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 1^st 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 1^st 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 1^st 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.

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.

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?

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.

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].

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.

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. 

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.

###

When something is lost, it is always found in the last place searched …because once found, searching is no longer necessary. With diagnoses: once identified, looking further is unnecessary. Unless something rare can masquerade as many other things, causing a false find – a diagnosis that looks like one thing but is really something else.

So it is with Martorell’s Ulcer. It is so rare and atypical, it is frequently missed when it presents. One of the rarer lower extremity wounds, Martorell’s Ulcer is often unrecognized, leading to ineffective treatment and prolonged, intense pain for patients.

The wound associated with Martorell’s Ulcer is an ischemic lesion appearing on the lower leg and sometimes near the Achilles tendon. Historically, it was thought that women between the ages of 50-70 were more likely to develop Martorell’s Ulcer. However, current literature suggests the average age is 74 and there does not seem to be evidence that women any more than men are likely to develop them. A significant marker for Martorell’s Ulcer is the disproportionate level of pain as compared to the size of the wound; Martorell’s Ulcer causes extreme pain

In all cases, the patient will have severe, long standing, systemic and uncontrolled hypertension and nearly 60 percent will have diabetes. The Ulcers can be triggered by trauma, however, 50 percent will be spontaneous in formation. The wound will be of varying depth, have a necrotic base, bluish or purple edges, an irregular shape, and can be singular or present with satellite sites.

Before being treated by a wound specialist, a patient may see a general practitioner. The generalist will assess a patient presenting with a lesion and leg discoloration and ulceration. Being unfamiliar with Martorell’s Ulcer, the generalist may diagnose it as a more common venous wound.

Even wound care specialists may determine the evidence to be something other than Martorell’s Ulcer. Frequently, Pyoderma Gangrenosum is diagnosed first. While the symptoms of both Martorell’s Ulcer and Pyoderma Gangrenosum are similar, the treatments are very different. Proper treatment for Pyoderma Gangrenosum is contraindicated for Martorell’s Ulcer.

A proper diagnosis for Martorell’s Ulcer is possible only with a large specimen sample biopsy. The specimen must be large and cut to the fascia, and include healthy skin from the wound border into the necrotic area of the wound. The specimen must remain intact, imbedded for histological examination and be of longitudinal orientation. A punch biopsy is insufficient to diagnose Martorell’s Ulcer and if used, has been shown to wrongly diagnose it as Pyoderma Gangrenosum.

Once diagnosed with the biopsy, treatment calls for surgical removal of the necrotic skin followed immediately by a split skin graft. Post-surgery, negative pressure treatment has been shown to help. While pain management was crucial prior to diagnosis and surgery, patients report pain reduction very quickly after surgery. Long term management requires blood pressure and diabetes control, cessation of smoking, and compression to the area. Wound area bacteria can be managed with topical anti-microbials or systematic antibacterial agents.

When a patient presents with longstanding hypertension and diabetes along with a very painful necrotic wound on the lower leg or near the Achilles tendon, health care providers should consider Martorell’s Ulcer and include it as part of the differential diagnosis.

For anyone who watched television in the 90s, the phrase “The More You Know” likely drums up memories of a bright yellow star shooting across the night sky, big purple letters, and celebrities offering helpful information about current social issues. A side-effect of our emphasis on knowledge is that when a patient enters your care, they come with the expectation that you will know “more,” if not “all” about the complaint. It can be tempting to jump into that persona, to go along with “seeming to know everything” at that moment, and fill in the gaps later. But what if admitting how little you know opened up a new window toward better wound care outcomes?

Physicians obtain their knowledge from many sources: medical school, clinical rotations, patient experiences, literature, and conferences.

Staying current is essential to providing patients with the care they deserve. But it takes time. And when new protocols or pharma solutions are presented, a physician will want to know more before changing known and successful programs. There is a risk that sticking for too long with what is known to be successful can cause us to miss something new, but it is essential to incorporate new learnings and challenge our comfort level with the care we provide.

In recently published trial results, I, along with my colleagues report on How Little We Know About Bacteria in Chronic Wounds, and the challenge to increase the accuracy by which bacteria is detected in wounds. By acknowledging we need to know more, we step outside the use of Clinical Signs and Symptoms (CSS) standards to detect infection in a wound and guide decisions regarding treatment.

There are many challenges with this approach, to use a three-step process to determine if the use of fluorescent light could help increase the accuracy of bacterial detection in chronic wounds. By starting with CSS, using fluorescent light technology and concluding with a biopsy to confirm the diagnosis, we were able to see the variance between what their professional opinion might have been on initial analysis and the reality of the wound.

In the first round of trials nearly 20 percent of the wounds that were originally determined not to be infected turned out to have significant amounts of bacteria present. Based on the photos from the fluorescent camera, many of the professionals participating in the trial were able to adjust treatment recommendations to better suit the patients’ needs and described feeling more confident they were making the right decisions.

The knowledge in the treatment room extends beyond what the physician knows. It is an illustration of the importance of a multi-disciplinary approach to wound care and treatment. It turns out, it is not The More YOU Know, it’s The More WE Know together.

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It is hard to believe but 1 in 5 infants in the Neonatal Intensive Care Unit and pediatrics units will develop a pressure ulcer (PrU).  What is even more alarming, is that there are very limited studies of risk, prevention, and treatment in this patient population.

Neonates are not mini-children just as children are not little adults. Nonetheless, nearly all known risk assessment scales and PrU prevention plans for neonates are adapted from adult protocols. For both legal and ethical reasons, research in the pediatric and neonatal patient population is limited creating a lack of knowledge among one of the most vulnerable patient populations.

While there is evidence that pediatric skin is resilient and tends to heal quickly, the skin is also more fragile than that of an adult and immature systems can complicate wound care in pediatric patients.

As with the adult, a wound will cause increased risk for complications such as infection and water and electrolyte loss. However in the pediatric and neonatal population these risks are escalated due to their decreased surface area. In addition, the premature neonate’s skin is under developed which will reduce the skin’s barrier function, reduce their ability to regulate temperature, and increase their risk of water loss through the skin. In fact, absorption of seemingly benign topical medicines, lotions, creams or emollients can be dangerous in the neonate. The infant’s limited mobility and age appropriate mobilization patterns also present challenges to the prevention and management of wounds. Expression of discomfort and pain also complicate prevention, assessment and management of wounds in the neonatal and pediatric patient population.

When a neonate or pediatric patient develop a wound the treatment goals start with alleviating pain, reducing emotional distress, and minimizing scarring. To prevent additional trauma to the skin, dressings should be as small as possible to cover the wound and adhered using silicone or other gentle, non-skin stripping adhesives. In neonates, adhesives should be avoided altogether and replaced with loose or tubular bandages.

Pressure ulcers in hospitalized neonates and pediatric patients are significant and are frequently caused by immobility and medical devices necessary for their care. Of the various risk assessments used in adults, the Glamorgan Scale is reported to be the most readily adapted to infants and children.

The most common areas for pressure ulcers in this population occur on the heels, occipital region, and the sacrum/coccyx area. Medical device-related pressure ulcers can develop on the arm where blood pressure cuffs are applied or on fingers where pulse/oxygen meters are affixed. They may also develop in and around the nostril area from the prongs of oxygen tubes and masks.

Preventive efforts include padding prominent bony areas and rotating the patient to different positions or rotating the location of the medical devices. This population should receive a head-to-toe skin assessment on admission and again at 12 hour intervals with special attention to the sites where medical devices are in skin contact.

Pressure ulcers should be cleaned with room temperature sterile normal saline using a soft cloth or syringe. In the first two weeks after birth, no antiseptics or soaps should be used on the neonate. If emollients are necessary, careful evaluation is needed and must be applied sparingly to avoid systemic absorption – and avoided altogether in pre-term neonates.

Nutrition is key to healing of pressure ulcers, particularly among those with low birth rates or after neonate weight loss. Breast feeding can assist in promoting healing.

Infection risk is high in neonates necessitating close monitoring of the skin around the wound for subtle changes such as swelling or drainage, increased paleness around the wound or in the wound bed or increased redness around the wound. Healing is enhanced by using a moisture retentive dressing and close observation every 12-24 hours.

With little research to rely on, wound care providers treating neonatal and pediatric patients, have done well by adapting adult protocols. Forums for sharing experiences in this category can work to improve care for all those advancing wound care in young patients.

The Pediatric Wound Conference (ISPeW) will be held in Houston November 14-15. For further information visit ispew.org.

https://pedsinreview.aappublications.org/content/26/2/43

https://www.woundsource.com/patientcondition/pediatric-patients

https://advancedtissue.com/2015/05/how-to-treat-wounds-in-children/

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3985526/

It happened again. Of course, the IT in this context is a mass shooting -- two, in fact -- in fewer than 24 hours last week. The horror of El Paso was swiftly replaced with the tragedy of Dayton. Any town, USA.

Who bears blame and responsibility, and whatever the politics, a fix is an issue for everyone. However, the physical wounds that result are the direct responsibility of wound care professionals.

Unless in a war zone, civilian injuries resulting from gunshots have been linked largely to handguns or rifles. It is estimated that of the 67,000 people injured from gunshot injuries each year, approximately 32,000 will die. Legislation in 2004 lifting a ban on civilian ownership of assault weapons now enables consumers to obtain them.

And since the ban on assault rifles was lifted, there has been an increase in the number of mass shootings in which assault rifles were used.

Injuries inflicted by assault rifles are very different than those received from handguns or other non-assault style weapons. Patients presenting with non-assault style wounds typically have a wound with a defined entrance and exit. There is bleeding from the laceration and there may be fragments in the wound. Provided no vital organs have been hit and provided the patient has not lost too much blood prior to being treated, there is a good chance the patient can survive.

Assault rifle victims often present to an Emergency Department with injuries so severe recovery is not likely. The damage done is beyond repair.

Bullets from assault weapons tend to shred organs as a result of the high velocity at which they leave the weapon. The speed creates more energy as it passes through the body. The injuries result from tissue moving away from the bullet as it passes and then settling – a process known as cavitation. It leaves the tissue damaged or dead, and the cavitation impacts tissue and organs several inches from the bullet path. It is like a pebble tossed in a lake and the resulting eddies or concentric rings moving outward from the point of where the pebble entered the water, followed by the water becoming still again. The result may be injuries to organs not touched directly by a bullet but injured by the eddies created by the bullet path. The entry wound may be small, not unlike that of traditional guns. However, exit wounds from assault weapons tend to be large. Some bullets are designed to expand and fragment on impact and the exit can be as much as 12 inches in diameter.

Even if an assault weapon victim arrives to an Emergency Department alive, the tissue and organ damage may be beyond repair. Those who survive and receive life-saving surgery face long recoveries and require unique and ongoing wound care.

Long term treatment of victims of assault weapons parallels war wound care. Post- surgery, there are many concerns for survival. For wound care, the concern is for infection. Infection can result from residual dead and contaminated tissue or from foreign body material remaining in the wound. If that occurs, additional surgery may be necessary to remove it.

Leaving a wound open for healing may be indicated. Doing so allows for unrestricted swelling, exudation of serum from tissue, avoidance of an anaerobic environment, and to assure there is no residual dead and contaminated tissue.

Open wounds still require dressing. Dry and loose gauze may be indicated for wounds over tendons or with exposed bones. The gauze may be kept moist with saline. Cavities should not be packed but the dressings should be able to absorb blood and serum from the wound. The dressings should not contain petroleum jelly but antibiotic ointment may be used. All dressings should be non-constrictive, never tight, and there should be no adhesive encircling a limb. Doing so increases the risk of constriction. Plaster of Paris (POP) may be used for large wounds and for injuries near joints. If used, POP should not encircle the wound but serve as a support and remain split to the skin so the wound remains open.

As the wound heals, it is recommended not to examine it until 4-6 days after surgery. When changing dressings, do so to the outer dressing, leaving intact that in direct contact with the wound. This reduces the chance of cross-infection, avoids disturbing the wound healing process, avoids causing added pain to a patient, and reduces the amount of time and resources expended by a wound care provider.

Measuring progress includes monitoring for fever, examining for redness or tenderness around the area of the wound, odor from the dressing, and visually determining whether the dressing remains clean.

When the recommended time has passed for the wound to begin healing, look to see whether the wound is clean and red – both indicators of granulation as new tissue is formed. Note whether the deepest dressing is dry and hard indicating exudation. Gauze should remove easily with gentle pressure. These are indicators of improvement and healing.

If the patient has a fever, the dressing is wet with little bleeding and if the wound appears wet and shiny, shows pus, and skin erythema, the wound is not healing and different interventions are needed.

The physical wounds are only part of the damage done by assault weapons in shootings, mass or otherwise. The mental trauma from surviving either from physical wounds or guilt that others did not survive can be almost as difficult to heal. As part of a collaborative treatment team, wound care providers and all members of the treatment team must tend to the mental healing of the patient too. As the visible wounds heal, the invisible ones need equal but different attention.

Wound care providers and trauma teams can go to work together after a mass casualty from assault weapons, and their exquisite skills can result in almost miraculous outcomes. But these are skills no health care provider wants to be called upon to deliver. Until there is multi-platform change, health and wound care providers stand ready to put the pieces back together. 

For additional information, see (co-authored by AAWC’s Ruth Bryant, PhD, MS, RN, CWOCN) Nelson V. et al, Traumatic Wounds: Bullets, Blasts, and Vehicle Crashed. In Bryant, R. Nix, D. Coeditors: Acute and Chronic Wounds: Current Management Concepts, 5th Edition. St. Louis, Mosby/Elsevier January 2016

https://reference.medscape.com/slideshow/gunshot-wounds-6008960#19

https://www.scientificamerican.com/article/data-confirm-semiautomatic-rifles-linked-to-more-deaths-injuries/

https://tcf.org/content/commentary/the-assault-weapons-ban-did-it-curtail-mass-shootings/?session=1

https://www.outsidethebeltway.com/the-difference-between-ar-15-and-normal-gunshot-wounds/

https://www.nytimes.com/2018/03/04/health/parkland-shooting-victims-ar15.html

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.

Soon after his appendectomy, the eight year old’s mother was anxious for him to stand up tall and walk. He resisted, convinced his stitches would open and his insides would come out. When she lost patience with his hunched posture, he cried in fear while gradually standing ramrod straight. And his stitches gave way.

While nothing spilled out, the boy was traumatized not only from the appendectomy but from the reopening of the wound. Still an inpatient, new sutures were placed quickly.

Known as dehiscence[1], the reopening of surgical wounds is not uncommon. The boy’s fear of insides falling out, known as evisceration[2], is very serious and can be avoided with immediate treatment of dehiscence.

There are many options to close wounds, surgical or any other types. Catgut[3], manufactured from animal intestines has largely been replaced by synthetic materials which provide strength and yet are readily absorbed by the human body. But sutures are no longer the only option for closing a wound or incision. Other options include adhesive strips, staples and glue. Which option is used depends mostly on the type of wound requiring closure.

Sutures[4] are used to sew a wound closed. Dissolvable sutures are often used for internal wound closure. Non-dissolvable suture material must be removed by a medical professional. Sutures are used for deep incisions or wounds, can be done quickly, and are among the lesser expensive options for wound closure.

Staples[5], by look, feel and administration are exactly what one would find in an office supply store. Except those used with wound closure are larger, thicker, sterile, and applied using a medical device. Staples are especially strong and may be used in areas likely to move, such as abdominal incisions. Staples must be removed by a medical provider and done so in a timely manner so that new tissue growth does not grow around the staples causing further injury.

Surgical glue[6] may be used for small incisions that don’t require a lot of hold strength. Unlike other methods, the glue will dissolve and wear off over time, and does not need a medical person to remove it.

Adhesive strips[7] act like a tape to pull a wound closed. Areas where a wound is not in a high stress part of the body can use adhesive strips to close the wound. Caution is essential as individuals may be allergic to the adhesive on the strips.

Regardless of the method used to close a wound or incision, wound care is crucial for proper healing, to avoid infection, and to minimize scarring. Closed wounds establish a clean environment for healing internally and externally; open ones are a gateway for bacteria. Bandages must be changed regularly in a clean environment using clean tools and techniques. Beyond the bandages is the essential need to eat properly to fuel healing. Otherwise, healing can be delayed and there is greater potential for infection.[8]

Historian Thomas Carlyle is credited with developing what is known as “The Great Man Theory” when he said great leaders are born and not made. Having lived in the mid 1800’s he can be forgiven for not calling it The Great Man/Woman Theory. It suggests that certain traits or qualities are better suited to leadership, these are innate characteristics present at birth, and leadership will allude those lacking the genetics.

Legendary Green Bay Packers Coach Vince Lombardi had a different view of leadership. There on the frozen tundra, he claimed leaders are made, not born. That they are made by hard effort which is the price to be paid for achieving anything worthwhile.

And like any point of view, the truth is probably somewhere in the middle. It is leaders made and leaders born that the AAWC seeks with nominations for its slate of future directors.

“The AAWC board of directors are those charged with leading the organization in fulfillment of its mission,” said Victoria Elliott, R.Ph., MBA, CAE, and AAWC Chief Executive Officer. “Each board post reflects the composition of our membership and essentially provides each member with a voice and conduit to the organizational leadership.”

The AAWC Board of Directors includes president, president-elect, immediate past president, secretary, treasurer, and directors-at-large including positions for consumer, nursing, podiatry and physical therapy, research, international, and industry. A complete list of the current board of directors can be found at https://aawconline.memberclicks.net/board-of-directors .

The open positions for 2020 are secretary and these directors-at-large: industry, two nurse positions (each 2-year terms), two physical therapist positions (one 2-year term and one 1-year term), two physician positions (one 2-year term  and 1-year term), podiatric physician and research.

With the late 2018 transition to an independent status, the AAWC executive committee postponed elections till 2019. Incumbents are Tomas Serena MD, FACS, President, Ruth A. Bryant, PhD, MS, RN, CWOCN, President Elect, Gregory Bohn MD, UHM/ABPM, MAPWCA, FACHM, Immediate Past President, Kara Couch MS, CRNP, CWCN-AP, Secretary, and Tim Paine, PT, Treasurer.

“This decision enabled the AAWC to remain stable and member-focused during a transition year,” said Tomas Serena MD, FACS, AAWC president. “Each member of the board and the executive committee has been unwavering in support and commitment to AAWC with the needs of members as the primary focus.”

Short and long term goals have been established and are linked to membership input gleaned from a survey conducted last fall. The focus is on education and expansion of learning opportunities for membership, followed by two other pillars of public policy and research.

Ruth A. Bryant, PhD, MS, RN, CWOCN is president-elect and will assume the presidency in 2020. “We have a spectacularly strong organization,” she said. “Members have defined our future and have demonstrated keen insight in selection of solid leadership. With the call for nominations, we are excited to welcome new leaders to the board.”

A willingness to be nominated and then to serve presents opportunity and reward well-beyond wound care responsibilities. It is a chance to step outside a zone of comfort, face new kinds of challenges, and develop skills which may be dormant during the day-to-day. Further, these positions offer a chance to expand a professional network, change the industry, and try new things.

Nominations for candidates will be distributed to membership on July 11^th and will be accepted through July 28^th. Candidates must be AAWC members for no less than one year as of July 10, 2019.

When a patient presents with a wound, it is not surprising that the first field of focus is the wound itself. Assessing the wound indicates to the wound care professional what the wound condition is, whether it is chronic or the result of a recent injury, related to surgery, if infected and at what level, possible co-morbidities, and much more. The second field of focus is the computer screen to chart the course of treatment so the wound healing can begin.

All this can be achieved without ever looking beyond the wound or the chart. But limiting the focus and not including the patient’s complete condition is a mistake that can significantly delay wound healing. The injury from a wound goes far beyond the wound’s perimeter.

A study of outpatients in wound care clinics found 81 percent [1] of its patients tested positive for depression. Further, it found depression common in patients with wounds, especially those with wounds lasting more than 90 days[2].

“The visibility of the wound creates a negative self-image because much of our self-image is based on external appearance and is a reminder to the patient that they may no longer look like most other people, “said Tim Paine, physical therapist with Litchfield Hills Orthopedic Associates, Torrington, CT.

Chronic wounds are stressful for a patient. As a long term condition requiring ongoing care and medical attention, these individuals are often removed from their life’s routine, limited in mobility, and isolated from family and friends. It can result in depression and stress, especially in older individuals. [3]

“Healing a chronic wound takes a long time, and requires constant attention to help the healing process, and it is very common for the patient to become emotionally and physically fatigued, which often results in depression and loss of motivation. This in turn prolongs the healing process. This cycle of emotional fatigue, physical fatigue and change in self-image results in a cycle of slowed healing and loss of motivation,” Paine added.

Surgical wounds are likely representative of a co-morbidity meaning the patient is concerned not only with the healing of wounds at a surgical site but also the primary cause and disorder for which the surgery was indicated.[4]

The most common site for slower healing wounds are on the feet and lower legs.[5] Studies indicate patients with lower extremity wounds when combined with stress are 25 percent slower to heal than those patients in a healthy mental state.[6]

Pain associated with wounds can be severe, if left unmanaged. As healing begins, pain and itching can cause sleeplessness impacting emotions, energy and motivation – including motivation to heal.[7]

Mental health is among the leading causes of disability around the world [8],with depression and stress highly prevalent in those with wounds. And once a patient’s wound is considered healed, it is estimated that 12 percent [9] of those patients will have some sort of psychological impact from the experience.

It is long recognized that collaborative care improves wound healing when it includes nutrition, physical therapy, and other specialties.[10] Integrating mental and emotional health assessments in the initial stages of wound care and treatment has been shown to decrease healing time.[11] While mental and emotional health conditions are harder to detect, early intervention can help a wound care patient begin to adjust to potential long term life changes, work through acceptance and avoid withdrawal which may lead to deepening depression.[12]

Mental and emotional health may be overlooked as part of the collaborative care model. As wound care professionals, there is an opportunity to be aware and alert to potential injury beyond the site of the wound. Watch for hard to detect symptoms of emotional and mental suffering, and add to the care team appropriate care givers to treat the patient’s mind while the wound heals.

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The AAWC’s regional WIS meetings are well known by members and others in the wound care world as the Wound Infection Summits. However, the WIS acronym could just as easily stand for Where Information Starts. It is at the WIS meetings where key learnings, new findings, and bold treatment plans are shared and become the renewed start in advancing wound care.

The next WIS is August 16-17^th in Detroit. The two day meeting is overflowing with programs designed to engage those in attendance to individually and collectively advance wound care. Through a series of lectures, panels, and interactive discussions, those attending will learn about:

• bacteria and biofilms,
• special needs of those with wounds resulting from IV drug use,
• use of oxygen in hyperbaric chambers for wound care and therapy,
• impact of nutrition in wound care and treatment, and
• the application of advances in research on biofilms, topical antiseptics, swab cultures and planktonic bacteria to clinical practice.

Meeting attendees are encouraged to submit case studies for use in the “Making the Diagnosis” session where participants will engage with a multi-disciplinary panel to examine case-based differential diagnoses, identify gaps in assessment and discuss diagnosis and the complexity of wound infections.

“The AAWC is able to attract some of the most well-known names in wound care’” said Victoria Elliott, R.Ph., MBA, CAE, and AAWC Chief Executive Officer. “As the foremost recognized multidisciplinary organization in wound care, we find there is great interest in becoming part of the WIS faculty."

The speakers and panel leaders include nurses, doctors, physical therapists and other professionals in various categories of wound care. Among them are Thomas E. Serena MD, Garth James PhD, Claudiu Georgescu MD, Barbara Pieper MD, Jennifer Gaddy MD, Jennifer Hurlow, Greg Bohn MD, Lindsay Kalan PhD, Randy Wolcott MD, Frank Aviles PT, Karen Bauer DNP, Kara Couch CRNP, Jeff Shook DPM, and Munier Nazzal MD.

“The varied professions of the faculty represent the AAWC’s professional membership roster,” said Ms. Elliott. “Further, it is reflective of the collaborative disciplines brought together in teams to treat patients with wounds.”

Among the most anticipated event of the August WIS is a segment entitled “The Patient Experience.” Those in attendance will hear from a patient who has experienced a chronic wound that became even more complicated by infection. Facing the specter of amputation, the individual will share a story of personal bravery, bold treatment plans, a willingness to consider new therapies, comprehensive and collaborative care, and ultimately, the happy new beginning.

“This is an exciting addition for the AAWC Summits,” said Ms. Elliott. “To hear about the personal and successful journey of an individual who has benefited from the help of wound care professionals is a defining moment for those on the front lines of patient care. This story is the personification of how we advance wound care.”

Registration is open for this Wound Infection Summit, and the one to follow in Kansas City. Additional details about the program, the schedule of events, and the travel and lodging information can be found at www.aawcsummits.com

As the largest member based multi-disciplinary organization dedicated to the prevention and management of patients with and at risk for wounds, it is THE AAWC’S responsibility to draw attention to issues that IMPACT clinical practice and PATIENT CARE.  One such recent topic concerns terms used to describe skin breakdown that appears to coincide with impending death: the Kennedy Terminal Ulcer (KTU), acute skin failure, Skin Changes At Life’s End (SCALE) and Trombley-Brennan terminal tissue (TB-TTI).  First proposed and described in 1983, the KTU was introduced as a subset of pressure ulcers that a patient may develop as they were nearing death.  These were characterized by shape (pear, butterfly or horseshoe), edges (irregular), and color (red, yellow or black).  The KTU may initially be an abrasion, black or darkened area that then rapidly deteriorates into a Stage II, III or IV or unstageable pressure ulcer.  This concept has sparked much interest and debate, including validity of the concept, further descriptions of the event, and case reports.  In a recent scoping review of the concept, Latimer et al (2019) identified a need for further research to deepen understanding of the phenomenon which could then inform practice.  Similarly, Ayello et al (2019) reported a review of literature on the concepts pertaining to pressure ulcers in patients at end of life.  In this report the authors acknowledge that there exists a gap in Understanding of the pathophysiology of changes that occur in the skin as a patient is dying. 

Opinions abound on the merit and validity of KTU, SCALE and TB-TTI and skin failure.  These opinions and debates are beneficial to the discussion because they add perspective and challenge us in the way we think about these conditions in terms of biologic plausibility, defining characteristics, AMONG OTHERS. 

Thus far, the level of evidence that exists to substantiate or refine these phenomenon and terms is largely composed of expert opinion, case reports, and descriptive studies.  This is to be expected with new concepts (and yes 30 years for a relatively rare event, is still legitimately considered a “new” concept).  As the body of descriptive evidence grows, more sophisticated methods of research can be designed and conducted to validate and refine the terminology and thus move the science to a more objectively identified condition. 

However, there is also an expressed desire to agree on definitions and terms concerning skin failure and skin changes at end of life (Ayello et al, 2019).   Recently, an editorial by Schank (2019) hypothesized there may be a plan or steps being put into place to eliminate the terms such as KTU or SCALE.   The state of the existing science concerning the KTU or end of life skin changes phenomenon need a more objective and rigorous scientific process through which to advance what is known before terms can be dismissed or consolidated.

Traditionally the strategy that has been employed to advance policy concerning pressure ulcers has been the use of consensus conferences sometimes in a fully transparent process, sometimes not so much. This is a valid and appropriate methodology for rare conditions when the decision-making participants in the audience are experts with that rare event. Another scholarly approach is to use a process known as a concept analysis to compile what is known about a new condition or phenomenon and, through the rigor of the analysis, explore the utility, practicality, precision and appropriateness of that term.

It behooves all of us to be aware of the issues surrounding ulcers that may masquerade as pressure: the KTU, SCALE, TB-TTI and skin failure. The articles cited in this blog provide a succinct history of the evolution of these terms.  As the multidisciplinary membership of healthcare professionals interested in wound care, attention to these terms and these phenomena is critical so that we are prepared to engage and influence patient care, public policy and professional practice in a responsible, scholarly process that is informed by science, not opinion.

References:

1. Understanding the Kennedy Terminal Ulcer. http://kennedyterminalulcer.com/  Last accessed 6/15/19.
2. Latimer S, Shaw J, Hunt T, Mackrell K, & Gillespie BM (2019). Kennedy Terminal Ulcers: A scoping review. J Hospital and Palliative Nursing. doi: 10.1097/NJH.000 000 000 000 0563.
3. Ayello EA, Levine JM, Langemo D., Kennedy-Evans KL, Brennan MR., & Sibbald RG (2019).  Reexamining the literature on terminal ulcers, SCALE, skin failure, and unavoidable pressure injuries. Advances in Skin & Wound Care 32(3): 109-121.  www.woundcarjournal.com
4. Schank JE (2019). Special Report: Terminating the Kennedy Terminal Ulcer? Wound Management & Prevention (formerly Ostomy-Wound Management); 65(4). ISSN 2640-5245  http://www.o-wm.com/article/terminating-kennedy-terminal-ulcer

There is a difference between having a certificate and being certified. Having a certificate means that an individual has completed required courses of learning in a particular area. Being certified means that an individual has the specific knowledge and skills required to perform successfully in a particular role. Certification in health care originated from the specialty organizations in the field, with the purpose of conferring upon their members public recognition of having met these criteria of knowledge and required skills. Certifications of value have historically been those that are supported or endorsed by the specialty organization in the field.

In the healthcare field, being certified and maintaining certification is more often than not an essential requirement to remaining in a job. Standards of care evolve based on research findings and practical experience, and keeping current on best in class practices makes a difference in patient outcomes. Maintaining certification provides independent verification of certain levels of expertise and on the job capabilities.

In wound care, there are numerous certifications which can be earned, and members of the AAWC represent virtually all of them. Once earned, certifications are valid for varying periods of time and may last up to a decade before re-certification is required.

While some employers pay for an employee to maintain certification, it is increasingly a cost line axed by tightening budgets leaving an individual to cover the costs independently. Until now, there has been no alternative to the high cost of maintaining certifications.

The American Board of Wound Healing has recently offered a special opportunity to AAWC membership to grandfather existing certifications at no cost. Modeled after other American Board of Medical Specialties organizations, the ABWH is an example of a professional society that supports and endorses a certification in wound care. Further, ABWH does not charge annual maintenance fees to its certificate holders.
 
“This opportunity offers a significant savings to the AAWC membership,” said Victoria Elliott, R.Ph., MBA, CAE and Chief Executive Officer, AAWC. “We are grateful to ABWH for recognizing the depth of capabilities of our membership and its willingness to support the certification process in this way.”

Savings to the AAWC membership will vary according to the certifications held. For those with multiple certifications, the accumulating costs are significant. For example, an individual with a certificate valid for 10 years paying an annual maintenance fee of $150 will pay $1,500 for the duration of the certification. At expiration, additional fees are required to complete reexaminations to maintain certification and once renewal is earned, the maintenance fees continue unabated.

With the offer from ABWH, through November 2019 all AAWC members may apply for a conferment of their existing certification(s) to the equivalent ABWH certification. On completion of a satisfactory review by the ABWH Board, the comparable certification(s) will be issued. The ABWH does not charge an annual maintenance fee. Successful applicants must maintain AAWC membership for the duration of the certification period. Re-certification requirements as outlined with each exam category will apply.

“ABWH recognizes the high degree of expertise represented by the AAWC membership,” said Greg Bohn, MD and President, American Board of Wound Healing. “We are pleased to make this offer to them.”

The process for AAWC members to take advantage of this opportunity is as follows. An applicant would identify the appropriate category for certification and submit the required documentation as indicated in the application. In addition, the Applicant would provide ABWH with:

• Current certification, including dates of expiration
• Documentation of current AAWC membership
• A complete application with required information supporting the certification requested

After review and confirmation by ABWH leadership, comparable certification will be issued. A copy of the certificate can be provided on request and for a small fee. ABWH will advise the AAWC about which members have become certified and the expiration date of the certification. To qualify for certification conferment, applicants must maintain continuous membership in AAWC and comply with re-certification requirements as outlined with each exam category. 

More information can be obtained by visiting https://abwh.net/recertification/.

A simple search of professional medical and healthcare organizations reveals thousands of options for medical professionals. Without looking at the remainder of the alphabet, there are hundreds beginning with the letter A: American this, Academy that, Association of – it is an almost endless list and presents myriad choices for those in the medical and healthcare communities.

Professional organizations are the members’ sources for industry trends, legislative updates, connections of clinical practices with advancing research, and peer-to-peer relationships, among other benefits. But membership alone is not sufficient. Studies on member value show membership becomes meaningful only when individuals feel engaged and attached with the organization.

Being active and informed, developing relationships with other professionals while advancing the organization’s mission, is the difference between being a member of something versus being a part of something. The Association for the Advancement of Wound Care offers many opportunities to enhance membership and make it matter.

“We are what our members make us,” said Victoria Elliott, R.Ph., MBA, CAE, & AAWC Chief Executive Officer. “It is through member engagement and participation that the AAWC drives its vision to advance wound care worldwide. We rely on the volunteers to support the three strategic pillars of Education, Policy and Research.”

The AAWC has a class of 150 volunteers engaged throughout the year on many important issues and programs that membership at large has defined as key to their profession. Volunteers are the ones who serve as conference planners and speakers, facilitators, moderators and program reviewers. Content creators develop newsletter articles, blogs, social media posts and other content for various communications platforms. Those involved in policy matters develop letters and position papers, write platform materials, and visit with elected state and federal officials. In the area of awards and scholarships, volunteers work to define appropriate honors, review submissions and requests, and select recipients.

Recent achievements of AAWC volunteers include successful focused-topic regional summits, and advancing policy considerations in Washington, D.C. by giving voice to the need for increased prevention of pressure ulcers for our nation’s veterans. Educational programs have improved with expanded and participatory Journal Clubs featuring AAWC volunteer faculty, linking new research findings from the lab with the practice in clinical settings.

Volunteers report having a greater sense of community in the wound care profession and a deeper connection with their peers across all disciplines of care. “I was unsure whether I really had anything to contribute,” said one volunteer. “I was new to the AAWC and fairly new in my job, and was intimidated by the experience of others. But by becoming involved in a committee for one of the Summits, I was able to build my skills and develop a greater sense of confidence.”

There are currently a variety of education, content creation and committee volunteer positions available to members. For more information, go to https://aawconline.memberclicks.net/volunteer-opportunities.