By DOT WEIR, RN, CWON, CWS
The specialty of wound management is one that the average lay person is not going to know even exists. Beginning as a young child, we expect that our "boo boos" will heal by magic with the right bandage and a kiss from mom. Even into adulthood, the average wounds or injuries that one has had over their life to date has generally healed without incident. It's the expectation. Humans are designed to heal.
It has been estimated that chronic wounds affect up to 6.5 million patients, with an expense in excess of 25 billion dollars. A 2012 study by Fife et al, looking at 5240 patients with 7099 wounds revealed a mean age of 61.7 years, 52.3 percent were male, 73.1 percent were Caucasian, 52.6 percent were Medicare beneficiaries, and the average wound surface was 19.5 cm.
A further critical piece to this equation is that the mean number of co-morbid conditions was 1.8, with the three most common being diabetes (46.8 percent), obesity or overweight (71.3 percent) and cardiovascular and peripheral vascular disease (51.3).
In the US venous leg ulcers (VLUs) have been estimated to cause the loss of 2 million work days and result in treatment costs of approximately $3 billion per year. The statistics in the diabetic foot ulcer (DFU) population are much grimmer. Approximately, 26 million people, comprising 8.3 percent of the US population are estimated to have diabetes. In 2010 alone, there were 2 million new cases of diabetes diagnosed. Of the U.S. diabetic population, it is estimated that 15 percent will develop DFUs in their lifetime. Armstrong and colleagues reported the 5-year mortality rates for patients with neuropathic and ischemic DFUs and diabetes-related amputations compared with other conditions, including several common types of cancer, using data gathered from multiple sources. By 5 years, 45 percent to 55 percent of patients with neuropathic and ischemic DFUs, respectively, will die. These common complications of diabetes have higher mortality rates than many common cancers.
Wound healing is known to occur in four overlapping phases; hemostasis, inflammation, proliferation and remodeling, and usually is complete in approximately 28 days, with the remodeling phase lasting up to 2 years. In acute wound healing, wounds move through these phases unimpaired and without incident resulting in wound closure. In chronicity, the wound has become stalled, usually in the inflammatory phase for a variety of reasons; bacteria, poor blood flow/oxygenation, repeated trauma, or co-morbid conditions and/or the drugs required to treat them. In retrospective studies assessing time to healing in large groups of patients, those patients with DFUs who were not at least 50 percent closed by 4 weeks were unlikely to heal by 12 weeks, and those with VLUs who were not 40 percent closed by 4 weeks were unlikely to heal by 24 weeks.
A critical component to healing chronic wounds is in preparing them to heal. Wound bed preparation is the platform on which wound healing pathways are built and includes wound debridement, management of bacterial bioburden, management of wound exudate and the creation of a moist wound bed, and attention to the wound edge. The more rapidly this is accomplished, the sooner the wound can proceed on a healing trajectory. The two most common wound types seen in outpatient wound centers are DFUs and VLUs illustrating the importance of early intervention with an evidence based pathway designed to move patients to a healing trajectory as quickly as possible.
The management of chronic wounds provided in a wound center enables the care to be provided in a patient-centered environment taking into consideration the certainty of an accurate diagnosis, attention to pain, quality of life, the ability to continue working, acquisition of supplies, and the utilization of technologies such as advanced dressings, negative pressure wound therapy, hyperbaric oxygen, cellular and tissue based products and growth factors at the appropriate time to accelerate wound healing. The importance of using these advanced technologies at the right time for the right patient will enhance earlier healing while ensuring cost effectiveness of the care.