If you are a wound management practitioner, then like me, you’ve continued to care for patients during the pandemic. It wasn’t easy before COVID-19 and it’s even harder now. My clinic is only able to see half the volume (due to the time required for COVID-19 screening, room cleaning, etc.) Family members are not allowed in the waiting or examination rooms, which means I need to spend extra time talking to them in hallways or calling them on the phone to discuss the complex issues affecting their loved one. Delivery systems remain fragmented. However, I fear that COVID-19 is not the real problem when it comes to “doing the right thing” for patients with non-healing wounds. Here’s a case I saw a few days ago that illustrates why I stay frustrated:
An 82-year-old woman has had a non-healing wound since the removal of a skin cancer two years ago. She had been cared for at another wound center for over a year with compression bandaging and the application of cellular products. In the middle of the COVID-19 epidemic, her son brought her to see me because he was frustrated with her lack of improvement.
CMS has endorsed the US Wound Registry (USWR) quality measure that patients with non-healing lower extremity wounds be screened for arterial disease at their first visit, and that’s what we do. At her initial visit, I screened her for arterial disease. My preferred method is skin perfusion pressure (SPP) and pulse volume recording (PVR), although I do still use transcutaneous oximetry. Her SPP was only 27 mmHg on the lateral leg near the wound in the region of the peroneal artery. (A value of 30 mmHg or less suggests that the wound will not heal.) The PVR of the right leg was biphasic and of low amplitude, suggesting that the reason for the poor tissue perfusion was arterial disease. As further evidence that arterial disease is the reason she had failed to heal, she had ischemic rubor of her entire lower leg (redness which is not hot to the touch and which goes away with elevation (read more here). Extreme leg pain kept her awake at night.
There’s more. She is a life-time smoker and had not had a cardiac evaluation. She also weighed only 95 lbs – her BMI (body mass index) was a shockingly low 16.3! She was literally starving, but had not undergone any type of nutritional evaluation or been recommended to take nutritional supplements. (See a previous blog post about this). Failure to recognize malnutrition is the reason that the USWR has developed a nutritional screening quality measure for patients with chronic wounds and why Intellicure added the quality measure to their wound care EHR, and new quality measures are now available developed by the Academy of Nutrition and Dietetics.
Let me recap the situation: An elderly woman at high risk for vascular disease (lifetime smoker), with a non-healing leg wound for two years and symptomatic arterial disease (nocturnal rest pain), had been treated for nearly a year at a wound center with compression bandaging and expensive cellular and/or tissue based products (CTPs) – without having undergone an arterial assessment that would have found her PAD, and without being treated for malnutrition despite a BMI indicating she is starving.
This is not an unusual scenario. I see at least one patient like this every month.
Here’s my manifesto – and there’s enough in the short list below to generate a lot of heated debate:
- If you run a wound center, you should be able to screen patients for arterial disease in your center, without sending them to a vascular lab and waiting days for the results.
- Arterial screening should be done at the first visit on patients with non-healing lower extremity leg ulcers – and an arterial brachial index (ABI) is not good enough to establish whether a wound will heal, although it can be used to determine whether compression can be applied safely. To determine whether a wound will heal, you need a physiological test such as skin perfusion pressure or transcutaneous oximetry. A facility that calls itself a “wound center” should offer this type of screening and perform it consistently.
- Patients with non-healing wounds should undergo nutritional screening. I personally think nutritional supplements should be universally recommended. I know it’s possible to have an esoteric argument about the details, but since the average patient in a wound center has had a non-healing wound over 100 days – do we really need to argue about the evidence base for specific blood tests or supplements when malnutrition is being missed among patients with a BMI less than 18? (It’s my personal opinion that all patients with non-healing wounds should have a Vitamin D-OH level checked as well as other basic nutritional labs.)
In keeping with my hospital’s COVID-19 policy, the patient’s son had to wait in the hallway outside the wound center while I did her evaluation, after which I went out to explain to him what needed to be done. It was an awkward conversation because I first had to explain that while I WAS worried about her leg, the most urgent thing was a cardiac work up, even though she had no cardiac symptoms. Why? Patients with peripheral arterial disease (PAD) usually have coronary artery disease. Early in my career I lost a patient to an acute MI while I was busy treating their leg. As soon as we were sure she didn’t have a life-threatening cardiac problem, we’d tackle the leg ulcer starting with her PAD, but today we could start addressing her malnutrition.
Non-healing wounds are a SYMPTOM. Our job is to diagnose and treat the underlying disease(s) responsible. As we engage in the discussion of the “wound center without walls,” I continue to have a terrible uneasiness about what happens inside the wound centers that HAVE walls. If we can’t do the right thing when a (supposedly trained) advanced practitioner is directing the care, how will we do it somewhere else?
Do you want to know what happened to this woman? Stay tuned. I referred her to cardiologist Dr. Sanjaykumar Patel. He’s going to guest blog in the coming days to tell you the rest of the story.
Why is it hard to do the right thing in wound care? I don’t know.
In the absence of a recognized sub-specialty, I believe the ANSWER is quality reporting. We have data proving that practitioners who report the quality measures of arterial screening, diabetic foot ulcer off -loading and venous ulcer compression have higher healing rates than practitioners who don’t report those measures – and yes, we do control for wound/patient severity. If you would like to join me and a growing number of wound management practitioners who do the right thing and prove it by reporting USWR quality measures, you can find out more about what the US Wound Registry does.
Dr. Fife is a world renowned wound care physician dedicated to improving patient outcomes through quality driven care. Please visit my blog at CarolineFifeMD.com and my Youtube channel at https://www.youtube.com/c/carolinefifemd/videos
If this wound was treated for a year in wound clinic with use of advanced therapies, what is the reason that it still has so much slough?
Reminds me of a Peanuts saying: “You’re a good man Charlie Brown”. Or the saying: “You’re a good nut.” Or another one….
You’re a good egg, Dr. Fife!
As an ICU doc and wound care doc, I love the concept of wound care center without walls. I had that at my former institution. My current institution is getting better, but in some ways they’ve perfected the model of the silos.
As always a superb teaching tool for my students. Ahem! Me and my Colleagues!
Well said again Dr. Fife. Nutri-Heal is available to all wound care centers to help meet the USWR’s nutritional screening quality measure.
WOW – this is scary all the way around. Thanks for sharing and doing right Dr Fife!
I like the idea of being able to be screened for arterial disease without having to go to a vascular lab. That would save someone a ton of time in the case of wound care. They could be in serious pain and need immediate attention.