Editor’s Opinion: Getting Back to Basics

  Several recent events made me think about the “basics” of healthcare and wonder why they appear to be so easily forgotten. As Weinstein¹ observed, “As we pass the sesquicentennial of Semmelweis’ seminal observations on the importance of hand hygiene in reducing the incidence of nosocomial childbed fever, why does hand washing remain the most breached infection control measure in hospitals?” Why, in the year 2014, do we continue to need major campaigns and Centers for Disease Control and Prevention efforts to remind healthcare workers to wash their hands? Albeit not all related to poor hand-washing habits, results of a recent study² suggest that, on any given day, one of every 25 patients in United States’ acute care hospitals has at least one healthcare-associated infection. That is a staggering statistic!

  Chronic wound management basics, covered in every textbook and guideline of care, include addressing the underlying etiology and cause of the wound. I live in a geographic location replete with healthcare providers, world-renowned hospitals, and wound clinics. Yet recently when I talked with a patient who was just discharged after a week of IV antibiotics and daily debridement to treat his infected plantar foot ulcer, I learned he had not undergone any vascular diagnostic evaluations — none whatsoever. Moreover, the wound was still open, not healing at all, and he was walking on it. No offloading was mentioned or provided. He took himself to another wound clinic where he was diagnosed with severe ischemia and underwent a bypass procedure and a partial toe amputation the next day. When we spoke again 6 weeks later, he told me that following the procedure, he had been admitted to an extended care facility for strict bed rest to let the wound heal. By now he was very weak, the wound was still open, and he was having trouble walking with “all the bandages wrapped around his foot.” This was particularly upsetting to him because he wants to exercise and get his strength back so he can return to work. The need for offloading to let the wound heal and to prevent a recurrence was not discussed. What happened to the basics?

  In a recent study, Dr. Fife and colleagues³ examined 221,192 wound clinic visit records of 11,784 patients with 25,114 diabetic foot ulcers (DFUs). The study authors learned offloading was documented in only 2.2% of visits! Even if clinicians simply forgot to document the type of offloading device used in a substantial number of cases, this number is astounding. As the authors concluded, “Despite the fact that offloading is universally recommended to reduce the pressure and strain on a DFU, the study confirms that the practice of offloading remains underutilized in the wound care setting.” This is small comfort to the patients whose lives, limbs, and livelihood are affected by clinicians who fail to provide evidence-based, standard care.

  Remember the stickers given to patients to remind healthcare providers to wash their hands? Do we need stickers to remind healthcare providers to address the underlying etiology and cause of these wounds? Seriously. What can we do to ensure that nobody forgets the basics?

This article was not subject to the Ostomy Wound Management peer-review process.

1. Weinstein RA. Controlling antimicrobial resistance in hospitals: infection control and use of antibiotics. Emerging Infect Dis. 2001;7(2):188–192.

2. Magill SS, Edwards JR, Bamberg W, Beldavs ZG, Dumyati G, Kainer MA, et al. Multistate Point-Prevalence Survey of Health Care-Associated Infections. N Engl J Med. 2014;370:1198–1208. DOI: 10.1056/NEJMoa1306801.

3. Fife CE, Carter MJ, Walker D, Thomson B, Eckert KA. Diabetic foot ulcer off-loading: the gap between evidence and practice. Data from the US wound registry. Adv Skin Wound Care. 2014;27(7):310–316.