The Wound Bed Preparation (WBP) paradigm was first published in 2000. The paradigm was introduced to highlight the treatment of the "whole patient" and not just "the hole in the patient." The key messages are to identify/treat the wound cause and examine patient-centered concerns; practitioners should determine if the wound is healable before focusing on the local wound and surrounding region. There is also an emphasis on monitoring the rate of healing, identifying stalled but healable wounds for potential adjunctive therapies, and the need for healthcare systems to facilitate coordinated and integrated interprofessional care.

Sufficient blood supply is needed for a wound to heal, and technology can assist in new ways of identifying adequate circulation. Times change, and in this 2021 version of WBP, we have introduced a new way to identify the cause by examining arterial wave forms with a commonly available handheld portable 8-MHz bedside Doppler (audible handheld Doppler [AHHD]) as an alternative to the traditional ankle-brachial pressure index (ABPI). Dr Dieter Meyer has recorded a helpful video outlining the AHHD procedure that can be accessed at https://journals.lww.com/aswcjournal/Pages/videogallery.aspx?videoId=20.

There are several advantages of the AHHD versus the traditional ABPI:

* It is quicker because the patient does not need to be recumbent for 10 to 20 minutes; if needed, the test can be performed with the patient sitting on a chair.

* There is no squeezing of the calf muscle, which can cause increased pain for the patient.

* The result is never falsely inflated by calcification of the arteries (ABPI >=1.3) because the waveform is independent of arterial calcification.

* Any multiphasic (biphasic or triphasic) wave will result in an AHHD value equivalent to an ABPI >0.9.

* Comparing AHHD with great toe pressure (>55 mm Hg) is 97.55% specific as an alternative method to rule out arterial disease.1

* The screening for arterial disease with only monophasic waveforms triggering an automatic sequential Duplex lower leg Doppler can save healthcare system dollars.

The AHHD signal will correctly identify the absence of arterial disease in most persons tested.1 However, there are always exceptions to the rule, including angiosomal (segmental arterial) defects or aberrant arteries. The absence of arterial disease should be confirmed with a physical examination.2

Further, not all patients are mobile or can attend wound care clinics in the community. Given the added risk of novel coronavirus 2019 (COVID-19) infection, and to facilitate virtual and blended care models, the AHHD signal can be recorded by a healthcare professional on a cell phone and transmitted to healthcare facilities with interprofessional wound care experts for leg and foot ulcer care. That is, patient data can be gathered at the bedside by a visiting nurse or qualified healthcare professional with secure connectivity. A comprehensive interprofessional assessment can be completed synchronously or asynchronously.

The advantage of a synchronous assessment is that the patient can hear the Doppler sounds and participate in ensuing discussion. The patient can approve management options to adequately address his/her specific concerns. Practitioners can advise patients about realistic outcomes based on their blood supply and ability to manage the wound cause. Although most wounds are healable, practitioners must tailor their approaches to maintenance and nonhealable wounds to emphasize patient-centered concerns.3

With COVID-19 delaying routine patient care and the possibility of viral mutation threatening the continued need for safe interactions, procedures for virtual care and lessons learned from COVID-19 need to be embedded in healthcare systems. Blended care can be combined with WBP principles to optimize wound treatment for improved patient outcomes and lower costs.

R. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM

Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN

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