Chronic wounds continue to baffle health care providers, as the required treatment can be quite complex. Or is it that we overlook the basics while working in “silos” that prevent us from seeking the expertise of others who might have more experience?
Let’s consider that the number of chronic conditions is increasing among the United States population. As such, chronic wounds are on the rise. Yes, certain resources may be scarce and we always have to navigate through the “insurance-based practice” world to provide the best possible treatments. Patient education and communication are that much more important when considering that our wound care patients often are not referred in a timely manner and that a lack of coordinated services generally tends to exist throughout the healthcare continuum. During this time of a coronavirus pandemic, our patients must be involved throughout their treatment by proof of adherence if they will have any chance at real healing. The need to avoid inconsistent treatment and self-care follow-through has become a necessity to an unprecedented degree.
First Things First
Of course, for many of our patients, wound care itself is just a part of the health care equation. Undiagnosed and undertreated conditions such as occult infections, poor perfusion, malnutrition, and atypical wounds have our patients in especially precarious positions. Why does this seem to be the case when we have so much technology and information at our fingertips? A common mistake for clinicians is concentrating on taking care of the “hole” in the patient, thus forgetting the “whole” patient. (Yes, even after all of this time and after all we have supposedly learned in wound care.) Specifically, insisting that the patient be an active participant in his/her healthcare is often overlooked or given up on by the provider. Even for our most successfully engaged patients, encouraging active participation is an unending task.
As I continue to interact with colleagues globally about their chronic wound cases, it becomes apparent that a good, old-fashioned assessment continues to be missed prior to the wound clinic visit. While this scenario is quite frustrating to the wound care provider, it is that same provider’s responsibility to ensure that the proper assessment is rendered.
Experts and Advocates
Patients need their expert wound care providers to be their advocates, and part of being an advocate is reversing the trend when it’s noticed that care is not appropriate. For example, if a patient living with a lower-extremity diabetic wound does not have an arterial workup, then this patient does not yet have an advocate. If the same patient has signs of infection and you don’t properly investigate which organism may be at fault, then this patient has no advocate. Pointing the finger at the wound being infected is not enough.
The term “non-compliant” is a fossilized medical term. In too many instances, patients may opt to live with the consequences of having an open ulcer, even if it ends in amputation, because the provider did not effectively and aggressively demand contributions in care from the patient.
When advocating for patients by helping them to, in turn, be their own advocates as well, some questions to consider include:
• What are the patient’s goals?
• What is his/her education level and understanding of present situation? Is this the first chronic wound?
• Does the patient have available resources? Does he/she have assistance at home?
• Has the patient been treated by a knowledgeable wound care clinician or team that has followed best practices prior to arriving at your clinic?
• What will it take to have the patient follow recommendations? Can you “connect” with the patient?
If you can’t answer these questions, you can’t advocate for this patient’s needs.
Look To The Literature
Research continues to demonstrate the benefits of having a team approach to a wound care program. Flores et al in 2019 demonstrated that volume and outcomes improved by having multiple team members.1 At our hospital, we have demonstrated that preventing the rate of pressure injuries and improving the care we provide our patients with wounds across the continuum is possible through the team model. It takes a lot of planning, effort, communication, and coordinating, but if done properly, the patient will see benefits.
It takes a great deal of work to be an effective team, and teamwork characteristics include:2
• Good communication—being able to listen well and communicate clearly. Resolving difficulties experienced within the team.
• Respecting/understanding roles—understanding how the roles impact the patient. Respecting and understanding the roles of others.
• Appropriate skill mix—the value of diversity, including personalities, individual attributes, professions, and experience
• Quality and outcomes of care—being able to capture the team’s effectiveness. The team should accept criticism and act on it, define goals, and provide feedback to others.
• Appropriate team processes and resources—having needed physical resources, having enough time to do the job
• Clear vision—understanding the role and purpose of the team
• Flexibility (of the team and the individuals within the team)—covering each other’s roles and knowing boundaries
• Leadership and management
• Team culture—camaraderie and team support/relationships, trust, mutual respect, commitment, fun, and friendship among colleagues
• Training and development opportunities—gaining new knowledge, education, and continuing professional development
• External image of the service—presentation of the team and service to others
• Personal attributes—important to consider such things as approachability, appropriate delegation, confidentiality, decisiveness, empathy, organizational skills, initiative, knowing one’s strengths and weaknesses, openness to learning, and patience
• Individual rewards and opportunity—individual returns on teamwork, good financial rewards, career development, and challenges within the role and opportunity to think outside the box.
Be An Active Advocate
Recently, I received a message from an out-of-town provider for a referral patient … with stipulations. The patient was adamant about only traveling from afar to see our team if we would satisfy a simple question: What will you do different from the other clinics to help me heal as I continue to concentrate on my career? For confidentiality purposes, the patient’s information has been modified here.
After contacting “Beau,” it was apparent that he has been seen by multiple clinics and wound clinicians over a period of 12 years. Yes, 12 years! Beau has had everything but the kitchen sink thrown at his problematic ulcer, with no progression. He lost faith in wound care providers and recently decided to live with the ulcer, as he was actively pursuing a career that continues to require being in a chair for 11 hours per day.
After spending a few minutes talking to Beau, I concluded that wound care basics and multiple causative factors were not consistently addressed. At the same time, little to no education or understanding of the problem occurred while he was not engaging as the main player in his care. It was noted that his nutritional status was poor, he had poor hydration, offloading was non-effective, and inadequate assistance occurred at home. Our plan was simple but it caught his attention—our team would not be able to offer interventions unless he had “skin in the game,” meaning that if wound healing is the end goal, that he would have to become an active participant by ensuring things like proper nutrition, hydration, offloading, and dressing interventions.
Beau was able to understand the severity of his problem, the importance of being a vested participant, and that he needed a team to help him progress. Beau was appreciative of our talk and stated that no one in the past took time to explain his care in detail or explain that he needed to commit to care as a patient.
We must be patient advocates and not work in silos. Patients have an increased number of comorbidities and the number of chronic wounds continue to grow exponentially. Remember, that is not “just doing the right thing” but knowing what the right thing is during these difficult times. Don’t be afraid to speak up and understand that some health care workers will not agree with some of your decisions. Just follow best practices and guidelines and have a team available to help each individual patient in your clinic.
Frank Aviles Jr. is wound care service line director at Natchitoches (LA) Regional Medical Center; wound care and lymphedema instructor at the Academy of Lymphatic Studies, Sebastian, FL; physical therapy (PT)/wound care consultant at Louisiana Extended Care Hospital, Natchitoches; and PT/wound care consultant at Cane River Therapy Services LLC, Natchitoches.
1. Flores A, Mell MW, Dalman RL, Chandra V. Benefit of multidisciplinary wound care center on the volume and outcomes of a vascular surgery practice. J Vasc Surg. 2019 Nov;70(5):1612-1619.
2. Nancarrow S, Booth A, Ariss S, et al. Ten principles of good interdisciplinary team work. Hum Resour Health. 2013;11:19.