Why We Need To Take A Closer Look At The Roles Of ‘Wound Care Specialists’

Currently, there are a number of people on the health care team touting themselves as wound care specialists. For those of you who may not know, the term “wound care specialist” does not imply a physician, a physician’s assistant or even a member of the nursing staff for that matter. Scores of people who might otherwise be considered “volunteer staff” or “nursing assistants” are now being sent for an abbreviated course in wound care products and, after taking this course, are subsequently referred to as “wound care specialists.”

These specialists, often laypeople, may be working without the strict supervision of another medical specialist. In a day and age when the health care team is being expanded to include more home care provided by people under the auspices of social services, some patients may be falling between the cracks.

In order to underscore the ramifications of these developments, I would like to present the following case in the hope of increasing awareness that the field of wound care specialists is being diluted by private entities focused more at supplying wound care materials than providing medical care.

Considering The Case Of An Obese Female With Diabetes And An Infected Heel Ulcer

The potential complications of a decubitus heel ulcer in a patient with diabetes can be devastating. When this condition is compounded by poor health, even common pathology can become morbid. The stepwise approach to clinical evaluation and management for the heel decubitus ulcer cannot be understated. While the heel decubitus ulcer is often manageable with the benefit of appropriate offloading and local wound care, serious complications can occur if valuable time is wasted on ill-conceived wound care plans.

The case presented herein centers on a 73-year-old morbidly obese, hypertensive, diabetic female patient with known peripheral vascular disease and hypercholesterolemia. She was at an extended care facility and, over time, developed a heel ulcer. A wound care specialist provided care for this ulcer. The wound care specialist’s treatment plan included offloading of the heel by elevation and using various wound care agents multiple times per day. The patient was subsequently transported to the emergency room due to progressively uncontrolled diabetes and an infected heel ulceration.

Upon presentation, the patient had an enlarged eschar on the most proximal aspect of the plantar medial heel that was atop a base of spongy and very mobile subcutaneous tissue (see Figures 1 and 2). The borders of the eschar were detached from the periphery but remained anchored to the tissue beneath it. The malodor present was suspicious for Pseudomonas.

The treating physicians consulted the podiatric medicine department after the patient was on the hospital floor and under medical management. Surprisingly, there was an additional ulceration on the lateral heel that appeared chronic in nature despite the fact that all accounts from the extended care facility indicated treatment for a solitary ulcer of the plantar heel over time. It is reasonable to surmise that the offloading plan instituted by the “wound care specialist” resulted in a transfer of pressure to the lateral heel, which lead to a second site of ulceration. This second ulceration apparently went unnoticed prior to the patient’s presentation in the emergency room.

A Staged Approach To Evaluation And Management

The initial goal was to choose the optimal empiric therapy while determining the nature and extent of the pathology in the lower extremity. The patient was placed on ampicillin-sulbactam regimen based upon the patient’s renal function. The second goal was to obtain fresh tissue specimens for both pathology and microbiology in order to study the local soft tissue and bone. Before this could be done, medical clearance from vascular surgery and internal medicine teams would be required.

After the vascular surgery consult, the patient underwent non-invasive vascular testing followed by an arteriogram. The patient had significant occlusive vascular disease within the femoral artery and the trifurcation of the lower extremity in question. The vascular team was familiar with this patient and deemed her to be a non-salvageable vascular case given the failure of prior bypass grafting in the affected limb. Local debridement of bone and soft tissues was suggested in an attempt to eradicate infection as a last resort to avoid a major amputation.

We performed provisional wound debridement and followed this with VAC therapy (KCI). We considered VAC therapy the most physiologic as it allows continuous drainage while the patient begins empiric antibiotic therapy.

We obtained an indium leukocyte (WBC) scan given the longstanding presence of the calcaneal decubitus in the presence of severe peripheral vascular disease. While the indium leukocyte scan can identify the site of infection, it doesn’t provide meaningful anatomic information. Given this fact, I recommend performing the indium leukocyte study in conjunction with a routine 99mTc-MDP bone scan, which provides the anatomical mapping for a precise biopsy of the given pathology identified on the indium leukocyte scan.

With the results of this combination imaging (Figures 3-5), one can see indium-labeled leukocytes very proximal into the calf muscle group. The extent of this infectious process is much more extensive than the clinical condition would have suggested. Consequently, the clinical condition deteriorated despite local debridement and intravenous antibiotic therapy adjusted for chronic renal insufficiency. Ultimately, an above-knee amputation was required and the patient ultimately returned to the extended care environment.

Final Points

Patients with diabetes and infection are often fraught with complex medical conditions that complicate the wound care plan. The heel decubitus ulcer can be a particularly difficult wound to treat even when underlying comorbidities are clinically stable (which is often not the case). It is not unusual for ancillary “wound care specialists” within extended care facilities to develop wound care plans that may not be optimal for the patient. As with this case, they may overlook the big picture and fail to take into consideration the patient’s entire medical history and the severity of the present illness.

This case clearly emphasizes that point. If surgical debridement had been provided much earlier, the infectious process may have been averted.

In some cases, ill-conceived wound care plans may very well delay more aggressive efforts such as surgical wound debridement and wound biopsy/culture. For any patient with diabetes who develops a wound, a thorough medical history and clinical evaluation are essential. Aggressive offloading and protection in addition to appropriate medical and surgical consults will ensure an optimal total care plan for the patient.

The offloading plan must be supplemented by a decubitus prophylactic care plan in which the patient’s sleeping or resting position is modified every two hours to prevent secondary sites of pressure necrosis and ulceration. This not only requires the nursing staff to adjust the patient’s position, it requires follow-up observation of the patient in order to identify early evidence of irritation or unusual skin changes.

Physicians should establish clinical benchmarks once they have identified deep dermal defects and set stringent targets for wound progress. A simple rule of thumb in gauging wound healing is to determine whether the patient has achieved 50 percent of wound closure within four weeks of treatment. If this is not the case, one has to reconsider the culprits that may be delaying wound healing. Causal factors may include infection, dysvascularity, immune compromise or other complicating factors.

Obtaining a biopsy of the wound is essential to identify both microorganisms of infection as well as other pathologic tissue changes that may impact wound healing.

It remains untold as to whether our patient would have been able to avoid the below-knee amputation. However, I suspect most patients with diabetes would have a much better chance at healing a wound if they are referred for treatment as early as possible. Just because this patient was in an extended care facility does not imply that there was a thorough care plan involving the multiple specialists required to achieve optimal management for patients with complex diabetic wounds.

Figure 1. Necrotic eschar with decubitus ulcer
Figure 2. Lateral heel ulcer
Figure 3. Tc-MDP blood pool reveals vascular tree of the calf and little else
Figure 4. Tc-MDP 5hr delay reveals increased intensity in the heel bone consistent the pathology
Figure 5. 45hr delayed Indium-WBC reveals infection tracking along Achilles tendon


Anonymoussays: June 22, 2009 at 5:50 pm

Having worked in both the best and worse of nursing homes, patient's are lucky to have minimal care in most. For off loading and re-positioning a patient's sleeping, I'd be willing to estimate that less than 5% of even the best facility would follow your orders.
My true feeling is that another ulcer or even the present one is not reported as it means more work for the staff. Pathetic isn't it?
Also some training should be given as to wrapping the foot if that's the order with rolled gauze. I find the bandages falling off and not even covering the ulcer.

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Anonymoussays: June 23, 2009 at 2:51 pm

Thank you Dr. Judge for your most informative article on the diabetic with vascular and wound problems of the lower extremity. I am a Registered Nurse Nationally Certified in Wound Care for almost 10 years. I have treated exactly what you describe and fought the battle of not only Skilled Nursing Facility Wound Care persons who do not have the expertise to address a patient's overall health issues. This also happens in the area of Home Health. I was Clinical Coordinator of an Inpatient and Outpatient Hyperbaric Oxygen Therapy and Wound Care Dept. If you are familiar with that program, you will understand the team approach utilizing the vascular surgeon, infectious disease specialist, dieticians, and RNs and LVNs trained in wound care procedures. The process included TCPO2 testing, sharp debridement,wound cultures with administration of the appropriate antibiotics (to manage,in many cases, osteomyelitis), nutritional assessment and meticulous wound care and HBO therapy when needed. If a podiatrist referred to our facility, they followed the patient for extensive debridements. The VAC system was utililzed frequently--sometimes more than necessary.
In any case, thank you again for pointing out the flaws in the term "wound specialist". C.A., RN, CWS

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Anonymoussays: June 25, 2009 at 11:24 pm

It is refreshing to hear that I am not alone in the frustration regarding the out break of "wound care specialist" that fall outside the actual practice of medicine. I believe it is important to pay special attention to pre ulcerations and ulcerations regardless of whether they occur in patients at home, in the extended care facility or in the hospital. The problem is that our present system allows people ill equipped for medical management and problem solving to serve these patient populations. At present we are now being infiltrated by "wound care specialists" that are actually social services employees with little to no experience in wound care or the study of health for that matter. With the trend toward universal health care and government regulated medical management this will get worse.

If there were ever a time for evidence based medicine it is now. I feel strongly that the medical community should be able to report cases to a centralized data base
to compile these cases and report the morbidity and mortality associated with them. I believe the statistics would be frightening to both patients and physicians alike. Unfortunately these poorly managed cases are increasing due to the degenerating condition of the extended health care team and the so called wound care specialists lurking outside of the medical community. They do not function with any degree of accountability and so when these bad outcomes arise the only one holding the ball is the last physician to attempt to help the patient.

Further, I don't think that these patient's are provided with informed consent to be treated by people outside of the medical community and that is another problem.

Thanks for your comments and I look foward to hearing more from you in the future.

Molly

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