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Medical Stewardshp in the Wound Care World

The principle of stewardship centers on an individual’s responsibility to use resources in a responsible manner. In medicine the emergence of resistant organisms has given rise to the concept of antibiotic stewardship.

Initial efforts, focused primarily on inpatient antibiotic use, led to the development of hospital stewardship committees monitoring patterns of resistance and antibiotic utilization.  But what about outpatient wound care centers? Antibiotic and antiseptic use follows no prescribed guidelines and varies drastically between centers.

Recent evidence suggests patients on antibiotics heal faster. However, in the absence of reliable diagnostic tools and the inaccuracy of clinical examination in making the diagnosis of infection in chronic wounds, clinicians prescribe antiseptics and antibiotics in a random fashion.

The AAWC Wound Infection Summit will face head on antibiotic stewardship in the wound center, presenting evidence and suggesting practical approaches. Join us in Atlanta April 26th and 27th to become a better steward. Click here to learn more or to register for the Wound Infection Summit – Atlanta.

More than Calor, Dolor, Rubor and Tumor

The classic signs of infection first recorded by Celsus in the first century A.D. (warmth, pain, redness and swelling) fail the wound clinician. Infected chronic wounds do not exhibit the classic signs and symptoms known since antiquity. As a result, clinical examination detects only a percentage of infections. Unseen biofilms mature in the non-healing ulcers open for weeks to months. Scientific research on infection in chronic wounds is expanding rapidly; however, a gap in knowledge exists between the bench and the bedside. 

The AAWC plans to convene three Wound Infection Summits this year focusing on infection in chronic wounds. These inter-professional conferences will examine the scope of the problem, present the latest evidence from the lab to recently completed clinical trials, and provide attendees with practical information that will have an immediate impact on their practices. The meeting format encourages discussion and debate.

Registration is open for the AAWC’s First Wound Infection Summit of 2019 in Atlanta from April 26-27th. Join us to advance the practice of wound care and learn from one another how we can improve our practices on behalf of our patients.


The Things We Don't Know

Donald Rumsfeld famously said, “There are things we don’t know we don’t know.” From the depths of this ignorance come the most astonishing surprises and devastating disasters. In the wound care world, the unknown dangers lurk in halls of Medicare and in the sprawling, luxuriously appointed offices of private insurance companies.

The unsung heroes of the AAWC Health and Public Policy committee continuously monitor and rapidly respond to the endless policy publications of our bureaucratic overseers. Without their tireless efforts, wound care practitioners would never know the regulations that directly impact them and their patients. Recently, a physician asked me why joining the AAWC was important. I replied, “Among the many things AAWC does is protect your practice from payers and regulators because we don’t know what we don’t know.”

The AAWC has designated Public Policy as one of its three strategic pillars. We focus on the rules and restrictions that hamper our practice. In addition, we are expanding our Public Policy efforts. This month we are meeting with a member of Congress at our Pressure Ulcer Summit to discuss the challenge of pressure ulcers in the United States and the impact they have on cost and outcomes. We are expanding our initiatives to be more proactive rather than simply reactive in our advocacy on regulation and reimbursement. 
Strong positions on Public Policy require a committed membership speaking with one voice. Your participation and input help shape that voice and are vital to our success. Join us in protecting patients, ensuring access to care and making wound care a priority in Washington so there will be fewer things we don’t know.

Infectious Thoughts

Infectious Thoughts

    The patient seated on the exam table surprised me. I had seen him many times at hospital meetings and charity events. I quickly double checked the cover sheet on the chart to confirm his high-level connection to the institution. He presented to the wound clinic with a venous leg ulcer and wanted to enroll in one of our clinical trials. He appeared to be a candidate: My examination determined that the wound was not clinically infected, documenting a complete absence of signs and symptoms in the source documents.  The trial required a quantitative tissue culture biopsy, which I performed before placing him in compression. The following week the culture report revealed infection with a high bacterial load. Treating him with topical antimicrobials sped up his healing and he went on to complete closure in 6 weeks.

    Reflecting on the shortcomings of my clinical examination in this case led me on a career-long interest in improving lessons learned from a case such as this: the clinical signs and symptoms of infection in chronic wounds are unreliable, critical colonization is an ill-defined term, and bacterial counts may not tell the whole picture in chronic wounds. The journey continues, promising many more twists and turns as we gather more information.

    The AAWC leadership and membership agrees that this is an area that deserves focused attention. In response, we have planned a series of Wound Infection Summits for 2019. The summits will examine the current state of the art diagnostics, antibiotic stewardship and opportunities for future research. The first Summit is planned for April 26th and 27th in Atlanta and will be hosted by the Piedmont Atlanta Hospital. If you have an interest in this rapidly changing area of wound care, join us. Stay tuned to the AAWC website for program and registration information coming soon.

Advancing the Specialty

I challenge any nursing, medical or other specialty to surpass Wound Care providers in passion for their work or dedication to their patients. We are a special breed of clinicians with a unique passion for our work and dedication to our patients. However, uniqueness comes with a price: an obligation to advance wound care beyond its rudimentary beginnings. The AAWC has dedicated itself to providing forums that challenge the status quo, promote new ideas for practice and research and, most importantly, share information that immediately enhances the care we provide to the patients that so desperately need our expertise. To advance as a specialty our educational programs must not focus on novices and consist of redundant sanitized content; it requires open debate and critical evidence-based analysis. AAWC education is the best investment of your 2019 CME/CE time and money.

AAWC’s Pressure Ulcer Summit in Atlanta February 8-9 will take a deep dive into the evidence for the treatment of pressure ulcers. There are new confusing and frustrating changes in staging for pressure ulcer treatment. And it is controversial. We will debate it, review the evidence, and discuss alternative approaches. We need your perspective and want your opinion. Join us.

In April AAWC will hold its first Wound Infection Summit examining the problem of bacterial bioburden in chronic wounds. New evidence will challenge long held beliefs on the role of bacteria in healing chronic wounds. We will debate the importance of biofilms, challenge the ability of clinical examination to diagnose infection in chronic wounds. Also, we will take a hard look at diagnostics and discuss antibiotic stewardship for the wound care clinician.

As the 2019 AAWC educational program evolves, there are several more Summits across the country in development. In addition, there are new tracks in collaborating society events such as the Cardiovascular Catheter Therapeutics: Advanced Endovascular and Coronary Intervention Global Summit (C3). The AAWC will host an education track focused on a multidisciplinary approach to wound care issues such as chronic infection, pain management, edema/lymphedema treatment, use of advance wound care products, developing a clinical research program.
These AAWC 2019 educational seminars are the places where passion for our practice expands. We look forward to hearing from you, learning from one another, and sharing our skill set for the advancement of wound care.

AAWC: Your Voice on Public Policy

My end of the year blogs continue to focus on the accomplishments of our amazing AAWC volunteers. The AAWC’S Healthcare Public Policy Committee (HPPC) faced several challenges this year and the efforts of our volunteers deserves acknowledgement. When CMS proposed reducing Evaluation and Management codes from five to two categories, the change threatened a substantial reduction in physician fees, endangering the specialty of wound care. Collaborating with numerous other societies to defeat the proposal, the HPPC successfully overturned the decision thereby preserving the current payment scheme. In addition, United Healthcare (UHC) issued a problematic coverage policy during the summer limiting choices of cellular and/ or tissue-based products available to clinicians. With cooperation and assistance from the Alliance of Wound Care Stake Holders, the AAWC prepared and submitted comments to UHC to request policy changes. Finally, the HPPC evaluated and responded to numerous CMS coverage determinations and policy proposals.

On behalf of the wound care community, the HPPC remains the watch dog of the AAWC. Our volunteers continuously survey the reimbursement and regulatory landscape, responding rapidly to protect the interest of our members, allowing patients to receive best in class care. The 2018 membership survey identified public policy as one of the top priorities for the AAWC. We listened. The Committee will continue to monitor the ever-changing policies and coverage determinations with the full support of the AAWC.

A special thanks to the current HPPC members: Peggy Dotson, RN BS, Chair, Ali Baros, MD, Kara Couch, MS, CRNP, CWS, CWCN-AP, MS, Gary Gibbons, MD, FACS, Mary Haddow, RN, CWCN, Eric Lullove, DPM and Kathy Schaum, MS.

Our Future Is Bright

Que Future Mas Bello

“The future is bright,” to quote  Spanish crooner Pablo Alboran. And so it is, especially for members of the AAWC. In the next series of weekly Presidential addresses, I want to share how the accomplishments of 2018 have set the platform for a successful 2019 and beyond.
     Strategic Partnerships: Among the AAWC’s strongest initiatives is the Wound-Care Experts FDA-Clinical Endpoints Project (WEF-CEP). This collaborative project with the Wound Healing Society focuses on clinically relevant endpoints for wound-healing clinical trials. The result is advanced wound care products will have a smoother FDA approval pathway providing cutting edge solutions for our patients.
     Influential Leadership: A recently accepted article to be published in Wound Repair and Regeneration entitled “Evidence Supporting Wound Care Endpoints Relevant to Clinical Practice and Patients' Lives. Part 2. Literature Survey” was written by members of the WEF-CEP Committee. The compelling findings enabled Peggy Dotson, Marissa Carter, Vickie Driver and Gary Gibbons to appear before the FDA to discuss the details.
    Patient Participation: The WEF-CEP Committee reached out to those beneficiaries of our care to ask patients for their perspective on wound care products. The findings from over 400 patients are currently under review and will be published once available.  As a next step, the committee will recommend up to four scientifically achievable, clinically relevant, & patient-centered wound endpoints to serve as primary wound care outcome to the FDA.

    Your AAWC is engaged, influencing policy, and is being heard by the FDA to advocate for patients and clinicians. These are meritable achievements and a credit to your leadership and membership engagement. These accomplishments are the basis of the AAWC’s commitment to speak as one voice for the wound community.

To learn more about the WEF-CEP Project you may access the November AAWC Journal Club Webinar presented by Drs. Lisa Gould and Vickie Driver on the subject.