Working with the wounded returning from Afghanistan during 2009 through 2011 was extremely challenging.  The wounds I saw during this time were the worst I had seen since arriving at National Naval Medical Center (NNMC), Bethesda in 2007.  The reason was partly due to the mission modification in Afghanistan by the US military in late 2009, when the Marines and Army began to engage in “dismounted” patrols or walking patrols versus patrolling in armored vehicles.  They were exposed and thus more susceptible to injury from improvised explosive devices (IEDs).  Their injuries were likely to be catastrophic because the enemy employed a technique that caused an IED to explode as the Marine/Soldier was standing directly over the device.  The explosions were devastating - these IEDs caused significant soft-tissue injuries and multiple amputations.  The force of the blast drove sand, dirt, debris, and organisms deep into the tissues, causing additional complications.

At NNMC and Walter Reed Army Medical Center (WRAMC) the typical method for managing these catastrophic wounds included serial debridements and washouts in the OR followed by the application of negative pressure wound therapy (NPWT) using reticulated open cell foam dressings (ROCF).  At that time, the trauma teams exclusively used the ROCF dressings containing silver due to their antimicrobial properties.  However, in late 2009 the manufacturer of the ROCF dressings notified us that these dressings would not be available for at least six months.  Because of the complexity of these wounds and the high potential for infection an alternative solution was needed immediately.  We began placing thin layers/sheets of silver impregnated dressings directly in the wound bed and then applying the ROCF dressing on top.  This practice seemed to be effective but not ideal - the application process was more complicated because it was difficult to get good coverage with the silver sheet dressings.

Soon after the silver impregnated ROCF dressings were no longer available we were faced with another issue.  Combat-wounded patients began developing angio-invasive fungal infections (Aspergillus) from the soil imbedded deep in the tissues of their wounds. The next challenge was to implement a therapy that would support NPWT and provide topical antibacterial and antifungal coverage.  Our topical wound therapy included NPWT with the instillation of antimicrobial fluid directly into the wound.  Since this therapy was not frequently being used at this time, it was difficult to find more than a couple of the NPWT units equipped with this function available for use.  The next challenge was to select the appropriate solution as it needed to be antibacterial, antifungal, and non-damaging to healthy wound tissue. 

Our research led us to use a dilute Dakin’s solution of 0.025%, and the initial results were very positive.  Prior to using the Dakin’s instillation with NPWT we would observe black mold growing in the wound as soon as 2-3 days after a debridement and washout.  After initiating the Dakin’s solution as an instillation during NPWT, we no longer saw the black mold within the wound bed.  The treatment was so effective that NPWT with instillation (NPWTi) of dilute Dakin’s became the standard of care for our combat-wounded with complex soft-tissue injuries.  Additionally, the Clinical Practice Guideline for initial management of blast injuries with significant soft-tissue injury and suspected fungal infection was changed to include the use of 0.025% Dakin’s solution moistened gauze as the preferred initial dressing after debridement in the combat theatre.

We typically performed (NPWT) dressing changes 3 times a week during trips to the OR while the patient was undergoing debridements and washouts.  We found that this worked best as the wounds were very large and anesthesia was necessary.  We decreased to twice weekly as the wounds improved and the mold growth decreased.  The surgeons typically used the 0.025% Dakin’s solution until they were ready to perform a skin graft.  This time period varied from 2 to 3 weeks depending on wound progression and tissue cultures.  These wounds were heavily contaminated and often were associated with traumatic amputations.

It is important to see the recent increased attention given to the use of negative pressure wound therapy with instillation in both traumatic and chronic wounds.  The lack of availability of those silver dressings had a far-reaching impact on our care of the combat-wounded as well as future civilian wound care

CDR (Ret) David Crumbley was the Coordinator for the Complex Wound and Limb Salvage program at Walter Reed National Military Medical Center from 2008-2011.  He is currently Professor of Practice at Auburn University School of Nursing and continues to practice wound care at Baptist South Medical Center, Montgomery, Alabama.

Today, we will discuss seven WFPB nutrition tips that apply to wound care and the role of the wound care physician/practitioner in caring for a patient with a disease that can be complicated by poor diet and lifestyle habits. While reading today, take the time to reflect on what obligations we have toward those who are at risk but have not sought our help. Any wound care practice must be evidence-based. Just as prescribing services must be founded on solid evidence, the same is true for dietary advice.  Was there a sincere evaluation of the patient's nutrition status? What should be done next with this information? Should time be spent reviewing articles to place in your personal armamentarium?  Primary care physicians do not perform general surgeries or run  urinalysis; neither do they need to do their own diet counseling. That is the job of a qualified dietitian/nutritionist. The wound care practitioner simply needs to know that nutrition is important, wound healing nutritional deficiencies need correction, and clear communication with the patient is imperative, while providing a solid referral to other interdisciplinary professionals.

TIP #1: The building evidence of a healthy diet
What type of diet is recommended for a patient with a wound?
With accumulative scientific evidence supporting a healthy diet, whole-food plant-based (WFPB) diets are steadily on the rise. A WFPB diet consists of vegetables, fruits, legumes, whole grains, nuts, seeds, herbs, and spices. The United States Department of Agriculture, American Heart Association, American Institute for Cancer Research, National Kidney Foundation, and American Diabetes Association all promote WFPB diets, and it doesn't have to be an all or nothing.  Evidence-based studies show a positive correlation between WFPB diet compliance and overall well-being.

TIP #2: WFPB benefits
Why are WFPB diets becoming more popular? 
Aside from improved healing with proper nutrition, what benefits are there to my patient? WFPB diets are associated with:

1. Lowering overall mortality
2. Lowering ischemic heart disease mortality
3. Supporting a healthy weight
4. Reducing medications
5. Reducing obesity
6. Reducing obesity-related inflammatory markers
7. Reducing hyperglycemia
8. Reducing hyperlipidemia
9. Reducing hypertension
10. Reversing advanced cardiovascular disease
11. Reversing Type 2 Diabetes.
    
    

TIP #3: Protein
Can the protein needs of wound and geriatric patients be met with WFPB diets? 
Absolutely! The primary food sources for proteins are legumes (beans, lentils, peas, peanuts), nuts, seeds, and soy foods. Poor appetite and poor dentition are complications with geriatric wound care patients, making meat alternatives, such as smoothies, cooked cereals, lentil or bean-rich soups, and spreadable hummus nutritionally dense additions to their diets. Nevertheless, one must remember to temper the increased desire for a high protein wound care diet and the need to satisfy a low protein diet in chronic kidney disease patients, especially CKD Stage II and Stage III. This is similar to the scenario of a patient with severe lymphedema, aggressive congestive heart failure, or pulmonary edema.

**Brenner BM. Remission of renal disease: recounting the challenge, acquiring the goal. J Clin Invest. 2002;110(12):1753-1758. doi:10.1172/JCI17351

TIP #4: Vitamin B12
Will you have to supplement vitamin B12? 
Yes! Numerous research studies demonstrate vitamin B12 supplementation in metformin-treated type 2 diabetes patients is beneficial in order to prevent the occurrence of vitamin B12 deficiency complications.  Deficiency in the elderly population is high due to inadequate intake and malabsorption. Treatments are safe and effective for adults over 60 years, regardless of their diet. Vitamin D should also be supplemented if sun exposure is not a viable option for patients.

**Goraya N, Munoz-Maldonado Y, Simoni J, Wesson DE. Fruit and Vegetable Treatment of Chronic Kidney Disease-Related Metabolic Acidosis Reduces Cardiovascular Risk Better than Sodium Bicarbonate. Am J Nephrol. 2019;49(6):438-448. doi:10.1159/000500042

TIP #5: Nutritional Drinks
Are commercial products the only option for complete nutrition, muscle loss prevention, and wound care healing? No. Therapeutic nutrition drinks and powders have been shown to support wound healing clinically. However, eating a balanced diet high in fiber and low in animal proteins has shown to support wound healing.  For example, pumpkin seeds have one of the highest concentrations of arginine. Other foods are sesame & sunflower seeds, and tree nuts, which all have high omega-3 fatty acids. Another supplement frequently added to nutritional drinks is beta-hydroxy-beta-methyl butyrate (HMB). But is it necessary?  HMB on exercise performance and body composition did not make a difference when comparing whey, soy, or leucine-enriched soy protein. HMB helps with slowing age-related muscle loss (sarcopenia). How do you balance supplements versus instructing patients to eat healthier with a soy product?

**Wilson GJ, Wilson JM, Manninen AH. Effects of beta-hydroxy-beta-methylbutyrate (HMB) on exercise performance and body composition across varying levels of age, sex, and training experience: A review. Nutr Metab (Lond). 2008;5:1. Published 2008 Jan 3. doi:10.1186/1743-7075-5-1

TIP #6: What about fats? 
A high-fatty diet and alcohol consumption delay the healing process by decreasing stimulation of collagen synthesis and reduction of granulation tissue and reepithelialization. Diabesity is the worldwide twin epidemics of obesity and diabetes. The American Heart Association recommends limiting saturated fats to less than 14 grams in a 2000 calorie daily diet. By the way, trans fats have been banned in the United States since 2018, with an extended compliance date for these foods until January 1, 2020. 

Monounsaturated fat (MUFAs) and polyunsaturated fats (PUFAs) are associated with lowering blood pressure, improving blood cholesterol levels, and decreasing the risk of heart attack and stroke.  Omega-6 PUFAs have a particular role in the structural integrity and barrier function of the skin. Omega-3 PUFAs give aid in signaling molecules that influence the inflammatory response in the skin, while MUFAs aid in angiogenesis and aid in the regulation of insulin levels and blood sugar control. 

Eating a colorful variety of WFPB foods promotes a large variety of micronutrient exposure, antioxidants, and other cellular regulatory properties such as vitamin C, calcium, iron, vitamin K, selenium, zinc, and healthy MUFAs & PUFAs. Nothing new here.  

TIP #7: Got a fiber gap?
Currently, only 5% of the United States population meets the daily target of 25 grams of fiber for women and 38 grams of fiber for men. The benefits of prescribing a high fiber diet are correlated with a reduction in comorbidities for patients with wounds. However, how does a high fiber diet help wound care patients? Well, gut bacteria of vegans produce neuroactive molecules like gamma-aminobutyric acid (GABA) which in turnreduces the stress response in humans, along with decreasing cortisol levels. GABA also counters high glucocorticoid levels, which impair wound healing. Overall, WFPB high fiber diets modulate GABA, which regulates blood pressure and heart rate, influences GI motility, and plays a role in anxiety, depression, pain sensation, and immune response.  Emotionally happy wound patients with reduced stress heal faster. 

**Briguglio M, Dell'Osso B, Panzica G, et al. Dietary Neurotransmitters: A Narrative Review on Current Knowledge. Nutrients. 2018;10(5):591. Published 2018 May 10. doi:10.3390/nu10050591

**Ebrecht M, Hextall J, Kirtley LG, Taylor A, Dyson M, Weinman J. Perceived stress and cortisol levels predict speed of wound healing in healthy male adults. Psychoneuroendocrinology. 2004;29(6):798-809. doi:10.1016/S0306-4530(03)00144-6

Finally, the wrap-up,  I hope this stimulates your view into the world of nutrition, WFPB, and patient care. Jump into your research and become a student in the adventure toward better patient care. None of the information is new, but the POV might be. History has taught us that Occam's razor or law of parsimony states, "plurality should not be posited without necessity" --  translation -- The state of fact should not be assumed as a fact.

It's all about the simplicity of two competing theories; the simpler explanation of an entity is to be preferred. 

Unhealthful eating habits affect the whole family. Medications are no substitute for dietary interventions.

Gauze and Chicken Divan have some commonalities: both are easy, quick, inexpensive, and have French connections-- which somehow makes both seem perhaps better than they really are. But both Chicken Divan and gauze may be too easy and as such, create an unwillingness to try something new.

It was the Ancient Egyptians and Greeks who first used woven fabric as bandages for wounds thousands of years ago. However, the continued use of gauze is far more based on tradition than on its functionality. Ancient Egyptians were familiar with the classic signs of infection; however, it was not until the nineteenth century work of Louis Pasteur and Robert Koch that the link was made between infection and specific pathogenic microbes. Then, it wasn’t until the 1978 work of JW Costerton that the biofilm paradigm was discovered, named, and defined by this pioneer.  Ongoing research is now showing that effective treatment of a chronic wound requires aggressive treatment of biofilm.

The French connection comes from the French word “gaze” which means gauze and is linked to the concept of gazing through a gauze veil. It is this lattice work which allows bacteria to penetrate up to 60 layers of gauze. Further the gauze itself is a breeding ground for bacteria, allowing maturation of biofilm within access of host nutrition but above and separated from action of host immunity. Bacteria can be up to 1000 times more tolerant to antimicrobial treatment than planktonic/free floating microorganisms. The recalcitrance of biofilm cannot be effectively addressed by a simple gauze sponge therefore more advanced modalities must be added to routine treatment options. 

When it comes to topical wound and post op incisional management, gauze is used far too often. It is no longer considered the standard of care as a primary wound dressing. So why does it remain the go-to, top drawer tool for wound care providers? A simple answer is that wound care is not taught routinely in medical and nursing schools. Therefore, many providers are not aware that the science and practice has advanced to more sophisticated wound dressings which treat patients more effectively. There are times when gauze is exactly the right option. However, It can also be labor intensive, require ongoing monitoring and frequent change, can be painful to remove, can leave pieces behind in the wound, and increases the bacteria and bioburden in the wound area.

There are thousands of other options available and there are multiple options for each stage of wound healing. Some kill bacteria-causing infection and include antimicrobial agents. Others have electronic sensors that can indicate changes in the wound as it heals. Some are skin substitutes, others are regenerative material. These can decrease healing time, be cost effective, and improve a patient’s quality of life.

The current challenge is in selecting from among these myriad options. The acronyms NERDS & STONEES help with that determination. NERDS for Non-Healing, Exudate, Red Friable Tissue, Debris/Discoloration, and Smell; STONEES for Size Increasing, Temperature Elevation, OS (probe to bone), New Breakdown, Erythema/Edema, Exudate, and Smell. Is it topical? Or is systemic treatment necessary? Each wound requires careful assessment to determine proper care.

Like medicine and wound care, treatment options evolve and improve. Gauze, like Chicken Divan, is likely to remain an option in the arsenal of wound care. But like other recipes, it is no longer the only choice and wound care must continue to provide the highest level of evidence-based care to patients.

How to Achieve Complete, Accurate Documentation

Elizabeth E. Hogue, Esq.
Office: 877-871-4062
Fax: 877-871-9739
E-mail: [email protected]
Twitter: @HogueHomecare


Complete, accurate documentation is paramount in health care!  Practitioners can’t achieve quality of care for their patients without it. Licensure and certification depend upon it.  It’s necessary for payment.  Avoiding possibly devastating results from audit activities by outsiders; including target probe and educate (TPE), RACs, ZPICs, etc.; relies upon complete, accurate documentation.  It’s just plain crucial!  And yet…providers continue to struggle mightily with inadequate documentation that regularly produces adverse results.  How can the problem be addressed effectively?  

Anecdotally, it seems that most providers know how to produce complete, accurate documentation, but they don’t.  Now there is a study that seems to verify that this is indeed the case.  Researchers from the University of Manchester, Columbia University and Appalachian State University worked with the Visiting Nurse Services of New York (VNSNY) to address questions about compliance.  The results of the study appeared in the American Journal of Infection Control on June 14, 2018.

The study revealed that knowledge is not the most important factor with regard to compliance with effective infection control measures.  The nurses in the study certainly knew about and understood standards of care regarding effective infection control.  Rather, the study showed that attitude, as opposed to knowledge and experience, was the key factor to achieving compliance.  The results of this study also seem applicable to compliance with applicable standards for complete, accurate documentation.

When providers identify deficiencies in documentation, it is often tempting to provide additional education to staff about how to document completely and accurately.  The assumption seems to be that practitioners aren’t documenting completely and accurately because they don’t know how to do it.  Instead, it now appears that the issue isn’t knowledge or experience at all.  According to this study, it’s all in the attitude!

Consequently, targeted strategies to alter the attitudes and perceptions of staff members are needed.  When staff members see documentation as the linchpin that it is, they will do a better of completing documentation that is complete and accurate.  How can managers change the attitudes and perceptions of staff members?  

It seems likely that documentation must become personal.  That is, practitioners must have some “skin in the game.”  In other words, the importance of complete, accurate documentation is not avoidance of some distant payment denials or adverse audit results that may impact staff members little, if at all.  The consequences of inadequate documentation must come home to practitioners in order to change attitudes and perceptions.

Managers can likely determine how best to accomplish necessary changes in attitudes and perceptions of their staff members. It may be helpful to individualize strategies for doing so.  Perhaps it’s time to tie compensation extremely closely to the timely preparation of complete, accurate documentation.

In short, less emphasis on reeducation and more emphasis on attitudes and perceptions is needed now!



©2018 Elizabeth E. Hogue, Esq.
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