Chronic and complex wounds of the lower extremity frequently recur. It is difficult to determine the precise recurrence rate across patients with different lower extremity wound types, including diabetic foot ulcers, arterial ulcers, pressure injuries, and venous ulcers. However, we know that...
By Thomas E. Serena MD, FACS, FACHM, FAPWCA
The Emperor's New Clothes was one of my favorite childhood stories. In this Hans Christian Anderson tale, two weavers clothe the emperor in what today would be referred to as "virtual finery." All of his ministers, advisers, factotums and subjects praise the beauty of the unseen linens until a small boy states the obvious truth, "Look, the Emperor is naked."
I must admit that since I joined the ranks of the woundologists, I find myself frequently sans vetements. When I stand at the podium I pray I will not catch sight of a small person running toward the stage shouting, "You're naked, Doctor! There's no evidence for that therapy at all!!"
Standards of Wound Care: Is it Based on Evidence or Opinion?
Our specialty has so many times substituted opinion for evidence, which when repeated frequently enough becomes the standard of care. Recently I found myself again bare and embarrassed. The American College of Physicians (ACP) published their guidelines for the prevention and treatment of pressure ulcers earlier this year.1,2 The authors exposed the utter paucity of evidence in both prevention and treatment for this condition, which affects more than 3 million Americans. For years we have pushed our recommendations and guidelines for healing and preventing pressure ulcers, but the naked truth is we are naked before our critics.
An entire industry emerged based on our recommendations for the use of alternating air and low air loss mattresses and overlays with meager evidence to support these support services. As a result, the cost of treating these ulcers continues to increase and the legal exposure escalates for clinicians who choose to follow the evidence rather than the dogma. In addition, in the absence of standardized clinical trials and registries, the adverse events for these devices remain largely unknown. At this time, the ACP can only recommend the use of advanced static mattresses or advanced static overlays for patients at risk for pressure related skin breakdown.
However, I do not want to focus solely on mattresses. We are all uncovered! The review fails to find support for the use of heel boots, wheelchair cushions, repositioning, sundry skin care products and the vast majority of interventions which I prescribe for pressure ulcer prevention.
The treatment guidelines are no less scathing. The ACP concluded that studies performed to date are of low quality and represent "weak" evidence. They suggest that there is low level evidence for protein/amino acid supplements, hydrocolloids, foams and electrical stimulation, but not much else.2
The Need for Diagnostic Tools for Pressure Ulcer Detection
Although not specifically addressed in the ACP guidelines I have personally struggled with the lack of diagnostic tools for early detection and treatment of pressure ulcers. Making treatment decisions and conducting clinical trials without objective diagnostic tools is "flying blind."
We are exposed. We can no longer praise our fine garments. If we hope to gain respect and status as a medical specialty, we must clothe ourselves in evidence. We must strive to compare and contrast the various treatments for pressure ulcers. We must base our treatment decisions on clinical efficacy and fiscal responsibility. We must demand that manufacturers produce evidence before adopting their devices. We must join together and cooperate in comparative effectiveness studies on a large scale.
We don't need a few good tailors; we need a few dedicated physicians.
1. Qaseem A, Mir TP, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Risk assessment and prevention of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162:359-69. doi:10.7326/M14-1567.
2. Qaseem A, Humphrey LL, Forciea MA, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Treatment of pressure ulcers: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2015;162:370-9. doi:10.7326/M14-1568.
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.