn more about WAWLC or volunteer opportunities to work in AAWC Global Alliance active sites. Appreciate the outcomes that can be achieved when dedicated individuals and organizations integrate their efforts enabling WAWLC volunteers and trusted local practitioners to work in synergy using evidence-based principles to optimize wound and lymphedema patient outcomes in low-resource environments.
Address correspondence to:
Laura L. Bolton, PhD
15 Franklin Place
Metuchen, NJ 08840-2307
Phone: 732-548-0344
Email: llbolton@gmail.com
A second meeting that was held March 5–7, 2008 in Geneva, Switzerland, was convened to further define the white paper and to establish the “Global Initiative for Wound and Lymphedema Care” (GIWLC). As a result of this meeting, pilot site evaluations were conducted in Cameroon, Ghana, Sierra Leone, and Uganda. A June 2008 Footwear Workshop in Mali supported by several NGDOs and led by Dr. Geyer added the potential for off-loading the insensate foot to this uniquely integrated agenda. In March 2009, the first GIWLC teaching seminars were conducted in Ghana in the cities of Accra and Kumasi.
In October 2009, representatives from multiple international associations, NGDOs, and industry met in Geneva, Switzerland. The official name of the organization was changed from the Global Initiative for Wound and Lymphedema Care to the World Alliance for Wound and Lymphedema Care (WAWLC). The WAWLC is truly the first global organization devoted to advocating and coordinating the work of different associations involved in wound and lymphedema activities.
As you read the WAWLC story by Dr. Macdonald, WAWLC Secretariat, consider the insight, courage, and integrity of these pioneers who were all willing to collaborate and listen to one another to find effective evidence-based ways of improving the lives of people with chronic wounds and lymphedema. Imagine the work involved in summarizing the enormous burden of wound and lymphedema care and working with public health authorities to lift that burden.
Drs. Erik Post and Mary Jo Geyer describe how the WAWLC is developing integrated teaching materials to support health workers in implementing wound and lymphedema care across diseases. These materials reflect the content of the white paper2 providing the plan for pilot projects to improve wound and lymphedema outcomes. The process continues with the time-tested paradigm of the WHO, beginning with standardized, valid, reliable baseline indicators related to wound and lymphedema outcomes, such as amputation rates, in each WAWLC training site. At specified intervals after pilot implementation, the same indicators will be used to measure progress toward the goal of improving wound and lymphedema outcomes in each site to document WAWLC intervention efficacy and set the stage for protocol improvement.
Attaining goals does not stop with measuring progress. Communicating that progress and improving the processes that achieved it are vital for program success. Providing caregiver feedback regarding measured outcomes reportedly helps improve venous and diabetic foot ulcer healing,3,4 further enhancing patient outcomes and program results. Post and Geyer describe how the WHO Innovative Care for Chronic Conditions4 framework involves healthcare professionals, the patient, and the community in a comprehensive expanding spiral of interaction, communication, and wound and lymphedema outcomes improvement.
Consider wound and lymphedema challenges in your own setting. What aspects of your practice are under-resourced? Some professionals practicing in certain regions of the United States may not be reimbursed for adequate multilayer graduated sustained compression required to heal venous ulcers and manage chronic venous insufficiency.4 Resulting limitations on access to quality wound and lymphedema care in these regions amounts to placing patients and the professionals who serve them in a dangerously under-resourced environment. Perhaps the proven WHO Innovative Care for Chronic Conditions framework and methods5 for making a difference in under-resourced environments may serve as a template for improving patient outcomes in environments faced with such constraints on access to quality resources.
Nancy Kelly describes roles and responsibilities of Health Volunteers Oversees (HVO), the organization that assesses potential sites, advises, and prepares volunteers for their adventure in teaching and learning. HVO partners with many organizations including the AAWC Global Alliance for Wound Care,6 which serves sites in Cambodia, India, Peru, and St. Lucia. Ms. Kelly describes the effort behind assuring that wound care volunteers are safe, secure, and prepared to help train or work with local caregivers on improving patient outcomes. You’ll appreciate all that goes into smoothly expediting volunteers’ journeys and providing them with the tools to optimize the success and enjoyment of their experiences.
Drs. Treadwell and Keast complete the description of the WAWLC initiative to improve wound and lymphedema patient outcomes by describing volunteer experiences while conducting initial site assessment processes in Ghana and Uganda. Their experiences offer an example of the extraordinary reports you will find on the WAWLC website (www.WAWLC.org). How would you cleanse a wound without water? What would you use to debride a wound? How would you manage a patient’s wound when there is a limited supply of dressings? The volunteer medical professionals who performed these baseline assessments were faced with many similar questions that forced them to think “outside the box.” The creativity and versatility of local professionals in meeting patient needs with enthusiasm and consideration despite lack of resources inspired awe and humility. WAWLC learning is a two-way experience.
This review of patient outcomes initiatives associated with the WAWLC provides a fascinating overview of how the program began, gained momentum and credibility, and with the support of the WHO, is now in the process of developing a standardized program to improve wound and lymphedema outcomes in settings with limited resources. Read on and visit www.WAWLC.org or www.HVO.org to learn more about WAWLC or volunteer opportunities to work in AAWC Global Alliance active sites. Appreciate the outcomes that can be achieved when dedicated individuals and organizations integrate their efforts enabling WAWLC volunteers and trusted local practitioners to work in synergy using evidence-based principles to optimize wound and lymphedema patient outcomes in low-resource environments.
Address correspondence to:
Laura L. Bolton, PhD
15 Franklin Place
Metuchen, NJ 08840-2307
Phone: 732-548-0344
Email: llbolton@gmail.com
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