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

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

3. Impact of Wounds on the US Population

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

5. 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

6. 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…

7. Overview of Advanced Wound Care

8. 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

9. 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

10. 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 )

11. 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.

12. 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

13. Venous Ulcer
(mention ‘champagne bottle’ deformity)

14. 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

15. Arterial Ulcer

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

17. 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.

18. THE POTENTIAL IMPACT OF A DIABETIC FOOT ULCER

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

20. Diabetic Ulcer

21. 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

22. Pressure Ulcer
Staged according to DEPTH of injury…

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

24. Atypical Wounds: Autoimmune
RA, Sojourns
Pyoderma
Vasculitis

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

26. Advanced Therapies

27. 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, 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

28. 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

29. 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).

30. 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.

31. 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

32. 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.

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

34. 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.

35. Referral Guidelines for Advanced Wound Care

36. 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

37. 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…

38. 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.

39. Questions?