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To Feed, or Not to Feed, That is the Question…

Enterocutaneous (ECF) and entero-atmospheric fistulas (EAF) can create a challenge for the certified wound clinician. The hope is always that the fistula will spontaneously close while at the same time managing the current situation.

Back to basics…

A fistula is an abnormal connection between two structures. In wound care, we see many types of fistulas, often classified by the structures that are connected or by the amount of output noted. Two types that are often seen are the enterocutaneous (intestine to the skin) and entero-atmospheric (intestine to the open wound). These may then be classified further into high, moderate, and low output fistulas. A high output fistula is one that produces >500ml/day, moderate is 200-500ml/day, and low is <200ml/day.

Spontaneous closure is the goal for the patient with an ECF or EAF and is often achieved with time, patience, and conservative management. Many factors contribute to the development of EC and EA fistulas and therefore should be considered when managing and encouraging spontaneous closure. For example, was the fistula caused by a surgical event or does the patient have a history of Crohn’s Disease? Has the patient had previous radiation therapy, or do they suffer from malnutrition? Do they have a history of peptic ulcer disease or an intra-abdominal abscess? Each of these factors, if applicable, will affect the treatment plan and how the patient responds to therapy.

Several general management guidelines are appropriate for any fistula, regardless of the etiology. They are defining the fistula, fluid andelectrolyte replacement, infection control, skin protection, and nutrition.

Defining the fistula refers to identifying the communicating structures, and in so practitioners gain a better understanding of the specifics of management. For example, a small bowel fistula will likely have higher output, need greater nutritional management, and meticulous skin protection.

Fluid and electrolyte replacement is extremely important, as well, particularly when managing those fistulas involving the small intestine or whose output is >500ml/day, or high output. Patients with high output fistulas are at risk for dehydration, as well as electrolyte imbalance and its sequelae, much like a high output ileostomy.

It is also important to identify and treat sepsis. Often the infection is a concern due to spillage of intestinal contents into the abdominal cavity and the resulting inflammation decreases the chances of spontaneous closure while increasing the chances of further fistulation.

Small bowel contents are very corrosive to the skin and require meticulous skin care to prevent skin breakdown.

And finally, nutrition…

The nutritional variables that one might evaluate are the current nutritional status, current health status, past medical history, amount of fistula output, and how nutrition will be administered, enterally versus parenterally. How is the mode of nutrition determined? If utilizing parenteral nutrition, for how long?

Each of the steps to managing fistulas, previously listed, requires consideration of nutritional status:

  1. Ensure there is no active sepsis. If so, treat it. Sepsis causes hypercatabolism which carries with it increased nutritional requirements. A high output fistula may require as much as twice the baseline protein and caloric intake, approximately 2.0g/kg/day and 40kcal/kg/day respectively. Can the patient obtain these requirements with TPN? Would an enteral diet cause an increase in output?

  2. Optimize fluid and electrolyte status. Fistulas, especially those that are high output, can lead to excessive loss of protein-rich fluids and electrolytes. Not only can loss of fluid lead to hypovolemia and circulatory failure, but the corresponding loss of electrolytes may also cause any number of problems from weakness to EKG abnormalities. Is the patient physically able to take in the required fluid and nutrients?

  3. Protect peri-fistular skin. Different modes of nutrition can affect the amount of fistula effluent which may then influence skin integrity and cause skin breakdown. Is the patient’s diet affecting the amount of output? Are there pouching issues and leakage due to increased output?

Now that we see how important nutrition is in the management of EC and EA fistulas, how should it be administered? Shouldn’t the bowel have an opportunity to rest? With input into the bowel, won’t there then be output? And won’t the output flow through the fistula minimizing the chance of spontaneous closure? In the mind of this wound nurse, this is a dilemma…

Current evidence suggests that for a low output fistula (<200ml/day) a short course of bowel rest may be attempted with or without TPN. The patient should be monitored during this time for decreased output and spontaneous closure. If no spontaneous closure, consider reintroducing oral intake and manage the fistula like an ostomy until the nutritional status is optimized. One may then consider surgical closure after approximately six months or so.

For a high output fistula, which often involves the small bowel, nutritional maintenance with an enteral diet is more challenging due to the greater losses of nutrients via the fistula and the likelihood of further increased output with increased oral intake. TPN is a viable option for longer periods, in this scenario, leading to surgical closure after approximately six months as well.

The bottom line is that the patient needs adequate nutrition for maintenance of life, wound healing, and fistula repair, whether spontaneous or surgical. Each patient will be different and each situation unique. It is important to look at the “big picture” and not assume each patient will respond in the same way to the same therapies. Personalize therapy to meet the individual needs of the patient while considering the ultimate goal of successful fistula closure.

References:

Bryant, R.A. & Nix, D.P. (2016). Acute & chronic wounds: Current management concepts (5th ed.). St. Louis, MO: Elsevier.

Stein, S.L. (2019). Enterocutaneous and enteroatmospheric fistulas. Retrieved from https://www.uptodate.com/contents/enterocutaneous-and-enteroatmospheric-fistulas?source=history_widget.

Willcutts, Kate, Scarano, K, & Eddins, C.W. (2005). Ostomies and fistulas: A collaborative approach. Nutrition Issues in Gastroenterology, 33, p 63-79.

Surgical Site Infection and Post-Operative Dressing

Surgical site infections (SSI) increase medical costs, length of hospital stays, and readmission rates. Although this rate may be under-reported, the incidence of SSI in the US is estimated to be 2.8%. In the inpt setting or generally?

There are many factors involved in the development of an SSI. Bacterial factors include the inoculum size. Bacterial load at the site of infection of greater than 105 is considered to be indicative of infection rather than colonization. Virulence characteristics, resistance characteristics, and enzymatic activity also play a large role in the development of superficial surgical site infection. (superficial vs deep?)

Patient factors that increase the risk of SSI include age, nutritional status, significant weight loss within 6 months of surgery, immunosuppression, comorbidities (especially obesity, DM, and peripheral artery disease), and post-operative anemia. Each of these factors has been shown to play a significant role in increased risk for an SSI.

Surgical characteristics can also increase the chance of developing an SSI. Poor surgical technique, operative procedure length >2Hr, operative field contamination, and poor skin preparation/shaving have all been shown to increase the risk of an SSI. The American College of Surgeons (ACS) has classified surgical cases based on infective risk.

  • Class I (Clean) Operative field is uninfected, there is no inflammation, no hollow viscera are entered, and the respiratory, GI, reproductive/GU are not breached. There are no major breaks in sterile technique. Operative incisions after blunt trauma where the respiratory, GI or GI/GU tracts are not injured also fall into this category. Infective Risk is
  • Class II (Clean Contaminated) Operative field is uninfected, there is no inflammation, but the respiratory, GI, reproductive/GU tracts are breached but in a controlled manner as part of the operative plan, and without excessive or unusual contamination. There are no major breaks in sterile technique. Infective risk is < 10%

  • Class III (Contaminated) Recent open (traumatic) wound, traumatic wounds older than 12 hours, surgeries or procedures with major breaks in sterile technique or major spillage from the GI tract, or incision into actively inflamed tissue (without purulence). Infective risk is 15-20%

  • Class IV (Dirty/Infected) A wound where the organism causing the post-operative infection was present in the operative field before the procedure. There is an uncontrolled entry into hollow viscera. Active inflammation, as well as gross purulence, can be seen. Infective risk is up to 40%

It is common practice to utilize dressings to cover a surgical incision that has been closed by primary intent (skin edges are reapproximated using sutures, staples, skin glue, or other means). It is a common belief that the benefit of a post-operative dressing is to control exudate and bleeding, protect the incision from external contamination, protect healing tissue, and prevent infection of the incision.

However, a 2016 Cochrane Review does not support the use of a post-operative dressing, or any specific type of dressing, as a factor in preventing an SSI. The review included 29 articles (5718 subjects) published up to September 2016. While included studies were randomized and controlled, many were underpowered due to small sample sizes, varied surgical case types, and study bias and imprecision. As a result, the evidence quality was graded as low or very low for many of the studies. The authors could not find sufficient evidence that covering a surgical incision with any dressing reduced the risk of an SSI. They also could not support any specific type of dressing as reducing the risk of an SSI.

Due to the morbidity of SSI, interventions such as the Surgical Care Improvement Project (SCIP) have been instituted with the stated goal of reducing SSI. The use of a post-operative dressing is standard practice for most surgeons. While the postoperative dressing does control exudate and bleeding and provides a physical barrier while the incision epithelializes, further research is needed to determine if this practice is beneficial in the prevention of SSI.

References:

A Report from the NNIS System. Am J Infection Control. 1996 Oct 24(5):380-8.

Barie PS. Surgical Site Infections: Epidemiology and Prevention. Surg Infect. 2002; 3(Suppl) 1: S9-21.

Cruse PJ, Foord R. The epidemiology of wound infection. Surg Clin N Am. 1980 Feb 60(1):27-40.

Dumville J, Gray TA et al.  Dressings for the prevention of surgical site infection. Cochrane Systematic Review. 20 December 2016.

Malone DL, Genuit T et al. Surgical site infections; Reanalysis of Risk Factors. J Surg Res. 2002; 103(1): 89-95.

Rosenberger L, Politano A et al. The Surgical Care Improvement Project and Prevention of Post Operative Infection, Including Surgical Site infection. Surg Infect. 2011 June; 12(3)L 163-168.

Our Passion for Wound Care and Healing – How Did We Get Here?

As a talented group of professionals in our areas of specialization, we have formed a common goal to conquer any wound, regardless of the location, source, chronicity, or barriers to healing. At least, this may be our belief. Did any of us have a burning desire as aspiring professionals to work to advance the cause of evidence-based wound care? As a team of multidisciplinary professionals of physicians, nurses, pharmacists, physical therapists, researchers, and industry personnel, we were able to recognize an area of need for patients who suffer from chronic wounds. For each of us, there was something which ignited the passion to serve, to research, and to lend our expertise to this subject. Our strides to promote wound care from a multidisciplinary approach have led us to improved overall outcomes for our patients.

To my knowledge, there is not one aspect of higher education in the subject of wound care for everyone to attend. It appears we have all come to this crossroads in our respective professions. Some attend to the clinical aspects of wound care, some research, while others may possess a formalized training in business and are able to identify a need in the area of wounds and wound healing. Simply expressed, there is not a formal institution of higher learning for wound care. Fortunately, there are educational programs, certifications, and extended classes and degrees which promote the spectrum of wound care.

I dare say, as we embarked upon the road less traveled, we developed a desire to care for patients with wounds and to promote wound healing holistically. As professionals, we may have provided care to a patient who performed a “do it yourself” technique on their wound, such as preparing a full-strength bleach soak for their feet, which caused more harm than good. There is the non-compliant patient and family, although educated repeatedly about their disease process, prefer to remain non-compliant.  I encourage you to reflect upon the patient with multiple co-morbidities who managed their underlined disease of diabetes or congestive heart failure and still experienced disappointments of limb loss.

As clinicians, we are at the forefront of identified problems and the exploration of various ways and means to solve the problems. Perhaps, a short term or long-term goal of care was determined for treatment. Did the patient need antibiotic therapy, local wound care, or surgery? What type of therapy was needed for the patient? What did the labs show? There were many ways to explore a singular problem. However, through a multi-disciplined approach, we likely determined to connect our desires with others who shared the same goal to bring healing and awareness to this important category.

You may ask, what led to my passion for wounds? I was the nurse in a critical care unit where patients with chronic, surgical, or trauma wounds were my norm. Where others shied away, I could care for the entire patient without any bias toward their wounds. This was a time to provide timely assessment and care while noting any changes to the area of concern. It was not always pleasant, but my goal was to provide the needed, direct patient care with compassion. I began to read evidenced-based literature to determine the findings of my peers. This led to my attendance to a wound, ostomy, continence educational program and ultimately a certification in wound care to solidify my passion and my commitment to additional education.

Some may argue the need for a more formal educational program for all specialties. But the modality of wound care and management is ever-changing. An all “boots on the ground” approach is needed to assist patients onto the path of healing. The Association for the Advancement of Wound Care (AAWC) is available to those in the healthcare field with a mission to assist persons with wounds and identification of at-risk persons. Ongoing educational programs are held in various forms to foster new advances in this area of wound care to those who are at the bedside, research, or any aspect of care.

For the reader, I ask, what led you to this pathway? Was it a specific patient or the types of patients seen with chronic wounds? Was your area of expertise in business management or research which caused you to discover your pathway? The development of your concern for wound care and healing may provide endless areas of discussion. As you go about your day, week, month, and years in the subject of wound care and healing, please remember the passion which placed you in this needed field of care.

Say Goodbye to Wet to Dry

Despite the vast amount of advanced wound care products available as well as an evidence-based practice that supports wet to dry dressings are substandard, I still receive daily calls from clinicians reporting new wound care orders for wet to dry dressings to be performed in the home setting, usually twice daily.

What exactly is a wet to dry dressing?

A typical wet to dry is a saline moistened dressing, which is placed in the wound bed. It is left to dry and removed usually every 4 to 6 hours. Removing this dried gauze acts as a mechanical debridement agent.

Now let’s discuss what happens to and in the wound with this removal process. 

First, non- selective mechanical debridement. When that dry gauze is pulled from the wound bed, it also pulls any tissue that has adhered during the drying process. Often it is newly formed, healthy viable tissue that is removed, causing trauma and/or bleeding to the wound bed as well as increased pain for the patient.

The second thing that occurs is local tissue cooling. Wounds are very picky about the climate of the environment in which they can heal. Cells tend to do their best work at a normal body temperature of 98.6 F. When the wound temperature decreases, it may take up to 4 hours to return to an optimal temperature. During this time, healing stops. Therefore, the more frequent dressing removal, the less time the wound is healing.

Finally, the risk of infection is greater with wet to dry dressings due to strands of gauze that maybe be left in the wound. The local tissue cooling discussed above leads to vasoconstriction and lower oxygen amounts being delivered to the tissue, which also increases susceptibility to infection.

Shying away from wet to dry dressing can lead to decreased healing times, decreased infection risk, decreased over-utilized home health visits, as well as decreased pain with dressing changes which may increase compliance.

When discussing why wet to dry dressings are not the standard with providers who tend to write for wet to dry dressings exclusively, I have found discussing the topics above has allowed me to further educate on the products available to provide a moist wound environment, therefore increasing healing rates. As the saying goes, a little extra knowledge goes a long way.

 

A Cut Above: Ensuring Mobility Isn’t Hindering Healing

I am that person, the one who is thrilled the more challenging the wound looks. But I guess we all are, right? That is what has brought us together, this group of people who have never met, we are all connected through one simple thing, a passion for those hard to heal wounds. Unfortunately, we likely all have had those wounds that we have tried hard to heal and failed. That’s right, I have failed, we all have. I wish I was perfect; I wish I got it right from the start every time, but I don’t. It’s these really difficult wounds that help us grow as practitioners and I hope that as I share my mistakes with you, you don’t have to make them as well.

Let’s go back a few years. I am a new practitioner, excited to go into the wound care world and ready to fix everyone, or so I thought. I knew I would specialize, eventually, but I had my doctorate and I wasn’t going to wait to change the world. I noticed right away that I was having difficulty healing those pesky foot wounds. You know the ones—on the fifth metatarsal head or the tips of the toes. I was using the right dressings and I thought I was offloading appropriately, but I still couldn’t get them to heal. Skip ahead a few years, and I now realized I was forgetting a very important part of it all – understanding what was causing the wound in the first place. Perhaps they had decreased first toe extension, leading to a change in their pressure distribution; I would forget to address that, thus doing a disservice to my patient.

Now, when I treat a foot wound, the first thing I do is check their 1st digit extension and dorsiflexion mobility. It has significantly decreased the healing time for my patients. I look at the callus formations on their feet as this is an easy way to see where they are getting high pressure and shear. These calluses may not be the site of a current wound, but they are sites for potential wounds in the future. If I can change their mechanics to prevent further breakdown, of course, I am going to! 

Let’s look at how these changes in mechanics change the pressure through our foot. With normal gait, we start with our heel strike, then roll through our foot, at which point we start dorsiflexing to about 15 degrees. At the end of the stance phase, our ankle starts to plantarflex, and our 1st toe must extend 60 degrees. When all of these components are working, we distribute pressure through the foot the way our body was designed to do; i.e. no wounds. The moment we remove or change a component of this pattern, we must compensate to complete the stance phase, thus changing our pressure distribution.  For example, when a patient has limited dorsiflexion, they may roll through the outside of their foot rather than through the first toe at the end of the stance phase, leading to increased pressure at the fifth metatarsal head. Or maybe they compensate by externally rotating their hip; this is going to increase the pressure at the first metatarsal head. These changes are common with diabetic patients due to glycation of the ankle joint and thickening of the Achilles. When you combine increased pressure and repetitive stress, a wound is going to occur.  If we do not address these orthopedic issues, we will have a difficult time healing the wounds and leave our patients at risk for developing the same wound again and again.

Once you have decided that your patient has decreased mobility, the next stage is treating it. The simplest way to increase mobility is to stretch the structures, but oftentimes this alone is not enough due to the soft tissues not being the only structures limiting motion. Despite this, I do give the patient some ownership of the issue by having them stretch at home. The best results for stretching would be a 90-second hold, 1-2 times per day, if the patient can tolerate it. Which stretch do I have them do? It depends on the patient and what they can do; I might have them do a standing gastric soleus stretch or one with a belt. If they have the mobility, I will have them manually stretch their toe into extension, if they don’t, I might recruit their caregiver to assist. As with any treatment, we must tailor it to our patients, their needs, and their abilities. Generally, I will also incorporate joint mobilizations and soft tissue work in the clinic to work towards improved mobility. I also give the patient strengthening for their foot intrinsic musculature, as deterioration often occurs in conjunction with the aforementioned issues. Unfortunately, these changes don’t happen overnight and you must have something in the interim for offloading. For me, Dr. Jill’s Offloading Felt has been a lifesaver, with my preference being the ½ inch felt. One side is adhesive, and you can stick it right to the foot so there is no need for the patient to adjust it or concerns of it shifting on the insensate foot. I cut out a piece the size and shape of the patient’s foot, as well as an additional cutout to offload the wound. There are a few downsides, you need to have good scissors and strong hands as the felt are not easy to cut. With an additional half-inch of material on the bottom of their foot, getting shoes on can be difficult as well.

There will be patients that we cannot get their mobility back for various reasons. I had one patient with a wound on his first metatarsal head who had a fused 1st toe and neurological damage that led to a very stiff ankle. With him, I enlisted the help of a prosthetist to help create a device that would offload the foot. Over time, the prosthetic created new pressures and new wounds, so we instead transitioned to a custom orthotic with a plastizote lining and cut-outs to offload the area. I have also seen numerous patients over the years who have a deformity that is no longer mobile; I see this frequently with claw toes. I am lucky enough to work in an orthopedic clinic with multiple surgeons who can assist me with these patients that may require a surgical cleanup of the joint, lengthening the Achilles, or techniques that may be outside of my scope.

Please don’t repeat my mistakes.  Ensure that each patient who walks through the door with a foot wound has their foot mobility checked. You will see a change in the way you practice and how easily your wounds heal.  Apply these principles, and you will be “a cut above” the rest.

Tag! You’re It!

Nursing homes are among the most tightly regulated institutions, and any healthcare provider in this setting knows the dreaded F-word…F-tag. (Insert shudder here). Regarding wound care, what used to be F-tag 314 is now F-tag 686. Within the 749 pages of the State Operations Manual Appendix PP – Guidance to Surveyors for Long Term Care Facilities, Section 483.25(b) Skin Integrity with 483.25(b)(1) Pressure Ulcers involves twenty pages of explanation. The good news: CMS typically utilizes the terms and definitions established by the National Pressure Ulcer Advisory Panel (NPUAP) and implements those terms and definitions into the Minimum Data Set (MDS). The bad news: Not understanding and following the guidance could be costly.

One of the most critical actions a healthcare provider in long-term care can take is to proactively document all aspects of wound management. Aside from knowing that wound documentation is required at least weekly and having a wound sheet, there are additional aspects of the regulations to know and understand in order to ensure compliance. Several will be highlighted in this blog.

  1. Concisely document how wound healing is impacted by tissue perfusion, nutritional status, co-morbidities, inflammation, and age, among other factors4. For example to address one section under 483.25(b)(1) which reviews modifiable and nonmodifiable risk factors that “…increase a resident’s susceptibility to develop or to not heal pressure ulcers…”, wound documentation should specifically identify and discuss factors that are present that potentially impede wound healing such as arterial disease, diabetes, end-stage renal disease, medications, etc.).

  2. Wound documentation should review both the patient’s prognosis as well as the wound prognosis. For example, under Nutrition and Hydration, the 483.25(b)(1) regs state, “continuing weight loss and failure of a pressure injury to heal despite reasonable efforts to improve caloric and nutrient intake may indicate the resident is in multi-system failure or an end-stage or end-of-life condition warranting an additional assessment of the resident’s overall condition.” Describe how wound healing is impacted by a patient’s end-stage disease that requires a more palliative approach. A great phrase to utilize in documentation is “delayed wound healing expected” with a succinct but clear explanation. Residents with advanced dementia are expected to lose weight as the disease progresses. It is important to connect how advanced or progressive illnesses (i.e., end-stage dementia) impact wound healing for the surveyors. In addition, collaboration with the dietitian to follow the American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines, as well as patient-centered nutritional goals, are valuable components in wound documentation.

  3. Document and describe pressure injuries that occur at the end of life and the Kennedy terminal ulcer (KTU). Powerful pieces of documentation include the location and appearance of the KTU, that appropriate preventative measures were in place, and that the KTU appeared suddenly, within hours. The website, kennedyterminalulcer.com is a great website for further information on this condition. Though skin failure and other end of life skin conditions are not listed or described (example: 3:30 syndrome or Trombley-Brennan terminal tissue injury), surveyors do have two paragraphs explaining potentially unavoidable pressure injuries. As the regs state, “it is important for surveyors to understand that when a facility has implemented individualized approaches for end-of-life care in accordance with the resident’s wishes, the development, continuation, or worsening of a pressure injury may be considered unavoidable.” Thus it is critical to explicitly describe in the medical record the wound, its healing potential, and all factors that contribute to or impede wound healing. NPUAP supports not turning residents every two hours at the end of life, emphasizing the importance of documenting why…that turning causes more distress and pain and is not beneficial for comfort at the end of life.

  4. Documentation should clearly how “resident choices” impact the appropriateness or feasibility of interventions and wound healing. The section, “Resident Choices,” describes how care plans should establish relevant goals and interventions for pressure injury management. In addition, facility staff and practitioners should document clinically valid reasons why an intervention may not be appropriate or feasible. For example, when a patient chooses to smoke despite education on the detrimental effects of smoking on wound healing, the healthcare provider should objectively document that education was provided, that the patient comprehended the education and has chosen to continue to smoke. As an example: “Delayed wound healing expected due to smoking, which causes vasoconstriction and reduces blood flow to the extremity.” The resident has every right to continue smoking. The provider also should absolutely provide the standard of care. The treatment plan will then need to be developed based on the patient’s preference, the goals of care, and what fiscally makes sense.

  5. Time parameters reflecting the duration of the activity, sitting schedules and progress toward healing should also be documented. The 483.25(b)(1) regulations include comments on specific time recommendations. For example, under “Healing Pressure Ulcer/Injuries”, the regs state, “residents with pressure injuries on the sacrum/coccyx or ischia should limit sitting to three times a day in periods of 60 minutes or less.” Therefore, documentation should include when the patient is in bed and that the patient is in a less than 90-degree position when in the chair or bed. There is wiggle room in the regs that allow for modification of sitting schedules per patient/family preference. Another time interval to be mindful of within the regs: “if a pressure injury fails to show some evidence of progress toward healing within 2-4 weeks, the area and the resident’s overall clinical conditions should be reassessed. Re-evaluation of the treatment plan includes determining whether to continue or modify the current interventions.” A thorough wound evaluation also includes the rationale for the treatment plan, especially when the wound does not appear to be improving using the current treatment plan.

Extra time documenting goes a long way to avoid F-tags, litigation, etc. Wound care is an interdisciplinary effort. Nursing should not be the only profession commenting on pressure injuries (or other wounds for that matter) in nursing homes. Physicians, advanced practice providers, therapists, dietitians, and nursing staff should all be looking at the wounds as well as documenting them. In addition, there should be a consensus on the staging and periodic discussions to ensure everyone is on the same page and agrees with the staging and plan for the pressure injury. Lastly, be consistent with terminology in the documentation. Call a spade a spade…if it’s due to pressure, then it is a pressure injury, and everyone should describe it as such. The F-word (i.e. F-tag) does not have to be a dirty word in long-term care if the team is documenting appropriately.

Take Advantage of BIG LEx Savings

Save $75 on AAWC’s Lower Extremity Summit (LEx), November 2-3, at the Sheraton Grand Sacramento Hotel. Register to save and benefit from educational sessions lead by a multidisciplinary team of practitioners with years of wound care experience.

Take advantage of our Flash Sale!

 Register with 
SAVE75 for $75 off 

Educational sessions will be presented by a multidisciplinary team, including:

 

Kim Thomas, DNP, is an Advanced Registered Nurse Practitioner and works at the University of Washington Health-Valley Medical Center. Kim has 20 years of experience in lower extremity wound care and nursing and has been an Advanced Practice Nurse since 2010. Her specialties include Wound, Ostomy, and Continence Nursing. 

 

 

 LEx Educational Sessions lead by Kim include: 

    •  Wound Care Work Up: The Basics

    •  If it Quacks is it a Duck? Atypical Wounds

 

 

James McKee, DPM, is a surgical podiatrist with MultiCare in Washington State where he works in a hospital-based clinic to facilitate limb-salvage in a high-risk population. Dr. McKee completed his residency in podiatric medicine and surgery (PMS-36) at Puget Sound VA in Seattle, Washington where he focused primarily on diabetic and limb-salvage medical and surgical treatments.

 

LEx Educational Sessions lead by Dr. McKee include: 
•  Wound Bed Preparation: Debridement: The Art Form and the Science
•  When Do You Call the Surgeon - Surgical Interventions?

 

William Tettelbach, MD, is a certified wound specialist who is actively board certified in Undersea & Hyperbaric Medicine, Infectious Diseases, Internal Medicine with formal training in Biomedical Informatics. Dr. Tettelbach is currently the acting Associate Chief Medical Officer for MiMedx Group, Inc. and is the Medical Director of Wound Care, Antibiotic Stewardship, and Infection Prevention at Promise Hospital.

LEx Educational Sessions lead by Dr. Tettelbach include: 
   •  Confucius Say - All mixed up! Wounds with Mixed Etiologies
   •  Bioburden Continuum 2: Systemic Infections, Antibiotic Stewardship

LEx is accredited for Physicians through ACCME and for Nurses through ANCC and Texas Physical Therapists. For more information, or to view details on accreditation for podiatrists, please click here


Have questions or inquiries? Please contact [email protected].

Meet AAWC’s 2019 Board of Directors Election Candidates!

AAWC Board of Directors election is right around the corner. Before voting opens on Monday, October 14, 2019, we invite you to learn about the 18 candidates who are running to help lead the future of AAWC. At its core, AAWC is a multidisciplinary organization that champions the four pillars of education, public policy, research, and infrastructure to support wound care patients, researchers, advocates, and practitioners of all specialties. The AAWC Board of Directors serves to advance the initiatives of the AAWC which are focused on the strategic plan consisting of the four pillars.

This year’s candidates have a variety of professional backgrounds and skills, reinforcing the dynamic team approach that AAWC is founded on. On the elections webpage, each nominee describes how their qualifications align with the four pillars and their plans to support the Board in its efforts to meet AAWC's strategic objectives. Candidate’s credentials, years of AAWC membership, and CV are also available.

 “2020 is going to be a pivotal year for AAWC. Strong leadership is essential to carrying out a successful strategic plan. I am confident we have a highly proactive and experienced selection of qualified candidates. In the coming weeks, I encourage everyone to take the opportunity to get familiar with the Board of Directors candidates and vote.” Victoria E. Elliott, RPh, MBA, CAE, chief executive officer, Association for the Advancement of Wound Care.

Voting for AAWC’s Board of Directors ends on Sunday, November 10, 2019. Support the success of AAWC through participation in the upcoming election. Every voice counts in the direction and leadership of AAWC, the premiere voice of wound care.

Candidates include:

  • Industry
    • Matthew Davis RN, CWON, CFCN
    • William Tettelbach MD, FACP, FIDSA, FUHM, CWS
  • Nurse
    • Jacalyn Brace Ph.D. ANP-BC RN-BC WOCN
    • Maria Luisa Faner DNP, APRN, FNP-C, CWS
    • E. Lynette Gunn APRN, GCNS-BC, CWCN CFCN
    • Victoria Nalls GNP-BC, CWS, ACHPN
  • Physical Therapist
    • Rose Hamm PT, DPT
    • Marta Ostler PT, CWS, CLT, DAPWCA
    • Brandy Rose PT, DPT, CWS
  • Physician
    • Ali Bairos MD, CWSP, FACCWS
    • Jonathan Johnson MD, MBA, CWSP
    • Naz Wahab, MD
  • Podiatric Physician
    • Marcela Farrer DPM, MBA, CWS
    • Marc Jones DPM, FACFAOM
    • Jared Shippee DPM, DWC, WCC, PCWC, FAPWCA
  • Research
    • Alisha Oropallo, MD
    • Nicola Waters Ph.D., MSc, RN
  • Secretary, Executive Committee
    • Kara Couch MS, CRNP, CWCN-AP

Learn more about each candidate by clicking here. For more information visit AAWC.

 

Unlocking Resources for Wound Care Teams: Tips for Demonstrating Value

Members of AAWC are known for top tier commitment, specialization, and passion for wound care. Yet among the greatest of challenges advanced wound care professionals face, one is how to demonstrate and communicate the impact and value provided to administrators and clinicians managing or overseeing multiple clinical services.

After all, it’s only recently that advanced wound care has begun to become recognized as a specialty and service line -- and there is still a long way to go, not only scientifically or clinically.

Getting the proper buy-in, which in turn unlocks resources for staffing, products, technologies, training, and infrastructure, requires more than the ability to deliver evidence-based, patient-centric wound care. While a short post is not enough to tackle this important subject, what follows are some actionable ways to ensure recognized value:

  1. Determine baseline metrics and KPIs (key performance indicators):

    Tracking clinical (e.g. healing rate, healing velocity, average days to heal, etc.), operational (e.g. new patients, visits, cancellation rates, staffing ratios, etc.), and financial (e.g. revenue, expense, profit, cost per dressing change or per healed wound, etc.) metrics and KPIs makes a difference. Starting with baseline historical stats from prior to when the current wound care program (or the new investment in staff, technology, training, etc.) began is a must, though it’s never too late to start. Aside from hospital-acquired pressure ulcers (HAPUs), surgical site infections (SSIs), and a couple others which all are influenced by many factors that can be tough to control for, healthcare administrators - especially in care settings that are not hospital-based - have very little insight into the correct ways of telling whether investments are paying off (or if budget cuts are costing more than they’re saving). Part of delivering wound care is to ensure administrators have the information to make decisions and see the return on investment (ROI) for advanced wound care.

  2. Ensuring a proper organizational and financial structure:

    What is the chain of command for wound care services in each care setting? Is it seen as a function of clinical education? Quality and compliance? A revenue stream? A way to attract patients to the facility? This affects alignment (or lack thereof) with senior administration, key executive goals, and ultimately impacts the availability of resources. Likewise, the smaller the wound care team, the less likely there is to be a separate budget. Tracking an individual and separate budget for wound care apart from ancillary services, nursing administration, education, or other umbrella departments avoids unnecessary politicization and more difficulty/time spent to obtain unique resources necessary for wound care.

  3. Use a dashboard report to regularly share (in person) with institutional administration:

    Once items one and two are in place, it’s important to distill them into a concise dashboard which can be used as a framework for discussions with administration and clinical leadership. Today, there are more tools than ever for tracking and visualizing changes in your data and outcomes over time.

As with many industries, the more senior the executive or administrator, the less familiar management will be with specific challenges and needs. At the same time, they tend to rely more on data (clinical + operational + financial) to gauge whether investments are being deployed in an impactful manner. Whether part of a large clinic or hospital team, or the sole specialist in an SNF or home care agency, the ability to regularly articulate a wound care program’s needs and performance to administration, using real-world metrics, in a relatable and useable form is a key component of ensuring wound care efforts are properly resourced.

About the Author
Rafael Mazuz is the managing director of Diligence Wound Care Global. To contact, email: [email protected].

Practitioners sharpened their wound-healing skills at AAWC Wound Care Tricks of the Trade

As the premier voice of wound care, AAWC offers the hands-on education that elevates a practitioner’s wound care knowledge and skills. Most recently, AAWC held Wound Care Tricks of the Trade on September 11, 2019. This Wild on Wounds pre-conference workshop gave nurses and physicians insider wound care tricks and expert training. View photos here!

The workshop was a day-long educational session lead by seasoned wound care practitioners, Catherine T. Milne MSN, APRN, ANP/ACNS, CWOCN-AP, Kara S. Couch, MS, CRNP, CWCN-AP, and Marta Ostler, PT, CWS, CLT. During the workshop, attendees benefitted from educational sessions and hands-on training that covered:

  • Selecting topical dressings
  • Basic Negative Pressure Wound Therapy
  • Advanced Negative Pressure Wound Therapy
  • Choosing and applying compression
  • Managing Lymphedema
  • Clinical management of diabetic foot ulcers and Total Contact Casting

Each session provided unique “tricks of the trade” including useful tips on how to identify, dress, manage, and treat wounds both quickly and effectively. Throughout the day, seasoned instructors helped attendees navigate difficult wound care choices and learn how to adapt without specific wound care supplies. Towards the end of the program, attendees had the opportunity to learn about Total Contact Casting (TCC). Many nurses performed TCC casting for the first time with guidance on proper procedure and application from AAWC instructors.

Wound Care Tricks of the Trade educational sessions reinforced the idea of creativity. The premise that if a practitioner doesn’t have all the tools, then the solution relies on creativity. Hands-on sessions encouraged attendees to be creative and get in the habit of choosing the best course of action given select resources when practicing wound care.

In addition to hands-on, expert-led training, attendees benefitted from:

  • Registration that included a one-year AAWC membership
    • AAWC members have access to the monthly Journal Club, Trip Database, event discounts, and more
  • The opportunity to earn up to 6.75 ongoing education credits
  • $100 off Wild on Wounds Conference, an exclusive offer for AAWC members 

AAWC has many educational opportunities throughout the year. Near or far, join us for our September Journal Club "A Standardized Approach to Evaluating Lower Extremity Wounds" tomorrow evening, 8:00-9:00 p.m. EST, presented by Marta Ostler CWS, CLT, PT, and Mary Haddow, RN, CWCN. Register to get a unique preview of the topics that will be covered at AAWC’s Lower Extremity Summit (LEx), November 2-3, in Sacramento California.

This year’s Wound Care Tricks of the Trade would not be possible without the generous support from its sponsors.

Thank you, Wound Care Tricks of the Trade Sponsors!
KCI An Acelity Company
Integra Life Sciences
Tissue Analytics
Molnlycke
Prism
Medline

For more information visit AAWC.

 

 

AAWC Town Hall Key Takeaways

The Association for the Advancement of Wound Care (AAWC) is focused on success and stepping boldly into the future. AAWC held a Town Hall live webinar on Thursday, September 5th at 7:30 p.m., eastern time, led by AAWC’s Chief Executive Officer, Victoria E. Elliott, RPh, MBA, CAE. This interactive Town Hall provided a review of the association’s 2019 accomplishments, and a preview into the upcoming initiatives that will enable AAWC to reach its full potential as the leading voice in wound care.

Over the course of an hour, Victoria revealed new meeting opportunities, research initiatives, plans for a robust public policy agenda, and a new program to be launched this fall. Lead by AAWC’s core strategic pillars: Education, Public Policy, Infrastructure, and Research, Victoria discussed how each pillar will be strengthened moving forward.

Last fall, AAWC members indicated they desired more initiatives in education, impact on legislation, research to improve the patient care, and an increased AAWC presence. Victoria spoke to the programs and opportunities that will fulfill the needs of our association’s members.

In terms of education, AAWC offers a monthly Journal Club and regional educational programming. This year, AAWC offered a Pressure Ulcer Summit, two Wound Infection Summits, and has scheduled a Lower Extremity Summit that will take place November 2-3, in Sacramento, California. Looking ahead, AAWC will host its 3rd Annual Pressure Ulcer Summit tentatively scheduled for early February, introduce new Summits in 2020, have new journal club offerings, and provide more online professional development opportunities.

AAWC members received additional educational benefits this year, including:

• A complimentary copy of the WoundSourceTM 2019 publication
• Member-only access to Trip Database, an online clinical search engine 
• The opportunity for cross-certification in wound care through an ABWH certification conferment

The association is also involved in an international capacity as well. This year, AAWC had its first-ever exhibit booth at the European Wound Management Association’s annual meeting in Gothenburg, Sweden. AAWC is also a supporting society of the World Union of Wound Healing Societies and will be supplementing next year’s WUWHS conference in Abu Dhabi with a panel of AAWC wound care experts and a pre-conference workshop.

AAWC is passionate about its public policy pillar. In 2019 AAWC meet with former representative Jack Kingston, and his staff at Squire Patton Boggs, to discuss how to leverage its position in the wound care arena and mobilize a public policy agenda, especially as it relates to pressure ulcers. Additionally, President-Elect Ruth Bryant met with a number of House and Senate offices to educate lawmakers on the need for increased prevention of pressure ulcers for our nation’s veterans. As a commitment to making meaningful change, AAWC continues to be an active member of the Alliance of Wound Care Stakeholders.

This year, AAWC has strengthened its infrastructure by partnering with MCI USA. The new management partner brings over 30 years of experience to AAWC with expertise in the medical sector. MCI USA will assist AAWC staff and leadership in efforts to improve member engagement, expand educational initiatives, and strengthen AAWC’s position as the premier voice for wound care professionals. AAWC has also redesigned the board-approved nominations process, yielding numerous new candidates for the 2020 Board of Directors. Elections are scheduled to open on Monday, October 14, 2019.

As science and technology rapidly evolve, AAWC is committed to investing in research initiatives that will benefit members. AAWC is working to create a research agenda based on identified gaps in summits, a toolkit for developing a clinical question, a three-part education series on research project development and a task force to solidify a global common data set. Research work will also continue on the development of the Pressure Ulcer Description Tool.

Towards the conclusion of the meeting, Victoria announced plans for a new membership recognition opportunity: the AAWC Fellowship Program. This unique designation will be of great value for AAWC members where credentialing holds specific importance in career work.

AAWC’s future is brighter than ever before. The Town Hall confirms that plans are set in motion to have a strong finish to 2019 and an even brighter beginning to 2020. An AAWC membership holds incredible power, value, and commitment to outstanding patient care and best practices in the wound care space. The coming months and years are only the beginning of the incredible difference AAWC will make as the premiere voice of wound care. 

AAWC members can access the full September 11, 2019, Virtual Town Hall recording by clicking here. 

Wound Healing from the Sidelines The Role of the Periwound

When fans take the stands and players take the field at sporting events, the focus tends to be on the pitcher, the quarterback or the goalie. A win or a loss begins with these positions. The arena for wound treatment is not very different. The eyes of the care providers tend to go direct to the center of the wound, the wound bed. But the action on the periwound or the wound sidelines can make a difference in how rapidly the patient may heal.

The periwound offers key information crucial to overall wound healing. Following these recommendations can make the wound care team take home a win.

Maintaining the moisture balance of the periwound is essential to wound contraction and epithelialization. If the skin around the wound is too wet, the epithelium cannot crawl across the wound bed and the wound cannot contract appropriately. 

Heavy moisture is an indicator of other issues such as venous insufficiency in a leg wound, an unaddressed bioburden causing heavy exudate, systemic fluid overload, or a primary dressing that is perhaps creating an inappropriate moisture balance for the wound.

Once adequate arterial flow to lower extremities is confirmed, compression can be utilized to help with edema to periwound skin. A liquid adhesive can be applied to protect the periwound skin and will control maceration. Removal of the callus ring enables visualization of the real periwound and minimizes pressure, and using a dressing with more moisture helps wounds that are dryer.

Bioburden is a factor in any wound healing, particularly in the perineal areas or the feet. A foul odor from the wound is a hint of a bioburden. Sharp debridement and physically breaking the biofilm then dressing the wound with an antimicrobial dressing can help optimize wound healing after the biofilm is broken.

If bioburden has been ruled out and the periwound is red, other factors are at play. Offloading pressure and reducing friction even when it is not the primary etiology can help. 

Necrotic tissue in the periwound or wound bed that is resistant to treatment may indicate cancer or autoimmune disease. Though rare, these should not be discounted. A biopsy can provide answers.

Necrosis also can be caused by arterial insufficiency from large or small vessel disease. A toe brachial index in addition to an ankle brachial index can reveal the problem and potential for healing.  Particularly with foot wounds, small vessel disease requires a lower level of negative wound pressure therapy so there is no clamping of the periwound small vessels.

Edema is another consideration. Localized edema treatment is more effective once the patient is euvolemic. With lymphedema, specialists are required to assure the proper treatment.

Crunchy sounds caused when there is gas under the skin is called crepitus, and it is an emergent condition. It can indicate gas gangrene, requiring systematic antimicrobial therapy and possibly surgery. Fluctuance, or sensation of a pocket of fluid trapped in the tissues in either the periwound or under the wound itself, with or without erythema, may require surgical intervention.

Epibole Is when the periwound curls in. In a healthy periwound, epithelial cells should be observed as moving across the wound bed. If they have stopped or the periwound is curled in, something is preventing normal contraction and epithelialization from happening. Scraping the curled area with a curette and then treating with an advanced dressing and an antimicrobial component will disrupt the potential biofilm as well as help correct the defect.

Like other players on a sports team, the periwound may not be the central attraction. But what it does and how it plays impacts the healing of a wound as much as the other players impact the outcome of the game. The periwound needs to be evaluated with the wound bed, treated at different stages of healing, and supported as it plays its crucial role in the wound healing challenge.

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