The Importance of Diversity, Equity, and Inclusion in Wound Care

One case jumped off the page as the wound care team sorted through the day’s consultations. The bedside clinical team requested a “stat wound care consult for gangrenous perineum.”  This ominous wording elicited fear in the heart of the wound team working in a small low-resource safety net acute care hospital. The wound team, comprised of clinicians from various countries, nursing backgrounds, and ethnicities, felt a sense of immediate panic. The team thoroughly examined the electronic medical record, looking for clues to help formulate a plan of action to execute before, during, and after the client’s care. The elderly patient was a minority, non-English speaking, and surrounded by a loving and supportive family. The physical exam revealed hyperpigmentation of the perineum, a common finding for clients with similar skin tones. 

Interestingly, the wound team also witnessed the other end of the spectrum—delayed consultations for individuals with darker skin tones with suspected deep tissue injuries (sDTIs). Often, bedside teams did not recognize the early subtle warning signs and symptoms of pressure injuries (PIs) until the overlying tissues began to slough. The literature contains a plethora of similar observations nationally. Patients of color (POC) suffer from severe full-thickness PIs at a higher rate than their fairly complected counterparts due to the lack of early recognition. As a result, POCs experience poorer outcomes than patients with lighter skin tones.¹ One potential explanation lies in the standard definition of a stage 1 or deep tissue injury taught over the years. Also, classic hallmarks of infection, including erythema and pain, may be hard to identify in clients of color or those afflicted with neuropathy. 

Improving health outcomes for all clients requires a solid commitment to improving diversity, equity, and inclusion (DEI) in all clinical settings. DEI may not happen organically; as a result, organizations must make DEI a core part of their mission and values. DEI takes work and must be an intentional practice. Organizations can foster DEI through the creation of diverse healthcare teams. Such teams can better devise creative solutions for complex issues because individual team members bring unique perspectives.² Also, a diverse clinical team is likelier to have better patient outcomes due to an improved ability to recognize conditions that are not textbook.  

UC Davis Health (UCD) brought together individuals from differing ethnicities, nationalities, sex, and age to create the wound team. The group’s clinicians speak Hmong, Ukrainian, Russian, Spanish, and Farsi. During morning huddles, team members discuss and embrace each other’s cultural use of language, dietary choices, values, and practices. This huddle provides insight into how to provide care and support their diverse patients and family caregivers. 

The organization and wound team’s DEI initiatives expanded to include patients frequently admitted to the hospital with PIs. The data revealed 100 spinal cord injury (SCI) clients experienced 4 or more lengthy inpatient stays per year.³ A deeper dive into the demographic data showed that young men of color comprised a high number of this vulnerable population.³ Another commonality shared by this patient population was the cause of the SCI, which was gun-related violence.³ These young men also experienced healthcare inequities in the primary care setting. Due to numerous logistical reasons, SCI patients could not get out of their chairs at the primary care physician’s (PCP’s) office. When the UCD team collaborated with the PCPs to find solutions, the providers acknowledged a lack of specialized knowledge and training to develop effective wound care plans. Furthermore, PCPs did not have ready access to wound dressing supplies. Another contributing factor included social determinants of health. This particular SCI population often lives with family caregivers in low-income housing. The family units did not have adequate educational support or modes of transportation to and from appointments. Other challenges included an inability to develop a health maintenance plan due to financial and insurance reasons. Ultimately, these patients utilize the emergency department (ED) as their PCP to receive wound care, needed supplies, and address additional health concerns. To help support these clients, UCD recruited a diverse group of volunteers to improve health equity amongst these thrice-stigmatized individuals (POC, victims of violence, and wheelchair dependent). The group’s diversity allowed for the development of patient-centered solutions resulting in decreased hospital visits and hospitalizations while improving health outcomes.

Systems and teams must strive for and commit to DEI’s best practices. DEI is like a garden. To reap a harvest, the farmer must carefully and lovingly tend the crops to ensure a successful yield. In wound care, that harvest is improved patient outcomes via the early detection of complex conditions, equitable delivery of health care, and inclusion of all patients regardless of their diverse needs and access to resources.

Dr Kirkland-Kyhn is the director of wound care, UC Davis Medical Center, Sacramento, CA. The opinions and statements expressed herein are specific to the respective authors and not necessarily those of Wound Management & Prevention or HMP Global. This article was not subject to the Wound Management & Prevention peer-review process.