Keywords

decision making

Triple Aim

back to basics

Issue: Volume 65 - Issue 6 - June 2019 ISSN 2640-5245

Introduction

What drives the decision-making process when managing the patient with a wound? There are different schools of thought, including published concepts, philosophies, and algorithms that help illustrate the concepts behind the clinician’s approach to wound care.

The Triple Aim

In 2010, the Institute for Healthcare Improvement initiated the Triple Aim theory to improve population health and health system performance. Built on the premise of improving health by providing cost-effective care that addresses quality and patient satisfaction, this philosophy fits perfectly with providing care for wound healing. Much ado is made about “expensive” products we may use on patients with wounds; unquestionably, we need to be mindful of costs. Likewise, we cannot assume patients will heal “eventually”; we need to think about how to achieve healing expeditiously. The oft-quoted prognostic indicators of 50% healing of a diabetic foot ulcer and 40% healing of a venous leg ulcer by 4 weeks equating to earlier healing should be heeded.1-3 Faster healing will almost invariably offer the potential clinical benefits of removing the nidus for pain, reducing the potential for infection, getting the patient moving and back to work sooner, and improving quality of life wherever it has been impacted, not to mention lower costs. Utilizing critical resources earlier rather than later when the wound has become even more chronic and inflamed makes sense, but doing so requires vigilance. Healing progress must be closely monitored to avoid spending weeks using the same treatment with little or no improvement. Clinicians must remember that improvement is not always reflected in smaller measurements alone; progress also can be evident in other short-term goals such as reduction of exudate, improved periwound skin, reduction of pain, and reduced edema.

Healability

Although the word healability cannot be found in the dictionary, it makes good sense. Sibbald et al4 coined the phrase in their 2014 paper on wound bed preparation and describes the associated goals for wound management as:

Healable

A wound with adequate blood supply that can be healed as long as the underlying problem can be addressed

Maintenance

There may be healing potential, but patient or health system barriers, (including patient nonadherence to a treatment plan or health care resource limitations) may compromise healing

Nonhealable

Wounds, including those in patients receiving palliative care, cannot heal because of irreversible causes or associated illnesses, including critical ischemia or non- treatable malignancy.

Healable. Evaluating the patient’s potential to heal from the get-go aids in appropriate goal- setting and treatment decision-making. Clinicians treating wounds that fall into the healable category always need to consider barriers and other potential impediments to healing such as comorbid conditions, necrotic tissue, and inflammation. Early management should be able to reverse these obstacles and move wound healing onto a positive trajectory.

Maintenance. Wounds that fall into the maintenance category may not lack the ability to heal, but they will require more resources to do so. These may include, but are not limited to, instituting earlier interventions to correct underlying pathology, more aggressive attention to and management of inflammation and biofilm, and nutritional evaluation and support. Treating such wounds should include revisiting or broadening the search for reasons for nonhealing using diagnostics such as imaging or biopsy.

Although a patient may be labeled noncompliant, clinicians should consider giving the benefit of the doubt. Frank discussions with patients who are seemingly nonadherent to care should be queried as to why they are unable to follow the prescribed treatment plan. It may be that not working is not an option if the treatment creates a work issue or they may have difficulty making/keeping appointments or they may be the only caregivers for small children or grandchildren; the list can go on and on. Compassionately attempting to find an alternate treatment plan patients can follow may not be expeditious, but it could foster a sure if slower path to healing.

Nonhealable. For nonhealable wounds, the most reasonable approach may be to develop an appropriate and protective palliative care program with goals to manage pain, odor, and exudate; avoid further injury; and keep the wound clean and uninfected. All of these efforts will help put valuable resources in the right place.

Step Down Then Step Up

In the Consensus Guidelines for the Identification and Treatment of Biofilms in Chronic Nonhealing Wounds,5 Greg Schultz et al described a management strategy that advocates for the initiation of multiple therapies in combination early. These therapies might include aggressive debridement, bioburden and biofilm management, aggressive attention to host factors, and use of available point-of-care diagnostics and DNA culturing to rapidly obtain a well-prepared wound. The clinician then can monitor optimization and personalization of the therapy according to the individual’s healing status and de-escalate treatment as the wound improves. As wound follow- up approaches 4 weeks, the clinician can evaluate healing and decide whether continuing with standard of care will facilitate a healing trajectory or if treatment should be stepped up to advanced therapies. Depending on the site where care is being provided, clinicians also should consider moving the patient to a higher level of care (eg, a specialty clinician or center) sooner rather than later.

Topical treatment. One aspect of wound management that is decided at each evaluation is the choice of topical treatments. Recent installments of “Back to Basics” have described cleansing, exudate absorption, and moisture management and the myriad of dressings and products to answer the needs of the wound based on a thorough assessment. Unfortunately, multiple providers with multiple dressing opinions also can create clinical and cost inefficiencies. Changing the type or category of dressing simply because a clinician likes one over another is always going to be costly, especially if dressings have already been ordered and provided to the patient at home or in a skilled nursing facility. Dressing changes should be based on changes in wound status and altered if the current plan of care is not meeting the environmental needs of the wound — for example, utilizing a superabsorbent product rather than layering an absorbent product such as an alginate and covering with a foam.

Wounds are dynamic; over time, their needs will and should change. There is no “one size fits all” as we nurture the wound toward healing. Each and every time a dressing is changed, the wound surface is disrupted; a change in temperature, pain, and trauma to the wound bed and/or surrounding skin potentially can occur. The goal is to reach a point where we can step back, let the body heal by design, and disturb the wound as little as possible utilizing a dressing that manages exudate effectively, maintaining the optimal moisture and temperature level, providing protection from contamination and minimizing trauma.

Dr. Steven Covey6 (7 Habits of Highly Effective People) advises, “Begin with the end in mind.” Preparing for the desired wound outcome and controlling and directing the resources toward that outcome can put the patient on a healing pathway.