Sensible Decision Making

What drives the decision-making process when managing the patient with a wound? There are different schools of thought, including published concepts, philosophies, and algorithms that help illustrate the concepts behind the clinician’s approach to wound care.

In 2010, the Institute for Healthcare Improvement initiated the Triple Aim theory to improve population health and health system performance. Built on the premise of improving health by providing cost-effective care that addresses quality and patient satisfaction, this philosophy fits perfectly with providing care for wound healing. Much ado is made about “expensive” products we may use on patients with wounds; unquestionably, we need to be mindful of costs. Likewise, we cannot assume patients will heal “eventually”; we need to think about how to achieve healing expeditiously. The oft-quoted prognostic indicators of 50% healing of a diabetic foot ulcer and 40% healing of a venous leg ulcer by 4 weeks equating to earlier healing should be heeded.^1-3 Faster healing will almost invariably offer the potential clinical benefits of removing the nidus for pain, reducing the potential for infection, getting the patient moving and back to work sooner, and improving quality of life wherever it has been impacted, not to mention lower costs. Utilizing critical resources earlier rather than later when the wound has become even more chronic and inflamed makes sense, but doing so requires vigilance. Healing progress must be closely monitored to avoid spending weeks using the same treatment with little or no improvement. Clinicians must remember that improvement is not always reflected in smaller measurements alone; progress also can be evident in other short-term goals such as reduction of exudate, improved periwound skin, reduction of pain, and reduced edema.

Although the word healability cannot be found in the dictionary, it makes good sense. Sibbald et al⁴ coined the phrase in their 2014 paper on wound bed preparation and describes the associated goals for wound management as:

• Healable
  • A wound with adequate blood supply that can be healed as long as the underlying problem can be addressed
• Maintenance
  • There may be healing potential, but patient or health system barriers, (including patient nonadherence to a treatment plan or health care resource limitations) may compromise healing
• Nonhealable
  • Wounds, including those in patients receiving palliative care, cannot heal because of irreversible causes or associated illnesses, including critical ischemia or non- treatable malignancy.

In the Consensus Guidelines for the Identification and Treatment of Biofilms in Chronic Nonhealing Wounds,⁵ Greg Schultz et al described a management strategy that advocates for the initiation of multiple therapies in combination early. These therapies might include aggressive debridement, bioburden and biofilm management, aggressive attention to host factors, and use of available point-of-care diagnostics and DNA culturing to rapidly obtain a well-prepared wound. The clinician then can monitor optimization and personalization of the therapy according to the individual’s healing status and de-escalate treatment as the wound improves. As wound follow- up approaches 4 weeks, the clinician can evaluate healing and decide whether continuing with standard of care will facilitate a healing trajectory or if treatment should be stepped up to advanced therapies. Depending on the site where care is being provided, clinicians also should consider moving the patient to a higher level of care (eg, a specialty clinician or center) sooner rather than later.

Topical treatment. One aspect of wound management that is decided at each evaluation is the choice of topical treatments. Recent installments of “Back to Basics” have described cleansing, exudate absorption, and moisture management and the myriad of dressings and products to answer the needs of the wound based on a thorough assessment. Unfortunately, multiple providers with multiple dressing opinions also can create clinical and cost inefficiencies. Changing the type or category of dressing simply because a clinician likes one over another is always going to be costly, especially if dressings have already been ordered and provided to the patient at home or in a skilled nursing facility. Dressing changes should be based on changes in wound status and altered if the current plan of care is not meeting the environmental needs of the wound — for example, utilizing a superabsorbent product rather than layering an absorbent product such as an alginate and covering with a foam.

Wounds are dynamic; over time, their needs will and should change. There is no “one size fits all” as we nurture the wound toward healing. Each and every time a dressing is changed, the wound surface is disrupted; a change in temperature, pain, and trauma to the wound bed and/or surrounding skin potentially can occur. The goal is to reach a point where we can step back, let the body heal by design, and disturb the wound as little as possible utilizing a dressing that manages exudate effectively, maintaining the optimal moisture and temperature level, providing protection from contamination and minimizing trauma.

Dr. Steven Covey⁶ (7 Habits of Highly Effective People) advises, “Begin with the end in mind.” Preparing for the desired wound outcome and controlling and directing the resources toward that outcome can put the patient on a healing pathway.