Initiating Proactive Wound Care Principles Into Daily Practice

There are many examples of proactive care in health care. In some health care systems, physicians are looking at preventable disease and other hospital systems look to avoid unplanned admissions or readmissions for “vulnerable populations,” such as those patients with complex physical or mental health issues. 

One example may involve an elderly obese patient who has a large joint replacement and might be at increased risk for developing postoperative infections. In most hospitals, patients with BMI greater than 30 are now reviewed for either weight reduction by standard methods or referral for bariatric surgery prior to joint replacement. The goal of these actions is to reduce the risk of joint displacement and/or infection following surgery.

Five years ago, I started to look informally at a proactive wound care approach in my practice and have instituted a more formal approach to this in the last two years. 

Every new wound patient I see in my office gets the customary thorough history and exam, which includes vascular status, dermatologic exam, medication history, etc. Over the past year, I have become more regimented about using an in-house “registry,” a fancy word for an Excel spreadsheet that lists all of my patients with wounds. The patient’s note will contain much of the same information on this registry but the registry helps me follow the status of patient wounds more easily in terms of wound area reduction from week to week and what products we have used.

This in-house registry is also useful as a work list for my staff to follow so every week, they know exactly what the patient’s status should be and what we are likely to do next. The registry also includes insurance coverage information about items that particular patient will need based on his or her wound etiology. This could include MRI, becaplermin gel (Regranex, Smith and Nephew) for diabetic wounds or compression garments for venous wounds. It will also indicate whether we have achieved the WAR (wound area reduction) percentage in wound improvement.

In their pivotal paper, Sheehan and colleagues state “Subjects with a reduction in ulcer area greater than the 4-week median had a 12-week healing rate of 58%, whereas those with reduction in ulcer area less than the 4-week median had a healing rate of only 9% (P < 0.01)”¹ If wound healing exceeded this expectation, then I would continue on the current treatment plan. If, however, the WAR percentage is less than 58 percent at four weeks, as stated in the original paper, I will proceed to initiate the use of an advanced modality. 

Once I have ruled out all other risk factors (infection, vascular insufficiency that could prevent or delay healing), I do prescribe becaplermin gel for every patient who has a diabetic foot ulcer, regardless of the length of time he or she has had the ulcer.This modality helps continue the healing cascade, reducing inflammation and facilitating the debridement of non-viable tissue. 

All patients with venous ulcers in my practice receive multilayer compression therapy once I have ruled out factors such as vascular disease and made appropriate adjustments to reduce the layers of compression based on the vascular readings of the patients. In a 1999 paper, Margolis and coworkers demonstrated that ulcers of ≤ 6 months duration and ≤ 5 cm² that are treated with compression are highly likely to heal within 24 weeks.2 Conversely, they found that ulcers of > 6 months duration and > 5 cm² are unlikely to heal within 24 weeks.² 

For now, in my opinion, both the Sheehan and Margolis studies serve as the best evidence in the literature upon which to base treatment plans for DFUs and VLUs respectively. There may be new tools available in the near future that give us different perspectives on wound healing potential and recurrence.  

Getting back to the in-office registry, it allows us to log patients with wounds and proactively check on insurance benefits for products and procedures they may require. Having this information available at the time it is needed can help prevent delays in care. In order to follow the patient’s weekly progress or lack thereof, we calculate the WAR percentage every four weeks. If we have not achieved the set target reduction at the four week checkpoint, we go back to the drawing table. I order X-rays every four weeks if the wound is not where it should be so I can detect any changes in bone appearance, etc

I continue to have a clinic at a hospital outpatient wound center. The staff there will only check insurance coverage, benefits when the wound becomes ready for, say, a biologic tissue. Then I have to wait until the next week to see if there are benefits or issues that wind up delaying the care the patient receives. This is not the case at my office where I know about coverage by the end of the week in which the patient presented to the office. When I am ready to move to the next level of care, I can initiate the care that day. 

I do understand that all my patients at the wound center have wounds. However, even though 30 percent of the patients in my private practice have wounds, efficiency is greater in my office. My office staff has to get authorization and benefits for patients with wounds as well as patients with other conditions. We have a proactive approach and it is working well. 

I generally get referrals of patients with chronic wounds. Approaching chronic conditions reactively does not serve patients well. Reactive care does not stop conditions from getting worse or prevent patients from experiencing unpleasant symptoms in the first place. Reactive care is usually more expensive than providing the right care at the right time. Patients see their registry, know the target we are aiming for and are then more likely to adhere to offloading or compression and elevation needs. They are also not surprised when you have to tell them a biopsy or surgery is necessary as we explained all of this to them from the beginning. Patients also don’t want to have to come to a doctor’s office every week for six months or more. They have lives and families they would rather spend time enjoying, or they would rather return to work than continue to dress a wound.  

Providing care with the goal in mind from the beginning allows us to never lose sight of why we do what we do. If you have read the book, Start With Why, by Simon Sinek, this applies in wound care just as much as any other business. If we “start with the why,” we will not continue to delay care foran open wound.

References

1. Sheehan P, Jones P, Caselli A, Guirini JM, Veves A. Percent change in wound care of diabetic foot ulcers over a 4-week period is a robust predictor of complete healing in a 12-week prospective trial. Diabetes Care. 2003;26(6):1879-1882.
2. Margolis DJ, Berlin JA, Strom BL. Risk factors associated with the failure of a venous leg ulcer to heal. Arch Dermatol. 1999;135(8):920-926.
3. Sinek S. Start With Why: How Great Leaders Inspire Everyone To Take Action. Porfolio, New York, 2009.

Dr. Aung is the President of Aung Foot Health Clinics located in Tucson, Ariz. She is a member of the APMA Coding Committee, is a Certified Wound Specialist, and is a professional coder/auditor. For more information on Dr. Aung and her practice, visit www.healthy-feet.com