In 1988, Roberta Abruzzese, EdD, RN, an action-oriented visionary, founded and became the first editor of the journal Decubitus, which today we know as Advances in Skin & Wound Care. As a compendium of prevention and treatment of pressure ulcers (PrUs), the journal focused on PrUs. By 1990, the tag line for Decubitus had changed to “the Journal of Skin Ulcers.” In 1994, the readership’s interests had reached far beyond PrUs, and along with a new cover design, the name of the journal was changed to Advances in Wound Care with the tag line “The Journal for Prevention and Healing.” In 2000, we changed the name again to the current title, Advances in Skin & Wound Care.
The interdisciplinary journal founded by Dr Abruzzese was anchored on 3 pillars—education, practice, and research. Her beliefs about the provision of education in wound care were rooted in collaboration. Dr Abruzzese’s vision for interprofessional alliances was apparent when she wrote, “The problem of PrUs belongs to no one group of healthcare professionals: all on the healthcare team must work together to diminish the incidence and severity of pressure ulcers.”1 Our special 25th anniversary issue editorial allows the opportunity to honor Dr Abruzzese and her extraordinary vision by discussing the current concepts in transprofessional wound care based on the pillars of education, clinical practice, and research.
“Education is about the only thing lying around loose in the world, and it’s about the only thing a fellow can have as much of as he’s willing to haul away.” —George Horace Lorimer, American journalist and author.
In 1990, Roberta (as she was affectionately known) asked Elizabeth A. Ayello, PhD, current clinical editor of Advances in Skin & Wound Care, to join her at Decubitus. Roberta’s influence as a mentor to Elizabeth has endured even after Roberta’s death in 2005.2 Dr Ayello believes Roberta would be very proud that the journal has continued to thrive under current management and the guidance of its editors in chief: previously, Joanne Maklebust, MSN, RN, ACNS-BC, AOCN, FAAN, and David Margolis, MD, PhD, and at present, Richard “Sal” Salcido, MD. And, of course, the journal would not sustain success without the support of authors from around the globe and the invaluable input from the prestigious editorial board and peer review panel.
Roberta always helped authors improve their manuscripts. In her last editorial for the journal, she revealed how much she liked the “opportunity to choose cutting-edge topics in wound care” and the “satisfaction of finding gems of knowledge in dissertations and coaxing them to publication.”3 In her first editorial, Roberta wrote “this publication can become the primary resource, the ‘index’ to decubitus literature and practice, which will save hours of valuable time in searching for answers to pressure ulcer problems.”1
Roberta was an educator who believed that educating at the bedside and helping clinicians translate knowledge into clinical action were very important. This was especially transformational, as 25 years ago education was generally a passive process in the classroom. Roberta wrote about the importance of “clinical educator and resource” and supported the emerging role of industry to provide educational programs.4 She reminded us that all healthcare settings—acute, subacute, long term, and home care—needed ongoing education. Roberta was an early supporter of self-study educational opportunities and continuing education for license renewal.4 She was excited to announce in 1994 “the first article designed for self-study with contact hours to be awarded for successful completion of a questionnaire appears in this issue.”5
In her educator role, Roberta urged us to not spend time on the question of whose fault it was when a person developed a PrU but rather how the healthcare team could work together to answer questions about the “most cost–effective ways to prevent pressure ulcers.”6 As any great educator in the role of guide would do, she urged us in wound care to focus on prevention.7
So where are we now? Education is no longer passive, but active. Rather than sitting and listening to “the sage on the stage,” learners also participate in interactive Web programs, CDs and other virtual modalities, and simulation of skills. For example, rather than just talking about debridement modalities, professionals can master their debridement surgical skills using simulation techniques using a variety of sources.
Education is available 24/7 year-round! Through multimedia configuration through the World Wide Web, learners can now access didactic courses at their convenience and are no longer bound by time, space, or place. Education is now global and interprofessional, with emphasis on lifelong learning.8 This, of course, involves patients and their families. In this issue, some examples of international interprofessional educational programs and their outcomes are described.
The clinical practice of wound care has been hampered by the fact that a wound is a clinical sign of a disease, but there are many disorders that can result in an acute or chronic wound (eg, postsurgical, venous disease, diabetic neuropathy, and trauma or ulcers due to pressure, shear, and friction). The average person with a chronic wound is often older than 60 years and may have coexisting diseases and medications that can impair healing. We need to improve our advocacy for persons with wounds to improve their quality of life and ability to access appropriate care.
After the classic work of George Winter in the 1960s, moist interactive healing was often interpreted with the application of saline-soaked gauze to a wound. Hydrocolloids were introduced in the 1970s and 1980s to further facilitate moist interactive healing and to reduce pain, infection rates, and the frequency of dressing changes. More recently, other classes of moist interactive dressings became available including foams, hydrofibers, hydrogels, and films. Non-adherent and adhesive dressings were supplemented in the 1990s with silicone surfaces that prevented pain and trauma especially during dressing removal. A review of the last 25 years of dressing development is on page 87.
Wound bed preparation (WBP) was introduced in 2000 by Sibbald et al.9 The concept in its fullest intent stresses the holistic approach to persons with chronic wounds, treating the cause and patient-centered concerns. The WBP paradigm also defines local wound care with the triad of debridement, infection/inflammation, and moisture balance (D-I-M). The fourth component of local wound care represents the non-advancing edge. This edge is often cliff-like and represents a stalled chronic wound versus the sandy beach transition between the wound and wound margin, where there is a rim of purple new epithelium signifying a healing wound (reepithelialization). There are many advanced therapies for stalled chronic wounds, such as skin grafts, skin substitutes, growth factors, hyperbaric oxygen therapy, and negative-pressure wound therapy. These treatments work ideally when the cause has been corrected (etiology, enough blood supply to heal, and other aggravating factors minimized). The treatment of patient-centered concerns should include pain control and the facilitation of everyday activities. Local wound care can be optimized with a treatment of the D-I-M triad.
Education as outlined in the previous section needs to include not only basic knowledge but also skills and attitudinal change, such as the following:
- Knowledge, skills, and attitudinal education need to be interactive, longitudinal, interprofessional, and linked to patient-care outcomes.
- Best practices and evidence-informed practice need to be adapted for local resources.
- Key opinion leader training is crucial to sustainability.
- Funding agencies and healthcare system support are needed at the local, regional, and national levels to create the readiness for change.
All of these interventions treat the ulcer after it has happened; however, prevention is the key to improving population heath. For example, a simple 60-second screening developed by Shane Inlow, MD, can identify the high-risk foot for persons with diabetes. Plantar pressure redistribution devices are central to preventing foot ulcers that can lead to major lower-limb amputations. There is a need to change health policy to provide appropriate foot assessment and treatment for persons with diabetes. This education-clinical practice and healthcare system reform process is generalizable in developing or developed countries to improve population health.
In the last quarter of a century, we have witnessed significant advances in wound care, including the use of combination medical devices with biological dual-active ingredients and applications ranging in focus—from WBP to the final stages of wound healing.
The modalities we use include physical energy and biological and pharmacologic agents. We now have cavitational ultrasound-based devices, use bioelectrical stimulation, and use advanced wound drainage systems; negative-pressure therapy, hyperbaric oxygen therapy, and systemic and topical therapy are now standards of care. Near infrared or light-emitting (monochromatic) diodes that stimulate nitric oxide production and serve as oxygen-free radical scavengers to limit the senescence of viable cells needed in the wound healing process have enormous potential.
Pharmacologic therapeutic antimicrobial wound dressings and dermal wound healing platforms are here and will potentially change our practices now and well into the future. They include surgical biofilms, wound-healing peptide gels, protein kinase, nanobandages, bionanotechnology, nanocrystals, and the use of autologous platelet gel preparations. The use of living cell–based therapy, including mesoblast stem cells and autologous platelet therapy, has appeared in our journal. Acceleration of intrinsic healing as a novel approach to wound healing is emerging. And antimicrobial wound dressings and computerized wound imaging analysis and documentation systems have advanced and continue to improve.
Advancing wound technology must be significantly aligned with the myriad of clinical problems from which our patients suffer. We cannot survive on technology looking for clinical applications; it should be the other way around—the technology adapted specifically to the clinical problem! Targeted therapeutic innovations to eradicate, heal, and restore optimal integrity of the skin and the form and function of the human body are inextricably linked. The pillars of clinical care, education, and public policy drive research advancements, while at the same time rationalize investments and expenditures for patient care resources. Although we have made enormous advances in wound care, we are at the “tip of the iceberg” in regard to prevention and treatment. The entire community of wound care professionals, clinicians, educators, researchers, industry manufacturers, healthcare organizations, public policy makers, politicians, and patients has worked tirelessly and will continue to do so.
We would like to close with the final words from Roberta’s editorial when the name of the journal changed in 1994,5 in the words of Dag Hammarskjöld, “For all that has been, thanks. For all that will be, yes.”