Achieving Wound Balance: A Case Review

Wound care experts, Dr. Laura Swoboda and Dr. Alton Johnson, break down their SAWC Fall posters and detail the Wound Balance Concept. Through cases and discussion, they demonstrate what achieving Wound Balance looks like and the benefits to the patient and care team.
 

Dr. Laura Swoboda is a Professor of Health Sciences, Family Nurse Practitioner, and certified wound specialist in Milwaukee Metro, Wisconsin. Dr. Swoboda is on the NPIAP’s Prophylactic Dressing Standards Initiative Task Force, a member of the editorial board for the Wound Care Learning Network and Wound Management and Prevention, and on the board of directors for the WOCNCB and the AAWC.

Dr. Alton R. Johnson Jr. is currently a Clinical Assistant Professor and Attending Physician/Surgeon at The University of Michigan School of Medicine in the Department of Orthopaedic Surgery. Dr. Johnson is the National Chair of the Board of Directors for the American Society of Podiatric Surgeons and Chief Executive Officer of AJ Educational Empowerment, LLC a company developed to empower individuals of all backgrounds through educational services to be tomorrow’s leaders. He attended the Kent State University College of Podiatric Medicine, Doctor of Podiatric Medicine. Dr. Johnson went on to complete a three-year Podiatric Medicine & Surgery Residency at HCA Florida Aventura Hospital in Miami, FL and a two-year wound care fellowship at the University of Pennsylvania. 
 

Transcript:

Laura Swoboda:

Hi, I am Dr. Laura Swoboda. I am a translational scientist, a family nurse practitioner, and a wound specialist.

Alton Johnson:

How are you doing? My name's Alton Johnson. I'm a podiatrist, podiatric surgeon, and wound care specialist at the lower extremity.

Laura Swoboda:

So we're here today to talk about wound balance. Wound balance is a conceptual framework of wound care where we're looking at all of the factors that affect our outcomes. So we're looking at the wound microenvironment, looking at patient factors, looking at societal factors and how we can balance those to lead to better outcomes for our patients. It's really a way to look at being proactive in management and to focus on healing wounds instead of just treating them in a more palliative type of a way. We want to focus on how we can actually transform the healing process for people.

Alton Johnson:

So my poster was titled Various Use Cases of All Lower Extremity Super Absorbent Dressings. My cases, I had three different cases. One was a typical venous ulceration. One was a graft-versus-host-disease patient that had developed a chronic lower extremity ulceration on the plantar feet. And another one was actually a chronic sclerodermal patient that had bilateral lower extremity wounds secondary to scleroderma, and also the medications that she was on for immunosuppression.

So mainly the reason why I designed the poster or decided to present this poster was mainly to focus on the super absorbent use cases when it comes to wound balance, whether it's actually making an impact on the small microenvironment when it comes to the management of MMPs, when they bind to the super absorbents and not leeching back into the wound, and also when it comes to just the actual management for the patient of reducing the frequency of dressing changes, and also reducing pain, because all three of these patients had sensation, unlike most of the patients that I deal with.

So this was... Using super absorbent dressings, I wanted something that they didn't have to change often or frequently, but also wouldn't compromise the wound environment because it also basically impacts their psychological factors and impacts the time that their family member or caregiver has to do this dressing changes. So most of these patients were getting dressing changes three, sometimes four times a day, most of them were actually doing it themselves, or had either a close family member doing it, not necessarily home nursing around the clock available for something like that. And when using the super absorbents, they were able to reduce that to once a day, and sometimes twice a day, depending on how much drainage they're getting or their medication regimen during that time period.

So that was the main use presentation of the posters, just to get providers and clinicians to think outside of the box when it comes to these dressing management or utilizations or selections for these types of wounds, and essentially the synopsis of my poster.

Laura Swoboda:

Great. I think that's one thing that I always try and keep in mind too is undisturbed wound healing and trying to maximize the time between dressing changes so that we're not creating normothermia or local hypothermia in the wound bed, slowing down fibroblasts, providing an opening for bacterial transmission.

I really like that you brought up the patient and family too, because you need to have another person there, and it takes time and to be able to... And it's painful to change the dressing, so to be able to stretch that out with an SAP dressing, something that can be in place longer and still sequester the drainage is really important.

Alton Johnson:

Exactly, and the main thing is with these super absorbents is the fact that, like you said, you could stretch it out longer and be safe, stretch it out with some of the competitor dressings or generic dressings out there, and they put their wound at compromise and actually could get a cellulitis or a limb-threatening infection.

Laura Swoboda:

Yeah. And what's so nice is that it's still, I think, an affordable option when a lot of people are still unfortunately using gauze. And to be able to get this out there as an option for people, people in primary care, people in environments that may not have access otherwise, and know this is something simple to use. There's science behind it, the science is complex of why it's effective, why it's sequestering those MMPs, but that when you're actually changing it, it is like a bordered gauze, right? It still has the ease of that, but you're doing the right thing for the wound bed, I guess.

Alton Johnson:

Yeah. Thanks for emphasizing the ease of use. Correct. It's easy to use, both home health-wise, patient care if you're a family member or the patient themselves, which that's true because some of those dressings are not as... They could be the same efficacy, but they may not be as easy to use.

Laura Swoboda:

Yeah. Yeah. So you're trying to stretch out that dressing change as much as possible, but we all know wounds don't fit in a box. There are people who still are going to need daily dressing changes, especially in the beginning when you're managing the inflammation, when the exudate levels are still high. And then as you control that bioburden and it starts to go down, but in the beginning, sometimes you need daily dressing changes. So to be able to have a dressing option where you can do that and it's covered by insurance... I call it insurance-based practice instead of evidence-based practice, but sometimes you got to follow what you're able to do and to be able to get a really good daily dressing, I think.

Alton Johnson:

Yeah, definitely. The way it is coded, you can actually order the 30 days versus the half because of the actual design of the product. And like you said, then patients feel even more comfortable, because now if they do need to change it, even if this particular dressing becomes saturated, they can change it comfortably without worrying about resource utilization. I agree that with this particular dressing Zetuvit or Zetuvit Plus border dressings, that you can order a 30-day supply versus the competitors where typically these are indicated as foam border dressings, and you can't get the full 30 days and you have to do it to 15 days. So this also makes the patient feel more comfortable using those resources, so they won't put their limb at risk if they need to change it, because I have patients tell me, "Yeah, I know I needed to change it, but I only have X amount of dressing supplies left." So knowing that we can get the 30-day coverage with the coding is always a plus sign, so thank you for reiterating that.

Laura Swoboda:

I'm going above the knee here, but sometimes when you have issues in other areas, you need to be changing it more often, not necessarily because of the wound microenvironment, and I think that fits into the whole wound balance piece as you're looking at the patient factors. You're looking at, are they able to lift when they're transferring or scooting on their sacrum or that type of a thing, and you still need daily dressing changes just because of lifestyle factors and that type of a thing. So yeah, I think being able to get a daily dressing that's still very, very effective is great.

Alton Johnson:

I agree. And especially, like you said, because of the hygiene, some people are worried about odors depending on their lifestyle, depending on what they're doing as a profession, so they still may want to change it, even if that's super adsorbent could handle the drainage of their experience. I agree.

Laura Swoboda:

Yeah, so and my poster really discusses how I frame patient care. It goes over kind of my thought processes and how I try to achieve wound balance, balancing the wound microenvironment, kind of starting with as clean of a slate as we can, cleansing with a non-cytotoxic cleanser, doing a really thorough sharp debridement.

Dressings are never meant to work in a silo. They're part of a comprehensive effective plan of care. So starting with as clean of a slate as possible by doing that good wound bed prep, and then we can use a dressing based on how long it needs to remain in place, all those patient factors that go into it, and then having a balance, so finding out what the patient's needs are. Maybe they have transportation difficulties, so we get into societal factors too. So if the dressing needs to stay in place a whole week because of transportation issues or what have you, then having a safe option for that.

Alton Johnson:

Agreed. Agreed.

Laura Swoboda:

Yeah. I had two patient scenarios that I chose to highlight. The first one was a diabetic foot ulcer. So he had presented with uncontrolled diabetes, hadn't really been seen in healthcare very much prior, and I think we get those patients quite a bit.

Alton Johnson:

Right.

Laura Swoboda:

In wound care, it's nice because we see our patients more frequently than pretty much any other specialty. There's very few specialties where we get that opportunity for exposure for people and gets a really unique opportunity to help manage comorbidities like diabetes, that type of a thing. And that happened with this patient. So he presented to the clinic, gave him my spiel, did really good wound bed prep. But he returned in two weeks. The wound measurements were the same. They're same. I was like, well, what's going on here? There's something missing here. And we have good wound bed prep.

We had the right dressing in place for those two weeks, but there was something else, and that was his just wildly uncontrolled blood glucose level. So able to get him in with a diabetic educator, got him a continuous glucose monitor, which got him really involved in his own healthcare, being able to check that and see in real time what food was doing. And he happened to really like cooking. So then he was able to learn some new recipes and would show me these elaborate fancy dishes that were now not going to skyrocket the blood glucose levels. And it's amazing with that control, how quickly that can help with the healing process. So then he was able to go on to closure in a relatively short period of time.

Just having that whole picture in balance, having the offloading, the wound bed prep, controlling the micro-environment, the proteases, all of that, and then having the comorbidities in check too, and lifestyle and all those things.

Alton Johnson:

Yeah. I like that. Thanks for sharing that. Yeah, I agree. Because when you think about that wound balance concept of the holistic patient, what is it? It's not just the hole in the patient, it's the whole patient.

Laura Swoboda:

That's right.

Alton Johnson:

It's corny, but it's actually useful, especially when you're teaching young providers how to take care of these wounds, because they're thinking, oh, they taught me the best way of treating these dressings like you just did, or treating these wounds using these dressings, but it was something else missing. And you always have to step back and look to see what's going on because, yeah, you're right, the dressing isn't in a silo by itself. You have to use it in conjunction with management of the sugars. So that is a great way of circling back to the whole patient. And I think that's a good patient advocacy, a great workup. They're lucky to have provider like you.

Laura Swoboda:

That's right. Yeah. My other patient in the poster really fit into the wound balance concept too, because they had a complicated abdominal wound dehiscence, a new colostomy in place on their abdomen, which is an incredibly stressful time for people. They're dealing with a whole new way of bodily elimination and bodily function and trying to learn to take care of themselves again. They're trying to heal this large open wound, which is very stressful. Stress impacts healing. I had a wound vac on her and she granulated in really well, and relatively quickly, but it can be difficult to have that in place too. You have to carry it around, the sound at night. It can cause orthopedic complaints. So she was just fed up with this wound vac in discussion. Can you do it another week? Can you hang in there another week? Yeah. Yeah. But that next week, no, this is driving me bananas.

And so then being able to switch to an option to get that balance because you want the patient to be in a good mind space too, their psychological health. So being able to switch to an SAP dressing to Zetuvit. And then I also used an antimicrobial collagen collective AG with her, too, to keep the inflammation down. Because It was a contaminated wound to begin with she had a perforated diverticulitis. So we were able to stop the wound vac and get her some healthier mind space, and then get the wound closure in another 2 weeks. So that really, I think, was a good illustration of balancing the wound microenvironment, keeping the microenvironment in check, but also really considering the patient and how they're doing and what their needs are.

Alton Johnson:

Yeah. Yeah, it's great to have those options, because you're right. Otherwise, you've took it off, had a wound vac holiday, or even postponed the wound vac, but now she's burdened with changing the dressings even more frequently. Obviously, a wound vac can change once a day maybe, or even once every 2 days, but she would've may have changes 3 or 4 times if she didn't have access to Zetuvit or something like that, if you didn't have access to Zetuvit. So, that's awesome.

Laura Swoboda:

Yeah. Yeah. Yeah, and she had kids too, so yeah, that's a good point is that we were able to put this dressing in place, keep it in place, undisturbed wound healing, and also not the pain, the trauma of dressing changes, the disruption of your daily life if you're coming to the clinic for it. Yeah, so that's a really good point.

Alton Johnson:

When it comes to chronic wounds or identifying red flags for chronic wounds, it is true, sometimes you get, we call that hole in the sand or head in the dirt type thing. So sometimes you do have to reassess why this wound has stalled and looking for if it is something, like you said, the high glucose levels or if the wound bed or the biofilm is not protected, or maybe like you said, when it comes to management of exudate sometimes the periwound is the stalling point, right? And now it's because you may be doing the best wound dressings, but the secondary dressing may not be holding up to what you need to do. So definitely being able to know those factors, so such as redness or actual increased pain compared to the last couple of visits our patient never had pain in the wound, maybe there is an underlying infection that you need to identify.

And then going back to your wound bed prep and knowing how your foundations of wound care helps when it comes to that. Because if you just go have that patient come in and you're just slapping new dressings on, it's not going to heal because you haven't really gotten to the meat and potatoes of what's going on and actually gotten that bio-burden out using sharp and mechanical debridement or enzymatic debridement to get it done, but definitely love to hear what you would say about red flags and chronic wound healing.

Laura Swoboda:

Yeah, yeah, we were talking about-

Laura Swoboda:

That's right. We were talking about checklists earlier, and I think having all those boxes checked beforehand helps you know that you've done everything that you can and there's something else going on. So no, I've checked the box. I'm not using a cytotoxic cleanser. I checked the box. I did some debridement, whatever form that you have access to or that you're able to do from a [inaudible 00:15:18] type of a thing. And then using the correct dressing, managing the exudate, managing the periwound and sequestering that inflammatory drainage. So you're managing the bioburden. And if you're doing all those things properly, proactively from day 1 and the wound isn't healing, you know that that's a red flag that something else is going on.

Alton Johnson:

Right. And you got to go back to the drawing board of metabolic issues. Even like you said, stress, too. So even we don't think about mental health stress, you never know, maybe they're not eating as well or more stressed out about this particular wound or something at home. I never know.

Laura Swoboda:

A lot of people with wounds are also dealing with a new diagnosis, whether it's a new diagnosis of peripheral arterial disease, diabetes, cancer, that type of a thing, and there's just a tremendous amount of stress and worry that goes along with that. So yeah, I agree.

Alton Johnson:

I agree. Yeah, I definitely tell patients, if you're seeing me, you're not healthy, per se. Even if it's something I'm missing or even if it's a surgical wound, something's not right, right? It is something going on that's underlying, that's kind of from the deviating from that pathway of healing that you would normally have if you just had an injury and healed.

Laura Swoboda:

Yeah. I always teach to avoid ritualistic wound care by thinking about knowing the reason of why you're doing something. I like to know why I'm debriding. I'm removing the bioburden, the senescent cells, I'm getting endothelial exposure. Or if you're using a dressing, I'm sequestering the proteases, I'm removing our proteases and the bacterial proteases and sequestering some of that bacteria away from the wound too. And knowing that's why you're doing the things and that's why they're effective, or why you're not doing things. I always have an elevator speech for new clinicians, for nurses, residents on avoiding gauze, right? We still have to go there unfortunately these days. So it's causes an inflammatory reaction, like a foreign body reaction and my local hypothermia spiel and all that.

Alton Johnson:

Yeah, I agree. Definitely we would call ritualistic or routine approach into the wound management for the patient is important, and that's why I always bring in a second pair of eyes every time. So my medical assistant or my nurse, or even some of the wound care techs will come in or hyperbaric techs will come in every time, especially if it's a wound that's been stalled, sort of how you mentioned that patient case earlier where you've done what you normally would do when it comes to it, and there's something not happening, I always have that second pair of eye, because you're right. Maybe it is because putting on gauze and it shouldn't be in there, and that's actually causing inflammation, and they say, you should probably use Zetavit or different foam dressing or something like that to kind of get it more, or even co-active plus because the micro-environment is not appropriate, and I'm willing to always stay open. Sometimes the patients know too, maybe I've healed something on their left foot, and they're like, "You never did that. You didn't do that on my right foot."

Laura Swoboda:

Surprise!

Alton Johnson:

Oh yeah, right! Like you said, sometimes I get caught into a routine or not really have given that patient the attention that they need for the changes that I miss or didn't absorb during the visit that day.

Laura Swoboda:

Yeah. And I like bringing up other team members too because I think wound care is a team sport. And whether it's the nurse, the tech, there's people that are spending more time with the patient than the provider might be, and to not get into ritualistic conversations too. It's patient specific and you pick up on these little things that, "Oh, well, oh, you were at a theme park for the whole weekend. Well, that explains why your wound isn't healing." And patients sometimes know what may be holding up their healing, but they want you to say it to them.

Alton Johnson:

Exactly. That's why I tell the patient, they're like, oh yeah, you never used that powder stuff on this, but I'm like, I thought maybe I assumed they knew to do it, or the nurse needs to tell them or the physical therapist and it's true. So then the patient, because maybe they're trusting us so much where it's like they don't want to kind of step on her and tell them, but I tell the patient, this is a relationship. Let me know if I'm going to something or if I didn't tell you. Actually, going back to the balance, I didn't educate you on why I did this or I didn't do that on this time around. Things like

Laura Swoboda:

That. Yeah. So I think continuity of care is a challenge, especially in the US because we have a pretty fragmented system. So it is important to have communication, whether that be between case management or some form of communication, an accessible plan. So you can't use an advanced therapy that's only available in this one setting if the patient is bouncing around long-term care, a hospital outpatient acute care type of a thing.

Alton Johnson:

Exactly. Which is why it's like, yeah, so having options like Zetuvit there where okay, if they're inpatient outpatient, you can still usually have access or even if the inpatient service doesn't have that particular dressing, they can bring it from home. Most of these patients have other issues. Because it may not even be hospitalized for the particular wound situation that we're managing at that time, so you definitely want to have that. And I agree with the communication aspect. Luckily, a lot of the systems, EMRs, are more communicative or integrated than previous years, so yeah but having that in, like you said, accessible, and we still do try to give patients those after-visit summaries. As much as I don't like doing them, it's something you got to do, another stuff you have to do. But it is true because had patients go to the ED the same night, and it's like, "I just saw you, but it's for something else." Maybe bowel problem or constipation or something.

And they're there and it's like, well, we didn't get, what if my dressing orders from that previous visit was totally different, and they're using those previous visit dressing orders because I didn't update my after-visit summary. So I still do it for those situations, and it happens more often than we think. Most of our patients are, like you said, have other comorbidities that we're dealing with besides the wound.

Laura Swoboda:

We know that the longer a wound has been around, the harder it is to heal. Early referral to a wound specialist is critical. You're super involved with limb salvage.

Alton Johnson:

Right.

Laura Swoboda:

You know that mean time is limb, right? Time is tissue. There you go. Yeah. Yeah. And with the shortage of health care providers at all levels—specialty, primary care, nursing—it's going to take longer to be seen a lot of times. So to get an early referral in as is, I think just so important.

Alton Johnson:

Yeah, I agree. And luckily, a lot of doctors or providers or clinicians, therapists know to try to get whatever wound care specialist that's at the particular practice involved as soon as possible because have anywhere or no, the orthotist or the Podiatrist will call me and say, "This is different from the last time I saw him.” Maybe I had him healed him, they healed, and they come in to the orthotics to get something modified and they're like, oh, this is a new situation. So it definitely helps with that going back to that line of communication. And then they'll just send patient portal, and we'll start the referral process all over because usually it's a contralateral foot or something else going on, or even some other wound issue or ankle issue going on on the lower extremities. So I would agree early referral is definitely the best way because getting into a wound care center or a wound care outpatient practice at this point is very tough, nationwide, globally, really, not even just nationwide.

And so I would agree with that. Information-wise to take care of these wounds. But luckily they are kind of on it. I would say, at least in my system, there's little nuances paying attention to those details. It's almost like... I have a mentor that says everything... You said wound care is a team sport. It's like my mentor is a basketball hall of Fame basketball hall of fame player, and she's a wound care doc. And she said everything, what we did when she won 3 back-to-back championships, it was the details. It was the little small things like foot placement. So for wounds, it's wound dressing placements, how often you having them change it, or how often you're debriding, how aggressive are you're debriding. Sometimes you may be debriding too aggressively, or you may not be debriding enough. So it's always those little nuances that you have to take.

So every patient isn't the same. Wound care is not cookie cutter. I wish it was. We would probably heal a lot more patients, but each patient has a different social economic situation that they're battling, home environment, psychological environment that they're dealing with—nutrition, going back to nutrition. Some people don't have access to fresh vegetables and fresh fruit, clean water, even in the United States, unfortunately. So it's little things like that, especially then in Michigan where we have tainted water throughout the entire state. So things like that, it's like those all play factors into that whole wound balance. And it's more than just addressing. It's more than just our debridements. It's a lot more to it. So it's very integral approach to wound management.

Laura Swoboda:

I think it's always important to stay on your toes. And once you think that you have the basics mastered, I think there's this curve of overconfidence that I've seen illustrated before where you still have to remain vigilant even once you get what you feel are the basics, whether it be evidence-based, wound bed preparation, or something like that, and have your eyes open for the little clues as to chronicity and, do I need a biopsy? Do I need to look more into in alternative disease etiology or a patient factor like one of the ones you talked about? So always be open to learning, and that's how you're going to be providing best care for people.

Alton Johnson:

Agreed.