Transcript

Karen Bauer, DNP:

Good afternoon everyone, and welcome. We're really excited to be with you all today. Thank you for being here. Today we're going to have some really good conversation around integral debridement and exploring what that looks like, what that looks like across settings, and what that might look like in the future. So, we're excited to share our expertise and input on this. My name is Karen Bauer. I'm a DNP currently out of Toledo, Ohio. I'm the director of Wound and Vascular Services at UT here in Toledo. I'm the current president of the Society for Vascular Nursing, as well as a board member for the Association for the Advancement of Wound Care. I have 2 highly experienced professionals with me today to talk about this topic. Amanda and Dr. Siegel, if you all would like to introduce yourselves. 

Amanda Murray, NP:

Sure. Thanks for having me, Karen. I am so excited to talk to you guys about this topic today on integral debridement. For those of you who don't know me, I am Amanda Murray. I'm a nurse practitioner. I've been taking care of wound care patients going on 17 years, and opened a hospital outpatient department in 2020, going strong, and also see patients inpatient and in the OR. So thanks for having me. 

Micah Siegel, MD:

And thanks Amanda and Dr. Bauer. I'm Dr. Micah Siegel. I'm down in New Orleans. I am the medical director of outpatient and inpatient wound care and the hyperbaric department at one of the hospitals in New Orleans. I've been doing hyperbarics and wound care exclusively for 10 years now. And Amanda, it's good to see you again. I guess it's since Orlando, so it's good to see you. And yeah, so I'm happy to be here and talk about a topic that I think we're all pretty passionate about, 

Karen Bauer, DNP:

Right, and we know that the concept of biofilm and debridement has really evolved over the last 10 to 15 years. We're learning more and more. So really great time, and you can see we have some really huge expertise to be talking about this today. Before we dive in, I want to revisit the concept of debridement, which at its basic we know is the removal of viable and non-viable tissue, other wound-based components like necrosis, slough, biofilm, the inflammatory cytokines, microorganisms, extracellular molecules, all that stuff that gets at the base of the wound. We've known for a pretty long time that we really should be debriding our wounds and ulcers, especially when nonhealing, regularly. 

With that, we have kind of a new concept that we're really excited about sharing today, and that's the concept of integral wound debridement, which really looks at how comprehensive we have to be when we're looking at debridement, where gone are the days where we really can be using just one modality and looking at just sharply debriding and then moving on. So, the concept of integral wound debridement is the combined use of augmented or complimentary modalities that kind of keep that debridement going and really amplify each other so that we can maximize and optimize debridement, especially across care settings where resources are sometimes limited. This concept is something that should be tailored to the patient. Again, it's based on wound response, so really a more complex way of looking at debridement. With that, Dr. Siegel and Amanda, I'd love to hear your input on how integral debridement can support wound care across settings, and kind of on a basic level, how both of you are seeing that being used as you traverse the system. 

Amanda Murray, NP:

Well, thanks for that definition, and we know debridement is essential to wound healing. We've known that for a long, long time, even post-World War I they were using some form of debridement. So, it's important, no doubt, and I want to give credit really where credit is due for wound care practitioners. It's been a problem to get debris, biofilm, necrotic tissue out of the wound, and we've been using several forms of debridement for a long time out of necessity. And so now, I mean, I think it's a new buzzword in wound care, “integral debridement,” but I really want to give us credit, because we've been doing this for a long time, using multiple forms of debridement, because we can't always get it out with sharp debridement. Maybe the patient has pain, maybe it's really fibrous and stuck to that wound bed, so we have to use a different form, but I think we have better tools in our toolbox now to make it more efficient. What do you think, Dr. Siegel? 

Micah Siegel, MD:

Yeah, I agree. It's definitely the buzzword in the wound care community, but not a new idea or practice within the specialty of wound care. I think more and more there are products or tools that are coming out that allow us maybe an easier or less painful way for some patients or on patients, the peripheral arterial disease that we can't sharp debride, having these new products and tools to allow us to do this integral debridement between our sharp debridement or if, like I said, if we were unable to use a sharp tool on some of these patients as well. 

Karen Bauer, DNP:

Yeah, great points. I think you're right that we've kind of already been doing this. I think that with the concept or that comprehensive approach comes the need to make sure that we're really proactive and aggressive with it, especially as our patients are traversing the system, so that when they go away from us, we don't lose sight of the things that we're already doing and that we're kind of amplifying the amplifiers, right? That we're educating the systems around us so that those things continue across the care continuum. What products or tools have the two of you guys noticed as patients are going home to home health or to the ECF or in the acute care setting? What sorts of things are you using and seeing that can help augment or further help with regard to use of some of the amplifiers and tools? 

Amanda Murray, NP:

I guess I'll take this. So, you want to keep that continuity of care that's so important. So, what's effective inpatient we know what will be effective outpatient. It's hard when we have to transition that to conform to what home health may carry. But I don't know about you guys, but I want my hard work to pay off. So, when I sharp debride my patients, I want a continuous method of debridement. When my patients come back, I know that necrotic tissue and that biofilm is recollecting in that wound within 24 hours of their discharge. So, it would be really great if what I did in the hospital would continue on that outpatient side, and we can do that with a continuous form of debridement. And so Dr. Siegel, do you want to talk about what you use to kind of keep that necrotic tissue and that bacteria out of the wound bed once you've worked so hard to get it out of there, in inpatient or an outpatient setting? 

Micah Siegel, MD:

Sure. That being said too, I'd just like to bring up, before the product I use, is my paraplegic patients that have pressure injury that logistically it's impossible to come in weekly for sharp debridement. So, having other tools out there, especially in those type of patients that I know that I can't do a sharp debridement on every week, it's been very beneficial. 

So, one of those products is the UrgoClean Ag, which is, I like to describe it as kind of a product that draws from the wound, but it also has an antimicrobial layer to it too. It does have electric charge that attracts the bioburden within the wound. And so it's doing that kind of debridement in between my sharp debridement. Of course, nothing's as good as a sharp debridement, but in my experience with using a product like this, it has allowed the amount of bioburden to be a lot less in between my debridements. So it's been really great in that aspect. 

Amanda Murray, NP:

Yeah, I think Dr. Siegel brings up a really good point. There's patients that we don't want to sharp debride for multiple reasons. Most recently, even last week, I had a vascular patient and some critical anatomy just right there in the wound base and definitely didn't want to roll the dice and sharp debride that wound. So, there's nice to have better options then maybe some of the less effective and efficient forms of the debridement we've had to use in the past. So UrgoClean Ag has been a great tool in my practice as well for those same reasons. 

Karen Bauer, DNP:

Wonderful. I think with that, one of the other tools that is known to be an amplifier to sharp and other forms of debridement is the hypochlorous acid, or Vashe®, specifically. So, I know in my practice quite frequently, and this is in all care settings before and after debridement, for those patients that we can't see as frequently, helping them to get that in the home, it's very easy for the home health nurse, for the skilled nursing or extended nursing nurses, to be able to do the soak with Vashe®. And then I have some confidence that even though that patient's going away from me, wound hygiene is extremely important. 

And when we're talking about, if you look at the June 2024 supplement in the Journal of Wound Care that really defines this and goes heavy into this, that's one of the things that we do need to look at is how consistently can we do these things, and do the nurses and the staffs know how to do these things when they are leaving us? When we look at negative pressure instill, that's something that's still just available in the inpatient setting. So, what do they do when they then end up somewhere else? 

What sort of unique patients, other than the ones that you've mentioned, or unique challenges have you all seen where you've had to be creative with regard to some of this in mixing the sharp debridement with hypochlorous acid and/or some of these dressings? Do you have any patient examples that you'd like to share where the patient is going back and forth between in and outpatient and the extended care facility? 

Amanda Murray, NP:

Dr. Siegel, do you have any thoughts? 

Micah Siegel, MD:

Well, to start off with, I think Vashe® has also incorporated itself into my daily practice. I don't think there's a patient that comes through my clinic or inpatient that is not going to have Vashe® incorporated into their wound care dressing. And then of course the Vashe® in conjunction with the UrgoClean Ag is that the Vashe® will change the pH in a way that will allow the UrgoClean to work even better. So, as far as specific examples, I think really it's still my paraplegics, but also been using the Vashe® on wounds that really don't have any visible bioburden to begin with and may be still needing some debridement, but not that real fibrous, hard-to-debride that Amanda mentioned before. But so I already have this fresh and really granular looking wound and applying the Vashe® and then the UrgoClean on top just to keep that bioburden at bay. I've noticed it's worked really, really well in those scenarios and also probably shortened my healing time for those types of wounds as well. 

Amanda Murray, NP:

Sure. And I guess an example is I live in central Montana, and so we kind of have this demographic that in winter sometimes my patients can always get here because of the weather, and I feel like if I can teach them something simple, like Karen mentioned, if I can just say, hey, if you put Vashe® on a gauze and soak your wound, and then this is just silver side down to the wound bed, they don't need to know all the science behind it. I know that it's easy to teach, so some people come from the high line, the Canadian border, and we don't have home health services go out there. And so I can pretty much teach a kindergartner to soak with Vashe® and 4x4s and put an UrgoClean on top diamond side down, silver side down. And so I can teach any patient surely in my practice to do that, knowing that it's going to keep that bio burden down, the bacterial load, inflammation, and really give me a nice response when they do get back to my clinic. 

Karen Bauer, DNP:

Nice. I think those are great points. I think one of the patient populations that comes up for me, and a lot of this is, like we talked about, it's commonplace, and we're kind of doing these things on most of our patients now, but one of the places that I've seen probably the most high-impact clinical outcomes are with our renal transplant patients. We have a really robust renal transplant program here in Toledo, and so a lot of my patients are immunocompromised, and we think abdominal wounds posttransplant that end up infected, but we also have the ischemic wounds and the diabetic feet in our renal transplant patients. So, we have a really high population of that. And I think I can say that the use of these complimentary tools has really augmented and been a good thing for clinical outcomes in that patient population as well. So while it's commonplace, I think selecting patients who are at increased need is really important too. 

What sorts of things do you guys see coming down the pipe? What sorts of things would you guys like to see with regard to making sure that we have protocols to implement these tools and/or research with regard to debridement and bioburden and that sort of thing? 

Amanda Murray, NP:

What I'd like to see is more protocols to increase that continuity of care. We know that increases the quality of care, so I just do my best. I mean, after 17 years, it's my preference just to be in clinic with my patients, but after 17 years, you've gleaned some experience that I think it's important to share. So, I do teach at the nursing school here. We just got a medical DO program here that I want to go out and teach at. And then I do teach my home health staff once a year with a lunch and learn. And by the way, they teach me just as much as I teach them. So it's a really great way to say, hey, I want to implement these products. These are some consensus guidelines. Why don't read through them, know what's the best tools for your toolbox, and just share some information that way. So, I think if we increase education, we increase the continuity of care and the quality of care. 

Mica

I agree. 

Amanda Murray, NP:

As far as research, Sorry to interrupt. As far as research, I was just googling what's the first tool in debridement we ever used. And the Mayans used maggot therapy, and I wish we could use more maggot therapy, except it's cumbersome. Patients kind of get freaked out about it. But it does a really good job of cleaning up a wound. And then I want to see more research and more products that will help us continuously debride these wounds, keep them clean. UrgoClean Ag is a great product, but what about this thick eschar tissue? Maybe some more enzymatic debriders that we could apply that aren't so expensive that we talk about, things of that nature. So, I think I've answered both of those questions now. Sorry about that, Dr. Siegel. 

Micah Siegel, MD:

Oh, no, I mean, I totally agree. I'm not sure I have much more to add other than education being key. It's interesting in general, I think throughout the medical community that people will either shy or are scared about wounds and have no insight on even how to approach them from the get-go. I mean, I joke with my patients, oh, well it's job security for me because I know what I'm doing. But I think more education to at least get the basics wound care 101 going, whether it is just a Vashe® soak gauze, it would be better than what I'm seeing on a day-to-day basis. So, yeah, education is always key. I mean, what we're doing right now is a part of that as well. So, more and more getting out there and sharing our insights as being so-called experts in the field, I think is priceless. 

As far as research, I don't know. I'm stuck in my clinical world. I just want to see my patients. So, I guess they're my research guinea pigs in a way. And I guess, in general, one of the things I love about wound care is how dynamic it is. There isn't really one set way to approach any one patient, let alone one wound. And so it's always a trial and error and a discussion with the patients on which way to proceed. So, I don't know. I'm excited to see what else is out there in the future. I agree, if there's other options for enzymatic debriders, or if there's a way to really get through those thick, chronic eschars, which we've scored in the past, which I've really never seen much that do much for anything. So, it'd be interesting to see just in general how we can approach these wounds when they're not in front of us, a captive audience, in our clinics, in our inpatient facilities, nursing homes, or in the home. 

Amanda Murray, NP:

And these products make it so much easier to teach primary care providers and those patients that go to other providers, especially here in Montana, we're Central Montana, but there's people who can't come here always right away, especially. And so if we could get this in the hands of primary care providers, and we make the education simple, and we know it's going to be effective and efficient, I mean that's the goal. And I'm so glad there's people smarter than me in labs and scientists that think about these things and close the gaps for us. Right? 

Micah Siegel, MD:

Oh, absolutely. Absolutely. 

Karen Bauer, DNP:

I think the 3 of us are kind of well-aligned like that. I want to be there with my patients, and I want something in my hands that's going to allow me to be able to do that and to be able to get them what they need, which is why I love the concept of some of these things that we're starting to see that can help us work when we're not there with them. 

I have a question for you all with regard to some of this. We're all in different settings, and for me, being in smaller institution, I work with a demographic that is under-resourced, marginalized communities, and I sometimes struggle having my patients get their hands on some of these things. Do either of you have tools or things that you've used or ways or specific situations that you've encountered where patients couldn't get this, or we couldn't get their hands on some of these things that we're using? And if so, how can we work together to mitigate the ability for other institutions, other settings, right, the extended care of a setting to stock some of these things. What success stories or what can you offer there? 

Amanda Murray, NP:

So, Karen, you were asking about how we can get these products into the hands of our patients, and I think protocols are really going to help, but we're going to have to talk to maybe case managers about access when they discharge patients from the hospital and our home health nurses and our skilled nursing facilities. And really the only way we're going to get those products into the hands of those people is education, talking to them frequently, but also using supply companies for our patients who don't have home health. And we are going with Byram and Verse Medical in my clinic, and they've been really helpful to get those products in the hands of my patients. And then it just comes down to education and how we're going to use them. 

Micah

To pretty much piggyback again with Amanda going about this. Education wise, me personally has done exactly what Amanda's done. I've sat with both my supply companies and my home health agencies and redone their formularies to remove things I don't use that much, to introduce the newer products that might be a little bit more expensive. And then also what I've done from just a Vashe® standpoint is talk to my pharmacist. So now on my outpatient pharmacies that are hospital-based, they are all stocking Vashe®, which is over the counter, which has been a lifesaver for both my clinic patients that I say, hey, just go across the hall. But also my inpatient wound care team knows that they can continue the Vashe® as well by, when they're discharged from the hospital, they can go right downstairs on their way out to their car and have that Vashe® readily available to them. But yeah, I think really the trick is the case managers, the home health agencies, and the supply companies to get the access to these somewhat more expensive products out there. But it's definitely not impossible to do. 

Karen Bauer, DNP:

Wonderful. Yeah, I think with the Vashe® specifically because of the DMEs with regard to that, I think that's a great tool for the outpatient pharmacies. And I think there, too, it's really important that we involve our industry representatives as well. My representative in my area has been crucial with helping us get our outpatient pharmacy have access. And we were actually cold-calling some of the other outpatient pharmacies that are in the area to try to get them to get it on their shelves. And I know that that eventually led to that being stocked in a lot of outpatient pharmacies, but us as providers, knowing where our patients can get it and helping price that out for insurance, non-coverage, and whatnot, is really important. So I think those are good tools. And Amanda, I totally agree that I think that protocolizing a lot of this is going to help, and a lot of the research like this 2024 consensus document is going to be really, really imperative as we move forward. So, kudos to both of you, obviously doing this and advocating for it. 

We're out of time for today. Is there anything that either of you would like to share in closing? 

Amanda Murray, NP:

Well, in closing, I feel like I've learned something, even just listening to you two talk, and I am going to add access or wound care supply companies to my protocols. That's such a great idea. I don't know why I have never thought about that before, but maybe sitting down with your colleagues is helpful to think about how we close these gaps. 

Karen Bauer, DNP:

For sure. 

Micah Siegel, MD:

Yeah, well, thanks for having me, both of you. I'm not sure I have anything else to add, but it's always good to connect with our wound care warriors from across the country. And for me, that's been a kind of growing family. So, it's exciting to see the future of wound care. And hopefully I'll see both of you in person in the future.