Wound Care Perspectives: Looking Back and Forward at the Same Time
by Catherine T. Milne, APRN, MSN, BC-ANP, CWOCN-AP
Editor's Note: This letter originally appeared in the print edition of WoundSource 2015.
My grandmother knew wound care. "Soak it in salt water," she'd say. "Keep it open to air!" she would emphatically declare the next day. You never knew what to expect. We've all heard the sage old dermatology advice "If it's wet, keep it dry, and if it's dry, keep it wet." Perhaps my grandmother was a guest lecturer at a dermatology conference and they were too intimidated not to incorporate her wisdom.
As busy wound care professionals, we look forward to the next new technology or nugget of a novel physiological process, and yearn to see the next "biggest breakthrough" to improve wound outcomes. We are always looking forward. Paraphrasing George Santayana, "Those who do not learn from history are condemned to repeat it."1 I was inspired by a WoundSource blog written by Dr. Michel Hermans as he pondered what the next great advancement in wound care would be. But it's also good to look back.
Wound Care Products
Although some may argue that modern wound care began with cave dwellers, our little chunk of wound care history began with the groundbreaking work of Dr. George Winter. As you remember, it was his research that led us to a paradigm shift of employing moist wound healing.2 While the events of the Woodstock music festival and racial violence in Selma were shocking a society that had been stuck in the status quo, bedside clinicians were still using antacids and heat lamps. And honey. And placental tissue. Leeches and maggots, too. How far have we come? Plenty far. But it's good to look back.
In the last few years, the trend in wound care has certainly gone high tech. Hyperbaric oxygen, non-contact ultrasound, immunofluorescence angiography, stem cell therapy, topical growth factors, amniotic membrane, and epidermal harvesting are commonplace forms of therapy. Delivery of wound care, once considered to be primarily in the realm of the nursing profession, has now expanded to require an interdisciplinary approach. The American College of Wound Healing and Tissue Repair recognizes that specialty board certification for physicians must exist so that evidence-based wound practice is practiced. It's good to look forward.
State of the Science/Research
Our non-wound care colleagues often look at our practice and declare, "Snake oil!" It is correct to reply in defense of our specialty, which blends devices, pharmaceuticals, and biologics (each with its own approval standards) and couples them with only one accepted clinical end point—complete epithelialization—and which is still maturing in determining what the evidence should be.
The European Wound Management Association has published recommendations to assist those conducting wound care modality research, and those who read it, on including essential elements that remove questionable practices.3 Notwithstanding, numerous organizations in North America—including the Association for the Advancement of Wound Care (AAWC); the Wound, Ostomy and Continence Nurses Society (WOCN); and the Registered Nurses' Association of Ontario (RNAO), to name just a few—have published evidence-based guidelines that serve to raise the bar of our specialty. We still face an uphill battle. We need more comparative effectiveness studies as well as research on the impact that value-based purchasing has on outcomes. Learn from the past, and look forward to the future.
Professional Wound Care Organizations
We've seen a proliferation of wound care organizations in the last decade or so. The WOCN arose out of the International Association for Enterostomal Therapy. The AAWC, the first interdisciplinary wound care organization, is celebrating its 20th anniversary in 2015. The Wound Healing Society, the American Professional Wound Care Association, the American College of Hyperbaric Medicine and the National Alliance of Wound Care and Ostomy are well-known professional groups also supporting the mission of caring for wounded patients.
In other areas of health care, a proliferation of associations breeds ill will. In the wound care circle, there is a stakeholders group with representatives from the majority of the organizations. The Alliance of Wound Care Stakeholders has been our advocate for a number of common issues, including representing the wounded patient's best interest in the face of health care regulation. When reimbursement for compression garments used to treat venous insufficiency was threatened, this group stepped up. It's good to look back.
The Delivery of Wound Care
Does anyone look longingly back to the days when a patient routinely stayed in the hospital to receive care? The entire episode of care happened under one roof. It is human nature to rewrite history in our heads, remembering only what we wish to. The pressures to reduce the costs of health care, in conjunction with the recent explosion of knowledge on this topic, require a different approach. The comorbidities associated with the wounded patient—diabetes, obesity, fragility, trauma, heart failure, vascular insufficiency—often require a myriad of specialists to manage. Centers of excellence in wound care were developed, in part, to address these needs.
The focus on providing less costly outpatient care has inadvertently created silos of care. Transitioning our wounded patients through this maze while maintaining a consistent treatment plan with communication among multiple providers in a system whose complexities rival the building of the Roman Empire is difficult at best. Add on different wound care providers in each setting, with separate formularies and individualized practice patterns, and one has the perfect recipe for delayed wound healing. Or worse. To paraphrase Dr. Seuss: red foot, blue foot, two foot, one foot. It's good to look back but look forward very carefully.
Long gone are the halcyon days of free samples, pens, and sticky note pads. The Sunshine Act allows the transparency of provider activity. The device and dressing manufacturers and pharmaceutical companies that have revolutionized wound care through the support of educational conferences, generous contributions to charitable causes, organizational meetings and research have also undergone transformation. Rather than have outside oversight, companies with wound care business lines have pledged allegiance to the AdvaMed Code of Ethics.4 These voluntary guidelines adopted by many of our wound care industry partners encourage ethical communication with clinicians directed at maintaining the patient's best interest as the primary focus. We have learned from history, after all.
Industry consolidation, buyouts and venture capital have made strong wound care companies stronger. Encouraging innovation and forward movement helps clinicians heal wounds faster, better and cheaper. Did I hear you gasp? It seems technology is getting more expensive, I think I heard you say. Instead of looking forward or backward, we need to be looking sideways, at our colleagues in Europe. Due to a vastly different payment system, but still faced with the same financial and clinical challenges, in Europe, the use of economic modeling to determine cost and comparative effectiveness is routine. We'd be wise to adopt this approach too.
Getting the Word Out
The first edition of WoundSource: The Kestrel Wound Product Sourcebook was published in 1998. The founding clinical editor, Glenda Motta, RN, BSN, MPH, ET, recalls the difficulty in obtaining information on the nine dressing product categories. There are now over 25. Conference listings, educational offerings, wound care organizations and other pragmatic subjects are now included on the expansive companion website, WoundSource.com. Who could have looked forward and imagined a website that puts information such as timely, informative white papers straight into the hands of clinicians?
The Editorial Advisory Board and Kestrel Health Information management personnel take reader comments seriously and make every attempt to address them, often making changes or additions in content. A fine blend of superior clinical, reimbursement, educational and organizational knowledge allows us to bring the whole package to our readers. Blogs from WoundSource.com bring unique perspectives and create dialogue among us all. The WoundSource Career Center launched this year. At the very least, it brings us fulfilling fantasies of changing jobs after a bad day of work. At best, it can launch a fruitful endeavor. Look forward to the introduction of new website features in the months to come.
If my grandmother were still alive, she'd give this advice: Keep the hard copy of WoundSource available to view when the smartphone is acting dumb. The past is the foundation for the future.
1. Santayana G. From The Life of Reason, Volume 1, 1905. Available at: http://www.quotationspage.com/quotes/George_Santayana/21. Accessed February 27, 2015.
2. Winter G. Formation of the scab and the rate of epithelialization of superficial wounds in the skin of the young domestic pig. Nature. 1962;193:293-4.
3. European Wound Management Association. Outcomes in controlled and comparative studies on non-healing wounds—recommendations to improve quality and evidence in wound management. Available at: http://ewma.org/english/publications.html. Accessed April 23, 2015.
4. Advanced Medical Technology Association. The AdvaMed Code of Ethics on Interactions with Health Care Professionals. Available at: http://advamed.org/issues/1/code-of-ethics. Accessed February 27, 2015.
About the Author
Catherine T. Milne, APRN, MSN, BC-ANP, CWOCN, is the co-owner of Connecticut Clinical Nursing Associates, a practice focusing on direct patient care, consultation, education and research in the fields of wound, ostomy and continence care.
The views and opinions expressed in this blog are solely those of the author, and do not represent the views of WoundSource, Kestrel Health Information, Inc., its affiliates, or subsidiary companies.