Advanced Therapies

After attending the Spring Symposium for Advanced Wound Care and hearing many great lectures, I got to thinking, “What are the pillars of chronic wound care?” We have all heard of the concept “look at the whole patient and not the hole in the patient.” Heck, I have even written about it. But we also need to have a good foundation for how to implement this phrase or where to even start. I did a quick Internet search and came up with some interesting articles that talked about the basics of wound care and management. I found discussions on everything from maintaining a moist wound environment to being financially responsible. All of this information leads me to the concept of developing easy-to-understand pillars or categories to consider when caring for a patient with a chronic wound.

For the wound healing process to be successful, it must pass through four stages: hemostasis, inflammation, proliferation, and remodeling or maturing. Wound healing requires inflammation, but it can be detrimental if it is persistent or encouraged by other factors, such as infection. It is during this phase that wound healing is most likely to stall.

Chronic venous leg ulcerations (CVLUs) are one of the most common lower extremity wounds with a recurrence rate of as high as 70%. Among the wound care community, there is a common understanding that optimal healing requires the management of tissue, infection/inflammation, and moisture balance within the wound bed, along with appropriate compression therapy. It is also vital for patients with CVLUs to be evaluated by a multidisciplinary team. This evaluation includes a comprehensive vascular evaluation from both a venous and arterial standpoint. While there has been tremendous progress in treating venous insufficiency from a surgical perspective along with advanced wound healing techniques, CVLUs are still a major hurdle to overcome.

Chronic and non-healing wounds are those that do not progress through the healing process in a timely or predicted manner. They are a global problem and are becoming harder to treat. Medicare estimates that over 8 million Americans have chronic wounds that cost the national health care system between $18.1 and $96.8 billion dollars annually.

Benjamin Franklin famously stated, “An ounce of prevention is worth a pound of cure.” This statement was made in reference to the importance of fire prevention in 18th century Philadelphia, but it aptly applies to modern diabetic limb salvage. The multidisciplinary model for amputation prevention has been in place now for almost two decades, but how far have we really come? Recent literature suggests that there has not been a significant decline in reamputation rates for diabetic patients despite the team approach to care. Diabetes is a complex and aggressive disease that affects multiple organ systems and robs patients of sight, sensation, limb, and quality of life. Treating such an aggressive disease is challenging, to say the least, and often the desired outcome is not achieved.

By Emily Greenstein, APRN, CNP, CWON, FACCWS Last month I introduced you to the concept of how being a wound care professional is often a lot like being a detective. This blog post is going to start our “cases.” I decided, in keeping with the theme, to write it up similar to what you would see in a court document.

Wound healing typically progresses through four phases: hemostasis, inflammation, cell proliferation or granulation and repair, and epithelialization and remodeling of scar tissue. Clinicians should achieve wound closure through a standardized framework such as the TIMERS (tissue management, infection or inflammation, moisture balance, edge or epithelialization, regeneration, and social factors) tool, which provides a comprehensive approach to wound management and optimizes the wound bed and conditions to support progression of wounds through the healing process.

The last year and a half have proven to be an extreme challenge for many, especially health care providers. There have been lockdowns, quarantine, medical office closures, staffing shortages, and the overall concern of an unknown virus. The fallout from the last year and a half will likely be ongoing for many years, and although it’s still too soon to truly know all the effects of what has happened, it is an interesting point of reflection on how the field of wound care has been impacted.

When a wound fails to progress through the phases of healing in a timely fashion despite the standard of care wound treatment provided, advanced therapies may be warranted. Wound care often needs a multifaceted approach that involves the treatment of entire patient, not just the wound. Clinicians should obtain a comprehensive medical history of the patient and conduct a thorough skin and wound assessment of the patient. This medical history and assessment will lay the foundation of initial treatment.

When working with a person who has been living with a chronic wound, it can be frustrating to try to figure out why the wound isn’t closing as the wound healing model would predict. Not all patients follow the “traditional” timeline. The wound may not progress neatly through the four phases of wound healing as expected. There may be an underlying issue that is preventing the wound from healing. How, as clinicians, can we address this? Can we actually expect closure of this wound based on the specific patient’s condition, or should we consider a palliative approach?