Karen L. Bauer, DNP, APRN-FNP, CWS, FAAWC:
Hi everyone. I'm Karen Bauer. I am A DNP out of currently the University of Toledo Medical Center where I'm the director of wound services and the lead wound and vascular APP. I'm also headed down to Emory Healthcare where I'll be working with a limb salvage program. I've been doing wound care for about 16 years now and added vascular on about 8 years in full.
So, I think when we look at hospital-acquired wound infections, obviously it adds a layer of complexity because of that acquisition factor; we really have to look at multiple factors, one of which is just the complexity of the patient. And then 2 is the complexity of the system, right? So, there's lots of considerations with that. First and foremost in this situation, which is a little bit different from when I'm looking at my harder-to-heal wounds or my more chronic wounds, I'll look at the local wound environment and what's truly going on, how much drainage is there, how much slough is there? Are there local or regional signs of infection that might need more mitigation than just topical? But I really hone in on that topical factor when it comes to the surgical site infections, and then from there, make the decision with what's going on in that local wound environment.
I think one of the bigger systematic or systemic complex factors that I think about is in the hospital, especially when there's infection involved, there's a lot of people that want to see the wound. So, one of the things that I consider on the inpatient side of things with infection that is a little bit different from other environments is that I plan for more frequent dressing changes, and I try to select something that is going to align with that, just knowing that oftentimes even with our best efforts, people are going to be coming in to look at that wound fairly frequently. So I either need something that can be replaced, really easily lifted and looked at and replaced, evaluated somewhat through the dressing, or that will tolerate some more frequent dressing changes, at least initially while everyone wants to look at that wound.
I love that. So, I think that advanced modalities, we’re starting to learn more and more, and I think that the paper that was recently published on integral debridement plays nicely into that. I think gone are the days that we can use those basic dressings from any standpoint, right? From a regulatory cycle or a patient outcome standpoint. We really need to be looking at the advanced modalities. Know better, do better. So I think with regard to that, looking at the options that are more current and modern, there are a lot of new things that we're looking at and that are available to us now, historically using the silver and now moving towards some of the other antiseptic and osmotic factors as well as some of those dressings that are either 1. impregnated or 2. looking at transparency and things like that. So I really think that there is no comparison. I think that we really need to make sure that we're following that evidence base and using the advanced modalities in every situation possible.
It's a great question. So, I think that a lot of that, I've started to look at dressing selection almost as like risk stratification. We do risk stratification for other things prior to surgery or prior to procedures. Obviously we cannot plan for hospital stays all of the time. But I think looking at that from a host factor standpoint, that if you have a patient who is obese who maybe doesn't have the social resources at home or otherwise to practice good overall hygiene or nutrition, you have a patient who is in that pro-inflammatory chronic state with diabetes, and when these patients are acutely ill, right, their body's focused on multiple other things. So, I think that the selection and some of the challenge with selection comes with looking at those host factors still and making sure that we are as preventative as possible by noticing and taking note of those host factors first and foremost, so that we select dressings that might be a little bit more aggressive or antimicrobial even prior to the point at which we have an infection or a local situation.
With regard to that, I think that one of the biggest challenges of using the advanced modalities, even when we're addressing those host factors, is simply that the current state of affairs is just so routinized. It's habitual for people to be using what they know, the tried and the true in their minds. And I think wound care being as multispecialty and interdisciplinary as it is, it's hard to really reach everybody in a standardized way or in a systematic way to make sure that we have good algorithms, that almost no matter who comes into that room or who's doing a surgery or where that patient is, we can have the same quality of care. So, I think that one of the biggest challenges is just changing the mindset and continuing to be persistent with changing that paradigm that we have better options.
So, 1 is the habits that I talked about, right? It's just it's habit for people. They're going to grab what they know to grab off the shelf. But 2, I think the second problem is awareness. I don't know that people who are not able to attend these conferences or fully invested in wound care as a full-time thing or even a part-time thing, they're really not aware that these dressings are out there. And if they do have awareness, that awareness is kind of in their periphery and they're not sure how to get access. So I think the first problem awareness, I think the second problem is access to where, if somebody who is not well connected or well checked into the daily wound care world, which I think does happen on the acute care side of things relatively frequently, where we have people that are either engaged or treating those wounds, but maybe not full-time woundologists. Once we have that access, how do we then algorithm how they can use those products? So, I think that we need to really simplify all 3 steps. One is awareness and teaching, getting the word out of there. Two is making sure that people who don't have daily access can gain access to these modalities. And 3 is simplifying that clinical algorithm so that they don't have to think about what's on the shelf as much they can kind of grab, knowing that they're going to follow that and really change those habits.
Yeah, I've been saying a lot lately, hindsight is 20-20, right? We can all learn from the cases that we maybe didn't do optimally. So, we recently had a patient who had had a venogram. He was an overweight patient, social situation was not ideal, and he, a venogram is considered, it's more of a puncture site, so it's still risk of infection, but it's not an open procedure. And the gentleman got sent home essentially with dry gauze and a clear adherent dressing over the wound with the resident and the surgeon thinking, yeah, this guy's going to be fine. It was a puncture site. The poor gentleman was in and out of the ER 3 or 4 times with a seroma, and then subsequently the seroma got infected. And when the patient presented to the ED, only 1 of those 3 or 4 times did they actually call us as wound care people to weigh into that.
And unfortunately, he ended up having to have a washout. And at that point, we were able to get involved and get some of those advanced modalities on him. But the time that we got consulted or got involved, unfortunately that habit took precedent, right? Everybody just said, well, hey, it's not really infected. We don't need to admit you right now. Let's keep doing what we're doing and hope for a different outcome. So, that was a good learning point for me, because I take it for granted, especially in our institutions, that we are going to get called, but then it made me take a step back and also think through the fact that as a field, we need to make sure that we're educating our colleagues, so that if I am on vacation or they're not consulting the people who are at the point of care, in this case, it was the ED, can give appropriately consistent care as if we were there. And that goes back to the awareness, the access, and the algorithm.
I think things like this, continuing the conversation, and I love that. I think that we need to pay heavy attention to the care setting where the patient is, because I think with wound care, we oftentimes do get caught up in the hospital outpatient department as a primary source of wound care. And I think that organizations are now starting to alert us to the importance of wound care in the post-acute setting. And we've looked at a lot of things on the inpatient or the acute care side, but I think it's really important that we embrace that and we look at the setting and that we kind of do concierge education or concierge programs for each individual setting, similar to how we would do with each individual patient, because each setting is uniquely complex. So, I appreciate that, and I think that that would be the only other point that I would make is we really need to give the setting that the patient is credit and adjust how we're approaching it accordingly.
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