All Pressure Ulcers are not due to pressure !

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In my role as an expert witness, I am frequently asked to defend hospitals being sued by patients who have developed a skin breakdown during a tumultuous stay in the ICU. The complaint invariably reads that the patient was not turned every two hours or that the patient’s Braden scale was not completed or if completed, done incorrectly.  First of all, recent evidence suggests that turning and repositioning does not prevent pressure ulcers; in fact, it may increase the incidence of early stage ulcers in some patients. I still believe in using scales but the evidence is that they do not predict or prevent pressure ulcers. Why do ICU patients develop pressure ulcers? It is skin failure. The skin like the heart or kidneys will fail if there is inadequate perfusion. It is no surprise that a critically ill patient on pressors is going to have skin failure and develop skin breakdown. It usually occurs in a watershed zone like the sacrum.  All the turning and scales in the world won’t prevent the skin breakdown.

Moreover recent animal studies have suggested an ischemia-reperfusion mechanism for skin failure. During the patients acute illness the skin becomes ischemic. As the patient recovers the skin is reperfused leading to skin damage and subsequent breakdown.

Clearly, in our wound care world it is the best of times, but it is also the worst of times, it is an age of clinical excellence, it is an epoch of outdated protocols,  it is a season fewer amputations, it is a season of lost limbs, it is the spring of hope, it is the winter of despair. All told, whatever your view, it is time to stop blaming the nurses and get on with the business of healing.

Staging Pressure Ulcers: Time to stop the nonsense?

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I have the pleasure and honor serving on a board designed to reevaluate the current staging on pressure ulcers. The following comments are my opinion and not necessarily the opinion of the board. However, I want to credit the members of the board for introducing me to the topic.

Under the current system we stage pressure ulcers I-IV with additional categories for deep tissue injury and unstagable. It is a system that has served us well for quite some time. However, like so many staging or grading systems in medicine it has become dogma. The truth is that the staging system does not reflect the current scientific knowledge with regard to wound development.  My first criticism of the present staging system is that there is no evidence that ulcers progress from one stage to another. One naturally assumes that these ulcers progress from I to IV. They do not. Moreover, stage II ulcers are not caused by pressure but shear forces and moisture. Why call them pressure ulcers?

“Partial thickness wound” would be a more accurate term. In addition, stage I ulcers are not ulcers at all. I suspect that they are a form of tissue injury. Why stage III and IV ulcers separately when the treatment is the same?  They are full thickness ulcers. Unstagable are only “unstaged” until I take out my scalpel. They are really “untreated” ulcers. We do not need a stage for them in most instances—some heel ulcers may be an exception. Diane Krasner and Gary Sibbald have begun to publish and present some of these heretical ideas. Be sure to look for them. In my opinion, it is time to overturn the dogma and revamp the staging system.

Spike and my grandma knew a thing or two about wound dressings.

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Manuka honey bush

Listening to stories in the physician’s lounge can only be compared to tales told by my ex-military-master-diver buddies after a few beers.  In Last week’s blog, I shared one of my experiences worthy of attention in the either venue. The case of Spike, the only patient, to date, to eat his wound VAC dressings.  The thought of ingesting a wound dressing used or unused is nauseating to say the least. More than one student has experienced sudden uncontrollable emesis after encountering the mere aroma of a malodorous wound care patient.

However, there may be one exception: MEDIHONEY®. I was first introduced to MEDIHONEY® dressings at a clinical advisory board meeting for Derma Sciences.  As we passed the dressing around the table, I  eventually succumbed  to the temptation to touch this sweet honey alginate to my tongue.  Spike would have loved this dressing; and he would not be alone in

his love for honey dressings.  I have never had a dressing loved by more patients. Everyone’s grandmother, aunt or other distant relative  imbued with wound healing knowledge used honey to treat abrasions, cuts and open sores of all varieties.

But, is this honey dressing all hype?  The answer is that Spike and Grandma knew a thing or two about wound dressings.  Manuka Honey is produced by bees in Northern New Zealand who frequent the Manuka plant. The resulting honey is a potent antimicrobial.  In fact, it is far more effective than supermarket honey—although not as good on toast.  Used in a wound dressing Manuka Honey reduces the bacterial burden in the wound bed, thereby promoting wound healing.

MEDIHONEY® alginate dressing

One might ask, “…who needs another topical antimicrobial?”  We are swimming in Silver dressings and I have even learned to pronounce PHMB. However, working in the world of wound care clinics I often forget that not everyone has habituated the distinctive odor that identifies our practice.  Manuka honey not only kills bacteria, it smells good. I am still tempted to taste it occasionally–unused of course.  This feature is important to patients and their quality of life.  Patients treated in a palliative fashion particularly appreciate odor control.  Finally, Honey dressings are relatively inexpensive compared to other antimicrobials that improve our quality of life.

 

 

Please refrain from eating your wound dressing

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At a certain point in your career, the early morning ruptured aneurysm is no longer the highlight of your week.  That is not to say that I don’t enjoy the adrenaline surge from an emergency case now and then.  In fact, recently, I was called by Pat Ferrell, a friend of mine and a brilliant veterinarian.  He requested an urgent consultation for one of his patients.  Spike had a complex, non-healing leg wound.  It was not responding to conventional therapy.  Pat feared that he might have to put the dog down.  “Bring some human medicine and help me heal this dog!” Pat ordered over the phone.  Spike’s owner, an elderly widower, was devastated at the mere mention of losing his only companion.  They ate lunch together at Wendy’s every day.  Apparently Spike was fond of square hamburgers.

I rushed to the animal hospital.  After examination of the wound we decided to use a doggy VAC.  The folks at KCI graciously donated a research unit.  It was a challenge to apply the adhesive to Spike’s tough dog skin, but after struggling for an hour or so we achieved success.  In our celebration we forgot to apply the inverted “lamp shade”.  During our post anesthetic check we turned to see Spike with black foam in his mouth.  To date, he is the only patient to eat his wound dressings.

Quality Indicators (QIs) in wound care

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A ogni ucello suo nido e bello (to every bird his nest is beautiful). ~Italian Proverb

I recently heard a presentation by a well-meaning program director who bragged that she had the best center in the US, the world, and beyond because her center’s healing rates were 96%.  I suggested that she might be exaggerating inasmuch as my healing rates were 100%. She was dismissive. It is true, I added, hang around the wound clinic long enough and we will eventually heal you.

The point that I was trying to make was that healing rates are terrible quality indicators. In fact, they are not quality indicators at all. The wound care field is in desperate need of QIs. None of the QIs currently published by the National Quality Forum (NQF) would fit into wound care.  It is clear that if the wound care community does not establish bonafide QIs they will be thrust upon us.

If not healing rates then what?  There are several potential candidates. For example, the number of venous leg ulcer patients that receive compression; diabetic foot ulcers and pressure ulcers that are prescribed and receive adequate off-loading; glucose control during hyperbaric therapy.

The Alliance of Wound Care Stakeholders plans to tackle this problem in the coming year. There is another Italian proverb that comes to mind:

“Chi bene incominciaa `a meta dell’o pera ,” (Well begun is half done.)

We should set our minds to the task. I suggest clinicians, hospitals, management companies, industry and even patients join in on this initiative.

Who is profiting from your wound care and hyperbaric center?

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The obvious answer to this question should be the patients who receive state-of-the-art treatment in a multidisciplinary setting; physicians who can reduce overhead while increasing revenues; and hospitals that can realize improved income directly from the efficient delivery of care and the “halo” effect of the wound and hyperbaric center.

What about the management company?  It plays an essential role in establishing and overseeing the center. However, as the center matures, the need for management services decreases—usually without a corresponding decrease in fees. As a result many hospitals do not renew their management contract when it reaches term.  Nonrenewal is a drastic measure that usually adversely impacts the center. The common sense solution is to modify the contract so that the hospital only pays for the services it needs.

I have coined the term, “Transitional Management Services,” to describe the solution to this problem. TMS contracts provide only the management services the center requires at about 1/4 to 1/3 the price.  The remaining income drops to the hospitals bottom line.  The center continues to run efficiently. Moreover, TMS companies tend to be more clinically oriented and can add services, such as research, to the center. The result is focused and expanded services at vastly reduced cost.

For more information on these services please visit: http://serenagroup.net/transitionalmanagement/index.html

How often should I see my patients?

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There is some very interesting data suggesting that weekly visits to a wound clinic improves healing rates. It may also be true that twice weekly visits might be better than weekly visits. Why?  The most obvious reason is adherence with the treatment regimen. Patients who are seen in the wound clinic and receive frequent education and instruction are more likely to follow the treatment prescribed.

The other reasons may not be so obvious.  I recently decided to ask my diabetic patients to demonstrate their dressing technique for me.  I found that a large number of patients simply could not follow the regimen: their eyesight was too poor or they could not reach the wound.

Another possibility for the increased healing with increased visits is the bond that develops between the patient and the wound care team.  There is no doubt that if our patients feel welcome in the wound center, they are more likely to follow some of our more draconian suggestions, such as wearing a compression wrap in 100 degree heat for weeks.

I suggest we see the majority of our wound care patients weekly.

The Woundologist and the Inpatient

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A year or so ago I gave a lecture as part of a Pennsylvania Pressure Ulcer Partnership event. In the presentation I suggested that all patients with pressure ulcers discovered on admission should be seen by a physician to document that the ulcer was “present on admission.” During the question and answer period one of the inpatient nurses in the audience asked me where she was going to find the doctor to see all of these patients. I replied, the physician from the outpatient wound clinic of course.  I was almost laughed off the stage.  The wound clinic has become an isolated outpatient phenomenon in most hospitals. This may be because the majority of centers are staffed by part-time “dabblers” rather than Woundologists. The woundologist practices beyond the outpatient clinic: participating in inpatient rounds, working with home health agencies and facilitating treatment in the long term care setting.

In the future the wound care center will become part of an accountable care organization (ACO) structure. One of the features of the new ACOs is likely to be the delivery of care across all patient care settings. The woundologist will easily assimilate into the ACO.

Research is an Essential Component of a “Center of Excellence”

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“Wound care, like other specialties, requires a robust research program to flourish…”

Wound healing is burgeoning specialty as evidenced by the increasing number of wound and hyperbaric centers opening throughout the United States. The ultimate goal of every practitioner is to establish a center of excellence for the care of patients with acute and chronic wounds.  Following an evidence-based wound care guideline is a great start, but the problem is there is too little evidence in our field.

At this stage all of us should be involved in developing the evidence.  This is accomplished by participating in clinical research.  The studies can be as simple as participating in registries or as complex as early phase trials for FDA approval or clearance of products.

We should follow the example of a successful specialty clinic: the oncology clinic. In order to be a state-of-the-art cancer center you must participate in clinical protocols.  We in the wound care world should emulate this practice.

How did a woundologist end up studying adult male circumcision in Rwanda?

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Wound healing and skin viability are part of my everyday life. However, with the heavy emphasis on chronic wounds in the wound and hyperbaric centers, I sometimes forget that wound healing is common to all medical and surgical specialties. One day last summer I was asked to consult for the government of Rwanda on a clinical trial being conducted in the capital, Kigali.

The goal of the trial was to evaluate the effectiveness of a new painless, bloodless circumcision technique for adult males.  My initial response was to refer them to my urology colleagues. As it turns out there were some terrific urologists on the committee already.  They needed someone who understood foreskin. “I’m in!”

Off to Kigali to observe the technique. My contribution as a wound healing expert was to determine when to remove the foreskin after a series of rings gradually cuts off the blood supply. If you remove it too early there will be wound healing problems; too late and the patients experience discomfort.  It was great fun for a woundologist.

Why do we want to circumcise adult males in Africa?  It is estimated that circumcising the adult male population in sub-Sahara Africa would lead to a 60% reduction in the incidence of HIV/AIDS.

For more on this project: New Device Makes Circumcision Safer & Cheaper

Or check out: Rwanda Leads Innovation in HIV Prevention