The Wound Bed Preparation model is an organized approach to wound care. First published in 2000,1 it emphasizes the correct identification of the cause, prevention, and/or treatment of wounds. We recognize that holistic care involves the treatment of the cause along with patient-centered concerns (see https://journals.lww.com/aswcjournal/Fulltext/2015/10000/Optimizing_the_Moisture_Management_Tightrope_with.6.aspx). Often, this implicates two key elements: available resources and provider education, both of which are addressed in a variety of ways in this month’s globally focused issue.
Wound healing is truly a worldwide community, and much can be learned from developing countries. Febe A. Bruwer, Yvonne Botma, and Magna Mulder examine the identification and treatment of venous leg ulcers in the central South African province of Gauteng in one of our feature articles this month. They obtained 160 files on patients with venous leg ulcers from 48 public and private wound care facilities. Their checklist analysis for optimal venous ulcer healthcare services uncovered several gaps in care, including:
- A lack of hand-held Dopplers in 34% of facilities; in other facilities, available devices were not always used.
- Compression therapy was used in 71% of patients, but ankle-brachial pressure indices were determined in only 30%.
- A surprising 27 cases (17%) were associated with amputation (possibly related to inappropriate compression).
- 61% of staff had no formal wound care training.
- Assessments implemented in 92% of facilities lacked key aspects including factors that could impair healing (eg, smoking and anemia).
- A lack of distinction between local and deep/surrounding infection, with accompanying overuse of topical and systemic antimicrobial agents.
However, these problems are not unique to South Africa. In Ontario, Canada, many northern remote and underserviced communities do not have portable handheld Dopplers available for many of their patients in several service locations. The lower limb amputation rate is much higher than most southern and central communities.
We recognize that not all venous ulcers are healable, and some of the amputations in Sister Bruwer’s article may be attributable to unrecognized arterial predominant coexisting disease or deep and surrounding infection, lack of patient adherence to treatment, or systemic unavailability of key treatment modalities (eg, compression). These problems require coordinated interprofessional care that is lacking in many healthcare systems. Unfortunately, healthcare systems in both developing and developed countries often lack the structure to deliver optimal but cost-effective care.
Also in this issue, Elaine Song and her colleagues have implemented a digital solution to improve product formularies for cost-effective wound management. The authors were concerned about the costs associated with local wound care and the suboptimal linking of product function to clinical use in everyday practice. They were also concerned about the high cost of selected products and stocking too many products with similar indications. Their design thinking module was developed with four steps: discover, define, develop, and deliver.
This process resulted in a 36% reduction in formulary products, 38.73% decrease in monthly dollars spent on chargeable products, and 29.56% decrease on per-patient visit chargeable products. This is a win for the healthcare system, professional staff efficiency, and reduced costs!
The care of individuals with chronic wounds is a universal problem. We must be aware of patient-centered concerns around optimal pain control to tolerate compression therapy and expertise of healthcare providers to apply appropriate compression for venous disease based on arterial circulation assessment. Local wound care also can be optimized through the components of the Wound Bed Preparation Model: debridement, infection/inflammation, and moisture management.2 Ultimately, the developed world can learn from the developing world about cheap and cheerful solutions to common problems through reverse innovation.3 We continue to ask you, as a member of the interprofessional team: Are you up to the challenge?
R. Gary Sibbald, MD, DSc (Hons), MEd, BSc, FRCPC (Med Derm), FAAD, MAPWCA, JM
Elizabeth A. Ayello, PhD, MS, BSN, RN, CWON, ETN, MAPWCA, FAAN
1. Sibbald RG, Williamson D, Orsted HL, et al. Preparing the wound bed—debridement, bacterial balance and moisture balance. Ostomy Wound Manage 2000;46:14–35.
2. Sibbald RG, Elliott JA, Ayello EA, Somayaji R. Optimizing the moisture management tightrope with wound bed preparation 2015©. Adv Skin Wound Care 2015;28:466–76.
3. Govindarajan V, Trimble C. Reverse Innovation. Create Far From Home, Win Everywhere. Boston, MA: Harvard Business Review Press; 2012.