Getting Chronic Non Healing Wounds to Heal - PowerPoint Presentation

Slide1

Getting Chronic Non Healing Wounds to Heal

Presented by

Rafat

Choudhry, MD,

FAPWHc

, FAWMS

Wound Care Physician

AtlantiCare Wound Healing CenterSlide2

Objectives

Overview of the significant impact of untreated wounds in the US

Overview of advanced wound care

Referral guidelines for Advanced Wound CareSlide3

Impact of Wounds on the US PopulationSlide4

Many suffer for months and years with wounds such as these:

Venous Stasis

Osteoradionecrosis

Diabetic Foot Ulcer

Pressure UlcerSlide5

Providers/Hospitals/Payers are Challenged by Treating Wounds

By having an outpatient Wound Healing Center, the problems of treating difficult and expensive wounds can be helped

.

The Advisory Board estimated that inpatient wounds were costing hospitals on average:

Four additional days per discharge

7.2% increase in mortality discharges

$5,423 additional costs per discharge

Often, a transfer to an outpatient wound healing center may lead to reduced lengths of stay and costs.

Care will be regular on a weekly basis for visits to reduce complications and readmissions. Care is coordinated with all providers on an outpatient basis including Home Health Nurses , dressing companies, PCP’sSlide6

By the Numbers…

Chronic wounds affect 6.5 million Americans per year at a treatment cost of $25 billion per year

Additional $39 billion in lost wages per year

$15.3 billion estimated expense on wound care products in 2010Slide7

Overview of Advanced Wound CareSlide8

What is a Chronic Wound?

“An insult or injury that has failed to proceed through an orderly and timely repair process to produce anatomic and functional integrity”

Masoro and Austad, 2006 Slide9

Cellular

Activity

Chemotactic Migration

Mitosis

Angiogenesis

Synthesis of ECM

Proteolytic Turnover of ECM

Inflammation

Proliferation

Remodeling

Normal Wound HealingSlide10

Degrades ECM

impaired cell migration

impaired connective tissue deposition

Degrades Growth Factors

Prolonged Inflammation

Stimulation of macrophage and neutrophils to wound bed

Repeated Trauma

Local Tissue Ischemia

Necrotic Tissue

Heavy Bacterial Burden

Tissue Breakdown

Activation of macrophages with release of cytokines



Production MMPs and



TIMPs

Chronic Wound

Delayed Healing

TNF

 and IL-1

3

Mast BA & Schultz GS (1996 )Slide11

What is Advanced Wound Care?

Specialized wound care is a focused, evidence-based specialized approach to the treatment of chronic wounds through clinical practice guidelines to achieve the best outcome.

Specialized wound care addresses the many conditions and

co-morbidities that impact wound healing requires the intervention by multiple healthcare disciplines applying the appropriate therapy at the proper time.

Types of Wounds Treated:Slide12

Venous Ulcer

Location: midcalf to heel (Gaitor area)

Appearance: shallow, irregular, exudate is common, painful

Origin: Venous valve incompetence

V

enous hypertension

Extravascular blood loss/edema

RBCs  hemosiderin staining

WBCs  enzyme-mediated tissue destruction Slide13

Venous UlcerSlide14

Arterial Ulcer

Location: distal lower extremity

Appearance: distinct margin (cookie cutter), with central necrosis in setting of PAD:

Cool extremity

Diminished /absent pulses

Shiny skin /hair lossSlide15

Arterial UlcerSlide16

Diabetic Ulcer

Location: Typically, plantar aspect of the foot beneath a bony prominence.

Appearance: ill-defined borders, prominent callus, and

palpable

pulses.Slide17

Diabetes Growth = 165% from 2000-2050

Diabetes-related complications, including amputations,

lower-extremity neuropathies and premature cardiovascular

disease are a major cause of chronic wounds.Slide18

THE POTENTIAL IMPACT

OF A DIABETIC FOOT ULCERSlide19

Amputations’ Mortality Rates

Compare to Cancer

Patients with amputations and diseases related to diabetes die at a rate as high as many cancers.

IschemicSlide20

Diabetic UlcerSlide21

Pressure Ulcer

Location: beneath a

bony prominence

(heel, sacrum).

Appearance: irregular in size and depth.

Origin:

Prolonged contact

with inappropriately padded surface

 focal ischemic necrosis. Worsened byfriction / moisturemalnutrition co- morbidities.Slide22

Pressure Ulcer

Staged according to

DEPTH

of injury…Slide23

5. Atypical Wounds

Depend upon Causative factors

Examples:

Brown Recluse Spider Bite

Post radiation treatment

Malignancy

Autoimmune process

Slide24

Atypical Wounds: Autoimmune

Pyoderma

RA, Sojourns

VasculitisSlide25

Factors Affecting Wound Healing

Chronic

Wound

Soft Tissue Infection

Systemic Illness

Osteomyelitis

Wound Environment

Nutrition

Edema

Compliance

Systemic Healing Ability

Perfusion

Pressure

OxygenSlide26

Advanced TherapiesSlide27

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Using HBO Therapy As Part of the Approach

Hyperbaric Oxygen Therapy (HBOT) is a

powerful adjunctive therapy,

reimbursed by Medicare and most

payers, that is indicated for 10-15% of

patients with chronic wounds.

Medicare-Approved Non-Emergent Indications:

94% of diabetic foot ulcer patients treated with HBOT maintained an intact limb at 55 months post-HBOT.

1

27

1

. Cianci P. Advances in the treatment of the diabetic foot: Is there a role for adjunctive hyperbaric oxygen therapy? Wound Repair Regen 2004;12(1):2-10Slide28

Causes of Hypoxia in

Wound Healing

Arterial Insufficiency

Diabetes – impaired microcirculation

ABI/TCOM/Vascular Studies

Smoking

Infection

Bacteria promote an oxygen dump

EdemaCompression requiredRadiation tissue damageDecrease in the quantity of blood vessels

Key Components of Wound Healingare all dependent on Oxygen to function.Slide29

HBOT Definition

The administration of 100% oxygen at greater than 1 atmosphere pressure absolute (ATA).

Achieved in a chamber in which the whole body is instilled.

Only method of HBO that is approved by CMS (Center of Medicare Service).Slide30

Hypoxic Tissue Benefits

Restoration of microcirculation.

Decreased local edema.

Improved cellular energy metabolism.

Improved local tissue oxygenation.

Improved leukocyte-killing ability.

Improved effectiveness of antibiotics.Slide31

Indications-Wound Care

Diabetic wounds of the lower extremity.

Acute peripheral arterial insufficiency.

Treatment of compromised skin grafts or flaps.

Chronic refractory Osteomyelitis.

Osteoradionecrosis.

Soft tissue radionecrosis.

Acute traumatic peripheral ischemia

Crush injuries and suturing of severed limbsProgressive necrotizing infectionsGas gangreneSlide32

Debridement

How?

Mechanical

Autolytic

Enzymatic

Surgical

Why? Enhance wound assessmentDecrease potential for infectionsNecrotic tissue delays formulation of granulation and epithelial tissueSlide33

Additional Advanced Therapies

Topical Growth Factors

Compression

Bioengineered Skin Substitutes

Topical AntimicrobialsSlide34

Advanced Dressing Decision treeSlide35

Referral Guidelines for Advanced Wound CareSlide36

Benefits to Patients to be part of the Wound Care Continuum

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Faster healing and a shorter recovery period

Limb salvage

Restoration of health and mobility

Improved quality of life

Wound Care education to help patients understand their condition and prevent complicationsSlide37

What Can You Do?

Recognize who is at RISK for chronic wounds

Perform an accurate assessment of the WOUND and the PATIENT

Implement PREVENTATIVE measures

Nutritional support

Surface offloading/ Skin protection

Choose appropriate DRESSINGS

Make prompt REFERRALS for wound care and HBOTSlide38

Guidelines For Referral

Full Thickness Wounds That Fail to Show Significant

Improvement in 2 Weeks or Complete Healing in 4 Weeks.

All Full Thickness Ulcers That Involve Tendon, Ligament, Bone and/or Joint and/or Are Significantly Infected.

Neuropathic Ulcers in Diabetic Patients, Especially Those With Accompanying Foot Deformity.

Any wound in a Diabetic patient due to the compromised healing ability

Ulcers in Compromised Patients.

Venous Ulcers, Especially Those With Arterial Component or chronic lower extremity swelling

Ulcers With Significant Ischemia.Slide39

Questions?