1. Woo, Kevin Y. PhD, RN, FAPWCA

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It is estimated that more than 400 million people worldwide have wounds of various etiologies.1 Chronic wounds, however, are often complex and recalcitrant to healing and may persist for months or years because of underlying disease processes or complications. With an aging population and increased prevalence of chronic diseases, the majority of wounds are becoming difficult to heal. This places a significant burden on the healthcare system and individual patients. The exact mechanisms that contribute to poor wound healing remain elusive but likely involve an interplay of systemic and local factors.


In an effort to address the growing demand in wound care management that is evidence based and cost-effective, I would like to highlight several gaps in wound care management and their potential solutions.


1. Systematized and holistic approach to wound management. The healing of acute wounds follows a predictive sequence of overlapping phases including inflammatory, proliferative, re-epithelialization, and remodeling stages.2 The complexity of healing depends on many intrinsic and extrinsic factors, which regulate the complex biochemical and cellular events that culminate in closure of a wound with fibrotic scar tissue. Unlike acute wounds, chronic wounds, such as pressure ulcers, venous leg ulcers, and diabetic foot ulcers, do not always follow predictable temporal overlapping phases of healing because of the disruption of 1 or more elements of the healing process.3 Treatment of chronic wounds requires a systematized approach under the tenets of "wound bed preparation," which highlights the key individual components of wound care.4 Within this framework, it is important to treat the cause and address patient-centered concerns prior to local wound care. Best practices to prepare the wound bed for healing include debriding of unhealthy and nonviable tissue, controlling infection and bacterial bioburden, maintaining moisture balance, and addressing the unhealthy wound edges.


Although complete healing may seem to be the logical goal for most patients and clinicians, some wounds do not have the potential to heal because of a number of factors, such as inadequate vasculature, coexisting medical conditions, and medications that prohibit the healing process.5 By determining the potential for healing, a proposed framework (Table 1) describes the primary focus of care and categorizes wounds into healable, maintenance, or nonhealable.6 Future study is required to describe the cost-effective and patient-centered approach to manage nonhealable wounds.6

Table 1 - Click to enlarge in new windowTable 1. HEALABLE, MAINTENANCE, AND NONHEALABLE WOUNDS

2. Knowledge to improve nursing care in wound management. Nurses are fundamental to quality wound care. Yet, not all settings have provided adequate ongoing advanced education for nurses, as demonstrated by the level of knowledge toward prevention and management of wounds in some regions.7


Several studies from various countries have documented that measures to prevent pressure ulcers are not consistently applied by nurses across different healthcare settings, often because of the lack of time, poor knowledge, or perception of low priority in care. It is undisputable that knowledge and attitude could have a significant impact on the quality of wound-related care. Nurses who possess adequate knowledge and perceive wound care as rewarding are more likely to provide evidence-based care and lifestyle advice to their patients, compared with those who lacked knowledge and positive attitude.8 Patients (n = 88) who attended a diabetic foot care program that was led by nurses with advanced foot care training developed fewer fungal infections (P < .001) and calluses (P < .001) over 2 years.9 None of the patients who had a history of foot ulceration developed recurrence of callus-related foot ulcers. Ostrow et al10 documented a 40% reduction of amputation by providing specialized wound care training to an interprofessional team in Guyana. In a study that was funded by the Ministry of Health in Canada, Woo et al11 demonstrated that wound healing was improved by care provided by a nurse practitioner with advanced wound care training in the community. Clarke-Moloney et al12 provided training to 30 public health nurses in Ireland. The annual wound care audit indicated that the number of venous leg ulcers treated with high compression increased significantly by 16% (P < .0001). The frequency of dressing changes was reduced (P = .002) with an increase in once-weekly dressing changes by 10%, resulting in significant cost savings.


3. Emergence of diabetes and other chronic diseases. Diabetes is one of the most prevalent chronic diseases that has become a worldwide epidemic.13 According to the International Diabetes Federation, the number of people with diabetes internationally will increase from 246 million or 5.9% in 2007 to 380 million or 7.1% by 2025.11 Of persons with diabetes, 2% to 3% will develop a foot ulcer annually; whereas the lifetime risk of developing a foot ulcer is as high as 25% mainly because of neuropathy and potential coexisting vascular disease.14 In following patients with diabetes and neuropathy for 1 year, it was estimated that 7.2% of this population would develop a first-time foot ulcer.13 More than 80% of all nontraumatic amputations in diabetes are preceded by foot ulcers, which should be considered as one of the prognostic indicators for advanced diabetes.15


In most countries, the healthcare system costs of diabetic foot ulcers are exorbitant and include a high likelihood of hospitalizations. A comprehensive framework for diabetic foot care has been described involving multiple-level interventions, health policy revision, and healthcare organization remodeling.16 See Figure 1.

Figure 1 - Click to enlarge in new windowFigure 1. MULTI-LEVEL CHRONIC DISEASE SELF-MANAGEMENT MODEL

4. Primacy of self-management. Self-management and patient engagement are the cornerstone of chronic disease management. Self-management support is "the systematic provision of education and supportive interventions, by healthcare staff (and others), to increase patients' skills and confidence in managing their health problems, including regular assessment of progress and problems, goal setting, and problem-solving support. Traditional education has minimal effect on behavioral changes. A growing body of literature now validates various psychological interventions including the use of social support, problem-solving skills, contract setting, cognitive therapy, and self-monitoring of behaviors, to improve diabetic self-management.16


5. Delivery of psychosocial needs of people living with chronic wounds. People who are living with chronic wounds describe the experience as isolating, debilitating, depressing, and worrisome, which contributes to high levels of stress. People with chronic wounds have been shown to experience more mental health problems than people without wounds in the community and are less capable to marshal their resources and apply problem-focused strategies to cope with stressful events.14 In response to a web-based survey, healthcare practitioners (n = 908) acknowledged that mental health concerns are common in people with chronic wounds. More than 60% of the survey respondents indicated that between 25% and 50% of people with chronic wounds have mental disorders, such as anxiety and depression.18 A sense of urgency has emerged to move the practice paradigm toward a holistic approach that places equal emphasis on both physical and mental health concerns. Mental health problems have been shown to affect normal wound healing and self-care abilities contributing to increased morbidity and mortality. Despite the prevalence, Upton et al18 found that more than two-thirds of healthcare professionals believed either few (25%) or none (0%) of their chronic wound patients were receiving attention for their mental health problems.


The unmet need for mental healthcare will likely continue to grow as a result of the aging population. Structured training is necessary for nurses to develop therapeutic alliance and counseling for their clients. Although nurses are often focused on completing a task, the new management paradigm should emphasize structured interventions that foster self-care and problem-solving skills among people with chronic wounds.


Espousal of Interprofessionalism

The optimal care of individuals with chronic wounds is complex and time-consuming and requires the support of an interprofessional team.19 Management of these ulcers involves a detailed examination and discussion with patients to adequately address their concerns. The management of a chronic wound may be further complicated by the fragmentation of communication and services between acute, chronic, and home care.


An interprofessional team approach that draws on the required expertise from a number of healthcare professionals, including nursing, medicine, social work, infection control, chiropody, rehabilitation, and nutrition, is required to address the complexity of wound care.20




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