The Future of Wound Care
The patient population requiring wound care is ever increasing because of medical and epidemiological factors, such as increasing obesity and diabetes mellitus. More than 6.5 million people are affected by chronic wounds in the United States, resulting in annual treatment costs up to $25 billion.2 Chronic wounds are estimated to affect approximately 2% of the population with an array of etiologies and with a mortality rate that is comparable to some types of cancers.3 Wound care is an integral part of patient care that can markedly increase the quality of life for an individual. Many office-based treatments can provide positive outcomes, and patients with nonhealing wounds can be offered hope through an evidence-based systematic approach that involves surgical intervention and complementary care. Perioperative nurses need to be cognizant of the treatment options in the surgical realm that can be offered to this patient population to enhance healing and provide the best possible outcomes.
Medicare reimbursement changes, bundled payments, facility compliance audits, and regulatory standards have significantly affected the financial aspects of wound care. These elements coupled with numerous cuts to third-party payers, with Medicare being the largest payer for patients with chronic wounds, result in challenges related to cost containment and fiscal responsibility. Medicare reimbursement requires stringent documentation relative to the medical necessity for treatment with evidence of objective measurement of the wound and the potential and significant benefit of the specific treatment. Also, Medicare Part B has limited the conditions covered for hyperbaric oxygen therapy and for diabetic wounds, whereby three criteria must exist before a patient is eligible for this therapy.4 These three criteria include having a lower extremity wound that is directly related to diabetes, having a wound classified as Wagner grade III or higher, and having failed an adequate course of standard wound therapy.
Hospital administrators work on behalf of patients to obtain access to the treatments that can provide the best possible clinical outcome for these difficult-to-heal wounds. Bundled payments can potentially affect services by requiring wound care patients to be moved from hospital-based services to outpatient physician practices because of payment eligibility. The plethora of financial challenges that hospitals face to provide these services must be navigated with cautious optimism, and hospital leaders must promote a balance of cost containment while never losing sight of the goal of positive patient outcomes. Therefore, regenerative treatment modalities, such as biologic scaffolds, allogeneic or autologous stem cells, and recombinant growth factors, must be scrutinized and selected carefully to balance costs with what is best for the healing of wounds.
Currently, wound care practices across the country are healing chronic wounds of many different etiologies, including (but not limited to) ischemia, pressure, trauma, coagulopathies, infection, diabetes, vascular, and autoimmune disease. Appropriate and timely treatment helps prevent extensive surgery and ultimately prevents the need for amputation. Therefore, providing the optimum treatment modalities is vital to maximize the ability for a wound to heal. Successful treatment of wound care patients requires a holistic and systemic approach, including looking at the whole patient and not just the wound. The health care team needs to understand and address underlying physiological aspects of the patient that can affect wound healing, such as inadequate nutrition or endocrine, cardiac, and pulmonary disease processes. These complex patients deserve the most current evidence-based treatments for optimal outcomes.
The evolving need for advanced wound care presents an exciting opportunity for innovation. It will not be uncommon in the future for health care providers at wound centers to use noncontact planimetry to measure and assess a wound accurately to determine if it is healing. Noncontact planimetry involves capturing an image with the use of a high-resolution camera and then uploading the image to a computer. This image is analyzed by specialized software that digitally outlines the wound margin.5 Some software also can determine depth measurements and perform volume assessments.5
Another interesting innovation is the use of modern machine-learning methods and software engineering to create a predictive model for delayed wound healing that uses information collected during routine care in outpatient wound care centers across the country and aggregates the data in a wound registry.6 This will enable clinicians to guide treatment and clinical decision making based on comprehensive computer-generated data and not just personal experience.
Another new therapy being used to promote healing in preclinical and clinical studies is the application of mesenchymal stem cells in the form of a spray from a high-pressure spray gun.7, 8 This gun can spray autologous stem cells onto large wound surfaces commonly caused by burns, and is not painful and does not cause scarring.
IN THIS ISSUE
This issue of the Journal touches on many of the innovations in wound care and provides readers with a knowledge base to approach this patient population better and be able to treat these patients in the OR successfully. The articles tied to the special wound care theme in this issue are highlighted in the following text.
The article “The future of data-driven wound care” by Woods et al9 delves into the world of “big data” and machine learning and emphasizes their place in health care today and in the future. It also breaks down confusing computer language into simple and concrete concepts that are easy to understand. A scenario is built into this article to enable readers to understand the application of big data from the office setting to the OR and beyond. This article highlights important recent advances and discusses how these technologies may revolutionize advanced wound care.
The article “A perioperative approach to increase limb salvage when treating foot ulcers in patients with diabetes” by Howell et al10 examines the staggering current statistics on patients with diabetes and neuropathic foot ulcers and the approaches to decrease the number of amputations and improve the quality of life for these patients. The article provides photographs and explores clinical descriptions of neuropathy, treatment modalities for infection in foot ulcers, pathophysiology-based debridement, offloading for plantar neuropathic ulcers, and the use of adjuvant growth factor and cellular therapies for the treatment of refractory wounds.
The article “Hyperbaric oxygen therapy: indications, contraindications, and use at a tertiary care center” by Howell et al11 provides a brief history of the use of hyperbaric oxygen, reviews the indications and contraindications, and presents an overview of the hyperbaric oxygen program at a tertiary care facility, including the most commonly treated patient diagnoses, along with therapeutic protocols for the treatments used at this facility.
I hope this special issue will spark an appreciation for the wound care patient population and provide the knowledge perioperative nurses need to navigate the care of these patients when they enter the OR suite. Operating room nurses are poised to be a vital part of the process of providing necessary wound care treatment options to the surgical patient, and they must be able to discern the different wound care products and evidence-based technologies during surgery.
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