Getting Chronic Non Healing Wounds to Heal Presented by Rafat Choudhry, MD, FAPWHc, FAWMS Wound Care Physician AtlantiCare Wound Healing Center

Objectives Overview of the significant impact of untreated wounds in the US Overview of advanced wound care Referral guidelines for Advanced Wound Care

Impact of Wounds on the US Population

Many suffer for months and years with wounds such as these: Venous Stasis Pressure Ulcer Osteoradionecrosis Diabetic Foot Ulcer

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’s

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 2010 To answer this question, we simply need to do a little math…

Overview of Advanced Wound Care

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” ‘To begin with, we need to define the playing field, so the first question is …’ Masoro and Austad, 2006

Chemotactic Migration Proteolytic Turnover of ECM Normal Wound Healing Cellular Activity Chemotactic Migration Inflammation Mitosis Angiogenesis Synthesis of ECM Proliferation Proteolytic Turnover of ECM Remodeling

Chronic Wound Delayed Healing Repeated Trauma Local Tissue Ischemia Necrotic Tissue Heavy Bacterial Burden Tissue Breakdown Prolonged Inflammation Stimulation of macrophage and neutrophils to wound bed Activation of macrophages with release of cytokines Degrades ECM impaired cell migration impaired connective tissue deposition Degrades Growth Factors TNF and IL-1  Production MMPs and  TIMPs 3Mast BA & Schultz GS (1996 )

What is Advanced Wound Care? Types of Wounds Treated: 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.

Venous Ulcer Location: midcalf to heel (Gaitor area) Appearance: shallow, irregular, exudate is common, painful Origin: Venous valve incompetence Venous hypertension Extravascular blood loss/edema RBCs  hemosiderin staining WBCs  enzyme-mediated tissue destruction read

Venous Ulcer (mention ‘champagne bottle’ deformity)

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 loss read

Arterial Ulcer

Diabetic Ulcer Location: Typically, plantar aspect of the foot beneath a bony prominence. Appearance: ill-defined borders, prominent callus, and palpable pulses. ‘perfect storm’

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.

THE POTENTIAL IMPACT OF A DIABETIC FOOT ULCER

Amputations’ Mortality Rates Compare to Cancer Patients with amputations and diseases related to diabetes die at a rate as high as many cancers. Ischemic

Diabetic Ulcer

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 by friction / moisture malnutrition co- morbidities. read

Pressure Ulcer Staged according to DEPTH of injury…

5. Atypical Wounds Depend upon Causative factors Examples: Brown Recluse Spider Bite Post radiation treatment Malignancy Autoimmune process

Atypical Wounds: Autoimmune RA, Sojourns Pyoderma Vasculitis

Factors Affecting Wound Healing Soft Tissue Infection Pressure Systemic Illness Chronic Wound Osteomyelitis Oxygen Nutrition Perfusion Systemic Healing Ability Wound Environment Edema Compliance

Advanced Therapies

Using HBO Therapy As Part of the Approach Wound Care Center Enhancing the Practice of Others Using HBO Therapy As Part of the Approach Acute peripheral arterial insufficiency Acute traumatic peripheral ischemia Chronic refractory osteomyelitis Crush injures and suturing of severed limbs Diabetic wounds of the lower extremities Osteroradionecrosis Compromised skin grafts Progressive necrotizing infection Soft-tissue radionecrosis 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 Key Points: Systemic HBOT has been used in wound healing for more than 40 years and is evidence-based care proven to speed the healing process in certain types of wounds. HBO therapy heals wounds from the inside out. By super-oxygenating the wounds, HBO therapy reduces swelling, fights infection, and builds new blood vessels–ultimately producing healthier tissue. During HBO therapy, the patients are monitored to assess whether the high concentration of oxygen has increased in the blood near the wound; if the oxygen level is higher, the therapy is considered most likely beneficial to the patient. HBO therapy is an approved and accepted adjunctive therapy for diabetic wounds, Wagner Grade 3 or higher in severity. It is approved by Medicare and many other payers for the conditions listed. DCS Chief Medical Officer, Robert Warriner, III, M.D. provided Medicare with evidence-based research that demonstrated the effectiveness of HBOT on diabetic foot ulcers. As a result, Medicare designated diabetic foot ulcers as an approved indication for HBOT in 2002 and private insurance carriers began providing coverage shortly thereafter. A typical course of treatment involves the patient spending about 90 minutes a day in the chamber, five days per week, over a four-to-six-week period. The average cost for using HBO treatment to heal a diabetic wound is estimated to be less than $20,000. When compared to the over $100,000 cost of an amputation if a diabetic wound is not healed, this is a huge cost savings for the patient, payer, and leads to healing that might otherwise not be possible. DCS reports that 94% of patients receiving HBO therapy in DCS Wound Care Centers® maintained an intact limb 55 months after therapy. 1 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):2-10. 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):2-10 27 27

Causes of Hypoxia in Wound Healing Key Components of Wound Healing are all dependent on Oxygen to function. Causes of Hypoxia in Wound Healing Arterial Insufficiency Diabetes – impaired microcirculation ABI/TCOM/Vascular Studies Smoking Infection Bacteria promote an oxygen dump Edema Compression required Radiation tissue damage Decrease in the quantity of blood vessels

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).

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.

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 limbs Progressive necrotizing infections Gas gangrene

Debridement How? Why? Mechanical Enhance wound assessment Autolytic Decrease potential for infections Necrotic tissue delays formulation of granulation and epithelial tissue How? Mechanical Autolytic Enzymatic Surgical The first step in Wound Bed Preparation is to remove the necrotic tissue. This process is important for several reasons: 1. Devitalized tissue (eschar and slough) in the wound bed will reduce the ability of the clinician to adequately assess the depth of the wound, condition of the tissue and surrounding structures. 2. It may mask signs of infection and serve as a medium for the proliferation of bacteria. 3. The presence of necrotic tissue is a physical barrier to healing and necrotic tissue supports significant bacterial growth which may result in excessive amounts of proteases which can have a very negative effect on healing.

Additional Advanced Therapies Topical Growth Factors Compression Bioengineered Skin Substitutes Topical Antimicrobials

Advanced Dressing Decision tree So with this in mind…Here is an example of a dressing decision tree we use in our clinic (apologize for the print). The concept is that one size doesn’t fit all, and that dressings are selected based on the unique presentation of the wound and patient. For example, if the wound is highly exudative, we are going to want to absorb that drainage in order to avoid tissue maceration. So in this case, we might select a hydrofiber or calcium alginate.

Referral Guidelines for Advanced Wound Care

Benefits to Patients to be part of the Wound Care Continuum Wound Care Center Enhancing the Practice of Others Benefits to Patients to be part of the Wound Care Continuum 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 complications

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 HBOT …but let me remind you of some things you can do to benefit these ‘challenging’ patients. As caregivers, we have to…

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. These overall guidelines summarize the types of wounds that are candidates for referral to the Wound Management Program: They include: Full thickness wounds that fail to show significant improvement within four weeks or complete healing in eight weeks. The reason we state these time frames is because we are seeing significant improvement within four weeks or complete healing in approximately 8-12 weeks in the majority of cases at the Wound Management Program. Patients should not stay in the health care systems with nonhealing wounds for months and years duration now that there are effective management treatments available to them. Other types of wounds to be referred include: 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; ulcers in compromised patients; venous ulcers especially those with an arterial component as well; and ulcers with significant ischemia.

Questions?