Chronic wounds of the lower extremities impose an increasing burden on health care providers and systems, and they can have a devastating impact on patients and their families. These wounds include diabetic ulcers, venous ulcers, arterial ulcers, and pressure injuries. The estimated...
by Thomas E. Serena MD, FACS, FACHM, FAPWCA
"I believe we possess all the resources and talents necessary. But the facts of the matter are that we have never made the national decisions or marshaled the national resources required for such leadership."
-John F. Kennedy May 25, 1961
This past May we celebrated the anniversary of John F. Kennedy's quixotic "moon shot" presentation to congress during which he laid out a plan to put a man on the moon by the end of the decade. To the world's surprise, his leadership and unwavering commitment to this dream succeeded and in the aftermath, created our modern space program.
Fifty-five years later, visionaries facing seemingly insurmountable problems continue to emulate JFK's audacity. In stark contrast, there is an overwhelming lack of vision and leadership in certain areas that directly affect the practice of medicine in the United States. In April, the National Pressure Ulcer Advisory Panel (NPUAP) announced the latest revisions to their pressure ulcer staging system. Was there monumental new evidence in the prevention or care of pressure ulcers that spurred on this disruptive update? In Kennedy's case, it was the Russian launch of Sputnik; has there been a pressure injury Sputnik? Has this revision has been prompted by new evidence?
In a word: No. The NPUAP pressure injury staging protocol advances more of the same long-held but largely unfounded dogma concerning pressure ulcers. From my vantage, the staging system has always been centered on minority opinion rather than the evidence, so the recent changes came as no surprise to me. Expert opinion resides at the bottom of the evidenced-based pyramid! David Sackett is not even cold in his grave and we are abandoning the evidence-based principles he espoused. Moreover, dogma is dangerous: it behaves like a cancer invading the body of medical literature. And like all emotionally held ideas in science and medicine, it will prove difficult to work around. To me, this was apparent at the April open NPUAP meeting during which the panel seemingly refused to acknowledge any evidence that failed to support or contradicted their position.
Pressure Injury Areas of Impact
Since the time of Galileo, dogma has persisted for self-serving purposes. Unfortunately, I fear that this may true in this case as well. The NPUAP staging system has taken center stage in pressure injury litigation. Sadly, the most recent update may benefit our colleagues who are involved in legal activities far more than our patients.
In addition, all of the policies, procedures and innumerable forms in all patient care settings will require revision to conform to this thoroughly questionable update.
This will require consultants. More importantly, it will further increase the cost of delivering care, leaving less money for patients and much needed research. And caregivers who had yet to master the last staging update must now be retrained. The stakes are high. A failure to properly document under this new system will send lawyers and their experts to your institution waving the latest staging system. I suggest we make the cover of the next NPUAP staging pamphlet green to remind us of the money that this publication has the potential to drain from our system.
Leadership vs. Expert Opinion Wound Care
The solution is simple: wound care needs a JFK. A strong leader who will stand up and propose funding for research into the etiology, treatment and prevention of decubitus ulcers. There are far more unanswered questions than answers and we have overdosed on expert opinion. We need accurate, objective diagnostics for both prevention and treatment. We need randomized trials. We need comparative effectiveness research on dressings, therapies and offloading surfaces.
We need a leader – not committees clinging to a "flat earth" dogma.
About The Author
Dr. Thomas Serena has published more than 75 peer-reviewed papers and has made in excess of 200 presentations worldwide. He has been elected to the Board of Directors of both The Wound Healing Society and the American College of Hyperbaric Medicine (ACHM), the leading academic society in the field of Hyperbaric Medicine. In 2014 Dr. Serena was elected president of the American Professional Wound Care Association (APWCA). Dr. Serena has opened and operates Wound Care and hyperbaric oxygen treatment clinics across the United States.
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.