Wound Care:Where do we go from here?

Jesse M. Cantu, RN, BSN, CWS, FACCWS

April 20, 2012

San Antonio, TX

Disease Management(Wound Care Management)

• Evidence Based

• Best Practices

• Standards of Care

• Positive Outcomes

• Cost Containment

• Evolution of Dressings

• Summary

Wounds

• Types– Acute – Chronic

• Closure

• Phases of Wound Healing

Wounds

• Acute wound

– Planned / unplanned event

– Healing proceeds in an orderly and timely fashion

– Examples:

• Surgical

• Abrasion / laceration

Acute Wound

• Surgical incision

Wounds

• Chronic wound

– Exists two weeks or longer

– Does not proceed through normal healing process

– Examples:

• Pressure ulcers

• Diabetic / neuropathic ulcers

Chronic Wound

• Pressure ulcer

Chronic Wound

• Venous ulcer

Chronic Wound

• Post-operative dehisced wound

Wound Closure

• Primary intention

• Delayed primary

• Secondary intention

What do you do if the burden is too big?

Evidence Based / Best Practice

• Randomized control trials

• Protocols (NPUAP, WOCN, Canadian guidelines, AHCPR)

• Moist Wound Healing (George Winters)

• Wound Bed Preparation (Vincent Falanga)

The Building Blocks of the Foundation for Wound Care

Debride Moisture TopicalsOff-Load

Debride Moisture TopicalsOff-Load

SUCCESSFUL WOUND CARE

HYPERBARICSGROWTH FACTORS

BIOENGINEERED TISSUES

BIOLOGICDRESSINGS

NEGATIVE PRESSURETHERAPY

SILVER DRESSINGS

Best Practices

• Evidence Based

• Wound Bed Preparation

Wound Bed PreparationWhat Does It Mean?

Originally

• Debridement

Fibrotic Tissue

Hyperkeratotic Rim

Wound Bed PreparationWhat Does It Mean?

Today

“…a very comprehensive approach aimed at reducing edema and exudate, eliminating or reducing the bacterial burden and, importantly, correcting the abnormalities … contributing to impaired healing.”

Vincent Falanga , MD

Professor, Boston University School of Medicine

Other Voices….

“Think of it as removing various ‘burdens’ from the wound and the patient.”

• Exudate• Bacteria

• Necrotic/cellular debris

Elizabeth A. Ayello, PhD, RN & Janet Cuddigan, PhD RN

Standards of Care

• NPUAP

• WOCN

• AHCPR

• Canadian Guidelines

Positive Outcomes

• Wound Assessment at each dressing change

Cost Containment

• Wet to Dry Dressings (Gauze and Saline)– Frequent dressing changes

• Moist Wound Healing (George Winters 1961)

• Active Wound Healing (NPWT, Hyperbarics)

Evolution of Dressings

• Debridement

• Maintain a moist wound environment

• Reduce bacteria load

• Prolong dressing interval changes

• Stem cell technology

Summary

• Wound management not wound care– Need to jump start nonhealing or slow wounds

• Adequate assessment, debridement, and wound irrigation based on Best Practices, Evidence based, Standards of Care, Positive Outcomes, and Cost containment

• Case studies

Wound Care as Wound Management

• Properly treated wounds create the ideal win-win situation by decreasing hospitalizations, promoting wound healing in the home, improving quality of life, and improving patients’ sense of independence and well being.

Other Voices….

Wound Bed Preparation is “the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures.”

Schultz G, Sibbald G, Falanga V, et al:Wound bed preparation: A systematic approach to wound management.Wound Rep Regen 2003

What’s Needed to Heal a Diabetic Neuropathic Ulceration?

Control of Diabetes and General Health

Adequate Diet

Blood Supply

Absence of Infection

Regular Debridement

Offloading of Pressure

Moist Healing Environment

Total Contact Casts Custom Splints

Therapeutic Shoes Removable Cast Walkers

Common Methods to Common Methods to “Off-Load” the Foot“Off-Load” the Foot

So what is this going to cost me?

A lot less than traditional care…

“Incidence, Outcomes, and Cost of Incidence, Outcomes, and Cost of Foot Ulcers in Patients with Foot Ulcers in Patients with

Diabetes”Diabetes”

• What is the cost of a new foot ulcer, not previously treated?

Ramsey, Reiber, et al. Diabetes Care, Mar 1999 – Univ of Washington

–$27,987 over a two year period!

1. Benefits of a Closed Environment

• Moisture Balance• Reduction of

Nosocomial Infections• Prevents patient

interaction with the wound

2. Promotes Perfusion

• Replacement of fibrinous tissue with granulation tissue

• Filling deficits in wounds

• Wound constriction

• Promotes granulation tissue formation

Dompmartin A, et al J Wound Care 2004 June

4. Benefits of Maintaining a Moist 4. Benefits of Maintaining a Moist Wound BedWound Bed

Why do we keep a wound moist?

Promotes rapid migration of epidermal cells across the wound bed

Promotes perfusion

Why do we keep a wound moist?

Promotes rapid migration of epidermal cells across the wound bed

Promotes perfusion

Barrier against environmental contamination

Benefits of Using Negative Pressure Therapy as an Adjunct

70 patients with chronic, non-healing wounds

treated with VAC following skin grafts

100 % of the grafts healed in an average

of 48 days

Carson SN, Overall K, Lee-Jahshan S, Travis E.Ostomy Wound Manage. 2004 March

Escalating Bacterial Loads

• Contamination – Presence of nonreplicating microorganisms in the wound

• Colonization – Presence of nonreplicating microorganisms adhering to the wound, NOT causing injury to the host

• Critically Colonized – Bacteria cause a delay in wound healing

• Infection Local to Systemic – Presence of replicating microorganisms in wound and presence of injury to the host

Ayello and Cuddigan, 2003

BACTERIAL

LOAD

Wound Bed Preparation:Wound Bed Preparation:Combining Topicals with NPWTCombining Topicals with NPWT

Control of:

• Contamination, colonization and critical colonization to optimize the wound bed

• Odor

Case Studies

The Challenge of a Large Deficit Wound and Poor Vascularity

Ready for grafting