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DEPARTMENTS: PRACTICE REFLECTIONS

35 Years of Advances in Skin & Wound Care: Celebrating the Evolution of the Wound Care Team

Anand, Nimay BA; Niezgoda, Jeffrey MD, FACHM, MAPWCA, CWHS; Alavi, Afsaneh MD

Author Information
Advances in Skin & Wound Care: July 2022 - Volume 35 - Issue 7 - p 360-362
doi: 10.1097/01.ASW.0000822700.55194.34
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INTRODUCTION

For the 35th anniversary of Advances in Skin & Wound Care, a variety of thought leaders have been invited to share their insight into a range of topics of current interest to the field. In this special installment of Practice Reflections, three authors share their perspectives on the physician’s role in wound care and, in particular, the interprofessional nature of this unique discipline.

TEAMWORK AND WOUND CARE

For as long as human civilization has existed, wound care has been needed, and it has evolved significantly throughout those countless years. From the traditional medicines of honey, herbs, and oils to the advanced dressings and devices used today, wound healing has experienced considerable change. Evolution in the structure and composition of the wound care team, the specialties involved, and the products available has driven shifts in the practice of wound care.

Team Structure

In the 35 years since the inception of Advances in Skin & Wound Care, the landscape of the field has changed considerably, and is poised to keep doing so. In 1988, the practice of wound care was shifting; one of the largest debates at that time was centered on the structure of the wound care team. Traditionally, wound care was considered “the nurse’s responsibility.” In an early Editorial, Abruzzese1 wrote that “blaming poor nursing care for the development of pressure ulcers in [sic] the easy way out and, yet, an age old aspersion.”

Since then, our understanding of the pathogenesis, prevention, and treatment of wounds has shifted significantly. Today, we have a much more nuanced approach to wound healing. Not only are physicians now actively involved in diagnosis and treatment, but, commonly, an interprofessional team comprising both physicians and allied health staff work together to prevent and treat wounds. The hierarchy of the past has been replaced by a dynamic team structure in which responsibility is shared by team members. While remaining ultimately responsible, the physician’s role has transitioned from authoritarian to one of leadership and collaboration.

Many factors have contributed to this transformation, including changes in reimbursement. Insurance billing and payment standards have shifted to incentivize early detection and intervention, rather than treatment of wound complications (ie, prevention, rather than amputation in diabetic foot disease), resulting in increased physician involvement.2,3

Multispecialty Involvement and Lack of a Governing Body

The involvement of a wide variety of specialties has led to a profound diversity in practice and philosophy. When faced with challenges, the interdisciplinary team brings a variety of approaches, techniques, and skills to the clinical management strategy. However, this same diversity of practice has made it challenging to establish universal standards of care. Unfortunately, this foundational issue is compounded by the lack of a single clinical governing body to issue recommendations and practice guidelines.

This absence of standardization also limits true interdisciplinary collaboration. For example, a surgeon’s approach to wound care may significantly differ from an internist’s, hindering high-level discussions on best practices for clinicians, while at the same time potentially causing patient confusion. This impediment could be improved and harmonized with recommendations from a unified professional clinical authority.

Standardized evidence-based practice guidelines broadly accepted by all clinicians involved in wound care would enhance management strategies, improve communication, motivate better patient adherence, and ultimately result in enhanced healing outcomes. Wound specialists need a single society to represent them both professionally and legislatively. Rarely is the voice of a single or small group of clinicians heard. A consolidated and cohesive group is required to speak in representation of the profession and the patients they serve. Unfortunately, both corporate interests and the absence of formal board certification in wound care have hindered efforts.

In addition, wound care education and certification (which is mandatory to practice in some countries) are offered by a limited number of institutions. Further, the available courses mostly focus on training allied health staff, as opposed to physicians.

When functioning optimally, the interprofessional team provides broad-based expertise to positively impact the overall care of the patient. The knowledge and skill contributed by each physician and allied healthcare staff team member collectively contributes the best care plan for each patient. Multiple studies have shown the team approach also decreases burdens on healthcare systems.4,5

Wound care has become a more patient-centered field. Involving patients and encouraging them to share the responsibility for their care improves outcomes.6 Making decisions with the patient’s (as well as their family’s) input enables us to be more realistic with care goals and decreases the burden on the healthcare system.

Science and Technology

The science and technology surrounding wound care has evolved as well. Major debates in the field now focus on specific questions regarding the best way to handle different types of wounds and shorten the time to healing. In particular, the technology of debridement, control of infection and inflammation, the role of moisture balance in wound healing, and how to provide the optimal wound microenvironment are recognized as paramount themes.7 Sensors to detect biomarkers, pH, and different components in the wound have changed passive dressings into a more active component of wound care. The number of publications discussing wound care has been steadily increasing since the inception of Advances in Skin & Wound Care (Figure). Publication and interrogation of current clinical research as well as review and reporting of clinical outcomes and success are critical practices for wound care professionals. Access to a clinical journal is complementary to the success of a wound care clinician. Advances is the leading wound management journal and has served clinicians around the world for over 3 decades.

F1
Figure:
NUMBER OF PUBLICATIONS PER 5 YEARS INDEXED BY PUBMED CONTAINING THE WORDS “WOUND CARE”

Previously, a great deal of debate centered around the optimal prevention of wounds, surveillance frequency, and what types of techniques and technologies worked best. Exciting developments on the horizon today include artificial intelligence, particularly in combination with new imaging techniques. These developments may provide new technologies, devices, and methods to assess wound health and help decide on optimal treatment strategies.

The past decade has witnessed a vast increase in the number of products and devices available for wound management, all boasting novel improvements and functionalities. There are currently more than 500 different dressings and wound products available. Improvements in the design and function of newer-generation products have transformed the gauze and simple topical wound covers of yore to active dressings with dynamic roles in the healing process. Advanced “smart” dressings now play a role in the delivery of medication, monitoring phases of wound healing, and reacting to changes in the wound environment. Although advancements in technology may provide improved clinical outcomes, there may be hidden costs associated with the expansion of products with an overall negative impact on the delivery of wound care services.

One reason for this product explosion, specifically in the US, stems from the FDA clearance process. The number of technologies with rigorous validation of efficacy is far lower than the number on the market, primarily because of the ease of approval via the 510(k) process.8 The use of predicate devices allows for streamlined market entry without the requirement of clinical validation. However, the use of products without proven clinical efficacy contributes to cost inefficiency; wound care costs an estimated 28 billion in Medicare patients alone and is expected to keep rising.9 Today’s wound care specialist must be cognizant of the challenges of balancing the use of technology and achieving clinical success while maintaining fiscal control.

On the practice side, there has been a significant shift in focus from management to the prevention of chronic wounds. Prevention takes many different forms, from the outpatient to inpatient experience. Offloading pressure from wound-prone feet in patients with diabetes and implementing aggressive pressure redistribution and prevention protocols in the inpatient setting with patients at risk for pressure injury have both been successful.10

Continued growth in science and technology will bring new advances to wound care. The benefits of these advances will translate to enhanced patient outcomes in both healing and prevention. However, clinicians must be cautious when adopting new technology because they are the guardians of the fragile balance of efficacy and overall efficiency.

CONCLUSIONS

Since publication of the first issue of Advances, then named Decubitus, wound care has evolved considerably. One of the biggest changes has been the structure of the wound care team: from a hierarchy to an interprofessional team, incorporating the diversity of approaches, techniques, and products available today. One of the principal challenges today is the lack of standardization in care, thought, and education, due in part to the lack of a single governing professional wound care society. The articles, discussions, and conclusions found in the initial issues of Advances are almost prophetic. Many of the recommendations and visions of the standard of care for the future have become the realty of clinical practice today. In fact, the very first Advances article suggested that “in the future, all patients will need to be assessed for risk of pressure ulcers during admission.”11Advances remains today what it was 35 years ago: the reference standard for wound care journals.

REFERENCES

1. Abruzzese R. Whose fault is it anyway?Adv Skin Wound Care 1988;1(2):7–9.
2. Wakefield MK. Nurses and the Affordable Care Act. Am J Nurs 2010;110:11.
3. Wallis L. Some pressure ulcers are unavoidable. Am J Nurs 2010;110:16.
4. Davis MJ, Luu BC, Raj S, Abu-Ghname A, Buchanan EP. Multidisciplinary care in surgery: are team-based interventions cost-effective?Surgeon 2021;19:49–60.
5. Wayne PM, Buring JE, Eisenberg DM, et al. Cost-effectiveness of a team-based integrative medicine approach to the treatment of back pain. J Altern Complement Med 2019;25(S1):S138–46.
6. Armstrong N, Herbert G, Aveling EL, Dixon-Woods M, Martin G. Optimizing patient involvement in quality improvement. Health Expect 2013;16(3):e36–47.
7. Sibbald RG, Elliott JA, Persaud-Jaimangal R, et al. Wound bed preparation 2021. Adv Skin Wound Care 2021;34:183–95.
8. Frykberg RG, Banks J. Challenges in the treatment of chronic wounds. Adv Wound Care (New Rochelle) 2015;4:560–82.
9. Mahmoudi M, Gould LJ. Opportunities and challenges of the management of chronic wounds: a multidisciplinary viewpoint. Chronic Wound Care Manage Res 2020;7:27–36.
10. Huang HY, Chen HL, Xu XJ. Pressure-redistribution surfaces for prevention of surgery-related pressure ulcers: a meta-analysis. Ostomy Wound Manage 2013;59(4):36–8, 42, 44, 46, 48.
11. Pressure Points. Decubitis 1988;1(1):12–14.
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