American Professional Wound Care Association Director Dr Richard Schlanger tells HEQ about the challenges facing the treatment and care of wounds.
US-based non-profit the American Professional Wound Care Association (APWCA), which was launched in 2001, aims to advance the field of wound care and promote awareness and education in the field, through advocating for best practice in wound prevention and treatment, driving research, and fostering professional collaboration.
Dr Richard Schlanger, a member of the APWCA’s Board of Directors, tells HEQ about the challenges facing the treatment and care of wounds.
Are any groups particularly at risk for more severe or difficult-to-treat wounds?
We have found that these issues seem to occur more in our older population with multiple comorbidities, particularly diabetes. COVID-19 also causes problems around immune suppression, so we are now seeing more difficult wounds which may be a result of COVID-19 knocking down the immune system.
What can be done to minimise the risk of infection when treating difficult wounds?
Most wounds are already infected – it is just a question of degrees. When you look at a culture, it is either going to be what we call low, with around 10,000 colonies; moderate, between around 25,000 and 50,000; or heavy, over 100,000. The key is not to immediately go hog-wild and start throwing systemic antibiotics, which of course can contribute to resistance. The biggest problem that we are seeing is that of preventing a wound from developing a biofilm, which is a symbiotic relationship of multiple bacteria that normally do not interact well with each other, forming bonds which essentially act as a shield over the wound. What we have tried to do in almost all cases is, while it is not possible to set up a sterile wound care clinic at the patient’s bedside, trying to keep the wound and the surrounding environment as clean as possible, using what I would consider to be semi-sterile techniques. I am a surgeon by practice, so while I see my nurses, who are all certified specialists, clean the wound first and then the peripheral area, I will try to clean the periphery first to avoid it colonising the wound.
The issue which needs to be addressed most urgently with wound care patients is optimising their oxygenation and their nutrition, which are both paramount. Then it is important to make sure that the wound is not treated using any kind of caustic substance, which will cause more damage. In a lot of cases – especially in long-term care and nursing facilities, but it does also occur in hospitals – there is significant variation in the dressing of a wound, because the same person is not applying the dressing each time.
Looking at the general literature, as well as what we are seeing from a lot of suppliers, the available data just is not good and there are issues with pricing or availability of infection mitigation equipment. There is just not enough standardisation to keep wounds from becoming infected; and once they do become infected that introduces a whole new set of problems.
What are the key challenges facing the healthcare sector in preventing the spread of infection?
There are a couple of new antibiotics which are not taken systemically, but which are supposed to be good for biofilm, but there is not enough data to support rolling them out – it is just a case of people getting these ideas and starting to put things on wounds. I think we really need to introduce a system for categorising wounds, asking questions like: is there an infection? Is it causing systemic issues?
The key issue for me, when I am looking at a patient, is determining what is going on with the wound. One of my very learned professors always told me that a wound is not just a hole in the patient, but you have to treat the whole patient to take care of the wound. With that in mind, I think we need to determine in particular whether a wound looks angry and how angry it looks; and then establish whether we should just clean and dress it or whether we need to take a culture, or even a possible biopsy. Beyond that, we need to limit the external factors: are we keeping the patient’s diabetes under control? Have we examined the wound for oxygenation? A wound that has even a minimal partial pressure of oxygen is going to have a degree of bacterial resistance. If it does not have that in place, there will be further problems; so we need to make sure the patient is oxygenated.
We need to make sure that they are basically keeping the area clean, because there are patients who will have problems – some hospital settings use speciality beds equipped with low air loss mattresses which are meant to reduce pressure, but this is essentially a rubberised mattress that acts as a pool, so if the patient is incontinent then their waste will just rest on top of the mattress and act as a breeding ground for infection.
When I take care of a patient, the first step is to establish a comprehensive history. I will look at the wound, take a biopsy or culture from the wound, make sure that sure I have an excellent idea what medications the patient is taking and what comorbidities they might have, and then try to maintain what I consider a very healthy field – this means that there is no cross-contamination, the dressings are effective, but not in a hostile way, and they will not irritate the wound. I consider every wound to be infected, but I need to determine how best to take care of it. This can mean applying antiseptics or systemic antibiotics, doing this entails making a definite commitment to causing disruption to the wound that you may not want. I am a big believer in debridement: removing unhealthy tissue as much as possible, while being careful not to remove good tissue. It is an excellent way to remove the debris and get back to a healthy substrate.
Has the COVID-19 pandemic had a significant impact on the treatment and care of patients with wounds?
The impact that we are seeing is twofold. First, the patients are coming in late – there was a tremendous fear factor for many patients, where they did not want to come to the emergency room because they were concerned that if they came in, they would automatically contract COVID-19. This means that when they do come in, it is with more serious injuries. What we are also seeing with COVID-19 – and we saw the same with the H1N1 virus some years ago – is younger patients with a smoking history who have become septic with COVID-19, they are put on vasopressors and as a result they develop thrombosis: I now have a 22-year-old female patient who has ischemia with gangrene from her knees down. This is not unusual: during the H1N1 outbreak had around 60 patients who needed a variety of amputations; but their wounds were open, so they were infected; and it is very difficult to take care of.
A lot of patients are coming in with pressure wounds; several of them have wounds to the back of the head; and we are frequently seeing osteomyelitis of unusual joints – and it all seems to be due to the virus. For some reason this virus just knocks people down to the point where they do not have the reserves to fight, so they are now susceptible to all kinds of problems; and when they do get a wound, these wounds can be the portal of entry of some significant bacteria which they cannot fight. It seems to be just another layer that gets them in the ground. It is almost frightening to see what this virus is doing.
Is there a risk that wound care is overlooked in procurement and policy?
Absolutely. I have been practising surgery for 41 years and have been practising wound care for 20 of those years; I am the Emeritus Director of the Comprehensive Wound Center at Ohio State University and I have contributed to books and research projects within the field. The problem that we have, which I have been fighting about with the American College of Surgeons (ACS), is that the ACS does not consider wound care to be a speciality; and a lot of our other sister professions similarly do not consider it to be a major field of care.
When we first started to do laparoscopic surgery, there were about 600 companies all claiming to deliver the next best thing; and now there are only two. As far as wound care goes, there are 3M and Johnson & Johnson – there are so many companies making the same type of dressing or pushing the latest product; and the costs are unbelievable. My daughter was educated at the University of Uxbridge in the UK, and when she was over there she was on a respiratory medication that costs about 300 bucks here in the US – and she would go to the pharmacy in Uxbridge and they would apologise that the prescription cost £11. I would prescribe medications for some of my patients and they would call me on the phone and start screaming at me, because the two-week course that I had given them was $2,800 and it was not being covered by their health insurance. And this is what we are seeing in wound care: manufacturers keep getting different products, and they keep saying how wonderful these are; I will hear that amniotic pads are working great, but in order to work great they take 16 applications at $1,200 an application. I don’t understand how much better that is.
This seems to be the problem: there are not any good, formalised studies trying to determine what is the best product in each category, or how we can ensure that we all use the most effective products while keeping the price down. The biggest threat to patient care is the inability to get what you need, either because it is either too expensive, or it is not on their formulary, or it is not on their buying contract; and there is nobody higher up pushing for a national formulary.
Another major issue is that if you develop something novel, and you publish it and you try to get it distributed throughout the field, there are enough people in higher places – institutional review boards (IRBs) and such – who just do not get it; and that is actively a detriment to improving wound care. For example, one of the new things which has become popular in infection control is the use of antibiotic beads: clinicians place the beads on a site of potential infection and have to hope that they will stay in place. Instead, I have been using the antibiotic ‘slurry’ from which the beads are made directly in the wound: it goes into the interstices and covers the area and hardens; it works great. I published my findings, and then my own IRB said it did not have any interest. I also developed a modified wound scope which could be injected to examine tunnelling wounds; Stryker Corporation was going to produce it, but they were told there was no market. For every two steps ahead, I take four backwards; and that seems to be what we do in wound care.
What I think we need to do, as wound care specialists, is get together with a couple of good experts and write the definitive book of how to take care of patients with wounds – simple wounds, infected wounds, wounds in patients with comorbidities, wounds in people undergoing cancer therapy – there really needs to be a group of dedicated wound specialists who really want to push the envelope and not take no for an answer.
The biggest problem is that wound care is not glamorous. It is effectively the orphan speciality; and it is unfortunate because wounds are a key part of healthcare and need to be looked at seriously. I wish that would happen; and I hope it happens soon. Taking a lung out or doing a liver transplant is great; but trying to save someone’s leg, or if someone has a horrible abdominal wall fistula from an infected piece of graft, then getting them better and off intravenous feeding and sending them home – it does not get much better than that. But no-one has that kind of passion. When I talk to my students I say: you are going to be a surgeon, but when can you be in a speciality that touches all phases of medicine – nutrition, diabetes, cancer, surgery? You’ve got it all in this little wound.
Dr Richard Schlanger
American Professional Wound Care Association