Making the Case for Specialized Wound Care

  Although many physicians routinely treat acute wounds in their day-to-day practice, the variety and complexity of nonhealing chronic wounds presents a particular challenge. As with any chronic disease process, a wound, regardless of its cause, frequently requires intervention by multiple healthcare disciplines to address the many conditions and comorbidities that impact wound healing. This article demonstrates the need for and the value of taking a specialized, interdisciplinary approach to outpatient wound care.

What’s the Problem?

  By definition, a wound becomes “chronic” when it fails to proceed through an orderly and timely process to produce a sustained anatomic and functional result.¹ Chronic wounds are typically due to a number of well-understood etiologies: unrelieved pressure, venous reflux, arterial insufficiency, infection, and a variety of cancer-related and inflammatory conditions.² Of particular challenge are wounds occurring in the 26 million Americans living with diabetes mellitus. The literature suggests that approximately 15-25% of these individuals eventually develop foot ulcers.³ Moreover, the recurrence rate after initial healing is significant: More than 50% of ulcers return within two years and up to 24% of these patients ultimately undergo amputation. A study commissioned by the American Diabetes Association (ADA) in 2012 revealed diabetes has reached the status of “public health crisis,” costing the US at least $245 billion in 2012, a 41% increase over the last analysis done in 2008. This figure includes $176 billion in healthcare costs and an estimated $69 billion in indirect costs, such as lost productivity and disability.⁴

A History Lesson on Wound Care

  The treatment of acute and chronic wounds as an area of medical specialization is traced through a long and eventful clinical history with origins in ancient Egypt and Greece. Details of the use of lint, animal grease, and honey as topical treatments for wounds are found in literature circa 1500 BC. The Greeks were the first to differentiate between acute and chronic wounds, calling them “fresh” and “nonhealing,” respectively.⁵ Greek surgeons serving Roman gladiators made many contributions to the world of wound care. Notably, they acknowledged the importance of maintaining wound-site moisture to ensure successful closure.⁶ The 19th century witnessed the introduction of several profound medical advances impacting the practice of modern wound care. These include the development of sterile surgical technique, Louis Pasteur’s theories of the impact of microbes on disease, and Joseph Lister’s use of carbolic acid (phenol) as a microbiologic agent in surgery and gauze. The next major advances came in the mid-20th century with the rediscovery of the importance of moist wound-site care preparations and the use of polymer synthetics for wound dressings.

Wound Care Today

  New approaches to wound treatment continue to become more sophisticated and capture the attention of both wound care clinicians and research scientists. Areas of novel research are focusing upon recombinant DNA technology and genetic engineering to amplify the healing process. Additionally, a variety of new products and procedures including semi-synthetic human skin, dermal scaffolds, hyperbaric oxygen therapy (HBOT), negative pressure wound therapy (NPWT), topical growth factors, and a multibillion dollar dressing industry that lends strength to the growing armamentarium of tools valued in the challenging effort to heal chronic wounds.   Despite evolving technological advances, wound healing has been challenged with consistent and accurate methods of care delivery. This has been manifest by a lack of standardized treatment and interdisciplinary collaboration as well as insufficient evaluation of clinical outcomes to drive meaningful care. The majority of chronic wounds are still managed by clinicians with varying degrees of expertise in their private office. Despite this, studies suggest patient outcomes are better when care is provided in an environment of focused expertise.⁷ Moreover; as the medical needs and expenditures for chronic wound care have increased markedly over the past decade, wound care centers have grown in number nationwide. The viability of these centers, like all outpatient services, depends largely on their ability to deliver a differentially superior care experience as well as meet the evolving reimbursement’s demands for cost effectiveness. It’s estimated that 1,600 outpatient wound care centers are actively treating patients today.⁸ Interestingly, more than half of these are managed by outsourcing companies, with a progressive increase in this trend seen over recent years. Reasons for this include the ability of such companies to effectively navigate the myriad of challenges associated in running a specialty clinic while simultaneously giving attention to the practical considerations of operational efficiency and expense management. Management companies offer initial and ongoing quality improvement, exemplary compliance standards, ongoing benchmarking capabilities, and extensive clinical and operational training opportunities to further develop wound care staff.   A theme common to advanced practice wound care centers today is the necessity for a complete assessment of both the wound and the patient. Typically, this begins with a thorough initial assessment in an effort to determine the wound’s etiology and classification, the overall health status of that patient and his/her ability to comply with needed therapies. Because 60% of diabetic foot ulcers (DFUs) have an ischemic component, vascular diagnostic testing frequently results in vascular surgical or endovascular interventions. Radiologic imaging is usually required to identify the presence of osteomyelitis, and medical and surgical subspecialty consultations are often required. Based on this evaluation, a treatment plan is designed to optimize the therapies best suited to address the patient’s needs. As outlined below, a comprehensive treatment plan typically involves numerous steps in the sequence appropriate to complete wound closure.

Comprehensive Treatment: A Sample Approach

  Assessment of Blood Flow: This is the first step in the healing process, arguably the most important, and should precede the use of other advanced treatments in an attempt to maximize their subsequent effectiveness. It is well known that wounds without blood flow will not heal. Conversely, the likelihood of successful healing is predictably associated with the ability to accurately access and correct vascular perfusion abnormalities.   Debridement to Prepare Wound Bed: Debridement involves removal of all non-viable tissue present in the wound, as well as stimulation of growth factors that contribute to healing. Ideally, this procedure is associated with minimal tissue loss while lending to the preservation of functional anatomy. As noted above, debridement should sequentially follow tissue revascularization. As such, the surgeon’s experience in this area, accompanied by appropriate vascular surgery support, is important to achieve optimal results.⁹   Providing Infection Control and Treatment: A foot ulcer serves as a portal of entry for bacteria that can lead to wound infection. Appropriate diagnosis and treatment of infections is critical, as mild cellulitis can rapidly progress to a limb-threatening infection if left untreated.¹⁰   Selection of Dressings: Effective use of dressings is essential for optimal wound management. The concept of a clean, moist wound-healing environment is widely accepted and paramount to timely wound closure. Wound dressings that promote such decrease the risk of infection, as well as minimize tissue dehydration and cell death. Moreover, accurate dressing selection frequently translates into a cost savings to both patients and providers by minimizing treatment-related complications and the frequency with which dressings must be changed.   Pressure Offloading: Ulcerations often occur in high-pressure areas of the insensitive foot, and successful healing and prevention involves the use of total contact casting, half shoes, short leg walkers, and felted foam dressings to relieve the pressure on the foot. Regardless of the offloading technique employed, patients with DFUs must reduce their daily activity until the ulcer has completely healed.   Optimizing Tissue Growth: Even when basic, high-quality care principles are followed, some chronic wounds fail to respond to appropriate treatment. In these instances, advanced healing modalities such as NPWT, HBOT and skin substitutes are often employed to transition wounds from a chronic to active healing process.   NPWT: The use of NPWT devices may be useful in treatment of nonhealing wounds to reduce edema, remove bacterial products, and enhance wound contracture to promote ultimate closure. Significant clinical experience and published research has demonstrated the effectiveness of this technology, particularly in post-surgical wound healing and in the management of open surgical wounds, amputation sites, and pressure ulcers.   HBOT: HBOT works by increasing the concentration of oxygen supplied to the healing wound. By simple diffusion physics, it also increases the distance that oxygen molecules can travel from blood vessels into healing tissues. Clinical benefits associated with HBOT typically include vasoconstriction (reduction of edema) while maintaining tissue oxygenation, increasing collagen synthesis, angiogenesis, and enhancing leukocyte function (fighting infection).   A wealth of data exists to support the use of systemic HBOT for wound healing. This includes five meta-analyses and 13 controlled trials, seven of which were randomized in construct. As a result, in 1999 the ADA released a consensus statement on the diabetic foot, stating that HBOT was beneficial as an adjunctive therapy in certain diabetic ischemic wounds.   Additionally, the cost effectiveness of adjunctive HBOT as a treatment modality is increasingly apparent. A study by Guo et al modeled a cohort of 1,000 patients with severe DFUs (Wagner classification three or above). The cost-effectiveness model estimated the incremental cost per additional quality-adjusted life year gained at years one, five and 12 was $27,310; $5,166; and $2,255, respectively if HBOT had been used in addition to routine care. This study concluded that HBOT in the treatment of DFUs is cost effective, particularly on a long-term basis.¹¹   Skin Substitutes and Biologic Therapy: A new category of advanced wound products has been developed in response to an improved understanding of the impaired wound healing that’s integral in the chronic wound. Pathophysiologic defects such as decreased growth factors, production, and cellular inactivity have led to the development of products that address these deficiencies. Products in this category include recombinant platelet-derived growth factor and biological skin substitutes.

Future Directions

  Given the declining health of our aging and ever-expanding patient population, the need for specialized wound care is vitally important. This mandates a comprehensive evaluation and consistent application of the best evidence available in the care of our wounded patients. It also means creating new evidence through an ongoing analysis of the healing process to understand and correct wound pathophysiology at a molecular level. Additionally, it should be the goal of all wound care practitioners to apply the most clinically and cost-effective therapies, given the looming financial concerns facing our healthcare economy. When we unite as a community of professionals in a combined effort to advance the field of wound care beyond its current status as a fledgling medical specialty, all will benefit. D. Scott Covington is chief medical officer at Healogics, Jacksonville, FL.

References

1. Lazarus GS, Cooper DM, Knighton DR, et al. Definitions and guidelines for assessment of wounds and evaluation of healing. Arch Dermatol. 1994;130(4):489-493. 2. Krasner DL, Rodeheaver GT, Sibbald RG, eds. Chronic Wound Care: A Clinical Source Book for Healthcare Professionals. 3rd ed. Wayne, PA. HMP Communications: 2001. 3. Reiber GE. The epidemiology of diabetic foot problems. Diabet Med. 1996;13(suppl 1) S6-S11. 4. Economic costs of diabetes in the US in 2012. Diabetes Care. Published ahead of print March 6, 2013, doi:10.2337/dc12-2625. 5. Ovington, LG. The evolution of wound management: ancient origins and advances of the past 20 years. Home Healthcare Nurse. 2002;20:652-656. Association for the Advancement of Wound Care, statement on comprehensive multidisciplinary wound care, 2005. 6. Sipos P, Gyory H, Hagymasi K, Ondrejka P, Blazovics A. Special wound healing methods used in ancient Egypt and the mythological background. World Journal of Surgery. 2004;28: 211-216. 7. Margolis DJ, Kantor J, Berlin JA: Healing of diabetic neuropathic foot ulcers receiving standard treatment: A meta-analysis. Diabetes Care. 1999;22:692–695. 8. Healogics market research statistics on US wound care centers, 2013. 9. Saap LJ, Falanga V. Debridement performance index and its correlation with complete closure of diabetic foot ulcers. Wound Rep Reg. 2002;10:354-359. 10. Veves A, Giurini J, LoGerfo F. The diabetic foot: Medical and surgical management. Humana Press, Totowa, NJ. 2006. 11. Guo S, Counte MA, Gillespie KN, Schmitz H. Cost-effectiveness of adjunctive hyperbaric oxygen in the treatment of diabetic ulcers. Int J Technol Assess Health. 2003;19(4):731-737.