Charting A Path to Learning Through An Algorithm

If you are reading this column at the Symposium on Advanced Wound Care (SAWC) Spring 2019 conference in San Antonio, Texas, then I am proud to say that I have your attention during one of the most recognized and respected wound care events. Every time I attend this conference, I am delighted to see the number of clinicians who are seeking to further their knowledge. The education and the research shared at this show (I may be walking past you in the exhibit hall right now!) can be applied immediately into our everyday practice. 

Still, the reality today is that many clinicians, possibly due to facing multiple constraints, choose not to further their education by missing out on these types of events. Regardless, the person who ultimately reaps the benefits of attendance or potentially suffers the consequences of less exposure to best practices is the most important member of the health care team—the patient.

Lately, I have heard from prior students of mine throughout the country asking for advice or input on patients who are being treated at recognized wound centers. They consistently express that some wound care centers do not incorporate best practice guidelines or utilize evidence-based medicine (EBM) in their daily routines. Defined by the late David Sackett, MD, the reputed father of EBM,¹ this concept is defined as “the integration of best research evidence with clinical expertise and patient values.”² There are 3 components to Sackett’s EBM definition, but the conclusion is that it is contingent on new learned information as well as current research. This begs the question: What is an effective method to educate wound care clinicians in providing EBM, and how can you be part of the solution? I am convinced that the problem may be not doing what is right but, rather, that not everyone out there knows what is right.

Imagine receiving a phone call from an out-of-state acquaintance who is concerned about the care (or lack thereof) received by a friend living with diabetes at a wound care center for an ulcer on his hip. Your observation indicates that the patient’s wound is in a prolonged inflammatory phase and not doing well. You are concerned because there is a metal prosthesis under the wound, with noted periwound redness extending down the thigh along with swelling and pain. The necrotic/slough wound bed covers half of the incision line with a moderate amount of drainage. The patient was empowered to ask questions pertinent to his care; he asked the wound care provider if the wound was infected, how the presence of infection is determined, if antibiotics were needed, how the wound could heal with the state of of unhealthy tissue, and how the necrotic tissue would be removed. When the patient was not satisfied with the vague answers that he received (answers that did not seem to suggest best practices), he decided to visit another wound care clinician, where staff offered him a much different plan of care.

Similar scenarios occur more frequently than we would like to think they do, but patients may not always know when a second opinion may be warranted. Worse yet, they may think they have no choice but to proceed with an unfavorable first impression. Still, how many times have you had a patient report that he or she has been seen by a wound care clinician for more than a handful of years and the wound does not look any better? My observation in relation to wound care is that we have multiple challenges to consider when practicing EBM. Even if you currently consistently use best practice guidelines, we now must also practice “IBM” (insurance-based medicine) when caring for our patients with wounds. It is rare that a patient will agree to utilize noncovered interventions. 

Going With The Flow

This recent experience brought back memories of a 2-day advanced wound care class I taught about 10 years ago. At the time, it was soon apparent that nobody in that particular class seemed to know the basics of wound care treatment. There was one participant in particular who had very little knowledge and had recently been hired to run a hospital’s wound care program. That experience prompted me to develop a flowchart that could ultimately help clinicians make decisions based on what best practices suggest—something that would help wound care providers learn about “what is right” while helping patients receive better care. As life tends to happen, it was a project that I did not get to see all the way through, as time commitments related to my own patients offers only the opportunity for part-time teaching (and its related tasks). But the concept of this flowchart has never left me. As time has gone on, I have not seen anything developed that quite resembled what I had envisioned. Yes, there is a plethora of valuable information available to all of us today on best practices, including algorithms and digital technology that marries current information with our electronic health records for point-of-care guidance. These available resources are wonderful and should not be ignored. 

However, in an effort to be part of the solution, I have created an algorithm a flowchart for diabetic foot ulcer treatment strategies that is viewable on one page from start to finish, which I believe can help clinicians learn to do what is right in order to know what is right (Figure 1). At first glance, this the complex version may appear busy or overwhelming, but my goal remained to keep this as a 1-page tool, with the intent to offer a quick reference that can be consulted in the presence of the patient and/or other clinicians. If your time is limited, I also created a simplified version (Figure 2). It might be an “old school” approach, but it is something that will not interfere with any “new school” tools that we refer to on a daily basis.

As you review this document, please keep in mind that the main focus is to determine interventions based on which phase of healing the wound is currently in. The objective is to return all chronic, inflamed wounds to the proliferative phase, and there will be significant characteristics to identify when you have arrived at this phase. One common problem is that we utilize improper interventions at the wrong times because the wound is either in the inflammatory phase or keeps returning to it; this problem usually means there are issues being overlooked or not addressed properly. When you begin at the top of the chart and see where you land based on wound presentation, there are lessons to be learned. I also created a VLU/Ly flowchart based on the same principle. I hope that if you take the time to read this column in its entirety (and view the charts) that you will also try to seek me out at the SAWC or connect with me online. 

Frank Aviles Jr. is wound care service line director at Natchitoches (LA) Regional Medical Center; wound care and lymphedema instructor at the Academy of Lymphatic Studies, Sebastian, FL; physical therapy (PT)/wound care consultant at Louisiana Extended Care Hospital, Natchitoches; and PT/wound care consultant at Cane River Therapy Services LLC, Natchitoches.

1. Lowes, R. David Sackett, “father of evidence-based medicine,” dies at 80. Medscape. Accessed online: www.medscape.com/viewarticle/844845.

2. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh, Scotland: Churchill Livingstone; 2000.