1. Wound Care: Where do we go from here? Jesse M. Cantu, RN, BSN, CWS, FACCWS April 20, 2012 San Antonio, TX

2. Disease Management (Wound Care Management) Evidence Based Best Practices Standards of Care Positive Outcomes Cost Containment Evolution of Dressings Summary

3. Wounds Types –Acute –Chronic Closure Phases of Wound Healing

4. Wounds Acute wound –Planned / unplanned event –Healing proceeds in an orderly and timely fashion –Examples: Surgical Abrasion / laceration

5. Acute Wound Surgical incision

6. Wounds Chronic wound –Exists two weeks or longer –Does not proceed through normal healing process –Examples: Pressure ulcers Diabetic / neuropathic ulcers

7. Chronic Wound Pressure ulcer

8. Chronic Wound Venous ulcer

9. Chronic Wound Post-operative dehisced wound

10. Wound Closure Primary intention Delayed primary Secondary intention

11. What do you do if the burden is too big?

12. Evidence Based / Best Practice Randomized control trials Protocols (NPUAP, WOCN, Canadian guidelines, AHCPR) Moist Wound Healing (George Winters) Wound Bed Preparation (Vincent Falanga)

13. The Building Blocks of the Foundation for Wound Care DebrideMoistureTopicalsOff-Load

14. DebrideMoistureTopicalsOff-Load SUCCESSFUL WOUND CARE HYPERBARICS GROWTH FACTORS BIOENGINEERED TISSUES BIOLOGIC DRESSINGS NEGATIVE PRESSURE THERAPY SILVER DRESSINGS

15. DebrideMoistureTopicalsOff-Load HYPERBARICS GROWTH FACTORS BIOENGINEERED TISSUES BIOLOGIC DRESSINGS NEGATIVE PRESSURE THERAPY SILVER DRESSINGS DIETCIRCULATION CONTROL OF DIABETES

16. Best Practices Evidence Based Wound Bed Preparation

17. Wound Bed Preparation What Does It Mean? Originally Debridement Fibrotic Tissue Hyperkeratotic Rim

18. Wound Bed Preparation What Does It Mean? Today “…a very comprehensive approach aimed at reducing edema and exudate, eliminating or reducing the bacterial burden and, importantly, correcting the abnormalities … contributing to impaired healing.” Vincent Falanga, MD Professor, Boston University School of Medicine

19. Other Voices…. “Think of it as removing various ‘burdens’ from the wound and the patient.” Exudate Bacteria Necrotic/cellular debris Elizabeth A. Ayello, PhD, RN & Janet Cuddigan, PhD RN

20. Standards of Care NPUAP WOCN AHCPR Canadian Guidelines

21. Positive Outcomes Wound Assessment at each dressing change

22. Cost Containment Wet to Dry Dressings (Gauze and Saline) –Frequent dressing changes Moist Wound Healing (George Winters 1961) Active Wound Healing (NPWT, Hyperbarics)

23. Evolution of Dressings Debridement Maintain a moist wound environment Reduce bacteria load Prolong dressing interval changes Stem cell technology

24. Summary Wound management not wound care –Need to jump start nonhealing or slow wounds Adequate assessment, debridement, and wound irrigation based on Best Practices, Evidence based, Standards of Care, Positive Outcomes, and Cost containment Case studies

25. Wound Care as Wound Management Properly treated wounds create the ideal win-win situation by decreasing hospitalizations, promoting wound healing in the home, improving quality of life, and improving patients’ sense of independence and well being.

26. Other Voices…. Wound Bed Preparation is “the management of a wound in order to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures.” Schultz G, Sibbald G, Falanga V, et al:Wound bed preparation: A systematic approach to wound management.Wound Rep Regen 2003

27. What’s Needed to Heal a Diabetic Neuropathic Ulceration? Control of Diabetes and General Health Adequate Diet Blood Supply Absence of Infection Regular Debridement Offloading of Pressure Moist Healing Environment

28. Total Contact Casts Custom Splints Therapeutic Shoes Removable Cast Walkers Common Methods to “Off-Load” the Foot

29. So what is this going to cost me? A lot less than traditional care…

30. Incidence, Outcomes, and Cost of Foot Ulcers in Patients with Diabetes” “Incidence, Outcomes, and Cost of Foot Ulcers in Patients with Diabetes” What is the cost of a new foot ulcer, not previously treated? Ramsey, Reiber, et al. Diabetes Care, Mar 1999 – Univ of Washington –$27,987 over a two year period!

31. 1. Benefits of a Closed Environment Moisture Balance Reduction of Nosocomial Infections Prevents patient interaction with the wound

32. 2. Promotes Perfusion Replacement of fibrinous tissue with granulation tissue Filling deficits in wounds Wound constriction Promotes granulation tissue formation Dompmartin A, et al J Wound Care 2004 June

33. 4. Benefits of Maintaining a Moist Wound Bed

34. Why do we keep a wound moist? Promotes rapid migration of epidermal cells across the wound bed Promotes perfusion

35. Why do we keep a wound moist? Promotes rapid migration of epidermal cells across the wound bed Promotes perfusion Barrier against environmental contamination

36. Benefits of Using Negative Pressure Therapy as an Adjunct 70 patients with chronic, non-healing wounds treated with VAC following skin grafts 100 % of the grafts healed in an average of 48 days Carson SN, Overall K, Lee-Jahshan S, Travis E. Ostomy Wound Manage. 2004 March

37. The New Wound Care Armamentarium And yes… it is a war, so you want to increase your odds of winning

38. Escalating Bacterial Loads Contamination – Presence of nonreplicating microorganisms in the wound Colonization – Presence of nonreplicating microorganisms adhering to the wound, NOT causing injury to the host Critically Colonized – Bacteria cause a delay in wound healing Infection Local to Systemic – Presence of replicating microorganisms in wound and presence of injury to the host Ayello and Cuddigan, 2003 BACTERIALLOADBACTERIALLOAD

39. Wound Bed Preparation: Combining Topicals with NPWT Control of: Contamination, colonization and critical colonization to optimize the wound bed Odor

40. Case Studies

41. The Challenge of a Large Deficit Wound and Poor Vascularity

44. Protected environment

46. Ready for grafting

47. AFTER GRAFT IS APPLIED